Article infectious diseases
Salmonella Infections
John C. Christenson, MD*
Author Disclosure
Dr Christenson has
disclosed no financial
relationships relevant
to this article. This
commentary does not
contain discussion of
unapproved/
investigative use of
a commercial product/
device.
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Practice Gaps
1. Because Salmonella disease causes 93.8 million illnesses and 155,000 deaths
worldwide and 1 million foodborne illnesses and 350 deaths in the United States,
clinicians must learn to recognize, treat, and prevent these infections.
2. Young infants, persons with hemoglobin disorders, and individuals who are immune
compromised, such as those with human immunodeficiency virus and cancer, are at
risk for severe Salmonella disease, including bacteremia, meningitis, and
osteomyelitis.
Objectives After completing this article, readers should be able to:
1. Describe the epidemiology of nontyphoidal salmonellosis.
2. Recognize the clinical features of enteric fevers.
3. Appropriately treat the young child with Salmonella infection.
4. Understand ways to prevent Salmonella infections.
5. Use typhoid vaccines when indicated.
Introduction
Salmonella infection is a common cause of gastroenteritis and bacteremia worldwide. The
consumption of contaminated water and food and the close contact with colonized ani-
mals are frequent risk factors for acquisition. Young infants, persons with hemoglobin
disorders, and individuals who have immunocompromising conditions, such as human
immunodeficiency virus (HIV) and cancer, are at risk for severe disease, such as bacter-
emia, meningitis, and osteomyelitis. Salmonella Typhi and Salmonella Paratyphi are re-
sponsible for significant morbidity and mortality in developing countries. Clinicians must
learn to recognize these infections and know how to effectively treat and prevent them.
This review article provides the reader with enhanced knowledge of this diverse group of
pathogens.
Microbiology
The genus Salmonella is composed of motile gram-negative bacteria within the family En-
terobacteriaceae. They are oxidase-negative, indole-negative, and nonlactose fermenters.
The nomenclature of the genus Salmonella can be challenging. The Centers for Disease
Control and Prevention and the World Health Organization have been responsible for
maintaining the format for formula designation. There are 2 Salmonella species, Salmonella
enterica and Salmonella bongori, which are classified further into subspecies according to
their biochemical and genomic relatedness. Most human infections are caused by a serotype
of Salmonella enterica subsp enterica (subspecies I), which infect warm-blooded animals.
Five other subspecies (plus S bongori [subspecies V]) are known to colonize cold-blooded
animals and the environment: enterica subsp salamae (subspecies II), arizonae (subspecies
IIIa), diarizonae (subspecies IIIb), houtenae (subspecies IV), and indica (subspecies VI).
Although more than 2,600 serotypes of Salmonella have been identified, most disease
is caused by subspecies/serotypes Typhimurium and Enteritidis. Historically, serotypes
are frequently reported as species. For simplicity, in this review we use genus and
*Ryan White Center for Pediatric Infectious Disease, Indiana University School of Medicine, Riley Hospital for Children,
Indianapolis, IN.
Pediatrics in Review Vol.34 No.9 September 2013 375
infectious diseases salmonella
subspecies/serotype (eg, Salmonella Typhi or Salmonella
Typhimurium). Non–subspecies I are rarely reported as
human pathogens.
Certain serotypes frequently correlate with a disease
syndrome or food source. As examples, Salmonella chol-
eraesuis and Salmonella dublin are both frequently asso-
ciated with bacteremia and extraintestinal infections.
(1)(2)
Epidemiology
Nontyphoidal Salmonella Infections
Salmonella gastroenteritis is a serious public health prob-
lem in the United States. An estimated 1 million food-
borne illnesses occur each year, resulting in 350 deaths.
(3) The world burden is estimated at 93.8 million ill-
nesses, with 155,000 deaths each year. Salmonella Enter-
itidis is the most common isolated subspecies because it is
responsible for 65% of these infections, followed by S Ty-
phimurium at 12%. In the United States, exposures to
chicken and eggs are most likely sources for infection.
Many risk factors are associated with infection and dis-
semination. Achlorhydria, the use of antacids or proton
pump inhibitors, and rapid gastric emptying favor bacterial
survival. Conditions that impair cell-mediated lymphocyte
function, such as HIV/AIDS, malnutrition, corticosteroid
therapy, and posttransplantation immunosuppressive ther-
apy, are major risk factors. An overloaded reticuloendothe-
lial system with iron or hemoglobin, such as in patients
with sickle cell anemia, hemolytic anemia, thalassemia,
and malaria, may increase the likelihood of severe disease.
Infarcts in the gastrointestinal tract and bone and defective
phagocytic and opsonic function also appear to contribute
to the severity of disease observed in patients who have
sickle cell anemia. Diseases such as leukemia and lym-
phoma also impair the reticuloendothelial system function.
The morbidity and mortality associated with Salmonella
infections are also influenced by the serotype that causes
the infection. Salmonella choleraesuis is more likely to
cause invasive disease. In one study, 85% of isolates were
recovered from extraintestinal sites, especially blood.
(1) Seventy-two percent of patients were younger than
3 years. Pediatric patients were more likely to have diar-
rhea than adults. Most of the children with diarrhea were
also bacteremic. Mycotic aneurysms, a complication ob-
served in adults, was not detected in any of the pediatric
cases. Of importance, only 21% of children had leukocy-
tosis. Occult bacteremia, where the child presents only
with fever, was a common presentation.
In a population-based, case-control study of salmonel-
losis in infants younger than 1 year, infected infants were
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more likely to be bottle fed, have exposure to reptiles,
have ridden in a shopping cart next to meat or poultry,
traveled abroad, or attended a day care center with an in-
fected infant. (4)
Most Salmonella infections are foodborne. In Mexico,
pork, meat, and poultry were frequently found to be
contaminated with Salmonella. Consumption of con-
taminated orange juice led to an outbreak in a theme
park. An intentional contamination of restaurant salad
bars was responsible for a large outbreak of Salmonella
gastroenteritis in Oregon in 1984. Contaminated pea-
nut butter, ice cream, salami products, and mozzarella
cheese has been responsible for multistate outbreaks
in the United States. Outbreaks have also been associ-
ated with exposure to contaminated dry dog food and
pet treats.
Animals such as chickens, pigs, turtles, lizards, iguanas,
hedgehogs, and amphibians have been identified as res-
ervoirs of Salmonella. Many of these colonizations have
resulted in human outbreaks. An outbreak of S Typhi-
murium was associated with exposures to pet rodents.
Feeder rodents used for the feeding of reptiles and am-
phibians were found to be colonized with Salmonella,
resulting in human infections. Patients with Salmonella
arizonae acquired from iguanas and snakes have a predis-
position for musculoskeletal infections. In a rare event, 2
patients developed S Enteritidis sepsis (in one case fatal)
after a platelet transfusion. The donor most likely had
asymptomatic bacteremia from handling his pet boa
constrictor.
Nosocomial outbreaks are uncommon. However, in-
adequate infection control practices, understaffing, and
overcrowding may lead to environmental contamination.
In some developing countries, asymptomatic carriage of
Salmonella can be high among children attending day
care centers. Outbreaks of salmonellosis in day care cen-
ters have been reported, but these are considered rare
events.
Although the incidence of salmonellosis related to
international travel appears to be decreasing in the
United States, many travel-acquired cases are still re-
ported. Salmonella stanley, a common serotype in
Southeast Asia (second most common in Thailand),
has been frequently isolated in Europe. (5) In South-
east Asia, the serotype is frequently associated with
the pork industry.
Nontyphoidal Salmonella infections remain a frequent
cause of invasive disease in many regions of the world, es-
pecially in sub-Saharan Africa. Children younger than
3 years and those infected with HIV have the greatest
burden. Mortality remains high, especially in children with

bacteremia and meningitis. Seasonal peaks of disease
coincide with the rainy season, which leads to fecal con-
tamination of drinking water. In many countries, an as-
sociation between malaria and Salmonella is well known.
This situation often delays treatment, causing greater
morbidity and mortality. Frequently, febrile persons are
treated only for malaria without considering the likeli-
hood of a coinfection. Clinical features, such as fevers,
anemia, and splenomegaly, are frequent findings in both
conditions.
Enteric Fever (Typhoid and Paratyphoid Fever)
Enteric fever, an infection caused by S Typhi (typhoid
fever) or S Paratyphi A, B, or C (paratyphoid fever), is
a common cause of death and disease in many parts of
the world. Approximately 22 million cases are thought to
occur worldwide each year, with 200,000 deaths as a result.
(6) Most infections occur in Southern and Southeast Asia.
Parts of Africa and Latin America are also affected but at
a lower frequency. In Asia, it is estimated that the inci-
dence approximates 100 cases per 100,000 population.
Travelers to endemic regions are at risk. Most cases in
the United States have been associated with international
travel. Travelers visiting friends and relatives are at the
highest risk of infection.
In countries such as India, children and adolescents in
the 5- to 19-year age group are affected most. On rare
occasions, neonatal infections have been reported. These
infections are frequently acquired from the mother. In
South and Southeast Asia, S Typhi is the most common
cause of community-acquired bacteremia.
Between 1960 and 1999, 60 outbreaks of typhoid
fever had been reported in the United States. (7)
Ninety percent were domestically acquired. Recently,
cases were found to be related to the consumption of
a fruit shake made from frozen mamey fruit from
Guatemala. (7) In recent years, an outbreak of S Para-
typhi B was found to be related to exposure to pet
turtles.
The major factor responsible for the magnitude of this
problem is poor sanitary infrastructure, resulting in substan-
dard drinking water and contaminated food. Person-to-
person transmission from chronic asymptomatic carriage
also contributes to the infection of susceptible individuals
(eg, typhoid Mary).
Pathogenesis
The pathogenesis of salmonellosis is complex. Several vir-
ulence genes are responsible for the severity of disease ob-
served with certain species.
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infectious diseases salmonella
Nontyphoidal isolates are rarely invasive because most
do not extend past the lamina propria or the intestinal
lymphatic system. However, interactions with host cells
in the intestines may lead to a release of proinflammatory
cytokines that result in the recruitment of neutrophils to
the area, resulting in gastroenteritis. Some genes appear
to play a role in the survival of bacteria within the liver
and spleen and promote the replication within macro-
phages. (8)
Salmonella Typhi is known to adhere to epithelial cells
over the lymphatic Peyer patches, allowing for penetra-
tion through the intestinal mucosa. Engulfment by
macrophages and translocation into draining lymph
nodes results in bacteremia and subsequent dissemina-
tion. The organism survives within the host cells in a Salmo-
nella-containing vacuole, assuring its ability to replicate,
survive, and invade and resulting in the multiplication
and survival of bacteria within the liver, spleen, and
bone marrow. After an incubation period of 7 to 14 days,
bacteremia occurs and symptoms emerge. Salmonella
Typhi can be found in the gallstones of individuals
who live in endemic regions. Its presence correlates with
fecal shedding, and these people are known to infect
others.
Clinical Aspects
Nontyphoidal Salmonella Infections
Gastroenteritis is the most frequent presentation. Most
affected children are younger than 1 year. The usual in-
cubation period for Salmonella gastroenteritis is 6 to 12
hours. Nausea, vomiting, and diarrhea are common
symptoms. Diarrhea is usually nonbloody. Myalgias, ar-
thralgias, and headaches are also reported. Although ob-
served in children with Salmonella gastroenteritis, fever,
chills, and abdominal pain are more commonly observed
with shigellosis. The presence of rectal tenesmus accom-
panied by stools with mucus and/or blood is more dis-
tinctive of Shigella infections. Symptoms are generally
self-limited. Hepatomegaly and splenomegaly are infre-
quently noted.
Bacteremia is commonly observed in infants with gas-
troenteritis. Most children require hospitalization. Persis-
tent bacteremia can be detected in approximately 40% of
patients. Salmonella Enteritidis was a frequently isolated
pathogen in bacteremic patients. In children, bacteremia
is rarely fatal. In contrast, one-third of adults presenting
with primary bacteremia have extraintestinal organ in-
volvement and will die.
Clinical features or laboratory parameters were unable
to detect children more likely to have persistent bacteremia.
Pediatrics in Review Vol.34 No.9 September 2013 377
infectious diseases salmonella
Although focal infections were observed in 2.5% of pre-
viously healthy children, one-third of children with un-
derlying medical conditions had focal disease, consisting
of meningitis, osteomyelitis, septic arthritis, pneumonia,
or cholangitis. In parts of Africa, the fatality rate for bac-
teremia is close to 25%. Lower respiratory tract coinfec-
tions with tuberculosis and Streptococcus pneumoniae were
common.
Meningitis and musculoskeletal infections are com-
mon complications in infants younger than 3 months.
It is estimated that 50% to 75% of Salmonella meningitis
occurs in the first year of life. Asymptomatic disease is also
common in young infants. A well-appearing infant with
Salmonella gastroenteritis may be bacteremic.
Malaria has been found to be a risk factor for invasive
nontyphoidal Salmonella infections in children. A reduc-
tion in cases of salmonellosis was associated with a de-
crease in the number of malaria cases.
Compared with children with gastroenteritis
alone, bacteremic children appear to have a longer du-
ration of symptoms, a less severe clinical appearance,
and fewer signs of dehydration. This gradual presen-
tation with less dehydration and fewer toxic effects
may lead to premature discharges from emergency
departments.
Typhoid and Paratyphoid Fever
Fever, gastrointestinal symptoms (eg, vomiting, severe
diarrhea, abdominal distension, and pain), cough, rel-
ative bradycardia, rose spots (pink macules frequently
observed on the abdomen and chest), and splenomeg-
aly are frequently regarded as features of typhoid and
paratyphoid fever. However, many patients lack these
findings, making diagnosis difficult if solely based on
clinical features. In a reported foodborne epidemic,
most patients had nonspecific symptoms, consisting
of fever, headache, diarrhea, and anorexia. Hepato-
megaly was seen in 7% of patients, splenomegaly in
13% of patients, and rose spots in 5% of patients. Rel-
ative bradycardia and rose spots are seldom observed in
children. Jaundice is frequently observed among chil-
dren. Febrile convulsions have been reported in chil-
dren with enteric fever and may be the presenting
symptom in some children. The incubation period
for enteric fevers is generally 7 to 14 days, with a range
of 3 to 60 days.
In Pakistan, children younger than 5 years were
found to have more severe disease. More than 95% of
children had fever, 20% to 41% had hepatomegaly, 5%
to 20% had splenomegaly, 19% to 28% had abdominal
pain, and 8% to 35% had diarrhea. (9) Cough was
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observed in approximately 15% of patients. Severe dis-
ease resulted in more hospitalizations. Intestinal perfo-
ration was a rare complication observed in less than 1%
of children.
Thrombocytopenia and disseminated intravascular co-
agulation are markers of severe disease. Splenic abscess,
brain abscess, and subdural empyema are rare complica-
tions of typhoid fever.
An analysis of travel-related cases in the United King-
dom found that S Typhi and S Paratyphi infections were
indistinguishable clinically. (10) Infections caused by S
Paratyphi can be just as severe as those caused by S Typhi.
Most patients had normal white blood cell counts (91%),
and 82% of patients had an elevated alanine aminotrans-
ferase level. Among travelers, more cases of enteric fever
were caused by S Paratyphi A than by S Typhi. Guillain-
Barré syndrome has been described in association with S
Paratyphi A infection.
Mixed infections with multiple pathogens occur in
endemic tropical countries. Treatment against enteric
fever should be considered for children with unremit-
ting fevers after completing adequate antimalarial
therapy.
Diagnosis
There are no features of Salmonella gastroenteritis that
would allow its diagnosis based on clinical findings alone.
The routine microscopic stool examination for polymor-
phonuclear cells is of limited clinical utility because a large
number of children with gastroenteritis will have a nega-
tive test result (<5 polymorphonuclear cells per high-
power field). All young infants with diarrhea, especially
those younger than 3 months with a positive stool culture
result, should have a blood culture performed, even if the
infant is well-appearing. Infants younger than 3 months
with a positive blood culture result should undergo a lum-
bar puncture and careful examination assessing for the
presence of musculoskeletal involvement (Table 1).
(11) Any ill-appearing infant with a positive stool culture
result should undergo a blood culture and lumbar punc-
ture, be hospitalized, and be treated with parenteral
antibiotics.
The Widal test, a classic test that measures antibodies
against O and H antigens of S Typhi, was used for the
diagnosis of typhoid fever. However, its lack of sensitivity
and specificity has limited its utility. A false-positive test
result may lead to overtreatment and a delay in consider-
ing other conditions. This outcome is especially likely in
parts of the world where typhoid fever is rare among chil-
dren and significantly less frequent than other bacterial
pathogens.
 infectious diseases salmonella

Table 1. Management of Pediatric Salmonella Gastroenteritis

Signs and Symptoms Diagnosis
Age <3 months
Diarrhea (dysentery-like, bloody): Obtain stool culture
Obtain blood culture
Diarrhea <5 days, not dysentery-like or bloody No stool culture
Febrile Stool culture positive
Blood culture negative
Stool culture positive
Blood culture positive
History of exposure to Salmonella Obtain stool culture
Obtain blood culture
Age >3 months
Diarrhea ‡5 days: Obtain stool culture
Afebrile Stool culture positive
Febrile, but non–toxic-appearing Stool culture positive
Toxic, ill-appearing, or Stool culture positive
immunocompromised host
Stool culture positive
Blood culture positive
Adapted from: St. Geme J, Hodes H, Marcy SM, et al. Consensus: Management of Salmonella infection in the first year of life. Pediatric Infectious Disease
Journal. 1988; 7(9):615–621. Copyright 1988 (c) by Wolters Kluwer Health/Williams & Wilkens.
Management
Hydration
No antibiotics
Treat with parenteral antibiotics, 5-7 days
Lumbar puncture
Treat with parenteral antibiotics:
Bacteremia only: 14 days
Meningitis: 4-6 weeks
Osteomyelitis: 4-6 weeks
Observation
No antibiotics
Blood culture
Observe off antibiotics
Blood culture
Lumbar puncture
Treat with parenteral antibiotics
Lumbar puncture
Treat with parenteral antibiotics:
Bacteremia only: 14 days
Meningitis: 4-6 weeks
Osteomyelitis: 4-6 weeks

In patients with typhoid fever, blood culture results Treatment

are frequently positive, but stool cultures are less so. Al-
though liver enzyme levels are frequently elevated, leu-
kocytosis is not always observed. Leukopenia and
anemia are frequently associated with enteric fevers. A
normal white blood cell count does not rule out inva-
sive disease. Many suggest that bone marrow cultures
have a higher sensitivity. Obtaining this type of speci-
men is much more invasive and impractical in many cir-
cumstances. Approximately 20% of patients may have
pneumonia as documented by abnormal radiography
results.
Although pathogen-specific serologic and polymerase
chain reaction assays are the preferred methods for diag-
nosing enteric fever, diagnosis is still made using clinical
criteria in most lower-income countries. Unfortunately,
early features of enteric fever mimic other conditions,
such as pneumonia, malaria, sepsis, dengue, acute hepa-
titis, and rickettsial infections.
Previously healthy children and adults with uncompli-
cated gastroenteritis do not require antimicrobial
therapy because the disease is self-limited. Infants
younger than 3 months with Salmonella gastroen-
teritis should be treated because they have a high
incidence of extraintestinal complications, such as bac-
teremia, meningitis, and osteomyelitis (Table 1). Antimi-
crobial therapy may prolong the carrier state. Therapy
should be considered for those individuals with high-risk
medical conditions, such as HIV, sickle cell anemia, and
cancer.
Antimicrobial treatment must take into account
the local epidemiology and therapeutic practice in
the country where the infection was acquired. Chlor-
amphenicol, amoxicillin, and the combination of
trimethoprim and sulfamethoxazole are no longer rec-
ommended as first-line agents for the treatment of en-
teric fevers. The high frequency of treatment failures,

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infectious diseases salmonella
resistance, and relapse rates has diminished their use-
fulness. Antimicrobial resistance observed in many
countries has influenced the choice of agent for treat-
ing typhoid and paratyphoid fever. Ceftriaxone re-
mains the recommended agent in the most severe
cases in which parenteral therapy is indicated. Cefo-
taxime is an acceptable alternative. Although fluo-
roquinolones, such as ciprofloxacin, are generally
associated with high cure rates, defervescence within
a week, and lower relapse and fecal carriage rates, iso-
lates from many Asian countries demonstrate resistance,
rendering them ineffective. Azithromycin appears fa-
vorable in the treatment of these infections. (12) Until
recently, fluoroquinolone resistance was uncommon in
most regions of Africa. In a recent study from the
Democratic Republic of the Congo, decreased cipro-
floxacin susceptibility was detected in 15.4% of tested
isolates. (13) Proper hydration, perfusion, and fever
control still remain integral components of treating
enteric fever.
More than 10 years ago, multidrug resistance was un-
common in Latin America. Susceptibility to ampicillin
was common, and susceptibility to ceftriaxone was almost
universal. At the same time, in some Mediterranean
countries, close to one-third of isolates were resistant
to ampicillin.
In infections by S choleraesuis, resistance to cipro-
floxacin was observed in 28% of pediatric cases in
Taiwan, whereas more than 60% of cases in adults
had a resistant strain. (1) Irrespective of age, resis-
tance to trimethoprim-sulfamethoxazole remained
high.
Eighty-four percent of samples of ground meats
(beef, turkey, and pork) purchased at several supermar-
kets in the Washington, DC, area were found to be con-
taminated with Salmonella isolates that were resistant to
at least one antibiotic; 53% were resistant to 3 antibiot-
ics. (14) Of greater concern, 16% of the isolates were
resistant to ceftriaxone, the drug of choice for the treat-
ment of serious infections in children. In a recent
study of invasive salmonellosis among Thai children,
ceftriaxone resistance was detected in 17.4% of iso-
lates. (15)
Patients with typhoid fever complicated by delirium,
obtundation, shock, and coma may benefit from dexa-
methasone therapy. This adjunctive therapy appears to
lower mortality. (16)
Relapse rates in children are only 2% to 4% after ther-
apy but have been reported after most regimens. Pro-
longed carrier rates occur in less than 2% of infected
children.
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Prevention
Improving the quality of drinking water and food will
lead to a decrease in Salmonella cases, as will decreasing
exposure to high-risk animals (Table 2).
Routine vaccination of school-age children can be an
important component of a typhoid fever control pro-
gram in an endemic region. (17) Vaccinating children
younger than 2 years living in slums in India with the
Vi capsular polysaccharide typhoid vaccine demon-
strated a 61% protective effectiveness compared with
a placebo. In children age 2 to 5 years, the protective
effect was 80%. Of interest, the level of protection was
44% among unvaccinated members of Vi vaccinee clus-
ters. (18) Similar favorable results have been observed in
other countries.
Preventing Salmonella
Table 2.
Infections
High-risk animals
1. Parents and children should be counseled about the
potential risk of acquiring Salmonella when owning
an iguana, lizard, snake, or turtle.
2. Owners need to wash their hands after handling
animals, their cages, or their tanks.
3. Individuals at high risk of severe disease, such as
children age <5 years and those who are
immunocompromised, should avoid contact with
high-risk animals.
4. High-risk animals should be kept out of child-care
centers.
5. High-risk animals should not be allowed to roam free
within the home. They should not be kept in kitchens
or where food is prepared. Cages and tanks should not
be washed in kitchen sinks.
Food handling
6. Hand hygiene should be practiced when handling raw
meat. Cutting boards must be cleaned thoroughly
after preparing raw meat and food items that contain
raw egg.
7. People should not consume raw eggs and undercooked
meats.
8. Mothers are encouraged to breastfeed young infants.
This practice has shown to reduce infections.
Infection control
9. Young children with enteric fever (Salmonella Typhi
and Salmonella Paratyphi) should be kept out of child
daycare centers until they have at least 3 consecutive
negative stool culture results.
10. Infants and children with nontyphoidal Salmonella
gastroenteritis can return to child daycare center
once diarrhea has subsided.
 infectious diseases salmonella

Vaccination against typhoid fever is recommended
for all travelers to developing countries in Asia,
Latin America, and Africa, especially for those plan-
ning to visit friends and relatives with 2 vaccines
available (Table 3). Travel to India, Pakistan,
Mexico, and Bangladesh account for most travel-
related cases in the United States. Generally, typhoid
vaccines are 50% to 80% effective in preventing
disease.
In many highly endemic countries, S Paratyphi
causes close to 50% of all cases of enteric fever. In
the United States, most cases of paratyphoid fever
are related to international travel. No effective licensed
vaccine against S Paratyphi is available. However, cross-
protective efficacy of Ty21a oral typhoid vaccine
against paratyphoid fever B has been demonstrated.
(19)(20)
Parents and their children need to be counseled about
the potential risk of acquiring Salmonella if they own
a high-risk pet, such as an iguana, lizard, snake, or turtle
(Table 2). Owners need to wash their hands after han-
dling the animals. The Centers for Disease Control and
Prevention has advised that reptiles and amphibians
should be kept out of households with children younger
than 5 years. Individuals at high risk of severe disease
should have no contact with these animals. Reptiles
and amphibians should be kept out of child care centers
and households with children younger than 1 year.
All documented cases of Salmonella infection must be
reported to county and state health departments.

Complications and Prognosis

Vaccines Licensed for the Prevention of
Table 3. Ileal perforations in the tropics
Typhoid Fever are frequently considered to be
associated with enteric fever.
Oral typhoid Between 4% and 6% of ileal per-
vaccine Ty21a For persons age ‡6 years forations were associated with S
Live-attenuated
Typhi and S Paratyphi A. In
Series: 4 doses; 1 capsule every other day parts of Africa, 50% of all admis-
(days 0, 2, 4, and 6) sions for typhoid-related ileal
Take with cool water, 1 hour before meal
perforation were in children,
Must complete series at least 1 week before
exposure with close to two-thirds occur-
Capsules must be refrigerated ring between ages 5 and 6 years.
Capsules should not be broken and contents Underdiagnosing milder cases
mixed with food/water because this of enteric fever that resulted
inactivates the vaccine; should not be taken
in delayed or inadequate anti-
with antibiotics
Repeat 4-dose series every 5 years if exposure microbial treatment may have
continues resulted in a higher rate of per-
Contraindicated in individuals with forations.
immunocompromising conditions Fever, vomiting, and abdominal
Potential adverse effects: Nausea,
tenderness and distension are sug-
abdominal pain, cramps, vomiting,
fever, headaches, and rash gestive of ileal perforation. Postop-
Injectable Vi typhoid vaccine erative complications are common,
For persons ‡2 years
Capsular polysaccharide such as surgical wound infection,
Single injection, 0.5 mL, intramuscular, intra-abdominal abscesses, ileus,
deltoid
and reperforation. Mortality is
Vaccine must be administered at least
2 weeks before exposure. high in children: close to 40% in
Thimerosal-free children younger than 5 years
Booster: Every 2 years if exposure and 20% in children older than 5
continues years. (21)
Potential adverse effects: Injection
Rhabdomyolysis with acute renal
site pain, erythema, and induration;
occasional fever and flulike symptoms. failure has been reported as a com-
plication of typhoid fever.

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infectious diseases salmonella
Summary
• On the basis of strong research evidence, exposures to
contaminated food, water, and colonized animals are
major risk factors for Salmonella infections. (3)(4)(7)(14)
• On the basis of research evidence and consensus,
infants younger than 3 months with Salmonella
gastroenteritis are at an increased risk of
extraintestinal complications, such as bacteremia,
meningitis, and osteomyelitis, and must be treated
regardless of severity of illness. (4)(11)
• On the basis of strong research and epidemiologic
evidence, antimicrobial resistance is a serious problem
in the treatment of typhoid fever. (12)(13)(14)
• On the basis of strong research evidence, vaccines can
effectively prevent typhoid fever. (17)(18)(19)(20)
• On the basis of published guidelines and current
standards of care, children younger than 5 years and
those with immunocompromising conditions, such as
human immunodeficiency virus and cancer, should
avoid contact with turtles, iguanas, and snakes. (3)
References
1. Chiu CH, Chuang CH, Chiu S, Su LH, Lin TY. Salmonella
enterica serotype Choleraesuis infections in pediatric patients.
Pediatrics. 2006;117(6):e1193–e1196
2. Cohen JI, Bartlett JA, Corey GR. Extra-intestinal manifestations
of salmonella infections. Medicine (Baltimore). 1987;66(5):349–388
3. Chai SJ, White PL, Lathrop SL, et al. Salmonella enterica
serotype Enteritidis: increasing incidence of domestically acquired
infections. Clin Infect Dis. 2012;54(suppl 5):S488–S497
4. Jones TF, Ingram LA, Fullerton KE, et al. A case-control study
of the epidemiology of sporadic Salmonella infection in infants.
Pediatrics. 2006;118(6):2380–2387
5. Hendriksen RS, Le Hello S, Bortolaia V, et al. Characterization
of isolates of Salmonella enterica serovar Stanley, a serovar endemic
to Asia and associated with travel. J Clin Microbiol. 2012;50(3):
709–720
6. Bhutta ZA. Current concepts in the diagnosis and treatment of
typhoid fever. BMJ. 2006;333(7558):78–82
7. Loharikar A, Newton A, Rowley P, et al. Typhoid fever outbreak
associated with frozen mamey pulp imported from Guatemala to the
western United States, 2010. Clin Infect Dis. 2012;55(1):61–66
8. Lahiri A, Lahiri A, Iyer N, Das P, Chakravortty D Visiting the
cell biology of Salmonella infection. Microbes Infect. 2010;12(11):
809-818.
9. Siddiqui FJ, Rabbani F, Hasan R, Nizami SQ, Bhutta ZA.
Typhoid fever in children: some epidemiological considerations
from Karachi, Pakistan. Int J Infect Dis. 2006;10(3):215–222
Parent Resources From the AAP at HealthyChildren.org
The reader is likely to find material relevant to this article to share with parents by visiting these links:
• English: http://www.healthychildren.org/English/health-issues/conditions/infections/Pages/Salmonella-Infections.aspx
• Spanish: http://www.healthychildren.org/spanish/health-issues/conditions/infections/paginas/salmonella-infections.aspx
382 Pediatrics in Review Vol.34 No.9 September 2013
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10. Patel TA, Armstrong M, Morris-Jones SD, Wright SG,
Doherty T. Imported enteric fever: case series from the hospital
for tropical diseases, London, United Kingdom. Am J Trop Med
Hyg. 2010;82(6):1121–1126
11. Geme JW III, Hodes HL, Marcy SM, et al. Consensus:
management of Salmonella infection in the first year of life. Pediatr
Infect Dis J. 1988;7(9):615–621
12. Chinh NT, Parry CM, Ly NT, et al. A randomized controlled
comparison of azithromycin and ofloxacin for treatment of multidrug-
resistant or nalidixic acid-resistant enteric fever. Antimicrob Agents
Chemother. 2000;44(7):1855–1859
13. Lunguya O, Lejon V, Phoba MF, et al. Salmonella Typhi in
the Democratic Republic of the Congo: fluoroquinolone de-
creased susceptibility on the rise. PLoS Negl Trop Dis. 2012;6(11):
e1921
14. White DG, Zhao S, Sudler R, et al. The isolation of antibiotic-
resistant salmonella from retail ground meats. N Engl J Med. 2001;
345(16):1147–1154
15. Punpanich W, Netsawang S, Thippated C. Invasive salmonel-
losis in urban Thai children: a ten-year review. Pediatr Infect Dis J.
2012;31(8):e105–e110
16. Chisti MJ, Bardhan PK, Huq S, et al. High-dose intravenous
dexamethasone in the management of diarrheal patients with
enteric fever and encephalopathy. Southeast Asian J Trop Med
Public Health. 2009;40(5):1065–1073
17. Bhan MK, Bahl R, Bhatnagar S. Typhoid and paratyphoid
fever. Lancet. 2005;366(9487):749–762
18. Sur D, Ochiai RL, Bhattacharya SK, et al. A cluster-randomized
effectiveness trial of Vi typhoid vaccine in India. N Engl J Med. 2009;
361(4):335–344
19. Pakkanen SH, Kantele JM, Kantele A. Cross-reactive gut-
directed immune response against Salmonella enterica serovar
Paratyphi A and B in typhoid fever and after oral Ty21a typhoid
vaccination. Vaccine. 2012;30(42):6047–6053
20. Wahid R, Simon R, Zafar SJ, Levine MM, Sztein MB. Live oral
typhoid vaccine Ty21a induces cross-reactive humoral immune
responses against Salmonella enterica serovar Paratyphi A and S.
Paratyphi B in humans. Clin Vaccine Immunol. 2012;19(6):
825–834
21. Ekenze SO, Ikefuna AN. Typhoid intestinal perforation under
5 years of age. Ann Trop Paediatr. 2008;28(1):53–58
Suggested Reading
Gordon MA. Invasive nontyphoidal Salmonella disease: epidemiol-
ogy, pathogenesis and diagnosis. Curr Opin Infect Dis. 2011;24
(5):484–489
Tsai MH, Huang YC, Chiu CH, et al. Nontyphoidal Salmonella
bacteremia in previously healthy children: analysis of 199
episodes. Pediatr Infect Dis J. 2007;26(10):909–913
Whitaker JA, Franco-Paredes C, del Rio C, Edupuganti S. Re-
thinking typhoid fever vaccines: implications for travelers and
people living in highly endemic areas. J Travel Med. 2009;16
(1):46–52
 infectious diseases salmonella

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1. A 6–year–old girl who presents with fever and diarrhea after a trip to India is suspected of having typhoid
fever. Which of the following findings is most frequently noted with this diagnosis?
A. Normal hemoglobin level.
B. Normal liver enzyme level.
C. Normal white blood cell count.
D. Positive blood culture result.
E. Positive stool culture result.

2. A previously healthy 9–month–old with vomiting and nonbloody diarrhea has a stool culture result positive for
Salmonella. Which of the following is appropriate treatment of this infant?
A. Azithromycin.
B. Ceftriaxone.
C. Chloramphenicol.
D. No antibiotics.
E. Trimethoprim-sulfamethoxazole.

3. A 7–month–old girl is traveling with her parents to Pakistan. Which of the following preventive measures is
most appropriate for this child?
A. Avoid fresh fruits and vegetables.
B. Bathe only in fresh water ponds.
C. Injectable Vi typhoid vaccine.
D. Oral typhoid vaccine Ty21a.
E. Prophylaxis with azithromycin.

4. A 6–month–old female has a stool culture result positive for Salmonella. Her parents inquire as to what they
could do to prevent this from happening again. Which of the following features is an established risk factor for
this infection?
A. Breastfeeding.
B. Nanny at home.
C. Oatmeal cereal.
D. Pet turtle at home.
E. Travel to New Mexico.

5. Mixed infections with multiple pathogens occur in endemic tropical countries. Which of the following
disorders in children treated for enteric fever who present with unremitting fevers is therapy most appropriate?
A. Dengue.
B. Malaria.
C. Rickettsia.
D. Shigella.
E. Tuberculosis.

Pediatrics in Review Vol.34 No.9 September 2013 383

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 Salmonella Infections
John C. Christenson
Pediatrics in Review 2013;34;375
DOI: 10.1542/pir.34-9-375

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 Salmonella Infections
John C. Christenson
Pediatrics in Review 2013;34;375
DOI: 10.1542/pir.34-9-375

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/content/34/9/375

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