August 22, 2012 To: Sarpy/Cass County Health Care Providers Re: Increased number of Shigella Infections in the community From: Sarpy/Cass Department of Health and Wellness Since early August, Sarpy/Cass Department of Health and Wellness has investigated 5 confirmed cases of Shigella sonnei infection, 1of which have been hospitalized. Four of the cases have been between 3- 7 years of age. 90% percent have been associated with a child care setting. In 2010 there were two confirmed cases and in 2011 only one. Douglas County has had 50 confirmed cases since May 2012. Recommendations for Healthcare Providers Diagnosis
The spectrum of shigellosis manifestations ranges from loose, watery stools without systemic symptoms to more severe presentations with fever, cramps, and bloody diarrhea.
Consider Shigella in patients presenting with at least two of the following symptoms:
o Acute onset of diarrhea (loose watery stools, typically with blood or mucus in the stool), o Fever 100.4 or higher (38 C), o Abdominal pain.
Providers should consider ordering a stool culture to guide treatment and to identify antimicrobial resistance.
Testing, available commercially, may be done via stool culture or rectal swab
Laboratories must submit the isolate and/or specimen to the Nebraska Public Health Laboratory as specified in 173 NAC 1-007.03
Shigella is typically a self-limited illness lasting 48 to 72 hours. Antimicrobial therapy, while not generally required in mild cases, is somewhat effective in shortening duration of illness and can decrease transmission by hastening eradication of organisms from feces. (2012 AAP Red Book1)
Antimicrobial susceptibility testing results were available for one of which has been isolated from cases since August with one still pending. For that one case, susceptibility was determined for ampicillin, cefotaxime, ciprofloxacin, and trimethoprim-sulfamethoxazole although many of the specimens in the Douglas County cases demonstrated resistance to trimethoprim-sulfamethoxazole. Providers may consider empiric treatment with ampicillin or ciprofloxacin while awaiting culture and sensitivity results.
Control Measures (note: requirements for exclusion of child care attendees are being altered for this outbreak setting)
o Attendees should be held out until on appropriate antibiotics for 48 hours and symptom free for 24 hours before returning. If the child is not placed on antibiotics, 1 negative stool culture would be required before returning.
Food handlers and child and patient care providers
o Because of the small infective dose, patients with known Shigella infections should not be employed to handle food or to provide child or patient care until 2 successive fecal samples (collected 24 hours apart, but no sooner than 48 hours after discontinuance of antimicrobials) are found to be Shigella-free.
Patients must be told of the importance and effectiveness of hand washing with soap and water after defecation as a means of curtailing transmission of Shigella.
Patients should not participate in recreational water activities (e.g. swimming pools, water parks, splash parks) for 1 week after symptoms resolve.
Providers may opt to give a copy of the Shigella fact sheet to their patients (page 2 of this Advisory).
For additional information, please contact Sarpy/Cass Department of Health (402)-339-4334 x203. 1.American Academy of Pediatrics. Shigella Infections. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012: 645-7.
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