Management of Salmonella Gastroenteritis
Primary Recommendation
For otherwise healthy adults and children over 3 months with uncomplicated Salmonella gastroenteritis, do NOT give antibiotics—provide only oral rehydration and supportive care. 1, 2
Antibiotics fail to shorten illness duration, increase adverse effects (odds ratio 1.67), prolong fecal shedding beyond 3 weeks, and raise relapse rates compared to supportive care alone. 2, 3
Supportive Care (All Patients)
Fluid Management
- Oral rehydration solution (ORS) is the cornerstone of therapy for all patients with Salmonella gastroenteritis, regardless of whether antibiotics are indicated. 1, 2
- Administer ORS until clinical dehydration resolves, then continue to replace ongoing stool losses until diarrhea stops. 4
- Intravenous fluids are reserved for severe dehydration or inability to tolerate oral intake. 2
Dietary Approach
- Resume age-appropriate diet immediately after rehydration is complete—do not delay feeding. 4
- Continue breastfeeding throughout illness in infants. 4
Medications to AVOID
- Never give antimotility agents (loperamide) to children under 18 years—this is a strong contraindication that can precipitate toxic megacolon. 2, 4
- Avoid antimotility agents in any patient with high fever or bloody stools due to risk of toxic megacolon. 2
- Antiemetics (ondansetron) may be considered only in children over 4 years if vomiting interferes with oral rehydration. 2, 4
High-Risk Populations Requiring Antibiotics
Infants Under 3 Months (ALWAYS TREAT)
- All infants under 3 months require antibiotics due to bacteremia rates of 45% in neonates and 11% in older infants, with risk of progression to meningitis and osteomyelitis. 2, 4
- First-line options: TMP-SMX, ampicillin, cefotaxime, ceftriaxone, or chloramphenicol based on local susceptibility. 2, 4
- Avoid fluoroquinolones in children under 18 years except in life-threatening situations with no alternatives. 2, 4
HIV-Infected Patients (ALWAYS TREAT)
- Every HIV-infected person with Salmonella gastroenteritis requires antibiotics due to high risk of bacteremia and extraintestinal spread. 1, 2
- Preferred regimen for adults: Ciprofloxacin 750 mg orally twice daily. 2
- Treatment duration depends on CD4 count:
- Patients with prior Salmonella septicemia require long-term suppressive therapy to prevent recurrence. 2
Pregnant Women (ALWAYS TREAT)
- Treat all pregnant women due to risk of placental or amniotic fluid infection that can lead to pregnancy loss. 2
- Acceptable agents: Ampicillin, cefotaxime, ceftriaxone, or TMP-SMX. 2
- Avoid fluoroquinolones in pregnancy. 2
Other Immunocompromised Patients (ALWAYS TREAT)
- Treat transplant recipients, patients with malignancy, or other immunosuppression with the same regimens as HIV-infected adults to prevent disseminated infection. 2
- For suspected atherosclerosis (age >50 years), cardiac valvular disease, or significant joint disease: Consider antibiotic therapy. 1
Documented Bacteremia or Invasive Disease (ALWAYS TREAT)
- Any patient with confirmed bloodstream infection requires antibiotics. 2
- Immunocompetent adults with bacteremia: Ciprofloxacin 500-750 mg orally twice daily for 7-14 days. 2
- Immunocompromised patients with bacteremia: Start combination therapy (ceftriaxone 2 g IV daily + ciprofloxacin 500 mg orally twice daily) until susceptibility results available, then de-escalate. 2
Antibiotic Selection When Treatment Is Indicated
First-Line Therapy
- Adults: Ciprofloxacin 500-750 mg orally twice daily for 7-14 days. 1, 2
- Children (when antibiotics indicated): TMP-SMX, ceftriaxone, cefotaxime, or ampicillin based on susceptibility. 2, 4
- Azithromycin is increasingly preferred due to less resistance development and better safety profile compared to other agents. 5
Alternative Agents (Based on Susceptibility)
- TMP-SMX 1, 2
- Ceftriaxone (2 g IV daily for adults; 100 mg/kg/day in 1-2 divided doses for children) 1, 2
- Cefotaxime 1, 2
- Ampicillin (if susceptible) 1, 2
Geographic Resistance Considerations
- Avoid empiric fluoroquinolones for travel-related infections from Southeast and South Asia due to rising resistance. 2
- Serogroup B shows high resistance to ampicillin (only 21.6% susceptible) but remains susceptible to norfloxacin (98.1%) and co-trimoxazole (84.0%). 6
Critical Pitfalls to Avoid
Do NOT Treat These Scenarios
- Never give antibiotics for uncomplicated gastroenteritis in immunocompetent patients over 3 months—this increases adverse effects, prolongs shedding, and raises relapse rates. 2, 3
- Do NOT prescribe antibiotics for suspected Shiga-toxin-producing E. coli (STEC)—this increases risk of hemolytic-uremic syndrome. 2
Medication Errors
- Never use ceftriaxone monotherapy empirically for bacteremia in immunocompromised patients—combination therapy prevents treatment failure. 2
- Avoid undertreating duration in immunocompromised patients—inadequate treatment length leads to relapse. 2
- Never use antimotility agents in children or patients with high fever/bloody stools—risk of toxic megacolon. 2, 4
Monitoring Failures
- Reassess at 48-72 hours; if improving, obtain repeat blood cultures and consider de-escalation from combination to monotherapy based on susceptibility. 2
- Watch for persistent fever beyond 5-7 days, blood in stool with severe abdominal pain, or dehydration not responding to ORS. 4
Infection Control and Prevention
Hand Hygiene
- Perform hand hygiene after toilet use, diaper changes, before food preparation/eating, and after animal contact. 2, 4
- Use soap and water (preferred over alcohol-based sanitizers for Salmonella). 4
Activity Restrictions
- Ill people with diarrhea should avoid swimming, water activities, and close contact with others until diarrhea resolves. 2, 4
Household Contacts
- Evaluate household contacts of immunocompromised patients for asymptomatic carriage to prevent recurrent transmission. 2, 4
Food Safety
- Proper cooking and storage of meats and eggs prevents cross-contamination during food preparation. 2
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