Salmonellosis in a Nursing Home Patient on Enteral Feeding

BACKGROUND/OBJECTIVES: Salmonella is the most frequently reported foodborne illness in the United States. It is typically acquired though ingestion of contaminated meat or dairy products. However, person-to-person transmission of nontyphoidal Salmonella spp. may occur. During October 2005, the Baltimore County Health Department was notified of a Salmonella case admitted to an acute care facility. Blood and stool specimens were positive for Salmonella enterica. The morbidity report indicated the patientʹs permanent residence was a nursing home. METHODS: A routine gastroenteritis case report investigation was initiated. The nursing home administrator was interviewed. The resident (87 years) was unable to provide a food history. He suffered dementia and his nutrition was maintained by enteral feedings through a gastronomy tube. The product was a pre-prepared sterile solution in a sealed plastic container so the possibility of a contaminated commercial formulation was unlikely. The initial interview and follow-up determined: 1.) No healthcare workers caring for the patient ill prior to symptom onset had GI symptoms; 2.) No other cases of GI illness occurred among patients either concurrent or after the caseʹs onset of symptoms; 3.) Patient did not have a roomate; 4.) No family members or visitors had GI symptoms. The director of nursing was also interviewed. She reviewed the admission and census records and reported the case did have a roomate for several weeks. She also reviewed the roomateʹs history and physical. RESULTS: The roomate was a 19 year old male with an enterofistula who shared the room with the case for approximately 3 weeks and was discharged several days prior to onset of the caseʹs symptoms. He had been hospitalized for Salmonellosis in September 2005 before being transferred to the nursing home. During his stay in the nursing home, he had remained on antibiotic therapy. His morbidity report was documented in the Maryland Electronic and Surveillance System with the etiologic agent identified as Salmonella enterica, the same species as the patient on tube feedings. CONCLUSIONS: The epidemiologic evidence indicated that cross-transmission had occurred between the roomates even though phage typing was not performed on the isolates. The same nursing staff cared for both patients. The resident with the fistula was frequently soiled due to drainage through his surgical site. His long term antibiotic therapy increased the likelihood of prolonged Salmonella carriage. Nursing homes should develop and enforce polices which define the types of patients placed together in the same room. Adherence to Standard Precautions may have prevented this incident, but proper patient placement also plays a key role in preventing transmission in the long-term care setting.