Shigella infection: Treatment and prevention in adults
- Rabia Agha, MD
Rabia Agha, MD
- Assistant Professor of Pediatrics
- Albert Einstein College of Medicine
- Marcia B Goldberg, MD
Marcia B Goldberg, MD
- Professor of Medicine (Microbiology and Immunobiology)
- Harvard Medical School
Shigella infections are a major cause of morbidity and mortality in developing countries. Worldwide, about 165 million cases occur annually with 1 million associated deaths . In the United States, the incidence of Shigella infections is 4 to 8 per 100,000, with nearly 14,000 reported cases in 2004 . The mortality in developed countries is less than 1 percent . (See "Shigella infection: Epidemiology, microbiology, and pathogenesis".)
Shigella gastroenteritis is typically characterized by high fever, abdominal cramps, and diarrhea. The stools are characteristically small in volume, bloody, and mucoid. Individuals with underlying immune deficiency (including HIV infection) or malnutrition are at increased risk for complications of shigellosis [4-7].
The diagnosis of Shigella infection should be considered in a toxic-appearing patient with the sudden onset of bloody diarrhea, cramping, and tenesmus. Although the assay is rarely performed, polymorphonuclear leukocytes are typically present on a methylene blue stain of the stool. Shigella is isolated by culture of a stool specimen or rectal swab using techniques that are routine in most microbiology laboratories. Isolation of the organism from blood is uncommon.
The treatment and prevention Shigella infection in adults will be reviewed here. The clinical manifestations and diagnosis of Shigella and the management of Shigella infection in children are discussed separately. (See "Shigella infection: Clinical manifestations and diagnosis" and "Shigella infection: Treatment and prevention in children".)
NATURAL HISTORY OF INFECTION
Infection with Shigella is generally self-limited; the average duration of untreated Shigella gastroenteritis is seven days . Antibiotic therapy is not essential, since infection clears spontaneously in most individuals; however, because of the severity of the disease and for public health reasons, most favor antibiotic therapy for patients with positive stool culture . Antibiotics have been shown to decrease the duration of fever and diarrhea by about two days [10,11]. Shortening the duration of shedding with the administration of antibiotics can also reduce the risk of person-to-person spread.
- Kotloff KL, Winickoff JP, Ivanoff B, et al. Global burden of Shigella infections: implications for vaccine development and implementation of control strategies. Bull World Health Organ 1999; 77:651.
- Notice to readers: Final 2004 reports of notifiable diseases. MMWR Morbidity and Mortality Weekly Report 2005; 54:770. www.cdc.gov/MMWR/preview/mmwrhtml/mm5431a4.htm (Accessed on May 22, 2008).
- Ashkenazi S, Cleary TG. Shigella species. In: Principles and practice of pediatric infectious diseases, 3rd, Long SS, Pickering LK, Prober CG (Eds), Churchill Livingstone, Philadelphia 2008. p.817.
- Baer JT, Vugia DJ, Reingold AL, et al. HIV infection as a risk factor for shigellosis. Emerg Infect Dis 1999; 5:820.
- Angulo FJ, Swerdlow DL. Bacterial enteric infections in persons infected with human immunodeficiency virus. Clin Infect Dis 1995; 21 Suppl 1:S84.
- Struelens MJ, Patte D, Kabir I, et al. Shigella septicemia: prevalence, presentation, risk factors, and outcome. J Infect Dis 1985; 152:784.
- Greenberg D, Marcu S, Melamed R, Lifshitz M. Shigella bacteremia: a retrospective study. Clin Pediatr (Phila) 2003; 42:411.
- Dupont HL. Shigella species (bacillary dysentery). In: Principles and Practice of Infectious Diseases, 6th Ed, Mandell GL, Bennett JE, Dolin R (Eds), Churchill Livingstone, Philadelphia 2005. p.2655.
- Christopher PR, David KV, John SM, Sankarapandian V. Antibiotic therapy for Shigella dysentery. Cochrane Database Syst Rev 2010; :CD006784.
- Haltalin KC, Nelson JD, Ring R 3rd, et al. Double-blind treatment study of shigellosis comparing ampicillin, sulfadiazine, and placebo. J Pediatr 1967; 70:970.
- David KV, John SM, Sankarapandian V. Antibiotic therapy for Shigella dysentery. Cochrane Database Syst Rev 2010; :CD006784.
- Wong CS, Jelacic S, Habeeb RL, et al. The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med 2000; 342:1930.
- Bennish ML, Khan WA, Begum M, et al. Low risk of hemolytic uremic syndrome after early effective antimicrobial therapy for Shigella dysenteriae type 1 infection in Bangladesh. Clin Infect Dis 2006; 42:356.
- Rowe B, Threlfall EJ. Drug resistance in gram-negative aerobic bacilli. Br Med Bull 1984; 40:68.
- Heiman KE, Karlsson M, Grass J, et al. Notes from the field: Shigella with decreased susceptibility to azithromycin among men who have sex with men - United States, 2002-2013. MMWR Morb Mortal Wkly Rep 2014; 63:132.
- Kruse H, Kariuki S, Søli N, Olsvik O. Multiresistant Shigella species from African AIDS patients: antibacterial resistance patterns and application of the E-test for determination of minimum inhibitory concentration. Scand J Infect Dis 1992; 24:733.
- Ashkenazi S, Levy I, Kazaronovski V, Samra Z. Growing antimicrobial resistance of Shigella isolates. J Antimicrob Chemother 2003; 51:427.
- Sivapalasingam S, Nelson JM, Joyce K, et al. High prevalence of antimicrobial resistance among Shigella isolates in the United States tested by the National Antimicrobial Resistance Monitoring System from 1999 to 2002. Antimicrob Agents Chemother 2006; 50:49.
- Ud-Din AI, Wahid SU, Latif HA, et al. Changing trends in the prevalence of Shigella species: emergence of multi-drug resistant Shigella sonnei biotype g in Bangladesh. PLoS One 2013; 8:e82601.
- Gu B, Cao Y, Pan S, et al. Comparison of the prevalence and changing resistance to nalidixic acid and ciprofloxacin of Shigella between Europe-America and Asia-Africa from 1998 to 2009. Int J Antimicrob Agents 2012; 40:9.
- Cheasty T, Day M, Threlfall EJ. Increasing incidence of resistance to nalidixic acid in shigellas from humans in England and Wales: implications for therapy. Clin Microbiol Infect 2004; 10:1033.
- Rahman M, Shoma S, Rashid H, et al. Increasing spectrum in antimicrobial resistance of Shigella isolates in Bangladesh: resistance to azithromycin and ceftriaxone and decreased susceptibility to ciprofloxacin. J Health Popul Nutr 2007; 25:158.
- Kuo CY, Su LH, Perera J, et al. Antimicrobial susceptibility of Shigella isolates in eight Asian countries, 2001-2004. J Microbiol Immunol Infect 2008; 41:107.
- Boumghar-Bourtchai L, Mariani-Kurkdjian P, Bingen E, et al. Macrolide-resistant Shigella sonnei. Emerg Infect Dis 2008; 14:1297.
- Holt KE, Thieu Nga TV, Thanh DP, et al. Tracking the establishment of local endemic populations of an emergent enteric pathogen. Proc Natl Acad Sci U S A 2013; 110:17522.
- Centers for Disease Control and Prevention (CDC). Notes from the field: emergence of Shigella flexneri 2a resistant to ceftriaxone and ciprofloxacin --- South Carolina, October 2010. MMWR Morb Mortal Wkly Rep 2010; 59:1619.
- Wong MR, Reddy V, Hanson H, et al. Antimicrobial resistance trends of Shigella serotypes in New York City, 2006-2009. Microb Drug Resist 2010; 16:155.
- CDC. National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS): Human Isolates Surveillance Report for 2014 (Final Report). US Department of Health and Human Services, Atlanta, GA 2016. http://www.cdc.gov/narms/reports/annual-human-isolates-report-2014.html (Accessed on September 01, 2016).
- Bowen A, Hurd J, Hoover C, et al. Importation and domestic transmission of Shigella sonnei resistant to ciprofloxacin - United States, May 2014-February 2015. MMWR Morb Mortal Wkly Rep 2015; 64:318.
- Sjölund Karlsson M, Bowen A, Reporter R, et al. Outbreak of infections caused by Shigella sonnei with reduced susceptibility to azithromycin in the United States. Antimicrob Agents Chemother 2013; 57:1559.
- Bowen A, Eikmeier D, Talley P, 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 Morb Mortal Wkly Rep 2015; 64:597.
- Bowen A, Grass J, Bicknese A, et al. Elevated Risk for Antimicrobial Drug-Resistant Shigella Infection among Men Who Have Sex with Men, United States, 2011-2015. Emerg Infect Dis 2016; 22:1613.
- Hines JZ, Pinsent T, Rees K, et al. Notes from the Field: Shigellosis Outbreak Among Men Who Have Sex with Men and Homeless Persons - Oregon, 2015-2016. MMWR Morb Mortal Wkly Rep 2016; 65:812.
- CDC Health Advisory. Ciprofloxacin- and Azithromycin-Nonsusceptible Shigellosis in the United States. http://emergency.cdc.gov/han/han00379.asp.
- Shiferaw B, Solghan S, Palmer A, et al. Antimicrobial susceptibility patterns of Shigella isolates in Foodborne Diseases Active Surveillance Network (FoodNet) sites, 2000-2010. Clin Infect Dis 2012; 54 Suppl 5:S458.
- DuPont HL, Hornick RB. Adverse effect of lomotil therapy in shigellosis. JAMA 1973; 226:1525.
- Bennish ML, Salam MA, Haider R, Barza M. Therapy for shigellosis. II. Randomized, double-blind comparison of ciprofloxacin and ampicillin. J Infect Dis 1990; 162:711.
- Khan WA, Seas C, Dhar U, et al. Treatment of shigellosis: V. Comparison of azithromycin and ciprofloxacin. A double-blind, randomized, controlled trial. Ann Intern Med 1997; 126:697.
- Bennish ML, Salam MA, Khan WA, Khan AM. Treatment of shigellosis: III. Comparison of one- or two-dose ciprofloxacin with standard 5-day therapy. A randomized, blinded trial. Ann Intern Med 1992; 117:727.
- Bassily S, Hyams KC, el-Masry NA, et al. Short-course norfloxacin and trimethoprim-sulfamethoxazole treatment of shigellosis and salmonellosis in Egypt. Am J Trop Med Hyg 1994; 51:219.
- Gendrel D, Moreno JL, Nduwimana M, et al. One-dose treatment with pefloxacin for infection due to multidrug-resistant Shigella dysenteriae type 1 in Burundi. Clin Infect Dis 1997; 24:83.
- Basualdo W, Arbo A. Randomized comparison of azithromycin versus cefixime for treatment of shigellosis in children. Pediatr Infect Dis J 2003; 22:374.
- Replogle ML, Fleming DW, Cieslak PR. Emergence of antimicrobial-resistant shigellosis in Oregon. Clin Infect Dis 2000; 30:515.
- Curtis V, Cairncross S. Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infect Dis 2003; 3:275.
- Jennison AV, Verma NK. Shigella flexneri infection: pathogenesis and vaccine development. FEMS Microbiol Rev 2004; 28:43.
- Taylor DN, McKenzie R, Durbin A, et al. Rifaximin, a nonabsorbed oral antibiotic, prevents shigellosis after experimental challenge. Clin Infect Dis 2006; 42:1283.