What is the treatment for a patient with Salmonella enteritis ileus?

Treatment of Salmonella Enteritis with Ileus

For Salmonella enteritis complicated by ileus, withhold oral fluids until bowel sounds return, provide intravenous fluid resuscitation, and avoid antimotility agents; antibiotics are generally not indicated unless the patient has high-risk features such as immunosuppression, bacteremia, or severe systemic illness. 1, 2

Initial Management: Addressing the Ileus

The presence of intestinal ileus is an absolute contraindication to oral rehydration therapy. 1

• Patients with intestinal ileus should not be given oral fluids until bowel sounds are audible. 1
• Intravenous fluid resuscitation is mandatory for patients with ileus who cannot tolerate oral intake, as these patients are at risk for severe dehydration and shock. 1
• Monitor for signs of severe dehydration or shock (hypotension, altered mental status, oliguria) which require aggressive IV fluid replacement. 1

Critical Pitfall to Avoid

Do not attempt oral rehydration in the presence of ileus—this can worsen distension and increase the risk of aspiration. Wait for return of bowel function before transitioning to oral fluids. 1

Antimotility Agent Contraindication

Antimotility drugs such as loperamide are absolutely contraindicated in Salmonella enteritis, particularly when ileus is present. 1, 2

• Loperamide should be avoided at any age in suspected or proven cases where toxic megacolon may result, including inflammatory diarrhea or diarrhea with fever. 1
• The presence of ileus suggests more severe intestinal involvement, making antimotility agents particularly dangerous. 1

Antibiotic Decision-Making Algorithm

Most immunocompetent patients with uncomplicated Salmonella gastroenteritis do NOT require antibiotics. 2 However, antibiotics are indicated in specific high-risk situations:

Indications for Antibiotic Therapy:

Treat with antibiotics if ANY of the following are present:

• HIV infection or severe immunosuppression (cancer patients, transplant recipients, chronic steroid use) 2, 3
• Bacteremia or sepsis (positive blood cultures, fever with rigors, hypotension) 2, 3
• Age extremes: infants <3 months or elderly patients 2
• Pregnancy (risk of placental/amniotic fluid infection) 2, 4
• Prosthetic implants (vascular grafts, joint prostheses, heart valves) 2
• Severe systemic illness despite supportive care 2, 3

Antibiotic Selection When Indicated:

For adults requiring treatment:

• Ciprofloxacin 500-750 mg PO twice daily (or 400 mg IV q12h) is first-line therapy for susceptible strains. 2, 5
• Alternative options include ceftriaxone 2g IV daily, cefotaxime, TMP-SMX, or ampicillin based on susceptibility. 2

For pregnant women requiring treatment:

• Avoid fluoroquinolones—use ceftriaxone, cefotaxime, or ampicillin instead. 6, 4
• TMP-SMX can be used but should be avoided near delivery due to theoretical risk of neonatal hyperbilirubinemia. 4

Treatment duration:

• 7-14 days for immunocompetent patients with bacteremia 2
• 2-6 weeks for severely immunocompromised patients (HIV with CD4 <200 cells/μL) 2, 6

Transition to Oral Rehydration

Once bowel sounds return and ileus resolves:

• Begin oral rehydration solution (ORS) in small volumes (5-10 mL every 1-2 minutes), gradually increasing as tolerated. 1
• Resume age-appropriate diet immediately after rehydration is completed. 1
• Continue breastfeeding in infants throughout the illness. 1

Common Mistake to Avoid:

Do not allow a thirsty patient to drink large volumes ad libitum once oral intake resumes—this can trigger vomiting. Administer ORS slowly via spoon or syringe. 1

Monitoring and Complications

Watch for warning signs requiring escalation of care:

• Persistent high fever or worsening systemic symptoms despite 48-72 hours of appropriate therapy may indicate bacteremia or extraintestinal spread. 2, 3
• Acute renal failure can develop from severe dehydration and rhabdomyolysis, as documented in fatal cases. 7, 3
• Septic shock is a life-threatening complication, particularly in immunocompromised or elderly patients. 7, 3

Infection Control

Implement strict precautions to prevent transmission:

• Hand hygiene with soap and water (alcohol-based sanitizers are less effective against enteric pathogens) after toilet use and before food preparation. 1
• Use gloves and gowns when providing direct care to patients with diarrhea. 1
• Patients should avoid food handling, swimming, and sexual contact until symptoms resolve. 1