Shigella-Associated Diarrhoea in Children in Tripoli - Libya

Khalifa Sifaw Ghenghesh1*, MSc, PhD, DipBact

‫ﺧﻠﻴﻔﺔ ﺳﻴﻔﺎو ﻗﻨﻘﻴﺶ‬
Fawzi Ramadan Bara2, MBBCh, CABP
‫ﻓﻮزى رﻣﻀﺎن ﺑﺎرﻩ‬
Belquis Hassan Bukris2, MBBCh
‫ﺑﻠﻘﻴﺲ ﺣﺴﻦ ﺑﻮﺧﺮﻳﺺ‬
Salaheddin Shaban Abeid1, BSc
‫ﺻﻼح اﻟﺪﻳﻦ ﺷﻌﺒﺎن ﻋﺒﻴﺪ‬

1. Dept. of Medical Microbiology, Faculty of Medicine, Al-Fateh University of Medical

Sciences, Tripoli - Libya.
2. Aljala Children Hospital, Tripoli - Libya.

*Corresponding Author
Corresponding Address:
Dr. Khalifa Sifaw Ghenghesh,
Associate Professor,
P.O. Box 80013,
Tripoli - Libya
Fax: +218 21 360 29 71
e-mail: ghenghesh_micro@yahoo.com

To cite this paper:

Ghenghesh KS., Bara F., Bukris B., Abeid SS. 1997. Shigella-Associated Diarrhoea in Children in
Tripoli-Libya. Saudi Med J; 18: 557-559.
Abstract:
Objectives: To determine the prevalence of Shigella species in Libyan children with diarrhoea
and in controls and susceptibility of the isolates to antibiotics.
Methods: between September, 1992 and August, 1993, stool specimens from 157 children with
diarrhoea (cases) and 157 age- and sex-matched controls were examined for the presence of
Shigella. The children aged between a few days and 3 years.
Results: Shigella spp. were isolated from 9(5.7%) cases and 2(1.3%) controls (odds ratio,4.7; P =
0.03) with Shigella flexneri type2 the predominating serotype. Most (56%) of Shigella strains
from cases were isolated in autumn. The prevalence of shigellae were significantly higher in
children older than one year of age and were not isolated from children less than six months old.
All (100%) cases were on artificial feeding, 78% used untreated water for drinking. Blood and
mucus were observed in the stool of 56% of cases. Clinical examination revealed 67% with fever
and 33% with vomiting. One patient diagnosed as septicaemic and another one as having
generalized convulsions. All isolates were sensitive to ceftriaxone, ciprofloxacin, gentamicin,
nalidixic acid, and norfloxacin. Drug resistance to 3 or more drugs was found in 45% of the
isolates.
Conclusions: Because most of the isolates were resistant to trimethoprim-sulphamehtoxazole
(64%), this antibiotic should no longer be considered the drug of choice in the treatment of
Shigella-associated diarhoea in Libya. The present study shows that Shigella-associated
diarrhoea in children is still a public health problem in Libya and proper measures to combat it
should be taken.
Key words: Shigella, diarrhoea, antibiotic sensitivity, children
INTRODUCTION:
Shigella continues to be a common and important cause of diarrhoea, primarily in pre-
school children, throughout the world.1 In developing countries shigellae are leading causes of
infant diarrhoea and mortality.2,3,4 Reports on the incidence and epidemiology of Shigella in
Libya are lacking and in Northern African countries are few. The aim of the present study was to
determine the prevalence of Shigella species in chlidren with diarrhoea and in controls in Tripoli
- Libya and the sensitivity of the Shigella isolates to the commonly used antibiotics.

MATERIALS AND METHODS:

1. Patients:
One hundred and fifty seven children with diarrhoea (cases) and 157 age- and sex-
matched controls, attending the outpatients clinic of Aljala Children Hospital, Tripoli were
included in the present study. The age of children ranged from a few days to 3 years. Most of the
children (85%) were less than one year old. Diarrhoea was defined as three or more liquid stools
per day for less than two weeks. Controls were children attending the clinic for reasons other
than diarrhoea and did not take antibiotics 2 weeks prior to stool collection. Children were
examined clinically and parents were asked for source of drinking water, type of feeding, number
of stools per day, duration of diarrhoea, taking of antibiotics and history of travel abroad. This
study was conducted between September, 1992 and August, 1993.

2. Microbiology:
In addition to Shigella spp., Aeromonas, Campylobacter, Salmonella, and Yersinia
enterocolitica were also identified using standard techniques.5 Campylobacter was looked for in
95 cases and 95 controls.
To isolate shigellae, stool samples were plated onto MacConkey and Salmonella-Shigella
agars and incubated at 37oC for 24-48 hours. Non-lactose fermenting colonies were identified
using API 20E. Isolates identified as Shigella spp. were serogrouped and serotyped using
commercially available antisera (Wellcome Diagnostics, UK). Stools were also examined for the
presence of frank blood and mucus.
The disc diffusion method6 was used to determine the sensitivity of the isolates to the
following antibiotics (Oxoid, UK): ampicillin, chloramphenicol, ceftriaxone, ciprofloxacin,
gentamicin, kanamycin, nalidixic acid, norfloxacin, streptomycin and trimethoprim-
sulphamethoxazole.

RESULTS:
Shigella spp. were isolated from 9(5.7%) cases and from 2(1.3%) controls (odds ratio,
4.7; P = 0.03). Of the children with diarrhoea, shigellae were isolated equally from both sexes (5
from 85 males and 4 from 72 females). A total of 6 Sh. flexneri (all from patients) and 5 Sh.
sonnei (3 from patients) were isolated. Of the 6 strains of Sh. flexneri, 4 were of Sh. flexneri type
2, 1 of Sh. flexneri type 1 and 1 of Sh. flexneri type 3. Of the 9 Shigella strains from cases,
5(56%) were isolated in autumn, 1(11%) in winter, 1(11%) in spring and 2(22%) in summer.
Both isolates from controls were detected in autumn. Other enteropathogens include, Aeromonas
spp. from 15% of cases and 18% of controls, Campylobacter spp. from 6% and 3%, Salmonella
spp. from 11% and 4%, and Yersinia enterocolitica from 0.06% and 0.0% respectively.
Three Shigella strains were isolated from 50 children with diarrhoea aged 6 months to
one year, 6 strains from 24 cases aged more than one year old and none were isolated from
children less than 6 months old. All patients (100%) were on artificial feeding, 7 (78%) used
untreated drinking water, 1 took Bactrim 2 days prior to stool collection and none travelled
abroad in the last 30 days from stool collection. Blood and mucus were seen in the stool of 5
(56%) patients with diarrhoea. Clinical examination showed 6(67%) with fever and 3(33%) with
vomiting, 1 (11%) diagnosed as septicaemic and 1 (11%) as having generalized convulsions.
Clinical findings are shown in Table.
Of the 11 Shigella strains, 36% were resistant to ampicillin, 27% to chloramphenicol, 9%
to kanamycin, 91% to streptomycin and 64% to trimethoprim-sulphamethoxazole. All isolates
were sensitive to ceftriaxone, ciprofloxacin, gentamicin, nalidixic acid and norfloxacin. Drug
resistance to 3 or more drugs was shown by 45% of strains.
 Table: Information about Libyan children with diarrhea and their Shigella isolates
Length of Faeces with Presence of Species and
Patient Sex Age Month of diarrhea Episode serotype of
(months) occurrence (days) per day Mucus Blood Fever Vomiting Shigella
1 F 11 Sep 1 5 + + − − S. sonnei
2 F 30 Sep 2 3 − − − − S. flexneri type 2
3 M 27 Oct 1 6 − − + − S. sonnei
4 F 18 Oct 1 8 − − − − S. flexneri type 2
5 F 36 Oct 2 5-7 + + + − S. flexneri type 2
6 M 7 Dec 7 7-8 − − + − S. flexneri type 1
7 M 7 Apr 1 10 + + + + S. flexneri type 2
8 M 13 Jun 10 6-7 + + + + S. flexneri type 3
9 M 32 Jul 1 4 + + + + S. sonnei
DISCUSSION:
In the present study Sh. flexneri was found to be the most frequent isolate in children with
Shigella-associated diarrhoea in Tripoli with type 2 being the predominating serotype. These
findings conform with studies in Algeria,7 Jordan,8 Kuwait,9 Saudi Arabia,10 and other
developing countries.11,12 In some countries, shigellae were isolated more often from children
greater than 2 years of age than from younger children.13,14 In our experience Shigella spp. were
isolated only from children who were not breast-fed and significantly more frequently from
children older than one year of age. Human milk has been shown to protect against severe
shigellosis in children up to 35 months of age.15,16 Studies showed that all milk samples obtained
from mothers contained antibodies to antigens encoded by the large virulence plasmid in strains
of Shigella.17 In addition to this, children more than one year old are capable of moving around
and becoming into more direct contact with other children and adults which expose them, under
certain circumstances, to infection with these organisms.
Food and waterborne outbreaks of shigellosis have been reported from different parts of
the world.18,19 Most (78%) of our patients with stools positive for Shigella used untreated
drinking water supplies. In a waterborne outbreak of shigellosis, occured in 1995, in a Libyan
family of 8 members, we isolated Sh. flexneri from 5 members and from the contaminated water
used for drinking by all members of this family (K.S. Ghenghesh, unpublished data).
We found blood and mucus in the stools of 56% and fever in 67% of our patients. These
clinical findings are in line with those reported by other investigators in under-developed
countries.11,12
Several investigators reported cases of generalized convulsions associated with
shigellosis.9,20,21 Of our patients, only one (11%) had generalized convulsions and we believe this
the first time such a case to be reported from Libya. Daoud et al.9 studied 93 children with
shigellosis and found 15% of the patients developed generalized convulsions. They reported that
neither specific diagnostic procedures nor drug therapy are usually necessary due to the benign
and self-limiting nature of convulsions associated with shigellosis.
Antibiotics can be beneficial in the treatment of Shigella-associated diarrhoea, however
trimethoprim-sulphamethoxazole should no longer be considered the drug of choice as the
majority (64%) of the local isolates were resistant to this antibiotic. Several studies from the
Middle East reported the same findings.9,10 al-Eissa et al.10 from Saudi Arabia reported 74% of
their Shigella isolates were resistant to trimethoprim-sulphamethoxazole. All our isolates were
sensitive to ceftriaxone, ciprofloxacin, nalidixic acid, norfloxacin and most of them to ampicillin
thus, should be considered the drugs of choice for treatment of diarrhoea due to shigellae.
However, susceptibility testing before administring antibiotics is recommended.
The present study shows that Shigella-associated diarrhoea in children is still a public
health problem in Libya and proper measures to combat it should be taken.

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Bangladeshi children. Pediatrics 1992; 90: 406-411.
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 ‫اﻻﺳﻬﺎل ﻧﺘﻴﺠﺔ اﻧﻮاع اﻟﺸﻴﺠﻼت ﻓﻲ اﻻﻃﻔﺎل ﻓﻲ ﻃﺮاﺑﻠﺲ ‪ -‬ﻟﻴﺒﻴﺎ‬
‫ﻣﻠﺨﺺ‪:‬‬
‫اﻷهﺪاف‪ :‬ﺗﺤﺪﻳﺪ ﻣﺪى اﻧﺘﺸﺎر اﻧﻮاع اﻟﺸﻴﺠﻼت ﻓﻲ اﻻﻃﻔﺎل اﻟﻠﻴﺒﻴﻴﻦ اﻟﻤﺼﺎﺑﻴﻦ ﺑﺎﻻﺳﻬﺎل واﻻﻃﻔﺎل اﻻﺻﺤﺎء وﺣﺴﺎﺳﻴﺔ اﻧﻮاع‬
‫اﻟﺸﻴﺠﻼت اﻟﻤﻌﺰوﻟﺔ ﻟﻠﻤﻀﺎدات اﻟﺤﻴﻮﻳﺔ‪.‬‬
‫اﻟﻄﺮق‪ :‬ﻓﻰ اﻟﻔﺘﺮة ﻣﺎﺑﻴﻦ ﺳﺒﺘﻤﺒﺮ ‪ 1992‬و اﻏﺴﻄﺲ ‪ 1993‬ﺗﻢ اﻟﻜﺸﻒ ﻋﻦ وﺟﻮد اﻧﻮاع اﻟﺸﻴﺠﻼت ﻓﻰ ﻋﻴﻨﺎت ﺑﺮاز ﻣﻦ ‪ 157‬ﻃﻔﻞ‬
‫ﻣﺼﺎب ﺑﺎﻻﺳﻬﺎل )ﺣﺎﻻت( و‪ 157‬ﻃﻔﻞ ﺳﻠﻴﻢ ﻣﻦ ﻧﻔﺲ اﻟﻌﻤﺮ واﻟﺠﻨﺲ‪ .‬ﻳﺘﺮواح ﻋﻤﺮ اﻻﻃﻔﺎل ﻣﺎﺑﻴﻦ ﻋﺪة اﻳﺎم وﺛﻼﺛﺔ ﺳﻨﻮات‪.‬‬
‫اﻟﻨﺘﺎﺋﺞ‪ :‬ﺗﻢ ﻋﺰل اﻧﻮاع اﻟﺸﻴﺠﻼت ﻣﻦ ‪ (%5.7) 9‬اﻃﻔﺎل ﻣﺼﺎﺑﻴﻦ ﺑﺎﻻﺳﻬﺎل وﻣﻦ ‪ (%1.3) 2‬اﻃﻔﺎل اﺻﺤﺎء ﻣﻊ ﺳﻴﺎدة اﻟﻤﺼﻞ‬
‫ﺷﻴﺠﻼ ﻓﻠﻜﺴﻨﺮى ﻧﻮع ‪ . 2‬اﻏﻠﺐ ﺳﻼﻻت اﻟﺸﻴﺠﻼت ﺗﻢ ﻋﺰﻟﻬﺎ ﻓﻰ ﻓﺼﻞ اﻟﺨﺮﻳﻒ‪ .‬اﻧﺘﺸﺎر اﻟﺸﻴﺠﻼت آﺎن اﻋﻠﻰ ﻣﻌﻨﻮﻳﺎ ﻓﻰ اﻻﻃﻔﺎل‬
‫اآﺒﺮ ﻣﻦ ﺳﻨﺔ وﻟﻢ ﻳﺘﻢ ﻋﺰﻟﻬﺎ ﻣﻦ اﻃﻔﺎل اﻗﻞ ﻣﻦ ﺳﺘﺔ اﺷﻬﺮ‪ .‬آﻞ اﻟﺤﺎﻻت )‪ (%100‬ﺗﻨﺎوﻟﺖ ﺗﻐﺬﻳﺔ ﺻﻨﺎﻋﻴﺔ‪ ،‬و‪ %78‬اﺳﺘﺨﺪﻣﺖ ﻣﻴﺎﻩ‬
‫ﺷﺮب ﻏﻴﺮ ﻣﻌﺎﻟﺠﺔ‪ .‬ﺗﻢ ﻣﺸﺎهﺪة دم وﻣﺨﺎط ﻓﻰ ﺑﺮاز ‪ %56‬ﻣﻦ اﻟﺤﺎﻻت‪ .‬اﻟﻜﺸﻒ اﻟﻜﻠﻴﻨﻴﻜﻰ اﻇﻬﺮ ‪ %67‬ﻣﻦ اﻟﺤﺎﻻت ﻣﺼﺎﺑﺔ‬
‫ﺑﺎﻟﺤﻤﻰ و‪ %33‬ﺑﺎﻟﻘﻰء‪ .‬ﺣﺎﻟﺔ واﺣﺪة ﺗﻢ ﺗﺸﺨﻴﺼﻬﺎ ﻋﻠﻰ اﻧﻬﺎ ﺗﻌﺎﻧﻰ ﻣﻦ ﺗﻌﻔﻦ اﻟﺪم واﺧﺮى ﻟﺪﻳﻬﺎ اﻋﺮاض ﺗﺸﻨﺞ ﻋﺎم‪ .‬آﻞ اﻟﺸﻴﺠﻼت‬
‫اﻟﻤﻌﺰوﻟﺔ آﺎﻧﺖ ﺣﺴﺎﺳﺔ ﻟﻠﻤﻀﺎدات اﻟﺤﻴﻮﻳﺔ ﺳﻔﺘﺮﻳﺎآﺴﻮن‪ ،‬ﺳﻴﺒﺮوﻓﻠﻮآﺴﺎﺳﻴﻦ‪ ،‬ﺟﻨﺘﺎﻣﻴﺴﻴﻦ‪ ،‬ﻧﺎﻟﻴﺪﻳﻜﺴﻴﻚ اﺳﻴﺪ‪ ،‬وﻧﻮرﻓﻠﻮآﺴﺎﺳﻴﻦ‪.‬‬
‫ﻣﻘﺎوﻣﺔ ‪ 3‬ﻣﻀﺎدات ﺣﻴﻮﻳﺔ او اآﺜﺮ آﺎن ﻓﻰ ‪ %45‬ﻣﻦ اﻟﺸﻴﺠﻼت‪.‬‬
‫اﻻﺳﺘﻨﺘﺎﺟﺎت‪ :‬ﻧﻈﺮا ﻻن اﻏﻠﺐ اﻟﺸﻴﺠﻼت اﻟﻤﻌﺰوﻟﺔ آﺎﻧﺖ ﻣﻘﺎوﻣﺔ ﻟﻠﺘﺮاﻳﻤﺜﻮﺑﺮﻳﻢ‪-‬ﺳﻠﻔﺎﻣﻴﺜﻮآﺴﺎزول )‪ ،(%64‬ﻓﻬﺬا اﻟﻤﻀﺎد اﻟﺤﻴﻮي‬
‫ﻳﺠﺐ اﻻ ﻳﻌﺘﺒﺮ ﻣﻦ اﻻدوﻳﺔ اﻟﺘﻰ ﺗﺴﺘﺨﺪم ﻓﻰ ﻋﻼج اﻻﺳﻬﺎل اﻟﺬى ﺗﺴﺒﺒﻪ اﻟﺸﻴﺠﻼت ﻓﻰ ﻟﻴﺒﻴﺎ‪ .‬هﺬﻩ اﻟﺪراﺳﺔ اوﺿﺤﺖ ان اﻻﺳﻬﺎل‬
‫اﻟﺬى ﺗﺴﺒﺒﻪ اﻟﺸﻴﺠﻼت ﻻﻳﺰال ﻣﺸﻜﻠﺔ ﺻﺤﻴﺔ ﻋﺎﻣﺔ ﻓﻲ ﻟﻴﺒﻴﺎ وان اﻻﺟﺮاءات اﻟﻤﻨﺎﺳﺒﺔ ﻟﻌﻼج هﺬﻩ اﻟﻤﺸﻜﻠﺔ ﻳﺠﺐ اﺧﺬهﺎ‪.‬‬