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Shigellosis is the third most common enteric bacterial infection in the United States. Risk groups for infection include young children, men who have sex with men (MSM), and international travelers. Although shigellosis is generally self-limiting, patients with diarrhea frequently receive empiric ciprofloxacin treatment. The New York City Department of Health and Mental Hygiene (DOHMH) began monitoring antimicrobial resistance among Shigella isolates after detecting high levels of antibiotic resistance, including 5 ciprofloxacin-resistant Shigella isolates among non-travelers from 2006-2009, the first such strains detected in the US.
METHODS:
In NYC, clinicians and laboratories are required to report laboratory-confirmed shigellosis to DOHMH. Isolates are forwarded to DOHMH for confirmation, serogrouping, and antibiotic susceptibility testing. When appropriate, pulsed field gel electrophoresis (PFGE) is performed. All patients with ciprofloxacin-resistant isolates or their providers were interviewed with a standard questionnaire to assess antibiotic use and international travel before illness.
RESULTS:
Among 879 Shigella isolates tested from January 2011-October 2012, 22 (2.5%) were resistant to ciprofloxacin. The age of patients with ciprofloxacin-resistant shigellosis ranged from 1-71 years; 14 (64%) were male. Twelve case patients reported international travel to areas of endemic resistance, most commonly India and Bangladesh. Of these, 2 were treated with antibiotics while abroad and 8 upon return; antibiotic use was unknown for 2 patients. Of four ciprofloxacin-resistant isolates associated with travel to South Asia, PFGE patterns (using XbaI digest) of three were indistinguishable and the fourth was very similar. Of the 10 remaining patients, six were MSM and reported no known travel; the other 4 were not MSM and reported no travel, and one of those four reported antibiotic use before illness though the antibiotic was not ciprofloxacin. Three of the non-travel cases were <6 years of age and unrelated.
CONCLUSIONS:
In New York City, ciprofloxacin-resistant Shigella has emerged as a cause of infection among people with no travel history to endemic regions and no recent antibiotic use. Other jurisdictions, especially urban centers with high-risk groups such as MSM and international travelers, should consider monitoring ciprofloxacin resistance in Shigella isolates.