Transcription:
Shigella Uncovered: What You Need to Know

Melanie Cole (Host): Welcome to It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. Joining me today is Dr. Anirudh Rai. He's a physician at Henry Mayo Newhall, primary care. He's here to tell us about Shigella and what we need to know about this new bacteria, or maybe it's not new, but he's going to tell us.

Dr. Rai, it's always a pleasure to have you on with us today. What is Shigella? Tell us what this is.

Dr. Anirudh Rai (Guest): It's also a pleasure to be here. Thanks for having me. Yeah, so Shigella, oddly enough, actually has reemerged a bit. It's a pretty old organism. It's been around for quite some time. And classically we see it in people who've eaten or eaten food contaminated with it or have at least had water that has had the organism within it.

It's a pretty interesting organism, nonetheless. It's been around for quite some time, and oddly enough, it's pretty potent. Usually it takes about, I would say, at least 10 bacteria at least to get some infectious quality as, uh, associated with it. So it is something that we are always cautious about, something that we would always caution our patients about as well. And hygiene is ideal to keep this from contaminating other folks and other family members as well.

Host: Well, hygiene seems to be the message that you and I whenever we're talking about these infections or parasites or bacterias really make as the key message. But this is one I've never heard of. So tell me where is it mostly found? Is it something we're seeing, you are seeing that we're seeing in this country? Is it something around the world? Where are we seeing this?

Guest: Yeah, that's a great question. Overall, when it comes to the distribution of this kind of bacteria, we do see it in areas that don't have good sanitation. That's usually one of the more prominent areas where this occurs. Usually after natural disasters like earth can, earthquakes and hurricanes, we see this sometimes emerge as well.

And this is outside the US. Within the US we also have those areas that I mentioned before, which are contaminated areas, areas that don't have good water supply, bad sanitation. But right now in our demographics, we're also seeing it in those who have different demographics associated them.

For example, immunosuppressed patients who don't have a good immune system, tend to have more prominence of these organisms, organisms as well. Those who drink well water. We've know that have these organisms as well. And we also found out actually within the last 10 years, particular groups, specifically men who have sex with men, have a higher distribution of this bacteria being emerged as well.

And again, like we mentioned, hygiene is ideal for this because this bacteria spread what we call fecal oral, meaning that it has to be spread via essentially poop, and someone has to ingest particulates of poop . Best way to describe it.

Host: Well, I'd like to talk about transmission, and it does sound like, like c diff to me, similar in that it's a fecally transmitted, I don't know, fecally is a word, but that it's transmitted through fecal matter. So tell us a little bit, I mean like if we're changing a baby diaper, is that a risk? Obviously waters that are not cleaned or runoff water, and as you say, during earthquakes or natural disasters, how is it transmitted? Where are we seeing it the most?

Guest: So fecal oral is one of the primary roots of transmission, but we've learned, with a new strain at least that came out about five to six years ago, that it could also be transmitted sexually as well. So, when you mentioned baby diapers, it is pretty peculiar that we are cautioned that kids back in the day when Shigella was around and we didn't know what caused it, were the primary, essentially, organisms that caused a lot of death in that age group are usually less than five. So it is something that that we are really cautious of when we're seeing in kids. And it can cause massive dehydration because of the symptoms of diarrhea. Hygiene, like we mentioned, fecal, oral daycare settings; those are ideal places where you can have outbreaks that occur as well. And long-term care facilities are another place where again, hygiene has to be adhered to, to prevent spread of this organism. We'll probably talk about this as we come up. It is quite infectious to a certain root as well of patients who have active diarrhea, which is one of the symptoms of it tend to be actively shedding the bacteria and organism, and it could be spread quite easily in that sort of environment.

Host: We'll expand on that Dr. Rai, because you know, that's what we want to know is, how are we spreading it? And obviously we want to look at where it is, or as you said, baby diapers or anything, but tell us a little bit more about that fecal, oral transmission and what we know now.

Guest: Right to get more in depth than that, I guess I'll give you a sort of overview of what happens when you ingest it. So when you ingest this bacteria, you need only a small amount, about 10 to a hundred organisms. You eat it, it goes into your stomach, and then in the stomach goes into your small intestine where it divides and actually replicates and starts invading the local flora.

Then when it goes to the colon is when you start seeing the symptoms occur. Usually you, at this point, the bacteria should be in your system for approximately about three days. They kind of say, so you can ingest and not have symptoms for at least two to three days on average, and then around the third or fourth day you might have symptoms of a high fevers.

You might have stomach pains that are really bad. You might have diarrhea and we'll talk about specifically about, there's two forms of diarrhea you get this bacteria can cause because there's multiple strains. Watery diarrhea is the more, most common cause it's caused by the organism sonnei, which is pretty interesting just because it's about 80% of the organisms that we've found.

So watery diarrhea is one of the main symptoms we see in patients who have this. The offset of that would be you get a lot of bacteria that is shed and diarrhea, as you know, is quite watery. It's very easy to have that particulate, even get a little bit of airborne for small particulates and land on your hand.

Airborne is not the primary transmission, but essentially any area that has diarrhea that is being caused by this organism will have particulates that have this organism around. So any, essentially washing your hands is vital when it comes to any area that has diarrhea associated with this organism.

The other type of diarrhea that we see would be the bloody diarrhea, which is very scary honestly, and people get quite flustered when they see it. And the same sort of idea, but the organism that's caused by that is a bit more lethal. So we do want to keep an eye on those kind of symptoms. And ideally, like we mentioned, hygiene and washing hands is vital when it comes to preventing spread and what, like you mentioned, baby diapers always wash your hands afterwards.

Long care facilities where you're meeting patients who have immunosuppressed or who can't control their bowels as well. Always have good clean hygiene, even at home as well. It would be ideal to have hygiene that's just washing your hands persistently in those sort of environments to prevent spread.

Host: Well then Dr. Rai, if somebody comes up with these symptoms, as you've described, diarrhea for a few days, watery or bloody, a fever, stomach pains. Again, I'm bringing up C. diff because it sounds like the same. If you're testing somebody, why would you test for Shigella instead of C. Diff? How do you differentiate the symptoms? They sound exactly the same.

Guest: That's a great question. C. diff particularly is a nasty organism. And we typically see that after someone's ingested something that has messed with the good bacteria in your gut. So usually patients who've taken antibiotics prior are more prone to this sort of gut change, which leads to the formation of C. diff being essentially housed in your gut and that causes symptoms, diarrhea, fevers, chills, and it is similar, but when it comes to Shigella, the clinical symptoms and the history is a little bit different.

Usually we see of a history of either there's someone who's traveled in an area that's endemic to it, who's been in an area that has this organism prior to it. Who are in settings that have this organism more prone, which is gonna be again, daycares, long term care facilities. So these are more of a clinical symptom, which kind of help to differentiate between C. diff and Shigella, and that's vital when it comes to treatment as well. Just because the treatment for C. diff is different than treatment for Shigella.

Host: Then speak about treatment for Shigella. We'll do another one on C. diff at another time. But tell us the treatment. What are we looking to do right now?

Guest: Ideally about 80%, like I mentioned prior, is caused by Shigella sonnei, which is just watery diarrhea. And typically the symptoms resolve within four to five days or so. But that could expand if you're re- ingesting or getting reintroduced to the organism. So about 80% of the time it is self resolving.

But interestingly enough, about 10 years or so, a new strain of Shigella did come out, which we noted was resistant to some of the antibiotics we mentioned. And typically according to the IDSA, which is the Infectious Disease Society, they suggest that if someone has this bacteria and they're having this diarrhea, typically you don't treat it with antibiotics because it resolves on its own about 80% of the time.

Now that number is decreasing here and there. But about that 20%, or I would say 25% of patients who have the bloody diarrhea, the fever, that's not going away, after a time, we would recommend antibiotics and that typically would be done in a setting that's either you're seeing your doctor, getting a good sample of your stool and culturing it to kind of see, okay, why is this organism still here or what's causing it?

And about I would say 10 years, we found out that a lot of the Shigella has become, I would say of actually not a lot, 25% of it has become resistant to a lot of the medication we used to give for Shigella. So it is something that we're a bit more cautious about and anytime we're suspicious of it, we would actually go to the next step, which is going to be stool cultures, getting you on the right antibiotics if you absolutely need it. But ideally this resolves on it.

Host: Ideally. Wow. You know, this is so interesting when you come on and you tell us about these new bacteria and new infections, and you're so educational and informative, Dr. Rai. So, what do you want us to know about antimicrobial resistance and resistant shigella? And tell us a little bit about the CDC. When they're talking about a public health concern and the US being a hotspot, whether it's Shigella or something else, we hear about this antibiotic stewardship and resistance. Kind of put that together for us a little bit.

Guest: Yeah, that's a pretty vast topic, and it's something that we are learning more and more about. You mentioned the drug resistance part. Just to give you an idea of antimicrobial resistance. It's more of like a, I would say the best way to describe it would be almost a, I guess, the Cold War race where one party tries to advance the other party, it's almost in that sort of battle we see this. We see the organism, if we give them an antibiotic, they learn to adapt to it and get resistant to it, and then we get a better antibiotic and you have this race that we're going for. Ideally as physicians, we want to be clear as to when to give antibiotics. Sometimes giving antibiotics to a patient that doesn't need it is more harmful than good, even though it may seem like a good thing at that time.

So just something to be aware of. And we see this in Shigella. We've noted at least for the most part, that Shigella, ideally you need azithromycin, which is a classic Z-Pak, that can be helpful for this too. We know that fluoroquinolones like Ciprofloxacin i s ideally something that we used back in the day that was clear cut, easy.

You give this to them, people are good to go. But now we found out that this organism is adapting and learning to actually avoid these certain antibiotics, and we've learned to actually identify some of the bacteria that's causing it. We're still learning more about it. In fact, I think it was about a week ago where the CDC did release more information about what we learned about this Shigella resistance, that we're seeing in the US. I think in 2015 and 17, we did see an outbreak in San Diego actually, where they had this resistant strain. And if we are thinking about that, we have to actually report this to the CDC. It is a reportable sort of condition that we want to keep an eye on for it because it's very easy to spread it around.

Like we mentioned, fecal oral. It's a very easy to get that out of hand. And to give you a bit more information about that, well, we'll talk about that later, if anything. But ideally for our stewardship, I would say always be cautious and cognizant about when to give antibiotic for Shigella per se, because now a day Shigella is becoming smarter within quotes.

Host: Well, it seems like all the bacteria and things are getting smarter, and it's important that we don't ask our physicians for antibiotics at every little sniffle, right? We really have to look at it, plus what's in our food and the antibiotics that are all around us. But how does the CDC monitor bacteria like this, Dr. Rai?

Guest: Usually it's going to be reportings. The CDC has implementation with the lab that are pretty much within their vicinity. And anytime you grow a certain bacteria or a culture that is indicative of something that needs to be reported, it would go to the CDC, and the CDC would be observing it, monitoring it, and they would order the appropriate test to get further information and they would compile into the epidemiological sort of logs.

And with that, they would give us information and that's what actually they did about a week ago about this particular organism and that's how we got to the point where the information I'm telling you right now about this new resistant strain, about this new stuff we're learning, about the outbreaks that we're seeing here and there and to how to prevent it too, which is ideally, again, hygiene and being cognizant as physician as to when to order certain things and when to give antibiotics.

Host: Always so interesting and educational. Dr. Rai, wrap it up, the broader implications of Shigella and other bacteria like it. I'd like you to just summarize in terms of public health, what you would like us to know about preventing the spread and recognizing the symptoms so that we can get treatment if we need it.

Guest: Absolutely. So Shigella, in summary is an organism that's been around for decades and the symptoms we see are something that we described as an abdominal pain, fevers, diarrhea, which could be really bloody or very watery. And it takes typically about three to four days when you ingest it, when you have these symptoms.

And typically it resolves in five to seven days. So you, it is self- resolving about majority of the time, about 70, 80%. When the watery diarrhea is present and you can't replenish your electrolytes, you would go to the hospital and get treatment via antibiotics. But then unfortunately now, if those bacteria's getting smarter, where it's learning to avoid these antibiotics, just because of the nature of this organism, and, we are becoming more cognizant, we're becoming more aware about how to prevent the use of inappropriate antibiotics.

But ideally, the best way to prevent it is to actually at best cure is prevention is what I was told. So the best way to prevent it would be to have clean hygiene, wash your hands at all times. If you do have symptoms of it or you do have been diagnosed for it, ideally you should be essentially, isolated or somewhat, I wouldn't say quarantined, until the symptoms have resolved, particularly diarrhea. After which you would definitely be able to continue your normal lifestyle with heavy hygiene managements and continue monitoring those symptoms and making sure no one in your environment or your direct family members have those symptoms as well. So prevention is the best cure. And with Shigella, we learn that ideally.

Host: Thank you so much. As always, what a great guest you are, Dr. Rai. Thank you so much for joining us today and telling us all about this and what we can do to hopefully prevent it. And if you need a primary care physician, please call 661-200-1710, and for more information, you can also visit our website at henrymayo.com.

Also, we have a free health information library at library.henrymayo.com where there's so much reliable information that you can get. You can trust the information that you're getting from Henry Mayo Newhall Hospital. That concludes this episode of It's Your Health Radio with Henry Mayo Newhall Hospital.

I'm Melanie Cole. Thanks so much for joining us today.