We all love to eat raw eggs in our morning protein shake (with extra peanut butter), but occasionally an outbreak of Salmonella will cause us to rethink our dietary choices.  So, should we reconsider how we manage gastroenteritis in patients in the Peds ED?

Basics

• Nontyphyoidal salmonellosis is the leading cause of food-borne illness in the US; mostly due to ingested foodstuffs like diary and meats but can be many others as well.
• People with low gastric acid, recent antibiotic use, immunosuppression, or extremes of ages are at greater risk.
• For the majority of cases, infection is a self-limited disease, which is good because  multi-drug resistant salmonella strains have developed

What to do with the Peds patient with diarrhea during an outbreak?

• Determine % dehydration…. Utilize Oral Rehydration Therapy for those not severely dehydrated.
• Review local and hospital protocols (as well as CDC website).
• Consider fecal studies

But what about empiric antibiotics?

• For the majority of cases, salmonella will lead to a self-limiting condition that is NOT benefited by empiric antibiotics.
• Additionally, the appearance of multiple-drug resistance, including resistance to quinolones, means we need to be judicious (as always).

• Furthermore, antibiotics should NOT be prescribed simply to reduce the likelihood of secondary transmission. Make sure you teach everyone to WASH THEIR HANDS!

But what about if we know the patient has Salmonella?

• As stated already, the vast majority of cases will resolve without antibiotics. So most still will not need antibiotics.
• Those who need antibiotics:
  • Immunocompromised pts.
  • Non-immunocompromised if:
    • <3 Months (some literature says <6 months)
    • Positive blood cultures
      • One study actually showed that the kids who presented to the ED looking worse were not the ones that were more likely to have positive blood cultures.
      • Essentially, clinically you cannot discern who will have salmonella bacteremia in pediatric patients.
    • Dysentery or failure to thrive (so not usually upon the first ED visit).
    • Presence of indwelling hardware or prostheses
    • Valvular heart disease

What antibiotic should you pick if it is warranted?

• Make sure cultures have been obtained to ensure susceptibilities can help refine the drug selection.
• To start, TMP-SMZ or ceftriaxone have been suggested.

 

 

Davidson G, et al. Infectious Diarrhea in Children: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition. Journal of Pediatric Gastroenterology & Nutrition: August 2002 – Volume 35. pp S143-S150

Guerrant R, et al. Practice Guidelines for the Management of Infectious Diarrhea . Clinical Infectious Diseases 2001;32:331–50

Nelson SJ, Granoff D. Salmonella Gastroenteritis in the First Three Months of Life: A Review of Management and Complications. CLIN PEDIATR December 1982 vol. 21(12), 709-712.

Crum-Cianflone NF. Salmonellosis and the gastrointestinal tract: More than just peanut butter. Current Gastroenterology Reports, 2008: 10,