infections such as osteomyelitis, septic arthritis, and
soft tissue infections. Diagnosing infection with
Salmonella is dependent on culturing the organism,
usually from either stool or blood cultures. In the
case of nontyphoidal Salmonella, it is also worth
trying to culture organisms from the incriminated
food.
0017 Gastroenteritis from nontyphoidal Salmonella is
usually self-limiting, and rehydration is the most crit-
ical aspect of treatment. Antibiotic therapy is not rou-
tinely required for this aspect of Salmonella infection
and has in some instances been thought to promote
chronic carriage. When there is systemic invasion with
the bacteria and in cases of enteric fever, antibiotic
therapy is important. Third-generation cephalospor-
ins and quinolones are most frequently used, although
chloramphenicol has been the mainstay of treatment
for typhoid fever for many years and is still used in
many developing countries, but chloramphenicol does
carry a risk of complications.
0018 Antibiotic resistance has become a major problem
with many Salmonella serovars. Of particular con-
cern is the recent emergence and spread of Salmonella
DT104 that carries resistance to multiple antibiotics,
including, in some instances, to the fluoroquinolones
such as ciprofloxacin. In 2000, Salmonella strains
that were resistant to Ceftriaxone were also reported,
further raising the concern that the emergence of new
antibiotic resistance profiles were occurring.
Shiga Toxin-producing
E. coli
0019 Shiga toxin-producing E. coli (STEC) are relative
newcomers to the scene of foodborne pathogens.
The first STEC to be associated with disease in
humans was E. coli O157:H7 following two out-
breaks of hemorrhagic colitis in 1982. Since then, it
has been learned that there are in fact many different
serotypes of STEC, and at least 60 different types
have been associated with clinical disease. Recent
studies have suggested that around 1% of samples
submitted to clinical microbiology laboratories in
the USA contain STEC, of which around two-thirds
are O157:H7, the remainder being non O157. STEC
are present in the gastrointestinal tracts of many
mammalian species but appear to be especially
common in ruminants (cattle, sheep, deer, and
goats). Therefore, the main source of STEC in our
food supply is bovine products.
0020 Recently, there have been an increasing number of
reports associating STEC infection with fresh pro-
duce (lettuce, alfalfa sprouts, apple cider) and water.
This is thought to be mainly due to contamination
with fecal material from cattle pasture. Clinically,
STEC cause a variety of diseases ranging from
diarrhea, which may or may not be bloody, hemor-
rhagic colitis, and the hemolytic uremic syndrome
(HUS). HUS is a triad of renal failure, thrombocyto-
penia, and hemolytic anemia. Acutely, HUS has a
mortality rate of around 5%, and up to 50% of
HUS patients may have some degree of permanent
renal insufficiency. The main virulence factor from
STEC is the production of one or more bacterio-
phage-encoded Shiga toxins (Stx), which are of two
main types, Stx1 and Stx2. Following ingestion of the
bacteria, they colonize portions of the lower intestinal
tract and produce the toxins. Stx is then thought to
cross the intestinal epithelial cell barrier and damage
distant target sites, especially the kidney and brain, by
a direct effect on endothelial cells in the microvascu-
lature. The infectious dose of STEC may be very low,
in the region of 10–100 organisms in some instances.
Symptoms typically develop 2–4 days following in-
gestion but may occur in as little as 1 day or in as
much as 8 days. The diarrhea can be of variable type
(bloody or nonbloody) and may contain leukocytes.
The type of diarrhea is not a reliable indication of
who will go on to develop HUS. The mainstay of
treatment for STEC and its major complications is
supportive. There is a degree of controversy over
the use of antibiotics, and a number of studies have
suggested that certain antimicrobials (e.g., trimetho-
prim-sulfamethoxazole) actually increase the likeli-
hood that a patient will go on to develop serious
complications.
Yersinia
spp.
0021Of the three members of the genus Yersinia, Y. entero-
colitica and Y. pseudotuberculosis are considered to
be foodborne, whereas Y. pestis is not. Yersinia are
not very commonly found as causes of foodborne
illness compared with Salmonella or Campylobacter.
However, they are clearly transmitted in food and can
cause a significant gastrointestinal illness. The food
most frequently associated with yersiniosis is pork.
Swine are a major reservoir of these organisms, and
although they have been found in many other animals
(e.g., sheep, dogs, cats, and cattle), consumption of
undercooked pork is a common association. Milk
is another frequently reported source, and since
Y. enterocolitica can survive, and indeed multiply, in
milk at 4
C, small numbers of organisms can become
a significant health threat, even if the milk is refriger-
ated. Symptoms in Y. enterocolitica infection can
be prolonged, lasting several weeks or even longer.
Most infections are, however, self-limiting, although
complications may occur such as ulceration and in-
testinal perforation. A classic long-term complication
following yersiniosis is the development of reactive
EMERGING FOODBORNE ENTERIC PATHOGENS 2067