title: Antimicrobial-resistant Shigella sonnei: limited antimicrobial treatment options for children and challenges of interpreting in vitro azithromycin susceptibility.
abstract: BACKGROUND
  Antimicrobial-resistant Shigella sonnei is a growing problem in the United States and poses treatment challenges particularly among children. Azithromycin is recommended as an alternative oral agent for shigellosis.
  
  
  METHODS
  All isolates of Shigella submitted to Johns Hopkins clinical laboratory during the outbreak year (2002) were compared with a historical comparison group (1996-2000). Isolates were considered multiresistant if they were resistant to ampicillin and trimethoprim-sulfamethoxazole (TS). Selected outbreak and reference isolates were tested for azithromycin susceptibility by E-test, disk diffusion and broth dilution methods.
  
  
  RESULTS
  Between 1996-2000, among the 111 isolates submitted, 63% were from pediatric patients; 63% of isolates were resistant to ampicillin and 12% to TS. In 2002, among the 205 isolates submitted, 82% were from pediatric patients; 91% isolates were resistant to ampicillin and 67% to TS. The proportion of multiresistant isolates increased from 6% in 1996 to 65% in 2002 (P < 0.05). Azithromycin susceptibility by E-test and disk diffusion demonstrated 2 zones of inhibition for S. sonnei. Interpretation using the inner zone resulted in higher MICs (minimal inhibitory concentration) compared with the outer zones by E-test (P < 0.0001) and disk diffusion (P < 0.0001).
  
  
  CONCLUSIONS
  With increasing interest in using azithromycin for shigellosis, clinical laboratories should be aware of the interpretation difficulty caused by the dual-zone phenomenon seen with E-test and disk diffusion methods for S. sonnei.
authors.affiliation: Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA. sjain5@jhmi.edu
authors.forename: Sanjay K
authors.initials: SK
authors.lastname: Jain
authors.forename: Amita
authors.initials: A
authors.lastname: Gupta
authors.forename: Brian
authors.initials: B
authors.lastname: Glanz
authors.forename: James
authors.initials: J
authors.lastname: Dick
authors.forename: George K
authors.initials: GK
authors.lastname: Siberry
mesh_terms: D000293:Adolescent; D000667:Ampicillin / Q000494:pharmacology; D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use; D017963:Azithromycin / Q000494:pharmacology / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D024901:Drug Resistance, Multiple, Bacterial; D004405:Dysentery, Bacillary / Q000453:epidemiology* / Q000382:microbiology; D006801:Humans; D007223:Infant; D008826:Microbial Sensitivity Tests / Q000379:methods; D012764:Shigella sonnei / Q000187:drug effects*; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000494:pharmacology
chemical_list: D000900:Anti-Bacterial Agents; D000667:Ampicillin; D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D017963:Azithromycin