Emergence of Extensively Drug-Resistant Shigellosis — United States, 2011–2023

Shigellosis is a nationally notifiable diarrheal illness caused by gram-negative bacteria. Shigella infection is spread through fecal-oral transmission and sexual contact. Although most infections are self-limited, antibiotics are indicated for severe illness or to reduce transmission in settings with high risk for spread. Since 2015, a growing proportion of cases has been caused by extensively drug-resistant (XDR) Shigella species, defined as being resistant to ampicillin, azithromycin, ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole. No Food and Drug Administration-approved oral antimicrobial agents are available to treat these XDR infections. To describe U.S. trends and epidemiologic characteristics of XDR shigellosis, CDC analyzed Shigella isolates submitted to PulseNet, CDC's molecular surveillance network for enteric pathogens, during January 1, 2011-October 20, 2023; antimicrobial resistance was characterized using whole-genome sequencing data and antimicrobial susceptibility testing. Among 16,788 isolates with resistance data during this period, 510 (3.0%) were XDR. The percentage of XDR isolates increased from 0% during 2011-2015 to 8.5% in 2023. Species information was available for 505 (99%) of 510 XDR isolates; among those, 333 (65.9%) were Shigella sonnei and 172 (34.1%) were Shigella flexneri. Among patients with XDR shigellosis, the median patient age was 41 years (IQR = 31-54 years) and 86.2% were men. Among patients with available travel history, 76.2% (173 of 227) reported no recent domestic travel and 82.4% (169 of 205) reported no recent international travel. Among 116 persons with available HIV status, 54 (46.6%) reported HIV co-infection. Strengthened surveillance, timely reporting, and targeted prevention strategies are needed to limit transmission of XDR Shigella strains.