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サルモネラ症

著者: 倉井華子 静岡がんセンター感染症内科

監修: 大曲貴夫 国立国際医療研究センター

著者校正/監修レビュー済:2021/10/13
患者向け説明資料

概要・推奨   

  1. 免疫不全のない成人、小児の軽症の腸炎例に対する抗菌薬投与は推奨されない(推奨度3)
  1. 重症例に対する抗菌薬投与は有症状期間の短縮につながる可能性がある(推奨度2)
  1. 高齢者、1歳未満の小児、HIV感染者などの免疫不全患者は、菌血症などの合併症発生率が高いことが知られている。これらの患者に対する抗菌薬投与のcontrolled trialは行われていないが、合併症の発生頻度から専門家は抗菌薬使用を推奨している(推奨度2)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
倉井華子 : 特に申告事項無し[2021年]
監修:大曲貴夫 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. サルモネラ症とは、チフスやパラチフス以外のサルモネラ菌の感染により起こった感染症である。急性発症の発熱、腹痛、下痢が典型例であるが、嘔吐や血便を伴うこともある。
  1. 症状から、サルモネラ症と他の感染性腸炎と鑑別することは難しい。
  1. 発症は、95%以上が食事由来であり、卵や卵の加工食品が原因となることが多い。調理不十分な肉も次いで多い。カメなど爬虫類からの感染も報告されている。
  1. 潜伏期間は、摂取から12~72時間である。
  1. HIV感染者などの免疫不全者、高齢者(特に動脈瘤がある患者)、小児(特に3カ月未満)では、菌血症や心内膜炎、感染性動脈瘤、骨髄炎などの合併症のリスクが上がる。
  1. 血液培養から菌が消えない場合、発熱が続く場合、腰痛や関節痛が突然出現した場合などは菌血症を疑う。
問診・診察のポイント  
  1. サルモネラ症を疑う暴露歴があるか?

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文献 

著者: Melita A Gordon
雑誌名: J Infect. 2008 Jun;56(6):413-22. doi: 10.1016/j.jinf.2008.03.012. Epub 2008 May 12.
Abstract/Text Clinical syndromes caused by Salmonella infection in humans are divided into typhoid fever, caused by Salmonella typhi and Salmonella paratyphi, and a range of clinical syndromes, including diarrhoeal disease, caused by a large number of non-typhoidal salmonella serovars (NTS). Typhoid is a human-restricted and highly adapted invasive disease, but shows little association with immunocompromise. In contrast, NTS have a broad vertebrate host range, epidemiology that often involves food animals, and have a dramatically more severe and invasive presentation in immunocompromised adults, in particular in the context of HIV. Immunocompromise among adults, including underlying severe or progressive disease, chronic granulomatous disease, defects or blockade of specific cytokines (particularly IL-12/IL-23/IL-17 and TNF), and HIV, is associated with suppurative foci and with primary bacteraemic disease, which may be recurrent. These patients have markedly increased mortality. Worldwide, invasive recurrent NTS bacteraemia associated with advanced HIV disease is a huge problem, and the epidemiology in this context may be more human-restricted than in other settings. This review will describe the presentation and pathogenesis of NTS in different categories of immunocompromised adults, contrasted to typhoid fever.

PMID 18474400  J Infect. 2008 Jun;56(6):413-22. doi: 10.1016/j.jinf.20・・・
著者: R Gruenewald, S Blum, J Chan
雑誌名: Clin Infect Dis. 1994 Mar;18(3):358-63.
Abstract/Text Among 20- to 59-year-old residents of New York City who have septicemia, gastroenteritis, urinary tract infection, and multiple site infections due to Salmonella, those listed in the New York City AIDS Registry were highly overrepresented. Among the patients listed in the registry, males outnumbered females by 4:1 (septicemia), 9:1 (multiple site infections), 5.6:1 (gastroenteritis), and 2.5:1 (urinary tract infection); among patients not listed, males outnumbered females by 2.7:1 (septicemia), 3:1 (multiple site infections), 1.2:1 (gastroenteritis), and 1.6:1 (urinary tract infection). These results strongly suggest that most nonlisted males with septicemia and multiple site infections, and a minority with gastroenteritis and urinary tract infection, were human immunodeficiency virus (HIV)-positive. Among individuals who were HIV-positive, or likely to be so, Salmonella enteritidis was more competent in causing septicemia and less competent in causing gastroenteritis than was Salmonella typhimurium; among HIV-negative individuals, the reverse was true. The different capacities for infection with and invasiveness of S. enteritidis, S. typhimurium, and other Salmonella serotypes in HIV-positive and HIV-negative individuals and the use of HIV testing for Salmonella-infected individuals are discussed.

PMID 8011816  Clin Infect Dis. 1994 Mar;18(3):358-63.
著者: Ifeanyi A Onwuezobe, Philip O Oshun, Chibuzo C Odigwe
雑誌名: Cochrane Database Syst Rev. 2012 Nov 14;11:CD001167. doi: 10.1002/14651858.CD001167.pub2. Epub 2012 Nov 14.
Abstract/Text BACKGROUND: Non-typhoidal Salmonella (NTS) commonly causes diarrhoea, and is usually self-limiting, although sometimes people become ill with sepsis and dehydration. Routine antibiotic use for this infection could result in persistent colonization and the spread of resistant bacterial strains.
OBJECTIVES: To assess the efficacy and safety of giving antibiotics to people with NTS diarrhoea.
SEARCH METHODS: We searched the Cochrane Infectious Diseases Group trials register (up to August 2012), the Cochrane Controlled Trials Register (CENTRAL) published in The Cochrane Library (up to Issue 8 2012); and MEDLINE, African Index Medicus, CINAHL, EMBASE, LILACS, and the Science Citation Index, all up to 6 August 2012. We also searched the metaRegister of Controlled Trials (mRCT) for both completed and on going trials and reference lists of relevant articles.
SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing any antibiotic treatment for diarrhoea caused by NTS species with placebo or no antibiotic treatment. We selected trials that included people of all ages who were symptomatic for NTS infection. Examples of symptoms included fever, abdominal pain, vomiting and diarrhoea. We excluded trials where the outcomes were not reported separately for the NTS subgroup of patients. Two review authors independently applied eligibility criteria prior to study inclusion.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data on pre-specified outcomes and independently assessed the risk of bias of included studies. The primary outcome was the presence of diarrhoea between two to four days after treatment. The quality of evidence was assessed using the GRADE methods.
MAIN RESULTS: Twelve trials involving 767 participants were included. No differences were detected between the antibiotic and placebo/no treatment arms for people with diarrhoea at two to four days after treatment (risk ratio (RR) 1.75, 95% confidence interval (CI) 0.42 to 7.21; one trial, 46 participants; very low quality evidence). No difference was detected for the presence of diarrhoea at five to seven days after treatment (RR 0.83, 95% CI 0.62 to 1.12; two trials, 192 participants; very low quality evidence), clinical failure (RR 0.88, 95% CI 0.62 to 1.25; seven trials, 440 participants; very low quality evidence). The mean difference for diarrhoea was 0 days (95% CI -0.54 to 0.54; 202 participants, four studies; low quality evidence);for fever was 0.27 days (95% CI -0.11 to 0.65; 107 participants, two studies; very low quality evidence); and for duration of illness was 0 days (95% CI -0.68 to 0.68; 116 participants, two studies; very low quality evidence). Quinolone antibiotic treatment resulted in a significantly higher number of negative stool cultures for NTS during the first week of treatment (microbiological failure: RR 0.33, 95% CI 0.20 to 0.56; 166 participants, four trials).Antibiotic treatment meant passage of the same Salmonella serovar one month after treatment was almost twice as likely (RR 1.96, 95% CI 1.29 to 2.98; 112 participants, three trials), which was statistically significant. Non-severe adverse drug reactions were more common among the patients who received antibiotic treatment.
AUTHORS' CONCLUSIONS: There is no evidence of benefit for antibiotics in NTS diarrhoea in otherwise healthy people. We are uncertain of the effects in very young people, very old people, and in people with severe and extraintestinal disease. A slightly higher number of adverse events were noted in people who received antibiotic treatment for NTS.

PMID 23152205  Cochrane Database Syst Rev. 2012 Nov 14;11:CD001167. do・・・
著者: J Wiström, M Jertborn, E Ekwall, K Norlin, B Söderquist, A Strömberg, R Lundholm, H Hogevik, L Lagergren, G Englund
雑誌名: Ann Intern Med. 1992 Aug 1;117(3):202-8.
Abstract/Text OBJECTIVE: To evaluate the clinical and microbiologic efficacy and safety of norfloxacin for acute diarrhea.
DESIGN: Double-blind, placebo-controlled, randomized clinical multicenter trial.
SETTING: Six departments of infectious disease.
PARTICIPANTS: Patients 12 years of age or older with a history of acute diarrhea lasting 5 or fewer days. Eighty-five percent of patients (511/598) were evaluable for efficacy. Of these evaluable patients, 70% had traveled abroad within the previous 6 weeks.
INTERVENTIONS: Patients received either norfloxacin, 400 mg, or placebo twice daily for 5 days.
MEASUREMENTS: Enteric pathogens were isolated in 51% of the evaluable patients: Campylobacter species in 29%, Salmonella species in 16%, Shigella species in 3.5%, and other pathogens in 2.6%.
RESULTS: Norfloxacin had a favorable overall effect compared with placebo (cure rate, 63% compared with 51%; P = 0.003). There were statistically favorable effects in culture-positive patients, patients with salmonellosis, and severely ill patients but not in culture-negative patients or patients with campylobacteriosis or shigellosis. A significant difference was noted between norfloxacin and placebo in median time to cure among all evaluable patients (3 compared with 4 days, P = 0.02) and in patients with campylobacteriosis (3 compared with 5 days, P = 0.05) but not in patients. Culture-positive, but not culture-negative patients, in the norfloxacin group had significantly fewer loose stools per day compared with patients in the placebo group from day 2 onward (P less than or equal to 0.01). Norfloxacin was significantly less effective than placebo in eliminating Salmonella species on days 12 to 17 (18% compared with 49%, P = 0.006), whereas the opposite was true for Campylobacter species (70% compared with 50%, P = 0.03). In six of nine patients tested, norfloxacin-resistant Campylobacter species (MIC, greater than or equal to 32 micrograms/mL) appeared after norfloxacin treatment.
CONCLUSION: Empiric treatment reduced the intensity and, to some extent, the duration of symptoms of acute diarrhea. The effect was restricted to patients who had bacterial enteropathogens or who were severely ill. The clinical usefulness of this treatment is limited by the fact that norfloxacin seems to delay the elimination of salmonella and to induce resistance in campylobacter.

PMID 1616214  Ann Intern Med. 1992 Aug 1;117(3):202-8.
著者: M S Dryden, R J Gabb, S K Wright
雑誌名: Clin Infect Dis. 1996 Jun;22(6):1019-25.
Abstract/Text We conducted a randomized controlled trial to determine whether empirical treatment of severe acute community-acquired gastroenteritis (four fluid stools per day for > 3 days) with ciprofloxacin reduces the duration of diarrhea and other symptoms and to determine what effect ciprofloxacin has on the duration of long-term fecal carriage of gastrointestinal pathogens. A total of 173 patients were recruited for the study and received either ciprofloxacin (500 mg b.i.d.) or placebo for 5 days, during which time they recorded the duration of diarrhea and other symptoms (fever, abdominal pain, vomiting, and myalgia). Fecal samples were collected before treatment and regularly after treatment to determine the duration of carriage of gastrointestinal pathogens. Antibiotic susceptibility tests were performed, and the minimum inhibitory concentrations (MICs) of ciprofloxacin were determined. A significant reduction in the duration of diarrhea and other symptoms was observed after treatment, regardless of whether a pathogen was detected (P = .0001). Treatment failure occurred in 3 of 81 patients in the ciprofloxacin group and 17 of 81 patients in the placebo group. Significant pathogens were detected in 87% of patients, 85.5% of whom had cleared the pathogen at the end of treatment with ciprofloxacin, as compared with 34% who received placebo. Six weeks after treatment, there was no difference between the two groups in terms of the pathogen carriage rate (12%). Treatment with ciprofloxacin did not prolong carriage. High-level resistance to ciprofloxacin (MIC, > 32 mg/L) was detected in three strains (4%) of Campylobacter species.

PMID 8783703  Clin Infect Dis. 1996 Jun;22(6):1019-25.

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