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Salmonella Infection: Treatment & Medication
Updated: Apr 3, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Perform a standard evaluation of airway, breathing, and circulation.
- Provide intravenous fluids if signs or symptoms of dehydration are present.
Emergency Department Care
- Perform a standard evaluation of airway, breathing, and circulation.
- Treat with rehydration and electrolyte replacement via oral or intravenous solutions for an uncomplicated gastroenteritis.
- Transfusions should be based on hemoglobin and hematocrit levels.
- Symptomatically manage pain, nausea, vomiting, and diarrhea.
- Antibiotics are indicated for infants up to 2 months of age, elderly patients, immunocompromised patients, those with a history of sickle-cell disease or prosthetic grafts, or patients who have extraintestinal findings.
Consultations
- Admission may be required if the patient exhibits unstable vitals signs, harbors significant risk factors, is younger than 2 months of age or elderly, is immunocompromised, or shows signs or symptoms of an extraintestinal manifestation.
- Appropriate specialty consultation for specific extraintestinal manifestations is indicated.
- Arrange for follow-up care on an outpatient basis with the patient’s primary care physician if discharged from the emergency department.
Medication
Antibiotics, antidiarrheals, and glucocorticoids are used to treat symptoms and/or documented Salmonella infection.
Antibiotics
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.20 However, antibiotic treatment should be considered on a case-by-case basis to include patients with severe symptoms.21 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 that have extraintestinal findings. Treatment of those at-risk patients should last 2-5 days or until the patient is afebrile.6,3
Nontyphoid 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.22
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.6,3 Fluoroquinolone resistance is an important factor in Salmonella typhi and was reported by the CDC to be 41.8% in 2004. Trimethoprim-sulfamethoxazole and chloramphenicol has a 13.2% prevalence of resistance in Salmonella typhi, while ampicillin, streptomycin, and sulfisoxazole are 11.8%.22
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.23 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.24
Some evidence suggests that fluoroquinolones may be used in children with infections that are difficult to treat. When treating children and pregnant women, it should be noted that treatment with fluoroquinolones should be carefully weighed against the possibility of damaging developing cartilage.25
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.6
Salmonella antibiotic resistance is a global concern that includes multi-drug resistant strains.12 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.26
Recent outbreaks show that there may be a connection between antimicrobial drug treatment and the risk of disease from Salmonella.27 Subsequently, stool and blood cultures and sensitivities are important, as susceptibilities not only vary depending on region of the world, but also locally.
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.
Adult
500 mg PO bid
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
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.
Adult
Gastroenteritis: 500 mg PO/IV qid for 3-7 d
Typhoid fever: 500 mg IV qid for 14 d
Pediatric
75-100 mg/kg/d IV divided q6h
Administered concurrently with barbiturates, chloramphenicol serum levels may decrease while barbiturate levels may increase causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; hydantoins may either increase or decrease chloramphenicol levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use only for indicated infections, or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome)
Trimethoprim and sulfamethoxazole (Bactrim)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Adult
2 g (based on SMZ) PO bid
Pediatric
<2 months: Do not administer
>2 months: 8 mg/kg/d (based on TMP) PO tid/qid for 14 d
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia caused by folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, persons with chronic alcoholism, elderly patients, those receiving anticonvulsant therapy, or persons with malabsorption syndrome); hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
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.
Adult
1-2 g IV bid
Pediatric
50-75 mg/kg/d IV
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and persons allergic to penicillin
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.
Adult
Day 1: 1000 mg PO
Days 2-5: 500 mg PO qd
Pediatric
Day 1: 10 mg/kg PO; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO; not to exceed 250 mg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzyme levels and cholestatic jaundice; caution in patients with impaired hepatic function or prolonged QT intervals
Amoxicillin (Amoxil, Biomox, Polymox, and Wymox)
Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria.
Adult
4-6 g PO qd
Pediatric
100 mg/kg/d PO divided q8h
Reduces the efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
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.
Adult
500-3000 mg IV q4-6h; not to exceed 12 g/d
Pediatric
200-300 mg/kg/d IV divided q6h; not to exceed 12 g/d
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Antidiarrheals
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.
Adult
4 mg PO initial; then 2 mg after each loose stool; not to exceed 16 mg/d
Pediatric
13-20 kg: 1 mg PO bid
20-30 kg: 2 mg PO bid
>30 kg: 2 mg PO tid
Phenothiazines, tricyclic antidepressants, and CNS depressants may increase toxicity
Documented hypersensitivity; diarrhea resulting from infections; pseudomembranous colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue use if no clinical improvement in 48 h; because primarily metabolized in liver, monitor for CNS toxicity in patients with hepatic insufficiency; do not use if high fever or blood in stool coincides with diarrhea
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.
Adult
2 tabs or 10 mL PO qid
Pediatric
<2 years: Not recommended
>2 years: 0.3-0.4 mg/kg/d PO divided qid
May delay metabolism of drugs in liver; CNS depressants, MAOIs, and antimuscarinic agents may increase the toxicity of drug combination
Documented hypersensitivity; narrow-angle glaucoma or hepatic insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In young children, dehydration may influence variability of response and predispose patient to delayed diphenoxylate intoxication; exercise caution in patients with ulcerative colitis; decrease in intestinal motility may be detrimental to patients with diarrhea resulting from Shigella species, Salmonella species, and toxigenic strains of Escherichia coli
Glucocorticoids
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.
Adult
3 mg/kg IV once, then 8 doses of 1 mg/kg IV q6h
Pediatric
Administer as in adults
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization
Documented hypersensitivity; active bacterial or fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use
More on Salmonella Infection |
| Overview: Salmonella Infection |
| Differential Diagnoses & Workup: Salmonella Infection |
 Treatment & Medication: Salmonella Infection |
| Follow-up: Salmonella Infection |
| Multimedia: Salmonella Infection |
| References |
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References
Coburn B, Grassl GA, Finlay BB. Salmonella, the host and disease: a brief review. Immunol Cell Biol. Feb-Mar 2007;85(2):112-8. [Medline].
Grassl GA, Finlay BB. Pathogenesis of enteric Salmonella infections. Curr Opin Gastroenterol. Jan 2008;24(1):22-6. [Medline].
Chambers HF. McPhee SJ, Papadakis MA, Tierney LM, eds. Current Medical Diagnosis & Treatment. 47th ed. McGraw-Hill Co; 2008:1250-1252.
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. Apr 11 2008;57(14):366-70. [Medline].
Linam WM, Gerber MA. Changing epidemiology and prevention of Salmonella infections. Pediatr Infect Dis J. Aug 2007;26(8):747-8. [Medline].
Peques DA, Ohl M, Miller S. Mandell, Douglas, and Bennett's: Principles and Practice of Infectious Diseases. 6th ed. Elsevier; 2005:chap 220.
Braden CR. Salmonella enterica serotype Enteritidis and eggs: a national epidemic in the United States. Clin Infect Dis. Aug 15 2006;43(4):512-7. [Medline].
Jones TF, Ingram LA, Fullerton KE, et al. A case-control study of the epidemiology of sporadic Salmonella infection in infants. Pediatrics. Dec 2006;118(6):2380-7. [Medline].
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. May 16 2008;57(19):521-4. [Medline].
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. Feb 6 2009;58(4):85-90. [Medline].
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. Apr 15 2004;38 Suppl 3:S127-34. [Medline].
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. Dec 2005;18(6):513-21. [Medline].
Boyle EC, Bishop JL, Grassl GA, et al. Salmonella: from pathogenesis to therapeutics. J Bacteriol. Mar 2007;189(5):1489-95. [Medline].
Sethuraman U, Kamat D. Management of child with fever after international travel. Clin Pediatr (Phila). Apr 2007;46(3):222-7. [Medline].
Heymann DL. Control of Communicable Diseases Manual. 18th ed. American Public Health Association; 2004:469-473.
Perera N, Geary C, Wiselka M, et al. Mixed Salmonella infection: case report and review of the literature. J Travel Med. Mar-Apr 2007;14(2):134-5. [Medline].
Hatta M, Smits HL. Detection of Salmonella typhi by nested polymerase chain reaction in blood, urine, and stool samples. Am J Trop Med Hyg. Jan 2007;76(1):139-43. [Medline].
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). Jan 2007;86(1):18-25. [Medline].
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. Sep 2007;11(36):1-216. [Medline].
Sirinavin S, Garner P. Antibiotics for treating salmonella gut infections. Cochrane Database Syst Rev. 2000;CD001167. [Medline].
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. Aug 1 1992;117(3):202-8. [Medline].
Centers for Disease Control and Prevention. National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS): Human Isolates Final Report, 2004. [Full Text].
[Best Evidence] 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. Oct 8 2008;CD004530. [Medline].
Parry CM, Threlfall EJ. Antimicrobial resistance in typhoidal and nontyphoidal salmonellae. Curr Opin Infect Dis. Oct 2008;21(5):531-8. [Medline].
Grady R. Safety profile of quinolone antibiotics in the pediatric population. Pediatr Infect Dis J. Dec 2003;22(12):1128-32. [Medline].
Threlfall EJ, de Pinna E, Day M, Lawrence J, Jones J. Alternatives to ciprofloxacin use for enteric Fever, United kingdom. Emerg Infect Dis. May 2008;14(5):860-1. [Medline].
Molbak K. Human health consequences of antimicrobial drug-resistant Salmonella and other foodborne pathogens. Clin Infect Dis. Dec 1 2005;41(11):1613-20. [Medline].
Buchwald DS, Blaser MJ. A review of human salmonellosis: II. Duration of excretion following infection with nontyphi Salmonella. Rev Infect Dis. May-Jun 1984;6(3):345-56. [Medline].
Gunduz GT, Gonul SA, Karapinar M. Efficacy of myrtle oil against Salmonella Typhimurium on fresh produce. Int J Food Microbiol. Mar 31 2009;130(2):147-50. [Medline].
Bhutta ZA. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. Jul 8 2006;333(7558):78-82. [Medline].
Torok TJ, Tauxe RV, Wise RP, et al. A large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars. JAMA. Aug 6 1997;278(5):389-95. [Medline].
Amieva MR. Important bacterial gastrointestinal pathogens in children: a pathogenesis perspective. Pediatr Clin North Am. Jun 2005;52(3):749-77, vi. [Medline].
Connor BA, Schwartz E. Typhoid and paratyphoid fever in travellers. Lancet Infect Dis. Oct 2005;5(10):623-8. [Medline].
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. Jan 12 1984;310(2):82-8. [Medline].
Parry CM, Hien TT, Dougan G, et al. Typhoid fever. N Engl J Med. Nov 28 2002;347(22):1770-82. [Medline].
Punjabi NH, Hoffman SL, Edman DC, et al. Treatment of severe typhoid fever in children with high dose dexamethasone. Pediatr Infect Dis J. Aug 1988;7(8):598-600. [Medline].
Further Reading
Keywords
Salmonella, salmonella infection, salmonella gastroenteritis, salmonellosis, typhi, typhoid fever, enteric fever, typhimurium, enteritidis, choleraesuis, Salmonella infection, severe diarrhea, food-borne illness
