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Red Book Online Outbreaks: Onions – Salmonella Oranienburg Infections

January 19, 2022

As of November 16, 2021, 892 people have been infected with the strain of Salmonella Oranienburg found in onions in 38 states and Puerto Rico (see map). Since the last update on October 29, 2021, 84 more sick people were added to this outbreak Illnesses started on dates ranging from May 31, 2021, to October 25, 2021 (see timeline). Multiple companies have recalled onions. All recalled onions were supplied by ProSource Produce LLC and Keeler Family Farms and imported from the State of Chihuahua, Mexico, between July 1, 2021, and August 31, 2021. Sick people range in age from less than 1 year to 101 years, with a median age of 37, and 58% are female. Of 571 people with information available, 183 (32%) have been hospitalized.

FDA’s website has a table with information about each company’s recall.

Clinical Guidance

  • Presentation: Most people infected with Salmonella experience diarrhea, fever, and stomach cramps. Symptoms usually start 6 hours to 2 days after ingesting Salmonella, though incubation periods of a week or more have been reported. Most people recover without treatment after 4 to 7 days.
  • Who is at highest risk/complications: The incidence of non-typhoidal Salmonella infection is highest in children younger than 4 years. In the United States, rates of invasive infections and mortality are higher in infants, elderly people, and people with hemoglobinopathies (including sickle cell disease) and immunocompromising conditions (eg, malignant neoplasms, HIV infection).
  • Patients should be seen by their pediatrician, if they have any of these severe Salmonella symptoms:
    • Diarrhea and a fever higher than 102°F
    • Diarrhea for more than 3 days that is not improving
    • Bloody diarrhea
    • Not tolerating oral liquids
    • Signs of dehydration, such as:
      • Decreased urine output
      • Dry mucous membranes
      • Orthostatic hypotension
    • Diagnosis: Gastroenteritis is diagnosed by stool culture or molecular testing (including PCR); stool testing should be obtained in all children with bloody diarrhea or unexplained persistent or severe diarrhea. 
    • Precautions: Families should check to see if they have any recalled onions. If they have any recalled onions or if they can’t tell where their onions are from, they should throw them away. Families should wash surfaces and containers these onions may have touched using hot soapy water or a dishwasher.
    • Risk Mitigation: Families should not eat recalled onions supplied by ProSource Produce LLC and Keeler Family Farms imported from the State of Chihuahua, Mexico, between July 1, 2021, and August 31, 2021.
    • Treatment: Antimicrobial therapy usually is not indicated for patients with either asymptomatic infection or uncomplicated gastroenteritis caused by NTS, because therapy does not shorten the duration of diarrheal disease, can prolong duration of fecal shedding, and increases symptomatic relapse rate. Antimicrobial therapy is recommended for gastroenteritis caused by NTS serovars in people at increased risk for invasive disease, including infants younger than 3 months and people with chronic gastrointestinal tract disease, malignant neoplasms, hemoglobinopathies, HIV infection, or other immunosuppressive illnesses or therapies. It should also be considered for those experiencing severe symptoms such as severe diarrhea or prolonged or high fever. If antimicrobial therapy is initiated in patients in the United States with presumed or proven NTS gastroenteritis, a blood and a stool culture should be obtained prior to antibiotic administration and an initial dose of ceftriaxone should be given. The patient who does not appear ill or have evidence of disseminated infection can be discharged with oral azithromycin pending blood culture results. Once susceptibilities are available, ampicillin or trimethoprim-sulfamethoxazole may be considered for susceptible strains. A fluoroquinolone is an alternative option. For those who appear ill or have evidence of disseminated infection, hospitalization is required.
    • Reporting: Suspected cases should be reported to local department of public health.


Pediatric Practice Tools and Info

CDC: Salmonella Homepage | CDC


Public Health Resources

CDC case count map

Where Sick People Lived | Salmonella Outbreak Linked to Onions | CDC

When People Got Sick | Salmonella Outbreak Linked to Onions | CDC

Investigation Details | Salmonella Outbreak Linked to Onions | CDC


Information for Patients and Caregivers

AAP Food Poisoning and Food Contamination
In Spanish: Intoxicación y contaminación alimentaria


Infection Prevention and Control Resources

Project Firstline (

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