Shigellosis medical therapy
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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).
- 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.
- 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.
- 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.
- 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.
- 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).
- Recommended regimens are summarized below.
| Agent | Recommended Dose | Duration |
|---|---|---|
| Ciprofloxacin (First choice in the United States) |
500 mg PO twice daily | 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) |
| Trimethoprim/Sulfamethoxazole (TMP/SMX) | 160/800 mg PO twice daily Some strains are resistant (Check antibiogram) |
3 days (One week for immunocompromised patients) |