Bacteria: the Sequel

Salmonella, Shigella, Typhoid fever, Tetanus, Botulism, Campylobacter Jejuni, Cholera, C.diff, Diphtheria, Group B strep

Salmonellosis

A leading cause of foodborne illness in the US that is most common in children under 5 and adults above 70 linked to contaminated food, poor hygiene, and pet exposure

Salmonella enterica (S. enteritidis, S. typhimurium) incubates in 12-48 hours; transmitted via fecal oral lives in the GI tracts of animals

Etiology and transmission of Salmonellosis

Clinical diagnosis BUT confirmed by stool culture, PCR GI panel in moderate/severe cases, blood culture if febrile or immunocompromised, CBC, CMP

7 y/o male presents to the ED for abdominal pain with N/V/D. Mom states that the diarrhea was loose and watery but without blood. Vitals are stable with the exception of 100.2 temp. What is your workup?

Thug it out, Hydration and electrolyte replacement, NO antidiarrheals

7 y/o male presents to the ED for abdominal pain with N/V/D. Mom states that the diarrhea was loose and watery but without blood. Vitals are stable with the exception of 100.2 temp. What is your treatment plan?

Ceftriaxone, cipro, azithromycin

Abx choices for Salmonellosis - may prolong carrier states or open patients up to C. Diff

Infants under 3 months, immunocompromised, severe illness, invasive disease

Who are abx recommended for for Salmonellosis

Osteomyelitis (sickle cell), meningitis or endocarditis (neonates), bacteremia (immunocompromised or high risk), reactive arthritis, chronic carrier state, dehydration, electrolyte abnormalities

Complications of Salmonellosis

safe food handling, wash hands, avoid raw/undercooked eggs, poultry, and meat

Prevention of Salmonellosis

Typhoid fever

A systemic illness that is rare in the US, but associated with international travel - report in 1 week

Salmonella enterica serotype typhi and paratyphi A, B, C - Humans are the ONLY reservoir

Etiology for Typhoid fever

travel to South Asia, Africa, and parts of Latin America, ingestion of contaminated food or water, close contact with a carrier (shed bacteria for 12 months), chronic biliary disease/structural GI issues, inadequate hand hygiene

Risk factors for Typhoid Fever

Blood cultures (sensitive early), Stool cultures (sensitive later), Bone marrow culture (the MOST sensitive - but rarely needed), CBC, CMP, Widal test (no longer recommended)

45 y/o male presents to the ED for abdominal pain and malaise. He states that he’s had a fever every day since getting back from Brazil and it keeps getting higher. He also reports pea soup diarrhea. On physical exam you note faint salmon colored blanching macules on the trunk and hepatosplenomegaly. Vitals are stable with the exception of 55 bpm (faget’s) and 102.5 temp. What is your workup?

Azithro/Ceftriaxone 🥇, FQs (resistance common), fluids, antipyretics, nutrition, Corticosteroids (shock, delirium)

45 y/o male presents to the ED for abdominal pain and malaise. He states that he’s had a fever every day since getting back from Brazil and it keeps getting high. He also reports pea soup diarrhea. On physical exam you note faint salmon colored blanching macules on the trunk and hepatosplenomegaly. Vitals are stable with the exception of 55 bpm (faget’s) and 102.5 temp. What’s your treatment plan?

Prolong Abx, maybe cholecystectomy

Game plan for chronic carriers of Typhoid Fever

Intestinal perforation, Hemorrhage (peyer’s patches), encephalopathy (AKA typhoid state), hepatitis, myocarditis, carriage, sepsis

Complications of Typhoid - mortality up to 15% if untreated

Vaccines available (live oral and injectable), food and water precautions, treat chronic carriers, investigate outbreaks

Prevention of Typhoid fever

Shigelllosis

A common cause of inflammatory diarrhea that has a LOW infectious dose and is an important cause of daycare, institutional, and MSM outbreaks

Children under 5, poor sanitation, contaminated food and water, travel to endemic regions, MSM, homelessness

Risk factors for Shigellosis

Shigella sonnei (most common), flexneri, dysenteriae, boydii (gram neg rod 1-3 day incubation); fecal-oral human only pathogen that invades the colonic mucosa

Etiology and transmission of Shigellosis

Clinical BUT confirm with stool culture (species ID and sensitivity) or PCR panel, imaging if concerned for toxic megacolon, CBC/CMP (monitor systemic effects)

49 y/o female presents to the ED for sudden onset abdominal cramps and mucoid, bloody diarrhea. She also reports tenesmus and urgency. Vitals are stable with the exception of 101.7 temp. What is your workup plan?

Thug it out → fluids and electrolytes, NO ANTIDIARRHEALS

49 y/o female presents to the ED for sudden onset abdominal cramps and mucoid, bloody diarrhea. She also reports tenesmus and urgency. Vitals are stable with the exception of 101.7 temp. What is your treatment plan?

Children, MSM, elderly, institutional settings, immunocompromised

Abx (azithromycin and ceftriaxone) may shorten illness and shedding in Shigellosis but who’s getting them?

Seizures (kids), Toxic megacolon, dehydration, HUS (dysenteriae), reactive arthritis, prolonged carriage and shedding, IBD flares

Complications of Shigellosis

Handwashing 🥇, safe water and food practices, quarantine symptomatic patients

Prevention of Shigellosis

fever, cramps, bloody diarrhea

Classic triad of Shigellosis

1 week

Is Shigellosis reportable in Tx?

Tetanus (report in 1 week)

What can cause life-threatening muscle rigidity and spasms, especially in unvaxxed or elderly adults

developing countries, puncture wounds, crush injuries, burns, injection drug use, chronic wounds/ulcers, lack of vax, non-steril deliveries (neonatal)

Tetanus risk factors

Tetanospasmin toxin formed by Clostridium tetani found in soil, dust, and animal feces that enters through a break in skin (incubators in 3-21 days)

Etiology and transmission of Tetanus

trismus (lockjaw), dysphagia, neck stiffness

Early signs of Tetanus

ICU admit!! Tetanus immune globulin (TIG), Metro/Pen G, Benzo (muscle spasms), Beta blockers/Mg (autonomic instability), begin tetanus vaccine, intubate and vent at 1st sign of resp compromise

38 y/o male presents to the ED for generalized muscle rigidity. His wife states he pulled a rusty nail out of his foot a week ago, but they don’t believe in vaccines. On physical exam you note opisthotonos, trismus, skin is diaphoretic, and spasms are triggered by pain and noise. Vitals are stable with the exception of 158 bpm and 159/98. What is your management plan?

Laryngospasm, respiratory arrest, autonomic instability, aspiration pneumonia, long bone fractures, DVT, DEATH

Complications of Tetanus

clean, minor with 3 prior doses (no booster), dirty wound or 5+ years since last booster (give Tdap/Td), unknown or incomplete vaccination (TIG), boost every 10 years

Post-exposure prophylaxis rules (just stab’em tbh)

Botulism (report immediately - A$AP)

A rare but life-threatening neuroparalytic illness that presents with descending flaccid paralysis requiring urgent antitoxin administration and respiratory support

home-canned or fermented food, black tar heroin (wound), spore ingestion (honey - infant), GI surgery/abnormalities, cosmetic/therapeutic botox use

Risk factors for Botulism

Botulinum toxic (inhibits Ach) produced by Clostridium botulinum (anaerobic, spore forming gram + rod), spores are heat resistant, toxin is heat labile

Etiology for Botulism

Foodborne (ingestion of preformed toxin), infant (most common - in vivo toxin production), wound, iatrogenic (OD), NO person-person

Transmission for Botulism

respiratory failure

Leading cause of death in Botulism

Serum or stool toxin assay, wound culture, R/o mimics with CMP, CBC, ABG, CXR, CSF

Donatella Versace presents to the ED for facial paralysis after her 45th botox appointment this week. She says it started in her forehead and is moving down as well as double vision and dysphagia. On physical exam you note decreased deep tendon reflexes ptosis. What can you use to confirm your diagnosis, while we wait for the health department to bring the goods?

ICU admit!! Equine-derived heptavalent antitoxin (adults), Human botulism immune globulin (BIG -IV 👶), debridement + Pen G/Metro for wound, NO AMG, Supportive care

Donatella Versace presents to the ED for facial paralysis after her 45th botox appointment this week. She says it started in her forehead and is moving down as well as double vision and dysphagia. On physical exam you note decreased deep tendon reflexes and ptosis. Vitals are stable. What is your treatment plan?

Respiratory failure, aspiration pneumonia, prolonged paralysis and neuromuscular weakness, autonomic instability, secondary infections

Complications of Botulism

Proper food handling and canning, no honey until 12+ months old, prompt wound care in injection drug users,

Prevention of Botulism

Campylobacter Jejuni (report in 1 week)

One of the most common bacterial (curved gram neg rod) causes of gastroenteritis that can also trigger Guillain Barre

undercooked poultry, unpasteurized milk, contaminated water

Transmission for Campylobacter Jejuni

Stool culture, PCR, CT with contrast to r/o appendicitis

15 y/o male presents to the ER for crampy abdominal pain and watery, bloody diarrhea. He said he thinks he drank from the wrong stream on his camping trip. Vitals are stable with the exception of 103.5 temp. What are your diagnostics?

Supportive care, Azithromycin for severe/prolonged cases or high risk patients

15 y/o male presents to the ER for crampy abdominal pain and watery, bloody diarrhea. He said he thinks he drank from the wrong stream on his camping trip. Vitals are stable with the exception of 103.5 temp. What is your treatment plan?

Cholera (report in 1 day AKA immediately)

What can cause rapid, life-threatening dehydration but is rare in the US and endemic to Africa, Asia, and Haiti?

Vibrio Cholerae (gram neg comma shaped rod); fecal oral route

Etiology and transmission of Cholera

Aggressive oral/IV rehydration, Doxy may shorten the course

21 y/o male presents to the clinic for profuse, rice water diarrhea after returning from a mission trip in Africa. He also notes minor abdominal pain and vomiting. What is your treatment plan?

C. Diff (Clostridioides difficiles)

The leading cause of healthcare and antibiotic-associated diarrhea and colitis that has a risk of recurrence and complications

C. Difficile (anaerobic, spore forming gram positive rod), spread via spores

Etiology and transmission of C. Diff

Oral Vanc, fidaxomicin 🥇, NO antidiarrheals 🚫

75 y/o female presents to the ED for watery diarrhea and abdominal cramping. She states that she was recently on clindamycin. Vitals are stable with the exception of 102.3 temp. CBC shows leukocytosis. Toxins A/B are present in the stool. What is your treatment plan?

Diphtheria (report immediately)

A disorder caused by Corynebacterium diphtheriae (gram positive rod) that can cause life-threatening airway obstruction and myocarditis spread via respiratory droplets

Grey pseudomembrane on pharynx (DO NOT DISTURB), sore throat, low grade fever, cervical LAD (bull neck)

Presentation of Diphtheria

Diphtheria antitoxin + erythromycin/penicillin, quarantine patient

Management of Diphtheria

Clinical, confirm with toxin and culture

Diagnosis of Diphtheria

Group B streptococcus (GBS - report in 1 week)

A major cause of neonatal sepsis, pneumonia, and meningitis but is preventable with maternal screening at 35-37 weeks

Streptococcus Agalactiae (gram pos cocci); Colonizes maternal GI/GU transmitted perinatally

Etiology and transmission of Group B streptococcus

Blood, CSF, urine culture

Diagnosis of Group B streptococcus

respiratory distress, fever, poor feeding, lethargy (early), meningitis (late)

Presentation of Group B streptococcus in neonates

Pen G 🥇, intrapatum prophylaxis reduces risk

Management of Group B streptococcus