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Clinical Update Supplement CLINICAL UPDATE: March1991 SHIGELLOSIS Shigellosis, or ‘baciliary dysentery’, is an intestinal infection that is a major public health problem in many developing countries, where it causes about 5 to IO per cent of childhood diarrhoea. This special DD insert provides an overview of shigellosis, including cause, effect and treatment. Shigellosis is characterised by the frequent fluenced by nutritional status, and environ- and painful passage of stools that consist mental factors affecting transmission such largely of blood, mucus and pus, accom- as rainfall and temperature. Shigella infec- panied by fever and stomach cramps. In tions can occur throughout the year, but in some developing countries more people most communities the incidence is highest die from shigellosis than from watery diar- when the weather is hot and dry. This may rhoea. As many as 25 per cent of all diar- be because the scarcity of water limits rhoea related deaths can be associated with handwashing and other hygiene measures Shigella. that reduce transfer of the very small num- ber of bacteria needed to cause infection. Health workers are usually aware of the number of shigellosis cases, because symptoms are severe, and therefore children with Shigella infections are more likely to be brought to hospitals or clinics. Case fatality rates, even in hospitalised cases of dysentery, are six to eight times greater than for watery diarrhoea. Dysentery is associated with persistent diarrhoea. In rural north India, for example, Inflammation and tissue damage causes nearly a third of all persistent diarrhoeal painful straining to pass stools, which can episodes are dysenteric. lead to rectal prolapse. Blood and mucus in the stool are signs of During disease epidemics caused by shigellosis. Shigella dysenteriae type 1, as many as one late in the course of the illness. Young in ten people in affected communities will children and elderly people are most likely What causes shigellosis? become infected, and as many as 10 to 15 to die from the effects of shigellosis. At the The symptoms of shigellosis result from per cent of these will die. At the Diarrhoea ICDDR,B Treatment Centre, children infection with the Shigella bacterium. Two Treatment Centre of the International under 12 months of age account for 21 per of the four species of Shigella are common Centre for Diarrhoea1 Disease Research in cent of shigellosis admissions but up to 33 in developing countries. Shigellajlexneri is Bangladesh (ICDDR,B), over 700 patients per cent of all fatal cases. Dysentery is endemic (present at all times) in most com- a year with shigellosis are admitted to an especially severe and more likely to be munities. Shigella dysenteriae type 1 often in-patient unit. Ten per cent of these fatal in young infants, the malnourished, occurs in an epidemic pattern; the organism patients die while in hospital. Although children who are not breastfed, and follow- can be absent for a number of years, only these are patients with the most severe ing measles. Acute and particularly to reappear and infect a large proportion of illness, their high mortality rate shows the prolonged episodes of dysentery often the population. These two species of difficulties in treating patients with shigel- change marginal malnutrition to overt Shigella generally produce the most severe losis, especially when they come for care protein energy malnutrition, and can lead illness. In developed countries Shigella to vitamin A deficiency. sonnei is the most common and is the least virulent Shigella bacterium. Shigella What are the effects of boydii causes disease of intermediate Shigella infection? severity and is least common of the four, Shigella infect the cells of the lining of the except in the Indian sub-continent. large intestine (colon). The bacteria invade and damage these cells, producing breaks Who gets shigellosis, and (ulcers) in the mucous membrane lining the how common is it? intestine. These ulcers are most common in Shigellosis is found throughout the world, the rectum, which is the lowest part of the mostly in children aged under five. Rates A microscopic view of bloody diarrhoea, large intestine. Ulceration of the intestinal of Shigella infection are highest where showing red and white blood cells (from the lining results in increased production of sanitation is poor. They are also in- ulcerated intestinal wall). mucus, and the loss of blood and serum Produced by Dialogue on Diarrhoea, AHRTAG. 1 London Bridge Street. London SE1 9SG, UK. and the Applied Diarrhoea1 Disease Research Project (ADDR), Harvard Institute for International Development, Cambridge, MA 02138, USA SHIGELLOSIS proteins into the intestinal cavity. This of those infected. If antibiotics are given to Table 1: Percentage of stool causes the symptoms of dysentery, which children with shigellosis before they come culture showing positive for include blood and mucus in the stool to the clinic, the drugs may eliminate the Shigella taken from children (bloody diarrhoea); fever is also common. bacteria from their stools. In most studies The effects of Shigella infection on the that have been conducted in developing with dysentery intestine usually differ from those of or- countries, Shigella were recovered from a Study site Year of Per cent of ganisms such as enterotoxigenic E. coli and stool culture in half or more of all children (community study cases Vibrio cholerae, which cause watery diar- who had dysentery (see Table 1). and hospital showing rhoea, without fever. These organisms in- based) Shigella fect only the small intestine and cause little l Clinical signs and symptoms or no damage to the cells lining the intes- The use of clinical signs and symptoms is Dhaka, 1979 55 tine. Dehydration is the main complication therefore very important in identifying Bangladesh resulting from these infections. Oc- patients with shigellosis. Dysentery casionally Shigella causes only watery (bloody diarrhoea) is a very reliable in- Nonthaburi, 1986 44 diarrhoea and this will cause dehydration dicator of the infection in the majority of Thailand (unless appropriate rehydration fluids are cases. In many developing countries given). Shigella infection is the most common, and Rmgpur, 1988 50 Shigella dysentery may also lead to a potentially the most severe, cause of Bangladesh number of dangerous complications. These dysentery. After Shigella, Campylobacter include: jejuni and Salmonella are the next most Bangkok, 1991 37 . severe anorexia (loss of appetite) common causes of dysentery, but these Thailand . hypoproteinaemia (a low concentration usually produce self-limited illness that is sufficient for a diagnosis of amoebiasis. of blood protein) rarely as serious or life-threatening as shigellosis. The parasite Entamoeba his- Treatment of dysentery should therefore l hyponatraemia (a low concentration of tolytica, responsible for amoebic focus on the management of shigellosis. blood sodium) dysentery, is a rare cause of dysentery in Mothers are usually accurate observers . dilation of the large intestine children, accounting for less than 5 per cent of their children’s stools. If a mother of all episodes. Stool microscopy for reports that her child’s stools contain blood . seizures protozoa may not be available and it is and mucus, then it is reasonable to assume 0 anaemia often unreliable. Amoebiasis can only be that the child is infected with Shigella. l kidney damage diagnosed with certainty when Many communities have local terms used trophozoites of E. histolytica containing to describe different types of diarrhoea, . persistent diarrhoea red blood cells are seen in fresh stools. The including dysentery, and health workers . weight loss and malnutrition microscopic detection of cysts alone is not should become familiar with these terms. How can shigellosis be identified? Table 2: Appropriate antibiotics for shigellosis 0 Stool culture &htibiotic’ Children Adults Comments The most accurate way to find out if a person with diarrhoea is infected with (Zotrimoxazole TMP Smg/kg and TMP 16Omg and Not recommended Shigella is to make a culture of the stool, to (also called SMX 25mg/kg SMX 8OOmg twice for use in jaundiced check if the bacterium is present. But this rimethoprim twice a day for 5 a day for 5 days and premature is often impractical in developing !;TMP)- days infants under countries. Making a culture is expensive 'S;ulfamethoxazole 1 month old and facilities are often unavailable in the (SMX) rural communities and urban slums where the incidence of shigellosis is greatest. W: Moreover, the results are usually only !‘ available after two or three days, and treat- ttipicillin 25mg/kg 4 times a 1g 4 times a day for Safe for infants, and ment should not be delayed - a decision day for 5 days 5 days pregnant or regarding antibiotic use must be made im- lactating women mediately. Stool microscopy for pus cells to identify shigellosis is not necessary Alternative if Sbigella in the local area are resistant: when visible blood is present in stools. It may help to identify cases of mild shigel- Nalidixic acid 15mgJkg 4 times a lg 3 times a day for Not recommended losis, when stools are mucoid without day for 5 days 5 days for infants under blood, but this is too non-specific to be of two months any practical value. Shigella bacteria are not always found in 1. All doses are for oral administration. If a liquid form of the drug is not available foi the stool cultures of children who are in- children, give the approximate dose as crushed tablets. fected. Even in the best conditions, a stool culture may only identify about 70 per cent L Produced by Dialogue on Diarrhoea, AHRTAG. 1 London Bridge Street. London SE1 9SG, UK, and the Applied Diarrhoea1 Disease Research Project (ADDR). Harvard Institute for International Development, Cambridge, MA 02138, USA SHIGELLOSIS Treatment of shigellosis in Bangladesh: Treatment scheme used for children with bloody diarrhoea children ACUTE DIARRHOEA Children with visible blood in stools should be presumed to have shigellosis and be treated accordingly.
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