What is the treatment for a patient with gastroenteritis (GE) caused by Shigella and Enteroinvasive Escherichia coli (EIEC)?

Treatment of Gastroenteritis with Shigella and EIEC

Treat with antibiotics immediately—either azithromycin or a fluoroquinolone (ciprofloxacin) in adults, or azithromycin in children, based on local resistance patterns and travel history. 1

Antibiotic Therapy is Indicated

Since you have confirmed Shigella and EIEC (which behaves similarly to Shigella as an invasive pathogen), antibiotic treatment is warranted to reduce illness duration, prevent complications, and decrease bacterial shedding. 1, 2

For Adults:

• First-line options: 1

  • Ciprofloxacin (fluoroquinolone) OR
  • Azithromycin

• Choice depends on: 1

  • Local antimicrobial susceptibility patterns
  • Travel history (quinolone resistance is increasing globally, particularly in travelers)

• Ciprofloxacin is FDA-approved for infectious diarrhea caused by Shigella species. 3

For Children:

• Azithromycin is preferred for Shigella infections in pediatric patients. 1, 2

• Third-generation cephalosporin (e.g., ceftriaxone) should be used for: 1

  • Infants <3 months of age
  • Children with neurologic involvement

• Avoid fluoroquinolones in children unless absolutely necessary due to arthropathy concerns. 3

Critical Consideration: Rule Out STEC

Before initiating antibiotics, ensure this is NOT a Shiga toxin-producing E. coli (STEC) infection, particularly STEC O157 or other Shiga toxin 2-producing strains. 1, 4

• EIEC is distinct from STEC—EIEC causes invasive dysentery similar to Shigella but does NOT produce Shiga toxin. 3
• If STEC is detected or suspected, avoid antibiotics entirely as they increase the risk of hemolytic uremic syndrome (HUS). 1, 4
• Multiple retrospective studies show higher HUS rates in antibiotic-treated STEC patients. 1, 4

Supportive Care is Essential

Rehydration:

• Reduced osmolarity oral rehydration solution (ORS) is first-line for mild to moderate dehydration. 1, 5

• Intravenous isotonic fluids (lactated Ringer's or normal saline) for: 1, 5

  • Severe dehydration
  • Shock or altered mental status
  • Failure of oral rehydration

Avoid Antimotility Agents:

• Do not use loperamide or other antimotility agents in suspected invasive bacterial diarrhea, as they may worsen outcomes. 1, 4

Modify Treatment Based on Susceptibility

Once antimicrobial susceptibility results are available, narrow or modify therapy accordingly. 1

• Shigella resistance patterns vary regionally—azithromycin is increasingly preferred due to rising fluoroquinolone resistance. 2, 6, 7
• Regularly updated local antibiotic sensitivity data should guide empiric choices. 8

Special Populations

Immunocompromised Patients:

• Lower threshold for empiric antibacterial treatment in patients with severe illness and bloody diarrhea. 1, 5

Infants <3 Months:

• Treat empirically with third-generation cephalosporin due to risk of bacteremia and neurologic complications. 1

Common Pitfalls to Avoid

• Do not treat asymptomatic contacts—they should follow infection control measures instead. 1

• Do not withhold antibiotics in confirmed Shigella/EIEC when clinically indicated (fever, bloody diarrhea, dysentery symptoms). 1, 5

• Do not confuse EIEC with STEC—EIEC warrants antibiotics; STEC does not. 4, 3

• Do not continue empiric therapy unchanged once a pathogen is identified—adjust based on susceptibility. 1

Clinical Indicators Supporting Treatment

Your patient likely has bacillary dysentery if presenting with: 1

• Frequent scant bloody stools
• Fever documented in medical setting
• Abdominal cramps and tenesmus

These features strongly support immediate antibiotic initiation for Shigella/EIEC. 1, 5