– 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 stool1 , 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


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).


– 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 women2

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
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.1,2

– 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).

Ref Notes
1 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.).
2 Ciprofloxacin should be avoided in pregnant women. Nevertheless, if ceftriaxone is not available, the other antibiotics can be used, including ciprofloxacin if necessary.


  1. Karen L. Kotloff et al. Seminar: Shigellosis. The Lancet, Volume 391, ISSUE 10122, P801-812, February 24, 2018.

  2. Word Health Organization. Pocket book for hospital care in children: guidelines for the management of common childhood illnesses, 2013.;jsessionid=CE5C46916607EF413AA9FCA89B84163F?sequence=1 [Accessed 20 September 2018]