The discovery of Shigella as the etiologic agent of dysentery—a clinical syndrome of fever, intestinal cramps, and frequent passage of small, bloody, mucopurulent stools—is attributed to the Japanese microbiologist Kiyoshi Shiga, who isolated the Shiga bacillus (now known as Shigella dysenteriae type 1) from patients′ stools in 1897 during a large and devastating dysenteryepidemic. Shigella cannot be distinguished from Escherichia coli by DNA hybridization and remains a separate species only on historical and clinical grounds.
Shigella is a nonspore-forming, gram-negative bacterium that, unlike E. coli, is nonmotile and does not produce gas from sugars, decarboxylate lysine, or hydrolyze arginine. Some serovars produce indole, and occasional strains utilize sodium acetate. S.dysenteriae, S. flexneri, S.boydii, and S. sonnei (serogroups A, B, C, and D, respectively) can be differentiated on the basis of biochemical and serologic characteristics. Genome sequencing of E. coli K12, S. flexneri 2a, S. sonnei, S. dysenteriae type 1, and S. boydii has revealed that these species have ∼93% of genes in common. The three major genomic “signatures” of Shigella are (1) a 215-kb virulence plasmid that carries most of the genes required for pathogenicity (particularly invasive capacity); (2) the lack or alteration of genetic sequences encoding products (e.g., lysine decarboxylase) that, if expressed, would attenuate pathogenicity; and (3) in S. dysenteriae type 1, the presence of genes encoding Shiga toxin, a potent cytotoxin.
The human intestinal tract represents the major reservoir of Shigella, which is also found (albeit rarely) in the higher primates. Because excretion of shigellae is greatest in the acute phase of disease, the bacteria are transmitted most efficiently by the fecal-oral route via hand carriage; however, some outbreaks reflect food-borne or waterborne transmission. In impoverished areas, Shigella can be transmitted by flies. The high-level infectivity of Shigella is reflected by the very small inoculum required for experimental infection of volunteers [100 colony-forming units (CFU)], by the very high attack rates during outbreaks in day-care centers (33–73%), and by the high rates of secondary cases among family members of sick children (26–33%). Shigellosis can also be transmitted sexually.
Throughout history, Shigella epidemics have often occurred in settings of human crowding under conditions of poor hygiene—e.g., among soldiers in campaigning armies, inhabitants of besieged cities, groups on pilgrimages, and refugees in camps. Epidemics follow a cyclical pattern in areas such as the Indian subcontinent and sub-Saharan Africa. These devastating epidemics, which are most often caused by S. dysenteriae type 1, are characterized by high attack and mortality rates. In Bangladesh, for instance, an epidemic caused by S. dysenteriae type 1 was associated with a 42% increase in mortality rate among children 1–4 years of age. Apart from these epidemics, shigellosis is mostly an endemic disease, with 99% of cases occurring in the developing world and the highest prevalences in the most impoverished areas, where personal and general hygiene is below standard. S. flexneri isolates predominate in the least developed areas, whereas S. sonnei is more prevalent in economically emerging countries and in the industrialized world.
Prevalence in the Developing World
In a review published under the auspices of the World Health Organization (WHO), the total annual number of cases in 1966–1997 was estimated at 165 million, and 69% of these cases occurred in children <5 years of age. In this review, the annual number of deaths was calculated to range between 500,000 and 1.1 million. More recent data (2000–2004) from six Asian countries indicate that even though the incidence of shigellosis remains stable, mortality rates associated with this disease may have decreased significantly, possibly as a result of improved nutritional status. However, extensive and essentially uncontrolled use of antibiotics, which may also account for declining mortality rates, has increased the rate of emergence of multidrug-resistant Shigella strains. An often-overlooked complication of shigellosis is the short- and long-term impairment of the nutritional status of infected children in endemic areas. Combined with anorexia, the exudative enteropathy resulting from mucosal abrasions contributes to rapid deterioration of the patient's nutritional status. Shigellosis is thus a major contributor to stunted growth among children in developing countries.
Peaking in incidence in the pediatric population, endemic shigellosis is rare in young and middle-aged adults, probably because of naturally acquired immunity. Incidence then increases again in the elderly population.
Prevalence in the Industrialized World
In pediatric populations, local outbreaks occur when proper and adapted hygiene policies are not implemented in group facilities like day-care centers and institutions for the mentally retarded. In adults, as in children, sporadic cases occur among travelers returning from endemic areas, and rare outbreaks of varying size can follow waterborne or food-borne infections.
Pathogenesis and Pathology
Shigella infection occurs essentially through oral contamination via direct fecal-oral transmission, the organism being poorly adapted to survive in the environment. Resistance to low-pH conditions allows shigellae to survive passage through the gastric barrier, an ability that may explain in part why a small inoculum (as few as 100 CFU) is sufficient to cause infection.
The watery diarrhea that usually precedes the dysenteric syndrome is attributable to active secretion and abnormal water reabsorption—a secretory effect at the jejunal level described in experimentally infected rhesus monkeys. This initial purge is probably due to the combined action of an enterotoxin (ShET-1) and mucosal inflammation. The dysenteric syndrome, manifested by bloody and mucopurulent stools, reflects invasion of the mucosa.
The pathogenesis of Shigella is essentially determined by a large virulence plasmid of 214 kb comprising ∼100 genes, of which 25 encode a type III secretion system that inserts into the membrane of the host cell to allow effectors to transit from the bacterial cytoplasm to the host cell cytoplasm (Fig. 154-1). Bacteria are thereby able to invade intestinal epithelial cells by inducing their own uptake after the initial crossing of the epithelial barrier through M cells (the specialized translocating epithelial cells in the follicle-associated epithelium that covers mucosal lymphoid nodules). The organisms induce apoptosis of subepithelial resident macrophages. Once inside the cytoplasm of intestinal epithelial cells, Shigella effectors trigger the cytoskeletal rearrangements necessary to direct uptake of the organism into the epithelial cell. The Shigella-containing vacuole is then quickly lysed, releasing bacteria into the cytosol.
Invasive strategy of Shigella flexneri. IL, interleukin; NF-κB, nuclear factor κB; NLR, NOD-like receptor; PMN, polymorphonuclear leukocyte.
Intracellular shigellae next use cytoskeletal components to propel themselves inside the infected cell; when the moving organism and the host cell membrane come into contact, cellular protrusions form and are engulfed by neighboring cells. This series of events permits bacterial cell-to-cell spread.
Cytokines released by a growing number of infected intestinal epithelial cells attract increased numbers of immune cells [particularly polymorphonuclear leukocytes (PMNs)] to the infected site, thus further destabilizing the epithelial barrier, exacerbating inflammation, and leading to the acute colitis that characterizes shigellosis. Evidence indicates that some type III secretion system–injected effectors can control the extent of inflammation, thus facilitating bacterial survival.
Shiga toxin produced by S. dysenteriae type 1 increases disease severity. This toxin belongs to a group of A1-B5 protein toxins whose B subunit binds to the receptor globotriaosylceramide on the target cell surface and whose catalytic A subunit is internalized by receptor-mediated endocytosis and interacts with the subcellular machinery to inhibit protein synthesis by expressing RNA N-glycosidase activity on 28S ribosomal RNA. This process leads to inhibition of binding of the amino-acyl-tRNA to the 60S ribosomal subunit and thus to a general shutoff of cell protein biosynthesis. Shiga toxins are translocated from the bowel into the circulation. After binding of the toxins to target cells in the kidney, pathophysiologic alterations may result in hemolytic-uremic syndrome (HUS; see below).
The presentation and severity of shigellosis depend to some extent on the infecting serotype but even more on the age and the immunologic and nutritional status of the host. Poverty and poor standards of hygiene are strongly related to the number and severity of diarrheal episodes, especially in children <5 years old who have been weaned.
Shigellosis typically evolves through four phases: incubation, watery diarrhea, dysentery, and the postinfectious phase. The incubation period usually lasts 1–4 days but may be as long as 8 days. Typical initial manifestations are transient fever, limited watery diarrhea, malaise, and anorexia. Signs and symptoms may range from mild abdominal discomfort to severe cramps, diarrhea, fever, vomiting, and tenesmus. The manifestations are usually exacerbated in children, with temperatures up to 40°–41°C (104.0°–105.8°F) and more severe anorexia and watery diarrhea. This initial phase may represent the only clinical manifestation of shigellosis, especially in developed countries. Otherwise, dysentery follows within hours or days and is characterized by uninterrupted excretion of small volumes of bloody mucopurulent stools with increased tenesmus and abdominal cramps. At this stage, Shigella produces acute colitis involving mainly the distal colon and the rectum. Unlike most diarrheal syndromes, dysenteric syndromes rarely present with dehydration as a major feature. Endoscopy shows an edematous and hemorrhagic mucosa, with ulcerations and possibly overlying exudates resembling pseudomembranes. The extent of the lesions correlates with the number and frequency of stools and with the degree of protein loss by exudative mechanisms. Most episodes are self-limited and resolve without treatment in 1 week. With appropriate treatment, recovery takes place within a few days to a week, with no sequelae.
Acute life-threatening complications are seen most often in children <5 years of age (particularly those who are malnourished) and in elderly patients. Risk factors for death in a clinically severe case include nonbloody diarrhea, moderate to severe dehydration, bacteremia, absence of fever, abdominal tenderness, and rectal prolapse. Major complications are predominantly intestinal (e.g., toxic megacolon, intestinal perforations, rectal prolapse) or metabolic (e.g., hypoglycemia, hyponatremia, dehydration). Bacteremia is rare and is reported most frequently in severely malnourished and HIV-infected patients. Alterations of consciousness, including seizures, delirium, and coma, may occur, especially in children <5 years old, and are associated with a poor prognosis; fever and severe metabolic alterations are more often the major causes of altered consciousness than is meningitis or the Ekiri syndrome (toxic encephalopathy associated with bizarre posturing, cerebral edema, and fatty degeneration of viscera), which has been reported mostly in Japanese children. Pneumonia, vaginitis, and keratoconjunctivitis due to Shigella are rarely reported. In the absence of serious malnutrition, severe and very unusual clinical manifestations, such as meningitis, may be linked to genetic defects in innate immune functions [i.e., deficiency in interleukin 1 receptor–associated kinase 4 (IRAK-4)] and may require genetic investigation.
Two complications of particular importance are toxic megacolon and HUS. Toxic megacolon is a consequence of severe inflammation extending to the colonic smooth-muscle layer and causing paralysis and dilatation. The patient presents with abdominal distention and tenderness, with or without signs of localized or generalized peritonitis. The abdominal x-ray characteristically shows marked dilatation of the transverse colon (with the greatest distention in the ascending and descending segments); thumbprinting caused by mucosal inflammatory edema; and loss of the normal haustral pattern associated with pseudopolyps, often extending into the lumen. Pneumatosis coli is an occasional finding. If perforation occurs, radiographic signs of pneumoperitoneum may be apparent. Predisposing factors (e.g., hypokalemia and use of opioids, anticholinergics, loperamide, psyllium seeds, and antidepressants) should be investigated.
Shiga toxin produced by S. dysenteriae type 1 has been linked to HUS in developing countries but rarely in industrialized countries, where enterohemorrhagic E. coli (EHEC) predominates as the etiologic agent of this syndrome. HUS is an early complication that most often develops after several days of diarrhea. Clinical examination shows pallor, asthenia, and irritability and, in some cases, bleeding of the nose and gums, oliguria, and increasing edema. HUS is a nonimmune (Coombs test–negative) hemolytic anemia defined by a diagnostic triad: microangiopathic hemolytic anemia [hemoglobin level typically <80 g/L (<8 g/dL)], thrombocytopenia (mild to moderate in severity; typically <60,000 platelets/μL), and acute renal failure due to thrombosis of the glomerular capillaries (with markedly elevated creatinine levels). Anemia is severe, with fragmented red blood cells (schizocytes) in the peripheral smear, high serum concentrations of lactate dehydrogenase and free circulating hemoglobin, and elevated reticulocyte counts. Acute renal failure occurs in 55–70% of cases; however, renal function recovers in most of these cases (up to 70% in various series). Leukemoid reactions, with leukocyte counts of 50,000/μL, are sometimes noted in association with HUS.
The postinfectious immunologic complication known as reactive arthritis can develop weeks or months after shigellosis, especially in patients expressing the histocompatibility antigen HLA-B27. About 3% of patients infected with S. flexneri later develop this syndrome, with arthritis, ocular inflammation, and urethritis—a condition that can last for months or years and can progress to difficult-to-treat chronic arthritis. Postinfectious arthropathy occurs only after infection with S. flexneri and not after infection with the other Shigella serotypes.
The differential diagnosis in patients with a dysenteric syndrome depends on the clinical and environmental context. In developing areas, infectious diarrhea caused by other invasive pathogenic bacteria (Salmonella, Campylobacter jejuni, Clostridium difficile, Yersinia enterocolitica) or parasites (Entamoeba histolytica) should be considered. Only bacteriologic and parasitologic examinations of stool can truly differentiate among these pathogens. A first flare of inflammatory bowel disease, such as Crohn's disease or ulcerative colitis (Chap. 295), should be considered in patients in industrialized countries. Despite similar symptoms, anamnesis discriminates between shigellosis, which usually follows recent travel in an endemic zone, and these other conditions.
Microscopic examination of stool smears shows the presence of erythrophagocytic trophozoites with very few PMNs in E. histolytica infection, whereas bacterial enteroinvasive infections (particularly shigellosis) are characterized by high PMN counts in each microscopic field. However, because shigellosis often manifests only as watery diarrhea, systematic attempts to isolate Shigella are necessary.
The “gold standard” for the diagnosis of Shigella infection remains the isolation and identification of the pathogen from fecal material. One major difficulty, particularly in endemic areas where laboratory facilities are not immediately available, is the fragility of Shigella and its common disappearance during transport, especially with rapid changes in temperature and pH. In the absence of a reliable enrichment medium, buffered glycerol saline or Cary-Blair medium can be used as a holding medium, but prompt inoculation onto isolation medium is essential. The probability of isolation is higher if the portion of stools that contains bloody and/or mucopurulent material is directly sampled. Rectal swabs can be used, as they offer the highest rate of successful isolation during the acute phase of disease. Blood cultures are positive in <5% of cases but should be done when a patient presents with a clinical picture of severe sepsis.
In addition to quick processing, the use of several media increases the likelihood of successful isolation: a nonselective medium such as bromocresol-purple agar lactose; a low-selectivity medium such as MacConkey or eosin-methylene blue; and a high-selectivity medium such as Hektoen, Salmonella-Shigella, or xylose-lysine-deoxycholate agar. After incubation on these media for 12–18 h at 37°C (98.6°F), shigellae appear as nonlactose-fermenting colonies that measure 0.5–1 mm in diameter and have a convex, translucent, smooth surface. Suspected colonies on nonselective or low-selectivity medium can be subcultured on a high-selectivity medium before being specifically identified or can be identified directly by standard commercial systems on the basis of four major characteristics: glucose positivity (usually without production of gas), lactose negativity, H2S negativity, and lack of motility. The four Shigella serogroups (A–D) can then be differentiated by additional characteristics. This approach adds time and difficulty to the identification process; however, after presumptive diagnosis, the use of serologic methods (e.g., slide agglutination, with group- and then type-specific antisera) should be considered. Group-specific antisera are widely available; in contrast, because of the large number of serotypes and sub-serotypes, type-specific antisera are rare and more expensive and thus are often restricted to reference laboratories.
Antibiotic Susceptibility of Shigella
As an enteroinvasive disease, shigellosis requires antibiotic treatment. Since the mid-1960s, however, increasing resistance to multiple drugs has been a dominant factor in treatment decisions. Resistance rates are highly dependent on the geographic area. Clonal spread of particular strains and horizontal transfer of resistance determinants, particularly via plasmids and transposons, contribute to multidrug resistance. The current global status—i.e., high rates of resistance to classic first-line antibiotics such as amoxicillin—has led to a rapid switch to quinolones such as nalidixic acid. However, resistance to such early-generation quinolones has also emerged and spread quickly as a result of chromosomal mutations affecting DNA gyrase and topoisomerase IV; this resistance has necessitated the use of later-generation quinolones as first-line antibiotics in many areas. For instance, a review of the antibiotic resistance history of Shigella in India found that, after their introduction in the late 1980s, the second-generation quinolones norfloxacin, ciprofloxacin, and ofloxacin were highly effective in the treatment of shigellosis, including cases caused by multidrug-resistant strains of S. dysenteriae type 1. However, investigations of subsequent outbreaks in India and Bangladesh detected resistance to norfloxacin, ciprofloxacin, and ofloxacin in 5% of isolates. The incidence of multidrug resistance parallels the widespread, uncontrolled use of antibiotics and calls for the rational use of effective drugs.
Antibiotic Treatment of Shigellosis
(Table 154-1) Because of the ready transmissibility of Shigella, current public health recommendations in the United States are that every case be treated with antibiotics. Ciprofloxacin is recommended as first-line treatment. A number of other drugs have been tested and shown to be effective, including ceftriaxone, azithromycin, pivmecillinam, and some fifth-generation quinolones. While infections caused by non-dysenteriae Shigella in immunocompetent individuals are routinely treated with a 3-day course of antibiotics, it is recommended that S. dysenteriae type 1 infections be treated for 5 days and that Shigella infections in immunocompromised patients be treated for 7–10 days.
Table 154-1 Recommended Antimicrobial Therapy for Shigellosis |Favorite Table|Download (.pdf)
Table 154-1 Recommended Antimicrobial Therapy for Shigellosis
|Ciprofloxacin||15 mg/kg||500 mg|
|2 times per day for 3 days, PO|
|Pivmecillinam||20 mg/kg||100 mg||Cost|
|4 times per day for 5 days, PO||No pediatric formulation|
|Ceftriaxone||50–100 mg/kg||–||Efficacy not validated|
|Once a day IM for 2–5 days||Must be injected|
|Azithromycin||6–20 mg/kg||1–1.5 g||Cost|
|Once a day for 1–5 days, PO|
Efficacy not validated
MIC near serum concentration
Rapid emergence of resistance and spread to other bacteria
Treatment for shigellosis must be adapted to the clinical context, with the recognition that the most fragile patients are children <5 years old, who represent two-thirds of all cases worldwide. There are few data on the use of quinolones in children, but Shigella-induced dysentery is a well-recognized indication for their use. The half-life of ciprofloxacin is longer in infants than in older individuals. The ciprofloxacin dose generally recommended for children is 30 mg/kg per d in two divided doses. Adults living in areas with high standards of hygiene are likely to develop milder, shorter-duration disease, whereas infants in endemic areas can develop severe, sometimes fatal dysentery. In the former setting, treatment will remain minimal and bacteriologic proof of infection will often come after symptoms have resolved; in the latter setting, antibiotic treatment and more aggressive measures, possibly including resuscitation, are often required.
Rehydration and Nutrition
Shigella infection rarely causes significant dehydration. Cases requiring aggressive rehydration (particularly in industrialized countries) are uncommon. In developing countries, malnutrition remains the primary indicator for diarrhea-related death, highlighting the importance of nutrition in early management. Rehydration should be oral unless the patient is comatose or presents in shock. Because of the improved effectiveness of reduced-osmolarity oral rehydration solution (especially for children with acute noncholera diarrhea), the WHO and UNICEF now recommend a standard solution of 245 mOsm/L (sodium, 75 mmol/L; chloride, 65 mmol/L; glucose (anhydrous), 75 mmol/L; potassium, 20 mmol/L; citrate, 10 mmol/L). In shigellosis, the coupled transport of sodium to glucose may be variably affected, but oral rehydration therapy remains the easiest and most efficient form of rehydration, especially in severe cases.
Nutrition should be started as soon as possible after completion of initial rehydration. Early refeeding is safe, well tolerated, and clinically beneficial. Because breast-feeding reduces diarrheal losses and the need for oral rehydration in infants, it should be maintained in the absence of contraindications (e.g., maternal HIV infection).
Nonspecific, Symptom-Based Therapy
Antimotility agents have been implicated in prolonged fever in volunteers with shigellosis. These agents are suspected of increasing the risk of toxic megacolon and are thought to have been responsible for HUS in children infected by EHEC strains. For safety reasons, it is better to avoid antimotility agents in bloody diarrhea.
Treatment of Complications
There is no consensus regarding the best treatment for toxic megacolon. The patient should be assessed frequently by both medical and surgical teams. Anemia, dehydration, and electrolyte deficits (particularly hypokalemia) may aggravate colonic atony and should be actively treated. Nasogastric aspiration helps to deflate the colon. Parenteral nutrition has not been proven to be beneficial. Fever persisting beyond 48–72 h raises the possibility of local perforation or abscess. Most studies recommend colectomy if, after 48–72 h, colonic distention persists. However, some physicians recommend continuation of medical therapy for up to 7 days if the patient seems to be improving clinically despite persistent megacolon without free perforation. Intestinal perforation, either isolated or complicating toxic megacolon, requires surgical treatment and intensive medical support.
Rectal prolapse must be treated as soon as possible. With the health care provider using surgical gloves or a soft warm wet cloth and the patient in the knee-chest position, the prolapsed rectum is gently pushed back into place. If edema of the rectal mucosa is evident (rendering reintegration difficult), it can be osmotically reduced by applying gauze impregnated with a warm solution of saturated magnesium sulfate. Rectal prolapse often relapses but usually resolves along with the resolution of dysentery.
HUS must be treated by water restriction, including discontinuation of oral rehydration solution and potassium-rich alimentation. Hemofiltration is usually required.
Hand washing after defecation or handling of children's feces and before handling of food is recommended. Stool decontamination (e.g., with sodium hypochlorite), together with a cleaning protocol for medical staff as well as for patients, has proven useful in limiting the spread of infection during Shigella outbreaks. Ideally, patients should have a negative stool culture before their infection is considered cured. Recurrences are rare if therapeutic and preventive measures are correctly implemented.
Although several live attenuated oral and subunit parenteral vaccine candidates have been produced and are undergoing clinical trials, no vaccine against shigellosis is currently available. Especially given the rapid progression of antibiotic resistance in Shigella, a vaccine is urgently needed.