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Morning Report: Thursday, January 12 th. Welcome APPLICANTS!. Shigella Infection. Epidemiology. Common cause of bacterial diarrhea worldwide (especially in developing countries) In the US: Third in frequency (after Salmonella and Campylobacter) Primarily affects children

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  • Common cause of bacterial diarrhea worldwide (especially in developing countries)
  • In the US:
    • Third in frequency (after Salmonella and Campylobacter)
    • Primarily affects children
      • Peak incidence ages 1-4
the details
The Details…
  • Gram-negative bacilli
  • Four species:
    • S. dysenteriae
    • S. boydii
    • S. flexneri
    • S. sonnei

Only Shiga toxin-producing species!

Most common subtypes in the US

  • *Person-to-person via the fecal-oral route
    • Transmission in institutions
      • *Child care centers
        • Grouping of susceptible children
        • Lack of adherence to hand-washing procedures
        • Small inoculum required for disease production
    • Food borne transmission
      • Cold salads
      • Raw veggies
    • Sexual transmission
clinical presentation
Clinical Presentation
  • Incubation period 1-7 days, average 3 days
  • Range of GI illness
    • Mild diarrhea life-threatening dysentary
clinical presentation1
Clinical Presentation
  • Course
    • Presentation: abrupt onset of high fever, generalized toxicity, crampy abdominal pain*, high-volume, watery stools
    • 24-48h later: Small-volume, bloody, mucoidstools* with tenesmus
  • Neurologic manifestations (40%)
    • Severe HA
    • Seizures
    • Meningeal signs
    • Lethargy
    • Delirium/ hallucinations
physical exam
Physical Exam
  • VS: high fever (>102F)
  • Gen: toxic-appearing
  • Abd: lower quadrant abdominal pain, distension
  • GU: tenderness on rectal exam
  • +/- signs of dehydration
laboratory findings
Laboratory Findings
  • Bandemia
  • Stool microscopy
    • Large number of PMNs
    • +/- RBCs
  • Stool culture
    • Send stool specimen promptly to lab
    • Can be grown on MacConkey or Hektoen-Enteric agars
    • Always want speciation and sensitivities
  • Mainstay= SUPPORTIVE CARE!
    • Correction of fluid and electrolyte losses
      • Substantial volume depletion uncommon
      • Hyponatremia
    • NO intestinal antimotility drugs
    • Early restoration of oral intake
  • Antibiotics
    • Lead to improvement in symptoms and decreased spread of infection to contacts
    • The problem…increasing antimicrobial resistance!!
      • Ampicillin
      • TMP-SMX
    • So, who do I treat and what do I use to treat them?
  • Who to treat?
    • Red Book
      • Severe disease
      • Underlying immunosuppressive conditions
      • Dysentery
      • In mild cases Rx to prevent spread of the organism
  • What to use?
    • Parenteral
      • Ceftriaxone
      • Cipro
    • Oral
      • Azithromycin
        • First-line oral Rx for children <18yo when Abx susceptibility is unknown
      • Fluoroquinolones
        • First-line oral Rx for children >17yo and adults
  • What to use?
    • Oral
      • Cefixime
        • Alternative to azithromycin in children <18yo
      • Ampicillin or TMP-SMX
        • Only if sensitivities are known
control measures
Control Measures
  • Most importantly….
control measures1
Control Measures
  • Hospital
    • Contact precautions
  • *Day care
    • Notify local health department
    • Stool cultures should be performed on all symptomatic attendees and staff
    • Affected persons should be excluded until:
      • Initiation of appropriate ABx
      • ≥24 hours after diarrhea has resolved
      • Stool cultures are negative for Shigella
  • Intestinal
    • Proctitis or rectal prolapse
    • Toxic megacolon
    • Intestinal obstruction
    • Colonic perforation
  • Systemic
    • Bacteremia
    • Metabolic disturbances
    • Leukemoid reaction
    • Neurologic disease
    • Reactive arthritis
      • Alone or in association with conjunctivitis and urethritis (Reiter syndrome)
    • Hemolytic-uremic syndrome
      • Caused by EHEC (O157:H7), S. dysenteriae
a question
A Question…
  • A previously healthy 3 ½ yo girl presents following 2 days of diarrhea, vomiting, and low-grade fever. Her symptoms began shortly after the family dined at a local fast-food restaurant. She has had 4-6 watery, mucoid stools per day. Her parents are very concerned because the have started to see some blood in her stool. On PE, the alert, somewhat irritable child has a T 38.6C, HR 100, RR 16. Her oral MM are dry. CRT~2 secs. Her abdomen is diffusely tender without distension. Labs show HgB 11.5, WBC 14.5, Na 136, K 4.5, Bicarb 18. Of the following, which is the most appropriate treatment?
    • A. A glucose-electrolyte solution
    • B. Cholestyramine
    • C. Loperamide
    • D. Metronidazole
    • E. TMP-SMX
a question1
A Question…
  • A 5yo girl presents after having a brief generalized seizure. Her mother reports that the child has had a 3 day h/o fever, tenesmus, and bloody diarrhea. On PE, you find a mildly toxic-appearing child who has a T104F and diffuse abdominal tenderness. The rectal exam produces significant pain. Stool from her rectum is guaiac-positive. You tell the mother that you believe the diarrhea has an infectious cause. Of the following, the MOST likely pathogen is:
    • A. Cryptosporidium sp
    • B. Rotavirus
    • C. Salmonella sp
    • D. Shigella sp
    • E. Yersinia sp
a question2
A Question…
  • You are evaluating a 2 yo boy with a 10h history of a temperature of 40.0C and progressively worsening diarrhea. Yesterday he attended a birthday party at the petting zoo, but he had no other history of ill contacts or unusual exposures. His mother states that he has had 8 watery bowel movements with mucus and streaks of blood in the last 10h. On PE, the boy is irritable and has a temp of 39.5C. His MM are slightly tacky, and his abdomen is diffusely TTP. The rest of the PE is normal. Labs show WBC 16.0 with 65% neutrophilsand 9% bands. Microscopic exam of the stool shows fecal leukocytes, blood and mucus. Of the following, the MOST likely etiologic agent for this patient’s condition is
    • A. Campylobacter
    • B. E. Coli
    • C. Salmonella
    • D. Shigella
    • E. Yersiniaenterocolitica