Contents

Search

shigellosis (bacillary dysentery)

Etiology: - acute gastrointestinal infection with Shigella. Epidemiology: - transmitted person to person & consumption of contaminated food & water - occurs mostly in children - since only a few organisms are needed to transmit disease, Shigella is easily transmitted from person to person - outbreak of shigellosis due to Shigella sonnei resistant to azithromycin in Los Angeles 2012 [3] - cluster of shigellosis due to Shigella sonnei resistant to ciprofloxacin in 95 homeless in San Francisco 2014 [5] - ciprofloxacin-resistant shigellosis brought into the U.S. by international travelers & spreading domestically 2015 [5] - possible increase in resistance to ciprofloxacin & arithromycin [13] - men who have sex with men are at increased risk for multi- drug resistant shigellosis [10] Pathology: 1) may precede onset of Reiter's syndrome 2) neurotoxin may cause seizures in pediatric patients Clinical manifestations: 1) incubation period 1-5 days 2) dysentery - sudden onset, severe, small volume bloody diarrhea - mucoid stools may also occur - abdominal cramps, tenesmus - nausea/vomiting - high fever 3) dehydration 4) bacteremia may occur 5) infection lasts about 1 week Laboratory: 1) fecal leukocytes: mucus & pus in stools 2) serum chemistries consistent with dehydration a) diminished serum electrolytes - serum sodium, serum potassium, serum chloride variable b) increased serum urea nitrogen c) increased serum protein d) serum bicarbonate may be minimally low 3) complete blood count (CBC): - leukocytosis or leukopenia 4) Shigella serology - positive agglutinin tests 5) Shigella DNA [11] 6) Shigella identified by culture - antimicrobial susceptibility profile of stool culture isolate [6,7] - blood cultures - if ciprofloxacin minimum inhibitory concentration >= 0.12 ug/mL, consider fluoroquinolone-resistant [12] Special laboratory: - sigmoidoscopy: a) hyperemia b) mural edema c) purulent exudate Complications: - rare - hemolytic-uremic syndrome - reactive arthritis - erythema nodosum - irritable bowel syndrome [2] Management: 1) self-limited in most patients, supportive therapy a) oral hydration b) intravenous hydration may be necessary in severe cases c) hand washing to prevent spread d) contact precautions 2) CDC recommending not treating shigellosis with antibiotics unless clearly indicated [12] (2017) - immunocompromised patients - severe illness - outbreak 3) empiric antibiotic treatment may reduce risk of transmission a) adults: fluoroquinolone for 5 days 1] norfloxacin 2] ciprofloxacin [2,4] 3] emergence of fluoroquinolone resistance (2017) [12] b) ampicillin c) trimethoprim/sulfamethoxazole d) antibiotic therapy previously recommended in culture-positive shigellosis even if symptoms have resolved by the time culture results are reported [2] e) resistance to ampicillin, Bactrim, azithromycin in men who have sex with men [6] f) resistance to ciprofloxacin: - ceftriaxone & azithromycin mostly among men who have sex with men [7,10] 4) select drugs based on antimicrobial susceptibility testing [7]

Related

Shigella

General

bacterial gastroenteritis dysentery

References

  1. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 881
  2. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Centers for Disease Control and Prevention Notes from the Field: Outbreak of Infections Caused by Shigella sonnei with Decreased Susceptibility to Azithromycin - Los Angeles, California, 2012. MMWR. March 8, 2013 / 62(09);171-171 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a4.htm
  4. Guerrant RL, Van Gilder T, Steiner TS et al Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001 Feb 1;32(3):331-51. Epub 2001 Jan 30. PMID: 11170940
  5. Bowen A et al Importation and Domestic Transmission of Shigella sonnei Resistant to Ciprofloxacin - United States, May 2014-February 2015. MMWR Weekly. April 3, 2015 / 64(12);318-320 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6412a2.htm
  6. Bowen A et al Notes from the Field: Outbreaks of Shigella sonnei Infection with Decreased Susceptibility to Azithromycin Among Men Who Have Sex with Men - Chicago and Metropolitan Minneapolis- St. Paul, 2014 MMWR Weekly. June 5, 2015 / 64(21);597-598 PMID: 26042652 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6421a7.htm
  7. CDC Health Alert Network. June 4, 2015 Ciprofloxacin- and Azithromycin-Nonsusceptible Shigellosis in the United States. http://emergency.cdc.gov/han/han00379.asp
  8. Centers for Disease Control and Prevention (CDC) The 2013 NARMS Annual Human Isolates Report. CDC NARMS tracks antimicrobial resistance in Salmonella and other enteric (intestinal) bacteria that may cause mild or severe diarrhea or bloodstream infection. http://www.cdc.gov/narms/reports/annual-human-isolates-report-2013.html
  9. Christopher PR, David KV, John SM, Sankarapandian V. Antibiotic therapy for Shigella dysentery. Cochrane Database Syst Rev. 2010 Aug 4;(8):CD006784. Review. PMID: 20687081
  10. Bowen A, Grass J, Bicknese A, Campbell D, Hurd J, Kirkcaldy RD. Elevated risk for antimicrobial drug-resistant Shigella infection among men who have sex with men, United States, 2011-2015. Emerg Infect Dis. 2016 Sep;22(9):1613-6 PMID: 27533624 http://wwwnc.cdc.gov/eid/article/22/9/16-0624_article
  11. Loinc
  12. Centers for Disease Control & Prevention (CDC) CDC Recommendations for Diagnosing and Managing Shigella Strains with Possible Reduced Susceptibility to Ciprofloxacin. https://emergency.cdc.gov/han/han00401.asp
  13. Brooks M Rise in Possible Fluoroquinolone-Resistant Shigella Isolates, CDC Warns. Medscape - Jun 07, 2018. https://www.medscape.com/viewarticle/897806 - Orciari Herman A, Sadoughi S, Sofair A CDC: Shigella Resistant to Ciprofloxacin, Azithromycin on the Rise Physician's First Watch, June 11, 2018 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - Centers for Disease Control and Prevention (CDC) Update - CDC Recommendations for Managing and Reporting Shigella Infections with Possible Reduced Susceptibility to Ciprofloxacin. CDC Health Alert Network. June 7, 2018 https://emergency.cdc.gov/han/han00411.asp Contact: EntericBacteria@cdc.gov
  14. Centers for Disease Control and Prevention (CDC) Shigella - Shigellosis http://www.cdc.gov/shigella/