Name: Spokane Regional Health District
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Increase in Shigella Cases - 2025

Posted Jan. 27, 2025. Past health advisories and alerts are archived for historical purposes and are not maintained or updated.

Spokane County is beginning to see an uptick in Shigella cases. There have been 15 cases reported so far in 2025, several of whom are people experiencing homelessness (PEH). SRHD is closely monitoring this situation and seeks to keep the healthcare provider community informed. Centers for Disease Control and Prevention (CDC) has been monitoring andincrease in extensively drug-resistant (XDR) Shigella infections (shigellosis) reporting through national surveillance systems, as well.

Shigella bacteria causes a gastrointestinal infection called shigellosis. Shigella can spread easily from one person to another via fecal-oral transmission and can be transmitted for 2 weeks or more after diarrhea has subsided, due to bacterial shedding in feces. Shigella is highly contagious. It survives on surfaces for months, and a very small inoculum (10 to 200 organisms) is sufficient to cause infection.

Actions Requested

Be aware of shigellosis symptoms, diagnosis, and treatment

Most people with Shigella infection (shigellosis) experience:

Diarrhea that can be bloody or prolonged (lasting more than 3 days)
Fever
Stomach pain
Feeling the need to pass stool (poop) even when the bowels are empty.

Symptoms usually start 1-2 days after exposure and last 7 days. In some cases, bowel habits (frequency and consistency of stool) do not return to normal for several months.

Groups at higher risk for infection or severe illness:

People who are experiencing homelessness
Gay, bisexual, and other men who have sex with men: Preventing Shigella Infection Among Sexually Active People
Travelers (more likely to become sick with types of Shigella that are more difficult to treat)
Children younger than 5 years old
People who have weakened immune systems

Test

Order a gastrointestinal (GI) bacterial pathogen panel, by testing a stool sample from patients who present with diarrhea.

Order stool culture and antimicrobial susceptibility testing (AST) for patients suspected of having Shigella. Culture-independent diagnostic testing on its own (e.g., PCR) cannot be used to assess susceptibility.

Given the increase in extensively drug-resistant (XDR) Shigella infections (shigellosis), perform antimicrobial susceptibility testing (AST) if you plan to treat with an antibiotic.
When ciprofloxacin minimum inhibitory concentrations (MICs) are in the 0.12 – 1.0 μg/mL range, even if the laboratory report identifies the isolate as susceptible, be aware there may be one or more resistance mechanisms. It is unclear whether fluoroquinolone treatment in this range is associated with worse clinical outcomes; consultation with a specialist is advised if no alternative antibiotic options are available.

Laboratories should consider adding azithromycin to their AST for Shigella specimens using recently established clinical breakpoints for azithromycin for Shigella.

Many laboratories currently don’t do Shigella antimicrobial sensitivity testing (AST) for azithromycin, which is a common first-choice antibiotic treatment.

Ensure that laboratories send all specimens to the Washington State Public Health Lab (PHL) in Shoreline for confirmatory testing.

Best specimens include isolates and stool/swab in transport medium.
Enclose the Microbiology Requisition Form when sending specimens to PHL.

Treat

Although antibiotic therapy is not routinely recommended for mild infections, consider antibiotic treatment for:

Patients with more severe illnesses
Patients who are immunocompromised
Patients in settings where there is elevated concern for transmission to others (e.g., in homeless shelters)
And in outbreak settings

Fluoroquinolones (such as ciprofloxacin), azithromycin, and third-generation cephalosporins (such as ceftriaxone) are recommended antibiotics. Trimethoprim-sulfamethoxazole and ampicillin are options if susceptibility is documented.

If a patient has prolonged diarrhea (diarrhea lasting more than 3 days), follow-up stool cultures may be needed.

Food workers, healthcare workers, childcare workers, and people who attend childcare that test positive for Shigella must receive 2 negative PCR or cultured stool specimens (24 hours apart, at least 48 hours after completion of antibiotics) before returning to work/childcare.

Healthcare providers should consult with a specialist knowledgeable in the treatment of antibiotic-resistant bacteria to determine the best treatment option if there are concerns for XDR Shigella infections or in cases of treatment failure without AST results.

CDC does not have recommendations for optimal antimicrobial treatment because there are no data from clinical studies of treatment of XDR Shigella infections.