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SALMONELLOSIS - MODERN INFECTIVE ENDOCARDITIS
OP KAPOOR
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
Day by day I am convinced that in future we will very rarely see a case of undiagnosed septicaemia, which occurs in infective endocarditis, when the organisms can be nearly 100% cultured from the blood if the test is done properly and in a proper laboratory.
The terminology of endocarditis has changed from SBE (sub-acute bacterial endocarditis) to BE (bacterial endocarditis) and then to Infective endocarditis. Similarly, it is time the doctors change the terminology of typhoid fever which later on was named as enteric fever, and should now be labelled as Salmonellosis.
When the salmonella germs enter the body through a water borne mode, the patient might develop only an attack of diarrhoea but a rare patient can develop a salmonella liver abscess, brain abscess or osteo-myelitis. Thus, the salmonella infection of Peyer's patches of the small bowel occurs in some patients, who then develop a clinical picture of typhoid. Even this picture is changing day-by-day because a number of antibiotics will eradicate some salmonella organisms from the body.
The fact is that this organism is becoming multi drug resistant. In every 10 patients whom I see, at least 2 or 3 will need hospitalisation and a combination of IV antibiotics round the clock, often for a period of 10 days before the fever is controlled.
What is the solution? You must know that in the city of Mumbai, there are pathological laboratories like Metropolis and a few others, which are now open day and night. They also offer their services of sending their technician to the patient's house to collect the blood at a meagre cost of Rs. 50/- only. The family physicians should take advantage of this.
In the case of infective endocarditis, we went through a phase of changing methods to isolate the organisms. Initially we used to advise blood collection for culture daily for 3 days or on alternate days. Later on, the doctors would advise collection of the blood when there is high fever. Later on a series of 5-6 blood cultures were advised at 2 hourly intervals on a single day.
Very often I have heard the doctors saying (which I have experienced myself) that majority of the times the blood culture sent for salmonella is negative. To get more positive results, the doctors must learn to send the blood for culture possibly when the fever is high and repeat the culture at least one to two times more on the subsequent days, specially now that the facility of technicians from leading laboratories coming home, is available.
This will also prevent from many undesirable hospitalisation of the patients which in modern days is extremely costly and unaffordable to most of the patients. The money spent on this test is worthwhile. Ideally, the doctors should not start any antibiotic and start sending the blood from 2nd, 3rd day onwards in case the patient is running high fever specially without any symptoms of cough, cold or any local pain or any other symptoms which point towards another diagnosis.
Even when the antibiotics are given the "resin" culture will help to see more positive results. Also, a bonus to the doctors will be the MIC which when reported will tell you that how much dose of Ciprofloxacin the patient will need to kill the salmonella germs as compared to the dose prescribed in the Standard textbooks. Also you must see that no money is spent on asking for Widal test which has no role to play in the modern days and is often falsely positive or negative.
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