Max 500 mg/day · Duration: 3 days · Preferred oral agent when local resistance is not expected — combine with ORS
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Ceftriaxone • i.v. • 50–75 mg/kg/day • 1×/day
Max 2000 mg/day · Duration: 2–5 days · May shorten to 2 days if afebrile after 48 h without bacteremia or immunodeficiency
• Ceftriaxone: vomiting or inability to take oral therapy; severe or toxic illness; suspected bacteremia; infants <3 months; hospitalized children; oral treatment failure at 48 h (WHO, CDC, StatPearls).
• Ciprofloxacin: when Shigella is susceptible on culture or per local epidemiology (WHO first-line for dysentery in many endemic settings); alternative if azithromycin contraindicated or failed — off-label in children.
• Multidrug-resistant (MDR) or extensively drug-resistant (XDR) Shigella: do not continue empiric therapy if failing — tailor to susceptibilities; consult infectious diseases; rising XDR rates in US/Europe (CDC MMWR 2025).
• Acquisition in India, Pakistan, or Bangladesh: high resistance to azithromycin and ciprofloxacin — consider cefixime or ceftibuten per susceptibility, not routine empiric macrolide/fluoroquinolone (StatPearls).
• Alternate azithromycin regimen in some references: 12 mg/kg day 1, then 6 mg/kg days 2–4 (5 days total) — use if 3-day course fails and isolate remains susceptible.
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Clinical notes
• Antibiotic therapy is recommended for confirmed or strongly suspected shigellosis — shortens duration of illness, reduces transmission, and prevents complications; always combine with oral rehydration (ORS) (WHO, CDC, ESPGHAN, AAP).
• Obtain stool culture before or at start of antibiotics; antimicrobial susceptibility testing is essential to guide therapy and detect resistance — reassess at 48 h if no clinical improvement (CDC, WHO).
• MDR/XDR Shigella (resistance to ampicillin, TMP-SMX, azithromycin, ciprofloxacin, ceftriaxone) is increasing — switch therapy based on antibiogram; public health notification per local requirements (CDC 2024–2025).
• Hospital admission: severe dehydration or shock; persistent vomiting precluding oral intake; toxic appearance or sepsis; infants <3–6 months; immunocompromised hosts; bacteremia; or failed outpatient therapy (WHO, AAP).
• Avoid anti-motility agents (loperamide, diphenoxylate/atropine) — may prolong illness and worsen complications; do not withhold feeding once rehydrated (CDC, NICE).
• CDC — Shigella clinical overview and treatment (2024)
• CDC MMWR — Extensively drug-resistant Shigellosis, United States (2025)
• WHO — The treatment of diarrhoea (dysentery / Shigella) (2022)
+ 4 more
• ESPGHAN / NASPGHAN — Universal recommendations for management of acute diarrhea (2018)
• ESPID — Bacterial diarrheas and antibiotics (European recommendations) (2008)
• AAP Red Book — Shigella infections (2024)
• NICE NG84 — Diarrhoea and vomiting (dysentery principles) (2017)
