Shigella infections in the era of antimicrobial resistance: Insights into cephalosporin use

BACKGROUND: Shigella causes severe bacterial diarrhea, especially in children in low- and middle-income countries. Rising antimicrobial resistance (AMR), including multidrug-resistant (MDR) and ESBL-producing strains, threatens empirical treatment, particularly cephalosporins. METHODS: We conducted a structured narrative review of PubMed, Scopus, Web of Science, ScienceDirect, and WHO GLASS. Included studies comprised randomized trials, cohorts, case series, and relevant in vitro studies. Quality was appraised using Joanna Briggs Institute checklists; findings were synthesized narratively. RESULTS: Third-generation cephalosporins (ceftriaxone, cefotaxime) remain highly effective for severe Shigella infections in hospitalized and pediatric patients when isolates are susceptible. Resistance varies regionally, with higher ESBL prevalence in East and South Asia. Resistance mechanisms include ESBLs, efflux pumps, PBP mutations, and altered membrane permeability. Susceptibility-guided therapy yields favorable outcomes, but ESBL/XDR strains cause treatment failures, longer hospital stays, and carbapenem use. CONCLUSION: Cephalosporins are critical for severe shigellosis but are increasingly compromised by AMR. Structured surveillance, susceptibility-guided therapy, and stewardship are essential. Complementary strategies (vaccines, probiotics, phage therapy, novel antibiotics) are urgently needed.