In April, the Centers for Disease Control and Prevention (CDC) reported an increase in Ciprofloxacin-resistant Shigella sonnei cases and concluded that the drug resistance bacterium is mostly be introduced into the US via international travel.
In an health advisory issued today, federal health officials report a continuance of drug resistant Shigella, particularly in gay, bisexual, and other men who have sex with men (MSM).
The CDC advisory discusses several recent Outbreaks of Multidrug-Resistant Shigella sonnei Infections to include extremely drug-resistant (XDR) shigellosis, ciprofloxacin-resistant shigellosis and shigellosis with decreased susceptibility to azithromycin (DSA).
As of May 7, 2015, five confirmed cases of XDR shigellosis were identified with onset dates from September 7, 2014 through April 4, 2015, in Illinois and Montana residents. The isolates were tested by CDC’s National Antimicrobial Resistance Monitoring System (NARMS) and were resistant to ampicillin, ciprofloxacin, nalidixic acid, streptomycin, sulfisoxazole, tetracycline, and trimethoprim/sulphamethoxazole; had azithromycin minimum inhibitory concentrations >16 µg/ml.
From May 2014 through April 2015, 179 cases with one of five highly-related PFGE patterns were identified in 34 states and Puerto Rico; approximately half of those who provided information reported international travel before illness onset. Ten of the cases identified by PulseNet, and another 115 cases without PFGE data, were part of an outbreak in San Francisco, California. All San Francisco isolates, and 89% of isolates overall, were resistant to ciprofloxacin. Nineteen cases are known to have occurred among MSM, and several MSM sub-clusters have been reported throughout the United States.
MSM in Chicago, Illinois, and metropolitan Minneapolis/St. Paul, Minnesota, were involved in an outbreak from May 13 through December 8, 2014. Twenty-two isolates displayed highly similar PFGE patterns and had DSA; two additional isolates had indistinguishable PFGE patterns but did not undergo antimicrobial susceptibility testing. All 22 patients were adult males; 15 of 17 with information self-identified as MSM, and 12 were known to have HIV infection.
Shigellosis is very contagious and can spread quickly through communities and across different segments of the population.
CDC recommends meticulous handwashing and other hygiene practices to prevent shigellosis and encourages patients with symptoms of shigellosis such as diarrhea and fever to visit a healthcare provider. Clinicians should obtain stool cultures from patients suspected of having shigellosis, counsel patients about shigellosis prevention, and, when treatment is required, select drugs based on antimicrobial susceptibility test results.
The CDC offers the following specific prevention recommendations for Child care centers, MSM and international travelers:
- Childcare centers should:
- Ensure handwashing stations are at the appropriate height for young children, well-stocked with soap and paper towels, and located near diapering, toilet, food preparation, and dining areas.
- Require handwashing among children and staff upon arrival at the facility, after diaper changes and toileting, after outdoor play, before eating, and before departing the facility.
- Follow proper diapering procedures.
- Assign separate staff to food preparation and diapering.
- Avoid providing wading pools or basins of water for sensory play.
- Exclude children and staff with diarrhea as directed by local ordinances.
- MSM should:
- Avoid sex while ill or while partners are ill with diarrhea and for a few weeks after recovering.
- Wash hands, genitals, and anus with soap before and after sex.
- Use barriers such as dental dams and gloves during anal rimming and fisting.
- Use condoms during anal or oral sex
- International travelers should strictly observe food, water, and hand hygiene precautions and consider taking bismuth subsalicylate (e.g., Pepto-Bismol, Kaopectate) to prevent travelers’ diarrhea.