An outbreak of shigellosis in a Children Welfare Institute caused by a multiple-antibiotic-resistant strain of Shigella flexneri 2a

Shigella flexneri Outbreak at a Rehabilitation Center: First Report from Saudi Arabia

Background: Shigella flexneri is a major cause of shigellosis in developing regions and is known to cause outbreaks in institutional settings. Transmission occurs via the fecal-oral route. It invades intestinal epithelial cells, causing diarrhea, systemic symptoms, and complications such as hemolytic uremic syndrome. This study aimed to characterize the clinical presentation, administered treatment, infection outcomes, and infection control measures during a local S. flexneri outbreak at a rehabilitation center. Methods: This case series at King Saud University Medical City (Oct-Dec 2024) investigated S. flexneri infections from a rehabilitation center. Stool and blood samples were cultured and analyzed using microbiological methods. Molecular studies were used to verify the genetic linkage between the isolates and to study their virulence genes. Results: Four cases of S. flexneri were included, involving patients with various comorbidities, residing in a rehabilitation center, and presenting with symptoms like fever and diarrhea. Laboratory investigations revealed leukocytosis, electrolyte imbalances, and elevated inflammatory markers. Imaging studies showed findings consistent with colitis in two cases. Patients were managed with IV fluids and targeted antibiotics, leading to symptom resolution. Molecular studies confirmed the genetic relatedness between the S. flexneri isolates, with virulence genes indicating cellular invasion and inflammation as primary drivers of disease severity. Outbreak management comprised contact isolation, environmental disinfection, and education. Conclusions: S. flexneri outbreaks in long-term care facilities pose challenges among bedbound patients. Diapers may facilitate transmission, and infections may cause severe complications. Robust infection control, identifying outbreak sources, and strengthening prevention strategies are essential to protect vulnerable populations.

Infection control measures against multidrug-resistant Gram-negative bacteria in children and neonates

The increase in infections caused by multidrug-resistant (MDR) Gram-negative bacteria in neonatal and pediatric intensive care units over recent years is alarming. MDR Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii have constituted the main causes of the MDR Gram-negative bacteria problem. The implementation of infection control measures such as hand hygiene, cohorting of patients, contact precautions, active surveillance and environmental cleaning could diminish their spread. Recently, water safety has been identified as a major component of infection control policies. The aim of the current review is to highlight the effectiveness of these infection control measures in managing outbreaks caused by MDR Gram-negative bacteria in neonatal and pediatric intensive care units and highlight future perspectives on the topic.

The changing epidemiology of shigellosis in Australia, 2001-2019

Shigellosis is an increasing cause of gastroenteritis in Australia, with prolonged outbreaks reported in remote Aboriginal and Torres Strait Islander (hereafter "First Nations") communities and among men who have sex with men (MSM) in major cities. To determine associations between Shigella species and demographic and geographic factors, we used multivariate negative binomial regression to analyse national case notifications of shigellosis from 2001 to 2019. Between 2001 and 2019, Australian states and territories reported 18,363 shigellosis cases to the National Notifiable Diseases Surveillance System (NNDSS), of which age, sex and organism information were available for >99% (18,327/18,363) of cases. Of the cases included in our analysis, 42% (7,649/18,327) were S. sonnei, 29% (5,267/18,327) were S. flexneri, 1% (214/18,327) were S. boydii, less than 1% (87/18,327) were S. dysenteriae, and species information was unknown for 28% (5,110/18,327) of cases. Males accounted for 54% (9,843/18,327) of cases, and the highest proportion of cases were in children aged 0-4 years (19%; 3,562/18,327). Crude annual notification rates ranged from 2.2 cases per 100,000 in 2003 and 2011 to 12.4 cases per 100,000 in 2019. Nationally, notification rates increased from 2001 to 2019 with yearly notification rate ratios of 1.04 (95% CI 1.02-1.07) for S. boydii and 1.05 (95% CI 1.04-1.06) for S. sonnei. Children aged 0-4 years had the highest burden of infection for S. flexneri, S. sonnei and S. boydii; and males had a higher notification rate for S. sonnei (notification rate ratio 1.24, 95% CI 1.15-1.33). First Nations Australians were disproportionately affected by shigellosis, with the notification rate in this population peaking in 2018 at 92.1 cases per 100,000 population. Over the study period, we also observed a shift in the testing method used to diagnose shigellosis, with culture independent diagnostic testing (CIDT) increasing from 2014; this also coincided with an increase in notifications of untyped Shigella. This change in testing methodology may have contributed to the observed increase in shigellosis notifications since 2014, with CIDT being more sensitive than culture dependent testing methods. The findings of this study provide important insights into the epidemiological characteristics of shigellosis in Australia, including identification of high-risk groups. This can be used to inform public health prevention and control strategies, such as targeted communication programs in First Nations communities and places with high levels of interaction between young children, such as childcare centres. Our study findings also highlight the implications of culture independent testing on shigellosis surveillance, particularly a reduction in the availability of species level information. This emphasises the continued importance of culture dependant testing for national surveillance of shigellosis.

Stable Recombinant Invasion Plasmid Antigen C (IpaC)-Based Single Dose Nanovaccine for Shigellosis

Shigellosis, caused by the bacteria Shigella, is the leading cause of bacterial diarrhea and the second leading cause of diarrheal death among children under the age of five. Unfortunately, Shigella strains have acquired resistance to antibiotics, and a commercial vaccine is yet to be available. We have previously demonstrated that Shigella dysenteriae serotype 1 (Sd1)-based recombinant, stabilized, "invasion plasmid antigen C" (IpaC; 42 kDa) protein can induce robust immune responses in BALB/c mice against a challenge of a high dose of heterologous Shigella when immunized via three intranasal doses of IpaC without an adjuvant. In this work, in order to reduce the frequency of dosing and increase possible patient compliance, based on our previous screening, the minimum protective dose of stabilized IpaC (20 μg) was encapsulated in biodegradable polymeric poly(lactide-co-glycolide) nanoparticles (∼370 nm) and intranasally administered in BALB/c mice in a single dose. Interestingly, a single intranasal dose of the developed vaccine particles encapsulating only 20 μg of Sd1 IpaC led to a temporal increase in the antibody production with an improved cytokine response compared to free IpaC administered three times as described in our previous report. Upon intraperitoneal challenge with a high dose of heterologous Shigella flexneri 2a (common in circulation), the immunized animals were protected from diarrhea, lethargy, and weight loss with ∼67% survival, while all the control animals died by 36 h of the challenge. Overall, the developed nanovaccine could be explored as a potential noninvasive, cross-protective, single-dose, single-antigen Shigella vaccine amenable for scale-up and eventual mass immunization.

Antibacterial Effect of Eugenol on Shigella flexneri and Its Mechanism

Shigella flexneri (Sh. flexneri), which can be found in food and the environment, is a widespread food-borne pathogen that causes human diarrhea termed “shigellosis”. In this study, eugenol, a natural active substance, was investigated for its antibacterial activity against Sh. flexneri. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of eugenol against Sh. flexneri ATCC 12022 was 0.5 and 0.8 mg/mL. The growth curves and inhibitory effect in LB broth, PBS, vegetable juice, and minced pork showed that eugenol had a good activity against Sh. flexneri. Research findings indicated the superoxide dismutase activity of Sh. flexneri was inhibited after eugenol treatment, resulting in concentrations of intracellular reactive oxygen species and an increase in malondialdehyde. The flow cytometry analysis and field emission scanning electron microscopy results revealed obvious damage to cell membrane integrity and changes in the morphology of Sh. flexneri. In addition, the intracellular ATP concentration leaked from 0.5 μM to below 0.05 μM and the membrane potential showed a concentration-dependent depolarization after eugenol treatment. In summary, eugenol exerted strong antibacterial activity and has the potential to control Sh. flexneri in the food industry.

FTIR differentiation based on genomic DNA for species identification of Shigella isolates from stool samples

Shigellosis is one of the major public health concerns in developing and low-income countries caused by four species of Shigella. There is an apparent need to develop rapid, cost-effective, sensitive and specific methods for differentiation of Shigella species to be used in outbreaks and health surveillance systems. We developed a sensitive and specific Fourier-transform infrared spectroscopy (FTIR) based method followed by principal component analysis (PCA) and hierarchical clustering analysis (HCA) assays to differentiate four species of Shigella isolates from stool samples. The FTIR based method was evaluated by differentiation of 91 Shigella species from each other in clinical samples using both gold standards (culture-based and agglutination methods) and developed FTIR assay; eventually, the sensitivity and specificity of the developed method were calculated. In summary, four distinct FTIR spectra associated with four species of Shigella were obtained with wide variations in three definite regions, including 1800–1550 cm⁻¹, 1550–1100 cm⁻¹, and 1100–800 cm⁻¹ distinguish these species from each other. In this study, we found the FTIR method followed by PCA analysis with specificity, sensitivity, differentiation error and correct differentiation rate values of 100, 100, 0 and 100%, respectively, for identification and differentiation of all species of the Shigella in stool samples.

Development of a Self-Adjuvanting, Cross-Protective, Stable Intranasal Recombinant Vaccine for Shigellosis

With the acquirement of antibiotic resistance, Shigella has resulted in multiple epidemics of shigellosis, an infectious diarrheal disease, causing thousands of deaths per year. Unfortunately, there are no licensed vaccines, primarily due to low or serotype-specific immunogenicity. Thus, conserved subunit vaccines utilizing recombinant invasion plasmid antigens (Ipa) have been explored as cross-protective vaccine candidates. However, achieving cross-protection against Shigella dysenteriae 1, which caused multiple pandemics/epidemics in the recent past, has been difficult. Therefore, a rational approach to improve cross-protection in the preparation for a possible pandemic should involve conserved proteins from S. dysenteriae 1 (Sd1). IpaC is one such conserved immunogenic protein that is less explored as an independent vaccine due to its instability/aggregation. Therefore, to improve cross-protection and potential immunogenicity and to be prepared for a future epidemic/pandemic, herein, we stabilized recombinant Sd1 IpaC, expressed without its chaperone, using a previously reported stabilizing detergent (LDAO) in a modified protocol and assessed its vaccine potential without an adjuvant. The protein assembled into heterogeneous complex spherical structures in the presence of LDAO and showed improved stability at storage temperatures of -80, -20, 4, 25, and 37 °C while providing enhanced yield and concentration. The protein could also be stably lyophilized and reconstituted, increasing the convenience of transportation and storage. Upon intranasal administration in BALB/c mice, the stabilized-IpaC-immunized groups generated significant antibody response and were not only protected against a high intraperitoneal dose of homologous S. dysenteriae 1 but also showed 100% survival against heterologous Shigella flexneri 2a without an adjuvant, while the control animals showed visible diarrhea (bloody-Sd1 challenge), lethargy, and weight loss with 0% survival. Overall, this work demonstrates that stabilized IpaC can be explored as a minimalist, self-adjuvanting, cross-protective, intranasal, single-antigen Shigella vaccine.

Heterologous expression of Intimin and IpaB fusion protein in Lactococcus lactis and its mucosal delivery elicit protection against pathogenicity of Escherichia coli O157 and Shigella flexneri in a murine model

Escherichia coli O157:H7 and Shigella flexneri are the predominant diarrhoeal pathogens and those strains producing Shiga toxins cause life-threatening sequelae including hemolytic uremic syndrome (HUS) upon their entry into the host. Intimate adherence of E. coli O157 and invasion of S. flexneri in the host intestinal epithelial cells is mainly mediated by Intimin and IpaB proteins, respectively. In this study, we have synthesized chimera of immunodominant regions of Intimin (eae) and IpaB (ipaB) designated as EI and expressed it in Lactococcus lactis (LL-EI) to develop a combinatorial oral vaccine candidate. Immune parameters and protective efficacy of orally administered LL-EI were assessed in the murine model. Significant EI-specific serum IgG, IgA, and fecal IgA antibody titer were observed in the LL-EI group. Considerable increase in EI-specific splenocyte proliferation and a concurrent upregulation of both Th1 and Th2 cytokines was observed in LL-EI immunized mice. Flow cytometry analysis also revealed a significant increase in CD4 and CD8 cell counts in LL-EI immunized group compared to PBS, LL control group.In vitro studies using LL-EI immunized mice sera showed substantial protection against bacterial adhesion and invasion caused by E. coli O157 and Shigella flexneri¸ respectively. LL-EI immunized group challenged with E. coli O157 ceased fecal shedding within 6 days, and mice challenged with S. flexneri showed 93% survival with minimal bacterial load in the lungs. Our results indicate that LL-EI immunization elicits systemic, mucosal and cell-mediated immune responses, and can be a promising candidate for oral vaccine development against these pathogens.

Shigella flexneri: an emerging pathogen

Shigella flexneri is a leading etiologic agent of diarrhea in low socioeconomic countries. Notably, various serotypes in S. flexneri are reported from different regions of the world. The precise approximations of illness and death owing to shigellosis are missing in low socioeconomic countries, although it is widespread in different regions. The inadequate statistics available reveal S. flexneri to be a significant food and waterborne pathogen. All over the world, different antibiotic-resistant strains of S. flexneri serotypes have been emerged especially multidrug-resistant strains. Recently, increased resistance was observed in cephalosporins (3rd generation), azithromycin, and fluoroquinolones. There is a need for a continuous surveillance study on antibiotic resistance that will be helpful in the update of the antibiogram. The shigellosis burden can be reduced by adopting preventive measures like delivery of safe drinking water, suitable sanitation, and development of an effective and inexpensive multivalent vaccine. This review attempts to provide the recent findings of S. flexneri related to epidemiology and the emergence of multidrug resistance.

Development of quinolone resistance and prevalence of different virulence genes among Shigella flexneri and Shigella dysenteriae in environmental water samples

The purpose of this study was to find out the mechanism of quinolone resistance in Shigella sp. isolated from environmental water samples from various parts of Kolkata, India. Out of 196 Shigella sp. isolated from 2014 to 2017, we selected 32 Shigella isolates for antimicrobial susceptibility tests. The minimum inhibitory concentrations (MIC) for quinolones ranged from 30 to 50 μg ml^-1 for ofloxacin, 5-20 μg ml^-1 for ciprofloxacin and 20-30 μg ml^-1 for norfloxacin. A few amino acid changes were found in quinolone resistance determining region (QRDR) of gyrA. Mutations in gyrA lead to a higher increment of MIC of quinolones. Among the plasmid-mediated (PMQR) quinolone resistance genes investigated, qnrB and aac(6')-lb-cr genes were found in all isolates. qnrA and qnrS were found in 25% and 62% of the isolates, respectively. ipaH gene was found in all of the isolates followed by the presence of other virulence genes ial, sen and stx1. Almost all the isolates having high MICs showed efflux pump activity in drug accumulation assay. All the mechanisms may or may not be present in a single strain. Several types of efflux pumps, presence of PMQR genes and mutations in drug target site of QRDR region may play the crucial role for resistance in our isolates.

Prevalence and antimicrobial profile of Shigella isolates in a tertiary care hospital of North Karnataka: A 12-year study

Context

Shigella is a common cause of bacillary dysentery. Although it is reported worldwide, the majority of the infections are seen in developing countries with Shigella flexneri being the most common isolate. Prevalence of Shigella species and their antibiotic susceptibility profiles vary according to geographic area and season.

Aims

In the present study, the epidemiology and antimicrobial profile of Shigella from stool samples received at our hospital for a period of 12 years (January 2006 to December 2017) was evaluated.

Subjects and Methods

A total of 4578 stool samples were collected from the cases of acute gastroenteritis and diarrhoea. Samples were processed for culture and sensitivity according to standard microbiological techniques. The presumptive identification of Shigella species was done using standard conventional biochemical tests and confirmed using antisera.

Results

A total of 189 (4.2%) samples yielded Shigella spp. Isolation of Shigella spp. were more frequent from males (58.2%). S. flexneri was the commonest species isolated (47.6%) followed by Shigella sonnei(11.6%), Shigella dysenteriae (4.2%) and Shigella boydii (2.1%). Non-typeable Shigella was commonly recovered. The isolates showed high resistance to ampicillin (76.7%) and co-trimoxazole (75%) while highest susceptibility was observed to ceftriaxone (79.2%).

Conclusions

S. flexneri was the most prevalent species isolated at this centre. Shigella isolates from the study showed alarming resistance to recommended antibiotics. Non-typeable Shigella accounted for 34.4% isolates. Molecular discrimination between Shigella and Escherichia coli is essential.

The fates of microbial populations on pig carcasses during slaughtering process, on retail cuts after slaughter, and intervention efficiency of lactic acid spraying

This study was conducted to detect and identify microbial populations on pig carcasses at different slaughtering stages and on retail pork cuts at 24 h after slaughter as well as to evaluate the intervention efficiency of sprays containing different concentrations (2% and 4%) of lactic acid. The sprays were applied to the carcass surfaces at the end of the slaughter line. Microbial samples were collected from carcass surfaces after bleeding and after eviscerating, and from retail cuts at 24 h after chilling/spraying. The detected microorganisms were identified through using a Microflex identification instrument and 16S rRNA gene sequencing. The diversity of the bacterial genera; Staphylococcus, Salmonella, Shigella, Enterococci, Escherichia, Acinetobacter and Corynebacterium spp. showed counts ranging from 2.70 to 4.91 log₁₀ cfu/100 cm² on the carcasses during slaughter. Most of these genera were also detected on the carcasses after 24 h of chilling. Three species (Staphylococcus hyicus, Acinetobacter albensis, and Corynebacterium xerosis) were also found on the retail cuts of non-sprayed carcasses but not on those of the sprayed groups. Significantly greater reductions in all bacterial species were observed on the carcasses and retail cuts that were sprayed with lactic acid, particularly at the 4% level. Thus, spraying with 4% lactic acid may be an effective intervention for controlling bacterial contamination on pig carcasses to improve the microbiological safety of pork meat.

An Outbreak of Foodborne Infection Caused by Shigella sonnei in West Bengal, India

A foodborne acute gastroenteritis outbreak due to Shigella sonnei infection occurred in a household after eating foods in a housewarming party at Pakapol Village, South 24 Parganas District of West Bengal, an Indian state, in November 2016. Here, we report the epidemiological and microbiological findings of this outbreak. Thirty-four people attended the party on November 23, 2016, and had lunch together. The median incubation period from the time of food consumption to the development of acute gastroenteritis was 18.5 h (interquartile range, 16.5-22 h). The overall attack rate was 73% (25/34), and 76% (19/25) of them required hospitalization. All age groups were affected with 100% recovery rate. One served food item was significantly associated with the illness, i.e., tomato salad (risk ratio, 4.14; 95% confidence interval, 1.21-14.13). Among the 12 stool specimens tested, 8 (67%; 8/12) were positive for S. sonnei. All S. sonnei strains were completely resistant to nalidixic acid, norfloxacin, ciprofloxacin, ofloxacin, and erythromycin, and partially resistant to tetracycline, doxycycline, streptomycin, and trimethoprim/sulfamethoxazole. Pulsed-field gel electrophoresis analysis showed that the recent outbreak strains of S. sonnei were clonally related with the locally circulating strains in Kolkata.