今日の臨床サポート

赤痢菌性胃腸炎

著者: 小倉翔 虎の門病院 臨床感染症科

監修: 大曲貴夫 国立国際医療研究センター

著者校正/監修レビュー済:2022/08/03
患者向け説明資料

概要・推奨   

  1. 赤痢菌性胃腸炎は抗菌薬治療により発熱や下痢の持続期間を2日程度短縮できることが期待されるため、診断された患者には抗菌薬治療が強く推奨される(推奨度1)
  1. 日本における赤痢菌性胃腸炎に対する第1選択薬としてはフルオロキノロンがおそらく推奨される(推奨度2)
  1. 治療期間については、3~5日がおそらく推奨される(推奨度2)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
小倉翔 : 未申告[2022年]
監修:大曲貴夫 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、加筆修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 赤痢菌性胃腸炎は赤痢菌(Shigella species)によって引き起こされる消化管感染症である。
  1. 症状からカンピロバクターや非チフス性サルモネラなどの他の細菌性腸炎と鑑別することは困難である。
  1. テネスムスや膿粘血便など、赤痢菌性胃腸炎を疑うことができることはあるが、便培養なしに診断することは困難である。
  1. 赤痢菌には4種類の血清型がある。
  1. Shigella dysenteriae(group A)
  1. Shigella flexneri(group B)
  1. Shigella boydii(group C)
  1. Shigella sonnei(group D)
  1. 病原性が強いのはShigella dysenteriaeであるが、国内の疫学はほとんどがShigella sonneiShigella flexneriで占められる。
  1. 感染症の予防及び感染症の患者に対する医療に関する法律(感染症法)により三類感染症として直ちに届け出る義務がある。
  1. かつては国内でも流行していた感染症であり、戦後には年間5~10万人以上の患者が報告されていた。しかし、国内の衛生環境の改善などにより1960年代半ばから患者数は減少し始め、2000年以降は年間500~1,000人程度の発生となった。国立感染症研究所における感染症発生動向調査によると[1]、2010年以降は年間300例を下回っている。最新の公表されたデータでは、無症状病原体保有者を含めると、2018年268例、2019年140例、2020年87例となっている。2010〜2021年の期間における平均届け出数は164例/年であった。
  1. 推定感染地は58%を国外が占めていた。国外の推定感染地はアジアが多く、全体の75%を占めていた。国別ではインド、インドネシア、フィリピンの順に多かった。ただし、輸入例の実態が分かりづらく、実数はこれより多い可能性がある。特に、直近に海外渡航歴のある患者の診断において注意を要する。
問診・診察のポイント  
  1. 糞口感染する。少ない菌量でも感染が成立するため、感染力が高い。

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文献 

Prince Rh Christopher, Kirubah V David, Sushil M John, Venkatesan Sankarapandian
Antibiotic therapy for Shigella dysentery.
Cochrane Database Syst Rev. 2010 Aug 4;(8):CD006784. doi: 10.1002/14651858.CD006784.pub4. Epub 2010 Aug 4.
Abstract/Text BACKGROUND: Shigella dysentery is a relatively common illness and occasionally causes death, worldwide. Mild symptoms are self-limiting but in more severe cases, antibiotics are recommended for cure and preventing relapse. The antibiotics recommended are diverse, have regional differences in sensitivity, and have side effects.
OBJECTIVES: To evaluate the efficacy and safety of antibiotics for treating Shigella dysentery.
SEARCH STRATEGY: In June 2009 we identified all relevant trials from the following databases: Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, issue 4), MEDLINE, EMBASE, LILACS and the metaRegister of Controlled Trials (mRCT). We also checked conference proceedings for relevant abstracts, and contacted researchers, organizations, and pharmaceutical companies.
SELECTION CRITERIA: Randomized controlled trials of antibiotics for Shigella dysentery.
DATA COLLECTION AND ANALYSIS: Four authors, working in pairs, independently assessed trial eligibility, methodological quality, and extracted data. We calculated risk ratios (RR) with 95% confidence intervals (CI) for dichotomous data, and used the random-effects model for significant heterogeneity. We explored possible sources of heterogeneity, when present, in subgroup analyses of participant age and percentage of participants with confirmed Shigella infection.
MAIN RESULTS: Sixteen trials (1748 participants), spanning four decades and with differing sensitivity to Shigella isolates, met the inclusion criteria. Seven were judged to be at risk of bias due to inadequate allocation concealment or blinding, and 12 due to incomplete reporting of outcome data. Limited data from one three-armed trial of people with moderately severe illness suggest that antibiotics reduce the episodes of diarrhoea at follow-up (furazolidone versus no drug RR 0.21, 95% CI 0.09 to 0.48, 73 participants; cotrimoxazole versus no drug RR 0.30, 95% CI 0.15 to 0.59, 76 participants).There was insufficient evidence to consider any class of antibiotic superior in efficacy in treating Shigella dysentery, but heterogeneity for some comparisons limits confidence in the results. All the antibiotics studied were safe. There was inadequate evidence regarding the role of antibiotics in preventing relapses.
AUTHORS' CONCLUSIONS: Antibiotics reduce the duration of Shigella dysentery.Regularly updated local or regional antibiotic sensitivity patterns to different species and strains of Shigella are required to guide empiric therapy. More trials adhering to standard guidelines are required to evaluate the role of antibiotics in the treatment of severe forms of Shigella dysentery and in groups who are at high risk of complications.

PMID 20687081
K C Haltalin, J D Nelson, R Ring, M Sladoje, L V Hinton
Double-blind treatment study of shigellosis comparing ampicillin, sulfadiazine, and placebo.
J Pediatr. 1967 Jun;70(6):970-81.
Abstract/Text
PMID 5338090
H L DuPont, R B Hornick
Adverse effect of lomotil therapy in shigellosis.
JAMA. 1973 Dec 24;226(13):1525-8.
Abstract/Text
PMID 4587313
B P Petruccelli, G S Murphy, J L Sanchez, S Walz, R DeFraites, J Gelnett, R L Haberberger, P Echeverria, D N Taylor
Treatment of traveler's diarrhea with ciprofloxacin and loperamide.
J Infect Dis. 1992 Mar;165(3):557-60.
Abstract/Text To determine the efficacy of loperamide given with long- and short-course quinolone therapy for treating traveler's diarrhea, 142 US military personnel were randomized to receive a single 750-mg dose of ciprofloxacin with placebo, 750 mg of ciprofloxacin with loperamide, or a 3-day course of 500 mg of ciprofloxacin twice daily with loperamide. Culture of pretreatment stool specimens revealed campylobacters (41%), salmonellae (18%), enterotoxigenic Escherichia coli (ETEC, 6%), and shigellae (4%). Of the participants, 87% completely recovered within 72 h of entry. Total duration of illness did not differ significantly among the three treatment groups, but patients in the 3-day ciprofloxacin plus loperamide group reported a lower cumulative number of liquid bowel movements at 48 and 72 h after enrollment compared with patients in the single-dose ciprofloxacin plus placebo group (1.8 vs. 3.6, P = .01; 2.0 vs. 3.9, P = .01). While not delivering a remarkable therapeutic advantage, loperamide appears to be safe for treatment of non-ETEC causes of traveler's diarrhea. Two of 54 patients with Campylobacter enteritis had a clinical relapse after treatment that was associated with development of ciprofloxacin resistance.

PMID 1538160
G S Murphy, L Bodhidatta, P Echeverria, S Tansuphaswadikul, C W Hoge, S Imlarp, K Tamura
Ciprofloxacin and loperamide in the treatment of bacillary dysentery.
Ann Intern Med. 1993 Apr 15;118(8):582-6.
Abstract/Text OBJECTIVE: To compare the safety and efficacy of loperamide plus ciprofloxacin with those of ciprofloxacin alone in the treatment of bacillary dysentery.
DESIGN: Double-blind, placebo-controlled, randomized clinical trial.
SETTING: Hospital in Thailand.
PARTICIPANTS: Eighty-eight adults with dysentery seeking medical care between November 1990 and February 1992. Patients who had received prior antibiotics or antimotility drugs were excluded.
INTERVENTION: All 88 patients with dysentery were treated with ciprofloxacin, 500 mg twice daily for 3 days. Forty-two of these patients were randomly assigned to receive loperamide, a 4-mg initial dose followed by 2 mg after every loose stool (as many as eight caplets [16 mg] daily), and 46 were randomly assigned to receive placebo.
MEASUREMENTS: Stools were collected daily until resolution of diarrhea and again after 10 days. The time to passage of the last unformed stool, number of unformed stools, and symptoms were recorded after treatment.
RESULTS: Shigella or enteroinvasive Escherichia coli (53%), Vibrio parahaemolyticus (16%), and Salmonella (7%) were the most common bacterial enteric pathogens identified in 88 patients with dysentery. In patients infected with Shigella or enteroinvasive E. coli, the median duration of diarrhea was 19 hours (25th to 75th percentiles, 6 to 42 hours) for those receiving loperamide plus ciprofloxacin compared with 42 hours (21 to 46 hours) for those receiving ciprofloxacin alone (P = 0.028). The median number of diarrheal stools for those receiving ciprofloxacin and loperamide was 2.0 (1 to 5 stools) compared with 6.5 (2 to 9 stools) for those receiving ciprofloxacin alone (P = 0.016). None of the participants had a temperature greater than 38 degrees C after 24 hours of treatment. None of the patients was infected with the same bacterial enteric pathogen more than 1 day after receiving treatment.
CONCLUSIONS: Loperamide decreases the number of unformed stools and shortens the duration of diarrhea in dysentery caused by Shigella in adults treated with ciprofloxacin.

PMID 8452323
L Clifford McDonald, Dale N Gerding, Stuart Johnson, Johan S Bakken, Karen C Carroll, Susan E Coffin, Erik R Dubberke, Kevin W Garey, Carolyn V Gould, Ciaran Kelly, Vivian Loo, Julia Shaklee Sammons, Thomas J Sandora, Mark H Wilcox
Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).
Clin Infect Dis. 2018 Mar 19;66(7):e1-e48. doi: 10.1093/cid/cix1085.
Abstract/Text A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.

PMID 29462280
Kenji Hirose, Jun Terajima, Hidemasa Izumiya, Kazumichi Tamura, Eiji Arakawa, Nobuko Takai, Haruo Watanabe
Antimicrobial susceptibility of Shigella sonnei isolates in Japan and molecular analysis of S. sonnei isolates with reduced susceptibility to fluoroquinolones.
Antimicrob Agents Chemother. 2005 Mar;49(3):1203-5. doi: 10.1128/AAC.49.3.1203-1205.2005.
Abstract/Text We performed susceptibility testing with Shigella sonnei isolates from imported and domestic cases of infection in Japan during 2001 and 2002. Some S. sonnei isolates were resistant to nalidixic acid, tetracycline, and trimethoprim-sulfamethoxazole. Most of the nalidixic acid-resistant strains showed reduced susceptibility to fluoroquinolones but did not show fluoroquinolone resistance.

PMID 15728928
Japanese Association for Infectious Disease/Japanese Society of Chemotherapy, JAID/JSC Guide to Clinical Management of Infectious Disease/Guideline-preparing Committee, Intestinal Infections Working Group (WG), Kenji Ohnishi, Yusuke Ainoda, Akifumi Imamura, Sentaro Iwabuchi, Masumi Okuda, Takashi Nakano
JAID/JSC Guidelines for Infection Treatment 2015-Intestinal infections.
J Infect Chemother. 2018 Jan;24(1):1-17. doi: 10.1016/j.jiac.2017.09.002. Epub 2017 Oct 3.
Abstract/Text
PMID 28986191
Abstract/Text OBJECTIVE: To determine whether a single dose, or 2 doses, of ciprofloxacin are as effective as 5-day, 10-dose therapy for the treatment of shigellosis in adult men who are moderately to severely ill.
DESIGN: Randomized, double-blind clinical trial.
SETTING: A diarrhea treatment center in the capital city of a developing country, Bangladesh.
PATIENTS: A total of 128 adult men with dysentery of less than 96 hours duration. All had Shigella organisms isolated from a culture of stool.
INTERVENTIONS: Patients were randomly assigned to receive either a single 1-gram dose of ciprofloxacin at admission to the study (single-dose group; n = 40), a 1-gram dose of ciprofloxacin at admission and 24 hours later (2-dose group; n = 43), or 500 mg of ciprofloxacin every 12 hours for 5 days (10 dose group; n = 35). All patients were hospitalized for 6 days.
MEASUREMENTS: Stools were collected individually; their character and consistency were recorded and cultured daily. A physical examination and recording of symptoms were done daily, and the temperature was measured every 4 hours. Therapy was considered to have failed in patients who did not have improvement in the signs and symptoms of dysentery after 72 hours of therapy or in patients who on study day 5 had more than nine stools, or more than two watery stools, or were febrile.
RESULTS: There were no treatment failures in the 78 patients infected with species of Shigella other than Shigella dysenteriae type 1. Among the 40 patients infected with S. dysenteriae type 1, treatment failed in 4 of the 10 patients who received single-dose therapy, 2 of the 15 patients who received 2-dose therapy, and none of the 15 patients who received 10-dose therapy (P = 0.017, single-dose therapy group compared with 10-dose group; P = 0.15 for the single-dose group compared with the 2-dose group; P > 0.2 for the 2-dose group compared with the 10-dose group).
CONCLUSIONS: A single 1-gram dose of ciprofloxacin is effective therapy for patients infected with species of Shigella other than S. dysenteriae type 1. Single-dose therapy is inferior to 10-dose therapy for treating patients infected with S. dysenteriae type 1.

PMID 1416574

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