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The following Health Alert Network (HAN) notice originated from the CDC

CONTACT THE CDC WITH ANY QUESTIONS OR CONCERNS

Increase in Extensively Drug-Resistant Shigellosis in the United States

The Centers for Disease Control and Prevention (CDC) has been monitoring an increase in extensively drug-resistant (XDR) 

infections (shigellosis) reported through national surveillance systems [1]

infections reported to CDC were caused by XDR strains, compared with 0% in 2015. Clinicians treating patients infected with XDR strains have limited antimicrobial treatment options. 

strains can spread antimicrobial resistance genes to other enteric bacteria. Given these potentially serious public health concerns, CDC and the Louisiana Department of Health (LDH) ask healthcare professionals to be vigilant about suspecting and reporting cases of XDR 

infection to LDH and educating patients and communities at increased risk about prevention and transmission.

 Shigellosis is an acute enteric infection that is an important cause of domestically acquired and travel-associated bacterial diarrhea in the United States. Shigellosis usually causes inflammatory diarrhea that can be bloody and may also lead to fever, abdominal cramping, and tenesmus. Infections are generally self-limiting; however, antimicrobial treatment may be indicated to prevent complications or shorten the duration of illness [2]. CDC defines XDR 

as strains that are resistant to all commonly recommended empiric and alternative antibiotics — azithromycin, ciprofloxacin, ceftriaxone, trimethoprim-sulfamethoxazole (TMP-SMX), and ampicillin. Currently, there are no data from clinical studies of treatment of XDR 

 to inform recommendations for the optimal antimicrobial treatment of these infections. As such, CDC does not have recommendations for optimal antimicrobial treatment of XDR 

 bacteria are transmitted by the fecal-oral route, directly through person-to-person contact including sexual contact, and indirectly through contaminated food, water, and other routes. 

bacteria are easily transmitted because of the low infectious dose (as few as 10 – 100 organisms), and outbreaks tend to occur among people in close-contact settings [2–6]. 

Historically, shigellosis has predominantly affected young children (age 1 – 4 years) in the United States. More recently, CDC has observed an increase in antimicrobial-resistant 

 infections among adult populations [4,5] especially

Most people with diarrheal illness require only supportive care and fluid replacement. Antimicrobial agents are not always needed for mild shigellosis, but they may be indicated to

In the United States, recommended empiric antimicrobial agents include azithromycin, ciprofloxacin, or ceftriaxone. Ampicillin or TMP-SMX are recommended as alternative treatments for susceptible strains [2].

 In the United States, the percentage of 

infections caused by XDR strains reported to CDC increased from zero in 2015 to 5% in 2022 (

). Between January 1, 2015, and January 22, 2023, CDC received reports of 239 XDR

accounting for the largest percentage (66%) followed by

(34%). The median age of patients was 42 years (range 1–83 years). Among 232 patients with available information, 82% were men, 13% were women, and 5% were children. Among 41 patients who answered questions about recent sexual activity, 88% reported male-to-male sexual contact.

isolates that showed an extensively drug resistant (XDR)* phenotype or genotype in the United States, by year, 2015–2022† (See pdf attached for Figure 1).

bacteria (n=239) are defined as resistant to azithromycin, ciprofloxacin, ceftriaxone, trimethoprim-sulfamethoxazole, and ampicillin.

PulseNet Whole Genome Sequencing Database

 ; data are preliminary and based on broth microdilution susceptibility testing and/or presence of resistance genes and mutations found in whole genome sequences of bacterial DNA.

isolates with unique or worrisome antimicrobial susceptibility patterns and genetic resistance markers. In addition, CDC is conducting an analysis of antimicrobial-resistant 

 infections in the United States using data in the 

National Antimicrobial Resistance Monitoring System for Enteric Bacteria

Recommendations for Healthcare Professionals

 infections have been described among adult men and may be associated with transmission among MSM. Cases of 

shigellosis co-occurring with other sexually transmitted infections

 (STIs), including HIV, have been described among MSM [8].

Please counsel patients with suspected or confirmed shigellosis about measures they can take to keep others healthy. Patients taking antibiotics should continue to follow prevention measures. All patients with suspected or confirmed shigellosis should