多重抗藥性志賀氏菌在歐盟/歐洲經濟區的同性戀、雙性戀和其他男男性行為者中傳播

2023 年 7 月 18 日 / 流行病學更新 / ECDC

自 2023 年 4 月以來，歐洲疾病預防與控制中心 (ECDC) 已報告了 300 多例志賀氏菌病病例，其中許多病例患有多重抗藥性宋內志賀氏菌感染。

這些病例與七個國家和國際不同的微生物群有關，傳播鏈主要但不限於同性戀、雙性戀和其他男男性行為者 (gbMSM)。 比利時（26 例）、丹麥（13 例）、德國（33 例）、愛爾蘭（50 例）、荷蘭（21 例）、西班牙（> 60 例）和美國（106 例）已通報病例。 大多數病例記錄在 2022 年至 2023 年期間，但有些病例可以追溯到 2016 年。

2020 年至 2022 年期間，gbMSM 中廣泛抗藥性的宋內志賀氏菌感染有所增加。

這七個群聚中的所有菌株均顯示出對一線和二線抗生素的抗藥性，例如第三代頭孢菌素(cephalosporins)、氟喹諾酮類 (fluoroquinolones)、磺胺甲噁唑 (sulfamethoxazole) 和甲氧芐啶(trimethoprim)。 特別值得關注的是與這些群聚相關的一些菌株對阿奇黴素的抗藥性，因為這限制了有效治療的選擇。

感染和症狀

志賀氏菌症是一種由志賀氏菌引起的胃腸道感染。 它是透過攝入被人類糞便污染的物質、透過直接口腔肛門（或人與人）接觸或接觸過糞便的手/物體而感染的。 感染的劑量極小，只要 10−100 個生物體，使得志賀氏菌症容易傳播。 受污染的食物或水也可能導致感染。 症狀包括急性腹瀉，常伴隨發燒、腹痛和血便。 大多數感染具有自限性，持續約 5−7 天，不需要抗菌治療。 治療可將症狀持續時間縮短 1-2 天，並可能降低進一步傳播的可能性。 也可能發生嚴重感染，尤其是免疫功能低下的患者。

gbMSM 中志賀氏菌病和其他性傳播感染 (STI) 進一步傳播的風​​險隨著性接觸次數的增加而增加 – 例如 在同志驕傲節和其他國際活動期間。 志賀氏菌病在 gbMSM 的傳播也增加了 gbMSM 社群以外的密切接觸者的感染風險。

防治

為了最大限度地降低性活動中感染志賀氏菌的風險，建議採取更安全的性行為並確保良好的個人衛生。*

如果一個人出現胃腸道症狀，建議他們避免性活動，特別注意個人衛生，並尋求醫療保健以接受胃腸道病原體和其他性傳播感染的檢測。 重要的是要告知醫生感染可能是透過性行為獲得的。 有胃腸道症狀的人不應在餐飲場所處理或準備食物，並應避免在有胃腸道症狀時使用公共泳池、水療中心和熱水浴缸。

此外，被診斷患有志賀氏菌病的gbMSM 應在症狀完全消失後至少7 天內避免性活動，並在性交過程中避免口肛接觸四到六週，因為志賀氏菌可以在糞便中排出長達六週。 此外，應通知並鼓勵診斷為志賀氏菌病的患者的性伴侶聯繫醫療保健提供者，特別是如果他們在需要與公眾密切互動的環境中工作（例如醫療保健、兒童保育、餐飲場所）或如果他們出現感染症狀。

提高臨床醫生和微生物實驗室對多重抗藥性志賀氏菌國際傳播的認識，並確保對 gbMSM 胃腸炎病例進行志賀氏菌藥敏檢測，以指導抗菌治療非常重要。 醫生應該意識到，在年輕成年男性中，感染途徑可能是性行為（尤其是那些沒有前往已知志賀氏菌病風險增加的國家旅行史的人）。 必須向公共衛生當局報告志賀氏菌病例，並將志賀氏菌分離株送至國家參考實驗室，以監測抗菌素抗藥性的發展，並儘早發現和調查治療失敗的情況。 這些應反映在國家和國際治療指引的更新中。

*在 gbMSM 社區中適當使用針對志賀氏菌感染的保護措施包括用於指交或拳交的一次性手套、口交肛交期間的牙壩，以及在肛交和口交之間更換保險套。 建議不要共用性玩具，並確保使用後以及伴侶之間進行適當的清潔和消毒。 在性接觸前後洗手、生殖器和肛門區域也很重要。

臨床管理和預防訊息

有關臨床管理和預防實踐的更多詳細資訊可以在以下文件中找到：

愛爾蘭健康保護監測中心，2023 年6 月15 日。在目前與同性戀、雙性戀和男男性行為者 (gbMSM) 相關的抗菌藥物抗藥性志賀氏菌屬背景下，關於愛爾蘭志賀氏菌病管理方面的建議。

美國疾病預防控制中心 (CDC) 健康諮詢(，2023 年 2 月 24 日。美國廣泛抗藥性志賀氏菌病的增加。

ECDC 快速風險評估，2022 年 2 月 23 日。男男性行為者中廣泛抗藥性的宋內志賀氏菌感染增加。

Spread of multidrug-resistant Shigella in EU/EEA among gay, bisexual and other men who have sex with men

18 Jul 2023 / Epidemiological update / ECDC

Since April 2023, over 300 shigellosis cases, many with multidrug-resistant Shigella sonnei infections, have been reported to the European Centre for Disease Prevention and Control (ECDC).

The cases are linked to seven national and international distinct microbiological clusters, with chains of transmission largely, but not exclusively, among gay, bisexual and other men who have sex with men (gbMSM). Cases have been reported in Belgium (26), Denmark (13), Germany (33), Ireland (50), the Netherlands (21), Spain (> 60), and the United States (106). Most cases have been recorded during the period 2022−2023, but some date back to 2016. 

An increase in extensively drug-resistant Shigella sonnei infections among gbMSM was already noted during the period 2020−2022 

All strains in these seven clusters show resistance to first and second-line antibiotics, such as third-generation cephalosporins, fluoroquinolones, sulfamethoxazole, and trimethoprim. Of particular concern is resistance to azithromycin in some of the strains related to these clusters, as this limits the options for effective treatment. 

Infection and symptoms

Shigellosis is a gastrointestinal infection caused by Shigella bacteria. It is caught by ingesting material contaminated by human faeces, via direct oral-anal (or person-to-person) contact or hands/objects which have been in contact with faeces. The infective dose is extremely small, 10−100 organisms, making shigellosis easily transmissible. Infection can also result from contaminated food or water. Symptoms include acute diarrhoea, often accompanied by fever, abdominal pain and the presence of blood in stools. Most infections are self-limiting, lasting around 5−7 days, and do not require antimicrobial treatment. Treatment decreases the duration of symptoms by 1−2 days and may reduce the likelihood of onward transmission. Severe infection can also occur, especially in immunocompromised patients. 

The risk of further transmission of shigellosis and other sexually transmitted infections (STIs) among gbMSM increases with the number of sexual contacts − e.g. during Pride and other international events. Spread of shigellosis among gbMSM also increases the risk of infection for their close contacts outside the gbMSM community. 

Prevention and control

To minimise the risk of acquiring Shigella infection during sexual activity, it is recommended to practice safer sex and ensure good personal hygiene.*

If a person develops gastrointestinal symptoms, it is recommended that they refrain from sexual activity, pay extra attention to personal hygiene and seek healthcare to get tested for gastrointestinal pathogens and other STIs. It is important to inform the physician that the infection may have been acquired through sexual activity. People with gastrointestinal symptoms should not handle or prepare food in catering establishments, and should avoid using public pools, spas and hot tubs while they have gastrointestinal symptoms. 

Furthermore, gbMSM who have been diagnosed with shigellosis should avoid sexual activity for at least seven days after symptoms have completely disappeared and oral-anal contact during sex for four to six weeks, given that Shigella can be shed in stools for up to six weeks. In addition, sexual partners of patients diagnosed with shigellosis should be notified and encouraged to contact a healthcare provider, in particular if they work in settings requiring close interaction with the general public (e.g. healthcare, child-care, food catering establishments) or if they develop symptoms of infection.  

It is important to increase awareness among clinicians and microbiology laboratories of the international spread of multidrug-resistant Shigella bacteria and to ensure antimicrobial susceptibility testing of Shigella for cases of gastroenteritis in gbMSM, in order to guide antimicrobial treatment. Physicians should be aware that among young adult males the route of acquisition can be sexual (especially among those without travel history to a country with known increased risk of shigellosis). It is essential to report shigellosis cases to public health authorities and send Shigella isolates to national reference laboratories in order to monitor the development of antimicrobial resistance and enable the early detection and investigation of treatment failures. These should be reflected in updates of national and international treatment guidelines. 

*The appropriate use of protective measures against Shigellosis infection among the gbMSM community includes disposable gloves for fingering or fisting, dental dams during oral-anal sex, as well as changing condoms between anal and oral sex. It is recommended to not share sex toys and to ensure proper cleanin