Salmonella septicemia

- Christian Hoffmann -

Infection with non-typhoid Salmonella, which typically only causes enteritis in healthy individuals, can lead to severe septicemia in immunocompromised patients (Jacobs 1985). A newer study indicates that impaired immunity against nontyphoidal Salmonella bacteremia in HIV infection results from excess inhibitory antibodies against Salmonella lipopolysaccharides, whereas serum killing of Salmonella is induced by antibodies against outer membrane proteins (MacLennan 2010).

In Central Europe, Salmonella septicemia is rare in HIV patients, and accounts for less than 1% of AIDS cases. In the Swiss cohort of over 9,000 patients, only 22 cases of recurring salmonellosis were documented over a period of nine years (Burkhardt 1999).

In Southern Europe as well as Africa, salmonellosis is much more frequent. Infected food, particularly poultry, is the most widely recognized as a long-established reservoir for Salmonella. In most cases, relapses are frequent. In addition to septicemia, atypical infections with osteomyelitis, empyema, pulmonary abscesses, pyelonephritis or meningitis have been described (Albrecht 1992, Nadelman 1985). Recurring, non-typhoid Salmonella septicemia is considered an AIDS-defining illness. The risk of recurrent septicemia decreased significantly in the ART era (Hung 2007).

Signs and symptoms/diagnosis

Patients are often severely ill. Chills and high fever are usually present. If treatment is delayed, then there is always a danger of septic shock. Diarrhea may be absent.

Blood cultures mainly lead to isolation of enteritis-causing Salmonella strains such as S. enteritidis and S. typhimurium. The pathogens causing typhoid or paratyphoid fever, S. typhi and S. paratyphi, are rare.

Treatment

Ciprofloxacin is the treatment of choice (Jacobson 1989). Although oral bioavailability is good, intravenous dosing is preferable. In the US the resistance situation is comparably good (Forrest 2009). In contrast to Asia, where rates of ciprofloxacin resistances have clearly increased and risen to up to 30% (Hung 2007). In these cases, cephalosporins such as cefotaxime or ceftriaxone have proven to  be effective.

Treatment/prophylaxis of Salmonella sepsis (daily doses)
Acute therapy 7-14 days
Treatment of choice Ciprofloxacin Ciprofloxacin 1 bottle at 200 mg i.v. bid
Alternative Ceftriaxone Ceftriaxone 1 bottle at 2 g i.v. qd
Prophylaxis For relapses
  Ciprofloxacin 1 tbl. at 500 mg bid (6-8 months)

One week of treatment with ciprofloxacin or ceftriaxone is usually enough. Maintenance therapy should continue for 6-8 months and not be stopped too early (Hung 2001). However, lifelong secondary prophylaxis, which was propagated in the past (Nelson 1992), no longer seems necessary.

Prophylaxis

Drug prophylaxis is not recommended. However, HIV patients should generally be advised to pay attention to food hygiene , especially in warmer countries.

References

Albrecht H, Stellbrink HJ, Fenske S, Steiner P, Greten H. Salmonella typhimurium lung abscesses in an HIV-infected patient: successful treatment with oral ciprofloxacin. AIDS 1992, 6:1400-1.

Burckhardt B, Sendi P, Pfluger D, et al. Rare AIDS-defining diseases in the Swiss HIV Cohort Study. Eur J Clin Microbiol Infect Dis 1999, 18:399-402.

Forrest GN, Wagner LA, Talwani R, Gilliam BL. Lack of fluoroquinolone resistance in non-typhoidal salmonella bacteremia in HIV-infected patients in an urban US setting. J Int Assoc Physicians AIDS Care 2009, 8:338-41.

Gordon MA. Salmonella infections in immunocompromised adults. J Infect 2008, 56:413-22.

Hung CC, Hsieh SM, Hsiao CF, Chen MY, Sheng WH. Risk of recurrent non-typhoid Salmonella bacteraemia after early discontinuation of ciprofloxacin as secondary prophylaxis in AIDS patients in the era of HAART. AIDS 2001, 15:645-7.

Hung CC, Hung MN, Hsueh PR, et al. Risk of recurrent nontyphoid Salmonella bacteremia in HIV-infected patients in the era of highly active antiretroviral therapy and an increasing trend of fluoroquinolone resistance. Clin Infect Dis 2007;45.

Jacobs JL, Gold JW, Murray HW, Roberts RB, Armstrong D. Salmonella infections in patients with the AIDS. Ann Intern Med 1985, 102:186-8.

Jacobson MA, Hahn SM, Gerberding JL, et al. Ciprofloxacin for Salmonella bacteremia in the AIDS. Ann Intern Med 1989, 110:1027–1029.

Kitkungvan D, Apisarnthanarak A, Plengpart P, Mundy LM. Fever of unknown origin in patients with HIV infection in Thailand: an observational study and review of the literature. Int J STD AIDS 2008, 19:232-5.

MacLennan CA, Gilchrist JJ, Gordon MA, et al. Dysregulated humoral immunity to nontyphoidal Salmonella in HIV-infected African adults. Science 2010, 328:508-12.

Nadelman RB, Mathur-Wagh U, Yancovitz SR, Mildvan D. Salmonella bacteremia associated with the AIDS. Arch Intern Med 1985, 145:1968-71.

Nelson MR, Shanson DC, Hawkins DA, Gazzard BG. Salmonella, Campylobacter and Shigella in HIV-seropositive patients. AIDS 1992, 6:1495-8.

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Filed under 11. Opportunistic Infections, Part 3 - AIDS, Salmonella septicemia

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