Salmonella

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Background

  • Salmonella enteritidis is a common cause of food borne disease outbreaks
  • Infection commonly from foodborne transmission
  • Associated with poultry/hen eggs, peanut butter
  • Seen in infants often due to cross-contamination in household

Clinical Features

  • Severity dependent on dose ingested
  • Symptoms within 8-72 hours
    • Nausea
    • Vomiting
    • Fever
    • Diarrhea
    • Cramping
  • Course: Fever resolves within 48-72 hours; diarrhea resolves within 4-10 days
  • < 5% of patients develop bacteremia that is rarely complicated by endocarditis, osteomyelitis, or mycotic aneurysm.
  • Mortality < 0.5-1%

Differential Diagnosis

Acute diarrhea

Infectious

Noninfectious

Watery Diarrhea

  • Enterotoxigenic E. coli (most common cause of watery diarrhea)[1]
  • Norovirus (often has prominent vomiting)
  • Campylobacter
  • Non-typhoidal Salmonella
  • Enteroaggregative E. coli (EAEC)
  • Enterotoxigenic Bacteroides fragilis

Traveler's Diarrhea

Evaluation

  • Stool culture

Management

Supportive care

  • IVF

Antibiotics

  • Have not been shown to reduce duration of symptoms and not recommended in:[2][3]
    • Mild-moderate infection
    • Immunocompetent
    • Patients aged 2-50 years old
  • Antibiotics may have a role in patients with:[4]
    • Severe illness
    • IBD
    • Immunocompromised
    • Steroid use
    • < 3 months or > 65 years old
    • On hemodialysis
    • Sickle cell disease
  • Recommended regimens:[5]
    • Adults:
      • Levofloxacin (or other fluoroquinolone) 500mg daily x 7-10 days
      • Azithromycin 500mg daily x 7 days
      • Duration should be 14 days in immunocompromised
    • Children:
      • Ceftriaxone 100mg/kg/day divided into two doses x 7-10 days
      • Azithromycin 20mg/kg/day daily x 7 days

Antibiotic Sensitivities[6]

Category Antibiotic Sensitivity
Penicillins Penicillin G R
Penicillin V R
Anti-Staphylocccal Penicillins Methicillin R
Nafcillin/Oxacillin R
Cloxacillin/Diclox. R
Amino-Penicillins AMP/Amox I
Amox-Clav S
AMP-Sulb S
Anti-Pseudomonal Penicillins Ticarcillin S
Ticar-Clav S
Pip-Tazo S
Piperacillin S
Carbapenems Doripenem S
Ertapenem S
Imipenem S
Meropenem S
Aztreonam X1
Fluroquinolones Ciprofloxacin S
Ofloxacin S
Pefloxacin S
Levofloxacin S
Moxifloxacin S
Gemifloxacin X1
Gatifloxacin S
1st G Cephalo Cefazolin X1
2nd G. Cephalo Cefotetan X1
Cefoxitin X1
Cefuroxime X1
3rd/4th G. Cephalo Cefotaxime S
Cefizoxime S
CefTRIAXone S
Ceftaroline S
CefTAZidime S
Cefepime S
Oral 1st G. Cephalo Cefadroxil R
Cephalexin R
Oral 2nd G. Cephalo Cefaclor/Loracarbef X1
Cefproxil X1
Cefuroxime axetil X1
Oral 3rd G. Cephalo Cefixime S
Ceftibuten S
Cefpodox/Cefdinir/Cefditoren S
Aminoglycosides Gentamicin X1
Tobramycin X1
Amikacin X1
Chloramphenicol S
Clindamycin R
Macrolides Erythromycin R
Azithromycin I
Clarithromycin R
Ketolide Telithromycin R
Tetracyclines Doxycycline I
Minocycline I
Glycylcycline Tigecycline S
Daptomycin R
Glyco/Lipoclycopeptides Vancomycin R
Teicoplanin R
Telavancin R
Fusidic Acid R
Trimethoprim I
TMP-SMX I
Urinary Agents Nitrofurantoin S
Fosfomycin S
Other Rifampin R
Metronidazole R
Quinupristin dalfoppristin R
Linezolid R
Colistimethate X1

Key

  • S susceptible/sensitive (usually)
  • I intermediate (variably susceptible/resistant)
  • R resistant (or not effective clinically)
  • S+ synergistic with cell wall antibiotics
  • U sensitive for UTI only (non systemic infection)
  • X1 no data
  • X2 active in vitro, but not used clinically
  • X3 active in vitro, but not clinically effective for Group A strep pharyngitis or infections due to E. faecalis
  • X4 active in vitro, but not clinically effective for strep pneumonia

Table Overview

See Also

References

  1. Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
  2. Onwuezobe, I. A., Oshun, P. O., & Odigwe, C. C. (2012). Antimicrobials for treating symptomatic non-typhoidal Salmonella infection. The Cochrane database of systematic reviews, , CD001167.
  3. DuPont, H. L. (2014). Acute infectious diarrhea in immunocompetent adults. The New England journal of medicine, 16, 1532–1540.
  4. DuPont HL. Bacterial diarrhea. N Engl J Med 2009;361:1560-9.
  5. DuPont HL. Bacterial diarrhea. N Engl J Med 2009;361:1560-9.
  6. Sanford Guide to Antimicrobial Therapy 2014