SEARCH

SEARCH BY CITATION

Keywords:

  • paediatrics;
  • evidence-based medicine;
  • anti-bacterial agents

Abstract

  1. Top of page
  2. Abstract
  3. Non-typhoidal Salmonella infection
  4. What should we do in practice?
  5. What do the guidelines suggest?
  6. Commentary by J. Robinson
  7. Declaration of interest
  8. References

Eco-paediatrics is an occasional feature in Evidence-Based Child Health: A Cochrane Review Journal. Our goal is to contribute to the worldwide discussion on reducing waste in health care. In each instalment, we will select a recent Cochrane review highlighting a practice, still in use, which the available evidence tells us should be discontinued.

Excerpts from: Onwuezobe IA, Oshun PO, Odigwe CC. Antimicrobials for treating symptomatic non-typhoidal Salmonella infection. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD001167. DOI: 10.1002/14651858.CD001 167.pub2.

Non-typhoidal Salmonella infection

  1. Top of page
  2. Abstract
  3. Non-typhoidal Salmonella infection
  4. What should we do in practice?
  5. What do the guidelines suggest?
  6. Commentary by J. Robinson
  7. Declaration of interest
  8. References

Non-typhoidal Salmonella (NTS) infection is an important cause of food poisoning worldwide. It commonly causes diarrhoea, and is usually self-limiting, although sometimes people develop severe dehydration or extra-intestinal infection including bacteraemia and endovascular infections. In the USA, an estimated 1.4 million people suffer from the disease annually, of which about 80 000–160 000 seek medical attention, approximately 16 000 are hospitalized and about 600 people die from the disease (1. NTS infection is common in children younger than 5 years in developing countries, particularly in many places in sub-Saharan Africa (2.

What should we do in practice?

  1. Top of page
  2. Abstract
  3. Non-typhoidal Salmonella infection
  4. What should we do in practice?
  5. What do the guidelines suggest?
  6. Commentary by J. Robinson
  7. Declaration of interest
  8. References

For healthy children and adults, there is no evidence that antibiotics shorten the course of fever or diarrhoea. Antibiotics appear to prolong carriage and to increase the risk of adverse events. Therefore, antibiotics should generally be avoided for diarrhoea that is proven or suspected to be due to NTS. However, patients with severe disease were excluded from many studies. Immunocompromised hosts, children younger than 6 months and the elderly have a higher risk of extra-intestinal infections. Therefore, antibiotics are still recommended for these patient groups.

What do the guidelines suggest?

  1. Top of page
  2. Abstract
  3. Non-typhoidal Salmonella infection
  4. What should we do in practice?
  5. What do the guidelines suggest?
  6. Commentary by J. Robinson
  7. Declaration of interest
  8. References
National Institute for Clinical Health and Excellence, 2009 (3)

Guidance on antibiotic therapy:

 Do not routinely give antibiotics to children with gastroenteritis

Give antibiotic treatment to all children:

 with suspected or confirmed septicaemia

 with extra-intestinal spread of bacterial infection

 younger than 6 months with Salmonella gastroenteritis

 who are malnourished or immunocompromised with Salmonella gastroenteritis

Clinical Infectious Diseases Practice Guidelines for the Management of Infectious Diarrhea (4)Salmonella infections may warrant quinolone or other antimicrobial therapy when systemic spread is considered a risk or suspected, and for children <6 months of age; however, like other antibiotics, quinolones may prolong shedding of non-typhi species of Salmonella (5–8).
 A particularly worrisome development is the appearance of multiple-drug resistance, including resistance to quinolones, in clinical Salmonella strains (9). Antibiotics should not be prescribed simply to reduce the likelihood of secondary transmission. Other interventions, such as hand-washing, can achieve the same ends without introducing the risk of selecting for resistance (10).
Ontario Agency for Health Protection and Promotion, 2010 (11)Studies suggest that there is no change in duration of symptoms with the use antimicrobials in the treatment of NTS infection in these circumstances. Treatment has been associated with prolonged faecal shedding and increased risk of relapse. Antibiotic resistance is becoming more common in NTS infection to all classes of antimicrobials.
World Gastroenterology Organisation Practice Guideline: Acute Diarrhea (12)Antimicrobial therapy is not usually indicated in children and is reliably helpful only for children with bloody diarrhoea, suspected cholera with severe dehydration and serious intestinal infections.

Evidence-Based Child Health Canadian editorial office*

Evidence-Based Child Health, Editorial Office. E-mail: child@ualberta.ca

Commentary by J. Robinson

  1. Top of page
  2. Abstract
  3. Non-typhoidal Salmonella infection
  4. What should we do in practice?
  5. What do the guidelines suggest?
  6. Commentary by J. Robinson
  7. Declaration of interest
  8. References

Although it ‘feels right’ to prescribe antibiotics for a bacterial infection that is sometimes accompanied by bacteraemia, the evidence is convincing that healthy children 6 months of age or older do not benefit from antibiotics for NTS diarrhoea. Young children typically shed NTS in their stool for months following recovery. This is a benign condition for the child and there is usually no need to document when carriage ceases. However, carriage is of concern if the child is diapered and in child care as spread to other children may occur. Even in that setting, it does not make sense to prescribe antibiotics as the bit of data that we have from randomized trials indicate that antibiotics prolong carriage. It is fortunate that we no longer feel obligated to routinely treat NTS given the increasing resistance of NTS worldwide to antibiotics including amoxicillin, sulphas and quinolones.

Declaration of interest

  1. Top of page
  2. Abstract
  3. Non-typhoidal Salmonella infection
  4. What should we do in practice?
  5. What do the guidelines suggest?
  6. Commentary by J. Robinson
  7. Declaration of interest
  8. References

None.

Joan Robinson, EBCH Editor*

Department of Pediatrics, University of Alberta, Edmonton, Canada

Correspondence to: Joan Robinson, MD, 3-588D ECHA. 11405-87Ave, Edmonton AB Canada T6G 1C9. E-mail: jr3@ualberta.ca

References

  1. Top of page
  2. Abstract
  3. Non-typhoidal Salmonella infection
  4. What should we do in practice?
  5. What do the guidelines suggest?
  6. Commentary by J. Robinson
  7. Declaration of interest
  8. References
  • 1
    Mead PS, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, et al. Food-related illness and death in the United States. Emerg Infect Dis 1999; 5: 607625. Epub 1999/10/08.
  • 2
    Graham SM. Salmonellosis in children in developing and developed countries and populations. Curr Opin Infect Dis 2002; 15: 507512. Epub 2003/04/11.
  • 3
    Excellence NIfHaC (2009). Diarrhoea and vomiting in children under 5. 18 p. Available at: http://www.nice.org.uk/usingguidance/donotdorecommendations/detail.jsp?action=details&dndid=378 [accessed on 16 April 2013].
  • 4
    Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001; 32: 331351.
  • 5
    DuPont HL. Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1997; 92: 19621975. Epub 1997/11/15.
  • 6
    Neill MA, Opal SM, Heelan J, Giusti R, Cassidy JE, White R, et al. Failure of ciprofloxacin to eradicate convalescent fecal excretion after acute salmonellosis: experience during an outbreak in health care workers. Ann Intern Med 1991; 114: 195199. Epub 1991/02/01.
  • 7
    Nelson JD, Kusmiesz H, Jackson LH, Woodman E. Treatment of Salmonella gastroenteritis with ampicillin, amoxicillin, or placebo. Pediatrics 1980; 65: 11251130. Epub 1980/06/01.
  • 8
    Pegues DA, Hohmann EL, Miller SI, et al. Salmonella, including S. typhi. In: Blaser MJ, Smith PD, Ravdin JI, Greenberg HB, Guerrant RL, et al., eds. Infections of the Gastrointestinal Tract. New York: Raven Press; 1995; 785809.
  • 9
    Olsen SJ, DeBess EE, Marano N, et al., eds. Transmission of multi-drug resistant Salmonella associated with fluoroquinolone use in a nursing home. In: Annual Meeting of the Infectious Diseases Society of America. Alexandria, VA: Infectious Diseases Society of America; 1999.
  • 10
    Tuttle J, Tauxe RV, Ledger WJ. Antimicrobial-resistant shigella: the growing need for prevention strategies. Infect Dis Clin Pract 1993; 2: 5559.
  • 11
    Promotion OAfHPa (2010). Non-typhoidal Salmonella (NTS) infection: information for clinicians. Available at: http://www. oahpp.ca/resources/documents/clinicalguidelines/Clinical%20Guidelines%20NTS%20Aug%202010.pdf.
  • 12
    National Guideline C. WGO practice guideline: acute diarrhea. Rockville MD: Agency for Healthcare Research and Quality (AHRQ). Available at: http://guideline.gov/content.aspx?id=12679 [accessed on 4 March 2013].