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Difficulty: MediumGastroenterology and Hepatology

A 28-year-old otherwise healthy man is evaluated in an urgent care clinic for a 2-day history of frequent, watery diarrhea, abdominal cramping, and nausea. He states that his symptoms began approximately 24 hours after consuming homemade chicken salad at a community picnic. He has not noticed any blood or mucus in his stool. His past medical history is unremarkable, and he takes no medications. His temperature is 37.7°C (99.9°F), blood pressure is 118/76 mm Hg, pulse is 88/min, and respiratory rate is 14/min. Physical examination reveals slightly dry oral mucosa. The abdomen is soft and non-distended with mild, diffuse tenderness to palpation but no guarding or rebound. Bowel sounds are hyperactive. A rapid stool multiplex polymerase chain reaction panel is positive for *Salmonella enterica*. Which of the following is the most appropriate next step in management?

  1. Oral rehydration therapy aloneAnswer
  2. B
    Oral ciprofloxacin therapy
  3. C
    Oral azithromycin therapy
  4. D
    Intravenous ceftriaxone therapy
  5. E
    Oral metronidazole therapy

Answer

Oral rehydration therapy alone
The most appropriate next step in management for this patient is supportive care with oral rehydration therapy alone. This patient has acute, uncomplicated gastroenteritis secondary to non-typhoidal *Salmonella*. In healthy, immunocompetent individuals between the ages of 12 months and 50 years, *Salmonella* gastroenteritis is a self-limited illness. Antimicrobial therapy is generally not recommended because it does not significantly decrease the duration of symptoms and has been shown to prolong asymptomatic fecal shedding of the bacteria. Treatment should focus entirely on fluid and electrolyte replacement.

Step-by-Step Solution

1
Identify the patient's clinical syndrome and the etiologic agent.
The patient has acute, uncomplicated gastroenteritis caused by *Salmonella enterica*, presenting with watery diarrhea, cramping, and low-grade fever without signs of severe systemic toxicity.
Accurate diagnosis of the infection's severity and etiology is necessary to guide appropriate therapy.
2
Determine the indication for antimicrobial therapy in *Salmonella* gastroenteritis.
Antibiotics are not indicated for healthy, immunocompetent individuals aged 12 months to 50 years with mild to moderate disease.
In uncomplicated cases, antibiotics do not significantly shorten symptom duration and may prolong asymptomatic fecal shedding of the bacteria.
3
Select the most appropriate management strategy.
Supportive care with oral rehydration therapy is the standard of care to prevent or treat mild dehydration.
Maintaining hydration while the self-limited infection resolves naturally is the safest and most effective approach.

Key Concept

Uncomplicated non-typhoidal *Salmonella* gastroenteritis in healthy, immunocompetent individuals (age 1-50 years) should be managed with supportive care and oral rehydration alone, as antibiotic therapy can prolong asymptomatic fecal shedding.
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Topics

Gastroenterology and Hepatology

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