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Information for Healthcare Professionals

CDC Health Advisory: Recommendations for managing and reporting Shigella infections with possible reduced susceptibility to ciprofloxacin.

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Detailed technical information for medical professionals regarding Shigella infections is outlined below.

Treatment

Antibiotic-resistant shigellosis in the United States

An estimated 27,000 drug-resistant Shigella infections occur in the United States each year 1. In 2013, CDC declared antibiotic-resistant Shigella a serious threat 1 because:

  • Resistance to traditional first-line drugs (such as ampicillin and trimethoprim-sulfamethoxazole) has become so common that physicians must rely on alternative drugs like ciprofloxacin and azithromycin when treating Shigella 1
  • CDC’s National Antimicrobial Resistance Monitoring System, or NARMS, has detected increasing proportions of Shigella isolates resistant to azithromycin and ciprofloxacin — from 2004–2014. See the most recent NARMS report for more information.
  • Resistance to azithromycin and ciprofloxacin is also becoming more common globally 29.
  • Outbreaks of drug-resistant shigellosis have been reported recently within the United States and other industrialized countries 1015.
References
  1. CDC. Antibiotic resistance threats in the United States, 2013. [PDF – 114 pages].   2013.
  2. Bhattacharya D, Bhattacharya H, Sayi DS, Bharadwaj AP, Singhania M, Sugunan AP, Roy S. Changing patterns and widening of antibiotic resistance in Shigella spp. over a decade (2000-2011), Andaman Islands, India. Epidemiol Infect. 2015;143(3):470-7.
  3. Heiman KE, Karlsson M, Grass J, Howie B, Kirkcaldy RD, Mahon B, Brooks J, Bowen A. Notes from the field: Shigella with decreased susceptibility to azithromycin among men who have sex with men – United States, 2002-2013. MMWR Morb Mortal Wkly Rep. 2014;63(6):132-3.
  4. Zhang J, Jin H, Hu J, Yuan Z, Shi W, Yang X, Xu X, Meng J. Antimicrobial resistance of Shigella spp. from humans in Shanghai, China, 2004-2011. Diagn Microbiol Infect Dis. 2014;78(3):282-6.
  5. Ghosh S, Pazhani GP, Chowdhury G, Guin S, Dutta S, Rajendran K, Bhattacharya MK, Takeda Y, Niyogi SK, Nair GB, Ramamurthy T. Genetic characteristics and changing antimicrobial resistance among Shigella spp. isolated from hospitalized diarrhoeal patients in Kolkata, India. J Med Microbiol. 2011;60(Pt 10):1460-6.
  6. Baker KS, Dallman TJ, Ashton PM, Day M, Hughes G, Crook PD, Gilbart VL, Zittermann S, Allen VG, Howden BP, Tomita T, Valcanis M, Harris SR, Connor TR, Sintchenko V, Howard P, Brown JD, Petty NK, Gouali M, Thanh DP, Keddy KH, Smith AM, Talukder KA, Faruque SM, Parkhill J, Baker S, Weill FX, Jenkins C, Thomson NR. Intercontinental dissemination of azithromycin-resistant shigellosis through sexual transmission: a cross-sectional study. Lancet Infect Dis. 2015;15(8):913-21.
  7. de Paula CM, Mercedes PG, do Amaral PH, Tondo EC. Antimicrobial resistance and PCR-ribotyping of Shigella responsible for foodborne outbreaks occurred in southern Brazil. Braz J Microbiol.  2010;41(4):966-77.
  8. Kim JS, Kim JJ, Kim SJ, Jeon SE, Seo KY, Choi JK, Kim NO, Hong S, Chung GT, Yoo CK, Kim YT, Cheun HI, Bae GR, Yeo YH, Ha GJ, Choi MS, Kang SJ, Kim J. Outbreak of Ciprofloxacin-resistant Shigella sonnei associated with travel to Vietnam, Republic of Korea. Emerg Infect Dis. 2015;21(7):1247-50.
  9. Rahman M, Shoma S, Rashid H, El Arifeen S, Baqui AH, Siddique AK, Nair GB, Sack DA. Increasing spectrum in antimicrobial resistance of Shigella isolates in Bangladesh: resistance to azithromycin and ceftriaxone and decreased susceptibility to ciprofloxacin. J Health Popul Nutr.  2007;25(2):158-67.
  10. CDC. Notes from the field: Outbreak of infections caused by Shigella sonnei with decreased susceptibility to azithromycin–Los Angeles, California, 2012. MMWR Morb Mortal Wkly Rep.  2013;62(9):171.
  11. Gaudreau C, Barkati S, Leduc JM, Pilon PA, Favreau J, Bekal S. Shigella spp. with reduced azithromycin susceptibility, Quebec, Canada, 2012-2013. Emerg Infect Dis. 2014;20(5): 854–6.
  12. Gaudreau C, Ratnayake R, Pilon PA, Gagnon S, Roger M, Levesque S. Ciprofloxacin-resistant Shigella sonnei among men who have sex with men, Canada, 2010. Emerg Infect Dis. 2011;17(9):1747-50.
  13. Hoffmann C, Sahly H, Jessen A, Ingiliz P, Stellbrink HJ, Neifer S, Schewe K, Dupke S, Baumgarten A, Kuschel A, Krznaric I. High rates of quinolone-resistant strains of Shigella sonnei in HIV-infected MSM. [PDF – 5 pages] Infection. 2013;41(5):999-1003.
  14. Bowen A, Hurd J, Hoover C, Khachadourian Y, Traphagen E, Harvey E, Libby T, Ehlers S, Ongpin M, Norton JC, Bicknese A, Kimura A. Importation and domestic transmission of Shigella sonnei resistant to ciprofloxacin – United States, May 2014-February 2015. MMWR Morb Mortal Wkly Rep.  2015;64(12):318-20.
  15. Bowen A, Eikmeier D, Talley P, Siston A, Smith S, Hurd J, Smith K, Leano F, Bicknese A, Norton C, Campbell D. Notes from the Field: Outbreaks of Shigella sonnei infection with decreased susceptibility to azithromycin among men who have sex with men – Chicago and Metropolitan Minneapolis-St. Paul, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(21):597-8.

Medical management of patients with shigellosis

Testing the stool of patients with shigellosis-like symptoms, characterizing Shigella isolates, and using laboratory results to guide treatment decisions lead to more accurate diagnoses, targeted treatment (when needed), improved patient outcomes and earlier detection of outbreaks.

  • Among patients you suspect of having shigellosis, request stool specimens for culture or a culture-independent diagnostic test (CIDT).
    • If a CIDT is positive for shigellosis, confirm the diagnosis via stool culture.
    • Given the increasing rate of drug-resistant shigellosis, perform antimicrobial susceptibility testing for patients with culture-confirmed shigellosis.
  • Shigellosis can be mild, self-limited illness. When treatment is indicated, select an antimicrobial agent based on the susceptibility profile of the individual isolate, or during a local outbreak, on that of the outbreak strain.
    • Amoxicillin is absorbed rapidly from the intestines and, therefore, is not a good treatment for shigellosis. Ampicillin is preferred if the isolate is susceptible to penicillin.
  • For patients with treatment failure or prolonged diarrhea, obtain follow-up stool cultures at short intervals (e.g., weekly) until the patient has a negative culture.
    • Shedding of multidrug-resistant Shigella bacteria in feces may be prolonged, particularly if the patient was treated with an antimicrobial medication to which the isolate was resistant.
    • Confirming clearance of Shigella from a patient’s stool confirms resolution of infection and indicates they no longer pose a risk to public health through shedding of Shigella bacteria. Refer to local health department policies for guidance on returning to work, school, and childcare.

Counseling patients with drug-resistant shigellosis

Shigella is highly contagious; a very small inoculum (10 to 200 organisms) is sufficient to cause infection.1 To prevent the spread of Shigella bacteria, please share these prevention messages with your patients with shigellosis:

  • Wash hands with soap and water for at least 20 seconds:
    • After using the toilet
    • After hanging a diaper or assisting anyone with toileting
    • Note: Wash child’s hands in addition to your own.
  • Avoid preparing food for friends, neighbors, colleagues, and (if possible) your family while you are sick.
  • Try to stay home while you are sick.
    • If you work in healthcare, childcare, or the food service industry, follow the guidance of your local health department about when it is safe to return to work.
  • Children with shigellosis should not attend childcare, school, or group activities while they have diarrhea. Follow the guidance of your local health department about when it is safe to return to childcare or school.
  • Avoid swimming until you have fully recovered.
  • Wait to have sex (vaginal, anal, and oral) for one week after you no longer have diarrhea.2 Because Shigella germs may be in stool for several weeks, follow safe sex practices, or ideally avoid having sex, for several weeks after you or your partner have recovered.
  • When you start having sex again, wash your body and hands before and after sex, including in and around the anus and genitals.
    • During oral sex (fellatio or cunnilingus) or oral-anal sex (anilingus or mouth to anus), use barriers, such as condoms, natural rubber latex sheets, dental dams, or cut-open non-lubricated condoms between your rectum and your partner’s mouth.
    • Use condoms the right way, every time during anal or vaginal sex. Wash hands after handling used condoms or other barriers.
  • Urge others you know with similar symptoms to seek health care.
References
  1. DuPont HL, Levine MM, Hornick RB, Formal SB. Inoculum size in shigellosis and implications for expected mode of transmission. J Infect Dis. 1989;159(6):1126-8.
  2. Simms I, Field N, Jenkins C, Childs T, Gilbart VL, Dallman TJ, Mook P, Crook PD, Hughes G. Intensified shigellosis epidemic associated with sexual transmission in men who have sex with men–Shigella flexneri and S. sonnei in England, 2004 to end of February 2015. Euro Surveill. 2015;20(15).

Technical Information

Symptoms

Watery or bloody diarrhea, abdominal pain, tenesmus, fever, and malaise. Stools tend to be of small volume, and severe dehydration is uncommon.

Pathogen

Four species of Shigella: sonnei, flexneri, dysenteriae, and boydii.

Estimates

In the United States, it is estimated that there are about 500,000 cases of shigellosis every year, making it the third most common bacterial enteric disease 1. Shigellosis does not have a marked seasonality, likely reflecting the importance of person-to-person transmission. For more information, see the FoodNet Annual Report.

References
  1. Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson MA, Roy SL, Jones JL, Griffin PM. Foodborne illness acquired in the United States–major pathogens. Emerg Infect Dis. 2011;17(1):7-15.

Occurence

In 2015, the incidence of shigellosis in the United States reported to NNDSS was 7.3 cases per 100,000 individuals 1.

References
  1. Adams DA, Thomas KR, Jajosky RA, Foster L, Baroi G, Sharp P, Onweh DH, Schley AW, Anderson WJ; Nationally Notifiable Infectious Conditions Group. Summary of notifiable infectious diseases and conditions – United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;64(53):1-143.

Complications

Possible complications from Shigella infections include:

  • Post-infectious arthritis. A syndrome of joint pain, eye irritation, and painful urination after an infection is called post-infectious arthritis. This can happen in about 2% 1-3 of people who are infected with Shigella flexneri. Few cases have been reported in association with S. sonnei 4-5 or S. dysenteriae infection. It can last for months or years, and can lead to chronic arthritis. Post-infectious arthritis is caused by a reaction to Shigella infection that happens only in people who are genetically predisposed to it 2,8-10.
  • Bloodstream infections. Although rare, bloodstream infections are caused either by Shigella organisms or by other germs in the gut that get into the bloodstream when the lining of the intestines is damaged during shigellosis. Bloodstream infections are most common among patients with weakened immune systems, such as those with HIV, cancer, or severe malnutrition 10-12.
  • Seizures. Generalized seizures have been reported occasionally among young children with shigellosis, and usually resolve without treatment. Children who experience seizures while infected with Shigella typically have a high fever or abnormal blood electrolytes, but it is not well understood why the seizures occur 10,14-18.
  • Hemolytic-uremic syndrome or HUS. HUS occurs when bacteria enter the digestive system and produce a toxin that destroys red blood cells. Patients with HUS often have bloody diarrhea. When due to infection with Shigella, HUS is only associated with Shiga-toxin producing strains, most commonly Shigella dystenteriae 10,18-20.
References
  1. Noer HR. An “experimental” epidemic of Reiter’s syndrome. JAMA. 1966;198(7):693-8.
  2. Simon DG, Kaslow RA, Rosenbaum J, Kaye RL, Calin A. Reiter’s syndrome following epidemic shigellosis. J Rheumatol. 1981;8(6):969-73.
  3. Finch M, Rodey G, Lawrence D, Blake P. Epidemic Reiter’s syndrome following an outbreak of shigellosis. Eur J Epidemiol. 1986;2(1):26-30.
  4. van Bohemen CG, Lionarons RJ, van Bodegom P, Dinant HJ, Landheer JE, Nabbe AJ, Grumet FC, Zanen HC. Susceptibility and HLA-B27 in post-dysenteric arthropathies. Immunology. 1985;56(2):377-9.
  5. Lauhio A, Lähdevirta J, Janes R, Kontiainen S, Repo H. Reactive arthritis associated with Shigella sonnei infection. Arthritis Rheum. 1988;31(9):1190-3.
  6. Chen M, Delpech V, O’Sullivan B, Donovan B. Shigella sonnei: another cause of sexually acquired reactive arthritis. Int J STD AIDS. 2002;13(2):135-6.
  7. Mazumder RN, Salam MA, Ali M, Bhattacharya MK. Reactive arthritis associated with Shigella dysenteriae type 1 infection. J Diarrhoeal Dis Res. 1997;15(1):21-4.
  8. Morse HG, Rate RG, Bonnell MD, Kuberski TT. Reiter’s syndrome in a five-year-old girl. Arthritis Rheum. 1980;23(8):960-1.
  9. Hannu T, Mattila L, Siitonen A, Leirisalo-Repo M. Reactive arthritis attributable to Shigella infection: a clinical and epidemiological nationwide study. Ann Rheum Dis. 2005;64(4):594-8.
  10. American Academy of Pediatrics. Shigella infections. In: Red book: 2015 report of the Committee on Infectious Diseases. 2015.
  11. Morduchowicz G, Huminer D, Siegman-Igra Y, Drucker M, Block CS, Pitlik SD. Shigella bacteremia in adults. A report of five cases and review of the literature. Arch Intern Med. 1987;147(11):2034-7.
  12. Appannanavar SB, Goyal K, Garg R, Ray P, Rathi M, Taneja N. Shigellemia in a post renal transplant patient: a case report and literature review. J Infect Dev Ctries. 2014;8(2):237-9.
  13. Lahat E, Katz Y, Bistritzer T, Eshel G, Aladjem M. Recurrent seizures in children with Shigella-associated convulsions. Ann Neurol. 1990;28(3):393-5.
  14. Khan WA, Dhar U, Salam MA, Griffiths JK, Rand W, Bennish ML. Central nervous system manifestations of childhood shigellosis: prevalence, risk factors, and outcome. Pediatrics. 1999;103(2):E18.
  15. Galanakis E, Tzoufi M, Charisi M, Levidiotou S, Papadopoulou ZL. Rate of seizures in children with shigellosis. Acta Paediatr. 2002;91(1):101-2.
  16. Goldberg EM, Balamuth F, Desrochers CR, Mittal MK. Seizure and altered mental status in a 12-year-old child with Shigella sonnei gastroenteritis. Pediatr Emerg Care. 2011;27(2):135-7.
  17. Shamsizadeh A, Nikfar R, Bavarsadian E. Neurological manifestations of shigellosis in children in southwestern Iran. Pediatr Int. 2012;54(1):127-30.
  18. Rahaman MM, Greenough WB, 3rd. Shigellosis and haemolytic uraemic syndrome. Lancet. 1978;1(8072):1051.
  19. Bloom PD, MacPhail AP, Klugman K, Louw M, Raubenheimer C, Fischer C. Haemolytic-uraemic syndrome in adults with resistant Shigella dysenteriae type I. Lancet. 1994;344(8916):206.
  20. Butler T. Haemolytic uraemic syndrome during shigellosis. Trans R Soc Trop Med Hyg. 2012;106(7):395-9.

Transmission

Shigella germs are present in the stools of infected people while they have diarrhea and for up to a few weeks after the diarrhea has gone away 1 . Transmission of Shigella occurs when people put something in their mouths or swallow something that has come into contact with stool of someone infected with Shigella. This can happen when:

  • Contaminated hands touch someone’s food or mouth. Hands can become contaminated through a variety of activities, such as touching surfaces (e.g., toys, bathroom fixtures, changing tables, diaper pails) that have been contaminated by stool from an infected person. Hands also can become contaminated with Shigella bacteria while changing the diaper of an infected child or caring for an infected person.
  • Eating food contaminated with Shigella bacteria. Food may become contaminated if food handlers have shigellosis. Produce can become contaminated if growing fields contain human sewage 2. Flies can breed in infected feces and then contaminate food when they land on it.
  • Swallowing recreational water (for example, lake or river water) while swimming, or drinking water that has been contaminated by fecal matter containing Shigella.
  • Exposure to feces through sexual contact.
References
  1. DuPont HL, Hornick RB, Dawkins AT, Snyder MJ, Formal SB. The response of man to virulent Shigella flexneri 2a. J Infect Dis. 1969;119(3):296-9.
  2. Beuchat LR, Ryu JH. Produce handling and processing practices. Emerg Infect Dis.  1997;3(4):459-65.

People at Risk

  • Young children are the most likely to get shigellosis, but people of all ages are affected 1. Many outbreaks are related to childcare settings and schools, and illness commonly spreads from young children to their family members and others in their communities because it is so contagious.
  • Gay and bisexual men and other men who have sex with men (MSM) are more likely to acquire shigellosis than the general adult population 2Shigella passes from feces or soiled fingers of one person to the mouth of another person, which can happen during sexual activity. Many shigellosis outbreaks among MSM have been reported in the United States, Canada, Japan, and Europe since 1999 3-5, 6, 7-10. Resistance to clinically important antimicrobials may also be more prevalent among shigella bacteria isolated from MSM 3-5,11-13, 14-18. For more information, see Shigella Infections Among Gay & Bisexual Men.
  • People with HIV/AIDS and those who are immunocompromised can have more severe and prolonged shigellosis, including having the infection spread into the blood, which can be life-threatening 17, 19.
  • Travelers to developing countries may be more likely to get shigellosis, and to become infected with strains of Shigella bacteria that are resistant to important antibiotics 20, 21-25. Travelers may be exposed through contaminated food, water (both drinking and recreational water), or surfaces. Travelers can protect themselves by strictly following food and water precautions, and washing hands with soap frequently. For more information, see Travelers’ Health – Food and Water Safety.
  • Large outbreaks of shigellosis often start in childcare settings and spread among small social groups such as in traditionally observant Jewish communities 26. Similar outbreaks could occur among any race, ethnicity or community social circle because Shigella germs can spread easily from one person to another.

The term “men who have sex with men” is used in CDC surveillance systems because it indicates men who engage in behaviors that may transmit Shigella infection, rather than how someone identifies their sexuality. 

References
  1. Adams DA, Thomas KR, Jajosky RA, Foster L, Baroi G, Sharp P, Onweh DH, Schley AW, Anderson WJ; Nationally Notifiable Infectious Conditions Group. Summary of notifiable infectious diseases and conditions – United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;64(53):1-143.
  2. Aragon TJ, Vugia DJ, Shallow S, Samuel MC, Reingold A, Angulo FJ, Bradford WZ. Case-control study of shigellosis in San Francisco: the role of sexual transmission and HIV infection Clin Infect Dis. 2007;44(3):327-34.
  3. Gaudreau C, Barkati S, Leduc JM, Pilon PA, Favreau J, Bekal S. Shigella spp. with reduced azithromycin susceptibility, Quebec, Canada, 2012-2013. Emerg Infect Dis. 2014;20(5):854-6.
  4. Gaudreau C, Ratnayake R, Pilon PA, Gagnon S, Roger M, Levesque S. Ciprofloxacin-resistant Shigella sonnei among men who have sex with men, Canada, 2010. Emerg Infect Dis. 2011;17(9):1747-50.
  5. Hoffmann C, Sahly H, Jessen A, Ingiliz P, Stellbrink HJ, Neifer S, Schewe K, Dupke S, Baumgarten A, Kuschel A, Krznaric I. High rates of quinolone-resistant strains of Shigella sonnei in HIV-infected MSM. [PDF – 5 pages] Infection. 2013;41(5):999-1003.
  6. Bowen A, Eikmeier D, Talley P, Siston A, Smith S, Hurd J, Smith K, Leano F, Bicknese A, Norton C, Campbell D. Notes from the Field: Outbreaks of Shigella sonnei infection with decreased susceptibility to azithromycin among men who have sex with men – Chicago and Metropolitan Minneapolis-St. Paul, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(21):597-8.
  7. CDC. Shigella sonnei outbreak among men who have sex with men–San Francisco, California, 2000-2001. MMWR Morb Mortal Wkly Rep. 2001;50(42):922-6.
  8. Outbreak of Shigella flexneri and Shigella sonnei enterocolitis in men who have sex with men, Quebec, 1999 to 2001. Can Commun Dis Rep. 2005;31(8):85-90.
  9. Valcanis M, Brown JD, Hazelton B, OʼSullivan MV, Kuzevski A, Lane CR, Howden BP. Outbreak of locally acquired azithromycin-resistant Shigella flexneri infection in men who have sex with men. Pathology. 2015;47(1):87-8.
  10. Chiou CS, Izumiya H, Kawamura M, Liao YS, Su YS, Wu HH, Chen WC, Lo YC. The worldwide spread of ciprofloxacin-resistant Shigella sonnei among HIV-infected men who have sex with men, Taiwan. Clin Microbiol Infect. 2016;22(4):383e11-6.
  11. Heiman KE, Karlsson M, Grass J, Howie B, Kirkcaldy RD, Mahon B, Brooks J, Bowen A. Notes from the field: Shigella with decreased susceptibility to azithromycin among men who have sex with men – United States, 2002-2013. MMWR Morb Mortal Wkly Rep. 2014;63(6):132-3.
  12. Baker KS, Dallman TJ, Ashton PM, Day M, Hughes G, Crook PD, Gilbart VL, Zittermann S, Allen VG, Howden BP, Tomita T, Valcanis M, Harris SR, Connor TR, Sintchenko V, Howard P, Brown JD, Petty NK, Gouali M, Thanh DP, Keddy KH, Smith AM, Talukder KA, Faruque SM, Parkhill J, Baker S, Weill FX, Jenkins C, Thomson NR. Intercontinental dissemination of azithromycin-resistant shigellosis through sexual transmission: a cross-sectional study. Lancet Infect Dis. 2015;15(8):913-21.
  13. Aragon TJ, Vugia DJ, Shallow S, Samuel MC, Reingold A, Angulo FJ, Bradford WZ. Case-control study of shigellosis in San Francisco: the role of sexual transmission and HIV infection Clin Infect Dis. 2007;44(3):327-34.
  14. Watson, JT, Jones RC, Fernandez J, Cortes C, Gerber SI, Kuo KJ, Price JS, Brooks JT, Jennings D, Fair M, Mintz E, Bowen A. Shigella flexneri serotype 3 infections among men who have sex with men–Chicago, Illinois, 2003-2004. [PDF – 24 pages] MMWR Morb Mortal Wkly Rep. 2005;54(33):820-2.
  15. Morgan O, Crook P, Cheasty T, Jiggle B, Giraudon I, Hughes H, Jones SM. Shigella sonnei outbreak among homosexual men, London. Emerg Infect Dis. 2006;12(9):1458-60.
  16. HHS. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. [PDF – 425 pages] Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. 2015.
  17. Okame M, Adachi E, Sato H, Shimizu S, Kikuchi T, Miyazaki N, Koga M, Nakamura H, Suzuki M, Oyaizu N, Fujii T, Iwamoto A, Koibuchi T. Shigella sonnei outbreak among men who have sex with men in Tokyo. Jpn J Infect Dis. 2012;65(3):277-8.
  18. Bowen A, Hurd J, Hoover C, Khachadourian Y, Traphagen E, Harvey E, Libby T, Ehlers S, Ongpin M, Norton JC, Bicknese A, Kimura A. Importation and domestic transmission of Shigella sonnei resistant to ciprofloxacin – United States, May 2014-February 2015. MMWR Morb Mortal Wkly Rep.  2015;64(12):318-20.
  19. Baker KS, Dallman TJ, Ashton PM, Day M, Hughes G, Crook PD, Gilbart VL, Zittermann S, Allen VG, Howden BP, Tomita T, Valcanis M, Harris SR, Connor TR, Sintchenko V, Howard P, Brown JD, Petty NK, Gouali M, Thanh DP, Keddy KH, Smith AM, Talukder KA, Faruque SM, Parkhill J, Baker S, Weill FX, Jenkins C, Thomson NR. Intercontinental dissemination of azithromycin-resistant shigellosis through sexual transmission: a cross-sectional study. Lancet Infect Dis. 2015;15(8):913-21.
  20. Kantele A. As far as travelers’ risk of acquiring resistant intestinal microbes is considered, no antibiotics (absorbable or nonabsorbable) are safe. Clin Infect Dis. 2015.
  21. O’Donnell AT, Vieira AR, Huang JY, Whichard J, Cole D, Karp BE. Quinolone-resistant Salmonella enterica serotype Enteritidis infections associated with international travel. Clin Infect Dis. 2014;59(9):e139-41.
  22. Pons MJ, Gomes C, Martinez-Puchol S, Ruiz L, Mensa L, Vila J, Gascón J, Ruiz J. Antimicrobial resistance in Shigella spp. causing traveller’s diarrhoea (1995-2010): a retrospective analysis. Travel Med Infect Dis. 2013;11(5):315-9.
  23. De Lappe N, O’Connor J, Garvey P, McKeown P, Cormican M. Ciprofloxacin-resistant Shigella sonnei associated with travel to India. Emerg Infect Dis. 2015;21(5):894-6.
  24. De Schrijver K, Bertrand S, Gutierrez Garitano I, Van den Branden D, Van Schaeren J. Outbreak of Shigella sonnei infections in the Orthodox Jewish community of Antwerp, Belgium, April to August 2008. Euro Surveill. 2011;16(14).
  25. Garrett V, Bornschlegel K, Lange D, Reddy V, Kornstein L, Kornblum J, Agasan A, Hoekstra M, Layton M, Sobel J. A recurring outbreak of Shigella sonnei among traditionally observant Jewish children in New York City: the risks of daycare and household transmission. Epidemiol Infect. 2006;134(6):1231-6.
  26. Sobel J, Cameron DN, Ismail J, Strockbine N, Williams M, Diaz PS, Westley B, Rittmann M, DiCristina J, Ragazzoni H, Tauxe RV, Mintz ED. A prolonged outbreak of Shigella sonnei infections in traditionally observant Jewish communities in North America caused by a molecularly distinct bacterial subtype. J Infect Dis. 1998;177(5):1405-9.

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