Antibacterial and anti-parasitic activities of Terfezia claveryi methanolic extract against some common pathogenic agents of infectious diarrhea

Objective: To assess the antidiarrheal effects of Terfezia claveryi methanolic extract against Escherichia coli, Salmonella typhimurium, Shigella flexneri, and Giardia lamblia. Methods: Antibacterial effects of the Terfezia claveryi methanolic extract were carried out by determining the minimum inhibitory concentration (MIC) and minimum bactericidal concentration through micro broth dilution technique. Furthermore, reactive oxygen species production and protein leakage were evaluated. To evaluate the in vitro anti-giardial effects of Terfezia claveryi methanolic extract, Giardia lamblia WB (ATCC® 30957) trophozoites were treated with various concentrations of Terfezia claveryi methanolic extract for 10-360 min. In addition, the plasma membrane permeability of trophozoites treated with Terfezia claveryi methanolic extract was determined. The cytotoxicity effects of Terfezia claveryi methanolic extract against normal (HEK293T) and cancer (MCF-7) cells were also assessed using the MTT assay. Results: The MIC and minimum bactericidal concentration of Terfezia claveryi methanolic extract against bacterial strains were in the range of 0.52-1.04 and 1.04-2.08 mg/mL, respectively. The results revealed that reactive oxygen species production and protein leakage were significantly increased after the bacteria were treated with the Terfezia claveryi methanolic extract, especially at 1/3 and 1/2 MICs (P<0.001). Furthermore, Terfezia claveryi methanolic extract decreased the viability of Giardia lamblia trophozoites in a dose-dependent manner. Terfezia claveryi methanolic extract at 1, 2, and 4 mg/mL resulted in 100% mortality in Giardia lamblia trophozoites after 360, 240, and 120 min, respectively. Moreover, Terfezia claveryi methanolic extract altered the permeability of plasma membrane of Giardia lamblia trophozoites by increasing the concentration. MTT assay revealed that the 50% cytotoxic concentrations values for HEK293T and MCF-7 cells were 4.32 mg/mL and 6.40 mg/mL, respectively, indicating that Terfezia claveryi methanolic extract had greater cytotoxicity against cancer cells than normal cells. Conclusions: Terfezia claveryi methanolic extract had potent in vitro antibacterial and anti-parasitic effects on Escherichia coli, Salmonella typhimurium, Shigella flexneri, and Giardia lamblia by affecting cell membrane permeability and reactive oxygen species generation with no significant cytotoxicity on normal cells.

Shigellosis: Epidemiology in India.

Shigellosis is one of the major causes of diarrhoea in India. The accurate estimates of morbidity and mortality due to shigellosis are lacking, though it is endemic in the country and has been reported to cause many outbreaks. The limited information available indicates Shigella to be an important foodborne pathogen in India. S. flexneri is the most common species, S. sonnei and non-agglutinable shigellae seem to be steadily surfacing, while S. dysenteriae has temporarily disappeared from the northern and eastern regions. Antibiotic-resistant strains of different Shigella species and serotypes have emerged all over the world. Especially important is the global emergence of multidrug resistant shigellae, notably the increasing resistance to third generation cephalosporins and fluoroquinolones, and also azithromycin. This calls for a continuous and strong surveillance of antibiotic resistance across the country for periodic updation of the local antibiograms. The prevention of shigellosis is desirable as it will substantially reduce the morbidity associated with diarrhoea in the country. Public health measures like provision of safe water and adequate sanitation are of immense importance to reduce the burden of shigellosis, however, the provision of resources to develop such an infrastructure in India is a complex issue and will take time to resolve. Thus, the scientific thrust should be focused towards development of a safe and affordable multivalent vaccine. This review is focused upon the epidemiology, disease burden and the therapeutic challenges of shigellosis in Indian perspective.

Clinical and Microbiological Profiles of Shigellosis in Children.

Shigellosis presents with varied clinical features are dictated by the species involved, virulence factors of the strain, and the host immune status. We studied the species, virulence genes, and antibiotic susceptibility pattern of the Shigella strains isolated from 33 children aged less than 12 years, with clinical features of shigellosis. Identification and antibiotic sensitivity of Shigella species were done using disc diffusion and E-test. Multiplex PCR was done for the detection of virulence genes (ipaH, ial, set1A, set1B, sen, and stx) and ESBL genes. Parents of the children were interviewed using structured questionnaire to assess the severity of the disease; 26 (79%) of the isolates were Shigella flexneri. Ciprofloxacin and ceftriaxone resistance was seen in 23 (69%) and 3 (9%) Shigella isolates respectively. Two ceftriaxone-resistant strains were found to harbour blaCTX gene and the third blaTEM gene. Virulence gene ipaH was detected in 100% of strains while ial, sen, set1A, and set1B were detected in 85%, 61%, 48%, and 48% respectively.

Low Compliance with National Guidelines for Preventing Transmission of Group 1 Nationally Notifiable Infectious Diseases in Korea

PURPOSE: This study was performed to evaluate the compliance with, and adequacy of, the Korean national guidelines which had been recommended until 2011 for isolation of patients with group 1 nationally notifiable infectious diseases (NNIDs), namely cholera, typhoid fever, paratyphoid fever, shigellosis, and enterohemorrhagic Escherichia coli (EHEC) infection. MATERIALS AND METHODS: We evaluated the clinical and microbiological characteristics of confirmed cases of group 1 NNIDs and compliance with the guidelines in 20 Korean hospitals nationwide in 2000-2010. We also compared the Korean guidelines with international guidelines. RESULTS: Among 528 confirmed cases (8 cases of cholera, 232 of typhoid fever, 81 of paratyphoid fever, 175 of shigellosis, and 32 EHEC infections), strict compliance with the Korean guideline was achieved in only 2.6% to 50.0%, depending on the disease. While the Korean guidelines recommend isolation of all patients with group 1 NNIDs, international guidelines recommend selective patient isolation and screening for fecal shedding, depending on the type of disease and patient status. CONCLUSION: Compliance with the previous national guidelines for group 1 NNIDs in Korea was generally very low. Further studies are needed to evaluate whether compliance was improved after implementation of the new guideline in 2012.

Patrones de susceptibilidad antimicrobiana de cepas de Shigella sonnei aisladas durante tres períodos diferentes en la Región Metropolitana, Chile / Antibiotic susceptibility patterns among Shigella sonnei, isolated during three different periods in Región Metropolitana, Chile

Background: Shigella sonnei gastroenteritis improves clinically and microbiologically with antibacterial treatment; however choosing a useful drug is a universal challenge because of in vitro susceptibility of S. sonnei frequently evolves to be resistant. Objective: To evaluate in vitro susceptibility of S. sonnei strains isolated from patients attending at the Chilean Región Metropolitana and to know the evolution that resistant patterns of S. sonnei have experienced. Material: In this study, the antimicrobial susceptibility profile of 277 isolates of Shigella sonnei was compared. The analyzed periods of time were: period I (1995-1997) 85 strains; period II (2004-2006) 92 strains and period III (2008-2009) 100 strains, in Santiago, Chile. The method performed to analyze susceptibility patterns was the disc diffusion (Kirby-Bauer). Results: The strains showed rates of resistance to ampicillin: period I, 85.8%; period II, 53.3%; period III, 100%, trimethoprim/sulfamethoxazole: period I, 50.5%; period, II 46.7%; period III, 100%, chloramphenicol: period I, 36.4%; period II, 12%; period III, 100% and tetracycline: period I, 38.8%; period II, 30.4%; period III, 100%. 98.9% of the strains showed susceptibility to quinolones. Significant differences were observed in patterns of antimicrobial resistance for both individuals and for multidrug resistance (≥ 3 antimicrobials) in the three periods (p < 0.001, χ2 test). Of all resistant strains, 17% were resistant to 1 or 2 antibiotics, while 65.7% showed a pattern of multidrug resistance; 100% of the period III strains presented multidrug resistance. Conclusion: These results showed the temporal resistance dynamics of S. sonnei circulating strains in the Chilean Región Metropolitana. Due to the endemic behavior of shigellosis in Chile, it is urgent to maintain permanent surveillance of antimicrobial resistance profiles to improve both prevention and treatment of shigellosis.

Introducción: La infección entérica producida por Shigella sonnei mejora clínicamente y microbiológicamente con antibioterapia; sin embargo, la elección del antimicrobiano es un problema universal pues la susceptibilidad in vitro de S. sonnei evoluciona frecuentemente hacia la resistencia. Objetivo: Evaluar la susceptibilidad in vitro a antimicrobianos de S. sonnei y conocer la evolución que han experimentado los patrones de resistencia de cepas aisladas de cuadros clínicos en pacientes de la Región Metropolitana, Chile. Material y Métodos: Se comparó el perfil de susceptibilidad a antimicrobianos, de 277 cepas clínicas de S. sonnei aisladas durante tres períodos: período I (1995-1997) 85 cepas; período II (2004-2006) 92 cepas y período III (2008-2009) 100 cepas, en Santiago, Chile. El perfil de susceptibilidad a antimicrobianos se determinó mediante test de difusión en agar. Resultados: Las tasas de resistencia de las cepas en los periodos I, II y III respectivamente fueron: ampicilina: 85,8%; 53,3%; 100%, cotrimoxazol: 50,5%; 46,7%; 100%, cloranfenicol: 36,4%; 12%; 100% y tetraciclina: 38,8%; 30,4%; 100%. El 98,9% de las cepas fue susceptible a quinolonas. Se observó diferencias significativas en los porcentajes de resistencia para antimicrobianos individuales y multi-resistencia (≥ 3 antimicrobianos) en los tres períodos (p < 0,001; Test de χ2). De las cepas resistentes, 17% presentó resistencia a uno ó dos antimicrobianos, 65,7% mostró multi-resistencia antimicrobiana. El 100% de las cepas del período III presentó multi-resistencia. Discusión: Estos resultados evidencian la dinámica temporal de la resistencia en cepas de S. sonnei circulantes en la Región Metropolitana. Dado que en Chile la shigelosis tiene un carácter endémico, es prioritario mantener una vigilancia constante de los perfiles de resistencia a antimicrobianos, para mejorar la prevención y el tratamiento de la shigelosis.

Antimicrobial resistance and PCR-ribotyping of Shigella responsible for foodborne outbreaks occurred in southern Brazil

Little information about Shigella responsible for foodborne shigellosis is available in Brazil. The present study aimed to investigate the antimicrobial resistance and PCR-ribotyping patterns of Shigella isolates responsible for foodborne outbreaks occurred in Rio Grande do Sul State (RS), Southern Brazil in the period between 2003 and 2007. Shigella strains (n=152) were isolated from foods and fecal samples of victims of shigellosis outbreaks investigated by the Surveillance Service. Identification of the strains at specie level indicated that 71.1 percent of them were S. flexneri, 21.5 percent S. sonnei, and 0.7 percent S. dysenteriae. Ten strains (6.7 percent) were identified only as Shigella spp. An increasing occurrence of S. sonnei was observed after 2004. Most of the strains were resistant to streptomycin (88.6 percent), followed by ampicillin (84.6 percent), and sulfamethoxazole/trimethoprim (80.5 percent). Resistant strains belonged to 73 patterns, and pattern A (resistance to ampicillin, sulfamethoxazole/trimethoprim, tetracycline, streptomycin, chloramphenicol, and intermediate resistance to kanamycin) grouped the largest number of isolates (n=36). PCR-ribotyping identified three banding patterns (SH1, SH2, and SH3). SH1 grouped all S. flexneri and SH2 grouped all S. sonnei. The S. dysenteriae strain belonged to group SH3. According to the results, several Shigella isolates shared the same PCR-rybotyping banding pattern and the same resistance profile, suggesting that closely related strains were responsible for the outbreaks. However, other molecular typing methods need to be applied to confirm the clonal relationship of these isolates.

Conocimientos sobre shigellosis y su manejo epidemiológico en personal médico / Knowledges on shigellosis and its epidemiological management in medical staff

Introducción: la Shigella como agente causal de episodios diarreicos con sangre ha sido el germen aislado con mayor frecuencia en los laboratorios clínicos, no obstante, el número de casos reportados por el Sistema de Enfermedades de Declaración Obligatoria es inferior, lo que demuestra un subregistro en su notificación. Objetivos: elevar el nivel de conocimientos de médicos y alumnos internos sobre la shigellosis. Métodos: se realizó un estudio cuasi experimental antes-después, de una intervención educativa sobre la shigellosis y su manejo epidemiológico. La investigación se hizo en los policlínicos comunitarios docentes Marcio Manduley y Nguyen Van Troi en el período de enero a junio de 2008. La muestra quedó conformada por 64 médicos, de ellos 21 eran alumnos internos. Todos expresaron su consentimiento para participar en la investigación. Se aplicó la prueba no paramétrica ji cuadrada con un nivel de significación de p < 0,05. Los datos se expresaron en valores absolutos y relativos. Resultados: antes de la intervención se observó que los conocimientos taxonómicos eran buenos en solo 9 encuestados para el 14,06 por ciento, después de la intervención, el número de personas con buen nivel de conocimientos ascendió hasta el 90,63 por ciento. Se constató que el personal médico tenía escaso nivel de conocimientos sobre los principales síntomas de inicio de la shigellosis. Los encuestados con buenos conocimientos sobre las principales medidas profilácticas para prevenir la enfermedad, aumentaron significativamente después de la intervención e igual comportamiento se observó en relación con el tratamiento idóneo en pacientes con Shigella. Conclusiones: la intervención educativa elevó el nivel de conocimientos en el personal médico sobre Shigella. Es necesario continuar promoviendo e investigando esta temática en el nivel primario de atención y extender un plan de acción no sólo a los hospitales, policlínicos y consultorios sino que...

Introduction: Shigella as causal agent of diarrheic episodes with presence of blood has been the more frequent isolated agent in clinical laboratories; however, the number of cases reported by System of Diseases of Mandatory Statement is lower demonstrating a sub-registry of its notification. Objectives: to confirm the knowledge level of medical staff on the Shigellosis. Methods: a quasi-experimental study was conducted before and after a educational intervention on the Shigellosis and its epidemiological management. Research was made in the "Marcio Manduley" and "Nguyen Van Troi" Teaching and Community polyclinics from January to June, 2008. Sample included 43 physicians and 21 internal students in which the intervention was applied. Information was obtained by application of anonymous questionnaire. Results: before intervention it was possible to verify that taxonomic knowledges were satisfactory in only 9 polled persons for a 14,06 percent, after it, the figure of persons with a good level of knowledges raised to 90,63 percent. Authors confirmed that the medical staff had limited knowledges on the main symptoms of Shigellosis onset. The persons polled with high knowledges on main prophylactic measures to prevent this disease, increase significantly after intervention and a similar behavior was noted in relation to subject on suitable treatment in Shigella patients. Conclusions: educational intervention raised the knowledge level on Shigella in the medical staff. It is necessary to continue promoting and researching this subject matter at primary care level and to extend an action plan not only to hospitals, polyclinics and consulting rooms but also to involve family...

An Epidemiological Investigation on an Outbreak of Shigellosis in a Special School for Handicapped in Yeongcheon-si and in a Rehabilitation Facility in Gyeongsan-si, Korea, 2008 / 農村醫學 地域保健

OBJECTIVES: In September 2008, an outbreak of diarrhea occurred among students attending Y school in Yeongcheon-si. Shigella sonnei was cultured from some of the rectal swabs. An epidemiological investigation was carried out to determine the source of the infection and the mode of transmission of the shigellosis outbreak. METHODS: The index case lived in the D rehabilitation facility in Gyeongsan-si and an additional epidemiological investigation was carried out there. The cases could not be questioned due to their mental handicaps. The teachers were interviewed instead. A patient case was defined as a resident with diarrhea more than one time a day from September 18 to September 26, 2008 or a resident with confirmed Shigella sonnei at the Y school or the D rehabilitation facility. RESULTS: The attack rate was 1.2% (8 persons) among 659 persons in the Y school and D rehabilitation facility. Five persons were microbiologically confirmed to have the infection and three persons were diagnosed on the basis of symptoms. Shigella sonnei was cultured from five of the 659 rectal swabs. However, 80 environmental specimens including drinking water, preserved foods, and cooking utensils were negative. All eight patients were Y school students and had been living in group boarding and lodging. Six of them lived in the D rehabilitation facility and two lived in the dormitory at the Y school. Five cases showed pulsed-field gel electrophoresis patterns that were identical for Shigella sonnei. CONCLUSIONS: The results of this study showed that the infection source of the shigellosis outbreak, in the two places, were identical. It is likely that the infections initially spread from a teacher or volunteer and then among the students.

Serotipos y resistencia antimicrobiana de cepas de Shigella flexneri aisladas de niños con diarrea aguda: Relación entre el serotipo y la severidad del episodio / Serotype and antimicrobial resistance of Shigella flexneri strains isolated from children with acute diarrhea: Relationship between serotype and severity of the episode

Se determinó el serotipo, susceptibilidad a los antimicrobianos y la relación de severidad de la infección con el serotipo, a un grupo de 50 cepas de S. flexneri aisladas de niños menores de 5 años con diarrea: 25 niños deshidratados y 25 no deshidratados. Para la tipificación se utilizaron antisueros comerciales y la susceptibilidad a los antimicrobianos se realizó por el método de difusión en disco. Características epidemiológicas y clínicas de los episodios: media de edad 13,32 meses ± 12, clase obrera y marginal 94% (P< 0,05), eutróficos 80% (P<0,05), sangre macroscópica en heces 82% (P< 0,05), vómitos 60% (P> 0,05). El serotipo con mayor frecuencia fue el 2a (40%), seguido por el 3a (24%), 2b (18%), 1a (6%), 6 (4%), 3b (2%), 4a (2%), variante “X” (2%) y variante “Y” (2%). El mayor porcentaje de resistencia se observó a tetraciclina (96%), seguido por ampicilina (94%), cloranfenicol (90%), amoxicilina ácido clavulánico (84%) y trimetoprin-sulfametoxazol (72%). La desnutrición (36%, P< 0,05) y el serotipo 2a (56%, P< 0,05) se observaron con mayor frecuencia en los niños deshidratados, mientras que el serotipo 2b predominó en los no deshidratados (32%, P< 0,05). La prevalencia del serotipo 2a, su asociación con la severidad del episodio y la elevada resistencia a los antibióticos alertan sobre la problemática de la infección por Shigella en el país y refuerza la necesidad de estudios para ajustar pautas en el tratamiento.

Serotype, antimicrobial susceptibility, and severity of the infection according to serotype, were determined in a group of 50 Shigella flexneri strains isolated from children less than 5 years old with diarrhea: 25 children dehydrated and 25 non dehydrated. Commercial antisera were used for serotyping and antimicrobial susceptibility was determined by the disc diffusion method. Clinical and epidemiological characteristics of the episodes: mean age 13.22 ± 12 months; 94% belonged to laborer and marginal classes (P<0.05); 80% eutrophic (P<0.05); 82% macroscopic blood in feces (P<0.05); 60% vomits (P>0.05). The most frequent serotype was 2a (40%), followed by 3a (24%), 2b (18%), 1a (6%), 6 (4%), 3b (2%), 4a (2%), variant “X” (2%) and variant “Y” (2%). The highest resistance percent was found for tetracycline (96%), followed by ampicylline (94%), chloramphenicol (90%), amoxicylline clavulonic acid (84%) and trimetoprim-sulfametoxazol (72%). Malnourishment (32%, P<0.05) and serotype 2a (56%, P<0.05) were seen more frequently in dehydrated children, while serotype 2b predominated in non dehydrated children (32%, P<0.05). Prevalence of serotype 2a and its association with the severity of the episode and high antibiotic resistance alert regarding the problem of Shigella infections in our country and reinforce the need of further studies to adjust treatment norms.

Reversible Diffuse Brain Edema in Acute Encephalopathy with Shigellosis

Shigellosis is an acute inflammatory colitis by infection to one of the members of the genus Shigella. It is known that various CNS symptoms including headache and seizure can develop with shigellosis. Encephalopathy with severe brain edema in shigellosis were rarely reported even in children as well as in adults. We report a rare case of acute encephalopathy with shigellosis showing severe diffuse brain edema which resolved rapidly with administration of steroids in an adult.

The Development of Irritable Bowel Syndrome after Shigella Infection: 3 Year Follow-up Study / 대한소화기학회지

BACKGROUND AND AIMS: Bacterial gastroenteritis seems to be a risk factor of irritable bowel syndrome (IBS). The incidence of post-infectious IBS (PI-IBS) was reported to be in the range of 7-31%, but few studies have reported long term follow-up results. So, we investigated the clinical course and prognosis of PI-IBS three years after shigella infection. METHODS: The subjects were recruited from our previous study, in which we investigated the incidence and risk factors of PI-IBS. We had a questionnaire based on interview with 120 controls and 124 patients who had shigella infection three years ago. Both groups were evaluated for the presence of IBS, functional bowel disorders (FBD) except IBS before, one and three years after the infection, respectively. RESULTS: Ninty-five patients (76.6%) and 105 controls (87.5%) completed the questionnare. In patients group, 7 cases had IBS prior to infection (previous IBS), 12 cases (13.8%) had IBS after 1 year (PI-IBS). Four cases developed IBS newly after 3 years (new IBS). Thirteen cases (14.9%) in patients and 4 cases (4.5%) in controls had IBS over 3 years (OR 3.93: 1.20-12.86). The recovery rate over 3 years were 50.0% (2/4) in previous IBS and 25% (3/12) in PI-IBS. The incidence of PI-IBS after 3 years in previous FBD subjects was 28.6% and was 10.6% in normals (p<0.05). The female gender was a risk factor for FBD. CONCLUSIONS: Bacterial gastroenteritis is a trigger factor of IBS. About a quarter of PI-IBS patients are recovered over 3 years. Previous FBD except IBS is a risk factor after 3 years.

Epidemiological Characteristics of Shigellosis in Jeju Island in 2003 / 감염과화학요법

BACKGROUND: Shigellosis is one of the most important contagious diseases in Korea. Especially, Jeju island has been known as the main and large outbreak area in Korea. The purpose of this study was to investigate the epidemiologic characteristics of shigellosis in Jeju island, 2003. METHODS: Patients with shigellosis, confirmed by culture in Jeju island in 2003, were included in this study. We retrospectively reviewed epidemiologic questionnaires, medical records, and official documents. We also collected data from direct interview with the patients with shigellosis. Epidemiological analysis was performed by 3 categorized events and ages. RESULTS: Ninety-nine patients were included in this study. S. sonnei was identified in all of the patients. Shigellosis mainly occurred in preschool-aged children. However, there was no statistical difference according to sex. Although there were asymptomatic cases (15.15%), the chief complaints were loose stool (69.7%) and abdominal pain (12.12%). Initial symptoms in symptomatic patients were abdominal pain (43.43%) and fever (31.31%). The median duration of isolation in the hospital was 7 days. CONCLUSION: Large and chronic epidemic outbreaks of shigellosis have occurred in Jeju island. Throughout this survey, we could show the epidemiological characteristics and the nature of shigellosis in Jeju island.

Epidemiological Characteristics of Shigellosis in Jeju Island in 2003 / 감염과화학요법

BACKGROUND: Shigellosis is one of the most important contagious diseases in Korea. Especially, Jeju island has been known as the main and large outbreak area in Korea. The purpose of this study was to investigate the epidemiologic characteristics of shigellosis in Jeju island, 2003. METHODS: Patients with shigellosis, confirmed by culture in Jeju island in 2003, were included in this study. We retrospectively reviewed epidemiologic questionnaires, medical records, and official documents. We also collected data from direct interview with the patients with shigellosis. Epidemiological analysis was performed by 3 categorized events and ages. RESULTS: Ninety-nine patients were included in this study. S. sonnei was identified in all of the patients. Shigellosis mainly occurred in preschool-aged children. However, there was no statistical difference according to sex. Although there were asymptomatic cases (15.15%), the chief complaints were loose stool (69.7%) and abdominal pain (12.12%). Initial symptoms in symptomatic patients were abdominal pain (43.43%) and fever (31.31%). The median duration of isolation in the hospital was 7 days. CONCLUSION: Large and chronic epidemic outbreaks of shigellosis have occurred in Jeju island. Throughout this survey, we could show the epidemiological characteristics and the nature of shigellosis in Jeju island.

An Infection Control for Outbreak of Shigellosis in a University Hospital / 병원감염관리

BACKGROUND: The occurrence of an outbreak of food-borne infectious disease requires a hospital to do extended role. There has been no report of an outbreak and an outbreak management of food-borne infectious diseases in a hospital. Therefore, this report of an outbreak and management of Shigellosis in the hospital would help others to manage further cases. METHODS: This was a descriptive study for an infection control program for food-borne infectious diseases in a hospital. RESULTS: There was a shigellosis outbreak at a university hospital in Seoul between December 3 and 30, 2001, Five hundred eighty four were affected, of which 81 cases were suspected and 86 cases were confirmed Shigella sonnei in fetal culture. The source of infection was identified as a lunch box or seaweed rolled rice that was contaminated and was supplied from the S-catering facility. The infection control team had developed the various strategies to control the outbreak and implemented them. The strategies included an epidemiology investigation, the removal of infection sources, medical treatment and isolation of patients, education and management of public relationship, environmental control, withdrawal of medical students' training, prevention and control of asymptomatic cases, intensive care unit strong financial support, analysis and management various data and the construction of cooperation and reporting system with the public health system CONCLUSION: This outbreak was controlled by effective team approach. The effective management of an outbreak of food-borne infectious diseases requires a systematic infection control, public relationship strategies for the reputation of the hospital, and the cooperation with a public health system.

Bacillary Dysentery

Bacillary dysentery is still an important food-borne infection worldwide. Because a small inoculum can establish the infection, contact, food, and water are the usual transmission route. Abdominal pain and diarrhea are the early symptoms, followed by bloody and mucoid stool and tenesmus. Although the diagnosis of shigellosis is based on the stool culture, diarrhea with general symptoms persisting for several days and intrafamilial spread suggest the shigellosis. The high resistance rate against the first-line antimicrobials is a serious social problem in developing countries. In countries showing a high resistance rate of trimethoprim-sulfamethoxazole or ampicillin, including Korea, the treatment choice for shigellosis is fluoroquinolone for 3 days in adults. In Korea, there has been a dramatic increase of shigellosis from 1998. Shigella sonnei is the most common pathogen, and S. flexneri has been isolated continuously in a small number. Analyzing the incidence by age and provinces, the infection occurred most frequently in the age group under twenties, and Cheju, Kyeongnam, Chonnam, and Kangwon show the high incidence rate of shigellosis. Although seasonal variation of shigellosis was influenced by regional outbreaks, the infection occurred most commonly in late spring and early autumn. The resistance rate of trimethoprim-sulfamethoxazole was very high, over 90%, but ampicillin resistance varied widely according to the epidemics or regions. The analyses of several epidemics of shigellosis from 1998 to 2000 indicate that the school lunch program is the most important cause for the recent increase of shigellosis in Korea. The strict regulation of mass food handling is critical for the control of shigellosis.

A Clinical Observation on Childhood Shigellosis Occurred in Mass Outbreak / 대한소아소화기영양학회지

PURPOSE: The incidence of shigellosis had been decreased due to the use of antibiotics and the improvement of environmental sanitation but recently increases again. Shigellosis occurrs in mass outbreak through unsanitized meal preperation refered from welfare facility and school. We observed epidemic aspect and clinical coarse of childhood shigellosis. METHODS: from December 2001 to January 2002, 22 inpatients with shigellosis in Dongbu Municipal Hospital were observed epidemiologically, clinically and microbiologically. RESULTS: 1. The sexual ratio was 1:1 and mean age was 5.5+/-1.4 years (14 months to 11 years). 2. The clinical manifestations were following: diarrhea (95.5%), high feve (10%) and asymptomatic (4.5%). The mean duration was 3.9+/-2.1 days (1 to 12 days). All patients had no complication and normal serologic test. 3. S. sonnei was cultured in rectal swab, and was resistant to TMP/SMX and ampicillin, but susceptible to ampicillin/sulbactam and the 3rd generation cephalosporins. 4. The patients were treated by antibiotics with conservative treatment including electrolytes and fluid therapy for 5 days, resulting in improvement confirmed by negative reaction on stool culture. 5. These cases were all occurred in mass outbreak in day care center and were suspected to be secondary infection by members of family. CONCLUSION: This shigellosis occurred in day care center was secondary infection due to S. sonnei and had mild clinical coarse and improvement after antibiotic treatment.

A Clinical Study of Shigellosis Epidemics over 10 Years in the Kyung Nam Area

PURPOSE: The occurrence of shigellosis patients has increased radically in 2 recent years. For this, the authors investigated the epidemic aspect of shigellosis by regional groups to know whether the epidemic aspect of shigellosis is a general situation which occurs identically in various areas of Kyung Nam. METHODS: We reviewed pediatric patients who were hospitalized in Ulsan(eastern), in Masan(cen tral), in Chinju(western) of Kyung Nam from January, 1988 to April, 1999. RESULTS: A total of 54 cases of shigellosis were noted from Ulsan(12), Masan(21) and Chinju(21) over ten years. The number of patients was 1 each in 1991 and 1993, 5 each in 1998 and 1999 at Ulasan, 9 in 1988, 8 between 1990 and 1995, 3 in 1998, 1 in 1999 at Masan, 1 each in 1990, 1991, 1994, 4 in 1998, 14 in 1999 at Chinju. The shigellosis patients increased from 1998, especially in Chinju. S. flexneri was reported in Masan(AMP)(R)5, AMP+TMP/SMX(R)4) before 1990, in Masan (2) between 1990 and 1995 and in Chinju(AMP(R)7, AMP+MP/SMX(R)1) in 1999. S. sonnei was reported in Ulsan(AMP(R)1, TMP/SMX(R)1), in Masan(6) and in Chinju(AMP(R)2, TMP/SMX(R) 1) between 1990 and 1995 and in Ulsan(TMP/SMX(R)9, AMP+TMP/SMX(S)1), in Masan(TMP/ SMX(R)2, AMP+TMP/SMX(R)1+(S)1) and in Chinju(TMP/SMX(R)6) between 1998 and 1999. CONCLUSION: Independent of the past, shigellosis patients occurred by regional groups in three parts of Kyung Nam. The present epidemic aspect of the eastern area is similar to that of the central area, but is partially similar to that of western Kyung Nam.

Shigellosis in a suburban commune in Ha Noi

A total of 1125 diarrhea fecal samples were examined: 163 were positive by using PCR (14.5%) and 67 Shigella found by culture (5.9%). The highest prevalence of shigellosis was seen in children with 2 years old and in the group of ³16 years old (23% and 17.9% by PCR, and 30.7% and 52.2% by culture, respectively). The lowest prevalence was found in children £ 6 months (3.1%) by PCR, and 3% by culture). The positive cases were seen more in female than in male in the age group of ³16 years old. Shigellosis is a sporadic infection all year round but the higher frequency seen in the hot months.

Epidemiologic Investigation of an Outbreak of Shigellosis in Kyongju, Korea / 예방의학회지

OBJECTIVES: This study was carried out to investigate the sources of infection and modes of transmission of an outbreak of shigellosis that occurred among pupils of "M" primary school and residents near the school in Kyongju from Sept. 24 to Oct. 24, 1998. METHODS: The subjects who completed a questionnaire and a rectal swab for microbiologic examinations were 1,534 persons (781 males, 753 females), including 469 pupils of "M" primary school (268 males, 201 females). Bacteriological examinations of underground water and simple piped water were done. RESULTS: The attack rate of diarrhea was 28.7% in the subjects from Sept. 24 to Oct. 24, 1998. There was no difference in attack rate of diarrhea by gender, but it was significantly higher in the pupils of "M" primary school than others (p<0.01). The attack rate of diarrhea by resident areas was no different to the pupils of "M" primary school, but was significantly higher in the residents of Mohwa 2 Ri except pupils that "M" primary school is located in (p<0.01). The distribution of date of onset revealed the exposure date to be Sept, 22 and 23 in consideration of incubation periods and common source outbreak followed propagative spread in the epidemic curve. The major characteristics of diarrhea were watery (89.1%) in nature, 1~3 days (72.5%) in duration, 2~3 times (63.9%) in frequency. The clinical symptoms among the diarrheal cases included abdominal pain (74.1%), fever (56.4%), headache (55.9%), chill (40.4%) and tenesmus (31.4%). CONCLUSIONS: The source of infection was estimated to be contaminated underground water and simple piped water caused by leakage from the cess pool. It is highly necessary that the management of drinking water and cess pools should be done thoroughly.

Epidemiologic Investigation of an Outbreak of Shigella sonnei among Students in Bonghwa, 1999 / 예방의학회지

OBJECTIVES: This study was carried out to investigate the sources of infection and modes of transmission of an outbreak of shigellosis that occurred among students of B middle and high school in Bonghwa, Korea from May 1 to 21, 1999. METHODS: We conducted questionnaires to 468 students, 38 staffs and 9 food handlers twice times (May 6, May 21) for follow up and secondary attack rate. Personal details and history of illness and exposure to particular foods were sought. And we conducted rectal swab for culture to 243 students, 33 staffs and 9 food handlers. Bacteriological examinations of water in the school were done. Cases were identified as subjects who had diarrhea (two or more loose stools in a 24-hour periods) on or after May 1. RESULTS: A total of 307 cases (attack rate: 59.6%) of 515 subjects were identified, including 50 confirmed (46 students and 4 staffs) by S. sonnei. All 9 food handlers denied illness and were had rectal swab for culture at May 6 that were negative for S. sonnei. 146 of 307 reported fever, 156 had tenesmus, 44 reported vomiting, and only 5 of 307 reported blood in the stool. The median duration of diarrhea was 4 days (range: 1-18 days). The mean incubation period until onset of diarrhea was 63 hours (range: 16-144 hours) and the secondary attack rate was 2.8% (43 cases of 1,561 family members). Risk for illness was higher among students who had eaten watered kimchi at March 30 than among those who did not [301(72.7%) of 417 versus 5(9.6%) of 52; RR=7.51; 95% CI=3.26-17.31]. CONCLUSION: The source of infection was estimated to be contaminated watered kimchi by one or two food handler who is presumed to be carrier.