Shigellosis medical therapy: Difference between revisions
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*As with any infectious [[diarrhea]], the most important initial step in the management of patients with [[shigellosis]] is fluid and salt replacement. | *As with any infectious [[diarrhea]], the most important initial step in the management of patients with [[shigellosis]] is fluid and salt replacement. | ||
*Oral fluid replacement is sufficient for the majority of patients and can be accomplished by oral [[glucose]] or starch-containing electrolyte solutions. | *Oral fluid replacement is sufficient for the majority of patients and can be accomplished by oral [[glucose]] or starch-containing electrolyte solutions. Oral rehydration solutions should contain the WHO-recommended [[electrolyte]] concentrations (Na 90 mM, K 20 mM, Cl 80 mM, HCO3 30 mM, and glucose 111 mM).<ref name="pmid11170940">{{cite journal| author=Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV et al.| title=Practice guidelines for the management of infectious diarrhea. | journal=Clin Infect Dis | year= 2001 | volume= 32 | issue= 3 | pages= 331-51 | pmid=11170940 | doi=10.1086/318514 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11170940 }} </ref> | ||
*Oral fluid replacement is superior to IV fluids for patients who can tolerate it. | *Oral fluid replacement is superior to IV fluids for patients who can tolerate it. | ||
*Oral rehydration solutions can be prepared by mixing 3.5 g of NaCl, 2.5 g of NaHCO3 (or 2.9 g of Na citrate), 1.5 g of KCl, and 20 g of glucose or glucose polymer (e.g., 40 g of sucrose or 4 tablespoons of sugar or 50–60 g of cooked cereal flour such as rice, maize, sorghum, millet, wheat, or potato) per liter of clean water. | *Oral rehydration solutions can be prepared by mixing 3.5 g of NaCl, 2.5 g of NaHCO3 (or 2.9 g of Na citrate), 1.5 g of KCl, and 20 g of glucose or glucose polymer (e.g., 40 g of sucrose or 4 tablespoons of sugar or 50–60 g of cooked cereal flour such as rice, maize, sorghum, millet, wheat, or potato) per liter of clean water.<ref name="pmid11170940">{{cite journal| author=Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV et al.| title=Practice guidelines for the management of infectious diarrhea. | journal=Clin Infect Dis | year= 2001 | volume= 32 | issue= 3 | pages= 331-51 | pmid=11170940 | doi=10.1086/318514 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11170940 }} </ref> | ||
*IV fluid replacement should be tailored to the individual patient's lab findings ([[electrolytes]], [[BUN]], [[creatinine]]). | *IV fluid replacement should be tailored to the individual patient's lab findings ([[electrolytes]], [[BUN]], [[creatinine]]). | ||
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====Symptomatic Treatment==== | ====Symptomatic Treatment==== | ||
*Antimotility agents (such as [[diphenoxylate]] or [[loperamide]]) are not recommended for patients with documented ''Shigella'' infections. These agents may prolong the infection and increase the shedding of ''Shigella'' organisms. | *Antimotility agents (such as [[diphenoxylate]] or [[loperamide]]) are not recommended for patients with documented ''Shigella'' infections. These agents may prolong the infection and increase the shedding of ''Shigella'' organisms.<ref name="pmid14702426">{{cite journal| author=Thielman NM, Guerrant RL| title=Clinical practice. Acute infectious diarrhea. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 1 | pages= 38-47 | pmid=14702426 | doi=10.1056/NEJMcp031534 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14702426 }} </ref> | ||
*[[Fever]] should be treated with [[antipyretics]], particularly among pediatric patients, as shigellosis can be associated with prolonged high grade fevers and febrile seizures. | *[[Fever]] should be treated with [[antipyretics]], particularly among pediatric patients, as shigellosis can be associated with prolonged high grade fevers and febrile seizures. | ||
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====Antibiotic Therapy==== | ====Antibiotic Therapy==== | ||
*[[Antibiotic]] therapy is always indicated in patients with ''Shigella'', as it has been demonstrated to decrease bacterial shedding and shorten the duration of [[infection]]. | *[[Antibiotic]] therapy is always indicated in patients with ''Shigella'', as it has been demonstrated to decrease bacterial shedding and shorten the duration of [[infection]].<ref name="pmid14702426">{{cite journal| author=Thielman NM, Guerrant RL| title=Clinical practice. Acute infectious diarrhea. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 1 | pages= 38-47 | pmid=14702426 | doi=10.1056/NEJMcp031534 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14702426 }} </ref> | ||
*Antibiotic therapy should be considered even among [[asymptomatic]] patients with positive ''[[Shigella]]'' testing. | *Antibiotic therapy should be considered even among [[asymptomatic]] patients with positive ''[[Shigella]]'' testing. | ||
*[[Drug-resistant]] ''Shigella'' has been widely reported, and all patients with documented ''[[Shigella]]'' infections should have an [[antibiogram]] performed to identify the appropriate [[antimicrobial]] agent to use. | *[[Drug-resistant]] ''Shigella'' has been widely reported, and all patients with documented ''[[Shigella]]'' infections should have an [[antibiogram]] performed to identify the appropriate [[antimicrobial]] agent to use.<ref name=cdc>[Centers for Disease Control and Prevention (CDC) 2015. Multidrug-resistant Shigellosis Spreading in the United States http://www.cdc.gov/media/releases/2015/p0402-multidrug-resistant-shigellosis.html]</ref> | ||
*Ampicillin- and TMP/SMX-resistant Shigella are widespread in the United States. In March 2015, several cases of ciprofloxacin-resistant Shigella were reported in the US (45 cases in Massachusetts; 25 cases in California; and 18 cases in Pennsylvania). | *Ampicillin- and TMP/SMX-resistant Shigella are widespread in the United States. In March 2015, several cases of ciprofloxacin-resistant Shigella were reported in the US (45 cases in Massachusetts; 25 cases in California; and 18 cases in Pennsylvania).<ref name=cdc>[Centers for Disease Control and Prevention (CDC) 2015. Multidrug-resistant Shigellosis Spreading in the United States http://www.cdc.gov/media/releases/2015/p0402-multidrug-resistant-shigellosis.html]</ref> | ||
*Recommended regimens are summarized below. | *Recommended regimens are summarized below. | ||
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|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC;" |'''Ceftriaxone''' | |||
| style="padding: 5px 5px; background: #F5F5F5;" |'''1-2 g/day IV or IM Once''' <br> (Check antibiogram) | |||
| style="padding: 5px 5px; background: #F5F5F5;" |1 day | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" |'''Trimethoprim/Sulfamethoxazole (TMP/SMX)''' | | style="padding: 5px 5px; background: #DCDCDC;" |'''Trimethoprim/Sulfamethoxazole (TMP/SMX)''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" |'''160/800 mg PO twice daily''' <br> (Check antibiogram) | | style="padding: 5px 5px; background: #F5F5F5;" |'''160/800 mg PO twice daily''' <br> (Check antibiogram) | ||
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*Ampicillin is not recommended due to widespread resistance. Azithromycin, tetracycline, and cefixime have been used for the treatment of Shigellosis (off-label).<ref name="pmid15880088">{{cite journal| author=Niyogi SK| title=Shigellosis. | journal=J Microbiol | year= 2005 | volume= 43 | issue= 2 | pages= 133-43 | pmid=15880088 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15880088 }} </ref> | |||
==References== | ==References== | ||
Revision as of 13:51, 6 April 2015
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Serge Korjian; Yazan Daaboul
Overview
The cornerstones of the treatment of Shigellosis are fluid and salt replacement and antibiotic therapy. For the majority of patients, oral fluid replacement is adequate and should consist of water, glucose, and electrolytes such as sodium, chloride, potassium and bicarbonate. IV fluids should be reserved for patients with severe disease who cannot tolerate oral therapy, and should be tailored to their lab findings. Antimotility agents should be avoided as they prolong the duration of the infection. Antibiotic therapy is recommended among all patients and usually consists of a 3 day course of trimethoprim/sulfamethoxazole or ciprofloxacin in patients with a documented resistant strain.
Medical Therapy
Fluid Replacement
- As with any infectious diarrhea, the most important initial step in the management of patients with shigellosis is fluid and salt replacement.
- Oral fluid replacement is sufficient for the majority of patients and can be accomplished by oral glucose or starch-containing electrolyte solutions. Oral rehydration solutions should contain the WHO-recommended electrolyte concentrations (Na 90 mM, K 20 mM, Cl 80 mM, HCO3 30 mM, and glucose 111 mM).[1]
- Oral fluid replacement is superior to IV fluids for patients who can tolerate it.
- Oral rehydration solutions can be prepared by mixing 3.5 g of NaCl, 2.5 g of NaHCO3 (or 2.9 g of Na citrate), 1.5 g of KCl, and 20 g of glucose or glucose polymer (e.g., 40 g of sucrose or 4 tablespoons of sugar or 50–60 g of cooked cereal flour such as rice, maize, sorghum, millet, wheat, or potato) per liter of clean water.[1]
- IV fluid replacement should be tailored to the individual patient's lab findings (electrolytes, BUN, creatinine).
Symptomatic Treatment
- Antimotility agents (such as diphenoxylate or loperamide) are not recommended for patients with documented Shigella infections. These agents may prolong the infection and increase the shedding of Shigella organisms.[2]
- Fever should be treated with antipyretics, particularly among pediatric patients, as shigellosis can be associated with prolonged high grade fevers and febrile seizures.
Antibiotic Therapy
- Antibiotic therapy is always indicated in patients with Shigella, as it has been demonstrated to decrease bacterial shedding and shorten the duration of infection.[2]
- Antibiotic therapy should be considered even among asymptomatic patients with positive Shigella testing.
- Drug-resistant Shigella has been widely reported, and all patients with documented Shigella infections should have an antibiogram performed to identify the appropriate antimicrobial agent to use.[3]
- Ampicillin- and TMP/SMX-resistant Shigella are widespread in the United States. In March 2015, several cases of ciprofloxacin-resistant Shigella were reported in the US (45 cases in Massachusetts; 25 cases in California; and 18 cases in Pennsylvania).[3]
- Recommended regimens are summarized below.
| Agent | Recommended Dose | Duration |
|---|---|---|
| Ciprofloxacin | 500 mg PO twice daily (First choice in the United States) |
3 days (One week for immunocompromised patients) |
| Norfloxacin | 400 mg PO twice daily (Do not use in cases of bacteremia) |
3 days (One week for immunocompromised patients) |
| Ceftriaxone | 1-2 g/day IV or IM Once (Check antibiogram) |
1 day |
| Trimethoprim/Sulfamethoxazole (TMP/SMX) | 160/800 mg PO twice daily (Check antibiogram) |
3 days (One week for immunocompromised patients) |
- Ampicillin is not recommended due to widespread resistance. Azithromycin, tetracycline, and cefixime have been used for the treatment of Shigellosis (off-label).[4]
References
- ↑ 1.0 1.1 Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV; et al. (2001). "Practice guidelines for the management of infectious diarrhea". Clin Infect Dis. 32 (3): 331–51. doi:10.1086/318514. PMID 11170940.
- ↑ 2.0 2.1 Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.
- ↑ 3.0 3.1 [Centers for Disease Control and Prevention (CDC) 2015. Multidrug-resistant Shigellosis Spreading in the United States http://www.cdc.gov/media/releases/2015/p0402-multidrug-resistant-shigellosis.html]
- ↑ Niyogi SK (2005). "Shigellosis". J Microbiol. 43 (2): 133–43. PMID 15880088.