The epidemiology of extraintestinal non-typhoid Salmonella in Israel: the effects of patients’ age and sex

Management and Outcomes of Salmonella Gastroenteritis in the Era of Rapid Molecular Testing

BACKGROUND AND OBJECTIVES

Molecular diagnostics provide a rapid and sensitive diagnosis of gastroenteritis compared with a stool culture. In this study, we seek to describe the changes in medical management and outcomes of children with Salmonella gastroenteritis as our hospital system adopted molecular diagnostics.

METHODS

This study is a retrospective chart review of children <18 years of age diagnosed with nontyphoidal Salmonella gastroenteritis between 2008 and 2018 at a large pediatric health care system in the southeastern United States. Those with immunocompromising conditions and hemoglobinopathies were excluded. Patients diagnosed via molecular testing were compared with those diagnosed solely by stool culture for aspects of management including admission rates, blood culture obtainment, and antibiotic administration.

RESULTS

Of 965 eligible patients with Salmonella gastroenteritis, 264 (27%) had a stool molecular test and 701 (73%) only had a stool culture performed. Groups were similar in age and presentation. Those diagnosed by molecular methods had higher hospitalization rates (69% vs 50%, P <.001), more blood cultures obtained (54% vs 44%, P <.01), and received more antibiotics (49% vs 34%, P <.001) despite statistically similar rates of bacteremia (11% vs 19%, P = .05).

CONCLUSIONS

The rapid diagnosis of Salmonella gastroenteritis by molecular methods was associated with increased hospital admission rates, blood culture obtainment, and antibiotic use. This suggests possible overmedicalization of uncomplicated Salmonella gastroenteritis, and clinicians should remain cognizant of the possibility of providing low-value care for uncomplicated disease.

Epidemiological and Clinical Characteristics of Non-Typhoidal Salmonella Bloodstream Infections in Central Israel: A Case-Control Study

Non-typhoidal Salmonella (NTS) infection continues to be a significant cause of morbidity. In addition to gastroenteritis (GE), NTS may cause bloodstream infections (BSI). Our goals were to characterize the demographics, clinical characteristics and outcome of NTS-BSI in central Israel. The study was a retrospective, case-control study conducted at the Tel Aviv Sourasky Medical Center between 2001−2018. Cases with NTS-BSI were matched by age and compared with two control groups, hospitalized patients with NTS-GE and patients with E. coli BSI. The NTS-BSI group included 34 patients who were compared with 69 and 68 patients in the NTS-GE and E. coli BSI groups, respectively. In the NTS-BSI group, the median age was 59 years, with 20% of patients below 20 years of age. Diarrhea was less common in NTS-BSI patients compared with NTS-GE: 53% vs. 80% (p < 0.01). Compared with NTS-GE patients, NTS-BSI patients had a higher rate of recent antimicrobial use: 21% vs. 5.9%, p = 0.03, respectively. They also had a slightly higher Charlson Comorbidity Index score, and history of past malignancy and steroid use, but these differences were not statistically significant. Antimicrobial treatment was documented in 30/34 of the NTS-BSI patients vs. 55/69 of the NTS-GE patients (p < 0.001). NTS-BSI patients had higher rates of in-hospital death (23% vs. 4%, p < 0.01) and a longer length of stay (8 vs. 4 days, p < 0.001) compared with NTS-GE. There was no significant difference in the outcome compared with the E. coli BSI group. In conclusion, our study found relatively low rates of pediatric cases compared with previous studies in Israel. NTS-BSI patients had slightly higher rates of comorbidities compared with NTS-GE patients, and a similar prognosis to E. coli BSI patients.

The activity of BcsZ of Salmonella Typhimurium and its role in Salmonella-plants interactions

Salmonella enterica is one of the most common human pathogens associated with fresh produce outbreaks. The present study suggests that expression of BcsZ, one of the proteins in the bcs complex, enhances the survival of Salmonella Typhimurium on parsley. BcsZ demonstrated glucanase activity with the substrates carboxymethylcellulose and crystalline cellulose, and was responsible for a major part of the S. Typhimurium CMCase activity. Moreover, there was constitutive expression of BcsZ, which was also manifested after exposure to plant polysaccharides and parsley-leaf extract. In an in-planta model, overexpression of BcsZ significantly improved the epiphytic and endophytic survival of S. Typhimurium on/in parsley leaves compared with the wild-type strain and bcsZ null mutant. Interestingly, necrotic lesions appeared on the parsley leaf after infiltration of Salmonella overexpressing BcsZ, while infiltration of the wild-type S. Typhimurium did not cause any visible symptoms. Infiltration of purified BcsZ enzyme, or its degradation products also caused symptoms on parsley leaves. We suggest that the BcsZ degradation products trigger the plant’s defense response, causing local necrotic symptoms. These results indicate that BcsZ plays an important role in the Salmonella-plant interactions, and imply that injured bacteria may take part in these interactions.

Non-typhoidal Salmonella bacteremia: comparison of adults and children in a single medical center

Introduction. Non-typhoidal Salmonella (NTS) bacteremia can cause significant morbidity and mortality. There is high incidence of Salmonellosis in the Middle East, including Israel, but there is a paucity of data on the clinical and epidemiological features of children in comparison to adults.Hypothesis/Gap Statement. Previous studies describing the differences between paediatric and adult populations with Salmonella bacteremia are sparse.Aim. This study's aim was to describe the differences between adults and children with NTS bacteremia.Methodology. All records of patients with NTS bacteremia between 1 January 1998 and 31 July 2020 were reviewed. Data regarding clinical manifestations and laboratory results were extracted from the medical records; records of children (aged <18 years) were compared with those of adults.Results. Records for 137 cases of Salmonella bacteremia (69 adults and 68 children, aged 2 days to 98 years) were reviewed. Seventy nine (58 %) patients had concomitant gastrointestinal symptoms. Fifty-eight (84 %) adults and 13 (19 %) children had underlying conditions (P<0.001). Eighteen patients died, none of whom was a child. Over the study period, most of the children (n=46, 67 %) but only five adults were discharged from the emergency department on their first visit to the ED.Conclusions. The main characteristics of NTS bacteremia in children compared to adults, are higher rates of prior discharge from emergency department, higher rate of gastrointestinal symptoms and better prognosis.

Exotic dried fruits caused Salmonella Agbeni outbreak with severe clinical presentation, Norway, December 2018 to March 2019

We describe an outbreak of Salmonella Agbeni sequence type (ST)2009 infections in Norway. Between 31 December 2018 and 16 March 2019, 56 cases (33 female and 23 male; median age: 50 years, range: 2-91) were reported, of which 21 were hospitalised. Cases were defined as people living in Norway, with laboratory-confirmed infection with S. Agbeni ST2009 and cluster type (CT)2489, reported between 31 December 2018 and 30 March 2019. We conducted a case-control study, with three controls per case (matched by age, sex and municipality), using the Norwegian National Registry. Cases were more likely to have consumed a commercial mix of dried exotic fruits than controls (cases = 8, controls = 31; odds ratio: 50; 95% confidence interval: 3-2,437). The outbreak strain was confirmed by whole genome sequencing (WGS) and was isolated from the fruit mix consumed by cases, resulting in withdrawal from the market on 6 March 2019.The fruit mix consisted of fruits from different countries and continents. It was packed in Italy and distributed to several European countries, including Norway. However, no other countries reported cases. This outbreak highlights that dried fruits could represent a risk in terms of food-borne infections, which is of particular concern in ready-to-eat products.

Correlates of non-typhoidal Salmonella bacteraemia: A case-control study

OBJECTIVE

Limited up-to-date evidence exists on host-related characteristics of non-typhoidal Salmonella (NTS) bacteraemia in high-income countries. Correlates of NTS bacteraemia in Israel were examined in this study.

METHODS

A case-control study was conducted using the medical records of patients hospitalized with NTS bacteraemia in Jerusalem during 1997-2016 (n=106; 57 children, 49 adults). Two control groups were included: (1) randomly selected controls (n=101), who were patients hospitalized due to bacteraemia with other pathogens; (2) patients with salmonellosis without bacteraemia (n=112). Age-stratified logistic regression models were constructed.

RESULTS

In children, a recent emergency room visit was associated with an increased likelihood of NTS bacteraemia. In adults, the likelihood of NTS bacteraemia versus salmonellosis increased in relation to Charlson comorbidity score (adjusted odds ratio (aOR) 1.29, 95% confidence interval (CI) 1.00-1.66, for each 1-point increase in the score), while an inverse association was found with haemoglobin level (aOR 0.72, 95% CI 0.54-0.95). Steroid therapy increased the likelihood of NTS bacteraemia compared to patients with bacteraemia due to other pathogens (aOR 5.22, 95% CI 1.01-26.93).

CONCLUSIONS

In children, NTS bacteraemia was probably present at their prior emergency room visit. A high comorbidity burden increased the likelihood of bacteraemia in adults with Salmonella infection, while haemoglobin level might be protective.

Epidemiology of non-typhoid Salmonella infection in the Australian Capital Territory over a 10-year period

AIM

To describe the epidemiology of non-typhoid Salmonella (NTS) infection in the Australian Capital Territory (ACT), including factors associated with hospitalisation.

METHODS

This was a retrospective descriptive and observational study of culture-confirmed NTS infections using data collected from ACT public health, public pathology and hospital services in the period 2003-2012. Outcome measures include incidence and NTS serotype for total reported and hospitalised cases and focus of infection, complications and antibiotic susceptibility for hospitalised cases.

RESULTS

In total, 1469 cases of NTS infection were reported, with the crude annual incidence increasing from 24.4 to 61.3 cases per 100 000 population; 14% were hospitalised, representing an incidence of 5.9 hospitalisations per 100 000 population, without significant change over time. Hospitalisation incidence peaked at the extremes of age. Comorbid disease and age ≥ 80 years were associated with complications during hospitalisation. Salmonella serotype Typhimurium was the most common serotype, accounting for 64% of NTS. Independent risk factors for invasive disease included non-S. Typhimurium serotype (aRR 5.46, 95%CI 1.69-17.65 P = 0.005), ischaemic heart disease (aRR 4.18, 95%CI 1.20-14.60 P = 0.025) and haematological malignancy (aRR 6.93, 95%CI 2.54-18.94 P < 0.001). Among hospitalised patients, resistance to ampicillin, ceftriaxone, trimethoprim-sulfamethoxazole and quinolones was 9.9%, 0%, 4.4% and 2.5% respectively.

CONCLUSIONS

NTS notifications in the ACT have increased over time, with outbreaks of food-borne disease contributing to this increase. Crude age-specific incidence is highest in the very young, while rates of hospitalisation are highest in the elderly. Comorbid disease and infection with a non-S. Typhimurium serotype were associated with complicated NTS disease course. Antimicrobial resistance in NTS is low and has not increased over time.

Salmonella burden in Lebanon

Salmonellosis is a disease that represents a major public health concern in both developing and developed countries. The aim of this article is to evaluate the public health burden of Salmonella illness in Lebanon. The current scope of the Salmonella infection problem was assessed in relation to disease incidence and distribution with respect to age, gender and district. Factors that provide a better understanding of the magnitude of the problem were explored and highlighted. Data reported to the Epidemiologic Surveillance Department at the Lebanese Ministry of Public Health between 2001 and 2013 was reviewed. Information obtained was compared to information reported regionally and globally. The estimated true incidence was derived using multipliers from the CDC and Jordan. A literature review of all published data from Lebanon about Salmonella susceptibility/resistance patterns and its serious clinical complications was conducted. The estimated incidence was 13·34 cases/100 000 individuals, most cases occurred in the 20-39 years age group with no significant gender variation. Poor and less developed districts of Lebanon had the highest number of cases and the peak incidence was in summer. Reflecting on the projected incidence derived from the use of multipliers indicates a major discrepancy between what is reported and what is estimated. We conclude that data about Salmonella infection in Lebanon and many Middle Eastern and developing countries lack crucial information and are not necessarily representative of the true incidence, prevalence and burden of illness.

Nontyphoidal Salmonella infection in children: relation to bacteremia, age, and infecting serotype

BACKGROUND

Salmonella gastroenteritis, usually self- limited, can result in bacteremia and focal disease. This study was undertaken to determine the role of age and infecting Salmonella serotype on the risk of bacteremia in children.

METHODS

This was a review of medical records of children with positive nontyphoidal Salmonella cultures seen in an urban setting at the Children's Hospital of Michigan in Detroit between July 1993 and December 2007.

RESULTS

Isolates recovered from 633 patients, representing 50 serotypes, included 594 positive stool cultures and 72 (11.4% of all patients) positive blood cultures. Salmonella serotype Typhimurium was the most common serotype, accounting for 29.4% (186/633) of isolates, of which only 3 (1.6%) were recovered from blood. The most common serotype recovered from blood was serotype Heidelberg (40/120 of patients with Heidelberg serotype) accounting for 55.5% (40/72) of positive blood cultures. The patients' age range was 2 weeks to 20 years, with a median of 7 months (interquartile range, IQR = 4-23 months). Bacteremic patients (n = 72) had a median age of 6.5 months (IQR = 4-11 months) and were comparable in age to non-bacteremic patients (n = 266), who had a median age of 5.5 months (IQR = 3-11 months) (p = 0.24). The odds ratio (OR) for bacteremia in patients infected with serotype Typhimurium was 0.21 and in patients with serotype Heidelberg was 4.0. Patients with serotype Heidelberg infection in the age groups < 3 months, 3-6 months, 6-12 months, and > 12 months had an OR for bacteremia of 9.2, 2.5, 3.2, and 6.0, respectively.

CONCLUSION

In our patient population, children with Salmonella serotype Heidelberg infection are at higher risk of bacteremia than children infected with other Salmonella serotypes. The risk is highest during the first 3 months of life.

Clinical characteristics in adult patients with Salmonella bacteremia and analysis of ciprofloxacin-nonsusceptible isolates

BACKGROUND/PURPOSE

The purpose of this study is to describe clinical characteristics of Salmonella bacteremia in adult patients and analyze ciprofloxacin-nonsusceptible isolates.

METHODS

A total of 101 Salmonella blood isolates from adult patients were collected from January 2011 to December 2013 in MacKay Memorial Hospital. Eight ciprofloxacin-nonsusceptible Salmonella blood isolates were screened for carbapenemase and other β lactamase genes. Isolates were examined by PCR for the quinolone resistance-determining region (QRDR) of all subunits for DNA gyrase (gyrA and gyrB) genes and topoisomerase IV (parC and parE) genes.

RESULTS

There were 22 (21.78%) S. enterica serovar B, 5 (4.95%) S. enterica serovar C1, 7 (6.93%) S. enterica serovar C2, 65 (64.36%) S. enterica serovar D, and 2 (1.98%) S. enterica serovar Typhi (S. typhi) isolates. β-lactamase gene screening and sequencing yielded only one blaCMY-2-positive isolate. In multivariate risk factor analysis, renal insufficiency [odds ratio (OR) 3.774; p = 0.020] and heart disease (OR 2.922; p = 0.027) were more common among elderly patients (≥65 years). Independent risk factors for ciprofloxacin-nonsusceptible strains included S. enterica serovar C2 (OR 28.430; p = 0.032), renal insufficiency (OR 13.927; p = 0.032), and immunosuppression agent usage (OR 60.082; p = 0.006). 87.50% (7/8) of isolates had gyrA mutation, 62.50% (5/8) had parC mutation, and none had gyrB and parE mutations. Isolates with both Ser83Phe/Asp87Asn gyrA and Thr57Ser/Ser80Ile parC mutation genes were highly ciprofloxacin-resistant (minimum inhibitory concentration ≥4 mg/L).

CONCLUSIONS

Elderly patients with renal insufficiency and heart disease were at risk for Salmonella bacteremia. Those for ciprofloxacin-nonsusceptible strains included S. enterica serovar C2, renal insufficiency, and immunosuppression agent usage. The 8 ciprofloxacin-nonsusceptible isolates carried gyrA and parC mutations, which cause resistance that poses a major concern.

Area-level global and local clustering of human Salmonella Enteritidis infection rates in the city of Toronto, Canada, 2007-2009

BACKGROUND

Salmonella enterica serotype Enteritidis (S. Enteritidis) remains a major foodborne pathogen in North America yet studies examining the spatial epidemiology of salmonellosis in urban environments are lacking. Our ecological study combined a number of spatial statistical methods with a geographic information system to assess area-level heterogeneity of S. Enteritidis infection rates in the city of Toronto.

METHODS

Data on S. Enteritidis infections between January 1, 2007 and December 31, 2009 were obtained from Ontario's surveillance system, and were grouped and analyzed at the forward sortation area (FSA)-level (an area signified by the first three characters of the postal code). Incidence rates were directly standardized using the FSA-level age- and sex-based standard population. A spatial empirical Bayes method was used to smooth the standardized incidence rates (SIRs). Global clustering of FSAs with high or low non-smoothed SIRs was evaluated using the Getis-Ord G method. Local clustering of FSAs with high, low, or dissimilar non-smoothed SIRs was assessed using the Getis-Ord Gi* and the Local Moran's I methods.

RESULTS

Spatial heterogeneity of S. Enteritidis infection rates was detected across the city of Toronto. The non-smoothed FSA-level SIRs ranged from 0 to 16.9 infections per 100,000 person-years (mean = 6.6), whereas the smoothed SIRs ranged from 2.9 to 11.1 (mean = 6.3). The global Getis-Ord G method showed significant (p ≤ 0.05) maximum spatial clustering of FSAs with high SIRs at 3.3 km. The local Getis-Ord Gi* method identified eight FSAs with significantly high SIRs and one FSA with a significantly low SIR. The Local Moran's I method detected five FSAs with significantly high-high SIRs, one FSA with a significantly low-low SIR, and four significant outlier FSAs (one high-low, and three low-high).

CONCLUSIONS

Salmonella Enteritidis infection rates clustered globally at a small distance band, suggesting clustering of high SIRs in small distinct areas. This finding was supported by the local cluster analyses, where distinct FSAs with high SIRs, mainly in downtown Toronto, were detected. These areas should be evaluated by future studies to identify risk factors of disease in order to implement targeted prevention and control programs. We demonstrated the usefulness of combining several spatial statistical techniques with a geographic information system to detect geographical areas of interest for further study, and to evaluate spatial processes that influenced S. Enteritidis infection rates. Our study methodology could be applied to other foodborne disease surveillance data.

Salmonella typhimurium abscess of the chest wall

Patient: Male, 73

Final Diagnosis: Salmonella typhimurium abscess of the chest wall

Symptoms: —

Medication: Ciprofloxacin

Clinical Procedure:—

Specialty: Infectious Diseases

Incidence, distribution, seasonality, and demographic risk factors of Salmonella Enteritidis human infections in Ontario, Canada, 2007-2009

BACKGROUND

In Canada, surveillance systems have highlighted the increasing trend of Salmonella enterica serovar Enteritidis (S. Enteritidis) human infections. Our study objectives were to evaluate the epidemiology of S. Enteritidis infections in Ontario using surveillance data from January 1, 2007 through December 31, 2009.

METHODS

Annual age-and-sex-adjusted incidence rates (IRs), annual and mean age-adjusted sex-specific IRs, and mean age-and-sex-adjusted IRs by public health unit (PHU), were calculated for laboratory-confirmed S. Enteritidis cases across Ontario using direct standardization. Multivariable Poisson regression with PHU as a random effect was used to estimate incidence rate ratios (IRRs) of S. Enteritidis infections among years, seasons, age groups, and sexes.

RESULTS

The annual age-and-sex-adjusted IR per 100,000 person-years was 4.4 [95% CI 4.0-4.7] in 2007, and 5.2 [95% CI 4.8-5.6] in both 2008 and 2009. The annual age-adjusted sex-specific IRs per 100,000 person-years ranged from 4.5 to 5.5 for females and 4.2 to 5.2 for males. The mean age-adjusted sex-specific IR was 5.1 [95% CI 4.8-5.4] for females and 4.8 [95% CI 4.5-5.1] for males. High mean age-and-sex-adjusted IRs (6.001-8.10) were identified in three western PHUs, one northern PHU, and in the City of Toronto. Regression results showed a higher IRR of S. Enteritidis infections in 2009 [IRR = 1.18, 95% CI 1.06-1.32; P = 0.003] and 2008 [IRR = 1.17, 95% CI 1.05-1.31; P = 0.005] compared to 2007. Compared to the fall season, a higher IRR of S. Enteritidis infections was observed in the spring [IRR = 1.14, 95% CI 1.01-1.29; P = 0.040]. Children 0-4 years of age (reference category), followed by children 5-9 years of age [IRR = 0.64, 95% CI 0.52-0.78; P < 0.001] had the highest IRRs. Adults ≥ 60 years of age and 40-49 years of age [IRR = 0.31, 95% CI 0.26-0.37; P < 0.001] had the lowest IRRs.

CONCLUSIONS

The study findings suggest that there was an increase in the incidence of S. Enteritidis infections in Ontario from 2007 to 2008-2009, and indicate seasonal, demographic, and regional differences, which warrant further public health attention.

Geographical variations in Salmonella incidence in Israel 1997-2006: the effect of rural residency

The overall incidence and serotype distribution of non-typhoid Salmonella (NTS) may vary between different geographical localities. To investigate possible regional differences and the effect of demographic factors, we studied 15 865 episodes of laboratory-confirmed NTS infection in Israel. Using Poisson models we found significant variation in the average annual incidence rate of NTS in 15 administrative sub-districts, which was inversely associated with the percent of rural residency (incidence rate ratio 0.75, 95% confidence interval 0.65–0.86, P<0.001). Variation was also found in the relative incidence of the most prominent serotypes (Enteritidis, Virchow, Typhimurium, Hadar, Infantis), which was affected by rural residency, the percent of non-Jewish population in the sub-district, and the percent of population aged o55 years in the sub-district.Rural residency had a major effect on the epidemiology of salmonellosis in Israel. Future research is required to understand whether decreased incidence in rural areas is an under-detection bias or reflects true differences in NTS illnesses.

Clinical manifestations of nontyphoid salmonellosis in children younger than 2 years old--experiences of a tertiary hospital in southern Taiwan

BACKGROUND

Few published studies have explored the clinical manifestations of nontyphoid salmonellosis in children <2 years of age. The aim of this study was to investigate the clinical manifestations, microbiological features, complications, fecal excretion time, and responses to treatment in children <2 years of age with nontyphoid salmonellosis.

METHODS

Between January 2005 and December 2009, pediatric patients who were admitted to Kaohsiung Veterans General Hospital with positive cultures for nontyphoid Salmonella were enrolled. The following data were recorded: demographic, clinical, and microbiological features, underlying diseases, treatment regimen, complications, responses to treatment, and fecal excretion time. The clinical manifestations were compared between patients <2 years of age and patients >2 years of age.

RESULTS

Of a total 279 enrolled patients, 179 were >2 years of age. Compared with the patients who were ≥2 years of age, patients <2 years of age demonstrated a significantly higher incidence of bloody stool, mixed infection, extraintestinal infection, longer course of antibiotics, longer course of diarrhea after admission, and more days spent in the hospital. The rates of insusceptibility of nontyphoid Salmonella to ampicillin, chloramphenicol, trimethoprim/sulfamethoxazole, ceftriaxone, and ciprofloxacin in patients <2 years of age were 37.87%, 29.09%, 23.73%, 3.26%, and 2.25%, respectively. Younger patients were generally more susceptible to antibiotics than patients ≥2 years of age, although this result was not statistically significant.

CONCLUSION

The clinical manifestations of nontyphoid salmonellosis are more severe in younger children <2 years of age than older children. Local susceptibility patterns could serve as a guide for the prescription of antibiotics by clinicians.

An outbreak of salmonella chester infection in Canada: rare serotype, uncommon exposure, and unusual population demographic facilitate rapid identification of food vehicle

Salmonella Chester infection has rarely been reported in the literature. In 2010, 33 case patients were reported in 2 months in four Canadian provinces. We conducted an outbreak investigation in collaboration with public health agencies, food safety specialists, regulatory agencies, grocery store chains, and the product distributor. We used case patient interviews, customer loyalty cards, and microbiological testing of clinical and food samples to identify nationally distributed head cheese as the food vehicle responsible for the outbreak. The rare serotype, a limited affected demographic group, and an uncommon exposure led to the rapid identification of the source. Control measures were implemented within 9 days of notification of the outbreak.

Salmonella infections: an update on epidemiology, management, and prevention

Salmonella species are a group of Gram-negative enterobacteria and known human pathogens in developing as well as industrialized countries. Despite significant advances in sanitation, provision of potable water, and highly controlled food chain surveillance, transmission of Salmonella spp. continues to affect communities, preferentially children, worldwide. This review summarizes updated concepts on typhoidal and non-typhoidal Salmonella infections, starting with a historical perspective that implicates typhoid Salmonella as a significant human pathogen since ancient times. We describe the epidemiology of this pathogen with emphasis on the most recent non-typhoidal Salmonella outbreaks in industrialized countries and continued outbreaks of typhoid Salmonella in underserved countries. An overview of clinical aspects of typhoid and non-typhoid infections in developing and industrialized countries, respectively, is provided, followed by a description on current treatment concepts and challenges treating multidrug-resistant Salmonella infections. We conclude with prevention recommendations, and recent research studies on vaccine prevention.