Salmonella Treatments and Medications

There are countless ways salmonella bacteria can contaminate the food we eat. Whatever route it takes, salmonella infects the gut. Once infection takes hold, symptoms like diarrhea and fever can happen in just a few hours. Fortunately, infections typically resolve themselves without any outside interference. Learn more about the symptoms and treatment of salmonella in the sections that follow.

What is salmonella?

Salmonella is a common bacterial infection of the intestines and the most common cause of food poisoning. Over a billion people pick up a salmonella infection each year, and almost one and a half million of those folks live in the United States. Fortunately, most salmonella cases only infect intestinal tissues and clear up without treatment after a few days of diarrhea. For most salmonella cases, the primary threat is dehydration and loss of electrolytes.

However, the typhoid strains of Salmonella (Salmonella enterica variants—typhi and paratyphi) easily make their way through intestinal tissues, invade the body, and cause typhoid fever, one of the deadliest infectious diseases on the planet. Also called enteric fever, typhoid fever infects 21 million people a year and kills over 200,000 of them. Fortunately, typhoid fever is very rare in the United States, averaging about 400 cases a year, and almost all those patients catch the infection overseas.

Salmonella, then, is divided into two diseases. Typhoidal salmonella causes enteric fever. Non-typhoidal salmonella, or NTS, usually causes transient intestinal infections that, on rare occasions, may sometimes progress to a system-wide infection. In the United States, salmonella almost always refers to non-typhoidal salmonella, so we’ll focus on that disease with an occasional reference to typhoid fever.

Non-typhoidal Salmonella is passed from animals to humans. The normal route of transmission is for people to eat animal feces populated with Salmonella bacteria, but more than 95% of salmonella infections in the U.S. are food-borne; that is, people are eating food contaminated with feces. Considering that salmonella infects the majority of farm animals —especially chickens—it’s not hard to imagine how easily food can be contaminated.

Meat, especially ground beef or pork, can be contaminated when being processed. Eggs can be infected when they’re formed in the chicken, or afterward, the shell can become contaminated. Vegetables and fruit can be contaminated by fertilizer or by being processed or prepared along with contaminated meats. Food handlers with poor hygiene can contaminate foods. Handling or cleaning up after pets can spread salmonella to the hands, which can then contaminate food. There are a million ways for Salmonella bacteria to get into a person’s digestive system, but the basic equation always remains the same.

Typhoid fever, however, only infects humans. The infection is passed from person to person through feces. The risk factors for typhoid fever, then, are poor sanitation, untreated drinking water, and overcrowding, so travel to developing countries includes a risk for typhoid fever.

How is salmonella diagnosed?

A Salmonella infection, called salmonellosis, is always a prime suspect when a patient has diarrhea and fever. Healthcare providers only diagnose salmonella when they’ve confirmed the presence of Salmonella in the patient’s stools, urine, or blood.

To understand the risk for salmonellosis, it helps to understand what it takes to catch an infection. Salmonella bacteria have several formidable obstacles to overcome before they can cause an infection. First, they have to end up on food. They are wiped out if the food is cooked or cleared out if the food is washed. If the bacteria make it past that first hurdle, they then have to survive deadly acid in the stomach, which most don’t survive. Once in the intestines, normal intestinal motility sweeps them out before they can do anything. Those that don’t get swept out still have to face bacteria already living in the intestines, some of which can poison what little Salmonella remains. Finally, the immune system takes on the stragglers, clearing them out before an infection takes hold.

Considering all those hurdles, the risk factors for salmonella infection are

• Eating food that has been prepared in poor hygienic conditions

• Eating undercooked or raw meats, raw eggs, unpasteurized dairy products, or uncooked foods that have come in contact with raw meat

• Not washing hands after handling or cleaning up after pets

• Having low levels of stomach acid due to illness or medications (acid reducers),

• Antibiotic therapy or gastrointestinal surgery that has killed or altered the native population of bacteria in the intestines

• Impaired immunity due to illness, medications, or age, such as young children or the elderly

Symptoms appear in six to 48 hours. Diarrhea is the cardinal symptom, but patients often have nausea, vomiting, and abdominal cramps. Fever, chills, headache, bloody stools, and muscle pain are also common.

Typhoid fever, on the other hand, typically takes five to 21 days for symptoms to manifest. It may be preceded by intestinal swelling (gastroenteritis) with abdominal pain and either diarrhea or constipation. The most characteristic symptom of typhoid fever is a “stepwise” fever in the first week of infection—the body’s temperature increases, levels off for a while, then increases some more, plateaus again, and so on, eventually reaching a sustained, high fever. Stepwise fever is followed by the other distinguishing symptom of typhoid fever, a rash of “rose spots.”

Salmonellosis is only diagnosed when Salmonella is found in the stools either by culturing the bacteria or detecting antibodies. Typhoid fever is confirmed by culturing a blood sample, running antibody tests on blood or urine, or detecting Salmonella genes in the blood.

Approximately 0.5% of patients who get non-typhoidal salmonella and 3% of patients with typhoid fever become salmonella carriers without any symptoms, with “Typhoid Mary” being the first and most famous. A carrier continues to pass salmonella bacteria in their stools and urine for years and can continue to spread the infection. Called “asymptomatic carriage,” the carrier form of salmonellosis is diagnosed with regular stool samples but is usually only monitored in patients with typhoid fever. Since most non-typhoidal salmonella infections go undiagnosed and untreated, asymptomatic carriers usually go undiagnosed.

Salmonella treatment options

Non-typhoidal salmonellosis typically resolves in a few days without treatment, but if the infection threatens to spread, then medications, hospitalization, and even surgery may be required.

Rest and rehydration

Most non-typhoidal Salmonella infections will be treated with rest and rehydration. Patients with severe diarrhea or dehydration, however, will be hospitalized and put on intravenous fluids and electrolytes. Antibiotics can make the condition worse so they’re not recommended.

Antibiotics

The most serious complication for non-typhoidal Salmonella is a blood infection, or bacteremia, a potentially life-threatening infection that happens in 1-4% of cases. When this happens, about one in 10 patients will advance to more serious localized salmonella infections such as pneumonia, meningitis, osteomyelitis, or reactive arthritis. These cases are always treated with antibiotics. Some patients are more at risk for complications than others, such as young children and older adults, so they will often be put on antibiotics before the infection spreads.

Typhoid fever

Typhoid fever is always treated with antibiotics, if possible. The mortality rate for untreated typhoid fever is 10-30%; antibiotic treatment lowers the mortality rate to 1%. Also, typhoid fever can cause intestinal tearing (perforation) that will require surgery.

Carriers

Treatment for carriers involves a four-week course of antibiotics. Because the gallbladder can house a salmonella colony, it is usually the cause of asymptomatic carriage. If antibiotic treatment doesn’t work, surgical removal of the gallbladder, or cholecystectomy, may be necessary.

Salmonella medications

Non-typhoidal salmonella is treated with rest and rehydration, but both enteric fever and complicated salmonella infections will be treated with antibiotics. Salmonella infection is so common, however, that drug-resistant strains are prevalent. Many antibiotics that used to fight off salmonella can no longer be used.

Antibiotics

The initial antibiotic treatment for cases where salmonellosis is suspected but not confirmed is a third-generation cephalosporin such as ceftriaxone. Once a complicated salmonella infection or typhoid fever has been confirmed, the preferred antibiotics are fluoroquinolones (ciprofloxacin, ofloxacin, or fleroxacin), azithromycin, or ceftriaxone. Drug-resistant salmonella is always a risk, so treatment may have to switch to carbapenems (ertapenem or meropenem) particularly if the infection is acquired in Pakistan. . Patients with complicated NTS usually require seven to 10 days of antibiotics, but typhoid fever usually involves 10-14 days of treatment. Carriers will need to endure four weeks (or longer) of fluoroquinolones to clear the infection.

Vaccines

There are no vaccines for non-typhoidal salmonellosis, but there are two typhoid fever vaccines: oral Vivotif and injectable typhoid vaccine. Both are equally effective, so the choice will depend on the age of the patient and the number of years of immunity required. The Centers for Disease Control (CDC) recommend typhoid fever vaccination for all Americans traveling to developing countries.

Other medications

Patients with either non-typhoidal or typhoidal salmonellosis might use over-the-counter or prescription medications to relieve abdominal pain or nausea.

The most severe and deadly cases of typhoid fever will be treated with high doses of dexamethasone along with antibiotics. Dexamethasone is a corticosteroid that is used in typhoid fever to reduce potentially life-threatening swelling in the brain.

What is the best medication for salmonella?

Most cases of salmonella resolve without drug treatment. Antibiotics are only used if the infection spreads to the rest of the body. Healthcare providers use an established set of guidelines for prescribing antibiotics for salmonella infections, so there is no “best” antibiotic for salmonellosis.

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Best medications for salmonella