Shigellosis

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    Shigellosis is a highly contagious bacterial infection resulting in bloody diarrhoea. There are 4 serogroups of shigella: S. dysenteriaeS. sonneiS. flexneriS. boydii.

    S. dysenteriae type 1 (Sd1) is the only strain that causes large scale outbreaks. It has the highest case fatality rate (up to 10%). 

    Patients at risk of death are children under 5 years, malnourished patients, children after measles, adults over 50 years.

    Clinical features

    • Diarrhoea with bright red blood visible in stool a Citation a. This definition excludes: blood detected on microscope examination; stool containing digested blood (melaena); streaks of blood on the surface of normal stool (haemorrhoids, anal or rectal lesion, etc.). , with or without fever 
    • Abdominal and rectal pain frequent
    • Signs of serious illness: fever above 39 °C; severe dehydration; seizures, altered mental status
    • Complications (more frequent with Sd1): febrile seizures (5 to 30% of children), rectal prolapse (3%), septicaemia, intestinal obstruction or perforation, moderate to severe haemolytic uraemic syndrome

    Laboratory

    Shigellosis in an epidemic context:

    • Confirm the causal agent (stool culture) and perform antibiotic sensitivity tests.
    • Perform monthly culture and sensitivity tests (antibiotic resistance can develop rapidly, sometimes during the course of an outbreak).

    Treatment

    • Patients with signs of serious illness or with life-threatening risk factors must be admitted as inpatients.

     

    • Treat patients with neither signs of serious illness nor risk factors as outpatients.

     

    • Antibiotherapy:
    First-line treatment
    ciprofloxacin PO for 3 days
    Children: 15 mg/kg 2 times daily
    (max. 1 g daily)
    Adults: 500 mg 2 times daily
    • if the strain is sensitive
    • if there is no antibiotic sensitivity test
    • if oral administration is possible

    ceftriaxone IM for 3 days
    Children: 50 to 100 mg/kg once daily
    (max. 1 g daily)
    Adults: 1 to 2 g once daily

    • in patients with severe infection and/or oral administration is not possible
    • in pregnant women b Citation b. Ciprofloxacin should be avoided in pregnant women. Nevertheless, if ceftriaxone is not available, the other antibiotics can be used, including ciprofloxacin if necessary.
       

     

    If resistance or contra-indication to ciprofloxacin or if no improvement within 48 hours of starting first-line treatment:

    azithromycin PO for 5 days
    Children: one dose of 12 mg/kg on D1 then 6 mg/kg once daily from D2 to D5
    Adults: one dose of 500 mg on D1 then 250 mg once daily from D2 to D5
    or
    cefixime PO for 5 days
    Children: 8 mg/kg once daily (max. 400 mg daily)
    Adults: 400 mg once daily

     

    If there is no improvement 48 hours after starting second-line treatment, treat for amoebiasis [1] Citation 1. Karen L. Kotloff et al. Seminar: Shigellosis. The Lancet, Volume 391, ISSUE 10122, P801-812, February 24, 2018. [2] Citation 2. Word Health Organization. Pocket book for hospital care in children: guidelines for the management of common childhood illnesses, 2013.
    http://apps.who.int/iris/bitstream/handle/10665/81170/9789241548373_eng.pdf;jsessionid=CE5C46916607EF413AA9FCA89B84163F?sequence=1 [Accessed 20 September 2018]
    .

     

    • For pain and/or fever:
      paracetamol PO (see Pain, Chapter 1). All opioid analgesics are contra-indicated as they slow peristalsis.

     

    • Supportive therapy:
      • nutrition: nutritional supplement with frequent meals 
        + 2500 kcal daily during hospitalisation 
        + 1000 kcal daily as outpatients 
      • rehydration: administration of ORS according to WHO protocols (see Dehydration, Chapter 1).
      • zinc supplement in children under 5 years (see Acute diarrhoea, Chapitre 3).

     

    • Never give loperamide or any other antidiarrhoeal.

     

    • Management of complications: rectal prolapse reduction, septicaemia (see Septic shock, Chapter 1), etc.

    Shigellosis in an epidemic context 

    • Isolation of hospitalised patients; school exclusion of children treated as outpatients.
    • Hygiene (handwashing, hygienic preparation and storage of food, home hygiene, etc.).
    • Management if signs worsen or bloody diarrhoea in entourage (seek medical attention).

     

    Footnotes
    • (a)This definition excludes: blood detected on microscope examination; stool containing digested blood (melaena); streaks of blood on the surface of normal stool (haemorrhoids, anal or rectal lesion, etc.).
    • (b)Ciprofloxacin should be avoided in pregnant women. Nevertheless, if ceftriaxone is not available, the other antibiotics can be used, including ciprofloxacin if necessary.
       
    References