What is the recommended management for a patient with Salmonella diarrhea?

Management of Salmonella Diarrhea

For immunocompetent adults and children over 3 months of age with uncomplicated Salmonella gastroenteritis, provide oral rehydration and supportive care only—antibiotics are not recommended and may prolong bacterial shedding and increase adverse effects. 1, 2, 3

Initial Assessment and Risk Stratification

Determine if the patient falls into a high-risk category requiring antibiotic therapy:

• Infants <3 months of age (high risk for bacteremia and extraintestinal complications) 2, 4
• Immunocompromised patients including HIV/AIDS, transplant recipients, chronic immunosuppression, or malignancy 2
• Pregnant women (risk of placental infection and pregnancy loss) 2
• Adults >50 years with atherosclerosis or vascular grafts 5
• Patients with prosthetic devices or valvular heart disease 5
• Documented bacteremia or sepsis 2
• Severe systemic illness with high fever, toxicity, or signs of invasive disease 2

Rehydration and Supportive Care (All Patients)

Oral rehydration solution (ORS) is the cornerstone of treatment for all patients with Salmonella diarrhea:

• Administer ORS to correct existing dehydration until clinical signs resolve 1
• Continue ORS for maintenance to replace ongoing stool losses until diarrhea and vomiting cease 1
• Resume age-appropriate diet immediately after rehydration is completed—do not delay feeding 1
• Continue breastfeeding throughout the illness in infants 1

For patients with ileus (absent bowel sounds, abdominal distension):

• Withhold oral fluids until bowel sounds return 6
• Provide intravenous fluid resuscitation for patients unable to tolerate oral intake 6
• Monitor for severe dehydration including hypotension, altered mental status, or oliguria requiring aggressive IV replacement 6

Antimotility and Antiemetic Agents

Antimotility drugs are contraindicated in Salmonella infections:

• Never give loperamide to children <18 years with acute diarrhea 1
• Avoid loperamide in all patients with Salmonella enteritis, especially with fever, bloody stools, or ileus, due to risk of toxic megacolon and worsening distension 1, 6

Antiemetic use is limited:

• Ondansetron may be given to children >4 years and adolescents to facilitate oral rehydration tolerance 1

Antibiotic Therapy (High-Risk Patients Only)

For immunocompetent adults requiring treatment:

• Ciprofloxacin 500 mg orally twice daily for 7-14 days is first-line therapy 2, 7
• Azithromycin is an alternative based on local resistance patterns 2
• Avoid fluoroquinolones in children <18 years due to cartilage toxicity risk 2

For children requiring treatment:

• TMP-SMZ, ceftriaxone, cefotaxime, or ampicillin based on susceptibility testing 1, 2
• Ceftriaxone 2g IV daily for severe invasive disease until susceptibilities available 2

Treatment duration varies by immune status:

• 7-14 days for immunocompetent patients with bacteremia 2
• 2-6 weeks for severely immunocompromised patients (HIV with CD4+ <200 cells/µL) 2
• Long-term suppressive therapy may be needed for HIV-infected patients with septicemia to prevent recurrence 2

Critical caveat: Antibiotics in uncomplicated cases prolong fecal shedding, increase relapse rates, and cause more adverse effects without shortening illness duration 3. A Cochrane review found no clinical benefit in otherwise healthy individuals 3.

Adjunctive Therapies

Probiotics may reduce symptom severity and duration:

• Offer probiotic preparations to immunocompetent adults and children with infectious diarrhea 1
• Greatest efficacy demonstrated for viral etiologies, but may benefit bacterial infections 1

Zinc supplementation in specific populations:

• Administer oral zinc to children 6 months to 5 years in countries with high zinc deficiency prevalence or signs of malnutrition 1
• Reduces diarrhea duration by approximately 10 hours (27 hours in malnourished children) 1

Special Consideration: Salmonella Typhi (Typhoid Fever)

Typhoid fever requires different management than nontyphoidal Salmonella:

• Ciprofloxacin 500-750 mg orally twice daily for 7-14 days for acute typhoid in adults 5
• Third-generation cephalosporins preferred for children and quinolone-resistant areas 5
• Azithromycin is an alternative in quinolone-resistant regions 5
• Asymptomatic chronic carriers with S. Typhi should be treated with fluoroquinolones to reduce transmission, particularly if working in food service, healthcare, or childcare 1, 5

Follow-Up and Clearance

Most patients do not require follow-up testing:

• Follow-up stool cultures are not recommended for case management after symptom resolution in most people 1
• Serial stool cultures are required for certain high-risk occupations (food handlers, healthcare workers, childcare providers) per local health department policies before return to work 1
• Reassess patients with symptoms lasting ≥14 days for noninfectious conditions including lactose intolerance, inflammatory bowel disease, or post-infectious IBS 1

Infection Control and Prevention

Strict hygiene measures prevent transmission:

• Hand hygiene with soap and water after toilet use, diaper changes, before food preparation, before eating, and after animal contact 1
• Use gloves and gowns when providing direct care to patients with diarrhea 1
• Exclude patients from swimming, water activities, and sexual contact until symptoms resolve 1
• Proper food safety practices to avoid cross-contamination during shopping, preparation, and storage 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics to reduce secondary transmission—hand hygiene achieves the same goal without promoting resistance 1
• Do not use antibiotics in uncomplicated cases—they worsen outcomes by prolonging shedding and increasing adverse effects 3
• Do not give antimotility agents—they are absolutely contraindicated and may precipitate toxic megacolon 1, 6
• Do not delay feeding—resume normal diet immediately after rehydration 1
• Monitor older patients with sustained fever for vascular complications—perform imaging to detect aortitis or mycotic aneurysms 1, 5