{"id":10365,"date":"2025-03-01T14:07:46","date_gmt":"2025-03-01T19:07:46","guid":{"rendered":"https:\/\/dhss.delaware.gov\/dph\/dhan388\/"},"modified":"2025-03-02T00:53:57","modified_gmt":"2025-03-02T05:53:57","slug":"dhan388","status":"publish","type":"page","link":"https:\/\/dhss.delaware.gov\/dph\/php\/alerts\/dhan388\/","title":{"rendered":"php\/alerts\/dhan388 ~  Division of Public Health  &#8211; Delaware Health and Social Services &#8211; State of Delaware"},"content":{"rendered":"<div data-swiftype-index=\"true\">\n\n\n\n  <br>\n\n\n\n  <div class=\"container\" id=\"main_header\"> \n\n    <!-- BEGIN readspeaker div -->\n\n    <div class=\"rs_skip rsbtn rs_preserve\" id=\"readspeaker_button1\">\n\n      <a accesskey=\"L\" class=\"rsbtn_play\" href=\"https:\/\/app-na.readspeaker.com\/cgi-bin\/rsent?customerid=7262&#038;lang=en_us&#038;readid=main_content&#038;url=https:\/\/dhss.delaware.gov\/dph\/php\/alerts\/dhan388.html\" title=\"Listen to this page using ReadSpeaker\">\n\n        <span class=\"rsbtn_left rsimg rspart\"><span class=\"rsbtn_text\"><span>Listen<\/span><\/span><\/span>\n\n        <span class=\"rsbtn_right rsimg rsplay rspart\"><\/span>\n\n      <\/a>\n\n    <\/div>\n\n    <!-- END readspeaker div -->\n\n\n\n    \n\n    <header class=\"pull-left\">\n\n      <h1>Delaware Health Alert Network #<!--[type=EDIT name=\"DHAN Number\"]-->388 <!--[END]--> <\/h1>\n\n      <h2> <!--[type=EDIT name=\"DHAN Date\"]-->June 11, 2018 2:34 pm <!--[END]--> <\/h2>\n\n    <\/header>\n\n  <\/div><br>\n\n \n\n  <div class=\"container\">\n\n    <div class=\"row\">\n\n      <div class=\"col-md-3\" id=\"leftCol\">\n\n        <div class=\"panel-group\" id=\"accordion\">\n\n          <div class=\"panel sectionmenu_panel\">\n\n            <div class=\"panel-heading\">\n\n              <p class=\"panel-title\"><a class=\"agency_nav\" data-parent=\"#accordion\" data-toggle=\"collapse\" href=\"#collapseOne\"><strong><i class=\"fa fa-align-justify fa-fw\"><\/i> Public Health Menu<\/strong><\/a><\/p>\n\n            <\/div>\n\n\n\n            <div class=\"panel-collapse collapse in\" id=\"collapseOne\">\n\n              <div class=\"panel-body\" id=\"clf_nav\">\n\n                  <ul class=\"nav nav-stacked nav-pills-clf\" id=\"agency_sidebar\">\n    <li><a href=\"\/dph\/\"><h2>Home <i class=\"fa fa-home fa-fw\"><\/i><\/h2><\/a><\/li>\n    <li class=\"toplevel\"><a data-parent=\"#agency_sidebar\" data-toggle=\"collapse\" href=\"#HomeMenu\"><h2>About <i class=\"fa fa-caret-right fa-fw\"><\/i><\/h2><\/a>\n      <ul class=\"panel-collapse collapse\" id=\"HomeMenu\">\n        <li><a href=\"\/dph\/about.html\">About DPH<\/a><\/li>\n        <li><a href=\"\/dph\/sections.html\">Sections &#038; 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This is a follow-up to HAN 401: CDC Recommendations for Diagnosing and Managing \n\n\n\n\n\n<em>Shigella<\/em> Strains with Possible Reduced Susceptibility to Ciprofloxacin.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n<p>The Centers for Disease Control and Prevention (CDC) continues to identify an increasing number of <em>Shigella<\/em> \n\n\n\n\n\nisolates that test within the susceptible range for the fluoroquinolone antibiotic ciprofloxacin (minimum inhibitory \n\n\n\n\n\nconcentration [MIC] values of 0.12-1 \u00b5g\/mL), but harbor one or more resistance mechanisms. CDC remains concerned \n\n\n\n\n\nabout potential clinical failures with fluoroquinolone treatment.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n<p>Clinicians should carefully monitor patients with <em>Shigella<\/em> infections who require fluoroquinolone treatment \n\n\n\n\n\nand report any possible treatment failures. If treatment failure is suspected, clinicians should submit a stool specimen \n\n\n\n\n\nfor antimicrobial susceptibility testing and consider consulting an infectious disease specialist to identify best treatment \n\n\n\n\n\noptions.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n<p>CDC has also identified an increasing number of <em>Shigella<\/em> isolates with azithromycin MICs that exceed the \n\n\n\n\n\nepidemiological cutoff value (ECV), and is requesting reports of any possible treatment failures occurring among patients \n\n\n\n\n\nwith <em>Shigella<\/em> infections treated with azithromycin (see below).<\/p>\n\n\n\n\n\n\n\n\n\n\n\n<p>Shigellosis is a nationally notifiable condition; all cases should be reported to local health departments.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n<h2>Recommendations for Clinicians<\/h2>\n\n\n\n\n\n<ol>\n\n\n\n\n\n<li>\u00a0If antibiotic treatment is necessary, monitor patients carefully.<\/li>\n\n\n\n\n\n<li>\u00a0If you identify or receive a report of a patient with <em>Shigella<\/em> infection and possible fluoroquinolone \n\n\n\n\n\nor azithromycin treatment failure:\n\n\n\n\n\n<ul>\n\n\n\n\n\n<li>\u00a0Consider consulting an infectious disease specialist to identify other treatment options, because some \n\n\n\n\n\n<em>Shigella<\/em> isolates with susceptible ciprofloxacin MICs may harbor one or more quinolone resistance mechanisms.<\/li>\n\n\n\n\n\n<li>\u00a0Contact your local health department to coordinate reporting treatment failure information. This information \n\n\n\n\n\nshould be reported to CDC at <a href=\"mailto:EntericBacteria@cdc.gov\">EntericBacteria@cdc.gov<\/a>.<\/li>\n\n\n\n\n\n<li>\u00a0Collect a stool specimen for culture, and work with your clinical microbiology laboratory to submit for \n\n\n\n\n\nadditional antimicrobial susceptibility testing.<\/li>\n\n\n\n\n\n<li>\u00a0Request that your laboratory expedite submission of the <em>Shigella<\/em> isolate to your state public health \n\n\n\n\n\nlaboratory. Your state laboratory should notify CDC at <a href=\"mailto:EntericBacteria@cdc.gov\">EntericBacteria@cdc.gov<\/a> \n\n\n\n\n\nto coordinate additional laboratory testing and\/or shipment of the isolate to CDC.<\/li>\n\n\n\n\n\n<\/ul>\n\n\n\n\n\n<\/li>\n\n\n\n\n\n<\/ol>\n\n\n\n\n\n\n\n\n\n\n\n<h2>Background<\/h2>\n\n\n\n\n\n<p>In April 2017, CDC identified an increase in the percentage of <em>Shigella<\/em> isolates in the United States with MIC \n\n\n\n\n\nvalues of 0.12\u20131 \u00b5g\/mL for the fluoroquinolone antibiotic ciprofloxacin; this percentage continues to rise. \n\n\n\n\n\nPreliminary surveillance data from 2016 show that 8.2% of <em>Shigella<\/em> isolates tested by the National Antimicrobial \n\n\n\n\n\nResistance Monitoring System laboratory (<a href=\"https:\/\/www.cdc.gov\/narms\">https:\/\/www.cdc.gov\/narms<\/a>) had a ciprofloxacin \n\n\n\n\n\nMIC in the 0.12\u20131 \u00b5g\/mL range, and 9.5% had an azithromycin MIC greater than the ECV (i.e., non-wild-type; reduced \n\n\n\n\n\nsusceptibility). Testing of 2017 surveillance isolates is ongoing. Among those tested, 16.5% have a ciprofloxacin MIC in the \n\n\n\n\n\n0.12\u20131 \u00b5g\/mL range, and 22.1% have reduced susceptibility to azithromycin. Molecular data indicate that most \n\n\n\n\n\n<em>Shigella<\/em> isolates with ciprofloxacin MICs in the noted range harbor at least one quinolone resistance mechanism. \n\n\n\n\n\n<em>Shigella<\/em> isolates without a quinolone resistance mechanism typically have a ciprofloxacin MIC of =0.015 \u00b5g\/mL. \n\n\n\n\n\nClinical and Laboratory Standards Institute (CLSI) criteria categorize <em>Shigella<\/em> isolates with a ciprofloxacin MIC \n\n\n\n\n\nof =1 \u00b5g\/mL as susceptible to ciprofloxacin. Currently, clinical laboratories have limited ability to differentiate \n\n\n\n\n\nthe ciprofloxacin MIC values within the reduced susceptibility range, =1 \u00b5g\/mL. Additionally, CLSI does not have \n\n\n\n\n\nestablished azithromycin clinical breakpoints for <em>Shigella<\/em> isolates, only ECVs, which do not predict clinical \n\n\n\n\n\noutcome (2).<\/p>\n\n\n\n\n\n\n\n\n\n\n\n<p>CDC is particularly concerned about people who are at high risk for multidrug-resistant <em>Shigella<\/em> infections and \n\n\n\n\n\nare more likely to require antibiotic treatment, such as men who have sex with men, patients who are homeless, and \n\n\n\n\n\nimmunocompromised patients. These patients often have more severe disease, prolonged shedding, and recurrent infections.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n<p>In response to data and concerns presented by CDC, CLSI formed an ad hoc working group in June 2017 to assess any available \n\n\n\n\n\nand relevant clinical, pharmacologic, and microbiologic data. The workgroup found that no data are available on the high-risk \n\n\n\n\n\npopulations of concern. CDC has not received any reports of clinical treatment failures in patients with <em>Shigella<\/em> infections. \n\n\n\n\n\nTherefore, it is unclear whether fluoroquinolone treatment of a <em>Shigella<\/em> infection with a ciprofloxacin MIC of 0.12\u20131 \u00b5g\/mL \n\n\n\n\n\nis associated with a worse clinical outcome or whether such treatment increases the risk of transmission. At this time, CLSI \n\n\n\n\n\nciprofloxacin MIC breakpoints for the <em>Enterobacteriaceae<\/em> family (excluding <em>Salmonella<\/em>) will continue to apply \n\n\n\n\n\nto <em>Shigella<\/em> isolates.\n\n\n\n\n\n\n\n\n\n\n\n<\/p><p>CDC is working with CLSI and other partners to collect isolates and clinical information from people with <em>Shigella<\/em> infection \n\n\n\n\n\nand possible clinical treatment failure occurring after treatment with a fluoroquinolone or azithromycin. If treatment failure is suspected, \n\n\n\n\n\nclinicians should consider consulting an infectious disease specialist to identify best treatment options, and submit a stool specimen for \n\n\n\n\n\nantimicrobial susceptibility testing. Clinicians should monitor patients carefully and report cases of possible clinical treatment failure \n\n\n\n\n\nto CDC.<\/p><h2>Reporting<\/h2><p>To report cases of <em>Shigella<\/em> in Delaware, call <strong>302-744-4990<\/strong> (24\/7).<\/p><h2>For More Information<\/h2><ol>\n\n\n\n\n\n<li>\u00a0For general information about <em>Shigella<\/em> or shigellosis, visit <a href=\"https:\/\/www.cdc.gov\/shigella\/index.html\">https:\/\/www.cdc.gov\/shigella\/index.html<\/a><\/li>\n\n\n\n\n\n<li>\u00a0For general information about <em>Shigella<\/em> or shigellosis in Spanish, visit <a href=\"https:\/\/www.cdc.gov\/shigella\/esp\/index.html\">https:\/\/www.cdc.gov\/shigella\/esp\/index.html<\/a>\n\n\n\n\n\n<\/li><li>\u00a0For technical information about <em>Shigella<\/em> or shigellosis, including information about national surveillance and other educational resources for medical and public health professionals, visit <a href=\"https:\/\/www.cdc.gov\/shigella\/resources.html\">https:\/\/www.cdc.gov\/shigella\/resources.html<\/a><\/li><li>\u00a0For information about prevention and control of shigellosis, including recommendations for men who have sex with men, visit <a href=\"https:\/\/www.cdc.gov\/shigella\/audience-sexually-active.html\">https:\/\/www.cdc.gov\/shigella\/audience-sexually-active.html<\/a><\/li><li>\u00a0For more information about the serious public health threat posed by antimicrobial-resistant <em>Shigella<\/em>, refer to \u201cAntibiotic Resistance Threats in the United States, 2013\u201d available at <a href=\"https:\/\/www.cdc.gov\/drugresistance\/threat-report-2013\/pdf\/ar-threats-2013-508.pdf\">https:\/\/www.cdc.gov\/drugresistance\/threat-report-2013\/pdf\/ar-threats-2013-508.pdf<\/a><\/li><li>\u00a0For specific inquiries related to this HAN Update, email <a href=\"mailto:EntericBacteria@cdc.gov\">EntericBacteria@cdc.gov<\/a><\/li><\/ol><h2>References<\/h2><ol>\n\n\n\n\n\n<li>\u00a0<a href=\"https:\/\/emergency.cdc.gov\/han\/han00401.asp\">HAN 401: CDC Recommendations for Diagnosing and Managing Shigella Strains with Possible Reduced Susceptibility to Ciprofloxacin<\/a><\/li>\n\n\n\n\n\n<li>\u00a0<a href=\"https:\/\/clsi.org\/standards\/products\/microbiology\/documents\/m100\/\">CLSI. Performance Standards for Antimicrobial Susceptibility Testing. 28th ed. CLSI supplement M100. Wayne, PA: Clinical and Laboratory Standards Institute; 2018<\/a><\/li>\n\n\n\n\n\n<\/ol><p class=\"smalltext\">The Centers for Disease Control and Prevention (CDC) protects people\u2019s health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations<\/p><p>************************************<\/p><p>You are receiving this email because you are a registered member of the Delaware Health Alert Network.\n\n\n\n\n\nIf you are not a member and would like to subscribe, please register at <a href=\"https:\/\/healthalertde.org\">https:\/\/healthalertde.org<\/a><\/p><p>\n\n\n\n\n\n\n\n\n\n\n\n<br>\n\n\n\n\n\n<\/p><hr>\n\n\n\n\n\n<br>\n\n\n\n\n\n<p class=\"smalltext\"><a href=\"http:\/\/www.adobe.com\/products\/acrobat\/readstep2.html\"><img loading=\"lazy\" decoding=\"async\" alt=\"Download Adobe Acrobat Reader\" height=\"21\" src=\"\/wp-content\/uploads\/dhss\/img\/getacro60.gif\" width=\"60\"><\/a> Please note: Some of the files available on this page are in Adobe PDF format which requires Adobe Acrobat Reader.  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If you are using an assistive technology unable to read Adobe PDF, please either view the corresponding text only version (if available) or visit Adobe&#8217;s <a href=\"http:\/\/access.adobe.com\">Accessibility Tools page<\/a>.<\/p>\n<!--[END]-->\n\n  \n\n        <div class=\"panel panel-danger\">\n\n          <div class=\"panel-heading\">    \n\n      <h2>Categories of Health Alert messages:<\/h2>\n\n       <\/div>\n\n       <div class=\"panel-body\">\n\n      <ul>\n\n        <li><strong>Health Alert:<\/strong> Conveys the highest level of importance; warrants immediate action or attention.<\/li>\n\n        <li><strong>Health Advisory:<\/strong> Provides important information for a specific incident or situation; may not require immediate action.<\/li>\n\n        <li><strong>Health Update:<\/strong> Provides updated information regarding an incident or situation; unlikely to require immediate action.<\/li>\n\n            <\/ul>\n\n         <div><strong>NOTE: This page is for informational purposes only and dated material (e.g. temporary websites) may not be available.<\/strong><\/div>\n\n          <\/div> \n\n        <\/div><br>  \n\n\n\n      <\/div>\n\n    <\/div>\n\n  <\/div><!-- \/container -->\n\n  <\/div>","protected":false},"excerpt":{"rendered":"<p>Listen Delaware Health Alert Network #388 June 11, 2018 2:34 pm Public Health Menu Home About About DPH Sections &#038; Programs Office Locations Contact Info Calendar Services A-Z Services Air &#038; Water Quality Birth, Death, &#038; Marriage Records Clinics Health Data &#038; Statistics Emergency Preparedness Health &#038; Wellness Healthy Homes Healthy Workplaces Laboratory Restaurant Inspections [&hellip;]<\/p>\n","protected":false},"author":8,"featured_media":0,"parent":9294,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"class_list":["post-10365","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages\/10365","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/comments?post=10365"}],"version-history":[{"count":1,"href":"https:\/\/dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages\/10365\/revisions"}],"predecessor-version":[{"id":11541,"href":"https:\/\/dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages\/10365\/revisions\/11541"}],"up":[{"embeddable":true,"href":"https:\/\/dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/pages\/9294"}],"wp:attachment":[{"href":"https:\/\/dhss.delaware.gov\/dph\/wp-json\/wp\/v2\/media?parent=10365"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}