Outpatient Salmonella Antibiotic Treatment
For immunocompetent adults with uncomplicated Salmonella gastroenteritis in the outpatient setting, antibiotics are NOT routinely recommended, as treatment does not shorten symptom duration and may prolong fecal shedding. 1, 2
When to Treat vs. Observe
Treat These Patients:
- Infants <3 months of age - High risk for bacteremia and extraintestinal spread 1, 3
- All immunocompromised patients (HIV, transplant recipients, chronic immunosuppression) - High bacteremia risk 4, 1, 3
- Pregnant women - Risk of placental/amniotic fluid infection and pregnancy loss 5, 1
- Patients with bacteremia/septicemia - Documented bloodstream infection 1
- Severe disease requiring hospitalization 1
Do NOT Treat:
- Immunocompetent adults and children >3 months with mild-moderate gastroenteritis - No clinical benefit demonstrated, may prolong shedding 1, 2
First-Line Antibiotic Regimens (When Treatment Indicated)
Immunocompetent Adults:
- Ciprofloxacin 500 mg PO twice daily for 7-14 days 4, 1, 6
- Alternative: TMP-SMX (if susceptible) 4, 1
- Alternative: Ceftriaxone 2g IV once daily (for severe infections) 4, 1
Immunocompromised Adults/HIV Patients:
- Initial combination therapy: Ceftriaxone 2g IV once daily PLUS Ciprofloxacin 500 mg PO twice daily until susceptibilities available 1, 3
- Duration: 7-14 days if CD4+ >200 cells/μL; 2-6 weeks if CD4+ <200 cells/μL 4, 3
- Long-term suppressive therapy required for HIV patients with prior Salmonella septicemia to prevent recurrence 5, 4, 3
Children:
- Avoid fluoroquinolones - Use only if no alternatives exist 5, 4, 1
- Preferred options: TMP-SMX, ceftriaxone, cefotaxime, or ampicillin 5, 4
Pregnant Women:
- Avoid fluoroquinolones 5, 4, 1
- Preferred options: Ampicillin, ceftriaxone, cefotaxime, or TMP-SMX 5, 1
Supportive Care (All Patients)
- Fluid and electrolyte replacement is the cornerstone of therapy 3
- Oral rehydration preferred for mild-moderate dehydration 3
- Avoid antimotility agents (loperamide) in children <18 years 5, 3
- Avoid antimotility agents if high fever or bloody stools 5
Critical Pitfalls to Avoid
- Do not treat uncomplicated gastroenteritis in healthy adults - No benefit, prolongs shedding 1, 2
- Do not use fluoroquinolones in children or pregnant women unless absolutely no alternatives 5, 4, 1
- Do not undertreat immunocompromised patients - Inadequate duration leads to relapse 3
- Do not use ceftriaxone monotherapy empirically for bacteremia in immunocompromised patients - Combination approach prevents treatment failure 3
Special Considerations
- Expect persistent fever for 5-7 days despite appropriate therapy 1
- Treatment failure = lack of clinical improvement AND persistent positive blood cultures after completing therapy 1
- Screen household contacts for asymptomatic carriage to prevent reinfection 5, 1
- Follow-up stool cultures NOT generally required if complete clinical response demonstrated 1