Salmonella Infection

Article Last Updated: Jul 17, 2008

AUTHOR AND EDITOR INFORMATION

Author: Michael D Owens, DO, Clinical Faculty, Emer ency !edicine "esidency, #a$al !edical Center %ortsmouth& Consultin 'ta((, )epartment o( Emer ency !edicine, Chesapea*e Emer ency %hysicians, +nc, Chesapea*e "e ional !edical Center !ichael ) ,-ens is a mem.er o( the (ollo-in medical societies: American Academy o( Emer ency !edicine, American Colle e o( Emer ency %hysicians, and American ,steopathic Association Coauthor/s0: Dirk A Warren, MD, Emer ency !edicine "esident, #a$al !edical Center %ortsmouth Editors: Mark o!"en, MD, FA#E$, Assistant !edical )irector, Emer ency )epartment, )u*e "alei h 1ospital& Francisco Tala%era, $harmD, $hD, 'enior %harmacy Editor, e!edicine& &eter '&a() $ritchar" Ta(lor III, MD, Compliance ,((icer, Attendin %hysician Emer ency !edicine "esidency, )epartment o( Emer ency !edicine, %almetto "ichland !emorial 1ospital, Uni$ersity o( 'outh Carolina& &ohn D Halamka, MD, MS, Associate %ro(essor o( !edicine, 1ar$ard !edical 'chool, 2eth +srael )eaconess !edical Center& Chie( +n(ormation ,((icer, Care3roup 1ealthcare 'ystem and 1ar$ard !edical 'chool& Attendin %hysician, )i$ision o( Emer ency !edicine, 2eth +srael )eaconess !edical Center& &onathan A"ler, MD, Attendin %hysician, )epartment o( Emer ency !edicine, !assachusetts 3eneral 1ospital& )i$ision o( Emer ency !edicine, 1ar$ard !edical 'chool A!thor an" E"itor Disclos!re S(non(ms an" relate" ke(wor"s* Salmonella, salmonella in(ection, salmonella astroenteritis, salmonellosis, typhi, typhoid (e$er, enteric (e$er, typhimurium, enteritidis, choleraesuis, Salmonella in(ection, se$ere diarrhea, (ood4.orne illness

INTRODU#TION
+ack,ro!n"

Salmonella are ram4ne ati$e (acultati$e intracellular anaero.es causin a -ide spectrum o( disease5 6his spectrum can ran e (rom a astroenteritis, enteric (e$er /caused .y typhoid and paratyphoid serotypes0, .acteremia, (ocal in(ections, to a con$alescent li(etime carrier state5 6he type o( in(ection depends on the serotype o( Salmonella and host (actors5 +t maintains a .road host ran e, and (or un*no-n reasons, results in di((erent diseases in di((erent hosts5 Althou h the ta7onomy o( Salmonella can .e con(usin , all Salmonella serotypes are mem.ers o( a sin le species, Salmonella enterica5 !ore than 2800 sero$ars1, 2 ha$e .een descri.ed o( -hich humans are almost e7clusi$ely in(ected .y Salmonella enterica su.sp enterica serotypes typhi, typhimurium, and choleraesuis -orld-ide59 +n the United 'tates, Salmonella enteritidis /17:0, Salmonella typhimurium /1;:0, Salmonella newport /10:0, and Salmonella javiana /8:0 account (or nearly one hal( o( the human isolates5 < 'almonellosis caused .y Salmonella enteritidis is the most common .acterial in(ectious cause o( (ood4.orne disease in the United 'tates5 8 #inety4(i$e percent o( cases o( Salmonella in(ection are (ood4.orne& ho-e$er, the incidence o( direct contact e7posure -ith animal carriers is on the rise5 8 ,nce in(ected, salmonellosis har.ors a si ni(icant mor.idity and mortality5 ,ne third o( untreated patients e7perience complications and account (or three (ourths o( deaths associated -ith salmonellosis59 Campylobacter and Salmonella are the most common .acterial patho ens (ound in stool cultures reco$ered (rom patients -ho present -ith astroenteritis or se$ere diarrhea5 ; Salmonella has a -idespread distri.ution in the en$ironment, and certain host (actors ma*e humans particularly suscepti.le to in(ection5 +ts increasin antimicro.ial resistance, pre$alence, $irulence and adapta.ility, are a challen e -orld-ide5 For a related C!E=CE acti$ity, see C!E=CE 4 Companion Animals and 1uman 1ealth: %art ++ 44 >oonotic )iseases5

$atho-h(siolo,(
Salmonella in(ection most commonly .e ins -ith in estion o( .acteria in contaminated (ood or -ater5 1o-e$er, direct contact -ith animal and human carriers has also .een implicated5 "eptile and amphi.ian carriers are the most commonly reco ni?ed sources o( direct contact58 'tudies in$ol$in healthy human $olunteers re@uired a median dose o( 1 million .acteria to produce disease5 1o-e$er, point out.rea*s su est as (e- as 200 .acteria may produce nontyphoid astroenteritis5; ,nce the .acteria sur$i$e the acidic stomach, it coloni?es the intestine and translocates across the intestinal epithelium $ia 9 routes: /10 in$asion o( the enterocytes, /20 in$asion o( epithelial cells called ! cells, and /90 throu h

dendritic cells that intercalate epithelial cells5 2 +nteraction -ith the epithelium and resident cells promote a proin(lammatory response to include cyto*ines, chemo*ines, neutrophils, macropha es, dendritic cells, and 6 and 2 cells5 6his in(lammatory host response can actually .ene(it the intestinal patho ens and contri.ute to the nature and se$erity o( the in(ection .y esta.lishin a competiti$e ad$anta e a ainst the nati$e (lora52 A(ter crossin this epithelial layer, the .acteria replicate in macropha es in %eyerAs patches, mesenteric lymph nodes, and the spleen5 ,nce coloni?ed, the .acteria may then potentially disseminate to the lun s, all.ladder, *idneys, or central ner$ous system5 6he nontyphoid species o( Salmonella tend to produce a more locali?ed response .ecause they are (elt to lac* the human4speci(ic $irulence (actors5 1o-e$er, the typhi serotype can de$elop the more in$asi$e disease resultin in .acteremia5 6he se$erity o( disease is related to the serotype, num.er o( or anisms, and host (actors5 E s and poultry are the most common sources o( in(ection5 7, 8 +n estion o( contaminated -ater, mil*, mil* products, .ee(, (ruit, $e eta.les, and dairy products are also common sources5 %otential sources o( in(ection (or in(ants -ith Salmonella are e7posure to reptiles, ridin in a shoppin cart ne7t to meat or poultry, or consumin li@uid in(ant (ormula58 "ecent out.rea*s ha$e .een associated -ith contaminated peanut .utter, (ro?en potpies, pu((ed $e eta.le snac*s, and e7posure to turtles5< "eser$oirs o( the .acteria include humans, poultry, s-ine, cattle, rodents, and pets such as i uanas, tortoises, turtles, terrapins, chic*s, do s, and cats5 Up to B0: o( reptiles and amphi.ians har.or Salmonella in their astrointestinal tracts, and ;: o( nontyphoid disease is related to direct contact -ith these animals5 8 Fecal4oral transmission (rom person to person in areas -ith poor sanitation and contaminated or nonchlorinated -ater is the route (or enteric or typhoid (e$er5 1umans are the only *no-n carriers o( Salmonella typhi.8 +ndi$idual suscepti.ility to Salmonella in(ection increases -ith e7tremes o( a e, immunode(iciency states, prior anti.iotic use, neoplastic disease, achlorhydria or antacid use, recent .o-el sur ery, and malnutrition5

Fre.!enc(
Unite" States %re$alence estimates $ary secondary to inconsistent dia nosis and reportin techni@ues5 1o-e$er, an estimated 15< million people in the United 'tates are in(ected -ith nontyphoid Salmonella annually5 6he incidence o( nontyphoid disease in the United 'tates has .een sta.le since 200< .ut has decreased appro7imately 8: (rom 1BB;41BB8 le$els5 < 6he true .urden o( nontyphoid

Salmonella in the United 'tates is calculated to .e 820 cases per 100,000 compared -ith 195< cases per 100,000 o( la.oratory4con(irmed cases annually, ta*in into account appro7imately 985; cases o( nontyphoid Salmonella (or each culture con(irmed case5B, 10 6he reported 2007 incidence is 1<5B cases per 100,0005< Additionally, an estimated 800 people are in(ected -ith typhoid Salmonella annually58 !ost cases o( documented typhoid disease are related to (orei n tra$el to de$elopin nations such as +ndia /90:0, %a*istan /19:0, !e7ico /12:0, 2an ladesh /8:0, %hilippines /8:0, and 1aiti /8:05 8 International Fully industriali?ed nations report (re@uencies o( astroenteritis similar to that o( the United 'tates5 1o-e$er, -orld-ide estimates o( nontyphoid Salmonella ran e (rom 200 million to 159 .illion, -ith an estimated death toll o( 9 million each year51 6he sero$ars responsi.le (or typhoid or enteric (e$er, typhi and paratyphi, that cause systemic illness lead to 1;420 million cases and 200,000 deaths -orld-ide511, 12 Compared -ith tourists, tra$elers $isitin (riends or relati$es in de$elopin nations e7hi.it a much hi her incidence o( typhoid or enteric (e$er5 8

Mortalit(/Mor0i"it(
6-enty percent o( patients re@uire hospitali?ation, -ith an estimated death rate o( 05;:510 +n(ection -ith dru 4resistant nontyphoid Salmonella and Salmonella typhi increase the li*elihood o( hospitali?ation and death5 10 +n$asi$e nontyphoid Salmonella in(ection occurs in a.out 8: o( cases in +srael 10 and is responsi.le (or <004;00 deaths in the United 'tates each year 85 !ortality (or nontyphoid Salmonella is reported to .e as hi h as ;0: in A(rican patients -ith 1+C511 !ycotic a.dominal aortic aneurysms are more common in immunocompromised and 1+C patients5 6reated typhoid cases ha$e a 2: mortality rate -ith a 18: relapse rate5 9 A si ni(icant num.er o( typhoid patients .ecome chronic asymptomatic carriers and can shed hi h num.ers o( .acteria in the stool (or a li(etime -ithout o.$ious symptoms511 )ependin on the serotype, rou hly 1: o( adults and 8: o( children e7crete or anisms (or reater than a year5 19

A,e
Attac* rates are hi hest in persons youn er than 20 years or older than 70 years5 6he hi hest rate is (ound in in(ants /190 isolates per 100,00005

#eonates are at a reater ris* to (ecal4oral transmission secondary to relati$e decreased stomach acidity and .u((erin o( in ested .reast mil* and (ormula5 Elderly persons are at a relati$e reater ris* to in(ection secondary to chronic underlyin illness and -ea*ened immunity5 #ursin home residents ha$e a particularly hi her ris*5

# INI#A

Histor(

,.tain a dietary history5 +n@uire a.out potential restaurant sources, (ood preparation techni@ues, and e7posure to potentially contaminated or nonchlorinated -ater sources5 ,.tain a tra$el history5 6yphoid (e$er is increasin ly associated -ith international tra$el to de$elopin nations5 )etermine i( other patient contacts ha$e similar illnesses, (ood in estions, or animal contacts5 Salmonella syndromes can .e di$ided into astroenteritis, enteric (e$er, .acteremia, locali?ed in(ection, and a chronic carrier state5 3astroenteritis +ncidence is hi hest durin !ay throu h ,cto.er in temperate climates5; o 6he incu.ation period is (rom 84<8 hours a(ter the in estion o( contaminated (ood or -ater5 o 'ymptoms are acute onset o( (e$er and chills, nausea and $omitin , a.dominal crampin , and diarrhea5 o +( a (e$er is present, it enerally a.ides in 72 hours5 o )iarrhea is usually sel(4limited, lastin 947 days and may .e rossly .loody5 )iarrhea lastin more than 10 days su ests another dia nosis5; Enteric /typhoid0 (e$er
o o o

6he incu.ation period o( enteric /typhoid0 (e$er is 8421 days5 6ransmission is enerally (rom contaminated -ater or animal products or contact -ith an in(ected person or carrier5

6he initial prodrome lastin 7410 days includes headache, cou h, diaphoresis, anore7ia, -ea*ness, sore throat, malaise, a.dominal pain, and constipation or Dpea soupE diarrhea5 A.dominal pain is present in 204<0: o( patients5 ; Constipation is (ound in 10498: o( patients5; 6hese prodromal symptoms typically plateau as the (e$er increases in a step-ise (ashion pea*in in the second -ee* o( illness5 A(ter the prodrome, splenome aly, a.dominal distention and pain, relati$e .radycardia, rash, menin ismus, and mental con(usion may occur5 +t may disseminate to lun s, all.ladder, *idneys, or C#'5 Untreated patients e7perience either complications or resolution .y the (ourth -ee*5
o o

o o

+ntestinal per(oration occurs in 9410: o( patients5 ; ,ther complications include endocarditis, pericarditis, pneumonitis, orchitis, and (ocal a.scess5

2acteremia 2acteremia typically occurs in immunocompromised patients5 %rolon ed or recurrent (e$ers may occur5 +t may include (ocal in(ections5 !ycotic a.dominal aortic aneurysm may occur5 Locali?ed in(ection Locali?ed in(ection occurs in 8410: o( persons -ith .acteremia5 ; 6he endocardium, arteries, C#' /more commonly in(ants0, lun s, .ones, Foints, muscles, so(t tissues, reticuloendothelial system, *idneys, and enital re ions ha$e all .een documented sites o( e7traintestinal in(ection5 Chronic carrier state
o o o o o o o o o

Chronic carrier state is de(ined as Salmonella in the stool or urine (or reater than 1 year5 A chronic carrier state occurs in 052405;: o( patients -ith nontyphoid Salmonella5; A chronic carrier state occurs in 14<: o( patients -ith untreated typhoid Salmonella.

$h(sical
%hysical (indin s can $ary dependin on the clinical syndrome, serotype, and patientAs immune status5 1o-e$er, the physical (indin s in astroenteritis, enteric /typhoid0 (e$er, and .acteremia (re@uently o$erlap5

3astroenteritis

Fe$ers 9849BGC are common5 %hysical si ns o( dehydration may .e (ound5 'tool e7amination can .e ne ati$e to rossly .loody5 )i((use non(ocal a.dominal tenderness is commonly present5 +n rare cases, Salmonella in(ection mimics in(lammatory .o-el disease or pseudoappendicitis5; Enteric or typhoid (e$er A step-ise increase in temperature that plateaus in the second -ee* at 9B4<0GC may .e noted5 o Cer$ical adenopathy may occur5 o "elati$e .radycardia occurs in (e-er than 80: o( cases5 o A.dominal e7amination may re$eal distention -ith pain on deep palpation5 o 1epatosplenome aly is (ound in 80: o( patients5 ; o A rose spot rash that typically occurs in the second -ee* o( disease is seen in 90: o( patients5 6his rash is descri.ed as a (aint salmon4 colored 249 mm papule lesion located primarily on the trun* that (ades -ith pressure5 o Findin s o( menin ismus may appear a(ter the early prodrome5 2acteremia 2acteremia is usually associated -ith a prolon ed or recurrent (e$er5 o 3enerally, it is associated -ith a locali?ed in(ection5 o +t may .e a part o( a mi7ed Salmonella in(ection51< Chronic carrier state is asymptomatic5
o o

o o o o o

#a!ses
Currently, more than 2800 serotypes o( Salmonella enterica ha$e .een identi(ied51, 2 Althou h clinical mani(estations o( each o$erlap, typhi and paratyphi tend to cause enteric or typhoid (e$er and the more in$asi$e (orm o( the disease, -hereas most others cause a sel(4limited (orm o( astroenteritis5

DIFFERENTIA S
A.dominal 6rauma, 2lunt C2"#E 4 2otulism )i$erticular )isease 3astritis and %eptic Ulcer )isease

3astroenteritis %ediatrics, 3astroenteritis 6o7icity, 'hell(ish

Other $ro0lems to 0e #onsi"ere"

3astroenteritis 'hi ellosis Ame.ic dysentery Ciral astroenteritis Food poisonin Acute ulcerati$e colitis Enteric or typhoid (e$er
o o o o o o o o o o o o o

6u.erculosis +n(ecti$e endocarditis 2rucellosis Lymphoma H (e$er Ciral hepatitis !alaria Ame.iasis

a0 St!"ies

'erolo ic testin lac*s o$erall sensiti$ity and speci(icity and $aries -ith the sta e o( in(ection5;, 18, 9 Complete .lood cell count Anemia is a result o( .lood loss and in(lammation5 6he -hite .lood cell /I2C0 count in enteric or typhoid (e$er is o(ten lo-5 o Leu*ocytosis is common in the (irst 10 days in children and may also result (rom .acteremia, locali?ed in(ection, .o-el per(oration, or other e7traintestinal complications5 o "e$ersi.le throm.ocytopenia may occur5 Li$er (unction tests may .e mildly ele$ated5 Ele$ated alanine aminotrans(erase le$el /J70 +U=L0 can .e seen in enteric (e$er5 1; A re$ersi.le (orm o( a mild disseminated intra$ascular coa ulopathy /)+C0 may occur5
o o

Cultures
o o

6he dia nosis o( Salmonella in(ection is .ased on isolation o( the in(ectin or anism5 'tool culture results can ta*e 947 days5 6hree to ten rams collected o$er se$eral days are pre(erred519 )ue to the time in$ol$ed -ith stool culture detection, treatment decisions should .e .ased on the patientAs presentation5 "apid testin technolo ies, such as polymerase chain reaction /%C"0, ha$e not yet .een pro$en (easi.le5 17 Culture sensiti$ity decreases a(ter the (irst -ee* o( illness and anti.iotic therapy518, 9 2one marro- e$aluation has a sensiti$ity o( B0: .ut is rarely per(ormed5 2lood culture results in enteric (e$er are positi$e in 80470: o( cases5 %C" sensiti$ity on .lood is 8<58: and is as hi h as B8: -hen per(ormed in the (irst 8 days5 18 %C" e$aluations on urine and (eces are ;B: and <7: sensiti$e, respecti$ely518
o

o o o o o

Ima,in, St!"ies

A (ocused ultrasono raphic e7amination or C6 scan should .e per(ormed i( an e7traintestinal mani(estation is o( concern5 6his should include muscle=so(t tissue, hepato.iliary, spleen, urinary, enital, and .one5 An acute a.dominal series (or (ree air under the diaphra m may .e needed to rule out intestinal per(oration5 A C6 scan o( the .rain should .e per(ormed i( central ner$ous system complications arise /more commonly neonates05

$roce"!res

A rectal e7amination is needed to assess (or .leedin 5 A .lood trans(usion is rarely re@uired5

$rehos-ital #are

%er(orm a standard e$aluation o( air-ay, .reathin , and circulation5

%ro$ide intra$enous (luids i( si ns or symptoms o( dehydration are present5

Emer,enc( De-artment #are

%er(orm a standard e$aluation o( air-ay, .reathin , and circulation5 6reat -ith rehydration and electrolyte replacement $ia oral or intra$enous solutions (or an uncomplicated astroenteritis5 6rans(usions should .e .ased on hemo lo.in and hematocrit le$els5 'ymptomatically mana e pain, nausea, $omitin , and diarrhea5 Anti.iotics are indicated (or in(ants up to 2 months o( a e, elderly patients, immunocompromised patients, those -ith a history o( sic*le4cell disease or prosthetic ra(ts, or patients -ho ha$e e7traintestinal (indin s5

#ons!ltations

Admission may .e re@uired i( the patient e7hi.its unsta.le $itals si ns, har.ors si ni(icant ris* (actors, is youn er than 2 months o( a e or elderly, is immunocompromised, or sho-s si ns or symptoms o( an e7traintestinal mani(estation5 Appropriate specialty consultation (or speci(ic e7traintestinal mani(estations is indicated5 Arran e (or (ollo-4up care on an outpatient .asis -ith the patientAs primary care physician i( dischar ed (rom the emer ency department5

Anti.iotics, antidiarrheals, and lucocorticoids are used to treat symptoms and=or documented Salmonella in(ection5 Dr!, #ate,or(* Antibiotics #ontyphoid Salmonella astroenteritis is enerally sel(4limited5 A Cochrane Database Systematic Review o( 12 trials sho-ed no si ni(icant chan e in the o$erall len th o( the illness or the related symptoms in other-ise healthy children and adults treated -ith a course o( anti.iotics (or nontyphoid Salmonella disease5 Anti.iotics tend to increase ad$erse e((ects and prolon Salmonella detection in stools518 1o-e$er, anti.iotic treatment should .e considered on a case4.y4case .asis to include patients -ith se$ere symptoms5 1B Anti.iotics are currently indicated (or in(ants up to 2 months o( a e, elderly persons, immunocompromised persons, those -ith a history o( sic*le4cell disease or prosthetic ra(ts, or patients -ho ha$e e7traintestinal (indin s5 6reatment (or those at4ris* patients should last 248 days or until the patient is a(e.rile5;, 9 #ontyphoid Salmonella in(ections are commonly treated -ith

(luoro@uinolones and third4 eneration cephalosporins, such as cipro(lo7acin and ce(tria7one5 +n 200<, the pre$alence o( resistance amon nontyphoid Salmonella isolates -as 25;: (or @uinolones and 95<: (or third4 eneration cephalosporins5 20 Enteric or typhoid (e$er is .est treated -ith anti.iotics (or 847 days (or uncomplicated cases and up to 1041< days (or a se$ere in(ection5 ;, 9 Fluoro@uinolone resistance is an important (actor in S typhi and -as reported .y the C)C to .e <158: in 200<5 6rimethoprim4sul(ametho7a?ole and chloramphenicol has a 1952: pre$alence o( resistance in S typhi, -hile ampicillin, streptomycin, and sul(iso7a?ole are 1158:5 20 'ome e$idence e7ists that (luoro@uinolones may .e used in children -ith in(ections that are di((icult to treat5 Ihen treatin children and pre nant -omen, it should .e noted that treatment -ith (luoro@uinolones should .e care(ully -ei hed a ainst the possi.ility o( dama in de$elopin cartila e5 21 2acteremia and (ocal in(ections may re@uire anti.iotics (or up to <4; -ee*s dependin on the site o( in(ection and serotype o( Salmonella5 'peci(ic sur ical inter$ention is o(ten necessary in conFunction -ith anti.iotic mana ement5 Chronic Salmonella carriers re@uire 149 months o( oral anti.iotics dependin on the serotype, suscepti.ility, and anti.iotic used5 ; Salmonella anti.iotic resistance is a lo.al concern that includes multiKdru 4 resistant strains510 "ecent out.rea*s sho- that a connection may e7ist .et-een antimicro.ial dru treatment and the ris* o( disease (rom Salmonella.22 'u.se@uently, stool and .lood cultures and sensiti$ities are important, as suscepti.ilities not only $ary dependin on re ion o( the -orld .ut also locally5 Dr!, Name Ampicillin /%rincipen0 2road4spectrum penicillin5 +nter(eres -ith .acterial cell -all synthesis durin acti$e replication, causin .actericidal acti$ity a ainst suscepti.le or anisms5 Alternati$e to amo7icillin -hen una.le to ta*e medication orally5 )emonstrated e((ecti$eness in treatment o( astroenteritis, in$asi$e disease, and enteric (e$er5 80049000 m +C @<4;h& not to e7ceed 12 =d 2004900 m =* =d +C di$ided @;h& not to e7ceed 12 =d

Descri-tion

A"!lt Dose $e"iatric Dose

#ontrain"ications )ocumented hypersensiti$ity

Interactions

%ro.enecid and disul(iram ele$ate ampicillin le$els& allopurinol decreases ampicillin e((ects and has additi$e e((ects on ampicillin rash& may decrease e((ects o( oral contracepti$es 2 4 Fetal ris* not con(irmed in studies in humans .ut has .een sho-n in some studies in animals AdFust dose in renal (ailure& e$aluate rash and di((erentiate (rom hypersensiti$ity reaction Cipro(lo7acin /Cipro0 Fluoro@uinolone -ith acti$ity a ainst pseudomonads, streptococci, !"'A, S epidermidis, and most ram4ne ati$e or anisms .ut has no acti$ity a ainst anaero.es5 +nhi.its .acterial )#A synthesis and, conse@uently, ro-th5 +s e((ecti$e in treatment o( lon 4term carriers o( S Typhi5 800 m %, .id L18 years: #ot recommended J18 years: Administer as in adults Antacids, iron salts, and ?inc salts may reduce serum le$els& administer antacids 24< h .e(ore or a(ter ta*in (luoro@uinolones& cimetidine may inter(ere -ith meta.olism o( (luoro@uinolones& reduces therapeutic e((ects o( phenytoin& pro.enecid may increase serum concentrations& may increase to7icity o( theophylline, ca((eine, cyclosporine, and di o7in /monitor di o7in le$els0& may increase e((ects o( anticoa ulants /monitor %60 C 4 Fetal ris* re$ealed in studies in animals .ut not esta.lished or not studied in humans& may use i( .ene(its out-ei h ris* to (etus +n prolon ed therapy, per(orm periodic e$aluations o( or an system (unctions

$re,nanc(

$reca!tions Dr!, Name

Descri-tion

A"!lt Dose $e"iatric Dose

#ontrain"ications )ocumented hypersensiti$ity

Interactions

$re,nanc( $reca!tions

/e , renal, hepatic, hematopoietic0& adFust dose in renal (unction impairment& superin(ections may occur -ith prolon ed or repeated anti.iotic therapy Dr!, Name Descri-tion A"!lt Dose $e"iatric Dose 6rimethoprim and sul(ametho7a?ole /2actrim0 +nhi.its .acterial ro-th .y inhi.itin synthesis o( dihydro(olic acid5 2 /.ased on '!>0 %, .id L2 months: )o not administer J2 months: 8 m =* =d /.ased on 6!%0 %, tid=@id (or 1< d

)ocumented hypersensiti$ity& #ontrain"ications me alo.lastic anemia caused .y (olate de(iciency !ay increase %6 -hen used -ith -ar(arin /per(orm coa ulation tests and adFust dose accordin ly0& coadministration -ith dapsone may increase .lood le$els o( .oth dru s& coadministration o( diuretics increases incidence o( throm.ocytopenia purpura in elderly persons& phenytoin le$els may increase -ith coadministration& may potentiate e((ects o( methotre7ate in .one marro- depression& hypo lycemic response to sul(onylureas may increase -ith coadministration& may increase le$els o( ?ido$udine C 4 Fetal ris* re$ealed in studies in animals .ut not esta.lished or not studied in humans& may use i( .ene(its out-ei h ris* to (etus )iscontinue at (irst appearance o( rash or si n o( ad$erse reaction& o.tain C2Cs (re@uently& discontinue therapy i( si ni(icant hematolo ic chan es occur& oiter, diuresis, and hypo lycemia may occur -ith sul(onamides& prolon ed +C in(usions or hi h doses may cause .one marro- depression /i( si ns occur, administer 8418 m =d leuco$orin0& caution in (olate de(iciency /e , persons -ith

Interactions

$re,nanc( $reca!tions

chronic alcoholism, elderly patients, those recei$in anticon$ulsant therapy, or persons -ith mala.sorption syndrome0& hemolysis may occur in 34;4 %) de(iciency& patients -ith A+)' may not tolerate or respond to 6!%4'!>& caution in renal or hepatic impairment /per(orm urinalyses and renal (unction tests durin therapy0& i$e (luids to pre$ent crystalluria and stone (ormation Dr!, Name Ce(tria7one /"ocephin0 6hird4 eneration cephalosporin -ith .road4spectrum, ram4ne ati$e acti$ity& lo-er e((icacy a ainst ram4positi$e or anisms& hi her e((icacy a ainst resistant or anisms5 Arrests .acterial ro-th .y .indin to one or more penicillin4.indin proteins5 142 +C .id 80478 m =* =d +C %ro.enecid may increase le$els& coadministration -ith ethacrynic acid, (urosemide, and amino lycosides may increase nephroto7icity 2 4 Fetal ris* not con(irmed in studies in humans .ut has .een sho-n in some studies in animals AdFust dose in renal impairment& caution in .reast(eedin -omen and persons aller ic to penicillin Amo7icillin /Amo7il, 2iomo7, %olymo7, and Iymo70 +nter(eres -ith synthesis o( cell -all mucopeptides durin acti$e multiplication resultin in .actericidal acti$ity a ainst suscepti.le .acteria5 <4; %, @d 100 m =* =d %, di$ided @8h "educes the e((icacy o( oral

Descri-tion

A"!lt Dose $e"iatric Dose

#ontrain"ications )ocumented hypersensiti$ity Interactions

$re,nanc(

$reca!tions Dr!, Name

Descri-tion A"!lt Dose $e"iatric Dose Interactions

#ontrain"ications )ocumented hypersensiti$ity

contracepti$es $re,nanc( $reca!tions Dr!, Name 2 4 Fetal ris* not con(irmed in studies in humans .ut has .een sho-n in some studies in animals AdFust dose in renal impairment A?ithromycin />ithroma70 Acts .y .indin to 80' ri.osomal su.unit o( suscepti.le microor anisms and .loc*s dissociation o( peptidyl t"#A (rom ri.osomes, causin "#A4dependent protein synthesis to arrest5 #ucleic acid synthesis is not a((ected5 Concentrates in pha ocytes and (i.ro.lasts as demonstrated .y in $itro incu.ation techni@ues5 +n $i$o studies su est that concentration in pha ocytes may contri.ute to dru distri.ution to in(lamed tissues5 6reats mild4to4moderate micro.ial in(ections5 )ay 1: 1000 m %, )ays 248: 800 m %, @d )ay 1: 10 m =* %,& not to e7ceed 800 m =d )ays 248: 8 m =* %,& not to e7ceed 280 m =d

Descri-tion

A"!lt Dose

$e"iatric Dose

)ocumented hypersensiti$ity& hepatic #ontrain"ications impairment& do not administer -ith pimo?ide !ay increase to7icity o( theophylline, -ar(arin, and di o7in& e((ects are reduced -ith coadministration o( aluminum and=or ma nesium antacids& nephroto7icity and neuroto7icity may occur -hen coadministered -ith cyclosporine 2 4 Fetal ris* not con(irmed in studies in humans .ut has .een sho-n in some studies in animals 'ite reactions can occur -ith +C route& .acterial or (un al o$er ro-th may result (rom prolon ed anti.iotic use& may increase hepatic en?yme le$els and

Interactions

$re,nanc( $reca!tions

cholestatic Faundice& caution in patients -ith impaired hepatic (unction or prolon ed H6 inter$als Dr!, Name Chloramphenicol Acts .y inhi.itin .acterial protein synthesis5 2inds re$ersi.ly to the 80' su.unit o( .acterial 70' ri.osome and pre$ents attachment o( the amino acid4 containin end o( the aminoacyl4tran to acceptor site on ri.osome5 Acti$e in $itro a ainst a -ide $ariety o( .acteria, includin ram4positi$e, ram4ne ati$e, aero.ic, and anaero.ic or anisms5 Iell4 a.sor.ed (rom 3+ tract and meta.oli?ed in the li$er, -here it is inacti$ated .y conFu ation -ith lucuronic acid and then e7creted .y the *idneys5 ,ral (orm is not a$aila.le in the United 'tates5 3astroenteritis: 800 m %,=+C @id (or 947 d 6yphoid (e$er: 800 m +C @id (or 1< d 784100 m =* =d +C di$ided @;h Administered concurrently -ith .ar.iturates, chloramphenicol serum le$els may decrease -hile .ar.iturate le$els may increase causin to7icity& mani(estations o( hypo lycemia may occur -ith sul(onylureas& ri(ampin may reduce serum chloramphenicol le$els, presuma.ly throu h hepatic en?yme induction& may increase e((ects o( anticoa ulants& may increase serum hydantoin le$els, possi.ly resultin in to7icity& hydantoins may either increase or decrease chloramphenicol le$els C 4 Fetal ris* re$ealed in studies in animals .ut not esta.lished or not studied in humans& may use i( .ene(its out-ei h ris* to (etus Use only (or indicated in(ections, or as prophyla7is (or .acterial in(ections& serious and (atal .lood dyscrasias

Descri-tion

A"!lt Dose $e"iatric Dose

#ontrain"ications )ocumented hypersensiti$ity

Interactions

$re,nanc( $reca!tions

/aplastic anemia, hypoplastic anemia, throm.ocytopenia, ranulocytopenia0 can occur& e$aluate .aseline and per(orm periodic .lood studies appro7imately e$ery 2 d -hile in therapy& discontinue upon appearance o( reticulocytopenia, leu*openia, throm.ocytopenia, anemia or (indin s attri.uta.le to chloramphenicol& adFust dose in li$er or *idney dys(unction& caution in pre nancy at term or durin la.or .ecause o( potential to7ic e((ects on (etus / ray syndrome0 Dr!, #ate,or(* Antidiarrheals 6hese a ents may prolon the course o( the disease5 +( used, they should .e used sparin ly5 Dr!, Name Loperamide /+modium0 Acts on intestinal muscles to inhi.it peristalsis and slo- intestinal motility5 %rolon s mo$ement o( electrolytes and (luid throu h .o-el and increases $iscosity and loss o( (luids and electrolytes5 A$aila.le as 24m ta.lets and 14m =84mL li@uid5 < m %, initial& then 2 m a(ter each loose stool& not to e7ceed 1; m =d 19420 * : 1 m %, .id 20490 * : 2 m %, .id J90 * : 2 m %, tid

Descri-tion

A"!lt Dose $e"iatric Dose

)ocumented hypersensiti$ity& diarrhea #ontrain"ications resultin (rom in(ections& pseudomem.ranous colitis Interactions %henothia?ines, tricyclic antidepressants, and C#' depressants may increase to7icity 2 4 Fetal ris* not con(irmed in studies in humans .ut has .een sho-n in some studies in animals )iscontinue use i( no clinical impro$ement in <8 h& .ecause primarily meta.oli?ed in li$er, monitor (or C#'

$re,nanc( $reca!tions

to7icity in patients -ith hepatic insu((iciency& do not use i( hi h (e$er or .lood in stool coincides -ith diarrhea Dr!, Name )ipheno7ylate and Atropine /Lomotil0 )ru com.ination that consists o( dipheno7ylate, -hich is a constipatin meperidine con ener, and atropine to discoura e a.use5 +nhi.its e7cessi$e 3+ propulsion and motility5 'upplied as dipheno7ylate 258 m and atropine 05028 m per ta.let or per 8 mL o( li@uid5 2 ta.s or 10 mL %, @id L2 years: #ot recommended J2 years: 059405< m =* =d %, di$ided @id )ocumented hypersensiti$ity& narro-4 an le laucoma or hepatic insu((iciency !ay delay meta.olism o( dru s in li$er& C#' depressants, !A,+s, and antimuscarinic a ents may increase the to7icity o( dru com.ination C 4 Fetal ris* re$ealed in studies in animals .ut not esta.lished or not studied in humans& may use i( .ene(its out-ei h ris* to (etus +n youn children, dehydration may in(luence $aria.ility o( response and predispose patient to delayed dipheno7ylate into7ication& e7ercise caution in patients -ith ulcerati$e colitis& decrease in intestinal motility may .e detrimental to patients -ith diarrhea resultin (rom Shigella species, Salmonella species, and to7i enic strains o( Escherichia coli

Descri-tion

A"!lt Dose $e"iatric Dose #ontrain"ications

Interactions

$re,nanc(

$reca!tions

Dr!, #ate,or(* Glucocorticoids 6hese a ents may .e indicated in patients -ith se$ere enteric or typhoid (e$er or si ni(icant complications such as C#' mani(estations or )+C5 Dr!, Name Descri-tion )e7amethasone /)ecadron0 Used in the treatment o( $arious

in(lammatory diseases5 )ecreases in(lammation .y suppressin the mi ration o( polymorphonuclear leu*ocytes and re$ersin increased capillary permea.ility5 A"!lt Dose $e"iatric Dose #ontrain"ications 9 m =* +C once, then 8 doses o( 1 m =* +C @;h Administer as in adults )ocumented hypersensiti$ity& acti$e .acterial or (un al in(ection E((ects decrease -ith coadministration o( .ar.iturates, phenytoin, and ri(ampin& de7amethasone decreases e((ect o( salicylates and $accines used (or immuni?ation C 4 Fetal ris* re$ealed in studies in animals .ut not esta.lished or not studied in humans& may use i( .ene(its out-ei h ris* to (etus +ncreases ris* o( multiple complications, includin se$ere in(ections& monitor adrenal insu((iciency -hen taperin dru & a.rupt discontinuation o( lucocorticoids may cause adrenal crisis& hyper lycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypo*alemia, osteoporosis, euphoria, psychosis, myasthenia ra$is, ro-th suppression, and in(ections are possi.le complications o( lucocorticoid use

Interactions

$re,nanc(

$reca!tions

F!rther O!t-atient #are

Follo-4up treatment -ith the patientMs primary care physician is hi hly recommended5 Iorsenin symptoms -arrant a return $isit to the E)5 Anti.iotic treatment (or a chronic carrier in coordination -ith the patientAs primary care physician may .e indicated5 Asymptomatic carria e occurs

on a$era e (or a.out 8 -ee*s, -ith prolon ed duration e7istin in children youn er than 8 years529

Deterrence/$re%ention
)eterrence and pre$ention measures include the (ollo-in :

%roper hy iene and (ood stora e Neepin ra- meat and poultry a-ay (rom unprepared (oods Cleanin sur(aces, utensils, and hands a(ter contact -ith ra- (oods A$oidin eatin ra- or undercoo*ed e s Control o( animal reser$oir Caccination (or enteric or typhoid (e$er
o o

Current multi4dose oral $accine /8 years0 or sin le4dose parental $accine /9 years0 -ith an e((icacy o( 80480:8 6rials under-ay (or a sin le4dose oral $accine 11

#om-lications

1ypo$olemic shoc* Urinary retention !etastatic a.scess (ormation Acute or chronic hydrocephalus !enin itis %sychosis Cholecystitis 6o7ic me acolon +ntestinal per(oration 'eptic throm.ophle.itis !ycotic a.dominal aortic aneurysm !yocarditis #ephritis ,steomyelitis An asymptomatic chronic carrier state )+C in in(ants -ith typhoid (e$er2<

$ro,nosis

#ontyphoid Salmonella is enerally sel(4limitin 5 !ost patients are treated on an outpatient .asis5 E7tremes o( a e and an immunocompromised state increases mor.idity and mortality5 6yphoid Salmonella enerally re@uires treatment5
o o

 o o

!ortality rate (or treated cases is 2:, -hile complications occur in 90: o( untreated cases59 !or.idity and mortality increases -ith dru 4resistant S typhi.10

$atient E"!cation

Emphasi?e ood hand4-ashin , thorou h cleanin o( coo*in utensils, appropriate (ood preparation techni@ues, and ade@uate coo*in temperature (or *illin the .acteria5

Me"ical/ e,al $itfalls

Failure to a ressi$ely mana e patients -ho are immunocompromised, e7tremes o( a e, or ha$e complicatin (actors such as sic*le4cell disease or prosthetic ra(ts Failure to reco ni?e an e7traintestinal mani(estation Failure to @uery a.out recent tra$el to underde$eloped nations Failure to as* a.out pre$ious astric sur ery, use o( antacids and 12 anta onists, or any predisposition to-ard reduced stomach acid production Failure to consider alternati$e dia noses 4 %er(orated $iscous and atypical presentation o( appendicitis needs to .e considered5 Failure to reco ni?e that a sudden out.rea* o( Salmonella may .e secondary to an intentional contamination28

6he authors and editors o( e!edicine rate(ully ac*no-led e the contri.utions o( pre$ious author, "o.ert A 2arrali Jr, !), to the de$elopment and -ritin o( this article5 Ie -ould li*e to ac*no-led e the assistance o( !ichelle !an(redi in researchin this topic5

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95 Cham.ers 1F5 !c%hee 'J, %apada*is !A, 6ierney L!, eds5 Current #edical Diagnosis $ Treatment 5 <7th ed5 !c3ra-41ill Co& 2008:12804 12825 4. Centers (or )isease Control and %re$ention5 %reliminary Food#et data on the incidence o( in(ection -ith patho ens transmitted commonly throu h (ood4410 states, 20075 ##%R #orb #ortal %&ly Rep5 Apr 11 2008&87/1<0:9;;4705 O!edlineP5 5. Linam I!, 3er.er !A5 Chan in epidemiolo y and pre$ention o( 'almonella in(ections5 'ediatr In(ect Dis )5 Au 2007&2;/80:7<74 85 O!edlineP5 ;5 %e@ues )A, ,hl !, !iller '5 #andell, Douglas, and ennett*s+ 'rinciples and 'ractice o( In(ectious Diseases5 ;th ed5 Else$ier& 2008:chap 2205 7. 2raden C"5 'almonella enterica serotype Enteritidis and e s: a national epidemic in the United 'tates5 Clin In(ect Dis5 Au 18 200;&<9/<0:8124 75 O!edlineP5 85 Jones 6F, +n ram LA, Fullerton NE, et al5 A case4control study o( the epidemiolo y o( sporadic 'almonella in(ection in in(ants5 'ediatrics5 )ec 200;&118/;0:2980475 O!edlineP5 9. Coetsch AC, Can 3ilder 6J, An ulo FJ, et al5 Food#et estimate o( the .urden o( illness caused .y nontyphoidal 'almonella in(ections in the United 'tates5 Clin In(ect Dis5 Apr 18 200<&98 'uppl 9:'12749<5 O!edlineP5 10. Iein.er er !, Neller #5 "ecent trends in the epidemiolo y o( non4 typhoid 'almonella and antimicro.ial resistance: the +sraeli e7perience and -orld-ide re$ie-5 Curr !pin In(ect Dis5 )ec 2008&18/;0:8194 215 O!edlineP5 11. 2oyle EC, 2ishop JL, 3rassl 3A, et al5 'almonella: (rom patho enesis to therapeutics5 ) acteriol5 !ar 2007&18B/80:1<8B4 B85 O!edlineP5 12. 'ethuraman U, Namat )5 !ana ement o( child -ith (e$er a(ter international tra$el5 Clin 'ediatr ,'hila-5 Apr 2007&<;/90:222475 O!edlineP5 195 1eymann )L5 Control o( Communicable Diseases #anual 5 18th ed5 American %u.lic 1ealth Association& 200<:<;B4<795 14. %erera #, 3eary C, Iisel*a !, et al5 !i7ed 'almonella in(ection: case report and re$ie- o( the literature5 ) Travel #ed5 !ar4 Apr 2007&1</20:19<485 O!edlineP5 15. 1atta !, 'mits 1L5 )etection o( 'almonella typhi .y nested polymerase chain reaction in .lood, urine, and stool samples5 .m ) Trop #ed /yg5 Jan 2007&7;/10:19B4<95 O!edlineP5 1;5 2ottieau E, Clerin7 J, Can den Enden E, et al5 Fe$er a(ter a stay in the tropics: dia nostic predictors o( the leadin tropical conditions5 #edicine , altimore-5 Jan 2007&8;/10:184285 O!edlineP5 17. A.u.a*ar +, +r$ine L, Aldus CF, et al5 A systematic re$ie- o( the clinical, pu.lic health and cost4e((ecti$eness o( rapid dia nostic tests (or the detection and identi(ication o( .acterial intestinal patho ens in (aeces and (ood5 /ealth Technol .ssess5 'ep 2007&11/9;0:1421;5 O!edlineP5

185 'irina$in ', 3arner %5 Anti.iotics (or treatin salmonella ut in(ections5 Cochrane Database Syst Rev5 2000&C)0011;75 O!edlineP5 19. IistrQm J, Jert.orn !, E*-all E, et al5 Empiric treatment o( acute diarrheal disease -ith nor(lo7acin5 A randomi?ed, place.o4controlled study5 '-edish 'tudy 3roup5 .nn Intern #ed5 Au 1 1BB2&117/90:2024 85 O!edlineP5 20. Centers (or )isease Control and %re$ention5 0ational .ntimicrobial Resistance #onitoring System (or Enteric acteria ,0.R#S-+ /uman Isolates 1inal Report, 23345 OFull 6e7tP5 21. 3rady "5 'a(ety pro(ile o( @uinolone anti.iotics in the pediatric population5 'ediatr In(ect Dis )5 )ec 2009&22/120:11284925 O!edlineP5 22. !Rl.a* N5 1uman health conse@uences o( antimicro.ial dru 4 resistant 'almonella and other (ood.orne patho ens5 Clin In(ect Dis5 )ec 1 2008&<1/110:1;194205 O!edlineP5 23. 2uch-ald )', 2laser !J5 A re$ie- o( human salmonellosis: ++5 )uration o( e7cretion (ollo-in in(ection -ith nontyphi 'almonella5 Rev In(ect Dis5 !ay4Jun 1B8<&;/90:9<848;5 O!edlineP5 2<5 2hutta >A5 Current concepts in the dia nosis and treatment o( typhoid (e$er5 #)5 Jul 8 200;&999/78880:784825 O!edlineP5 25. 6oro* 6J, 6au7e "C, Iise "%, et al5 A lar e community out.rea* o( salmonellosis caused .y intentional contamination o( restaurant salad .ars5 ).#.5 Au ; 1BB7&278/80:98B4B85 O!edlineP5 26. Amie$a !"5 +mportant .acterial astrointestinal patho ens in children: a patho enesis perspecti$e5 'ediatr Clin 0orth .m5 Jun 2008&82/90:7<B477, $i5 O!edlineP5 27. Connor 2A, 'ch-art? E5 6yphoid and paratyphoid (e$er in tra$ellers5 5ancet In(ect Dis5 ,ct 2008&8/100:;29485 O!edlineP5 28. 1o((man 'L, %unFa.i #1, Numala ', et al5 "eduction o( mortality in chloramphenicol4treated se$ere typhoid (e$er .y hi h4dose de7amethasone5 0 Engl ) #ed5 Jan 12 1B8<&910/20:82485 O!edlineP5 2B5 %arry C!, 1ien 66, )ou an 3, et al5 6yphoid (e$er5 0 Engl ) #ed5 #o$ 28 2002&9<7/220:17704825 O!edlineP5 905 %unFa.i #1, 1o((man 'L, Edman )C, et al5 6reatment o( se$ere typhoid (e$er in children -ith hi h dose de7amethasone5 'ediatr In(ect Dis )5 Au 1B88&7/80:8B84;005 O!edlineP5