Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

gastroenteritis

1st line – fluid replacement

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ACUTE
|
gastroenteritis
1st line – 

fluid replacement

All patients with gastroenteritis should be assessed for volume depletion and electrolyte imbalances.[82]

Most individuals with acute diarrhoea or gastroenteritis are able to maintain fluid and salt balances through the consumption of water, juices, sports drinks, soups, and saltine crackers.[68]

Reduced osmolarity oral rehydration solution (ORS) is recommended as the first-line therapy for mild to moderate dehydration in infants, children, and adults with acute diarrhoea, and in people with mild to moderate dehydration associated with vomiting or severe diarrhoea.[66]

Infants, children, and adults with mild to moderate dehydration should receive ORS until clinical dehydration is corrected.[66]

Once the patient is rehydrated, maintenance fluids should be administered. Replace ongoing losses in stools from infants, children, and adults with ORS, until diarrhoea and vomiting are resolved.[66]

Nasogastric administration of ORS may be considered in infants, children, and adults with moderate dehydration, who cannot tolerate oral intake, or in children with normal mental status who are too weak or who refuse to drink adequately.[66]

Intravenous fluids, such as lactated Ringer’s and normal saline solution, should be administered when there is severe dehydration, shock, or altered mental status and failure of ORS therapy or ileus.[66] The use of balanced crystalloid solutions may be associated with slightly shorter duration of hospitalisation in children, compared with normal saline.[83] [ Cochrane Clinical Answers logo ] ​​ Intravenous rehydration should be continued until pulse, perfusion, and mental status normalise; and the patient awakens, has no risk factors for aspiration, and has no evidence of ileus.

Consider – anti-diarrhoeal

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ACUTE
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gastroenteritis
Consider – 

anti-diarrhoeal

Additional treatment recommended for SOME patients in selected patient group

Treatment with an anti-diarrhoeal is not a substitute for fluid and electrolyte therapy.[66] It can be considered once the patient is adequately hydrated.

Loperamide may be given to immunocompetent adults with acute watery diarrhoea, but should be avoided in suspected or proven cases where toxic megacolon may result in inflammatory diarrhoea, or diarrhoea with fever. Loperamide should not be given to children <18 years of age with acute diarrhoea.[66]

Bismuth subsalicylate can be given to adults to control rates of passage of stool and may help patients function better during bouts of mild to moderate illness.[68] 

Primary options

loperamide: adults: 4 mg orally initially, followed by 2 mg after each unformed stool, maximum 16 mg/day

OR

bismuth subsalicylate: adults: 524 mg orally four times daily

Consider – anti-emetic

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ACUTE
|
gastroenteritis
Consider – 

anti-emetic

Additional treatment recommended for SOME patients in selected patient group

Treatment with an anti-diarrhoeal is not a substitute for fluid and electrolyte therapy.[66] It can be considered once the patient is adequately hydrated.

Ondansetron may be given to facilitate tolerance of oral rehydration in children >4 years of age and in adolescents with acute gastroenteritis associated with vomiting.[66] [ Cochrane Clinical Answers logo ]

Primary options

ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg orally/intravenously every 8 hours when required

Consider – probiotic

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ACUTE
|
gastroenteritis
Consider – 

probiotic

Additional treatment recommended for SOME patients in selected patient group

Probiotics may be offered to reduce the symptom severity and duration in immunocompetent adults and children with infectious or antimicrobial-associated diarrhoea.[66]

Consider – zinc

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ACUTE
|
gastroenteritis
Consider – 

zinc

Additional treatment recommended for SOME patients in selected patient group

Oral zinc supplementation reduces the duration of diarrhoea in children 6 months to 5 years of age who reside in countries with a high prevalence of zinc deficiency or who have signs of malnutrition.[66]

Primary options

zinc sulfate: children <6 months of age: 10 mg orally once daily for 10-14 days; children ≥6 months of age: 20 mg orally once daily for 10-14 days

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Consider – antibiotic therapy

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ACUTE
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gastroenteritis
Consider – 

antibiotic therapy

Additional treatment recommended for SOME patients in selected patient group

For patients with severe illness or who are at high risk of developing more severe disease, i.e., bacteraemia or other forms of extraintestinal salmonellosis, a short course of antibiotics should be considered. These patient groups include: infants <3 months of age with suspicion of a bacterial aetiology; adults over 50 years of age; HIV-infected patients; people who have recently travelled internationally with body temperatures ≥38.5°C (101.3°F) and/or with signs of sepsis; patients with vascular abnormalities such as prosthetic valves or grafts; patients with prosthetic joints; and immunosuppressed people with severe illness and bloody diarrhoea.[44][45][66]​​[93]​​[94][95]

Antibiotics recommended to treat adults include a fluoroquinolone (e.g., ciprofloxacin) or azithromycin depending on the local susceptibility patterns and travel history.[66][68]

Resistance to fluoroquinolones has been described in some locations, so patients without an appropriate clinical response to a fluoroquinolone should be considered for alternative antibiotic therapy based on susceptibility results.[96][97][98]

Fluoroquinolones are associated with serious, disabling, and potentially irreversible adverse effects including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[100][101] The US Food and Drug Administration has also issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[102][103] 

A third-generation cephalosporin or azithromycin is recommended specifically for infants <3 months of age, depending on local susceptibility patterns and travel history.[66]

Treatment of children is complicated, given both increasing resistance among Salmonella isolates and potential toxicity of fluoroquinolone antibiotics in paediatric patients.[97][104][105][106][107]

A study of ciprofloxacin for the treatment of typhoid fever suggested that it may be used safely for Salmonella infections.[108] Ciprofloxacin is generally not recommended in the paediatric population due to the potential risk of arthropathy, but there are reports of successful and safe use in this patient population for certain indications.[109]

The typical antibiotic course is for 3 to 7 days or until after fevers resolve.[45][93] The antibiotic course among immunocompromised patients or for relapsing disease is often extended to 7 to 14 days.

Primary options

ciprofloxacin: children: 20-30 mg/kg/day orally given in 2 divided doses, maximum 1500 mg/day; adults: 500 mg orally twice daily, or 400 mg intravenously every 12 hours

Secondary options

azithromycin: children: 10 mg/kg/day orally, maximum 500 mg/day; adults: 1000 mg orally once daily on the first day, followed by 500 mg once daily thereafter

OR

ceftriaxone: children: 60 mg/kg/day intravenously given in 1-2 divided doses

OR

cefotaxime: children: 100 mg/kg/day intravenously given in 4 divided doses

ONGOING

chronic carrier state

1st line – antibiotic therapy

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ONGOING
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chronic carrier state
1st line – 

antibiotic therapy

Chronic carriage of non-typhoidal Salmonella (defined as positive stool or urine culture for Salmonella at 12 months or more following the acute illness) occurs in 0.5% of cases (compared with 3% of those with S Typhi).[32][33]

Certain groups are at higher risk for chronic carriage, including infants, women, patients with gallstones or kidney stones, and patients co-infected with Schistosoma haematobium.

Long-term rather than short-term antibiotics should be used. Despite appropriate antibiotic use, therapy may eradicate carriage in only 80% of cases.[115]

The type of antibiotic therapy is similar to that used for S Typhi: amoxicillin, trimethoprim/sulfamethoxazole, or ciprofloxacin.[45][115][116][117] The latter 2 antibiotics have superior penetration capabilities and may be the preferred agents.[118][119] Many providers opt for a fluoroquinolone given the possibility of resistance to other agents and the shorter treatment duration.[120]

Fluoroquinolones are associated with serious, disabling, and potentially irreversible adverse effects including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[100][101] The US Food and Drug Administration has also issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[102][103] 

Ciprofloxacin is generally not recommended in the paediatric population due to the potential risk of arthropathy, but there are reports of successful and safe use in this patient population for certain indications.[109]

The choice of the antibiotic should ultimately be based on sensitivity testing of the colonising isolate.

Primary options

ciprofloxacin: children: 20-30 mg/kg/day orally given in 2 divided doses for 1 month, maximum 1500 mg/day; adults: 500 mg orally twice daily for 1 month

Secondary options

trimethoprim/sulfamethoxazole: children >2 months of age: 12 mg/kg/day orally given in 2 divided doses for 3 months; adults: 160/800 mg orally twice daily for 3 months

More

Tertiary options

amoxicillin: children >3 months of age: 50-100 mg/kg/day orally given in 2-3 divided doses for 3 months; adults: 1000 mg orally three times daily for 3 months

Plus – initial treatment with praziquantel

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ONGOING
|
chronic carrier state
|
co-existing Schistosoma haematobium infection
Plus – 

initial treatment with praziquantel

Treatment recommended for ALL patients in selected patient group

Carriage of Salmonella may persist in the setting of parasitic infections.

Those with co-existing S haematobium infections should receive therapy with praziquantel before antibiotic therapy.[33]

Primary options

praziquantel: children and adults: 20 mg/kg orally twice daily for 1 day

Plus – cholecystectomy

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ONGOING
|
chronic carrier state
|
concurrent gallstones
Plus – 

cholecystectomy

Treatment recommended for ALL patients in selected patient group

Carriage of Salmonella may persist in the setting of concurrent gallstones.[33]

Cholecystectomy is recommended, especially if chronic carrier state persists despite antibiotic therapy.[121]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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