Salmonellosis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2] Jolanta Marszalek, M.D. [3]
Overview
Medical Therapy
Treatment of salmonellosis is often symptomatic, with electrolyte replacement and rehydration. Mild cases of salmonelloses usually resolve within 5 to 7 days. Patients with severe cases of the disease may require rehydration, often with intravenous fluids. Antibiotic treatment is not routinely recommended, unless the patient becomes severely dehydrated or infection reaches the blood stream.[1]
Salmonellosis commonly presents with unspecific gastrointestinal symptoms, such as diarrhea, fever, and abdominal pain. Antibiotic treatment of infectious diarrhea is considered controversial because:[2]
- Symptoms may be caused by different types of enteric pathogens, which makes the initial treatment of severe cases often "empiric"
- Antibiotic treatment of non-typhoidal salmonellosis prolongs shedding of the bacteria in feces.
Supportive Treatment
Initial therapy of infectious diarrhea, irrespectively from the causative agent, should start with rehydration. Oral rehydration with a glucose and electrolyte solution is preferred, except in cases where the patient is severely dehydrated or comatose. [3]
Nutritional support should also be provided, particularly in children, where it was shown to improve outcomes. The use of the "BRAT diet" is also frequently recommended. This diet consists in bananas, rice, applesauce and toast, with avoidance of dairy products, due to the potential deficiency of lactase following the gastrointestinal disturbance.[3][4]
Symptomatic Treatment
Although there is little evidence of the efficacy of most of the antidiarrheal agents on the marker, the following have demonstrated to be effective in controlled, randomized trials:[3][5]
Loperamide
Antimotility agent, with anti-secretory properties, able to inhibit intestinal peristalsis. Despite being an opiate, it does not have the potential of addiction, because it does not penetrate the nervous system.[6]
Loperamide should be avoided in patients with inflammatory or bloody diarrhea because of the relation between antimotility agents and prolonged fever in patients infected with Shigella and C. difficile.[7]
Bismuth Subsalicylate
Bismuth subsalicylate may alleviate symptoms such as: nausea, diarrhea and abdominal pain.[8] It was also shown to decrease stool output in pediatric patients.[9]
Antibiotic Treatment
Antibiotics are not recommended for uncomplicated salmonellosis because they prolong shedding of the bacteria, typically do not alleviate the diarrhea, and have been associated with relapse.[3][10][11] Antibiotic therapy is only indicated for patients with severe cases of the disease, and for those with risk factors for extra-intestinal infection, after blood and fecal cultures have been obtained. Risk groups for the development of extra-intestinal manifestations include:[2][12]
- Infants and elderly
- Patients with pernicious anemia
- Patients taking H2 antagonists and antacids
- Changes in endogenous bowel flora, in:
- Surgery
- Recent antibiotic treatment
- Diabetes
- HIV infection
- Malignancy
- Rheumatological diseases
- Blockage of reticuloendothelial system
- Immunosuppressive therapy
Antibiotic treatment may be indicated in cases when rapid interruption of fecal shedding of the bacteria is required to avoid outbreaks in institutions.[13]
For the cases where antibiotics are indicated, treatment should include:
Trimethropim-Sulfamethoxazole
- Indicated in children and cases when susceptibility is suspected.
- For 5 to 7 days
Fluoroquinolone
- For 5 to 7 days
Ceftriaxone
- 100 mg/Kg body weight/day
Multidrug Resistance
Some serovars of Salmonella enterica, particularly Typhimurium and Newport, are linked to more severe cases of salmonellosis and multi-drug resistance.[12]
Follow Up
Fecal cultures are not indicated for patient follow-up after uncomplicated cases of salmonellosis, irrespectively to the treatment administrated. The results tend to be intermittently positive for a long period of time, and do not show any utility in an asymptomatic patient.[2][14]
References
- ↑ "Salmonella (non-typhoidal)".
- ↑ 2.0 2.1 2.2 Hohmann EL (2001). "Nontyphoidal salmonellosis". Clin Infect Dis. 32 (2): 263–9. doi:10.1086/318457. PMID 11170916.
- ↑ 3.0 3.1 3.2 3.3 Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.
- ↑ "Managing Acute Gastroenteritis Among Children Oral Rehydration, Maintenance, and Nutritional Therapy".
- ↑ "Antidiarrheal Drug Products for Over-the-Counter Human Use; Amendment of Final Monograph".
- ↑ DuPont HL, Flores Sanchez J, Ericsson CD, Mendiola Gomez J, DuPont MW, Cruz Luna A; et al. (1990). "Comparative efficacy of loperamide hydrochloride and bismuth subsalicylate in the management of acute diarrhea". Am J Med. 88 (6A): 15S–19S. PMID 2192553.
- ↑ DuPont HL, Hornick RB (1973). "Adverse effect of lomotil therapy in shigellosis". JAMA. 226 (13): 1525–8. PMID 4587313.
- ↑ DuPont HL, Sullivan P, Pickering LK, Haynes G, Ackerman PB (1977). "Symptomatic treatment of diarrhea with bismuth subsalicylate among students attending a Mexican university". Gastroenterology. 73 (4 Pt 1): 715–8. PMID 330307.
- ↑ Figueroa-Quintanilla D, Salazar-Lindo E, Sack RB, León-Barúa R, Sarabia-Arce S, Campos-Sánchez M; et al. (1993). "A controlled trial of bismuth subsalicylate in infants with acute watery diarrheal disease". N Engl J Med. 328 (23): 1653–8. doi:10.1056/NEJM199306103282301. PMID 8487823.
- ↑ Wiström J, Jertborn M, Ekwall E, Norlin K, Söderquist B, Strömberg A; et al. (1992). "Empiric treatment of acute diarrheal disease with norfloxacin. A randomized, placebo-controlled study. Swedish Study Group". Ann Intern Med. 117 (3): 202–8. PMID 1616214.
- ↑ Neill MA, Opal SM, Heelan J, Giusti R, Cassidy JE, White R; et al. (1991). "Failure of ciprofloxacin to eradicate convalescent fecal excretion after acute salmonellosis: experience during an outbreak in health care workers". Ann Intern Med. 114 (3): 195–9. PMID 1898630.
- ↑ 12.0 12.1 Gal-Mor O, Boyle EC, Grassl GA (2014). "Same species, different diseases: how and why typhoidal and non-typhoidal Salmonella enterica serovars differ". Front Microbiol. 5: 391. doi:10.3389/fmicb.2014.00391. PMID 25136336.
- ↑ Lightfoot NF, Ahmad F, Cowden J (1990). "Management of institutional outbreaks of Salmonella gastroenteritis". J Antimicrob Chemother. 26 Suppl F: 37–46. PMID 2292544.
- ↑ Buchwald DS, Blaser MJ (1984). "A review of human salmonellosis: II. Duration of excretion following infection with nontyphi Salmonella". Rev Infect Dis. 6 (3): 345–56. PMID 6377442.