eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Salmonella Infection

Archana Chatterjee, MD, PhD, Professor of Pediatrics, Medical Microbiology and Immunology, and Pharmacy, Division of Pediatric Infectious Diseases, Chief of Division of Pediatric Infectious Diseases, Creighton University School of Medicine; Hospital Epidemiologist and Medical Director of Infection Control, Children's Hospital
Catherine O'Keefe, DNP, APRN, Assistant Professor of Nursing, Pediatric Nurse Practitioner, Pediatric Infectious Diseases, Creighton University School of Nursing; Meera Varman, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University School of Medicine

Updated: Jan 9, 2009

Introduction

Background

Infections due to Salmonella species represent a major public health problem in many countries. In the United States, nontyphoidal Salmonella (NTS) is the most common pathogen implicated in food-borne gastroenteritis. In most cases, NTS is a self-limiting disease that causes mild gastroenteritis; however, it can lead to a wide spectrum of complications including bacteremia, enterocolitis, and severe local infections such as meningitis and osteomyelitis. Salmonella serotype typhi can cause serious and prolonged bacteremic illness referred to as enteric fever or typhoid fever.¹

Pathophysiology

The extension of the disease to various organs depends on the serotype, the size of the inoculum, and the status of the host. If large enough numbers of bacteria are ingested, they can survive in the normally lethal acidic pH of the stomach.Once ingested, Salmonella can gain access to the small intestine, producing diffuse mucosal inflammation, edema, and microabscesses. Generally, most NTS do not extend beyond the lamina propria and lymphatics of the gut. Exceptions include Salmonella choleraesuis and Salmonella dublin, which can cause bacteremia with little intestinal involvement.² In individuals with S typhi, areas of intestinal necrosis can ulcerate and result in perforation. In addition, this mucosal penetration allows uptake into the draining lymph nodes, contributing to blood stream infections (BSI) and subsequent invasion of the liver, spleen, and bone marrow. This process explains the delayed onset of symptoms in S typhi.³

Frequency

United States

From 1996-2006, more than 50,000 laboratory-confirmed cases of NTS infections occurred annually, an average of 14.7 infections per 100,000 persons per year.^4,5  Approximately 400 cases of typhoid fever are reported per year. More than two thirds of cases are acquired from foreign travel. From 1985-1994, travel to Mexico and India accounted for most cases of typhoid fever. However, in the last 10 years US travelers to Asia, Africa, and Latin America have been especially at risk.⁶

International

The past 2 decades have seen an increase in the incidence of NTS in Europe and North America.⁴ Typhoid fever is endemic in many developing areas of the world. Five Asian countries are considered to be endemic for typhoid: China, India, Indonesia, Pakistan, and Vietnam.¹ Annually, the World Health Organization (WHO) estimates 16-33 million cases of typhoid fever worldwide and 500,000-600,000 deaths.

Mortality/Morbidity

Enteric infections account for significant morbidity and mortality in young children (aged 1-4 y). Morbidity and mortality rates are highest in infants (most dangerous in infants <3 mo with bacteremia), elderly patients, and patients with sickle cell disease, acquired immunodeficiency syndrome (AIDS), neoplasms, or other immunosuppressive conditions.^1,7 Substantial differences in outcomes have been noted based on varying serotypes.⁵

Race

The incidence of infection for all serotyped NTS is almost twice as high in blacks and Latinos, Salmonella typhimurium is the most common pathogen.⁸

Sex

No sex differences are noted.⁸

Age

Attack rates are highest in persons younger than 5 years or older than 70 years.^8,1

Clinical

History

Carefully obtain the patient's history to determine any potential sources of Salmonella and to help determine if the correct diagnosis has been made.

• General history
  • Inquire about any recent travel abroad.
  • Inquire about possible animal exposures, including contact with pet iguanas, turtles, tortoises, or other reptiles.
  • Inquire whether any family members have current or recent gastroenteritis.
  • Inquire whether any recent outbreaks have occurred in the community.
• Salmonella gastroenteritis
  • The incubation period of Salmonella gastroenteritis is 6-72 hours.
  • In most cases, children have cramping abdominal pain, nausea, vomiting, and loose watery stools.
  • Stools may be bloody; however, this is not as common as in infection with Shigella.
  • Fever, which rarely exceeds 39°C, occurs in approximately one half of infected patients.
  • Symptoms usually resolve spontaneously in 2-7 days.
• Enteric fever (typhoid fever)
  • Enteric fever is caused by S typhi and several other Salmonella serotypes.
  • The incubation period for enteric fever is 3-60 days, but symptoms typically occur in 1-2 weeks.
  • Patients may present with high fever, which rises in a steplike fashion.
  • Other symptoms include anorexia, abdominal pain, malaise, myalgias, headache, cough, diarrhea or constipation, and delirium.

Physical

• Salmonella gastroenteritis
  • Upon physical examination, patients may have signs of dehydration, such as delayed capillary refill, sunken eyes, dry mucous membranes, or tachycardia.
  • Patients may have tenderness to palpation on abdominal examination, which sometimes can be difficult to differentiate from appendicitis.
  • Rectal examination may reveal heme-positive stools, gross blood, or mucoid stools.
• Enteric fever (typhoid fever)
  • A typical finding of enteric fever is relative bradycardia for the height of the fever.
  • Hepatosplenomegaly may be found on examination.
  • Patients with enteric fever may develop rose spots; these spots are blanching pink papules most commonly found on the anterior thorax. They usually fade about 3-4 days after appearance, are 2-4 mm in diameter, and occur in groups of 5-20.

Causes

• Salmonella organisms are gram-negative rod-shaped bacilli in the family Enterobacteriaceae. All Salmonella organisms are to be considered a single species (Salmonella enterica) because of their close relationship by DNA hybridization studies.³
• Differences in lipopolysaccharide (LPS) and flagellar structure generate the antigenic variation that is reflected in the more than 2500 known serotypes that cause human disease.
• Nontyphoidal Salmonella (NTS)   serotypes are divided into O-antigen groups A through E. Since 1997, Salmonella enteritidis (D), S typhimurium (B), and Salmonella newport (C2) account for about half of the culture-confirmed Salmonella isolates.
• The principal reservoirs for NTS organisms are poultry, livestock, reptiles, and pets. The mode of transmission is ingestion of foods of animal origin, including poultry, red meats, unpasteurized milk, and eggs that have been contaminated by infected animals or an infected human.¹
• Recent Salmonella outbreaks have been attributed to commercially produced items, such as peanut butter, frozen pot pies, puffed vegetable snacks, and dry dog food.^{9,10,11,12,13} Contact with infected reptiles, such as iguanas, pet turtles, and tortoises, and ingestion of contaminated water are other modes of transmission.
• S typhi (D) is the species known to cause enteric fever (typhoid fever). S typhi is found only in humans. In the United States, typhoid fever is usually caused by foreign travel to countries with contaminated food and drinking water or by ingestion of food contaminated by a chronic carrier.¹ Travelers visiting friends and relatives in typhoid-endemic countries may be at more risk than tourists because of a lack of precautionary measures.¹⁴ Historically, Salmonella paratyphi (A) has been the cause of a smaller proportion of the cases of enteric fever. However, China and India are experiencing a substantial increase in enteric fever caused by S paratyphi (A).¹⁵
• Recently, excess antibiotic use in the prior year has been associated with a higher incidence of NTS. Disruption of the microflora of the gut has been offered as a possible cause; however, an alternate explanation may be that these individuals are a more medically fragile group, requiring more antibiotics and, in general, are more susceptible to illness.¹⁶

Differential Diagnoses

Colitis
Food Poisoning
Gastroenteritis
Shigella Infection

Other Problems to Be Considered

Viral enteritis
Toxic ingestions
Bacterial gastroenteritis
Parasitic infections

Workup

Laboratory Studies

The following tests are indicated in Salmonella infection:

• CBC count with differential
  • CBC count is often 10,000-15,000/μ L in simple gastroenteritis.
  • Patients with enteric fever commonly have anemia, thrombocytopenia, or neutropenia, although a shift to more immature forms can be seen on the differential count.
• Cultures
  • Isolation of Salmonella from cultures of stool, blood, urine, or bone marrow is diagnostic.
  • Cultures of rose spots and/or bone marrow aspirate may be positive in enteric fever even when stool culture findings are negative for Salmonella.
• Stool examination: Stool may be hemoccult positive and may have positive findings for fecal polymorphonuclear cells.
• Chemistry
  • Electrolyte tests may reveal metabolic acidosis or other abnormalities consistent with dehydration.
  • Patients with enteric fever may have mild hepatitis.
• Serologic tests: Tests for Salmonella agglutinins (febrile agglutinins, Widal test) may suggest infection with S typhi; however, they are not recommended because of the number of false-positive and false-negative results.

Imaging Studies

• Imaging studies are not necessary for most patients with simple gastroenteritis and enteric fever without any severe complications.
• Consider chest radiography if pneumonia is suggested as the result of bacteremia.
• Perform abdominal radiography if the patient presents with peritoneal signs on physical examination. Consider intestinal perforation as a complication of enteric fever.
• Perform a bone scan if osteomyelitis is considered as a complication of bacteremia. MRI, which is more sensitive, can be done to evaluate osteomyelitis.

Treatment

Medical Care

• Salmonella gastroenteritis
• For uncomplicated gastroenteritis caused by nontyphoidal Salmonella species, antimicrobial therapy is not indicated because it does not shorten the duration of illness and may prolong the duration of fecal excretion.
• Treatment involves monitoring hydration status and intravenous (IV) therapy to correct electrolyte imbalance or restore intravascular volume.
• Antidiarrheal agents may actually prolong GI transit time and the illness.
• Antimicrobial agents and hospital admission may be recommended in Salmonella gastroenteritis in infants younger than 3 months, infants younger than 12 months with temperatures of more than 39°C and unknown blood culture results, and patients with hemoglobinopathies, human immunodeficiency virus (HIV) infection or other causes of immunosuppression, neoplasms, or chronic GI illnesses.
• The recommended antibiotics for individuals at high risk for invasive disease include ampicillin, amoxicillin, and trimethoprim-sulfamethoxazole (TMP-SMZ). In areas with multidrug resistance, cefotaxime or ceftriaxone are recommended.
• Treatment of invasive Salmonella disease (bacteremia, extraintestinal manifestations)
• Empiric antimicrobial therapy should include a broad-spectrum cephalosporin (cefotaxime or ceftriaxone). Once susceptibilities are available, narrow-spectrum therapy includes ampicillin, amoxicillin, cefotaxime, ceftriaxone, chloramphenicol, TMP-SMZ, or a fluoroquinolone.
• A 14-day course of antibiotics is recommended for patients with bacteremia.
• Patients with localized infection, such as osteomyelitis or an abscess, or patients with bacteremia and HIV infections should receive 4-6 weeks of therapy.
• For Salmonella meningitis, ceftriaxone or cefotaxime is recommended for 4 weeks or longer.
• Enteric fever caused by S typhi infection
• For S typhi infection, initial empiric therapy with ceftriaxone is recommended due to widespread resistance. If susceptible, chloramphenicol, ampicillin, or TMP-SMZ may be used. Duration of therapy should be 14 days.   
• In severe infection, parenteral therapy is indicated.
• Use antipyretics with caution or not at all because they may cause precipitous drops in temperature and shock. Fever may last 5-7 days, even with appropriate therapy. 
• Relapse is common (£ 15%), and patients must be re-treated.
• A short course of high dose-corticosteroids may be involved in treatment of patients with life-threatening neurologic complications of enteric fever.
• High-dose ampicillin or high-dose amoxicillin plus probenecid for 4-6 weeks has cured many chronic carriers. Ciprofloxacin is the drug of choice for adult carriers.¹
• Multidrug resistance
• As many as 40% of nontyphoidal Salmonella (NTS) isolates in the United States are multidrug resistant, with increasing resistance to all Salmonella strains worldwide.³ In particular parts of the world (ie, India, Pakistan, Egypt), multiply antibiotic-resistant strains of S typhi are reported. Travelers from these regions should be treated with a 7-day to 10-day course of ceftriaxone or 5-day to 7-day course of ciprofloxacin or ofloxacin.
• Decreased ciprofloxacin susceptibility and ceftriaxone resistance has been reported in developing countries.^17,18,19

Surgical Care

• Cholecystectomy may be curative in carriers with chronic gallbladder disease.
• Focal abscesses may require drainage.³

Consultations

• Consider consultation with a pediatric infectious disease specialist if the appropriate antibiotic for treatment or the length of treatment are questioned in patients with documented Salmonella infection.
• Consider surgical consultation for patients with enteric fever who appear to have complications such as intestinal perforation, splenic rupture, or pancreatitis.

Diet

• Restrict initial oral intake to electrolyte solutions, such as Pedialyte or clear liquids.
• Add solid foods only when the diarrhea appears to be improving and dehydration is not present.
• Initially, children can be started on a BRAT diet (ie, bananas, rice, applesauce, toast) and then slowly advanced to a regular diet as tolerated.

Medication

In most simple gastroenteritis, antibiotics are not necessary and, in fact, can prolong the duration of illness.

Antibiotics

Patients who are susceptible to invasive disease, those with invasive Salmonella, and those with enteric fever require treatment with antimicrobials.

Amoxicillin (Amoxil, Polymox, Trimox)

Interferes with cell wall synthesis. High-dose amoxicillin can be used if treatment with parenteral therapy not necessary.

Dosing

Adult

4-6 g/d PO divided tid

Pediatric

100 mg/kg/d PO divided q6h

Interactions

Coadministration with allopurinol may increase risk of rash

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in patients with known renal failure

Ampicillin (Marcillin, Omnipen, Polycillin, Principen)

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

Dosing

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

Interactions

Coadministration with allopurinol may increase risk of rash

Contraindications

Documented hypersensitivity

Precautions

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; breastfeeding infants may have bowel flora modification, allergic response, and interference of culture results for fever workup

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad gram-negative coverage and CNS penetration. Ceftriaxone or cefotaxime is considered DOC for Salmonella meningitis.

Dosing

Adult

1-4 g/d IV/IM divided q12-24h

Pediatric

Meningitis: 100 mg/kg/d IV divided q12-24h; not to exceed 4 g/24h
Nonmeningitic dosage: 50-75 mg/kg/d IV divided q12-24h

Interactions

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, or aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution with penicillin-allergic patients secondary to cross-reactivity with penicillins; caution with renal impairment; may cause reversible cholelithiasis, sludging in gallbladder, and jaundice; use with caution in neonates and continuous dosing because of risk of hyperbilirubinemia

Cefotaxime (Claforan)

Third-generation cephalosporin. Cefotaxime or ceftriaxone considered DOC for treatment of Salmonella meningitis.

Dosing

Adult

1-2 g/dose IV q6-8h

Pediatric

Meningitis: 200 mg/kg/d IV divided q6h
Nonmeningitic dosage: 100-200 mg/kg/d IV divided q6-8h

Interactions

Probenecid may increase cefotaxime levels; coadministration with furosemide or aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution with hypersensitivity to penicillin; adjust dosage in patients with renal impairment; may cause neutropenia, thrombocytopenia, eosinophilia, positive Coombs test, and elevated BUN, creatinine, and liver enzymes

Chloramphenicol (Chloromycetin)

Considered by many to be DOC for treatment of enteric fever. PO chloramphenicol no longer available in United States.

Dosing

Adult

50-100 mg/kg/d IV divided q6h; not to exceed 4 g/24h

Pediatric

<2 weeks: 25 mg/kg/d IV divided q6h
>2 weeks: 50-100 mg/kg/d IV divided q6h; not to exceed 4 g/24h

Interactions

Concomitant use of phenobarbital and rifampin may lower serum levels; phenytoin may increase serum levels; may increase phenytoin levels, reduce metabolism of oral anticoagulants, and decrease absorption of vitamin B-12

Contraindications

Documented hypersensitivity

Precautions

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

Caution in G-6-PD deficiency, renal and hepatic dysfunction, and neonates; monitoring of serum levels in neonates and infants is essential; may cause idiosyncratic marrow suppression known as gray baby syndrome

Trimethoprim-sulfamethoxazole (TMP-SMZ, Septra, Bactrim)

Sulfonamide derivative. Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Dosing

Adult

160 mg/dose PO bid (based on TMP component)

Pediatric

<2 months: Contraindicated
>2 months: 8-10 mg/kg/d PO divided bid (based on TMP component)

Interactions

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 thrombocytopenic purpura in elderly patients; 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

Contraindications

Documented hypersensitivity; age <2 mo

Precautions

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

May cause kernicterus in newborns; may cause blood dyscrasias, crystalluria, glossitis, renal or hepatic injury, GI irritation, or Stevens-Johnson syndrome; may cause hemolysis in patients with G-6-PD deficiency; should not be used at term in pregnancy; reduce dose in renal impairment

Ciprofloxacin (Cipro)

Quinolone antibiotic considered DOC for adult chronic carriers with S typhi infection.

Dosing

Adult

500 mg PO bid for 14 d

Pediatric

20-30 mg/kg/d PO divided q12h; must be used with caution in patients <18 y; benefits of treatment with drug must outweigh risks

Interactions

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; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

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

Has caused arthropathy in immature animals; adjust dose in patients with renal failure

Glucocorticoids

Glucocorticoids have been demonstrated to have some benefit in patients with severe neurologic complications of enteric fever.

Dexamethasone (Decadron)

Demonstrated some potential benefits in patients with obtundation, shock, stupor, or coma from enteric fever.

Dosing

Adult

3 mg/kg IV for 1 dose, followed by 1 mg/kg IV q6h for total duration of 48h

Pediatric

Administer as in adults

Interactions

Barbiturates, carbamazepine, phenytoin, rifampin, and INH may reduce effects; estrogens may enhance effects

Contraindications

Documented hypersensitivity

Precautions

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

Adverse effects may include mood changes, seizures, hyperglycemia, diarrhea, GI bleeding, Cushingoid effect, and cataracts with prolonged use; must taper drug and monitor for adrenal axis suppression

Follow-up

Further Inpatient Care

• If admission is necessary in patients with Salmonella infection, monitor the patient's hydration and electrolyte levels, continue intravenous (IV) or oral (PO) antibiotics as needed, and observe for and appropriately treat complications of Salmonella.

Further Outpatient Care

• Monitor patient's hydration status as an outpatient. Admission is warranted if the patient has signs and/or symptoms of dehydration.
• Monitor patients treated for enteric fever for possibility of relapse.
• Follow up on all blood cultures if the patient is being treated as an outpatient.
• Monitor for postinfectious functional GI disorders, such as irritable bowel syndrome.²⁰

Deterrence/Prevention

• Good personal hygiene, handwashing, and appropriate sanitary practices deter spread of the disease.
• Standard precautions and contact precautions must be used during the entire hospitalization of patients, especially for children who are in diapers or who are incontinent.
• For patients hospitalized with S typhi infection, precautions must be continued until results of 3 stool cultures are negative 48 hours after stopping antibiotic therapy.¹
• No vaccination is available for nontyphoidal Salmonella (NTS).
• Typhoid vaccination can help reduce the incidence of  typhoid fever (50-75% efficacy).
  • Although vaccinations enhance resistance to infection with S typhi, immunity is overcome by a large bacterial inoculum.
  • Immunization is recommended for the following individuals: (1) those who travel to an endemic area, (2) those with intimate exposure to an individual known to be a carrier of typhoid fever, (3) laboratory workers with frequent contact with S typhi, and (4) individuals living in typhoid-endemic areas outside the United States.¹
  • Two vaccinations are available in the United States.
    • PO Ty21a vaccine is a live attenuated vaccination that can be given to children aged 6 years or older. Vaccination should be completed at least 1 week before exposure. A booster dose is recommended after 5 years in the case of continuous or repeated exposure.
    • Vi capsular polysaccharide vaccine can be given to patients aged 2 years or older and consists of one intramuscular injection at least 2 weeks before exposure. A booster is recommended in 2 years.^1,3

Complications

• Nontyphoidal salmonellosis
  • Bacteremia
  • Meningitis
  • Pneumonia
  • Endocarditis/pericarditis
  • Osteomyelitis (most common in patients with sickle cell anemia)
  • Hepatic/splenic abscess
• Typhoid fever (enteric fever)
  • Intestinal perforation and severe hemorrhage (occurs in 1-10% of children)
  • Toxic encephalopathy and cerebral thrombosis
  • Hepatitis, pancreatitis, arthritis, and myocarditis

Prognosis

• Nontyphoidal salmonellosis
  • Prognosis of patients with simple gastroenteritis is excellent except for very young infants or patients with debilitating diseases.
  • The prognosis for Salmonella meningitis or endocarditis is poor.
• Typhoid fever (enteric fever)
  • Therapy with antibiotics has decreased the mortality rate to 1%; however, prognosis depends on the extent of complications from the disease.
  • Relapse is common after therapy for enteric fever.
• Chronic carrier state: Patients who continue to shed bacteria for more than 1 year (approximately 1% of patients) are considered chronic carriers.
• NTS bacteremia: Increased mortality may be associated with a higher magnitude of NTS bacteremia.²¹

Patient Education

• Good personal hygiene and hand washing are essential for all people involved in food handling.
• All medical personnel must also use standard precautions when treating patients with Salmonella to avoid patient-to-patient transmission.
• For excellent patient education resources, visit eMedicine's Public Health Center. Also, see eMedicine's patient education article Foreign Travel and the Centers for Disease Control and Prevention Web site.

Miscellaneous

Medicolegal Pitfalls

• Failure to consider S typhi as a differential diagnosis because the patient does not initially present with diarrhea and may have constipation
• Failure to ask about foreign travel and, therefore, not considering S typhi as a differential diagnosis
• Failure to aggressively treat infants younger than 3 months, patients with sickle cell disease, and patients who are immunocompromised and thus avoid potentially serious complications and poor outcome

Special Concerns

• Salmonella infections in day care
  • When a child or a staff member in a daycare setting has been diagnosed with S typhi infection, stool specimens from all children and staff members of the daycare should be obtained. All infected individuals should be excluded from the center until results from 3 consecutive stool culture results are negative for children younger than 5 years. Children older than 5 years can return to group care if diarrhea has resolved for 24 hours.
  • When a child or adult contracts a case of Salmonella gastroenteritis (species other than S. typhi), children or staff members should not be allowed to return to the day care center until they are asymptomatic. Asymptomatic individuals do not need to give stool specimens.
• Salmonella infections among food handlers and health care workers: Infected individuals should be excluded from handling and preparing food and providing health care until asymptomatic.

References

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Keywords

Salmonella infection, bacterial gastroenteritis, infectious colitis, Salmonella typhi, S typhi, enteric fever, typhoid fever, Salmonella enteritidis, S enteritidis, nontyphoidal Salmonella, NTS, bacteremia, meningitis, food-borne gastroenteritis, osteomyelitis, cell disease, AIDS, neoplasms, appendicitis, hepatosplenomegaly, bradycardia

Contributor Information and Disclosures

Author

Archana Chatterjee, MD, PhD, Professor of Pediatrics, Medical Microbiology and Immunology, and Pharmacy, Division of Pediatric Infectious Diseases, Chief of Division of Pediatric Infectious Diseases, Creighton University School of Medicine; Hospital Epidemiologist and Medical Director of Infection Control, Children's Hospital
Archana Chatterjee, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, International Society for Infectious Diseases, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: GlaxosmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi-Pasteur Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; GlaxoSmithKline Grant/research funds Other; MedImmune  Other; Merck Grant/research funds Other; Novartis Grant/research funds Other; Sanofi-Pasteur Grant/research funds Other

Coauthor(s)

Catherine O'Keefe, DNP, APRN, Assistant Professor of Nursing, Pediatric Nurse Practitioner, Pediatric Infectious Diseases, Creighton University School of Nursing
Catherine O'Keefe, DNP, APRN is a member of the following medical societies: American Academy of Nurse Practitioners, National Association of Pediatric Nurse Practitioners, and Nebraska Nurse Practitioners
Disclosure: Nothing to disclose.

Meera Varman, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University School of Medicine
Meera Varman, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: phamaceutical companies Honoraria Speaking and teaching; phamaceutical companies Grant/research funds clinical trials

Medical Editor

José Rafael Romero, MD, Director of Pediatric Infectious Diseases Fellowship Program, Associate Professor, Department of Pediatrics, Combined Division of Pediatric Infectious Diseases, Creighton University/University of Nebraska Medical Center
José Rafael Romero, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, New York Academy of Sciences, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

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