Antimicrobial treatment options for extensively drug-resistant (XDR) shigellosis in men who have sex with men

Introduction

The sexual transmission of Shigella sonnei and Shigella flexneri has been observed since the 1970s between men who have sex with men (MSM) associated with living with HIV, sexually transmitted infection coinfections, recreational drug use and sexual behaviours that risk faecal contamination into the mouth.1 The relatively high consumption of antimicrobials and the horizontal transmission of plasmid-associated antimicrobial resistance genes have facilitated the rapid emergence of resistance in MSM-associated Shigella isolates.2 In 2024, the UK Health Security Agency reported higher and increasing rates of shigellosis among MSM compared with other groups (eg, returning travellers), particularly in geographical regions with high densities of MSM (eg, London, Brighton, and Manchester). Extensively drug-resistant (XDR) Shigella is defined as resistance to all five established antimicrobials historically used to treat shigellosis: azithromycin, ciprofloxacin, ceftriaxone, trimethoprim-sulfamethoxazole and ampicillin.2 XDR sexually transmissible Shigella spp harbouring genes conferring resistance to macrolides…

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