Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

suspected or confirmed shigellosis

1st line – oral rehydration solution

Back
ACUTE
|
suspected or confirmed shigellosis
|
mild to moderate volume depletion: with no vomiting
1st line – 

oral rehydration solution

In Shigella dysentery, oral rehydration therapy (using approved oral rehydration solution [ORS]) is indicated in mild to moderate volume depletion. Following rehydration, maintenance therapy with ORS to ensure hydration status is recommended.[13]​​[22]

Oral rehydration therapy using an approved ORS is safer than use of other beverages, which may be too concentrated and contain inappropriate carbohydrate and electrolyte concentrations. Homemade preparations may be equally problematic because errors may occur.

The World Health Organization recommends low-osmolarity ORS formula for diarrhea in all age groups.[31]

Plus – early nutritional support + health education + infection control measures

Back
ACUTE
|
suspected or confirmed shigellosis
|
mild to moderate volume depletion: with no vomiting
Plus – 

early nutritional support + health education + infection control measures

Treatment recommended for ALL patients in selected patient group

Early nutritional support has been found to improve outcomes, especially in the context of malnutrition. Continued feeding promotes recovery. Frequent small meals with familiar foods, rich in energy and protein, should be provided. Breastfed infants and children should continue to be breastfed as often and for as long as they want.[13]

The addition of green bananas to meals has been shown to reduce the duration of symptoms of shigellosis in children over 6 months of age.[32] In low- and middle-income countries, a 10- to 14-day course of zinc supplementation is recommended by the World Health Organization in children <6 years of age with acute diarrhea.[13] [ Cochrane Clinical Answers logo ] ​ Vitamin A is also recommended.[31]

Information regarding personal hygiene, food, and drinking water should be provided to all patients. Outpatients should be also clearly instructed how to disinfect clothes, personal items, and their immediate environment.[13] Sexual activities should be avoided while symptomatic and for up to 7 days after symptoms have stopped. Organisms in stool may continue to shed for up to 6 weeks, so fecal-oral contact during sex should be avoided for this period of time.[22][33]​​

Consider – antibiotic therapy

Back
ACUTE
|
suspected or confirmed shigellosis
|
mild to moderate volume depletion: with no vomiting
Consider – 

antibiotic therapy

Treatment recommended for SOME patients in selected patient group

Antibiotic therapy is reserved for where it is clinically indicated or when public health officials advise treatment in an outbreak setting or to reduce the likelihood of transmission in certain settings or situations.[35] Clinical indications for empirical antibiotics include all cases of fever with bloody diarrhea, bacillary dysentery, and abdominal cramping.[22]​ Antibiotics are also recommended for infants ages <3 months with suspicion of Shigella infection and people with body temperatures ≥38.5°C and/or signs of sepsis who have recently traveled internationally.[22]​ Antibiotics may be considered in people who are immunocompromised and have severe illness and bloody diarrhea.[22]

First-line options are azithromycin, ciprofloxacin, or ceftriaxone.[1][22] The choice of drug is dependent on local sensitivities. If available, antimicrobial susceptibility testing should be carried out before treating with antibiotics.[1]​ The rapid emergence of fluoroquinolone resistance is a concern, particularly in India and China.[13][36][37][38] Patients with a history of travel to Asia are thus at increased risk of fluoroquinolone-resistant infection.[39]​ If susceptibility is detected, trimethoprim/sulfamethoxazole or ampicillin are alternative options.[22][23]​​​​

Once infection has been confirmed, antibiotics should be promptly tailored to sensitivities to prevent resistance. If the correct antibiotic has been used initially but the patient is refractory to treatment, further cultures should be sent to exclude another pathogen, or an alternative diagnosis should be considered.

Primary options

ciprofloxacin: children: 15 mg/kg orally twice daily for 3 days, maximum 500 mg/dose; adults: 500 mg orally twice daily for 3 days

OR

ceftriaxone: children: 50-100 mg/kg intramuscularly/intravenously every 24 hours for 2-5 days, maximum 2 g/dose; adults: 1-2 g intramuscularly/intravenously every 24 hours for 2-5 days

OR

azithromycin: children: 6-20 mg/kg orally once daily for 1-5 days; adults: 1000-1500 mg orally once daily for 1-5 days

Secondary options

sulfamethoxazole/trimethoprim: children ≥2 months of age: 8-10 mg/kg/day orally given in 2 divided doses for 3-5 days, maximum 160 mg/dose; adults: 160 mg orally twice daily for 5-7 days

More

OR

ampicillin: children: 50-100 mg/kg/day orally given in 4 divided doses for 5-7 days, maximum 2000 mg/day; adults: 500 mg orally four times daily for 5-7 days

Consider – antipyretics or analgesics

Back
ACUTE
|
suspected or confirmed shigellosis
|
mild to moderate volume depletion: with no vomiting
Consider – 

antipyretics or analgesics

Treatment recommended for SOME patients in selected patient group

Symptomatic treatment should be given in case of fever and/or pain.

Primary options

acetaminophen: infants and children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

1st line – intravenous rehydration followed by maintenance oral rehydration solution

Back
ACUTE
|
suspected or confirmed shigellosis
|
severe volume depletion or vomiting
1st line – 

intravenous rehydration followed by maintenance oral rehydration solution

Hospitalization and intravenous rehydration therapy may initially be required for patients with severe dehydration or vomiting. Once rehydrated, maintenance therapy with oral rehydration solution (ORS) is recommended.[13] If rehydrated patients are unable to drink, maintenance therapy with ORS may be provided nasogastrically (when intravenous hydration is no longer required and any vomiting resolves).

Oral rehydration therapy using an approved ORS is safer than use of other beverages, which may be too concentrated and contain inappropriate carbohydrate and electrolyte concentrations. Homemade preparations may be equally problematic because errors may occur.[14] The World Health Organization recommends low-osmolarity ORS formula for diarrhea in all age groups.[31]

Consider – early nutritional support

Back
ACUTE
|
suspected or confirmed shigellosis
|
severe volume depletion or vomiting
Consider – 

early nutritional support

Treatment recommended for SOME patients in selected patient group

Early nutritional support has been found to improve outcomes, especially in the context of malnutrition. Continued feeding promotes recovery. Frequent small meals with familiar foods, rich in energy and protein, should be provided. Breastfed infants and children should continue to be breastfed as often, and for as long, as they want.[13]

The addition of green bananas to meals has been shown to reduce the duration of symptoms of shigellosis in children >6 months of age.[32] In low- and middle-income countries, a 10- to 14-day course of zinc supplementation is recommended by the World Health Organization in children <6 years of age with acute diarrhea.[13] [ Cochrane Clinical Answers logo ] ​​ 

Consider – antibiotic therapy

Back
ACUTE
|
suspected or confirmed shigellosis
|
severe volume depletion or vomiting
Consider – 

antibiotic therapy

Treatment recommended for SOME patients in selected patient group

Antibiotic therapy is reserved for where it is clinically indicated or when public health officials advise treatment in an outbreak setting or to reduce the likelihood of transmission in certain settings or situations.[35] Clinical indications for empirical antibiotics include all cases of fever with bloody diarrhea, bacillary dysentery, and abdominal cramping.[22]​ Antibiotics are also recommended for infants ages <3 months with suspicion of Shigella infection and people with body temperatures ≥38.5°C and/or signs of sepsis who have recently traveled internationally.[22]​ Antibiotics may be considered in people who are immunocompromised and have severe illness and bloody diarrhea.[22]

First-line options are azithromycin, ciprofloxacin, or ceftriaxone.[1][22] The choice of drug is dependent on local sensitivities. If available, antimicrobial susceptibility testing should be carried out before treating with antibiotics.[1]​ The rapid emergence of fluoroquinolone resistance is a concern, particularly in India and China.[13][36][37][38] Patients with a history of travel to Asia are thus at increased risk of fluoroquinolone-resistant infection.[39]​ If susceptibility is detected, trimethoprim/sulfamethoxazole or ampicillin are alternative options.[22][23]​​​​

Once infection has been confirmed, antibiotics should be promptly tailored to sensitivities to prevent resistance. If the correct antibiotic has been used initially but the patient is refractory to treatment, further cultures should be sent to exclude another pathogen, or an alternative diagnosis should be considered.

Consult with a specialist for guidance on duration of treatment in severe disease.

Primary options

ciprofloxacin: children: 15 mg/kg orally/intravenously twice daily, maximum 500 mg/dose; adults: 500 mg orally twice daily, or 400 mg intravenously every 12 hours

OR

ceftriaxone: children: 50-100 mg/kg intramuscularly/intravenously every 24 hours, maximum 2 g/dose; adults: 1-2 g intramuscularly/intravenously every 24 hours

OR

azithromycin: children: 6-20 mg/kg orally once daily; adults: 1000-1500 mg orally once daily

Secondary options

sulfamethoxazole/trimethoprim: children ≥2 months of age: 8-10 mg/kg/day orally given in 2 divided doses for 3-5 days, maximum 160 mg/dose; adults: 160 mg orally twice daily for 5-7 days

More

OR

ampicillin: children: 50-100 mg/kg/day orally given in 4 divided doses for 5-7 days, maximum 2000 mg/day; adults: 500 mg orally four times daily for 5-7 days

Consider – antipyretics or analgesics

Back
ACUTE
|
suspected or confirmed shigellosis
|
severe volume depletion or vomiting
Consider – 

antipyretics or analgesics

Treatment recommended for SOME patients in selected patient group

Symptomatic treatment should be given in case of fever and/or pain.

Primary options

acetaminophen: infants and children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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