Table 4. Current international guidelines for the treatment of shigellosis.

Guideline	Last update	Recommendations
IDSA [30]	2001; update in progress	Based on A-1 level of evidence
		[Where: A = good evidence to support a recommendation for use; and I = Evidence from at least one properly randomised, controlled trial]
		Selective therapy should be instituted for shigellosis
		•TMP-SMZ 160 + 800 mg, respectively (paediatric dose 5 and 25 mg/kg, respectively) bd for 3/7 if susceptible)
		or
		•Fluoroquinolone: e.g. ciprofloxacin bd for 3/7 (paediatric dosing not listed); 300 mg ofloxacin; 400 mg norfloxacin; or 500 mg nalidixic acid 55 mg/kg/day for 5/7 •Ceftriaxone 100 mg/kg/day in 1 or 2 divided doses
Therapeutic Guidelines (Australia) [31]	2014	Selective therapy for:
		•Children < 6 years •Institutionalised populations or food handlers •MSM •Immunosuppressed •Patients with severe disease
		Empirical therapy (while awaiting local sensitivities):
		•Ciprofloxacin 500 mg (12.5 mg/kg up to 500 mg) PO bd for 5 days
		or
		•Norfloxacin 400 mg (10 mg/kg up to 400 mg) PO bd for 5 days
		or
		•TMP-SMZ 160 + 800 mg (4 + 20 mg/kg up to 160 + 800 mg) PO bd for 5 days
		Second-line therapy:
		•Azithromycin 500 mg (10 mg/kg up to 500 mg) PO on day 1, then 250 mg (5 mg/kg up to 250 mg) PO daily for a further 4 days
American Academy of Pediatrics [7]	2015	•Do not treat mild episodes •Selected therapy: for those with severe disease or immunosuppressed
		Empirical therapy (while awaiting culture/susceptibility results): any of (not hierarchical):
		•Ciprofloxacin 15 mg/kg bd for 3 days •Azithromycin 12 mg/kg on day 1; then 6 mg/kg on days 2–4 (total course: 4 days) •Parenteral ceftriaxone (50–75 mg/kg daily) for 2–5 days – for seriously ill patients
		The guidelines also note that oral cephalosporins (cefixime) have been used successfully in treating shigellosis in adults.
BMJ Clinical Evidence [32]	2016	Selective therapy for:
		•Malnourished, immunocompromised or elderly patients; food handlers, health care workers •Severe disease: defined as bloody diarrhoea with cramping while systemically unwell
		Empirical therapy (while awaiting local sensitivities):
		•Ciprofloxacin: 15 mg/kg (max 500 mg) PO bd
		or
		•Norfloxacin: 10 mg/kg (max 400 mg) PO bd
		Second-line therapy:
		•Ceftriaxone: 50–100 mg/kg IM once daily (adults: 1–2 g intramuscularly once daily)
		or
		•Azithromycin: 6–20 mg/kg PO once daily
		All therapies state ‘consult with a specialist for guidance on duration of treatment’
British National Formulary [33]	2016	Ciprofloxacin 20 mg/kg bd (higher dose than 15 mg/kg previously recommended)