Treatment of shigella infections: why sulfamethoxazole-trimethoprim, tetracyclines and ampicillin should no longer be used

Abstract

Background: Bloody diarrhoea results in high morbidity and mortality especially in developing countries with shigellosis being the main cause of acute bloody diarrhoea. The use of appropriate antimicrobial agents in the treatment of acute diarrheal disease shortens the duration of illness and bacterial shedding leading to a reduction in morbidity and mortality. Treatment options for many infections are becoming limited due to globally emerging antibiotic resistance. Globally, resistance of shigella species to trimethoprim-sulfamethoxazole (TMP-SMX), tetracyclines and ampicillin has been reported with subsequent recommendations of not using these antimicrobial drugs for empirical therapy of acute bloody diarrhoea.

Objective: To establish the antimicrobial susceptibility patterns and antimicrobial drug use for treatment of shigella species in patients with acute bloody diarrhoea.

Design: A hospital based case control study.

Setting: Six health facilities, three in Kilifi County and three in Nairobi County.

Subject: A total of 284 stool specimens were collected from patients who fitted the standard cases definition for acute bloody diarrhoea.

Results: Eighty (28.2%) bacterial isolates were recovered from 284 stool samples collected from cases presenting with acute bloody diarrhoea of which 67 (83.8%) were Shigella species, nine (11.3%) were Enteroinvassive Escherichia coli isolates, three (3.8%) were Salmonella Typhi and one (1.3%) were Yersinia enterocolitica. Shigella isolates had high resistance to sulfamethoxazole-trimethoprim (97%), tetracycline (83.6%) ampicillin (58.2%) and chloramphenicol (20.9%). The isolates showed low resistance to nalidixic (4.5%) and ciprofloxacin (3.0%) while there was no resistance to ceftriaxone. The most common multidrug resistance pattern detected in Shigella strains combined sulfamethoxazole-trimethoprim, amoxicillin/ampicillin and tetracyclines.Antibiotic prescriptions were given to 243(85.6%) of the patients presenting with acute bloody diarrhoea. Among these, 94 (38.7%) were given prescriptions for ciprofloxacin, 53 (21.8%) for sulfamethaxazole-trimethiprin and 36(14.8%) for Tetracyclines. Chloramphenicol, amoxicillin/ampicillin, nalidixic acid and ceftriaxone were prescribed to 10.7 %, 3.7%, 2.9% and 0.4% of the patients respectively. A total of 123 (51%) received antibiotics which were ranked to have high resistance (sulfamethoxazole-trimethoprim, tetracyclines ampicillin and chloramphenicol).

Conclusion: The high rates of antimicrobial resistance among the commonly prescribed antimicrobials such as sulfamethoxazole-trimethoprim, tetracycline, ampicillin and chloramphenicol is of major concern. Despite recommendations discouraging the empirical use of sulfamethoxazole-trimethoprim, tetracycline, ampicillin and chloramphenicol for treatment of acute bloody diarrhoea, more than half of the patients with acute bloody diarrhoea were still treated with these antibiotics.There is need to train health care workers on the proper management of acute bloody diarrhoea and the importance of adhering to the clinical guidelines.