Health Advisory: Increase in Cases of Extensively Drug Resistant Shigella

This is a health advisory from the Washington State Department of Health (DOH) Office of Communicable Disease Epidemiology.

Current Situation in Washington

Recently, the Centers for Disease Control and Prevention (CDC) sent out a Health Alert about increases in extensively drug-resistant (XDR) Shigella infections being reported in the United States. Washington Department of Health (WA DOH) is concerned about this situation because: 

  • Shigella bacteria can easily be spread through person-to-person contact, including sexual contact; Shigella can also spread indirectly through contaminated food and water sources, as well as by contact with contaminated surfaces.
  • Public Health - Seattle King County (PHSKC) has reported recurrent Shigella outbreaks since December 2017 (see PHSKC health care advisories) which have impacted people experiencing homelessness, those living in shelters or encampments, and men who have sex with men. 
    • To date, numerous cases of multidrug resistant (MDR) Shigella have been reported, and one case of XDR Shigella was identified in King County in 2020. 
  • People who have oral-anal sexual contact including men who have sex with men, people with HIV or other immune-compromising conditions, and young children are at higher risk for Shigella infections.
  • XDR Shigella strains can spread antimicrobial resistance genes to other enteric bacteria.
  • Limited treatment options are available for patients infected with XDR Shigella.  Healthcare providers should seek specialist consultation in suspected cases.

Given these potentially serious public health concerns, we recommend the following actions: 

  • Health care professionals

    • Shigellosis (including XDR Shigella) is a notifiable condition and must be reported to local health jurisdiction within 24 hours.
    • Consider shigellosis in the differential diagnosis of acute diarrhea, especially in individuals with recent international travel, young children, people who have oral-anal sexual contact, people experiencing homelessness, and people living with HIV or other immune-compromising conditions.
    • When shigellosis is suspected, request a stool specimen for testing by culture or by a culture-independent diagnostic test (CIDT).
      • If a CIDT is positive for shigellosis, confirm the diagnosis with a stool culture.
      • Given the increasing rate of antimicrobial-resistant shigellosis, perform antimicrobial susceptibility testing (CIDT is not sufficient) if you plan to treat with an antibiotic.
    • Shigellosis can be a mild, self-limited illness. When treatment is indicated (individuals at risk for severe disease or those experiencing moderate to severe symptoms), select an antimicrobial agent based on the susceptibility profile of the individual isolate or, during a local outbreak, on that of the outbreak strain.
    • Fluoroquinolones (such as ciprofloxacin), azithromycin, and third-generation cephalosporins (such as ceftriaxone) are recommended antibiotics. However, local antibiotic resistance has been documented to fluoroquinolones as well as other alternative treatments including trimethoprim-sulfamethoxazole and ampicillin.
    • Counsel all patients with diarrheal disease to stay home and avoid healthcare, food service, and childcare jobs while they are sick with diarrhea. In addition, advise patients to:
      • Abstain from sexual activity during diarrhea and for 2 weeks after symptoms resolve, as Shigella bacteria may remain in stool. 
      • Wash hands often with soap and water.
      • Avoid preparing food for others.
      • Stay out of recreational water such as swimming pools, hot tubs, oceans, lakes, and rivers. 

  • Clinical laboratories

    • Shigellosis (including XDR Shigella) is a notifiable condition and must be reported to local health jurisdiction within 24 hours.
    • Submit the first Shigella isolate from each patient to the DOH Public Health Laboratory for confirmatory testing, typing, and sequencing.
    • Consider adding azithromycin to AST for Shigella specimens using recently established clinical breakpoints for azithromycin for Shigella.

Additional Information

To read this and other WA HAN messages, please visit the Washington Health Alert Network webpage.