Background and significance of the problem
Salmonella species are a group of Gram-negative enterobacteria associated with human and animal infections. There are two types of Salmonella strains viz. Typhoid Salmonella and non-typhoid Salmonella (NTS). The former causes enteric fever that leads to significant morbidity and mortality, especially in the developing countries. The epidemiology of Salmonella infections vary considerably depending on the species involved. The enteric fever caused by S. typhi and S. paratyphi is severe and life threatening condition whereas NTS infections are self-limiting. Humans serve as the reservoirs for typhoid Salmonella that transmits predominantly through water. On the contrary, NTS strains harbor animals as reservoirs and transmits through food (Sánchez-Vargas, Abu-El-Haija & Gómez-Duarte, 2011).
The cases of enteric fever are more frequent in infants, pre-schoolers and school children. The emergence of antibiotic resistance in S. typhi and S. paratyphi is reported worldwide. Multi-drug resistance S. typhi is frequently encountered in Asian and African countries. Another public health concern is the increasing incidence of NTS infections in the industrialized counties. These infections spread through contaminated food and feces of some animals (pets) and are often associated with daycare centers and contact with cats or reptiles (Sánchez-Vargas, Abu-El-Haija & Gómez-Duarte, 2011).
The role of nurses in the prevention and cure of Salmonella infections is very significant. The community and school nurses are instrumental in educating the public regarding preventive measures and patient teaching. Nurses should follow contact precautions while giving nursing care to gastroenteritis patients. They should wash their hands before and after providing care. They should continue the contact precautions until three consecutive stool cultures are negative. At the same time, they should wear gloves and gown while disposing the stools and contaminated objects. Nurses should observe the patients closely for the signs of bowel perforations such as sudden pain in lower right abdomen, tenderness and rectal bleeding.
Findings and interpretation of research articles
Bornemann et al. (2002) have described a nosocomial outbreak of Salmonella serotype Saintpaul gastroenteritis and have enumerated the risk factors for infection. The hospitalized children who developed the symptoms for gastroenteritis had received formula diets from the hospital’s formula preparation room. The infection disseminated to the nurses caring for these patients. Therefore, active surveillance began and all the patients who received formula mix from the hospital had their stool specimens tested for the pathogen. Stool specimens from formula preparation room staff were also cultured. In the present study, eleven patients and four staff members were found to be infected with nosocomial Salmonella infection. All the formula preparation room staff members were found negative for Salmonella. The method of formula preparation was reviewed and the investigation suggested that the source of this outbreak was the formula prepared in the hospital, and subsequent person-to-person infection. In the present case, the initial outbreak case-patient had given the infection to a nurse who further cared for other patients and spread the secondary infection. As the result of this outbreak, new policies aimed at improving cleaning and disinfection of equipment/environment were implemented. This outbreak demonstrates the importance of good hand hygiene and vigilance in safe preparation of enteral feedings.
Implementation of findings in clinical practice
Hand hygiene is a very important measure in preventing nosocomial infections and the dissemination of antimicrobial resistant pathogens. However, the non-compliance with hand hygiene may lead to severe outbreaks in healthcare settings. Cross-transmission of pathogenic microorganisms from one patient to the other via the healthcare practitioner takes place in five sequential steps. These step are: a) Microorganisms present on one patient’s skin are shed onto immediate surroundings of the patient, b) microorganism re transferred to the hands of healthcare staff including nurses, c) microorganisms survive on the hands of the staff and nurses, d) inadequate or omitted hand-washing and antisepsis leaves the microorganisms unaffected and, e) contaminated hands of the caregiver spread the pathogens to other patients and their immediate environment (Pittet et al, 2006).
Indications for the hand cleansing during patient care are related to the sequential steps of the cross transmission of microorganisms from one patient to the others. Hand hygiene is indicated after contact with patient, body fluids or excretions, wound dressings and immediate environment of the patient. Improved hand hygiene practices have been positively correlated with reduced infection rates (Pittet et al, 2006).
In the case of Salmonella infections, nurses have an important role in identifying the source of infection and containing the disease. Effective prevention and control of Salmonella infections require evidence-based risk assessment by the nurses. Young children are particularly at risk of Salmonella gastroenteritis and bacteriemia because they are more likely to put their hands and other items in their mouths. Therefore, nurses should educate the parents to use boiled/pasteurized milk and dairy products. At the same time, small children should not be allowed to handle pets. Reptiles and amphibians should not be kept in daycare centers and nursery schools and children should not be allowed to eat or drink near these pets. Adults should supervise hand washing for children.
Nurses should advise the patients and carriers of S. typhi to be scrupulous in hand hygiene practices. Patients, carriers, food handlers, children attending nurseries or similar groups should be considered for exclusion from school or work. In addition to healthcare practices, nurses should make an effort towards improving public understanding of the risk factors of Salmonella infections. They should monitor the effectiveness of prevention, including immunization. In conclusion, nurses can be instrumental in prevention of spreading of Salmonella infections. They can educate the public as well as patients regarding the risk factors and preventive measures for Salmonella infections (Xavier, 2006; CDC 2013).
Bornemann, R., Zerr, D. M., Heath, J., Koehler, J., Grandjean, M., Pallipamu, R., & Duchin, J. (2002). An outbreak of Salmonella serotype Saintpaul in a children's hospital. Infection Control and Hospital Epidemiology, 23(11), 671-676.
CDC. (2013). Reptiles, amphibians and Salmonella. Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/Features/SalmonellaFrogTurtle/
Pittet, D., Allegranzi, B., Sax, H., Dharan, S., Pessoa-Silva, C. L., Donaldson, L., & Boyce, J. M. (2006). Evidence-based model for hand transmission during patient care and the role of improved practices. The Lancet infectious diseases, 6(10), 641-652.
Sánchez-Vargas, F. M., Abu-El-Haija, M. A., & Gómez-Duarte, O. G. (2011). Salmonella infections: An update on epidemiology, management, and prevention. Travel medicine and infectious disease, 9(6), 263-277.
Xavier, G. (2006). Management of typhoid and paratyphoid fevers. Nursing Times.net, 102(17), 49.