List of Abbreviations
BP – blood pressure
WHO – World Health Organization
GI – gastrointestinal tract
EIA – enzyme immunoassay
Russian Ministry of Health – Ministry of Health of the Russian Federation
ICD-10 – International Statistical Classification of Diseases and Related Health Problems 10th Revision
OKI – acute intestinal infections
PCR – polymerase chain reaction
FTA – fluorescent treponemal antibody test
ESR – erythrocyte sedimentation rate
FZ – federal law
CNS – central nervous system
RR – respiratory rate
HR – heart rate
ShchD – mechanically and chemically sparing diet
ECG – electrocardiography
CDS dehydration scale (Clinical Dehydration Scale)
Ig M, G – class M, G immunoglobulins
pH – hydrogen ion exponent
Salmonella Pathogenicity Islands
Terms and Definitions
Clinical guidelines (treatment protocol) are a regulatory document of the healthcare standardization system that define the requirements for providing medical care to a patient with a specific disease, syndrome, or clinical situation.
Nosological entity – a set of clinical, laboratory, and instrumental diagnostic features that allow the identification of a disease (poisoning, trauma, physiological state) and its classification into a group of conditions with a common etiology and pathogenesis, clinical manifestations, and general approaches to treatment and condition correction.
A disease is an event, arising in connection with the impact of pathogenic factors disrupting body activity, working capacity, and the ability to adapt to changing environmental and internal conditions, accompanied by simultaneous changes in the body's protective-compensatory and protective-adaptive reactions and mechanisms.
Primary disease – a disease that, by itself or due to complications, creates the primary need for medical care owing to the greatest threat to working capacity, life, and health, or leads to disability, or becomes the cause of death.
Concomitant disease – a disease that has no causal relationship with the primary disease, is secondary to it in terms of the need for medical care, impact on working capacity, and danger to life and health, and is not the cause of death.
Severity of a disease or condition – a criterion determining the degree of damage to human organs and/or body systems or the impairment of their functions caused by the disease, condition, or their complications.
Disease outcomes – the medical and biological consequences of a disease.
Consequences (results) – disease outcomes, as well as the social and economic results of applying medical technologies.
Disease complication – the addition to a disease of a syndrome of physiological process impairment: disruption of the integrity of an organ or its wall; hemorrhage; developing acute or chronic dysfunction of an organ or organ system.
Condition – bodily changes arising from the impact of pathogenic and/or physiological factors that require medical care.
Clinical situation – a case requiring the regulation of medical care regardless of the disease or syndrome.
Syndrome – a condition developing as a consequence of a disease and defined by a set of clinical, laboratory, and instrumental diagnostic features that allow its identification and classification into a group of conditions with different etiologies, but a common pathogenesis, clinical manifestations, and general approaches to treatment, which nevertheless depend on the underlying diseases forming the basis of the syndrome.
Symptom – any sign of a disease that can be determined regardless of the method used for this purpose.
Patient – an individual receiving medical care or applying for medical care, regardless of the presence of a disease and their condition.
Medical intervention – a, performed by a medical worker in relation to a patient, affecting the physical or mental state of a person and having a preventive, exploratory, diagnostic, therapeutic, or rehabilitative orientation, types of medical examinations and/or medical manipulations, as well as artificial termination of pregnancy.
Medical service – a medical intervention or a complex of medical interventions aimed at the prevention, diagnosis, and treatment of diseases, and medical rehabilitation, and having an independent completed significance.
Quality of medical care – a set of characteristics reflecting the timeliness of medical care provision, the correctness of the choice of prevention, diagnostic, treatment, and rehabilitation methods during the provision of medical care, and the degree of achievement of the planned result.
Physiological process – an interrelated aggregate activity of various cells, tissues, organs, or organ systems (an aggregate of functions) aimed at satisfying a vital need of the entire organism.
Function of an organ, tissue, cell, or group of cells – a property constituting a physiological process that implements an action specific to the corresponding structural unit of the organism.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Salmonellosis is an acute infectious zoonotic-anthroponotic disease with a fecal-oral transmission mechanism, caused by Salmonella spp., characterized by symptoms of general intoxication and GI tract involvement, with rare development of generalized forms (typhoid-like, septicemic, and septicopyemic) [1-3].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Salmonellosis pathogens belong to the family Enterobacteriaceae, genus Salmonella, which includes only 2 species (based on DNA structure): Salmonella enterica with five subspecies (each comprising numerous serotypes depending on the presence of O- and H-antigens) and Salmonella bongori (comprising fewer than 10 very rare serovars), the latter being non-pathogenic to humans. For example, S. typhimurium should be systematically classified as S. enterica subspecies enterica serovar typhimurium. Currently, there are more than 2,500 Salmonella serotypes, but 10–15 serotypes are of practical importance, accounting for up to 90% of global morbidity; these include: S. enteritidis (S. enterica), S. typhimurium, S. derby, S. newport, S. heidelberg, S. panama, S. london, S. infantis, S. anatum.
Salmonellae are gram-negative rods measuring 0.7–1.5 × 2–5 µm, possessing 8 to 20 flagella, motile, non-spore-forming, facultative anaerobes that grow well on nutrient media. The optimal pH is 7.2–7.4, and the optimal cultivation temperature is 37 ◦C. The antigenic structure of Salmonella is quite complex; currently, O-, H-, Vi-, M-, and K-antigens are distinguished.
Salmonellae persist in the environment for a long time and tolerate low temperatures for several months. At 60 ◦C, Salmonellae die within 20–30 minutes, and at 100 ◦C, instantly. On linen, the bacteria can survive for 14–80 days, in stool for up to 30 days, and in dried feces for up to 4 years. They survive in running water for up to 10 days, tap water for up to 4–5 months, and dust for up to 6 months. In food products, Salmonellae not only persist well—in frozen meat for up to 3–6 months, frozen poultry carcasses for up to 1 year, sausages for up to 2–3 months, and butter, cheese, and egg powder for 9–12 months—but also multiply. Salmonellae are characterized by the ability to rapidly develop resistance to many antimicrobial drugs.
The primary site of Salmonella colonization in the body is the small intestine, though involvement of the large intestine is also possible.
The pathogenicity of Salmonella is encoded by chromosomal genes that form five "pathogenicity islands" (Salmonella Pathogenicity Islands, SPI: SPI-1, SPI-2, SPI-3, SPI-4, SPI-5). Products secreted by plasmid genes contribute to the extraintestinal dissemination of Salmonella.
In the gastrointestinal form of salmonellosis, the main changes are observed in the gastrointestinal tract, whereas in septicopyemic and septicemic forms, changes are detected in various organs and tissues (predominantly the liver, spleen, lungs, lymph nodes, and bones). In chronic forms of salmonellosis against the background of primary immunodeficiency, histological examination of parenchymal organs reveals lymphoid tissue hyperplasia, focal sclerosis, and signs of chronic non-specific inflammation, with changes resembling systemic vasculitis also possible. The mucosa of the gastrointestinal tract (in both the small and large intestines) shows changes ranging from catarrhal and erosive to ulcerative and ulceronecrotic, with characteristic hyperplasia of the small intestinal lymphoid follicles. The lamina propria exhibits hyperemia, edema, and macrophage infiltration. In generalized forms, dystrophic changes develop in the kidneys, adrenal glands, and myocardium (Table 1).
Table 1. Pathogenicity factors and mechanisms of their action
Pathogenicity factors | Mechanism of action |
|---|---|
Adhesion | Using their flagella, Salmonellae overcome the mucus layer and rapidly attach to enterocytes via a powerful fimbrial apparatus. These structures ensure rapid penetration of the mucous barrier, resistance to the bactericidal action of cationic proteins, and mucosal colonization. |
Invasion | In the pathogenesis of salmonellosis, the invasive activity of the pathogens is of great importance. Invasion factors (SPI-1, SPI-2, SPI-4) determine the pathogen's ability to invade. Salmonellae penetrate the intestinal mucosa through M cells; as a result of the invasion, the M cells are destroyed, and the bacteria invade the lamina propria and intestinal lymphoid formations, after which the Salmonellae penetrate the mesenteric lymph nodes, the thoracic lymphatic duct, and enter the bloodstream. |
Cellular persistence factors (SPI-1, SPI-2, SPI-4) | Substances produced under the influence of SPI-1 cause Salmonella invasion into non-phagocytic cells, while SPI-2 and SPI-4 mediate penetration, survival in the cytoplasm of phagocytes, and the ability to induce their apoptosis. As a result, phagocytosis becomes incomplete, which may act as a factor in the generalization of the infection. |
Bacteremia | In most cases, the entry of Salmonella into the bloodstream does not cause clinical manifestations of bacteremia, as they are rapidly destroyed by serum bactericidal factors. Some Salmonellae that escape destruction are sequestered in the macrophage-histiocytic system, where, in the presence of an immunodeficiency state, foci of proliferative or purulent inflammation may form. |
Toxin production | When Salmonellae die, a significant amount of endotoxin is released, causing non-specific host reactions: fever, vomiting, abdominal pain, non-specific activation of immune system cells through the synthesis of a wide range of cytokines, and intravascular blood coagulation, etc. Products of genes from the fifth pathogenicity island, SPI-5, play an important role in the development of diarrheal syndrome. Under their influence, cytotoxins are secreted that inhibit chloride ion secretion, leading to excessive fluid efflux from cells and the development of diarrhea. Lipopolysaccharide (LPS), released after bacterial death, plays a significant role in the inflammatory response, while the ability to produce a heat-stable enterotoxin—whose damaging effect is mediated by increased cAMP levels leading to impaired sodium and chloride ion secretion—plays a lesser role in the development of diarrheal syndrome. |
Immunity following the infection is short-lived (3–6 months) and serospecific [1-3].
1.3 Epidemiology of the Disease or Condition
Salmonellosis morbidity is predominantly sporadic, but large foodborne and, less frequently, waterborne outbreaks are also recorded, as well as nosocomial infection foci (maternity wards, intensive care units, departments for infants) and outbreaks in closed institutions (nursing homes, psychoneurological boarding facilities). The highest incidence of salmonellosis is characteristic of infants and preschool children.
The source of infection in salmonellosis includes animals and humans (patients and bacterial carriers), with carrier animals posing the greatest danger. The infectious dose is 105–108 microbial cells.
Salmonellosis cases are registered throughout the year with a peak in summer and autumn. The main route of transmission is foodborne, with the leading transmission factor being infected poultry products: chicken, turkey, and waterfowl meat, and eggs, while pork and beef have lesser epidemiological significance. It has been proven that specific animals serve as reservoirs for particular Salmonella serotypes. Infection via water and contact-household routes is much rarer. The contact-household transmission route (personnel hands, instruments, linen, toys, care items, etc.) is characteristic of hospital strains of salmonella carrying multiple antibiotic resistance plasmids: S. typhimurium variant copenhagen ranks first, and S. haifa ranks second; an airborne dust transmission route is also debated for these strains.
Bacteria of the genus Salmonella are one of the main causes of acute intestinal infections of bacterial etiology in residents of both developing and developed countries; global morbidity has increased 6-10 times over a short period. In most countries, Salmonella ranks first or second in the structure of invasive diarrheas. The disease occurs in all age groups, but preschool and school-aged children are most susceptible to salmonellosis [1, 2, 3, 4].
1.4 Features of Coding the Disease or Condition
A02.0 Salmonella enteritis
A02.1 Salmonella sepsis (considered accordingly in the clinical guidelines for sepsis)
A02.2 Localized salmonella infection (considered in the relevant clinical guidelines)
Salmonellosis
arthritis† (M01.3*)
meningitis† (G01*)
osteomyelitis† (M90.2*)
pneumonia† (J17.0*)
tubulointerstitial kidney disease† (N16.0*)
A02.8 Other specified salmonella infection
A02.9 Salmonella infection, unspecified
1.5 Classification of the disease or condition
There is no universally accepted classification of gastrointestinal salmonellosis. A classification indicating the type, severity, and course of the disease is used.
By type: typical (manifest form); atypical (latent form, or carrier state)
By form: monoinfection; combined form (with other infectious diseases)
By severity: mild form, moderate form, severe form.
By the presence of complications: uncomplicated, complicated.
By clinical course: acute (up to 14 days); chronic [1-3].
Table 2. Classification of salmonellosis
Clinical form | Disease variant | Course |
|---|---|---|
Gastrointestinal (97-98% of cases) | Gastritic Gastroenteritic Enteritic Gastroenterocolitic Colitic Hemocolitis | Mild Moderately severe Severe |
Generalized | Typhoid-like Septicemic Septicopyemic | Severe |
Bacterial carriage | Chronic Convalescent Transient |
1.6 Clinical presentation of the disease or condition
The incubation period for salmonella infection ranges from several hours to 5-7 days. Salmonellosis occurs in typical and atypical forms. Typical forms include the gastrointestinal form of salmonellosis, developing in 97-98% of cases, and the generalized form (typhoid-like, septic), accounting for 2-3%.
Gastrointestinal salmonellosis is characterized by two variants of disease onset: acute (about 80% of patients), when all main symptoms appear on the 1st day of the illness, and subacute, when diarrhea, vomiting, and fever join 1-2 symptoms (usually abdominal pain and intoxication) by the 2nd-3rd day of the illness.
General infection syndrome. Salmonellosis is characterized by a febrile reaction of varying severity; chills and profuse sweating may be noted. Salmonellosis is characterized by a pronounced intoxication syndrome, lethargy, weakness, decreased appetite, refusal to eat, and adynamia.
Local changes syndrome. Gastrointestinal tract (GIT) involvement is the leading symptom of salmonellosis and is characterized by abdominal pain of varying severity; the pain is usually diffuse and may intensify before defecation. Colonic spasm, as well as tenesmus and false urges, are rarely recorded. Nausea and repeated vomiting are frequently noted.
The pathogen's features and various pathogenetic mechanisms of intestinal damage in salmonella infection imply the development of diarrhea of both invasive, secretory, and invasive-secretory types. GIT involvement can manifest as gastritis, gastroenteritis, enteritis, gastroenterocolitis, enterocolitis, colitis, or hemocolitis syndrome. The duration of diarrhea ranges from 1-2 days to 7-14 days.
Dehydration syndrome of varying severity develops due to fluid loss with loose stools and vomiting. Dehydration syndrome typically develops in salmonellosis presenting with gastroenteritic and enteritic types.
Hepatosplenomegaly syndrome. In patients with acute salmonellosis, hepatomegaly develops in two-thirds of cases from the end of the first to the beginning of the second week of the disease and persists for up to 2-3 weeks; an enlarged spleen may occur in 10-20% of patients.
Typically, salmonellosis is characterized by a benign cyclic course and the presence of a symptom complex characteristic of this disease, as well as isolation of the pathogen from feces or detection of salmonella nucleic acids in feces.
Atypical forms of salmonellosis include:
mild and subclinical forms present with mild and rapidly transient symptoms, diagnosed predominantly in epidemic foci;
asymptomatic form occurs without clinical symptoms of the disease, but with increasing titers of specific antibodies in the blood. It is detected in infection foci and among agricultural workers directly in contact with infected poultry;
salmonella carriage can be convalescent (after acute salmonellosis), transient (detected in healthy individuals in infectious diarrhea foci), and chronic (more than 3 months).
The localized (gastrointestinal) form includes the following variants: gastroenterocolitis, gastroenteritis, enterocolitis, enteritis, mesadenitis, appendicitis. The generalized form manifests as salmonella septicemia or septicopyemia. According to the severity of the course, mild, moderately severe, and severe forms of the disease are distinguished. According to the character of the course—smooth and unsmooth, including with exacerbations and relapses. According to the duration of the disease and its outcome—acute (up to 1 month), protracted (up to 3 months), chronic (more than 3 months).
Depending on the clinical course, the following forms of salmonellosis are distinguished: mild, moderately severe, and severe.
The mild form (30-40%) of salmonellosis is characterized by a febrile reaction up to 38°C, moderate intoxication symptoms, mild abdominal pain syndrome, and diarrhea up to 4-5 times a day.
The moderately severe form (50-70%) is characterized by fever with temperature rising up to 40°C, chills, sweating, as well as symptoms of intoxication: weakness, dizziness, malaise. GIT involvement is characterized by diarrhea with stool frequency up to 10-20 times a day. Stool is copious, watery, with a green tint; in half of the cases, there is a massive mucus admixture, sometimes resembling "swamp ooze" or "frog spawn". With the development of the colitic variant of the disease, stools quickly become scanty, mucus and streaks of blood appear in them, and in about a quarter of patients, stools acquire the appearance of a "rectal spit". Nausea and vomiting are noted, frequently repeated. Diarrhea is accompanied by abdominal pain, sometimes cramping. The pain syndrome can last from several hours to ten or more days, and sometimes it precedes the onset of diarrhea. Palpation of the abdomen reveals tenderness in the umbilical region, as well as along the colon; spasm and tenderness of the sigmoid colon, as well as false urges, are uncommon. Hemocolitis phenomena are more characteristic of salmonellosis caused by S. typhimurium.
In the severe course of salmonellosis (3-7%), significant intoxication is observed, at the height of which delirium, meningism phenomena, or convulsions may develop. Fever becomes persistent and can last up to 7-10 days. The severe form is accompanied by a complex of signs of impaired function of the cardiovascular system, liver, pancreas, and kidneys. Pronounced diarrhea of watery, invasive, or mixed type occurs (stool over 15-25 times a day), as well as pronounced abdominal pain syndrome, mesadenitis, and hepatosplenomegaly. Some children develop neurotoxicosis: restlessness, limb tremor, seizure readiness, and convulsions, positive meningeal signs. Septic or hypovolemic shock may develop. The clinical picture is characterized by a sharp drop in blood pressure, tachycardia, hemodynamic disorders, impaired consciousness (stupor, sopor), presence of grade II-III dehydration symptoms, and grade II-III toxicosis [1-3].
The severe form of salmonellosis can occur in various variants — typhoid-like, septicopyemic, septicemic.
The typhoid-like form of salmonellosis is rare and is characterized by a hyperacute onset of the disease, pronounced intoxication symptoms, prolonged febrile fever, involvement of the central nervous system (CNS) in the pathological process (headache, lethargy, stupor, delirium, etc.), GIT involvement (diarrhea syndrome, flatulence), and exanthema may appear.
The septic form of salmonellosis usually develops in young children with a burdened premorbid background, elderly people, and immunocompromised individuals. It proceeds as septicemia and septicopyemia, purulent foci are formed in various organs, and thrombohemorrhagic syndrome is characteristic. Persistent fever (up to 40°C and higher) with large daily swings, chills, profuse sweat, gradual deterioration of trophic status, and anemia are characteristic. This is often accompanied by pronounced dyspeptic phenomena, diarrhea, and hepatosplenomegaly. The septic form can develop without prior GIT involvement, in which case the clinical picture of organ damage (meningitis, endocarditis, hepatitis, pleurisy, etc.) comes to the forefront [1-3].
The gastritic variant proceeds like bacterial food poisoning. After a short incubation period, multiple vomiting, abdominal pain, weakness, headache, and fever appear. The nature of the stool does not change, and the patient recovers in 2-3 days. The pathogen's features and various pathogenetic mechanisms of intestinal damage in salmonella infection imply the development of diarrhea of both invasive and secretory types. Diarrhea syndrome in the gastroenteritic variant of salmonellosis is characterized by copious liquid foamy stool, mixed with mucus and greens ("swamp ooze", "frog spawn"), and cramping diffuse abdominal pain. Development of dehydration syndrome of varying severity is possible.
Salmonella gastroenterocolitis and enterocolitis also manifest with copious stools mixed with mucus, greens, and from the 2nd-3rd day, blood streaks appear; abdominal pain, bloating, and flatulence persist for a long time, and repeated vomiting is characteristic. By the 5th-7th day, liver enlargement appears, and the development of splenomegaly is possible.
The colitic form and hemocolitis in salmonellosis are clinically similar to shigellosis: stool with an admixture of mucus, pus, and blood, but tenesmus and urgency are uncommon, a sharply spastic and tender sigmoid colon is not determined, and abdominal pain is diffuse in nature.
Changes in the coprogram correspond to the level and severity of the digestive tract lesion (enteritis is characterized by abundant extra- and intracellular starch, neutral fat, fatty acids, and muscle fibers; distal colon lesions are characterized by mucus, leukocytes, and erythrocytes). The hemogram reveals neutrophilic leukocytosis with a left shift, monocytosis, and, in severe cases, anemia and anethesio-eosinophilia [1-3].
Salmonellosis with contact transmission usually develops subacutely; by the 3rd–5th day from the onset of the disease, intoxication and intestinal syndrome increase, often accompanied by hemocolitis, and in some cases, watery diarrhea. Salmonellosis with contact-household transmission is most severe in mixed infections (with rotavirus gastroenteritis, respiratory viral infections, etc.) and infection with hospital strains [4-5].
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis/condition: requires analysis of complaints, epidemiological history, physical examination data, and laboratory and instrumental studies [6].
2.1 Complaints and Anamnesis
It is recommended that all patients with suspected salmonellosis be evaluated for epidemiological history data (autumn-winter period, preschool and school age, attendance at a preschool or educational institution, stay in crowded places, presence of contacts) [7-11]
Strong Recommendation Level CEvidence Level 5Level of recommendation confidence C (evidence reliability level - 5).
Comments: Infection can occur through the consumption of poultry and livestock products or through contact with Salmonella carriers.
Recommended in all patients with suspected salmonellosis to identify complaints of vomiting and abdominal pain, taking into account their duration and severity, as well as stool disorders [7-11].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comments: Vomiting combined with abdominal pain and loose stools, often resembling marsh mud, is characteristic; blood in the stool is possible.
Recommended in all patients with suspected salmonellosis to clarify the presence/absence of decreased diuresis and thirst according to complaints [1, 2, 3, 7, 11, 12, 13].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comments: gastrointestinal salmonellosis is characterized by the development of dehydration syndrome.
Recommended in all patients to identify signs of intoxication (headaches, decreased appetite, impaired general well-being) [1, 2, 3, 7, 11, 12, 13].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comments: moderately severe headaches, decreased appetite, lethargy, and nausea indicate the development of intoxication in patients with gastrointestinal salmonellosis
2.2 Physical Examination
Physical examination findings are described in the section «Clinical Presentation».
Recommended morning and evening body temperature measurement in all patients with salmonellosis [7, 11, 12, 13].
Level of Evidence CGrade of Recommendation 5Level of recommendation C (level of evidence - 5).
Comments: An increase in body temperature above 400 °C and/or persistence of fever for more than 3 days in salmonellosis indicate the possible development of complications.
Recommended in all patients with salmonellosis measurement of heart rate (pulse rate), respiratory rate (RR), and blood pressure (BP) on peripheral arteries [7, 11, 12, 13].
Level of Evidence CGrade of Recommendation 5Level of recommendation C (level of evidence - 5).
Comments: Changes in heart rate, respiratory rate, and blood pressure may indicate the development of complications.
Recommended body weight measurement in all patients with salmonellosis [7, 11, 12, 13]
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comments: with the development of dehydration syndrome, weight loss is possible, which requires dynamic monitoring of weight parameters
Recommended in all patients with salmonellosis to assess the degree of dehydration, including using the CDS scale [7, 11, 12, 13].
Strong Recommendation Grade CLevel of Evidence 5Level of Recommendation C (Level of Evidence - 5).
Comments: gastrointestinal salmonellosis is characterized by the development of varying degrees of dehydration.
2.3 Laboratory Diagnostics
At the diagnostic stage:
Recommended for all hospitalized patients with suspected salmonellosis to undergo a complete (clinical) blood count with hematocrit evaluation [7, 8-10, 42].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comments: red blood cell parameters, white blood cell differential, and mandatory evaluation of hematocrit as a marker of hemoconcentration in dehydration are assessed
Recommended in all patients with suspected salmonellosis to perform a coprological study to assess digestive function and the presence/absence of signs of inflammation [8-10, 14].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comments: Copropgrams reveal acidic pH and enzymatic disorders, as well as transparent mucus, with a possible admixture of leukocytes and erythrocytes.
Recommended for all patients with suspected salmonellosis to undergo etiological diagnosis to identify the causative agent of the disease: molecular biological study of feces for microorganisms of the genus Salmonella (Salmonella spp.) and/or microbiological (cultural) study of feces/rectal swab for microorganisms of the genus Salmonella (Salmonella spp.) with determination of susceptibility to antibacterial drugs; molecular biological study of feces for microorganisms of the genus Shigella (Shigella spp.) and/or microbiological (cultural) study of feces/rectal swab for microorganisms of the genus Shigella (Shigella spp.) with determination of susceptibility to antibacterial drugs; microbiological (cultural) study of feces/rectal swab for diarrheagenic Escherichia (EHEC, EPEC, ETEC, EAgEC, EIEC) [8-10, 14].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comments: The study is informative for the etiological diagnosis of the disease. However, it is known that the etiology of acute gastroenteritis does not affect the tactics of pathogenetic therapy [12, 13].
Recommended in all patients with suspected salmonellosis to perform etiological diagnostics aimed at excluding a viral or combined etiology of the disease: study of biological objects found in feces to determine their biological species; determination of rotavirus antigens (Rotavirus gr. A) in feces samples, molecular biological study of feces for rotaviruses (Rotavirus gr. A), determination of rotavirus RNA (Rotavirus gr. A) in feces samples by PCR, rapid immunochromatographic stool test for rotavirus; determination of norovirus antigens (Norovirus genogroup II, I) in feces samples, molecular biological study of feces for noroviruses (Norovirus genogroup II, I), determination of norovirus RNA (Rotavirus gr. A) in feces samples by PCR, rapid immunochromatographic stool test for norovirus [8-10, 14]
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comments: The study is informative for identifying the viral or combined viral-bacterial nature of the disease. However, it is known that the etiology of acute gastroenteritis/gastroenterocolitis does not affect the tactics of pathogenetic therapy, but may influence the tactics of etiotropic therapy.
Recommended in all patients with suspected salmonellosis to perform microscopic examination of feces for helminth eggs and larvae and microscopic examination of feces for protozoa [7, 12, 13, 42].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comments: The study is informative for the etiological diagnosis of the disease, as protozoa and parasites can be the cause of diarrhea [12, 13].
Recommended in hospitalized patients with salmonellosis, with grade I-II, II, and II-III dehydration, determination of blood electrolytes (study of blood potassium and sodium levels) [7, 8-10, 12, 13, 42].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comments: The study is informative for the diagnosis of electrolyte disorders in gastrointestinal salmonellosis.
Recommended performance of a complete (clinical) blood count, expanded with the study of white blood cell differential and hematocrit dynamically in patients with moderate and severe gastrointestinal salmonellosis [7, 8-10, 12, 13, 42].
Level of Evidence CGrade of Recommendation 5Level of recommendation C (level of evidence - 5).
Comments: The study is informative for diagnosing a complicated course of gastrointestinal salmonellosis, but the detection of leukocytosis and neutrophilia in the clinical blood count does not indicate the presence of a bacterial infection.
Recommended in patients with salmonellosis, if urinary system involvement is suspected, to perform a urinalysis (clinical urine test) [7, 8-10, 12, 13, 42].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comments: informative for detecting inflammatory changes in the urinary tract in patients with gastrointestinal salmonellosis.
Recommended performance of a general somatic biochemical blood test in hospitalized patients with salmonellosis (study of blood glucose level, study of serum C-reactive protein level, study of blood urea level, study of blood creatinine level, determination of alanine aminotransferase activity in blood, determination of aspartate aminotransferase activity in blood, determination of amylase activity in blood) [8-10, 12, 13].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comments: The study is informative in patients with moderate and severe gastrointestinal salmonellosis to detect complications and determine the severity of the disease.
2.4 Instrumental Diagnostics
It is recommended to perform a comprehensive ultrasound examination of the abdominal organs in patients with salmonellosis when it is necessary to perform differential diagnosis of gastrointestinal salmonellosis with other infectious and non-infectious diseases [8–10, 12, 13, 43, 46, 47].
GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)
Comments: The study is informative for the differential diagnosis of the disease and the diagnosis of abdominal organ involvement.
It is recommended to perform electrocardiography (registration of an electrocardiogram with decoding, description, and interpretation of electrocardiographic data) in patients with moderate and severe gastrointestinal salmonellosis to detect complications [7, 8–10, 12, 13, 43].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comments: The study is informative for diagnosing cardiovascular complications.
2.5 Other Procedures
Not recommended
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
The choice of treatment method for gastrointestinal salmonellosis depends on the clinical presentation, severity of the disease, and presence of complications [1, 2].
3.1 «Conservative treatment»
It is recommended to prescribe oral rehydration using oral rehydration salts for all patients with salmonellosis to restore water and electrolyte balance (taking into account the child's age, body weight, and degree of dehydration) [12, 13, 15–17].
Strength of Recommendation B (Level of Evidence 1)
Comments: It is indicated to prescribe oral rehydration salts with reduced osmolarity (225–245 mOsm/L) until the dehydration syndrome is completely resolved.
It is recommended to perform infusion therapy (if oral rehydration is ineffective) for the purpose of rehydration, detoxification, and correction of water and electrolyte balance using intravenous solutions: electrolyte solutions, electrolytes in combination with carbohydrates, and carbohydrates in patients with gastrointestinal salmonellosis (taking into account the child's age and indications) [12, 13, 18–20].
Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).
Comments: Parenteral fluid administration is carried out based on physiological requirements, ongoing pathological losses, and the existing fluid deficit.
It is recommended to prescribe intestinal adsorbents with cytomuco-protective action for pathogenetic therapy in patients with gastrointestinal salmonellosis (taking into account the child's age and indications) [12, 13, 21–22].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: prescribed to children until diarrhea resolves.
It is recommended to prescribe other adsorbing intestinal preparations based on diosmectite** in age-appropriate dosages in accordance with the medication instructions for patients with diarrhea [12, 13, 23–26].
GGR BLOC 1Grade of Recommendation B (Level of Evidence – 1).
Comments: prescribed to children until diarrhea resolves. The use of drugs that reduce gastrointestinal motility, slow down the passage of intestinal contents, and decrease the excretion of fluid and electrolytes with feces is not indicated.
It is recommended to prescribe antidiarrheal microorganisms with proven efficacy for pathogenetic therapy in patients with gastrointestinal salmonellosis (taking into account the child's age and indications) [12, 13, 27–29].
GGR BLOC 1Grade of Recommendation B (Level of Evidence – 1).
Comments: antidiarrheal microorganisms are prescribed in accordance with the instructions, age, and strain composition of the drug. Clinical efficacy has been proven for Bifidobacterium animalis subsp. lactis, Lactobacillus acidophilus, S. boulardii CNCM I-745, Lactobacillus GG, and Lactobacillus reuteri. Antidiarrheal microorganisms are recommended to be prescribed in accordance with the instructions for use both in the acute phase of the disease and in the convalescent phase.
It is recommended to prescribe antimicrobial therapy in the acute phase of the disease in cases of invasive moderate and severe gastrointestinal salmonellosis [12, 13, 30–34, 44].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: if indicated, systemic antibacterial drugs or intestinal antimicrobial drugs are prescribed in accordance with the instructions for use and the susceptibility of the isolated strains; first-line drugs include #azithromycin** 10 mg/kg of body weight per day for 5 days, ceftriaxone**, nifuroxazide [12, 13, 30–34, 44, 45].
It is recommended to use salmonella bacteriophage or intesti-bacteriophage in cases of transient or convalescent salmonella bacteriuria/excretion, provided the isolated strains are susceptible [30–31].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: Salmonella bacteriophage or intesti-bacteriophage is prescribed after determining the susceptibility of the strain that caused the disease. Antimicrobial therapy is not indicated for transient or convalescent salmonella excretion.
It is recommended to use immunostimulants and/or normal human immunoglobulins in cases of transient or convalescent salmonella excretion to correct secondary immunodeficiency states and indirectly stimulate local immunity [30–34, 35].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: The following preparations may be used in accordance with the instructions: normal human immunoglobulin [IgG+IgA+IgM], #glucosaminylmuramyl dipeptide 1 mg/day for 10 days, in three courses with a 20-day interval; azoximer bromide** in standard doses for 10 days in accordance with the instructions [30–34, 35, 36–38].
It is recommended to prescribe immunostimulants and/or normal human immunoglobulins for an immunomodulatory purpose to optimize therapy in patients with severe gastrointestinal salmonellosis, concomitant diseases, or mixed infectious diseases [43].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: Immunostimulants and/or normal human immunoglobulins may be used: #glucosaminylmuramyl dipeptide 1 mg/day for 10 days (in three courses with a 20-day interval), azoximer bromide**, normal human immunoglobulin [IgG+IgA+IgM]** [30–34, 36–39].
3.1 Diet therapy
Dietary therapy is recommended taking into account the nature of gastrointestinal lesions; a diet with mechanical and chemical sparing is prescribed for patients with gastrointestinal salmonellosis [12, 13, 34].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: Dietary therapy helps accelerate reparative processes in the affected digestive organs in patients with gastrointestinal salmonellosis. In infants, exclusive breastfeeding is recommended; for formula-fed infants with moderate disease severity, specialized medical dietary products for infants are recommended (lactose-free dry milk formula, low-lactose dry milk formula); for severe disease and pronounced malabsorption syndrome, a lactose-free formula based on extensive protein hydrolysate is recommended (in the presence of lactase deficiency).
In children over 2 years of age, a diet with mechanical and chemical sparing is recommended.
3.2 Other Treatment
It is recommended to implement measures aimed at preventing pain associated with medical procedures in children [40].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: medicines for the prevention of pain associated with procedures/medical manipulations may be used : application of topical local anesthetics (cream/patch) 1 hour before the procedure (when placing a peripheral catheter, etc.)
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Currently, rehabilitation methods have not been developed for patients with gastrointestinal salmonellosis.
It is recommended to provide medical rehabilitation for convalescents of severe forms of gastrointestinal salmonellosis in medical organizations of the state healthcare system or specialized structural units of medical organizations, including centers for restorative medicine and rehabilitation, as well as sanatorium-resort treatment [41].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
5. Prevention and Dispensary Observation
Preventive measures are aimed at early and active diagnosis and the isolation of patients from organized groups. Requirements for the complex of organizational, therapeutic, preventive, and sanitary-anti-epidemic (preventive) measures carried out to prevent the occurrence and spread of gastrointestinal salmonellosis are established by the Sanitary Rules SanPiN 3.3686-21 "Sanitary and epidemiological requirements for the prevention of infectious diseases".
The detection of patients with gastrointestinal salmonellosis is carried out by physicians of all specialties and secondary medical personnel of healthcare facilities, health resorts, and other institutions, regardless of departmental affiliation and forms of ownership. Patients with gastrointestinal salmonellosis are subject to mandatory recording and registration in the established manner. Information on each detected case of the disease is transmitted from the healthcare facility by telephone within 2 hours, and an emergency notification is sent within 12 hours to the territorial body of the federal executive authority authorized to exercise federal state sanitary and epidemiological supervision at the patient's place of detection (regardless of their place of residence).
Medical observation of contact persons belonging to privileged occupational groups (decreed populations) and children attending preschool educational institutions and summer health camps is carried out not only at their place of residence but also at their place of work (study, recreation).
The results of medical observation are recorded in outpatient charts, child development histories, and in inpatient settings—in medical case histories (when an outbreak is registered in a hospital).
The duration of medical observation is 7 days and includes questioning, physical examination, monitoring of stool consistency, and thermometry.
Workers in certain occupations, industries, and organizations, as well as children attending children's public educational institutions (PEIs), boarding schools, summer health camps, and adults and children in other types of closed round-the-clock institutions, must be discharged after clinical recovery and a single negative laboratory test performed 1–2 days after the completion of treatment in a hospital or at home.
Other patients who have had salmonellosis and do not belong to the above-mentioned categories are discharged after clinical recovery. The need for their bacteriological examination before discharge is determined by the attending physician, taking into account the clinical course of the disease.
If the laboratory test results obtained before discharge are positive, the treatment course is repeated.
If control laboratory tests of workers in certain occupations, industries, and organizations return positive results after a repeated course of treatment, they are placed under clinical observation with temporary transfer for 15 days to other work not related to the production, preparation, storage, transportation, and sale of food products, nor to work at water supply facilities or the direct care of children, the elderly, and disabled persons in inpatient and round-the-clock residential facilities. During these 15 days, a single laboratory test for salmonellosis is performed. If the result is negative, individuals are allowed to return to their main work; if positive, testing continues at 15-day intervals. If Salmonella is isolated for 3 months, these individuals are suspended from their main work for a period of at least 1 year. Upon expiration of this period, a 3-fold examination of feces and bile for the presence of Salmonella is performed at 1-2 day intervals. If negative results are obtained, these individuals are cleared for their main work. If at least one positive result is obtained, they are considered chronic bacterial carriers and are suspended from work where they may pose an epidemiological hazard.
Workers in certain occupations, industries, and organizations, children attending preschool educational institutions, boarding schools, summer health camps, as well as adults and children staying in round-the-clock residential institutions who have suffered from acute forms of salmonellosis, are allowed to return to work and attend these institutions after discharge from the hospital or home treatment based on a doctor's certificate of recovery and provided they have a negative laboratory test result for salmonellosis.
Children attending general education schools, summer health camps, and boarding schools are not allowed to perform dining hall duty for one month after recovering from the disease.
Clinical observation of children who have suffered from gastrointestinal salmonellosis lasts for 1 month.
Specific prevention of gastrointestinal salmonellosis has not been developed.
6. Organization of Medical Care
Treatment of patients diagnosed with mild to moderate salmonellosis in the absence of risk factors is carried out on an outpatient basis; severe cases, moderate cases with comorbid conditions or risk factors, and cases with epidemiological indications are treated in an inpatient setting; in the event of life-threatening complications, treatment is provided in an intensive care unit (ICU).
Hospitalization of detected patients (patients with suspected acute intestinal infections) and carriers of acute intestinal infection pathogens is carried out according to clinical and epidemiological indications.
Hospitalization is indicated for patients with severe and moderate forms of acute intestinal infections in children under 2 years of age and in children with burdened premorbid background, patients of all ages with severe comorbidities, patients with prolonged forms of the disease, patients with various forms of acute intestinal infections when it is impossible to comply with the anti-epidemic regime at the place of residence (detection of the patient), patients with acute intestinal infections from among decreed occupational groups, and patients with acute intestinal infections of various ages in closed institutions.
Indications for discharging a patient from a medical organization: relief of dehydration syndrome, normalization of body temperature, and stool consistency.
7. Additional Information
None.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance assessment (yes/no) |
|---|---|---|
1. | Body weight measurement performed | Yes/no |
2. | The degree of dehydration was assessed. | Yes/no |
3. | A complete blood count (CBC) with differential and hematocrit evaluation was performed. | Yes/no |
4. | Molecular biological testing of feces for microorganisms of the genus Salmonella (Salmonella spp.) and/or microbiological (culture) testing of feces/rectal swab for microorganisms of the genus Salmonella (Salmonella spp.) with determination of susceptibility to antibacterial drugs was performed; molecular biological testing of feces for microorganisms of the genus Shigella (Shigella spp.) and/or microbiological (culture) testing of feces/rectal swab for microorganisms of the genus Shigella (Shigella spp.) with determination of susceptibility to antibacterial drugs was performed; microbiological (culture) testing of feces/rectal swab for diarrheagenic Escherichia (EHEC, EPEC, ETEC, EAgEC, EIEC) was performed. | Yes/no |
5. | Oral rehydration was performed using oral rehydration salt formulations (depending on age and type of dehydration). | Yes/no |
6. | Infusion therapy was performed in cases of ineffective oral rehydration | Yes/no |
7. | Intestinal adsorbents were prescribed | Yes/no |
8. | Prescription of antidiarrheal microorganisms with proven efficacy was performed for pathogenetic therapy in patients with gastrointestinal salmonellosis (taking into account the children's age and clinical indications). | Yes/no |
9. | Prescription of systemic antibacterial drugs was performed in cases of invasive moderate and severe salmonellosis. | Yes/no |
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Appendix A1. Working Group Composition
Lobzin, Yuri Vladimirovich – MD, Professor, Full Member of the Russian Academy of Sciences, President of the Pediatric Research and Clinical Center for Infectious Diseases of the Federal Medical-Biological Agency, President of the Euro-Asian Society of Infectious Diseases, Association of Infectious Disease Physicians of St. Petersburg and Leningrad Region
Zhdanov, Konstantin Valerievich — D.Sc. in Medicine, Professor, Corresponding Member of the Russian Academy of Sciences, Director of the PRCCID FMBA, Member of the Euro-Asian Society for Infectious Diseases, and the Association of Infectious Disease Physicians of Saint Petersburg and Leningrad Region
Uskov, Alexander Nikolaevich – MD, Associate Professor, Advisor to the Director of the Pediatric Research and Clinical Center for Infectious Diseases of the Federal Medical-Biological Agency, Member of the Euro-Asian Society of Infectious Diseases, Association of Infectious Disease Physicians of St. Petersburg and Leningrad Region
Bekhtereva, Maria Konstantinovna – PhD, Senior Researcher at the Department of Intestinal Infections, Member of the Euro-Asian Society of Infectious Diseases, Association of Infectious Disease Physicians of St. Petersburg and Leningrad Region
Rychkova, Svetlana Vladislaovna – MD, Associate Professor, Head of the Medical Care Organization Department of the Pediatric Research and Clinical Center for Infectious Diseases of the Federal Medical-Biological Agency, Pediatrician
Zakharenko, Sergey Mikhailovich – PhD, Associate Professor, Deputy Director of the Pediatric Research and Clinical Center for Infectious Diseases of the Federal Medical-Biological Agency, Member of the Euro-Asian Society of Infectious Diseases, Association of Infectious Disease Physicians of St. Petersburg and Leningrad Region
Conflict of interest: none
Appendix A2. Methodology for Developing Clinical Guidelines
Methodology Methods used for collecting/selecting evidence: - search in electronic databases.
Description of methods used for evidence collection/selection: 41 — the evidence base for the recommendations includes publications from the Cochrane Library, EMBASE, MEDLINE, ClinicalKey (Elsevier), and the electronic library (www.elibrary.ru). The search depth was 10 years.
Methods used to assess the quality and strength of evidence: - expert consensus; - assessment of significance in accordance with the levels of evidence and grades of recommendation.
Target audience for these clinical guidelines:
- disinfectantologist;
- infectious disease physician;
- clinical laboratory diagnostics physician;
- clinical pharmacologist;
- general practitioner (family physician);
- pediatrician;
- district pediatrician;
- gastroenterologist
- preventive medicine physician;
- admission department physician;
- epidemiologist.
Table 1. Scale for assessing levels of reliable evidence (LRE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | There is only a rationale for the mechanism of action or expert opinion |
Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | There is only a rationale for the mechanism of action of the intervention (preclinical studies) or expert opinion |
Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision — at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Federal Law No. 323-FZ of November 21, 2011 "On the Fundamentals of Protecting Citizens' Health in the Russian Federation" (as amended on December 25, 2023);
Federal Law No. 326-FZ of November 29, 2010 (as amended on December 25, 2023) "On Compulsory Medical Insurance in the Russian Federation" (with amendments and additions, entering into force on January 1, 2024)
Federal Law of the Russian Federation No. 52-FZ of March 30, 1999, "On the Sanitary and Epidemiological Welfare of the Population" (as amended on April 27, 2023)
Order of the Ministry of Health and Social Development of Russia No. 521n of May 5, 2012, "On Approval of the Procedure for Providing Medical Care to Children with Infectious Diseases", registered with the Ministry of Justice of the Russian Federation on July 10, 2012, Registration No. 24867 (as amended on February 21, 2020);
Order of the Russian Ministry of Health No. 804n of October 13, 2017, "On Approval of the Nomenclature of Medical Services", registered with the Ministry of Justice on November 7, 2017, Registration No. 48808 (as amended on March 24, 2020);
Order of the Ministry of Health and Social Development of Russia No. 541n of July 23, 2010, "On Approval of the Unified Qualification Handbook of Positions of Managers, Specialists, and Employees", section "Qualification Characteristics of Healthcare Worker Positions", registered with the Ministry of Justice of the Russian Federation on August 25, 2010, Registration No. 18247 (as amended on April 9, 2018);
Order of the Ministry of Health of the Russian Federation No. 203n of May 10, 2017, "On Approval of Criteria for Assessing the Quality of Medical Care" (registered with the Ministry of Justice of the Russian Federation on May 17, 2017, No. 46740)
State Report "On the State of Sanitary and Epidemiological Welfare of the Population in the Russian Federation in 2020". Moscow: Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing, 2021.
On the state of sanitary and epidemiological welfare of the population in the Russian Federation in 2022: State Report. Moscow: Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing; 2023. 368 p. (In Russ.)
On the State of Sanitary and Epidemiological Welfare of the Population in the Russian Federation in 2023: State Report. Moscow: Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing, 2024. – 364 p.
State Register of Medicines. Available from: https://grls.rosminzdrav.ru/
Clinical Nutrition Standards. Methodological Guide. 2017. Access: http://cr.rosminzdrav.ru/#!/manuals/adults//
Resolution of the Chief State Sanitary Doctor of the Russian Federation No. 4 of January 28, 2021 (as amended on May 25, 2022) "On Approval of Sanitary Rules and Norms SanPiN 3.3686-21 'Sanitary and Epidemiological Requirements for the Prevention of Infectious Diseases'" (along with "SanPiN 3.3686-21. Sanitary Rules and Norms...") (Registered with the Ministry of Justice of the Russian Federation on February 15, 2021, No. 62500)
Appendix B. Physician Action Algorithms
Diagram
Appendix C. Patient Information
Salmonellosis is an acute infectious zooanthroponous disease (meaning the source of infection is animals and less frequently humans) with a fecal-oral transmission mechanism, caused by Salmonella spp., characterized by symptoms of general intoxication and gastrointestinal (GI) tract involvement, and in rare cases, the development of generalized forms.
The causative agents of salmonellosis are bacteria belonging to the family Enterobacteriaceae (to which most bacteria causing intestinal infections belong), genus Salmonella.
Salmonellae persist in the environment for a long time. On linen — 14–80 days, in tap water — up to 4–5 months, in dust — up to 6 months, in dried feces — up to 4 years. In food products, salmonellae not only survive well but also multiply.
The incidence of salmonellosis is sporadic, but large foodborne and, less frequently, waterborne outbreaks are also recorded. Unfortunately, outbreaks and clusters of infection can form in children's groups (nurseries, kindergartens, recreation camps, etc.), medical facilities, and closed institutions. Reports of such outbreaks regularly appear in the media.
How infection occurs. The source of infection in salmonellosis is animals and humans (patients and bacterial carriers). Salmonellosis can occur as an independent disease (monoinfection) or be combined with other infections, primarily intestinal ones, due to shared transmission routes. The most common is the combined shedding of salmonellae and rotavirus, which usually leads to a more severe course of the disease.
The incidence of salmonellosis is recorded throughout the year with a seasonal peak in the summer and autumn. The main route of infection spread is foodborne, with the leading transmission factor being infected poultry products: chicken, turkey, and waterfowl meat and eggs; pork and beef have a lower epidemiological significance. Infection via water and contact-household routes is significantly less common.
Immunity after a past infection is unstable (3–6 months), serospecific, meaning it is directed only against the specific strain that caused the disease.
The incubation period for salmonellosis infection ranges from several hours to 5–7 days. Salmonellosis occurs in typical and atypical forms. Typical forms include the gastrointestinal form of salmonellosis, which develops in 97–98% of cases.
Gastrointestinal salmonellosis, i.e., a disease with GI tract involvement, begins acutely with symptoms of general intoxication (in severe cases, with phenomena of neurotoxicosis or shock), fever, repeated vomiting, and diarrhea (loose stools).
Currently, asymptomatic and mild (forme fruste) forms of salmonellosis are frequently observed. In the mild form, the disease begins gradually, without fever. The general condition is usually undisturbed. Stool consistency changes are insignificant, with feces being mushy with admixtures of small amounts of mucus and green elements.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Appendix D1. Clinical Dehydration Scale (CDS)
Russian title: Clinical Dehydration Scale (CDS)
Original title (if available): Clinical Dehydration Scale
Source (official developer website, validation publication): Goldman R. D., Friedman J. N., Parkin P. C. Validation of the clinical dehydration scale for children with acute gastroenteritis // Pediatrics. – 2008. – Vol. 122. – No. 3. – P. 545-549, Jauregui J. et al. External validation and comparison of three pediatric clinical dehydration scales // PLoS One. – 2014. – Vol. 9. – No. 5. – P. e95739.
Type (underline): - rating scale
Purpose: assessment of dehydration severity in children
Content (template):
Key (interpretation): 0 points – no dehydration; 1 to 4 points – mild dehydration, 5–8 points correspond to moderate to severe dehydration