Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Not Just Food Poisoning: Salmonella in Young Infants Can Turn Deadly

Transcript

Not Just Food Poisoning: Salmonella in Young Infants Can Turn Deadly · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

0:05
I'm Holly Wayment and this is Pediatrics Now, cases, updates,
0:10
and discussions for the busy pediatric practitioner, brought to you by University
0:14
Health and UT Health San Antonio's Department of Pediatrics.
0:20
Today we're talking about salmonella in babies, a medical emergency.
0:25
We'll also talk about salmonella in children.
0:29
I'm thrilled today because joining me here in the podcast studio is Dr. J.B. Canty.
0:35
Dr. Canty is the first doctor to be double-boarded in infectious disease and neonatology.
0:43
He also has a master's in public health and is a contributing writer for Red Book.
0:48
Dr. Canty, thank you so much for being here today back on the show.
0:53
Hi, Holly. Thank you for having me back again. J.B., you told me something that really stood out.
0:58
Pediatricians are trained to be appropriately calm about salmonella in many
1:02
children, but in infants, it becomes a very different and urgent clinical situation.
1:07
Can you help explain why?
1:10
Yeah, no, it's a great question. So we are appropriately trained from an early
1:15
age in pediatrics that when salmonella causes uncomplicated gastroenteritis,
1:19
meaning just regular diarrhea, loose watery stools, maybe some vomiting,
1:24
that clinical course is going to resolve itself in time.
1:28
And providing antibiotics doesn't really change the speed of resolution or the
1:34
child's clinical outcomes.
1:35
So we take a very laissez-faire approach in many cases in terms of antimicrobial
1:39
treatment of salmonella gastroenteritis. I mean, obviously, we want to support
1:43
the family. We want to support the child and make sure that they're hydrated
1:46
and that they're looked after. But we don't move for antibiotics.
1:49
However, in infancy, especially in early infancy, the risk of that bacteria,
1:55
the salmonella, getting out of the gut and getting into the bloodstream and
1:58
going wherever it wants to from there is significantly higher.
2:02
And so it creates almost this blind spot among a lot of us where,
2:06
you know, we hear don't do anything, don't do anything, don't do anything.
2:09
But when it's a four-month-old or a two-month-old who's got salmonella gastroenteritis,
2:13
the burden of suspicion is much, much higher for has that bacteria gotten into the bloodstream?
2:18
And if so, where did it go from there? Did it go to the bones or the joints
2:22
or, heaven forbid, did it go to the meninges or the brain?
2:26
There have been recent serious salmonella cases in the San Antonio area.
2:31
What are you seeing clinically right now?
2:34
So a couple of the cases that have come to our attention here at Women and Children's.
2:39
Seem to have been linked to a child care setting where we saw a couple of different
2:43
patients in the same environment all come in with salmonella gastroenteritis.
2:47
We also see sporadic cases year-round. Salmonella is pretty ubiquitously disseminated
2:53
in the community. We see it in people, and people can pass it person to person in care settings.
2:59
We also see it in a lot of animals. So some mammals, but particularly birds
3:04
and reptiles, are very good transmitters of the infection.
3:08
And so we'll see cases pop up here and there, and all of a sudden we'll get
3:12
two or three or four in a row, which, as we talked about earlier,
3:15
kind of raises our eyebrows a little bit and makes us think,
3:18
do we have a true outbreak starting to brew in the community?
3:22
JB, before we dive into the clinical side, can you briefly explain scientifically
3:27
what salmonella actually is and why it can behave so differently in infants
3:32
versus older children and adults?
3:35
One of the reasons is that salmonella is pretty good at surviving just being
3:39
eaten by the regular white blood cells.
3:42
So some of the phagocytic leukocytes, meaning the white blood cells that come
3:46
around and munch up bacteria, they'll engulf a bacteria, bring it into the white
3:51
blood cell and then kill it with acid or sometimes let the bacteria drown in its own secretions.
3:56
Salmonella is pretty good at surviving within cells, and it's also able to invade
4:02
cells directly without going into one of those cranials, without sort of escaping
4:06
the little prison cell that the cell has prepared for it and just getting into
4:09
the cytoplasm of the cell itself.
4:11
And therefore, we are really reliant more so than other bacteria on our T cell
4:17
population to help isolate people.
4:21
Control and ultimately kill salmonella bacteria. Young infants don't have very
4:26
well-developed T cells.
4:28
So especially early in infancy, it's very easy for the salmonella to dodge the
4:33
T cells that are sort of just waking up in a young baby.
4:36
Can you tell us more about salmonella? Yes. So we divide salmonella into two broad categories.
4:41
It's basically salmonella typhi or typhoid fever, and then everything else,
4:45
which is just quote-unquote regular enteric salmonella that can cause gastrointestinal
4:50
disease, and in some cases, invasive disease.
4:54
When we're talking about typhoid fever, that is very much transmissible from
4:57
person to person, famously illustrated by Typhoid Mary, who was a woman in the
5:02
early 20th century who was colonized and managed to spread salmonella typhi
5:05
to a lot of people through close contact.
5:08
Most people either don't know or maybe have forgotten that enteric salmonella can do that as well.
5:15
So if someone's sick in the household and they're having diarrhea and vomiting,
5:18
it's possible to transmit those germs to other members of the household or if
5:22
they're in a daycare or school setting,
5:24
which is why washing your hands before and after going to the bathroom or before
5:27
and after preparing food and eating food is really important.
5:31
And salmonella is a member of a larger family of bacteria?
5:35
Called the Enterobacteriaceae, which is a mouthful and a really good Scrabble word.
5:40
And that family also includes things like E. coli and Klebsiella pneumoniae.
5:45
And so we see it carried in intestines. Now, again, generally in intestines
5:50
of birds or lizards, turtles, snakes.
5:53
But it can also be colonized, colonizing in humans, or it can be a pathogen in humans.
5:59
Once we have that gram-negative bacteria, that germ, it comes out in our poop.
6:03
And if we don't wash our hands, we can transmit it to other people.
6:06
So on one hand, it's a member of one of the most common classes of bacteria
6:11
that we deal with. Pediatricians deal with E. coli and Klebsiella pneumoniae
6:15
all the time in urine and in other situations.
6:20
However, salmonella is a less common but just as important member of that family.
6:25
And regarding salmonella testing, today we've moved toward molecular testing.
6:30
So, in the old days, when I was an intern, uphill both ways in the snow,
6:34
salmonella would be identified in stool culture.
6:38
Nowadays, we've mostly shifted towards molecular testing, and so a stool sample
6:42
is sent, and a multiplex PCR panel is going to look for 12 or 15 different bacterial
6:49
strains, one of which would be salmonella.
6:51
In an older child with uncomplicated diarrhea, that's the ballgame.
6:54
It's salmonella, lots of Gatorade, wash your hands, see you in a week if you're not better.
6:59
For young infants, the question then becomes, are we going to treat this?
7:04
Are we going to give antimicrobials because this child is young enough where
7:08
I'm worried about invasive disease?
7:10
And what the American Academy of Pediatrics recommends is that if antibiotics
7:14
are going to be given or if the infant is young, and they sort of leave it intentionally
7:18
vague, but certainly under three months or four months, the recommendation is
7:21
to also do a blood culture.
7:23
If the blood culture is sterile, it's okay to give a dose of ceftriaxone or
7:29
other antimicrobials, sometimes oral antimicrobials, to treat the gastroenteritis.
7:34
But if the blood culture is positive in a young infant, even if that infant looks really good,
7:39
then the recommendation is to do a lumbar puncture to look for meningitis and
7:42
to do a really thorough evaluation of the extremities to make sure there's no
7:46
septic arthritis or osteomyelitis
7:48
because once salmonella is in the blood, it is very tropic for other tissues
7:52
and it will happily go places it's not supposed to be.
7:55
It, unfortunately, can be pretty fulminant. Once, because salmonella is a gram
8:00
negative, it's very, very good at inducing inflammation. And so once salmonella
8:04
gets to the meninges, it's a matter of hours, not days, before that child can become critically ill.
8:10
What red flag should immediately raise concern? Sure. So there's really,
8:14
there's two circumstances. Well, let me say, there's three circumstances where
8:19
I think pediatricians have to have their radar up for more complications of salmonella.
8:24
The first of which would be in a young infant. And again, three months and under for sure.
8:29
If your spider sense is tingling at four or five, six months,
8:32
by all means, listen to it.
8:34
Second would be if a child is older than that, but has some immune immunocompromised.
8:38
So chronic steroid use because of an autoimmune condition, organ transplant,
8:43
bone marrow transplant, things like that are obviously going to raise the bar for evaluation.
8:47
And then finally, if the child has salmonella in the stool but looks ill,
8:52
so lethargy, sleepiness.
8:55
A painful limp, high fever that's sort of not fitting well, dysentery,
9:01
if the child is having painful, crampy, bloody stool rather than just generic
9:06
watery stool, that raises the risk that the bacteria may have invaded.
9:10
And so any of those circumstances or kind of the fourth miscellaneous category
9:15
of it just doesn't feel right, this kid doesn't quite look right,
9:18
it is completely reasonable to at a minimum draw a blood culture and make a
9:22
decision about antimicrobial therapy,
9:24
in consultation with pediatric infectious disease if necessary.
9:27
We're always happy to answer the phone.
9:31
Salmonella gastroenteritis that has a wrinkle or has some different clinical
9:36
aspect that's making the pediatrician uncomfortable is not the place to be super brave.
9:42
Because you don't get any bonus points for guessing right in this case.
9:46
It's better to be safe than sorry when it comes to this particular organism for sure.
9:51
Can we talk about symptoms in a baby? I'm laughing. As a neonatologist,
9:55
the answer is everything.
9:57
Certainly, you know, altered mental status, which is really,
10:00
really challenging in a young infant, lethargy, sleeping more,
10:04
decreased oral intake, not alerting or orienting to voice or to parents.
10:09
It's a long laundry list.
10:11
Again, generally, we'll listen to the parents. If the parents come in and say,
10:14
he's had diarrhea for three days and now he's doing this weird thing and I can't
10:18
put my finger on it, that would probably be enough for me.
10:20
But certainly altered mental status, abnormal vital signs, tachycardia that
10:24
can't be explained, hypotension or borderline hypotension that can't be explained.
10:29
I wouldn't ignore any of those in the setting of a child who's got a diarrheal
10:34
illness from salmonella.
10:35
Rarely things like rash. We tend to learn a lot of the typhoid fever symptoms
10:42
when we learn about salmonella in medical school or nursing school.
10:46
Those may not be present for non-typhoidal salmonella disease like we're going
10:50
to see here in the U.S., but certainly if they were present,
10:53
we would take them seriously.
10:54
So things like a purplish or violaceous rash, abnormal perfusion of the extremities,
11:00
certainly any petechiae purpura that's going to signal that this kid is sicker
11:04
than they might have looked like at first glance.
11:07
JB, with all of your experience in infectious disease, neonatology,
11:11
and public health, how do you approach antibiotic decisions in infants versus older children?
11:17
Right. So salmonella is the mercy of salmonella is it's generally susceptible to a lot of things.
11:24
So when the decision is made to treat, you want to make sure your blood culture is sterile.
11:30
If it is, what the Red Book recommends is for younger children, a dose of ceftriaxone.
11:35
For older children, they might be able to get away with just going straight
11:38
to an oral fluoroquinolone like ciprofloxacin or levofloxacin.
11:42
If the antibiotic is given and the blood culture is sterile and the kid is improving,
11:48
then you can finish out with oral therapy. And your options include amoxicillin,
11:52
azithromycin, which is usually the preferred one just because it's easiest and it's once a day dosing.
11:57
And an older child, a quinolone can be used to finish out. So lots of options.
11:59
There's a lot of ways to get it right. That's not the stressful part.
12:04
The stressful aspect of management is, do I do the blood culture and give antibiotics
12:07
in the first place or not?
12:10
And then the antibiotics could be causing some diarrhea.
12:14
Yes. This is robbing Peter to play Paul.
12:17
If the child is placed on antibiotics and things are getting better for a day
12:21
or two or three, and all of a sudden they get worse again, especially crampy
12:25
stools, bloody stools, then,
12:27
the concern is always, okay, did we fix the salmonella at the expense of causing
12:31
clostridioides difficile colitis, and that might be an indication where the
12:35
child has to come back and give another stool sample.
12:38
In infants, it's a little bit easier because inside of 9 to 12 months,
12:42
we tend not to see C. diff.
12:44
So in that particular case, if the diarrhea is suddenly worse,
12:48
they probably have to go back to the drawing board.
12:50
But certainly in an older child where the salmonella is better,
12:52
and on day 4, 5, 6, here come the bloody stools,
12:55
Probably nine times out of 10, that's going to be C. diff colitis rather than
12:59
the salmonella failing medical therapy.
13:02
Do you know, are stool transplants still available for C. diff?
13:06
They are. So I've had the pleasure of doing, or I shouldn't say doing them,
13:10
of being involved in kids who have received them at other hospitals.
13:16
I have not done one here in San Antonio. That may be more of a protocol thing
13:21
than any lack of evidence. They definitely work.
13:25
The downside, or I should say the tricky part of stool transplants in my limited
13:30
experience is that the children who benefit from them the most have the most
13:34
friable, compromised bowel.
13:36
So you have to be very, very careful when you're instilling the stool transplant
13:41
into their colon because you don't want to cause a perforation.
13:45
But they are very effective. It's amazing. Yep.
13:49
So I would, I stand by that the best thing to do is avoid the C.
13:52
Diff in the first place with good stewardship. But if we get to a point of C.
13:56
Diff, the stool transplants can be quite effective.
14:00
What are some common misconceptions or management pitfalls clinicians should be aware of?
14:06
So I think there's two things, one of which is making sure that in the infants,
14:13
especially the younger infants, that we do the full workup. because we do,
14:16
we get very used to, oh, this is a three-year-old salmonella gastroenteritis.
14:20
They look great. They're hydrated. They're going to be fine.
14:23
When it's a three-month-old, even if the kid looks wonderful,
14:26
we still have to do the blood culture before we decide on treatment or not because
14:30
the risk of invasive disease is so much higher. We've talked about that.
14:33
The other one, which has really come up in the molecular era,
14:36
and I always kind of forget about it, and then it happens and I'm like,
14:39
oh, right, I was going to warn people.
14:41
In the blood culture setting, most of the blood culture molecular tests that
14:47
we use will highlight not only the genus and species of the bacteria,
14:53
but they'll also highlight the family.
14:55
And so when Salmonella flags, it will flag as Enterobacteriaceae,
14:59
Salmonella enteritidus, which is the species name.
15:03
And it's been very frequent at a couple of different places I've worked where
15:06
people say, oh, they're growing two germs. They're growing Enterobacter and
15:10
they're growing Salmonella. And I'm like, wait, what? And I go to the computer. I'm like, no, no, no.
15:14
This is Enterobacteriaceae. That's the Salmonella as well. So I think it's a
15:18
really confusing way that we label it. And I think that's a regulatory problem
15:24
because it has to be reported that way for the FDA.
15:27
But it is very confusing when people aren't thinking about the family of the
15:31
bacteria and then they think, oh, my gosh, my child has two different things going on.
15:35
What exposures should pediatricians be specifically asking families about right now?
15:40
So most of the time when it's not human-to-human transmission,
15:47
most of the time it's going to be either animal or foodborne.
15:50
So whenever we're dealing with a child who has salmonella, generally we're going
15:53
to ask about pets or other animal exposures, especially reptiles and poultry.
15:59
And this might be a pet duck or a pet turtle or a class pet.
16:03
Sometimes it's a petting zoo where they're like, no, we don't have any pets,
16:06
but we went to the rodeo last week and got to play with the,
16:08
you know, the ducklings.
16:10
So we always ask about animal exposure and sometimes we have to be a little
16:13
bit creative in the way we ask, because it's not their pet, it's the cousin's
16:16
pet and like, oh yeah, I forgot he was at the cousin's house last week.
16:19
The other one would be food preparation. Because salmonella is present in a
16:23
lot of poultry, a lot of animal products, you can certainly get it through raw eggs, raw poultry.
16:29
And so if a baby is only drinking formula, but that formula is prepared from
16:34
powder on a kitchen counter that maybe was used to make chicken fajitas slightly
16:38
earlier, there can be some cross-contamination.
16:40
And as a parent of three kids who eat a lot, there's a lot going on in the kitchen.
16:46
And sometimes it doesn't always get cleaned exactly the way you would to a restaurant quality.
16:51
So it's very hard. My complete sympathies to those families.
16:55
So food preparation, animal exposure, and then daycare, school setting,
17:00
and is anyone sick there? Have there been any letters home? Things like that.
17:04
So would you recommend not having a pet duck or frog, et cetera?
17:09
I always laugh because infectious disease docs are sometimes this is where we
17:12
get to be unpopular because we're like, oh, you should live in a bubble.
17:14
No, I think that pets are amazing. And I think with the exception of things
17:18
like giant snakes that can eat me or spiders, I think pets are awesome.
17:23
I do encourage people, you know, if they're going to have a pet,
17:26
part of taking care of that pet
17:27
is washing your hands before and after and certainly before you go to eat.
17:30
But no, I think pet turtles, pet snakes, if that's your jam.
17:37
I think pets can be a very rewarding and awesome part of childhood.
17:40
And I wouldn't want to take that away from anybody, but there are some really
17:43
simple safety precautions that are part of pet ownership.
17:47
I had a pet duck as a child. Her name was Honey, and she acted more like a dog.
17:52
But I think that's a great way to put it. What do you do when your kids want a pet?
17:56
Yeah, 100%. It's a very similar answer to toxoplasmosis in pregnancy,
18:01
where people go, do I need to get rid of my cat before I get pregnant?
18:04
I say, no, absolutely not.
18:06
Cats are awesome, but you do need to wash your hands. Yes, so much,
18:10
as pediatricians know well, comes back to washing hands. It's important to stress.
18:15
Hand hygiene forgives a lot of other sins, as I say.
18:19
JB, as both an infectious disease physician and public health expert,
18:23
what do you personally do in your daily life to reduce the risk of salmonella
18:27
exposure to yourself and your family?
18:30
Can you give us the inside scoop? Well, so mostly serious.
18:34
You know, we try not to let the kids, especially younger, smaller kids,
18:40
eat raw poultry, raw eggs. So we try to make sure that the chicken is cooked
18:44
all the way through with a meat thermometer, or try to make sure that they're not eating raw eggs.
18:48
Now, I will say, as someone who loves cookie dough, I am the largest member
18:52
of my family. I'm about 225 pounds. And so I'll make a big batch of cookie dough
18:56
and I'll be eating the cookie dough. And my kids will say, can I have some?
18:59
I'm like, no, you make a steak from salmonella. I stuff my face full of it.
19:04
So one is just making sure food is cooked to the correct internal temperature.
19:09
It's an easy Google search for people who aren't sure exactly what beef or chicken
19:13
or pork need to be cooked to.
19:15
Cleaning down the counters before you start a meal and then washing your hands
19:19
before and after meal prep and eating before and after animal contact.
19:23
Let's talk more about that. For a healthy adult, getting salmonella from cookie
19:27
dough is actually less likely than many people think.
19:31
Can you explain that nuance and why the risk conversation changes for infants
19:36
and vulnerable populations?
19:38
It would be a challenge for a couple of reasons. First of all,
19:41
the cookie dough you can just buy at the store has been processed.
19:44
It doesn't have raw egg in it. So if I'm not encouraging this on a pediatric
19:48
podcast, but if anyone goes to the store and like gets a loaf of the cookie
19:51
dough and just eats it raw, you're probably not going to get salmonella because
19:54
it doesn't have the component.
19:55
But when you are cooking and using farm fresh eggs or regular eggs from the
20:00
grocery store, that can contain salmonella.
20:03
However, salmonella is very concentration dependent for whether it can get you sick or not.
20:10
It has a very, very high inoculum requirement. So somebody my size,
20:16
and I'm a bigger guy, I'm about 6'3", 6'4", 220.
20:20
Yeah, if I had any muscle on me at all, I'd be a football player, but no.
20:25
The amount of salmonella that somebody my size would have to eat to get sick is really pretty high.
20:31
In contrast, things like tularemia or measles, other germs, other bacteria,
20:37
viruses can get me sick at my size with five organisms or 10 organisms or 20 organisms.
20:43
I might have to eat two or three million salmonella organisms to get sick.
20:47
So it's a much higher inoculum.
20:49
That's a lot of cookie dough. It's a lot of cookie dough. And ironically,
20:52
the more cookie dough I eat, the bigger I get, which makes it harder for me
20:55
to get salmonella. It's a vicious cycle.
20:58
It is easier to get it directly from animals because the concentration that
21:03
the child is going to be exposed to is a lot higher coming directly from,
21:08
an animal who's colonized with salmonella than it would be eating their products,
21:12
their meat or their eggs or their milk.
21:14
So a child age four and up, they're probably okay having a little bit of cookie dough?
21:19
Speaking as a pediatric infectious disease doc, I would say that eating raw
21:24
poultry is probably never a good
21:25
idea. Speaking as a dad, in my limited experience, they were all fine.
21:30
Does a lot of chicken have the bacteria, though?
21:34
Not all do. So it's going to depend on the flock or the herd that the animal
21:39
is raised in, animal husbandry practices.
21:41
But there is, salmonella is the most common outbreak that's reported in the
21:46
U.S. food supply surveillance. So FoodNet is the American Food Safety Surveillance Network.
21:52
And if on a rainy day, if you go to FoodNet on the Internet and look at the
21:57
outbreaks, overwhelmingly, it is salmonella.
21:59
Fortunately, those are usually very short outbreaks, you know,
22:02
generally not highly mortal or highly morbid outbreaks, but it is the most common
22:05
one by far. So not every poultry animal, not every reptile has it,
22:11
but those are the reservoirs where we are the most likely to see it.
22:14
JB, what counseling points are most important for families regarding dehydration,
22:19
transmission, and return precautions?
22:23
Yeah, no, it's a good question. From a hydration standpoint,
22:26
we want to use as much as possible. we want to use isotonic fluids,
22:31
meaning fluids that have salt and sugar in them.
22:34
Gatorade, Pedialyte, I'm not promoting any one particular product,
22:38
but electrolyte drinks, sports drinks, or Pedialyte are specifically made to
22:43
have those electrolytes, to have those sugars.
22:45
And it's partly because it makes them taste better. It's a little bit easier
22:48
to get kids to drink that.
22:49
Secondly, it replaces a lot of the salts that are being lost.
22:53
And so kids who take in just water to replace their losses are going to have
22:58
their total body electrolyte levels drop, sometimes to dangerous levels.
23:02
And then thirdly, and this is probably more for the parents than the pediatricians,
23:06
but thirdly, the presence of the sugar and the salts together helps the body bring the water in.
23:11
There's special receptors in the gut that use the salt and the sugar together
23:16
to pull fluid into the body much more effectively, even if the entire rest of
23:21
the gut is busy pushing fluid out and making diarrhea, those receptors still work.
23:26
So even when you're really, really sick and you feel like you can't keep anything
23:28
down, you can keep electrolyte-containing sugary drinks in your system, which is good.
23:34
As far as when, you know, when a baby has loose stools versus diarrhea,
23:39
when to bring them in, it's tricky.
23:42
The younger they are, obviously, the lower the threshold to seek pediatric care.
23:46
Certainly, if it's pussy, crampy, or bloody stools, that's always going to be,
23:53
a concern. So we actually call that dysentery rather than diarrhea.
23:57
If you're pooping out pus or blood, you need to get seen.
24:01
If it's loose, watery diarrhea in an older infant,
24:04
certainly a toddler or a young child, and you're keeping up with your losses
24:08
and the mental status is normal and your kids lying on the couch watching black
24:11
and white movies and drinking the chicken soup and Gatorade you're bringing
24:14
them, then it's going to be parent judgment.
24:16
That may not be as acute as long as you can keep up with the losses.
24:19
But as always, for any parents who are listening, if you have a concern,
24:23
it's certainly worth either a phone call or a trip to your pediatrician just
24:26
to have someone else weigh in with you.
24:28
What do you most want busy pediatricians to remember from this discussion?
24:33
Yeah, so I think bottom line for salmonella is hand hygiene,
24:36
hand hygiene, hand hygiene for prevention. If people come in and say,
24:39
oh, I saw on the news that this, hand hygiene, being careful around animals,
24:44
being careful around food prep sites.
24:46
For the pediatricians themselves, if it's salmonella, gastroenteritis,
24:51
and an older kid who's doing okay, benign neglect, watching them,
24:55
making sure they're staying hydrated.
24:56
But if it's a younger kid or a kid who's not looking quite right or a kid who's immunocompromised,
25:01
please don't forget that before you do any antibiotics, you need to get that
25:04
blood culture because if that blood culture is positive, that child's going
25:07
to need to come into a hospital setting, get a full evaluation,
25:10
including a spinal tap and get treated.
25:12
We don't want to miss invasive disease in a child with salmonella in their stool.
25:18
When a baby has fever and diarrhea, when does that become an emergency?
25:24
So it becomes urgent if they've got fever and diarrhea and they either can't
25:29
keep up with their stool losses where we're getting dehydrated at home and I
25:32
can only give them so much Pedialyte and oh God, what do I do?
25:35
By all means, bring them in because that child may need medicine,
25:38
anti-nausea medicine, might need intravenous fluids, might need observation.
25:42
If they have diarrhea and they have altered mental status, well,
25:48
you know, again, the words all sort of blend together, but sleepy,
25:52
can't really get them to wake up, can't really get them to focus on me.
25:55
I'm getting nervous about the way they're interacting with me.
25:58
Certainly any abnormal movements that might be seizure-like activity.
26:02
So if you see any twitching or jerking of the arms and you go,
26:04
oh my gosh, what's that? I haven't seen that before.
26:07
Then we would worry about invasive salmonella. We also worry,
26:09
we don't see it as often, but we also worry about shigella.
26:12
Shigella is another bacteria in that same family that has a predisposition for causing seizures.
26:18
So altered mental status and diarrhea equals that child needs to be evaluated.
26:24
If they are younger than three months, four months, and they've got true diarrhea,
26:29
not loose stools because, you know, we're starting solids or we just switch
26:33
formulas and they're a little bit looser than normal, but true watery or bloody
26:36
stools, that child needs to get evaluated as well.
26:38
Because again, if it's salmonella, we're going to react differently at three
26:41
or four months and under than we would at three or four years.
26:45
The only other thing that I think it's probably worth mentioning is that I became, I've.
26:52
Aware of it through infectious disease training, much more cognizant of it as
26:57
a dad, that FoodNet exists.
26:59
Part of your tax money is going to this really well worked out system to look
27:05
at foodborne outbreaks.
27:07
And so if they push out a notification to Bayer County or they push out a notification
27:13
to Austin Health and Human Services and they say, you know, this spinach,
27:17
which is sold at these four stores with these lot numbers, has salmonella.
27:22
It doesn't take long to just double check your fridge because salmonella is
27:26
the most common foodborne outbreak. The system's very good at catching them
27:30
and recalling food and destroying food that's contaminated.
27:33
But because they're so common, it's hard to prevent it from entering the food chain at all.
27:39
So I guess, long story short, if you ever get one of those notifications,
27:42
take the 10 seconds out of your day to double check what's in your fridge because
27:45
it's a very easy way to prevent foodborne salmonella from coming into your home.
27:50
And I was reading that there's some outbreaks caused by supplements.
27:55
Right. So any less common, but definitely possible.
27:58
It can get into vitamin supplements. It can get into especially ones that are not FDA approved.
28:04
So sometimes the ones you can buy over the counter that aren't FDA regulated.
28:09
It is possible for bacteria to get into those production lines.
28:12
It's also been reported in infant formula.
28:14
So it's not just poultry, fresh dairy, meat.
28:19
It can be pretty much any part of the food chain as well, including vitamins
28:23
and supplements. So, yes, thank you for mentioning that.
28:25
Anything else you want to recommend that practitioners say to parents of newborns?
28:31
Yeah, I think the two things for parents of newborns, one is,
28:36
especially for people who are relying on powdered infant formula,
28:42
just be really, really careful about the preparation.
28:44
It's hard. I know you're exhausted. I know he's not sleeping through the night yet.
28:48
But if you've just made chicken parmesan and now you're going to make your baby's 10 p.m.
28:54
Bottle, just make sure the counter and the tools you're using to boil that water.
28:58
Make sure those are clean. because the salmonella is easier to spread than you think it is.
29:07
The second part would be, you know your baby better than anyone.
29:11
If the baby's having diarrhea, if the baby's having a change in behavior,
29:14
certainly if the baby's having fever, just a very low threshold to touch base
29:18
with your pediatrician and see what you think is going on, what they think is going on.
29:22
Don't say, oh, it's just diarrhea, he'll be fine, and wait out the weekend because
29:26
these kids can get sick in a hurry in the rare possibility that it is salmonella.
29:30
Can you give a quick overview about sepsis?
29:33
So sepsis comes from the Greek word meaning to rot.
29:36
And it's basically infection that reaches the bloodstream and then goes elsewhere
29:43
in the body and causes end-organ dysfunction.
29:46
And a lot of people in a lot of fancy committees and a lot of different age
29:50
ranges have tried to define from a laboratory or clinical standpoint what sepsis is.
29:55
But at its most fundamental, It is bloodstream infection with end organ dysfunction,
30:01
skin perfusion problems, brain perfusion problems, liver problems,
30:05
kidney problems, blood clotting problems, right?
30:09
And colloquially, we distinguish it from asymptomatic bacteremia.
30:13
So if I fall and I skin my knee on the basketball court, I'm probably going
30:17
to have some bacteria in my blood for a few minutes.
30:20
Being an otherwise healthy 40-year-old person, my immune system is going to take care of it.
30:25
If I don't, if the bacteria multiply and start to spread in my blood, I'm going to get sepsis.
30:30
And the old term was blood poisoning. You still see that sometimes,
30:33
but sepsis is an infection, usually bacterial, but any infection that spreads
30:38
throughout the body and overwhelms the body's immune system to the point where
30:42
the body's organs start shutting down.
30:44
And how would you know if your baby is exposed to salmonella in the daycare?
30:49
You would just go by the symptoms? Yeah, going by the symptoms.
30:52
So, you know, there are plenty of pathogens that some of us walk around with.
30:58
Some people are colonized with salmonella, not many, but some.
31:02
People might have recovered from salmonella and be feeling great,
31:05
but they're still shedding bacteria for a few weeks or months in their stool.
31:10
Obviously, if we're aware of an outbreak or a danger, we want to be cognizant
31:15
of that and take whatever prudent steps are necessary to avoid putting ourselves in a bad position.
31:21
But there are a lot of people with germs that don't know they have them,
31:25
that are completely asymptomatic, and they just touched that box of Captain
31:28
Crunch at HEB, or they just pushed open the door at Walmart.
31:31
And so just taking good care of ourselves, staying hydrated,
31:34
washing our hands, because we are going to come into contact with these bugs
31:38
almost no matter what we do.
31:39
And unless you're just never going to leave your house and do everything by,
31:42
you know, delivery services, you got to live in this world. We're going to run
31:46
into things. So hand hygiene, a thousand percent.
31:50
Is that how, with all your knowledge, you're able to continue with everyday life and enjoy life?
31:56
Yeah. Also, a lot of faith in, you know, especially outside those first few
31:59
months of life, a lot of faith in our immune system.
32:01
Like, yeah, there's a lot of germs out there, but we have a whole organ system
32:05
that's built to protect us. So as long as we wash our hands,
32:08
give our immune system, you know, good nutrition, good sleep,
32:11
and go see our doctor when we're starting not to feel well, it mostly works out well in the end.
32:16
At your clinic, it's called the Okape Clinic at University Health's Women's
32:21
and Children's Hospital. Yes, ma'am.
32:23
Ongoing Care of Congenital and Perinatal Infections, OCC, we blend the two C's together to make a K.
32:29
So Okapi Clinic, and it's for infants who either were exposed to something or
32:33
infected with something during the pregnancy or around the time of delivery
32:37
that they need follow-up. And isn't it your family's favorite animal, the Okapi?
32:42
It's one of my favorites. The Okapi, for those of you who have not had the pleasure,
32:46
it's a giraffe family member, but it really looks like a giraffe and a zebra
32:50
got smashed together. And it's a little nod to the fact that I do neonatology
32:55
and pediatric infectious diseases.
32:57
So I am also two weird specialties kind of smashed together.
32:59
So I feel a lot of sympathy for the Okapi.
33:02
I love it. Do you want to say anything to the practitioner about Ebola in case
33:07
they're getting asked about it? Sure.
33:09
So I had the misfortune of living in Dallas the last time we went through imported
33:14
Ebola cases in the United States.
33:16
And actually, someone who helped train me, Dr. Wendy Chung, who was the public
33:21
health specialist in Dallas and wound up in Vogue magazine, of all things.
33:24
No one's ever asked me to do a fat. No, I'm kidding.
33:26
Yeah. So certainly the symptoms of Ebola are not subtle by any means.
33:32
So high fever, respiratory distress, and then hemorrhagic shock.
33:36
So petechiae, purpura, bleeding, disseminated intravascular coagulopathy.
33:41
These patients are going to look a lot like a severe vasculitis.
33:46
So they're going to look a lot like Rocky Mountain spotted fever.
33:49
They're going to look like a severe case of typhus. They're going to look like
33:52
a severe case of dengue or chikungunya, which are diseases that maybe are a
33:56
little bit closer to home.
33:57
And the most important thing by far is going to be travel history.
34:01
We don't have any endemic cases in the U.S., knock on wood.
34:04
So these are going to be people who have been exposed to personnel or people
34:09
who have been in the Congo, been in sub-Saharan Africa, working on the outbreak,
34:13
and then have brought a case back with them.
34:16
So far, the WHO and the U.N. have done a really good job of quarantine,
34:23
but there are holes in the system.
34:25
Earlier this morning, our time, one of the hospitals was.
34:29
I want to use a charitable term. Some of the family members of deceased Ebola
34:32
patients broke into the hospital to recover their family's bodies and broke quarantine.
34:37
And so that's going to spread more virus locally earlier today.
34:41
And all it takes is one of those people to catch a bus or one of the hospital
34:45
workers to catch a flight and come back not realizing they're sick and transmit
34:50
through secretions person to person.
34:52
So, so far, no activity outside of the hot zone, but it only takes one,
34:58
and all of a sudden we're having a much different conversation.
35:00
We learned this 10, 12 years ago. Are you worried?
35:05
I'm not, if you ask me to list all the things I'm worried about, Ebola is pretty low.
35:10
Hantavirus is pretty low. The thing I'm actually the most worried about is human,
35:13
animal to human transmission of H5N1.
35:16
I think that's going to be our next immediate issue is novel influenza because
35:20
we're due for a big shift.
35:22
It's been 17 years since H1N1 arrived. And so we're due for a big typal shift.
35:28
And I think a flu pandemic is, if I was a betting man, that's the most likely,
35:34
next pandemic is going to be novel flu.
35:36
And to prepare for that, keep getting our yearly flu shots?
35:40
Keep getting yearly flu shots, keep exercising and being healthy and wash your
35:44
hands because when it comes, there's going to be a lag before H5N1 is included
35:50
in the seasonal flu vaccine.
35:51
So there's going to be a lag where we're going to have to rush out that vaccine
35:54
and get everyone vaccinated outside the normal flu schedule.
35:58
That being said, with the advances in mRNA vaccines from COVID,
36:01
I think that gap is going to be a lot shorter than it used to be,
36:04
maybe, you know, a couple of months rather than most of a year.
36:07
But there is going to be a window. And when H1N1 hit in the spring of 2009,
36:12
a lot of us were sick before the summertime. So even a short window can still
36:16
lead to a lot of Americans getting sick.
36:18
I didn't know we had to worry about that. Every time, flu has a,
36:23
it can be made up of one of many hemagglutinins, that's what the H stands for, or neuramidase.
36:30
That's what the N stands for. And so having now seen H1N1, I have N1 and likely
36:36
most of our listeners have N1 antibody.
36:38
Well, that's going to help when H5N1 comes around because we can make antibody
36:42
against the N1. Now it's going to be slightly different than the one we have
36:45
now, but not wildly different.
36:47
The problem is the H5. We haven't seen H5 in over 100 years at the population level.
36:53
So that H5 is going to take some getting used to, and it's going to get people
36:56
sick until we make a vaccine that includes the H5 vaccine.
36:59
J.B., thank you so much for being here in the podcast studio. It is such an honor.
37:04
Is there anything else you want to mention?
37:08
Oh, the one last thing I would mention just for the practitioners,
37:12
because I get this question every now and then, is that since we've shifted
37:15
to molecular tests, those molecular stool panels do not give susceptibilities.
37:21
So people will say, oh, I have a two-year-old.
37:24
They're looking pretty good. Their stool PCR is positive for salmonella.
37:28
I don't think I'm going to treat. But if I treat, how do I know what it's susceptible
37:32
to? And the answer is we don't.
37:34
So the Redbook gives you the options of azithromycin, amoxicillin,
37:38
cephalosporins, and you just got to kind of pick the one you like for that patient
37:43
and monitor their clinical response because without a culture from the old days,
37:47
we don't specifically do susceptibility testing anymore.
37:52
JB, here on Pediatrics Now, I like to promote having a life outside of medicine.
37:58
It's summertime. Are you and your family going on any fun trips or how are you going to unplug?
38:02
A couple of weeks of work now that school's ending, and then we're maybe going
38:06
to hopefully sneak off and go to Costa Rica for a week or so.
38:09
That sounds like it's going to be amazing.
38:12
Dr. J.B. Canty, infectious disease doctor, neonatologist, and public health
38:18
doctor with University Health and UT Health's Department of Pediatrics.
38:23
Thank you so much for being here back on the show, back on Pediatrics Now.
38:29
No, my pleasure. Thank you for having me.
38:32
Don't forget to click on the link in this podcast for free credit that may include
38:35
CME, MOC, or ethics credit, depending on our topic or podcast.
38:41
Our sister podcast is Pediatrics Now for Parents. We will have a shorter,
38:46
parent-friendly version regarding salmonella as a medical emergency in babies and
38:52
salmonella in children and how to prevent and what to do on Pediatrics Now for Parents.
38:59
That's also found wherever you get your podcast. The website is pediatricsnowforparents.com.
39:07
Our website is pediatricsnowpodcast.com. My email address is on there.
39:13
Please email me with your episode ideas and requests.
39:19
Coming up next week, when a baby has a misshapen head, if it's caught in time,
39:25
it's a minimal procedure.
39:27
If it's too late, it can be a major surgery.
39:29
We talk directly to the experts what to look for, how to spot it, what not to miss.
39:36
I'm Holly Wehmint. I'll see you next week. I hope you're having a great summer.
39:44
Remember the recent Artemis mission around the moon? It was breathtaking.
39:49
But did you know there was research happening on that mission and happening
39:53
now that will directly affect pediatric care.
39:57
I talked to the head researcher whose idea it was to do this research on this
40:02
mission, and she's also in charge of the plants growing in space. It's fascinating.
40:09
Check the Pediatrics Now news feed for my interview with her.