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Salmonella Infection in Emergency Medicine Medication

  • Author: Michael D Owens, DO, MPH, FACEP, FAAEM; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Mar 21, 2016
 

Medication Summary

Antibiotics, antidiarrheals, and glucocorticoids are used to treat symptoms and/or documented Salmonella infection.

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Antibiotic

Class Summary

Nontyphoid Salmonella gastroenteritis is generally self-limited. In a Cochrane Database of Systematic Reviews article, 12 trials showed no significant change in the overall length of the illness or the related symptoms in otherwise healthy children and adults treated with a course of antibiotics for nontyphoid Salmonella disease. Antibiotics tend to increase adverse effects and prolong Salmonella detection in stools.[32]

However, antibiotic treatment should be considered on a case-by-case basis to include patients with severe symptoms.[33] Antibiotics are currently indicated for infants up to 2 months of age, elderly, immunocompromised, those with a history of sickle cell disease or prosthetic grafts, or patients who have extraintestinal findings. Treatment of those at-risk patients should last 2-5 days or until the patient is afebrile.[3]

Salmonella infections are commonly treated with fluoroquinolones or third-generation cephalosporins, such as ciprofloxacin and ceftriaxone. In 2004, the prevalence of resistance among nontyphoid Salmonella isolates was 2.6% for quinolones and 3.4% for third-generation cephalosporins.[34]

Enteric or typhoid fever is best treated with antibiotics for 5-7 days for uncomplicated cases and up to 10-14 days for a severe infection.[3] Bacteremia and focal infections may require antibiotics for up to 4-6 weeks depending on the site of infection and serotype of Salmonella. Specific surgical intervention is often necessary in conjunction with antibiotic management. Chronic Salmonella carriers require 1-3 months of oral antibiotics depending on the serotype, susceptibility, and antibiotic used.

Some evidence suggests that fluoroquinolones may be used in children with infections that are difficult to treat. When treating children and pregnant women, note that treatment with fluoroquinolones should be carefully weighed against the possibility of damaging developing cartilage.[35] Ampicillin and amoxicillin have been the classic treatment of choice in pregnancy patients and neonates.[17]

Salmonella antibiotic resistance is a global concern that includes multidrug resistant strains.[16] Overuse, misuse, inappropriate antibiotic prescribing practices, and patient poor compliance lead to a continued increase in multidrug-resistant typhoid fever.[21] Traditional first-line antibiotic medications include ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole. Resistance to these first-line antibiotics defines multidrug resistance in S enterica.[36] Despite the increase in ciprofloxacin resistance in typhoid and paratyphoid, it is still considered the drug of choice by many physicians. However, in the case of treatment failures, a third-generation cephalosporin and macrolide are good alternatives.[37] The reemergence of chloramphenicol-sensitive strains in prior resistant organisms points towards the concept of antibiotic recycling.[17]

Outbreaks show that a connection may exist between antimicrobial drug treatment and the risk of disease from Salmonella.[38] A mouse model has shown enhanced ability of Salmonella to translocate the intestinal tract more easily in the presence of antibiotics.[9]

Subsequently, stool and blood cultures and sensitivities are important, as susceptibilities not only vary depending on region of the world but also locally. In developing countries such as India, ciprofloxacin continues to be the mainstay of treatment, even though the incidence of resistant strains is increasing.[17] Zinc and probiotic supplements have been shown to reduce the severity and duration of diarrhea.[39]

Fluoroquinolone resistance is an important factor in Salmonellatyphi and was reported by the CDC to be 41.8% in 2004. Trimethoprim-sulfamethoxazole and chloramphenicol have a 13.2% prevalence of resistance in Salmonella typhi, while ampicillin, streptomycin, and sulfisoxazole are 11.8%.[34]

In a Cochrane Database of Systematic Reviews article, 38 trials showed a reduced clinical relapse rate using fluoroquinolones versus chloramphenicol. However, this same review was not statistically significant for clinical failure or microbiological failure and was limited for other comparisons including children.[40] Additionally, because nalidixic acid resistance is no longer a reliable method for detecting decreased ciprofloxacin susceptibility, international in vitro studies suggest that gatifloxacin may be more active than ciprofloxacin in these isolates.[41]

Ciprofloxacin (Cipro)

 

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms but has no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth. Is effective in treatment of long-term carriers of S typhi.

Chloramphenicol

 

Acts by inhibiting bacterial protein synthesis. Binds reversibly to the 50S subunit of bacterial 70S ribosome and prevents attachment of the amino acid-containing end of the aminoacyl-tran to acceptor site on ribosome. Active in vitro against a wide variety of bacteria, including gram-positive, gram-negative, aerobic, and anaerobic organisms. Well-absorbed from GI tract and metabolized in the liver, where it is inactivated by conjugation with glucuronic acid and then excreted by the kidneys. Oral form is not available in the United States.

Trimethoprim and sulfamethoxazole (Bactrim)

 

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Ceftriaxone (Rocephin)

 

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Azithromycin (Zithromax)

 

Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.

Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.

Treats mild-to-moderate microbial infections.

Amoxicillin (Amoxil, Biomox, Polymox, and Wymox)

 

Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria.

Ampicillin (Principen)

 

Broad-spectrum penicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.

Demonstrated effectiveness in treatment of gastroenteritis, invasive disease, and enteric fever.

Cefpodoxime (Vantin)

 

Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins; bacteria eventually lyse because of ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.

Bactericidal activity is against gram-positive and gram-negative bacteria.

Cefotaxime (Claforan)

 

Third-generation cephalosporin with broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins, which in turn inhibits bacterial growth. Used for septicemia and treatment of gynecologic infections caused by susceptible organisms.

Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.

Cefixime (Suprax)

 

Third-generation oral cephalosporin with broad activity against gram-negative bacteria. By binding to one or more of the penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth.

Note: After a period of inavailability, oral Cefixime is again FDA-approved in tablet and suspension forms. However, at the time of writing, tablets remain unavailable in this country. Wyeth Pharmaceuticals (Collegeville, Pennsylvania) discontinued manufacturing cefixime (Suprax®) in the United States. In October 2002, the company ceased marketing cefixime tablets (200 mg and 400 mg) because of depletion of company inventory. Wyeth's patent for cefixime expired on November 10, 2002.

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Antidiarrheals

Class Summary

These agents may prolong the course of the disease. If used, they should be used sparingly.

Loperamide (Imodium)

 

Acts on intestinal muscles to inhibit peristalsis and slow intestinal motility. Prolongs movement of electrolytes and fluid through bowel and increases viscosity and loss of fluids and electrolytes. Available as 2-mg tablets and 1-mg/5-mL liquid.

Diphenoxylate and atropine (Lomotil)

 

Drug combination that consists of diphenoxylate, which is a constipating meperidine congener, and atropine to discourage abuse. Inhibits excessive GI propulsion and motility. Supplied as diphenoxylate 2.5 mg and atropine 0.025 mg per tablet or per 5 mL of liquid.

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Glucocorticoids

Class Summary

These agents may be indicated in patients with severe enteric or typhoid fever or significant complications such as CNS manifestations or DIC.

Dexamethasone (Decadron)

 

Used in the treatment of various inflammatory diseases. Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

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Contributor Information and Disclosures
Author

Michael D Owens, DO, MPH, FACEP, FAAEM Assistant Professor of Military/Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Clinical Faculty, Emergency Medicine Residency, Naval Medical Center Portsmouth; Consulting Staff, Department of Emergency Medicine, Chesapeake Emergency Physicians, Inc, Chesapeake Regional Medical Center

Michael D Owens, DO, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Dirk A Warren, MD Emergency Medicine Resident, Naval Medical Center Portsmouth

Dirk A Warren, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Emergency Physicians, Society of US Naval Flight Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor - Chief Editor for Medscape.

Additional Contributors

Mark Louden, MD Assistant Professor of Clinical Medicine, Division of Emergency Medicine, Department of Medicine, University of Miami, Leonard M Miller School of Medicine

Mark Louden, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

References
  1. Coburn B, Grassl GA, Finlay BB. Salmonella, the host and disease: a brief review. Immunol Cell Biol. 2007 Feb-Mar. 85(2):112-8. [Medline].

  2. Grassl GA, Finlay BB. Pathogenesis of enteric Salmonella infections. Curr Opin Gastroenterol. 2008 Jan. 24(1):22-6. [Medline].

  3. Chambers HF. McPhee SJ, Papadakis MA, Tierney LM, eds. Current Medical Diagnosis & Treatment. 47th ed. McGraw-Hill Co; 2008. 1250-1252.

  4. Centers for Disease Control and Prevention. Vital signs: incidence and trends of infection with pathogens transmitted commonly through food--foodborne diseases active surveillance network, 10 U.S. sites, 1996-2010. MMWR Morb Mortal Wkly Rep. 2011 Jun 10. 60(22):749-55. [Medline].

  5. Linam WM, Gerber MA. Changing epidemiology and prevention of Salmonella infections. Pediatr Infect Dis J. 2007 Aug. 26(8):747-8. [Medline].

  6. Peques DA, Miller SI. Salmonella Species, Including Salmonella Typhi. Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Disease. 7th ed. Elsevier; 2009. chap. 223.

  7. Centers for Disease Control and Prevention. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food - 10 states, 2009. MMWR Morb Mortal Wkly Rep. 2010 Apr 16. 59(14):418-22. [Medline]. [Full Text].

  8. Rai B, Utekar T, Ray R. Preterm delivery and neonatal meningitis due to transplacental acquisition of non-typhoidal Salmonella serovar montevideo. BMJ Case Rep. 2014 May 29. 2014:[Medline].

  9. Croswell A, Amir E, Teggatz P, Barman M, Salzman NH. Prolonged impact of antibiotics on intestinal microbial ecology and susceptibility to enteric Salmonella infection. Infect Immun. 2009 Jul. 77(7):2741-53. [Medline]. [Full Text].

  10. Braden CR. Salmonella enterica serotype Enteritidis and eggs: a national epidemic in the United States. Clin Infect Dis. 2006 Aug 15. 43(4):512-7. [Medline].

  11. Jones TF, Ingram LA, Fullerton KE, et al. A case-control study of the epidemiology of sporadic Salmonella infection in infants. Pediatrics. 2006 Dec. 118(6):2380-7. [Medline].

  12. Centers for Disease Control and Prevention. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food--10 states, 2007. MMWR Morb Mortal Wkly Rep. 2008 Apr 11. 57(14):366-70. [Medline].

  13. Centers for Disease Control and Prevention. Multistate outbreak of human Salmonella infections caused by contaminated dry dog food--United States, 2006-2007. MMWR Morb Mortal Wkly Rep. 2008 May 16. 57(19):521-4. [Medline]. [Full Text].

  14. Centers for Disease Control and Prevention. Multistate outbreak of Salmonella infections associated with peanut butter and peanut butter-containing products--United States, 2008-2009. MMWR Morb Mortal Wkly Rep. 2009 Feb 6. 58(4):85-90. [Medline]. [Full Text].

  15. Voetsch AC, Van Gilder TJ, Angulo FJ, et al. FoodNet estimate of the burden of illness caused by nontyphoidal Salmonella infections in the United States. Clin Infect Dis. 2004 Apr 15. 38 Suppl 3:S127-34. [Medline].

  16. Weinberger M, Keller N. Recent trends in the epidemiology of non-typhoid Salmonella and antimicrobial resistance: the Israeli experience and worldwide review. Curr Opin Infect Dis. 2005 Dec. 18(6):513-21. [Medline].

  17. Harish BN, Menezes GA. Antimicrobial resistance in typhoidal salmonellae. Indian J Med Microbiol. 2011 Jul-Sep. 29(3):223-9. [Medline].

  18. Meltzer E, Schwartz E. Enteric fever: a travel medicine oriented view. Curr Opin Infect Dis. 2010 Oct. 23(5):432-7. [Medline].

  19. Boyle EC, Bishop JL, Grassl GA, Finlay BB. Salmonella: from pathogenesis to therapeutics. J Bacteriol. 2007 Mar. 189(5):1489-95. [Medline]. [Full Text].

  20. Sethuraman U, Kamat D. Management of child with fever after international travel. Clin Pediatr (Phila). 2007 Apr. 46(3):222-7. [Medline].

  21. Zaki SA, Karande S. Multidrug-resistant typhoid fever: a review. J Infect Dev Ctries. 2011 May 28. 5(5):324-37. [Medline].

  22. Heymann DL. Control of Communicable Diseases Manual. 18th ed. American Public Health Association; 2004. 469-473.

  23. Hedican E, Hooker C, Jenkins T, et al. Restaurant Salmonella Enteritidis outbreak associated with an asymptomatic infected food worker. J Food Prot. 2009 Nov. 72(11):2332-6. [Medline].

  24. Brooks JT, Matyas BT, Fontana J, DeGroot MA, Beuchat LR, Hoekstra M, et al. An outbreak of Salmonella serotype Typhimurium infections with an unusually long incubation period. Foodborne Pathog Dis. 2012 Mar. 9 (3):245-8. [Medline].

  25. Parry CM, Wijedoru L, Arjyal A, Baker S. The utility of diagnostic tests for enteric fever in endemic locations. Expert Rev Anti Infect Ther. 2011 Jun. 9(6):711-25. [Medline].

  26. Nagaraja V, Eslick GD. Systematic review with meta-analysis: the relationship between chronic Salmonella typhi carrier status and gall-bladder cancer. Aliment Pharmacol Ther. 2014 Apr. 39 (8):745-50. [Medline].

  27. Hatta M, Smits HL. Detection of Salmonella typhi by nested polymerase chain reaction in blood, urine, and stool samples. Am J Trop Med Hyg. 2007 Jan. 76(1):139-43. [Medline].

  28. Bottieau E, Clerinx J, Van den Enden E, et al. Fever after a stay in the tropics: diagnostic predictors of the leading tropical conditions. Medicine (Baltimore). 2007 Jan. 86(1):18-25. [Medline].

  29. Abubakar I, Irvine L, Aldus CF, et al. A systematic review of the clinical, public health and cost-effectiveness of rapid diagnostic tests for the detection and identification of bacterial intestinal pathogens in faeces and food. Health Technol Assess. 2007 Sep. 11(36):1-216. [Medline].

  30. Laube T, Cortés P, Llagostera M, Alegret S, Pividori MI. Phagomagnetic immunoassay for the rapid detection of Salmonella. Appl Microbiol Biotechnol. 2013 Dec 21. [Medline].

  31. Kuhn KG, Falkenhorst G, Ceper TH, et al. Detecting non-typhoid Salmonella in humans by ELISAs: a literature review. J Med Microbiol. 2012 Jan. 61:1-7. [Medline].

  32. Onwuezobe IA, Oshun PO, Odigwe CC. Antimicrobials for treating symptomatic non-typhoidal Salmonella infection. Cochrane Database Syst Rev. 2012. 11:CD001167. [Medline].

  33. Wistrom J, Jertborn M, Ekwall E, et al. Empiric treatment of acute diarrheal disease with norfloxacin. A randomized, placebo-controlled study. Swedish Study Group. Ann Intern Med. 1992 Aug 1. 117(3):202-8. [Medline].

  34. Centers for Disease Control and Prevention. National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS): Human Isolates Final Report, 2004. [Full Text].

  35. Grady R. Safety profile of quinolone antibiotics in the pediatric population. Pediatr Infect Dis J. 2003 Dec. 22(12):1128-32. [Medline].

  36. Crump JA, Mintz ED. Global trends in typhoid and paratyphoid Fever. Clin Infect Dis. 2010 Jan 15. 50(2):241-6. [Medline]. [Full Text].

  37. Threlfall EJ, de Pinna E, Day M, Lawrence J, Jones J. Alternatives to ciprofloxacin use for enteric Fever, United kingdom. Emerg Infect Dis. 2008 May. 14(5):860-1. [Medline]. [Full Text].

  38. Mølbak K. Human health consequences of antimicrobial drug-resistant Salmonella and other foodborne pathogens. Clin Infect Dis. 2005 Dec 1. 41(11):1613-20. [Medline].

  39. Dekate P, Jayashree M, Singhi SC. Management of acute diarrhea in emergency room. Indian J Pediatr. 2013 Mar. 80(3):235-46. [Medline].

  40. Thaver D, Zaidi AK, Critchley JA, Azmatullah A, Madni SA, Bhutta ZA. Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever). Cochrane Database Syst Rev. 2008 Oct 8. CD004530. [Medline].

  41. Parry CM, Threlfall EJ. Antimicrobial resistance in typhoidal and nontyphoidal salmonellae. Curr Opin Infect Dis. 2008 Oct. 21(5):531-8. [Medline].

  42. Buchwald DS, Blaser MJ. A review of human salmonellosis: II. Duration of excretion following infection with nontyphi Salmonella. Rev Infect Dis. 1984 May-Jun. 6(3):345-56. [Medline].

  43. Corcoran M, Morris D, De Lappe N, O'Connor J, Lalor P, Dockery P. Commonly used disinfectants fail to eradicate Salmonella enterica biofilm from food contact surface materials. Appl Environ Microbiol. 2013 Dec 20. [Medline].

  44. Gündüz GT, Gönül SA, Karapinar M. Efficacy of myrtle oil against Salmonella Typhimurium on fresh produce. Int J Food Microbiol. 2009 Mar 31. 130(2):147-50. [Medline].

  45. Bhutta ZA. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. 2006 Jul 8. 333(7558):78-82. [Medline]. [Full Text].

  46. Torok TJ, Tauxe RV, Wise RP, et al. A large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars. JAMA. 1997 Aug 6. 278(5):389-95. [Medline].

  47. Adhikari B, Besser TE, Gay JM, et al. Introduction of new multidrug-resistant Salmonella enterica strains into commercial dairy herds. J Dairy Sci. 2009 Sep. 92(9):4218-28. [Medline].

  48. Amieva MR. Important bacterial gastrointestinal pathogens in children: a pathogenesis perspective. Pediatr Clin North Am. 2005 Jun. 52(3):749-77, vi. [Medline].

  49. Connor BA, Schwartz E. Typhoid and paratyphoid fever in travellers. Lancet Infect Dis. 2005 Oct. 5(10):623-8. [Medline].

  50. Hoffman SL, Punjabi NH, Kumala S, et al. Reduction of mortality in chloramphenicol-treated severe typhoid fever by high-dose dexamethasone. N Engl J Med. 1984 Jan 12. 310(2):82-8. [Medline].

  51. Parry CM, Hien TT, Dougan G, White NJ, Farrar JJ. Typhoid fever. N Engl J Med. 2002 Nov 28. 347(22):1770-82. [Medline].

  52. Perera N, Geary C, Wiselka M, Rajakumar K, Andrew Swann R. Mixed Salmonella infection: case report and review of the literature. J Travel Med. 2007 Mar-Apr. 14(2):134-5. [Medline].

  53. Punjabi NH, Hoffman SL, Edman DC, et al. Treatment of severe typhoid fever in children with high dose dexamethasone. Pediatr Infect Dis J. 1988 Aug. 7(8):598-600. [Medline].

 
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Under a moderately high magnification of 8000X, this colorized scanning electron micrograph (SEM) revealed the presence of a small grouping of gram-negative Salmonella typhimurium bacteria that had been isolated from a pure culture. Image courtesy of the Centers for Disease Control and Prevention, Bette Jensen, and Janice Haney Carr.
 
 
 
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