BACILLARY DYSENTERY TREATMENT

Dysentery must now be regarded as an endemic infection in large cities. In all parts of Great Britain notifications of the disease have increased greatly in recent years, and in view of the mild nature of the symptoms it may be assumed that the notifications represent but a proportion of the actual incidence. It is no longer true to say that the maximal incidence is always in the summer months. Notifications have been excessive throughout the year, and, in some years the peak has occurred in the first quarter. A large proportion of the patients are children under five years of age.. It is not sufficiently well known that the presence of blood or mucus is not a necessary feature of the illness, and in many cases a few loose stools may comprise the whole complaint. As a result, many infections are missed and so increase the spread of the disease. Some convalescents may become carriers for long periods of time and act as a source of infection.
Dysentery is seldom an " individual " infection. When a case is diagnosed in a family it is usual to find some other members with the organism in their stools. Outbreaks in day nurseries and children's homes are commonplace— and here again the diagnosis of one case will often unmask a widespread epidemic of carriers.
Unlike typhoid fever, the infection remains almost entirely localized to the bowel and agglutinins do not appear in the blood to any great degree. Apart from toxic absorption due to bowel ulceration, the main danger in severe infec­tions arises from exhaustion of the patient by loss of fluid and salt in watery stools. Such a degree of severity is fortunately unusual.
Diagnosis depends on accurate bacteriological examination. For this purpose a rectal swab outfit is used since by this means a suitable specimen can be secured quickly and easily. No time should be lost between obtaining the specimen and submitting it to the laboratory. Rectal swabbing and the use of selective media have added great precision to the diagnosis.
Dysentery is a notifiable disease. In Britain Flexner and Sonne types of Sh. dysenteries account for nearly all of the infections. The incubation period is two to five days.Prevention and Epidemiological Control.—The control of ward and institutional outbreaks often presents an overwhelming task. All further admissions should be stopped and a close search made for carriers and missed cases, both among patients and staff. The bacteriologist should be brought into consultation at once, for the addition to his routine work will be considerable and he should therefore be forewarned. Plans should also be prepared for the separation of those found to give positive results and arrangements made for the sterilization of food utensils, bed-pans, etc. Soiled napkins should be dropped direct into covered pails containing lysol. The nursing staff must be instructed regarding the method of transference of the infection and there must be great persistence in a campaign for repeated hand washing and a careful ritual of personal hygiene. The nurses should also be taught that the simplest case of diarrhoea may well be dysentery and that the occurrence of a loose or green stool should be reported at once.
The extent to which bacteriological freedom from infection prior to dis­charge is enforced must vary from case to case. When the patient is to return to a closed community—service personnel and children from nurseries—and when there is close association with food preparation it is desirable to obtain at least three negative bacteriological reports. When the patient is returning home, however, it is unnecessary to carry out protracted examinations, and the verage case may be regarded as free from infection by the eighth to tenth day of illness.
Curative Treatment.—The majority of cases/due to Sonne and Flexner infections, run a mild course of three or four days and call for little medicinal treatment. The administration of specific serum to cases of Shiga infection is of undoubted value. The dose is up to 100 ml. and the injection should be given intravenously after suitable precautions (p. 50).
SuJphonamides.—In most parts of Great Britain the endemic strains of shigella have now acquired resistance to sulphonamides, which are therefore no longer effective. In areas where this is not the case, sulphadiazine will prove as satisfactory as sulphaguanidine or succinylsulphathiazole.
Antibiotics.—Tetracyclines are effective in securing bacteriological clearance and do so in low dosage. This is undoubtedly important in dealing with food-handlers, etc. They should be used with caution in hospital wards, where the danger of superinfection of the bowel with resistant staphylococci is very real. It is doubtful if this complication will be encountered in general practice. The period of treatment should not exceed five days.
General Management.—The patient must be confined to bed and kept warm from the first symptom of the disease. When the attack is severe the bed-pan should be employed in order to avoid contamination of lavatory seats, etc. When the call to stool is incessant, the bed-pan may be dispensed with and the motions received into tow, which, when soiled, is collected and burnt.
In severe cases it will be necessary to correct the electrolyte disturbance by intravenous infusions. Apart from this, however, there is no need for special dietetic restrictions.
Carriers.—Persistent symptomless carriers are sometimes unmasked in the investigation of an outbreak. The strain isolated should be tested for sensitivity against a wide range of antibiotics effective against gram-negative organisms and an appropriate substance chosen.