BACILLARY DYSENTERY

I. DEFINITION

a. The word dysentery refers to any case of infectious bloody diarrhoea, a scourge that kills as
many as 700,000 people worldwide every year. Such condition is the body’s response to an
unwanted visitor in the digestive system. These culprits include a parasitic amoebae or a
number of bacteria, including Shigella.
b. Bacillary dysentery is an infectious disease of the intestinal tract caused by bacteria of the
genus Shigella, which is commonly a food-borne disease.
c. Shigella was discovered over a 100 years ago by a Japanese scientist named Shiga, for whom
they are named.
d. It grows best at 37°C and can grow between 6 and 47°C.
e. In general they survive best at low temperatures (refrigeration and sub-zero).
f. They can survive heating to 63°C for 2 to 3 minutes but are rapidly killed through heating to
temperatures above 65°C.
g. They generally survive better in low moisture foods. Can survive in butter for more than 100
days at 4°C and 20°C, in cheese and herbs for 50 days,
orange juice for 1 to 6 days, salad with mayonnaise for 19 to 32 days and can survive in soil.
h. They have been shown to grow on sliced fruits at room temperature.
i. It grows through a pH range of 4.8 to 9.3 and can grow in the presence or absence of oxygen.
j. Shigella is one of the most acid resistant food-borne pathogens and can survive at pH 2.5 to 3
for 2 hours.
k. There are four Shigella species, all of which causes dysentery: S. dysenteriae, S. flexneri, S.
boydii and S. sonnei.
i. S. dysenteriae , also known as “GROUP A”, is a species of bacteria that causes severe
diarrhea (shigellosis), often referred to as "dysentery." It is most common in developing
countries or areas where people live in close contact, such as refugee camps. According
to the Centers for Disease Control and Prevention, about 14,000 cases occur each year
in the United States. Shigella dysenteriae type 1 is the virulent form of shigella that
causes epidemics.
ii. S. flexneri, also known as “Group B” Shigella, accounts for all the rest.
1. This Shigella species is the most common cause of Shigellosis in the world.
2. Under this species, the severity is variable depending on the underlying health
and status of an individual. Usually, the young and old tend to be more severely
affected.
iii. S. boydii, also known as “GROUP C is mostly found in tropical regions of the world. It is
the least common amongst the four types of Shigella. Infections produced can be both
serious and fatal because they typically occur in 3 rd world countries where medication is
not prevalent
iv. S. sonnei, also known as “Group D” Shigella, accounts for over two-thirds of Shigellosis
in the United States.
l. Poor sanitation plays a huge role in the transmission of the bacteria.
m. Especially among children, Shigella bacteria can be carried to the mouth on dirty fingers that
have touched items soiled with feces, including dirty diapers, toilets and bathroom fixtures.
n. Epidemics of bacillary dysentery can sweep through entire villages, cities, or regions. Every
year, bacillary dysentery kills roughly six times as many people as amoebic dysentery does.

II. SYNONYMS

a. Shigellosis
b. Enteritis
c. Gastroenteritis

III. MORPHOLOGICAL DESCRIPTION

 a. The causative agent, Shigella, is a gram-negative straight rod, non-motile and non-spore
forming rod-shaped bacterium closely related to Escherichia Coli and Salmonella.
b. Shigella flexneri is physiologically similar to Shigella dysenteriae, Shigella boydii, and
Escherichia coli. It causes infection via a Type III secretion system. The secretion system acts
as a "biological syringe" that injects a protein called Ipa into epithelial cells. Ipa induces the
endocytosis of the bacterium and the subsequent lysis of the vacuolar membrane that releases
the bacterium into the cytoplasm, where the bacterium proliferates
T3SS – a protein appendage found in several gram negative bacteria. This
structure is used to secrete proteins that help the bacteria infect multicellular,
eukaryotic organisms. The proteins are secreted directly from the bacterial cell
into the cells of the organism to be infected (the host) using a needle-like structure
which is the hallmark of the T3SS.

IV. MODE OF TRANSMISSION

a. Humans and the higher primates are the only reservoir of this organism.
b. Fecal-oral and person-to-person transmission from infected individuals can take place
(especially during recovery).
c. In many countries food and water-borne transmission are more significant with the majority of
meals implicated having been contaminated by a food handler.
d. Water can be contaminated by sewage.
e. Flies carrying sewage or feces can contaminate food

V. SIGNS AND SYMPTOMS

a. SIGNS:
Diarrhoea(up to 20 or 30 watery bowel movements in 1 day and tends to be severe in
children, with sudden onset.)
i. Melaena
- the production of dark sticky faeces containing partly digested blood, as a result of
internal bleeding or swallowing of blood.
ii. Dehydration

b. SYMPTOMS:
i. Chills
ii. Nausea or vomiting
iii. Loss of appetite
iv. Muscle aches or pain
v. Tenesmus – mucus in stools
vi. Stomach cramps
vii. Fever
viii. Flatulence

VI. DIAGNOSIS/LAB TESTS

a. Examination of the stool sample is the most important laboratory test. A single specimen should
be submitted for a Wright’s stain for leukocytes, occult blood, Sudan stain for fat, and selected
bacterial cultures.
b. Confirmatory tests for the presence of Shigella
c. Serological identification of culture isolated from stool.
d. Sensitivity tests may also be performed.
o SPECIFIC TESTS
o Specimens
 fresh stool, mucus flecks, rectal swab – culture
 serum – serology
 o Culture
 EMB or MacConkey – colorless colonies
 Salmonella-Shigella agar – colorless colonies without black centers
 Hektoen enteric agar – green colonies without black centers

o Biochemical tests
 TSIA – acid butt, alkaline slant, no gas, no H2S
 MR positive
 Citrate – negative
 ODC – negative
 ADH – negative
 Deaminase (phenylalanine) – negative
 Urease – negative
 Carbohydrate fermentation
 sucrose – negative
 salicin – negative
 adonitol – negative
 dulcitol – negative
 D-mannose – positive

o Slide agglutination by specific Shigella antisera

Reaction Dysenteriae Flexneri Boydii Sonnei
Fermentation
of:
Lactose - - - +
Mannitol - + + -
ODC - - - +
ONPG - - - +

VII. PERIOD OF COMMUNICABILITY

a. The disease is communicable for as long as the infected person excretes Shigella in his/her
stool. Shigella are present in the diarrheal stools of infected persons while they are sick and for
a week or two afterwards. Asymptomatic carriers have the ability to transmit disease This
usually lasts for about four weeks from onset of illness. Effective antibiotic treatment has been
shown to decrease the shedding period to a few days.

VIII. INCUBATION PERIOD

a. Incubation period can vary from 12-96 hours, but is usually 1-3 days. It can be up to 1 week for
S. dysenteriae.

IX. PROGNOSIS

a. Usually curable in 7 days with treatment. Most Shigella infections are mild and don't require
drastic treatment.  In a severe attack, excessive dehydration can be fatal (especially in infants
and young children) if treatment is unsuccessful.

X. TREATMENT

SUPPORTIVE
a. Treatment includes replacement of fluids and salts, low-residue diet and medications(if
indicated).
b. Be sure to increase fluid intake
c. Use of a heating pad or hot-water bottle on the abdomen may relieve pain
 SPECIFIC
a. Although some experts say that bloody diarrhea should not be treated with antibiotics, most
physicians recommend prompt treatment of shigellosis with trimethoprim-sulfamethoxazole(TMP-SMZ).
b. The current antibiotics of choice are
i. Trimethoprim-sulfamethoxazole – blocks sequential microbial folate synthesis
ii. ciprofloxacin - Antimicrobial drug that interferes with nucleic acid synthesis by blocking
synthesis of nucleotides, inhibiting replication, or stopping transcription and
iii. norfloxacin is a quinolone antibiotic. It can kill certain bacteria or stop their growth.
c. For the treatment of enteritis caused by susceptible strains of Shigella flexneri and Shigella
sonnei when antibacterial therapy is indicated.
d. Antidiarrheal agents such as loperamide (Imodium*) or diphenoxylate with atropine (Lomotil*)
are likely to make the illness worse and should be avoided.
e. If Shigella is suspected and it is not too severe, the doctor may recommend letting it run its
course -- usually less than a week. The patient will be advised to replace fluids lost through
diarrhea. If the Shigella is severe, the doctor may prescribe antibiotics, such as ciprofloxacin or
TMP-SMX (Bactrim). Unfortunately, many strains of Shigella are becoming resistant to common
antibiotics, and effective medications are often in short supply in developing countries. If
necessary, a doctor may have to reserve antibiotics for those at highest risk for death, including
young children, people over 50, and anyone suffering from dehydration or malnutrition.

XI. PROPHYLACTIC MEASURES/ PREVENTIVE MEASURES

a. Food that is known to be implicated in the spreading of the disease must be removed from
consumption.
b. There is no vaccine to protect against shigellosis. To prevent the spread of Shigella bacteria,
you should:
c. Avoid contact with infected persons.
d. Keep flies from contaminating food.
e. Good hygiene and a little common sense are the keys to avoiding dysentery. If you're visiting or
living in an area with poor sanitation, be especially wary of the water. Simply brushing your teeth
with tap water or tossing a couple of ice cubes in a drink can be enough to make you sick. In
many areas, the only safe beverages are boiled water, canned or bottled sodas, beer, wine, and
tea and coffee (made with boiled water). If it's not possible to boil your water, treat it with
chemical disinfectants such as iodine or chlorine. For extra protection, strain the water through
an "absolute 1 micron" filter (available at camping supply stores) before adding the disinfectant.
f. In many places, the food can be as risky as the water. You should be especially suspicious of
salads, uncooked fruits and vegetables, unpasteurized milk, raw meat, shellfish, and any foods
sold by street vendors. In general, fruits that you peel yourself and hot meals are safer choices.
“boil it, cook it, peel it, or forget it.”
g. If you have the infection, you can protect others around you by washing your hands regularly
with soap and water, especially after using the toilet, after changing diapers, and before
preparing food.
h. Immerse soiled clothes and bedclothes in covered buckets of soap and water until they can be
boiled
i. Dispose of soiled diapers in closed-lid garbage cans.
j. Avoid drinking pool water