eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Salmonella Infection: Treatment & Medication
Updated: Jan 9, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
Adult
4-6 g/d PO divided tid
Pediatric
100 mg/kg/d PO divided q6h
Coadministration with allopurinol may increase risk of rash
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 patients with known renal failure
Ampicillin (Marcillin, Omnipen, Polycillin, Principen)
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
Coadministration with allopurinol may increase risk of rash
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; 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.
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
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, or 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
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.
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
Probenecid may increase cefotaxime levels; coadministration with furosemide or 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
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.
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
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
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
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.
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)
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
Documented hypersensitivity; age <2 mo
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.
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
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)
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
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.
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
Barbiturates, carbamazepine, phenytoin, rifampin, and INH may reduce effects; estrogens may enhance effects
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
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
More on Salmonella Infection |
| Overview: Salmonella Infection |
| Differential Diagnoses & Workup: Salmonella Infection |
 Treatment & Medication: Salmonella Infection |
| Follow-up: Salmonella Infection |
| References |
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References
Pickering L, Baker C, Long S, et al. American Academy of Pediatrics. Salmonella Infections. In: Red Book: Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:579-87.
Chiu CH, Chuang CH, Chiu S, et al. Salmonella enterica serotype Choleraesuis infections in pediatric patients. Pediatrics. Jun 2006;117(6):e1193-6. [Medline].
Reller ME. Salmonella Species. In: Long A, Pickering, L, Prober C (Editors). Principles and Practices of Pediatric Infectious Diseases Elsevier, Inc. 3rd ed. Orlando, FL: Churchill Livingstone; 2008:812-817.
Tsai MH, Huang YC, Chiu CH, et al. Nontyphoidal Salmonella bacteremia in previously healthy children: analysis of 199 episodes. Pediatr Infect Dis J. Oct 2007;26(10):909-13. [Medline].
Jones TF, Ingram LA, Cieslak PR, et al. Salmonellosis outcomes differ substantially by serotype. J Infect Dis. Jul 1 2008;198(1):109-14. [Medline].
Miller MA, Sentz J, Rabaa MA, et al. Global epidemiology of infections due to Shigella, Salmonella serotype Typhi, and enterotoxigenic Escherichia coli. Epidemiol Infect. Apr 2008;136(4):433-5. [Medline].
Galanakis E, Bitsori M, Maraki S, et al. Invasive non-typhoidal salmonellosis in immunocompetent infants and children. Int J Infect Dis. Jan 2007;11(1):36-9. [Medline].
CDC. Trends in incidence of frequently identified non-typhoidal Salmonella serotypes. FoodNet News. 2008;2(3).
CDC. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food--10 states, 2006. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):336-9. [Medline].
CDC. 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].
CDC. Multistate outbreak of human Salmonella infections associated with exposure to turtles--United States, 2007-2008. MMWR Morb Mortal Wkly Rep. Jan 25 2008;57(3):69-72. [Medline].
CDC. Salmonella Litchfield outbreak associated with a hotel restaurant--Atlantic City, New Jersey, 2007. MMWR Morb Mortal Wkly Rep. Jul 18 2008;57(28):775-9. [Medline].
CDC. Salmonella typhimurium infection associated with raw milk and cheese consumption--Pennsylvania, 2007. MMWR Morb Mortal Wkly Rep. Nov 9 2007;56(44):1161-4. [Medline].
Nguyen TQ, Reddy V, Sahl S, et al. Importance of Travel in Domestically Acquired Typhoid Fever Infections: Opportunities for Prevention and Early Detection. J Immigr Minor Health. May 29 2008;[Medline].
Ochiai RL, Acosta CJ, Danovaro-Holliday MC, et al. A study of typhoid fever in five Asian countries: disease burden and implications for controls. Bull World Health Organ. Apr 2008;86(4):260-8. [Medline].
Gradel KO, Dethlefsen C, Ejlertsen T, et al. Increased prescription rate of antibiotics prior to non-typhoid Salmonella infections: a one-year nested case-control study. Scand J Infect Dis. 2008;40(8):635-41. [Medline].
Rahman M, Siddique AK, Shoma S, et al. Emergence of multidrug-resistant Salmonella enterica serotype Typhi with decreased ciprofloxacin susceptibility in Bangladesh. Epidemiol Infect. Apr 2006;134(2):433-8. [Medline].
Gordon MA, Graham SM, Walsh AL, et al. Epidemics of invasive Salmonella enterica serovar enteritidis and S. enterica Serovar typhimurium infection associated with multidrug resistance among adults and children in Malawi. Clin Infect Dis. Apr 1 2008;46(7):963-9. [Medline].
Egorova S, Timinouni M, Demartin M, et al. Ceftriaxone-resistant salmonella enterica serotype Newport, France. Emerg Infect Dis. Jun 2008;14(6):954-7. [Medline].
Saps M, Pensabene L, Di Martino L, et al. Post-infectious functional gastrointestinal disorders in children. J Pediatr. Jun 2008;152(6):812-6, 816.e1. [Medline].
Gradel KO, Dethlefsen C, Schonheyder HC, et al. Magnitude of bacteraemia is associated with increased mortality in non-typhoid salmonellosis: a one-year follow-up study. APMIS. Feb 2008;116(2):147-53. [Medline].
Amieva MR. Important bacterial gastrointestinal pathogens in children: a pathogenesis perspective. Pediatr Clin North Am. Jun 2005;52(3):749-77, vi. [Medline].
CDC. Outbreak of multidrug-resistant Salmonella enterica serotype Newport infections associated with consumption of unpasteurized Mexican-style aged cheese--Illinois, March 2006-April 2007. MMWR Morb Mortal Wkly Rep. Apr 25 2008;57(16):432-5. [Medline].
Davis MA, Hancock DD, Besser TE. Multiresistant clones of Salmonella enterica: The importance of dissemination. J Lab Clin Med. Sep 2002;140(3):135-41. [Medline].
Fierer J, Guiney DG. Diverse virulence traits underlying different clinical outcomes of Salmonella infection. J Clin Invest. Apr 2001;107(7):775-80. [Medline].
Fleisher, GR, Ludwig, SL, Henretig FM. Infectious Disease Emergencies. In: Textbook of Pediatric Emergency Medicine. 5th ed. Baltimore, Md: 2005:783-851.
Gupta SK, Medalla F, Omondi MW, et al. Laboratory-based surveillance of paratyphoid fever in the United States: travel and antimicrobial resistance. Clin Infect Dis. Jun 1 2008;46(11):1656-63. [Medline].
Kliegman RM, Behrman RE, Jenson HB, et al. Salmonella. In: Nelson Textbook of Pediatrics. 18th ed. Elsevier Health Sciences; 2007:Ch. 195.
Leonard MK, Murrow JR, Jurado R, et al. Salmonella meningitis in adults infected with HIV: case report and review of the literature. Am J Med Sci. May 2002;323(5):266-8. [Medline].
Lu L, Walker WA. Pathologic and physiologic interactions of bacteria with the gastrointestinal epithelium. Am J Clin Nutr. Jun 2001;73(6):1124S-1130S. [Medline].
Ochiai RL, Wang X, von Seidlein L, et al. Salmonella paratyphi A rates, Asia. Emerg Infect Dis. Nov 2005;11(11):1764-6. [Medline].
Parry CM, Hien TT, Dougan G, et al. Typhoid fever. N Engl J Med. Nov 28 2002;347(22):1770-82. [Medline].
Rooney RM, Bartram JK, Cramer EH, et al. A review of outbreaks of waterborne disease associated with ships: evidence for risk management. Public Health Rep. Jul-Aug 2004;119(4):435-42. [Medline].
Rooney RM, Cramer EH, Mantha S, et al. A review of outbreaks of foodborne disease associated with passenger ships: evidence for risk management. Public Health Rep. Jul-Aug 2004;119(4):427-34. [Medline].
Yates J. Traveler's diarrhea. Am Fam Physician. Jun 1 2005;71(11):2095-100. [Medline].
Further Reading
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
