High-level tetracycline resistance in Neisseria gonorrhoeae is result of acquisition of streptococcal tetM determinant

An insight into the drug resistance profile & mechanism of drug resistance in Neisseria gonorrhoeae

Among the aetiological agents of treatable sexually transmitted diseases (STDs), Neissseria gonorrhoeae is considered to be most important because of emerging antibiotic resistant strains that compromise the effectiveness of treatment of the disease - gonorrhoea. In most of the developing countries, treatment of gonorrhoea relies mainly on syndromic management rather than the aetiological based therapy. Gonococcal infections are usually treated with single-dose therapy with an agent found to cure > 95 per cent of cases. Unfortunately during the last few decades, N. gonorrhoeae has developed resistance not only to less expensive antimicrobials such as sulphonamides, penicillin and tetracyclines but also to fluoroquinolones. The resistance trend of N. gonorrhoeae towards these antimicrobials can be categorised into pre-quinolone, quinolone and post-quinolone era. Among the antimicrobials available so far, only the third-generation cephalosporins could be safely recommended as first-line therapy for gonorrhoea globally. However, resistance to oral third-generation cephalosporins has also started emerging in some countries. Therefore, it has become imperative to initiate sustained national and international efforts to reduce infection and misuse of antibiotics so as to prevent further emergence and spread of antimicrobial resistance. It is necessary not only to monitor drug resistance and optimise treatment regimens, but also to gain insight into how gonococcus develops drug resistance. Knowledge of mechanism of resistance would help us to devise methods to prevent the occurrence of drug resistance against existing and new drugs. Such studies could also help in finding out new drug targets in N. gonorrhoeae and also a possibility of identification of new drugs for treating gonorrhoea.

Gonorrhea infection in women: prevalence, effects, screening, and management

Gonorrhea is a set of clinical conditions resulting from infection with the sexually-acquired bacterial pathogen Neisseria gonorrhoeae. Acquisition may involve multiple mucosal sites in the lower female genital tract, including the urethra, cervix, Bartholin’s and Skene’s glands, as well as the anorectal canal, pharynx, and conjunctivae. It may spread to the upper genital tract, uterine tubes, abdominal cavity, and other systemic sites. Gonorrhea is the second most commonly reported sexually-transmitted infection in the US and rates are higher among women than men. Women and infants are affected disproportionately by gonorrhea, because early infection may be asymptomatic and also because extension of infection is often associated with serious sequelae. Screening is critical for infection identification and the prevention or limitation of upper genital tract spread, and horizontal and vertical transmission. Routine genital screening is recommended annually for all sexually active women at risk for infection, including women aged < 25 years and older women with one or more of the following risks: a previous gonorrhea infection, the presence of other sexually transmitted diseases, new or multiple sex partners, inconsistent condom use, commercial sex work, drug use, or human immunodeficiency virus infection with sexual activity or pregnancy. Pharyngeal gonococcal infections are common in adolescents, and direct culture screening is necessary to identify affected individuals. Nucleic acid amplification tests (NAATs) are considered the standard for screening and diagnosis. Although urine NAAT testing is most commonly used, there is growing support for vaginal swabs collected by providers or patients themselves. Resistance to all antibiotics currently recommended for the treatment of gonorrhea has been documented and complicates therapeutic strategies. The Centers for Disease Control and Prevention recommend treatment of gonorrhea with a single class of drugs, ie, the cephalosporins.

Molecular analysis of antimicrobial resistance mechanisms in Neisseria gonorrhoeae isolates from Ontario, Canada

Surveillance of gonococcal antimicrobial resistance and the molecular characterization of the mechanisms underlying these resistance phenotypes are essential in order to establish correct empirical therapies, as well as to describe the emergence of new mechanisms in local bacterial populations. To address these goals, 149 isolates were collected over a 1-month period (October-November 2008) at the Ontario Public Health Laboratory, Toronto, Canada, and susceptibility profiles (8 antibiotics) were examined. Mutations in previously identified targets or the presence of some enzymes related to resistance (r), nonsusceptibility (ns) (resistant plus intermediate categories), or reduced susceptibility (rs) to the antibiotics tested were also studied. A significant proportion of nonsusceptibility to penicillin (PEN) (89.2%), tetracycline (TET) (72.3%), ciprofloxacin (CIP) (29%), and macrolides (erythromycin [ERY] and azithromycin; 22.3%) was found in these strains. Multidrug resistance was observed in 18.8% of the collection. Although all the strains were susceptible to spectinomycin and extended-spectrum cephalosporins (ESC) (ceftriaxone and cefixime), 9.4% of them displayed reduced susceptibility to extended-spectrum cephalosporins. PBP 2 mosaic structures were found in all of these ESC(rs) isolates. Alterations in the mtrR promoter, MtrR repressor (TET(r), PEN(ns), ESC(rs), and ERY(ns)), porin PIB (TET(r) and PEN(ns)), and ribosomal protein S10 (TET(r)) and double mutations in gyrA and parC quinolone resistance-determining regions (QRDRs) (CIP(r)) were associated with and presumably responsible for the resistance phenotypes observed. This is the first description of ESC(rs) in Canada. The detection of this phenotype indicates a change in the epidemiology of this resistance and highlights the importance of continued surveillance to preserve the last antimicrobial options available.

Conjugative plasmids of Neisseria gonorrhoeae

Many clinical isolates of the human pathogen Neisseria gonorrhoeae contain conjugative plasmids. The host range of these plasmids is limited to Neisseria species, but presence of a tetracycline (tetM) determinant inserted in several of these plasmids is an important cause of the rapid spread of tetracycline resistance. Previously plasmids with different backbones (Dutch and American type backbones) and with and without different tetM determinants (Dutch and American type tetM determinants) have been identified. Within the isolates tested, all plasmids with American or Dutch type tetM determinants contained a Dutch type plasmid backbone. This demonstrated that tetM determinants should not be used to differentiate between conjugal plasmid backbones. The nucleotide sequences of conjugative plasmids with Dutch type plasmid backbones either not containing the tetM determinant (pEP5233) or containing Dutch (pEP5289) or American (pEP5050) type tetM determinants were determined. Analysis of the backbone sequences showed that they belong to a novel IncP1 subfamily divergent from the IncP1α, β, γ, δ and ε subfamilies. The tetM determinants were inserted in a genetic load region found in all these plasmids. Insertion was accompanied by the insertion of a gene with an unknown function, and rearrangement of a toxin/antitoxin gene cluster. The genetic load region contains two toxin/antitoxins of the Zeta/Epsilon toxin/antitoxin family previously only found in Gram positive organisms and the virulence associated protein D of the VapD/VapX toxin/antitoxin family. Remarkably, presence of VapX of pJD1, a small cryptic neisserial plasmid, in the acceptor strain strongly increased the conjugation efficiency, suggesting that it functions as an antitoxin for the conjugative plasmid. The presence of the toxin and antitoxin on different plasmids might explain why the host range of this IncP1 plasmid is limited to Neisseria species. The isolated plasmids conjugated efficiently between N. gonorrhoeae strains, but did not enhance transfer of a genetic marker.

Genetics of chromosomally mediated intermediate resistance to ceftriaxone and cefixime in Neisseria gonorrhoeae

All strains of Neisseria gonorrhoeae with reduced susceptibility to ceftriaxone and cefixime (cephalosporin-intermediate-resistant [Ceph(i)] strains) contain a mosaic penA allele encoding penicillin-binding protein 2 (PBP 2) with nearly 60 amino acid differences compared to the sequence of wild-type PBP 2, together with a set of resistance determinants (i.e., mtrR, penB, and/or ponA1) that are required for high-level penicillin resistance. To define the individual contributions of these determinants to reduced susceptibility to ceftriaxone and cefixime, we created isogenic strains containing the mosaic penA allele from the Ceph(i) strain 35/02 (penA35) together with one or more of the other resistance determinants and determined the MICs of penicillin G, ceftriaxone, and cefixime. The majority of cefixime resistance is conferred by the penA35 allele, with only a small contribution coming from mtrR and penB, whereas ceftriaxone resistance is nearly equally dependent upon mtrR and penB. Unlike high-level penicillin resistance, the ponA1 allele does not appear to be important for Ceph(i). A strain containing all four determinants has increased resistance to ceftriaxone and cefixime but not to the levels that the donor Ceph(i) strain does, suggesting that Ceph(i) strains, similar to high-level-penicillin-resistant strains, contain an additional unknown determinant that is required to reach donor levels of resistance. Our data also suggest that the original Ceph(i) strains arose from the transformation of penA genes from commensal Neisseria species into a penicillin-resistant strain already harboring mtrR, penB, ponA1, and the unknown gene(s) involved in high-level penicillin resistance.

The use of cephalosporins for gonorrhea: the impending problem of resistance

Gonorrhea remains an important clinical and public health problem throughout the world. Gonococcal infections have historically been diagnosed by Gram stain and culture but are increasingly diagnosed through nucleic acid tests, thereby eliminating the opportunity for antimicrobial susceptibility testing. Gonococcal infections are typically treated with single-dose therapy with an agent found to cure > 95% of cases. Unfortunately, the gonococcus has repeatedly developed resistance to antimicrobials including sulfonamides, penicillin, tetracyclines and fluoroquinolones. This has now left third-generation cephalosporins as the lone class of antimicrobials recommended as first-line therapy for gonorrhea in some regions. However, resistance to oral third-generation cephalosporins has emerged and spread in Asia, Australia and elsewhere. The mechanism of this resistance seems to be associated with a mosaic penicillin binding protein (penA) in addition to other chromosomal mutations previously found to confer resistance to beta-lactam antimicrobials (ponA, mtrR, penB, pilQ). Few good options exist or are in development for treating cephalosporin-resistant isolates, as most have had multidrug resistance. Preventing the spread of resistant isolates will depend on ambitious antimicrobial management programs, strengthening and expanding surveillance networks, and through effective sexually transmitted disease control and prevention.

Molecular analysis of tetracycline-resistant gonococci: rapid detection of resistant genotypes using a real-time PCR assay

The aim of this study was to examine tetracycline-resistant gonococci and to set up a real-time PCR method to identify, in the same assay, both the chromosomally and the plasmid-mediated tetracycline-resistant genotypes. A retrospective analysis for tetracycline susceptibility was performed by the E-test and agar dilution methods on 289 gonococci isolated in Italy from 2003 to 2005. Molecular mechanisms of resistance were investigated by both sequence analyses of the three main genes associated with chromosomally mediated resistance (mtrR, penB and rpsJ genes) and by the identification of plasmids carrying the tetM determinant associated with plasmid-mediated resistance, by PCR (American- or Dutch-type plasmids). The genetic relatedness of nonsusceptible strains was evaluated by pulsed field gel electrophoresis (PFGE). The results showed the presence of 22.5% tetracycline-resistant and 49.5% tetracycline-intermediate gonococci. Coexistence of chromosomally and plasmid-mediated resistance to tetracycline was observed in the majority of resistant isolates. No clonal structure was highlighted by analysis of PFGE pattern profiles. Real-time PCR assay was able to identify all the tetracycline nonsusceptible gonococci correctly for the presence of both chromosomally and/or plasmid-mediated genotypes.

Spread of Streptococcus suis sequence type 7, China

Streptococcus suis sequence type (ST) 7 has been spreading throughout China. To determine events associated with its emergence, we tested 114 isolates. In all 106 ST7 strains responsible for human outbreaks and sporadic infections, the tetracycline-resistance gene, tetM, was detected on the conjugative transposon Tn916. Horizontal transmission of tetM is suspected.

Analysis of the contribution of molecular mechanisms into formation of gonoccocal resistance to tetracycline

We applied complex genetic analysis for evaluation of tetracycline-resistance markers in 129 clinical strains of Neisseria gonorrhoeae from Central, Privolzhskii, and Siberian regions. For detection of mutations in rpsJ gene and MtrRCDE locus we first used minisequence reaction followed by identification of products by MALDI-TOF mass spectrometry. The incidence of detection of resistance markers among the analyzed strains were: tetM--3.1%, mutations in genes rpsJ--82.2%, penB--62.8%, and mtrR--54.3%. The analyzed genetic markers were not detected in 17.5% strains. tetM gene was detected in only 12.5% strains from the Central Region. No differences were revealed in regional distribution of other genotypes. Genotypes tetM(pres), rpsJ(mut), mtrR(mut), and rpsJ(mut), penB(mut), mtrR(mut) reliably predict tetracycline resistance. Microbiological and genetic testing of tetracycline resistance yielded similar results.

Relation between genetic markers of drug resistance and susceptibility profile of clinical Neisseria gonorrhoeae strains

The main goal of this work is to clarify the predictive value of known genetic markers of Neisseria gonorrhoeae resistance to penicillin, tetracycline, and fluoroquinolones. The correlation between the presence of certain genetic markers and susceptibility of N. gonorrhoeae isolates to penicillin, tetracycline, and fluoroquinolones has been analyzed by means of statistical methods. Susceptibility testing with penicillin, tetracycline, and fluoroquinolones was performed by the agar dilution method. N. gonorrhoeae genomic DNA was isolated. The presence of bla(TEM-1) and tet(M) genes was analyzed by PCR. A novel method of polymorphism discovery based on a minisequencing reaction followed by matrix-assisted laser desorption ionization-time-of-flight mass spectrometry was applied for the analysis of chromosomal N. gonorrhoeae genes involved in antimicrobial resistance development. Clinical N. gonorrhoeae isolates (n = 464) were collected. Susceptibility levels to penicillin, tetracycline, and fluoroquinolones were found to be 25.9%, 35.9%, and 54.1%, respectively. Among the 19 N. gonorrhoeae isolates with penicillin MICs of > or =4 microg/ml, the bla(TEM-1) gene was detected in 12. The Tet(M) determinant was found in 4 of 12 N. gonorrhoeae isolates with tetracycline MICs of > or =16 microg/ml. The chromosomal genetic markers of penicillin and tetracycline resistance were detected especially in isolates with penicillin MICs of 0.25 to 2.0 microg/ml and tetracycline MICs of 0.5 to 4 microg/ml. Mutations in GyrA and ParC were found in 208 of 211 quinolone-resistant N. gonorrhoeae isolates. This work is the first representative molecular research of the N. gonorrhoeae population in Russia. Information about the prevalence of antibiotic resistance mechanisms and the positive predictive value of certain genetic determinants is given. The positive predictive values of the analyzed genetic markers were found to be different for fluoroquinolones (90.3%), penicillin (91.1%), and tetracycline (81.9%).

Importance of drug resistance in gonococci: from mechanisms to monitoring

Neisseria gonorrhoeae isolates continue to develop an impressive arsenal of resistance mechanisms to antimicrobial agents, including resistance to some of the antibiotics presently recommended for the treatment of gonococcal infections.

Mobilization of the gonococcal 5.2 kb beta-lactamase plasmid pSJ5.2 into Escherichia coli by cointegration with several gram-conjugative plasmids

We report the mobilization by cointegration of the gonococcal 5.2 kb beta-lactamase plasmid pSJ5.2 in an Escherichia coli background. Transfer of pSJ5.2 was measured by filter mating assays with five different conjugative plasmids from Enterobacteriaceae and the gonococcal 41 kb tet(M). Plasmid pSJ5.2 was mobilized to E. coli at frequencies of 1.7x10(-6), 9.3x10(-8) and 2.7x10(-5) by the tet(M), R64 drd-33 and N3 conjugative plasmids, respectively. Mobilization of pSJ5.2 by the 41 kb tet(M) conjugative plasmid resulted in stable Amp(R) E. coli transconjugants consisting of pSJ5.2 plasmid with an insertion located in the 2.4 kb BamHI-BamHI fragment. Mobilization of pSJ5.2 by R64drd-33 and N3 conjugative plasmids involved stable cointegrates as detected by Southern Blot with a DIG-labelled PstI-digested pSJ5.2 probe. Restriction analysis of the R64::pSJ5.2 and N3::pSJ5.2 cointegrates and Southern Blot with the pSJ5.2 probe showed that cointegrates formed by deletion of DNA regions within the 1.8 kb BamHI-HindIII fragment of pSJ5.2. The plasmid thus appears to use multiple recombination mechanisms for cointegration with different conjugative plasmids. The complete nucleotide sequence of pSJ5.2 was determined, and will be a useful tool to further investigate the molecular mechanisms leading to its cointegrative transfer.

Incidence and behaviour of Tn916-like elements within tetracycline-resistant bacteria isolated from root canals

INTRODUCTION

Tetracycline resistance is commonly found in endodontic bacteria. One of the most common tetracycline-resistance genes is tet(M), which is often encoded on the broad-host-range conjugative transposon Tn916. This study aimed to determine whether tet(M) was present in bacteria isolated from endodontic patients at the Eastman Dental Institute and whether this gene was carried on the transferable conjugative transposon Tn916.

METHODS

The cultivable microflora isolated from 15 endodontic patients was screened for resistance to tetracycline. Polymerase chain reactions for tet(M) and for unique regions of Tn916 were carried out on the DNA of all tetracycline-resistant bacteria. Filter-mating experiments were used to see if transfer of any Tn916-like elements could occur.

RESULTS

Eight out of 15 tetracycline-resistant bacteria isolated were shown to possess tet(M). Furthermore, four of these eight were shown to possess the Tn916-unique regions linked to the tet(M) gene. Transfer experiments demonstrated that a Neisseria sp. donor could transfer an extremely unstable Tn916-like element to Enterococcus faecalis.

CONCLUSIONS

The tet(M) gene is present in the majority of tetracycline-resistant bacteria isolated in this study and the conjugative transposon Tn916 has been shown to be responsible for the support and transfer of this gene in some of the bacteria isolated.

Porin-mediated antibiotic resistance in Neisseria gonorrhoeae: ion, solute, and antibiotic permeation through PIB proteins with penB mutations

Neisseria gonorrhoeae has two porins, PIA and PIB, whose genes (porA and porB, respectively) are alleles of a single por locus. We recently demonstrated that penB mutations at positions 120 and 121 in PIB, which are presumed to reside in loop 3 that forms the pore constriction zone, confer intermediate-level resistance to penicillin and tetracycline (M. Olesky, M. Hobbs, and R. A. Nicholas, Antimicrob. Agents Chemother. 46:2811-2820, 2002). In the present study, we investigated the electrophysiological properties as well as solute and antibiotic permeation rates of recombinant PIB proteins containing penB mutations (G120K, G120D/A121D, G120P/A121P, and G120R/A121H). In planar lipid bilayers, the predominant conducting state of each porin variant was 30 to 40% of the wild type, even though the anion selectivity and maximum channel conductance of each PIB variant was similar to that of the wild type. Liposome-swelling experiments revealed no significant differences in the permeation of sugars or beta-lactam antibiotics through the wild type or PIB variants. Although these results are seemingly contradictory with the ability of these variants to increase antibiotic resistance, they are consistent with MIC data showing that these porin mutations confer resistance only in strains containing an mtrR mutation, which increases expression of the MtrC-MtrD-MtrE efflux pump. Moreover, both the mtrR and penB mutations were required to decrease in vivo permeation rates below those observed in the parental strain containing either mtrR or porin mutations alone. Thus, these data demonstrate a novel mechanism of porin-mediated resistance in which mutations in PIB have no affect on antibiotic permeation alone but instead act synergistically with the MtrC-MtrD-MtrE efflux pump in the development of antibiotic resistance in gonococci.

Detection and characterization of tet(M) in tetracycline-resistant Listeria strains from human and food-processing origins in Belgium and France

In the present study, three Listeria monocytogenes strains and one Listeria innocua strain out of a collection of 241 Listeria isolates from human and food-processing sources were found to display resistance to tetracycline (TC) due to the presence of the tet(M) gene. Through sequence analysis, it was shown that tet(M) genes in two of the isolates belong to sequence homology group (SHG) II, a group comprising chromosomally encoded tet(M) genes previously found in Staphylococcus aureus and in lactobacilli. The tet(M) genes of the two other L. monocytogenes strains were associated with a member of the Tn916-Tn1545 family of conjugative transposons and were closely related to SHG III, which harbours enterococcal tet(M) genes associated with Tn916. One of these transposon-containing strains was able to transfer the tet(M) gene to Enterococcus faecalis recipient strain JH2-2. Collectively, these sequence and conjugation data indicate that the acquisition of tet(M) by Listeria strains may be triggered by successive transfers between other Gram-positive organisms.

High-level chromosomally mediated tetracycline resistance in Neisseria gonorrhoeae results from a point mutation in the rpsJ gene encoding ribosomal protein S10 in combination with the mtrR and penB resistance determinants

Neisseria gonorrhoeae becomes resistant to tetracycline by two major mechanisms: expression of a plasmid-encoded TetM protein and mutations in endogenous genes (chromosomally mediated resistance). Early studies by Sparling and colleagues (P. F. Sparling F. A. J. Sarubbi, and E. Blackman, J. Bacteriol. 124:740-749, 1975) demonstrated that three genes were involved in high-level chromosomally mediated tetracycline resistance (MIC of tetracycline > or = 2 microg/ml): ery-2 (now referred to as mtrR), penB, and tet-2. While the identities of the first two genes are known, the tet-2 gene has not been identified. We cloned the tet-2 gene, which confers tetracycline resistance, from tetracycline-resistant clinical isolate N. gonorrhoeae FA6140 and show that resistance is due to a single point mutation (Val-57 to Met) in the rpsJ gene (rpsJ1) encoding ribosomal protein S10. Moreover, the identical mutation was found in six distinct tetracycline-resistant clinical isolates in which the MIC of tetracycline was > or =2 microg/ml. Site-saturation mutagenesis of the codon for Val-57 identified two other amino acids (Leu and Gln) that conferred identical levels of resistance as the Met-57 mutation. The mutation maps to the vertex of a loop in S10 that is near the aminoacyl-tRNA site in the structure of the 30S ribosomal subunit from Thermus thermophilus, and the residue equivalent to Val-57 in T. thermophilus S10, Lys-55, is within 8 to 9 A of bound tetracycline. These data suggest that large noncharged amino acids alter the rRNA structure near the tetracycline-binding site, leading to a lower affinity of the antibiotic.

Comparative overview of the genomic and genetic differences between the pathogenic Neisseria strains and species

The availability of complete genome sequences from multiple pathogenic Neisseria strains and species has enabled a comprehensive survey of the genomic and genetic differences occurring within these species. In this review, we describe the chromosomal rearrangements that have occurred, and the genomic islands and prophages that have been identified in the various genomes. We also describe instances where specific genes are present or absent, other instances where specific genes have been inactivated, and situations where there is variation in the version of a gene that is present. We also provide an overview of mosaic genes present in these genomes, and describe the variation systems that allow the expression of particular genes to be switched ON or OFF. We have also described the presence and location of mobile non-coding elements in the various genomes. Finally, we have reviewed the incidence and properties of various extra-chromosomal elements found within these species. The overall impression is one of genomic variability and instability, resulting in increased functional flexibility within these species.

Molecular diversity and characterization of tetracycline-resistant Staphylococcus aureus isolates from a poultry processing plant

DNA fingerprinting and molecular characterization showed that the tetracycline-resistant Staphylococcus aureus population of a South African poultry processing plant comprised one or possibly several tet(K)-containing endemic clones that contaminated chicken and machinery surfaces at all sampled processing stages. The tet(K) gene was transferable by filter mating to S. aureus recipient 80CR5 and was located on a pT181-like plasmid.

Remarkable increase in central Japan in 2001-2002 of Neisseria gonorrhoeae isolates with decreased susceptibility to penicillin, tetracycline, oral cephalosporins, and fluoroquinolones

Four hundred sixty-two clinical isolates of Neisseria gonorrhoeae recovered from 1999 through 2002 in central Japan were examined for MICs of antimicrobial agents. The majority was sensitive to ceftriaxone and spectinomycin, but a remarkable increase in isolates with decreased susceptibility to penicillin, tetracycline, oral cephalosporins, and fluoroquinolones was observed from 2001 through 2002.

Molecular epidemiology of Neisseria gonorrheae isolates with plasmid-mediated tetracycline resistance in Canada: temporal and geographical trends (1986-1997)

Plasmid-mediated resistance to tetracycline in Neisseria gonorrhoeae (TRNG) isolates is caused by the acquisition of a 25.2-MDa conjugative, tetM-containing plasmid (TetM plasmid). The presence of the TetM plasmid is the leading cause of gonococcal resistance to tetracycline in most countries. Between 1986 and 1997, 6,306 TRNG isolates were isolated in different Canadian provincial laboratories and subsequently submitted to the national laboratory for further strain characterization. Because nonculture-based identification of N. gonorrhoeae was more widely used after 1995, this snapshot of the molecular epidemiology of TRNG in Canada, which is only possible if bacteria are cultured, represents a comprehensive data baseline that may no longer be achievable. Temporal trends indicate that TRNG isolations peaked in 1994 (18.9% of isolates tested). Antimicrobial susceptibilities (MIC) to tetracycline and penicillin were determined for 4,064 TRNG isolated between 1986 and 1994. The MICs of TRNG isolates ranged from 16 microg/ml to 32 microg/ml of tetracycline, although one isolate had an MIC of 8 microg/ml and the MICs of four isolates were 2 microg/ml. Penicillinase-producing TRNG (i.e., PP/TRNG) comprised 34.1% of all TRNG (n = 1,386) and 52 TRNG isolates exhibited chromosomal resistance to penicillin. Most of the PP/TRNG (94.1%) carried Africa type (3.2 MDa) beta-lactamase-producing plasmids; only 76 (5.5%) PP/TRNG carried Asia type (4.4 MDa) penicillinase-producing plasmids and three isolates carried Toronto type (3.05 MDa) plasmids. TRNG isolates were also retrospectively typed by auxotype (A), serovar (S), and plasmid (P) content analysis. Eleven auxotype/serovar (A/S) groups comprised the majority (93%) of 4,064 typed TRNG isolates with A/S classes NR/IB-2, NR/IB-3, and NR/IB-1 accounting for 75.1% of the strains characterized. Classification of 670 TRNG for tetM type demonstrated that the Dutch (n = 531) type TetM plasmids predominated over the American (n = 139) type TetM plasmids.

Susceptibility ofClostridium perfringensstrains from broiler chickens to antibiotics and anticoccidials

Clostridium perfringens strains isolated in 2002 from the intestines of broiler chickens from 31 different farms located in Belgium were tested for susceptibility to 12 antibiotics used for therapy, growth promotion or prevention of coccidiosis. All strains were uniformly sensitive to the ionophore antibiotics monensin, lasalocid, salinomycin, maduramycin and narasin. All were sensitive to avilamycin, tylosin and amoxicillin, while flavomycin (bambermycin) showed low or no activity. Chlortetracycline and oxytetracycline were active at very low concentrations, but low-level acquired resistance was detected in 66% of the strains investigated. Fifty percent of these strains carried the tetP(B) resistance gene, while the tet(Q) gene was detected in only one strain. One strain with high-level resistance against tetracyclines carried the tet(M) gene. Sixty-three percent of the strains showed low-level resistance to lincomycin. The lnu(A) and lnu(B) genes were each only found in one strain. Compared with a similar investigation carried out in 1980, an increase was seen in resistance percentages with lincomycin (63% against 49%) and a slight decrease with tetracycline (66% against 74%).

Molecular characterization of tet(M) genes in Lactobacillus isolates from different types of fermented dry sausage

The likelihood that products prepared from raw meat and milk may act as vehicles for antibiotic-resistant bacteria is currently of great concern in food safety issues. In this study, a collection of 94 tetracycline-resistant (Tc(r)) lactic acid bacteria recovered from nine different fermented dry sausage types were subjected to a polyphasic molecular study with the aim of characterizing the host organisms and the tet genes, conferring tetracycline resistance, that they carry. With the (GTG)(5)-PCR DNA fingerprinting technique, the Tc(r) lactic acid bacterial isolates were identified as Lactobacillus plantarum, L. sakei subsp. carnosus, L. sakei subsp. sakei, L. curvatus, and L. alimentarius and typed to the intraspecies level. For a selection of 24 Tc(r) lactic acid bacterial isolates displaying unique (GTG)(5)-PCR fingerprints, tet genes were determined by means of PCR, and only tet(M) was detected. Restriction enzyme analysis with AccI and ScaI revealed two different tet(M) allele types. This grouping was confirmed by partial sequencing of the tet(M) open reading frame, which indicated that the two allele types displayed high sequence similarities (>99.6%) with tet(M) genes previously reported in Staphylococcus aureus MRSA 101 and in Neisseria meningitidis, respectively. Southern hybridization with plasmid profiles revealed that the isolates contained tet(M)-carrying plasmids. In addition to the tet(M) gene, one isolate also contained an erm(B) gene on a different plasmid from the one encoding the tetracycline resistance. Furthermore, it was also shown by PCR that the tet(M) genes were not located on transposons of the Tn916/Tn1545 family. To our knowledge, this is the first detailed molecular study demonstrating that taxonomically and genotypically diverse Lactobacillus strains from different types of fermented meat products can be a host for plasmid-borne tet genes.

Detection of a novel Tet M determinant in tetracycline-resistant Neisseria gonorrhoeae from Uruguay, 1996-1999

BACKGROUND

Determination of the diversity within the tet(M) sequence from N gonorrhoeae is a useful epidemiologic tool for monitoring the movement or importation of strains within a geographic region. Only two distinct tet(M) genes in clinical gonococcal isolates have been described up to now: the Dutch and the American types.

GOAL

The study involved surveillance of the tet(M) gene types in high-level-tetracycline-resistant gonococcal isolates from Uruguay during the period 1996 to 1999.

STUDY DESIGN

Among 181 gonococcal isolates, those showing MICs >/=16 microg/ml to tetracycline were analyzed for detection and characterization of the tet(M) gene by a polymerase chain reaction (PCR) and further HpaII restriction fragment polymorphism methods, respectively. The plasmid content and antibiogram were determined.

RESULTS

Twenty-two of 181 isolates (12%) exhibited high levels of resistance to tetracycline (MICs >/=16 microg/ml) and harbored a putative 25.2-Mda plasmid that contained the tet(M) gene. A high percentage of isolates (95%; 21/22) presented the Dutch type tet(M) gene. One isolate from 1999 revealed a new restriction pattern. Such a pattern had been previously noted in 1991. This new restriction pattern has not been described previously as occurring in isolates of N gonorrhoeae. The tet(M) amplimer sequence showed 100% identity with a previously described tet(M)-carrying plasmid from N meningitidis.

CONCLUSION

A new HpaII restriction pattern of the tet(M) gene is present in low frequency. The tet(M) sequence was different from the gonococcal tet(M) sequences already known and not typable with the use of a differential PCR assay. Accordingly, with the genetic diversity already present within the tet(M) sequence of N gonorrhoeae isolates, we should be aware of the sensitivity of the PCR assays in use for tetracycline-resistant N gonorrhoeae detection.

Identification and analysis of amino acid mutations in porin IB that mediate intermediate-level resistance to penicillin and tetracycline in Neisseria gonorrhoeae

PenB is the third resistance determinant in the stepwise acquisition of multiple resistance genes in chromosomally mediated resistant Neisseria gonorrhoeae (CMRNG). Alterations in por(IB), one of two alleles at the por locus that encodes the outer membrane protein porin IB (PIB), were recently reported to be responsible for the increased resistance to penicillin and tetracycline conferred by penB, but the specific mutations conferring antibiotic resistance were not identified experimentally. To determine which amino acids in PIB confer increased resistance, we transformed a recipient strain with chimeras of the por(IB) genes from strains FA1090 and FA140 (penB2). These studies revealed that two amino acid changes, G120D and A121D, were both necessary and sufficient to confer increased resistance to penicillin and tetracycline. Site-saturation and site-directed mutagenesis of Gly-120 and Ala-121 revealed that both a single mutation, G120K, and the double mutations G120R A121H and G120P A121P also conferred antibiotic resistance to the recipient strain. The identical mutations in PIA increased penicillin and tetracycline resistance either moderately or not at all. Analysis of por(IB) genes present in the GenBank database from 51 clinical isolates demonstrated that lysine and aspartate mutations at positions 120 and/or 121 also occur in nature. These studies demonstrate that charged amino acids at positions 120 and 121 in PIB are highly preferential for conferring resistance to penicillin and tetracycline in N. gonorrhoeae.

Current concepts in the management of gonorrhoea

The incidence of gonorrhoea is again rising in developed countries and a high disease rate has been maintained in less developed regions for a number of years. The need not only for treatment of the individual but also for control of gonorrhoea at a community level has increased significantly following recognition of its role in the amplification of human immunodeficiency virus (HIV) transmission. A sustainable decrease in the incidence of gonorrhoea and other sexually transmitted diseases (STDs) requires an integrated approach combining improved prevention, better diagnosis and optimal treatment. Effective antibiotic treatment is an essential element of this approach. However, antibiotic treatment of gonorrhoea has been severely hampered by the development of antibiotic resistance in Neisseria gonorrhoeae, to the extent that many therapies are no longer effective. Those treatments that retain acceptable efficacy are often unaffordable where they are most needed. Penicillins and tetracyclines should no longer be used in gonococcal disease, there are limitations on the effectiveness of newer macrolides and spectinomycin and in many parts of the world quinolones have been withdrawn from schedules for the treatment of gonorrhoea. Of all the current agents used to treat all forms of gonococcal disease, only the third generation cephalosporins (most notably ceftriaxone) have retained their efficacy; however, decreased susceptibility to these antibiotics has also appeared. Continuing reliance on antibiotic treatment for controlling gonorrhoea in the absence of other necessary approaches will see a further deterioration in the situation. In these circumstances the possibility that gonorrhoea will be untreatable becomes more real.

Tetracycline antibiotics: mode of action, applications, molecular biology, and epidemiology of bacterial resistance

Tetracyclines were discovered in the 1940s and exhibited activity against a wide range of microorganisms including gram-positive and gram-negative bacteria, chlamydiae, mycoplasmas, rickettsiae, and protozoan parasites. They are inexpensive antibiotics, which have been used extensively in the prophlylaxis and therapy of human and animal infections and also at subtherapeutic levels in animal feed as growth promoters. The first tetracycline-resistant bacterium, Shigella dysenteriae, was isolated in 1953. Tetracycline resistance now occurs in an increasing number of pathogenic, opportunistic, and commensal bacteria. The presence of tetracycline-resistant pathogens limits the use of these agents in treatment of disease. Tetracycline resistance is often due to the acquisition of new genes, which code for energy-dependent efflux of tetracyclines or for a protein that protects bacterial ribosomes from the action of tetracyclines. Many of these genes are associated with mobile plasmids or transposons and can be distinguished from each other using molecular methods including DNA-DNA hybridization with oligonucleotide probes and DNA sequencing. A limited number of bacteria acquire resistance by mutations, which alter the permeability of the outer membrane porins and/or lipopolysaccharides in the outer membrane, change the regulation of innate efflux systems, or alter the 16S rRNA. New tetracycline derivatives are being examined, although their role in treatment is not clear. Changing the use of tetracyclines in human and animal health as well as in food production is needed if we are to continue to use this class of broad-spectrum antimicrobials through the present century.

Tetracycline antibiotics: mode of action, applications, molecular biology, and epidemiology of bacterial resistance

Tetracyclines were discovered in the 1940s and exhibited activity against a wide range of microorganisms including gram-positive and gram-negative bacteria, chlamydiae, mycoplasmas, rickettsiae, and protozoan parasites. They are inexpensive antibiotics, which have been used extensively in the prophlylaxis and therapy of human and animal infections and also at subtherapeutic levels in animal feed as growth promoters. The first tetracycline-resistant bacterium, Shigella dysenteriae, was isolated in 1953. Tetracycline resistance now occurs in an increasing number of pathogenic, opportunistic, and commensal bacteria. The presence of tetracycline-resistant pathogens limits the use of these agents in treatment of disease. Tetracycline resistance is often due to the acquisition of new genes, which code for energy-dependent efflux of tetracyclines or for a protein that protects bacterial ribosomes from the action of tetracyclines. Many of these genes are associated with mobile plasmids or transposons and can be distinguished from each other using molecular methods including DNA-DNA hybridization with oligonucleotide probes and DNA sequencing. A limited number of bacteria acquire resistance by mutations, which alter the permeability of the outer membrane porins and/or lipopolysaccharides in the outer membrane, change the regulation of innate efflux systems, or alter the 16S rRNA. New tetracycline derivatives are being examined, although their role in treatment is not clear. Changing the use of tetracyclines in human and animal health as well as in food production is needed if we are to continue to use this class of broad-spectrum antimicrobials through the present century.

Identification of the conjugative mef gene in clinical Acinetobacter junii and Neisseria gonorrhoeae isolates

The mef gene, originally described for gram-positive organisms and coding for an efflux pump, has been identified in clinical isolates of Acinetobacter junii and Neisseria gonorrhoeae. These strains could transfer the mef gene at frequencies ranging from 10(-6) to 10(-9) into one or more of the following recipients: gram-negative Moraxella catarrhalis, Neisseria perflava/sicca and Neisseria mucosa and gram-positive Enterococcus faecalis. Three Streptococcus pneumoniae strains could transfer the mef gene into Eikenella corrodens, Haemophilus influenzae, Kingella denitrificans, M. catarrhalis, Neisseria meningitidis, N. perflava/sicca, and N. mucosa at similar frequencies. The mef gene can thus be transferred to and expressed in a variety of gram-negative recipients.

The molecular mechanisms of tetracycline resistance in the pneumococcus

Tetracycline resistance in the pneumococcus is a result of the acquisition of one of two resistance determinants, tet(M) or tet(O). These genes encode ribosomal protection proteins that have homology to the elongation factors G and Tu. Tet(M) and Tet(O) both have GTPase activity that appears to be important in the displacement of tetracycline from the ribosome. Modification of tRNA may also be important for tetracycline resistance. Transcription of tet(M) is thought to be regulated by transcriptional attenuation. Transcription of tet(O) is constitutive, however, upstream of the gene are sequences that also appear to be involved in transcriptional attenuation. tet(M) is transferred on the conjugative transposons, Tn1545 and Tn5151. It is not yet known whether tet(O) is transported on transposons or plasmids, or whether it is chromosomally integrated, in pneumococci.

Erythromycin-resistant Neisseria gonorrhoeae and oral commensal Neisseria spp. carry known rRNA methylase genes

Two Neisseria gonorrhoeae isolates from Seattle and two isolates from Uruguay were resistant to erythromycin (MIC, 4 to 16 microg/ml) and had reduced susceptibility to azithromycin (MIC, 1 to 4 microg/ml) due to the presence of the self-mobile rRNA methylase gene(s) ermF or ermB and ermF. The two Seattle isolates and one isolate from Uruguay were multiresistant, carrying either the 25.2-MDa tetM-containing plasmid (Seattle) or a beta-lactamase plasmid (Uruguay). Sixteen commensal Neisseria isolates (10 Neisseria perflava-N. sicca, 2 N. flava, and 4 N. mucosa) for which erythromycin MICs were 4 to 16 microg/ml were shown to carry one or more known rRNA methylase genes, including ermB, ermC, and/or ermF. Many of these isolates also were multiresistant and carried the tetM gene. This is the first time that a complete transposon or a complete conjugative transposon carrying an antibiotic resistance gene has been described for the genus Neisseria.

The epidemiology of Neisseria gonorrhoeae in Europe

This review addresses the occurrence, the trends, and the risk groups of Neisseria gonorrhoeae in Europe over the past decade. A decline has been observed in most of Europe since the 1980s, except for an increase in the Baltic countries (early 1990s) and an increase among men who have sex with men (between 1989 and 1991), and heterosexuals in some countries (between 1995 and 1997). Despite the overall fall in the incidence of gonorrhoea, plasmid-mediated resistance to penicillin and tetracycline increased in Europe. More recently, resistance to fluoroquinolones has been documented, mainly imported from Southeast Asia. Until now, no resistance to third-generation cephalosporins has been observed.

Antimicrobial susceptibilities and plasmid contents of Neisseria gonorrhoeae isolates from commercial sex workers in Dhaka, Bangladesh: emergence of high-level resistance to ciprofloxacin

Commercial sex workers (CSWs) serve as the most important reservoir of sexually transmitted diseases (STD), including gonorrhea. Periodic monitoring of the antimicrobial susceptibility profile of Neisseria gonorrhoeae in a high-risk population provides essential clues regarding the rapidly changing pattern of antimicrobial susceptibilities. A study concerning the prevalence of gonococcal infection among CSWs was conducted in Bangladesh. The isolates were examined with regards to their antimicrobial susceptibility to, and the MICs of, penicillin, tetracycline, ciprofloxacin, cefuroxime, ceftriaxone, and spectinomycin by disk diffusion and agar dilution methods. The total plasmid profile of the isolates was also analyzed. Of the 224 CSWs, 94 (42%) were culture positive for N. gonorrhoeae. There was a good correlation between the results of the disk diffusion and agar dilution methods. Some 66% of the isolates were resistant to penicillin, and 34% were moderately susceptible to penicillin. Among the resistant isolates, 23.4% were penicillinase-producing N. gonorrhoeae (PPNG). 60.6% of the isolates were resistant and 38.3% were moderately susceptible to tetracycline, 17.5% were tetracycline-resistant N. gonorrhoeae, 11.7% were resistant and 26.6% had reduced susceptibility to ciprofloxacin, 2.1% were resistant and 11.7% had reduced susceptibility to cefuroxime, and 1% were resistant to ceftriaxone. All PPNG isolates contained a 3.2-MDa African type of plasmid, and a 24.2-MDa conjugative plasmid was present in 34.1% of the isolates. Since quinolones such as ciprofloxacin are recommended as the first line of therapy for gonorrhea, the emergence of significant resistance to ciprofloxacin will limit the usefulness of this drug for treatment of gonorrhea in Bangladesh.

An essential saccharide binding domain for the mAb 2C7 established for Neisseria gonorrhoeae LOS by ES-MS and MSn

A study of bacterial surface oligosaccharides were investigated among different strains of Neisseria gonorrhoeae to correlate structural features essential for binding to the MAb 2C7. This epitope is widely expressed and conserved in gonococcal isolates, characteristics essential to an effective candidate vaccine antigen. Sample lipooligosaccharides (LOS), was prepared by a modification of the hot phenol-water method from which de-O-acetylated LOS and oligosaccharide (OS) components were analyzed by ES-MS-CID-MS and ES-MSnin a triple quadrupole and an ion trap mass spectrometer, respectively. Previously documented natural heterogeneity was apparent from both LOS and OS preparations which was admixed with fragments induced by hydrazine and mild acid treatment. Natural heterogeneity was limited to phosphorylation and antenni extensions to the alpha-chain. Mild acid hydrolysis to release OS also hydrolyzed the beta(1-->6) glycosidic linkage of lipid A. OS structures were determined by collisional and resonance excitation combined with MS and multistep MSn which provided sequence information from both neutral loss, and nonreducing terminal fragments. A comparison of OS structures, with earlier knowledge of MAb binding, enzyme treatment, and partial acid hydrolysis indicates a generic overlapping domain for 2C7 binding. Reoccurring structural features include a Hepalpha(1-->3)Hepbeta(1-->5)KDO trisaccharide core branched on the nonreducing terminus (Hep-2) with an alpha(1-->2) linked GlcNAc (gamma-chain), and an alpha-linked lactose (beta-chain) residue. From the central heptose (Hep-1), a beta(1-->4) linked lactose (alpha-chain), moiety is required although extensions to this residue appear unnecessary.

Molecular epidemiology of tetM genes in Neisseria gonorrhoeae

OBJECTIVE

To examine the epidemiology of the tetM gene in Neisseria gonorrhoeae strains with high level resistance to tetracycline (TRNG) using a polymerase chain reaction (PCR) assay.

METHODS

A single tube PCR was developed which distinguishes between the American and Dutch variants of the tetM gene. Between 1988 and 1995, 518 strains of TRNG (tetracycline MIC > 8.mg/l) were referred to the Gonococcus Reference Unit by other laboratories or isolated from routine swabs taken at local clinics. The strains were analysed for plasmid content, auxotype, serovar, and the tetM gene type. Travel details of the patients were determined by a questionnaire.

RESULTS

A PCR product was obtained from all TRNG examined. 387 TRNG strains produced a 778 bp PCR product (American type tetM) and 131 produced a 443 by PCR product (Dutch type tetM). Infections acquired in the United Kingdom contributed 57% of the TRNG strains included in this study; 82% of these carried the American type of tetM. The number of UK acquired TRNG received by the GRU increased each year except 1993--from four strains received in 1990 to 92 in 1995. After the United Kingdom, Caribbean and African countries contributed most strains, with 56 and 60 TRNG acquired in each area respectively. All strains originating in Africa, except one from South Africa, contained the American type tetM. Infections caught in Nigeria and Kenya contributed most strains (15 and 14 respectively). The TRNG originating from Caribbean countries comprised 36% Dutch tetM type. Infections caught in Jamaica accounted for 82% of the Caribbean strains. All 35 TRNG strains originating in the Far East contained the Dutch type tetM. 25 of the Far East strains were also penicillinase producing (PPNG). Infections originating in Indonesia accounted for 49% of the Far East strains but these belonged to 12 different auxotype/serovar combinations. A geographical variation in the type of penicillinase coding plasmids found in PPNG/TRNG was also detected.

CONCLUSIONS

These data suggest that the Dutch type tetM may have originated in the Far East and the American type in the African continent. Subsequent spread has resulted in a heterogeneous distribution of TRNG types in other parts of the world. At completion of the survey the numbers of TRNG imported each year from the major overseas sources had reached a plateau while UK contracted TRNG continued to rise providing evidence for the establishment of endemic TRNG strains in the United Kingdom.

Surveillance of antibiotic resistance in Neisseria gonorrhoeae in The Netherlands, 1977-95

OBJECTIVE

To evaluate the prevalence and epidemiology of penicillinase producing Neisseria gonorrhoeae (PPNG) and tetracycline resistant N gonorrhoeae (TRNG) in the period 1977-95 in the Netherlands. To compare auxotypes, serovars, and antibiograms of PPNG, non-PPNG, and TRNG. To identify determinants in patient characteristics for the epidemic spread of TRNG/PPNG.

METHODS

With respect to the national gonococcal surveillance all PPNG isolates from 30 laboratories over the country in 1977-90 and all gonococcal isolates from five sentinel laboratories (during 1 month per quarter) in 1991-5 were collected. Isolates were auxotyped and serotyped, the susceptibility for various antibiotics was tested and plasmid contents were evaluated. Additional data on PPNG infected individuals were collected retrospectively during a microepidemic of TRNG/PPNG. Univariate and multivariate analyses were performed to identify risk factors for TRNG/PPNG infections.

RESULTS

In 1995 an overall high prevalence of PPNG infection (27%) and TRNG among PPNG infection (24%) was found in the Netherlands. Importantly, PPNG were found to have higher MICs for ceftriaxone and ciprofloxacin than non-PPNG; clinically relevant resistance to these antibiotics (or related agents) may emerge first among these strains. The observed diversity of strains (123 auxo/serovar classes since 1988) indicates a continuous introduction of new strains into the community. The epidemic increase of TRNG/PPNG was mainly caused by A/S classes NR/1B-6, PRO/1A-3, and PRO/1A-6, suggesting a clonal spread of a few strains; the rapid spread was associated with transmission in high risk individuals (that is, prostitutes and their clients).

CONCLUSION

The prevalence of PPNG in the Netherlands remains high and reduced sensitivity to other antimicrobials was detected among the PPNG strains. This underlines the necessity for a continuous national surveillance of resistance in gonococci including limited epidemiological information.

Antimicrobial susceptibility and types of Neisseria gonorrhoeae in Greece. Data for the period 1990 to 1993

BACKGROUND

Surveillance of the rapidly changing patterns of antimicrobial resistance of Neisseria gonorrhoeae is imperative for monitoring gonococcal infection.

GOAL

To describe the types and the antimicrobial susceptibility profile of a representative samples of gonococci isolated in Greece between 1990 and 1993.

STUDY DESIGN

The antimicrobial susceptibilities, serovar/auxotypes classes, and plasmid contents of 263 consecutive isolates of N. gonorrhoeae, recovered from cases of male gonococcal urethritis, were determined.

RESULTS

Penicillinase-producing N. gonorrhoeae (PPNG) were isolated at a rate of 6.1% and were mostly from imported cases of infection. Six (2.3%) of the isolates (one PPNG and five non-PPNG) were highly resistant to tetracycline, and one PPNG strain was resistant to norfloxacin and ciprofloxacin. Strains with chromosomal resistance to penicillin, tetracycline, erythromycin, and chloramphenicol accounted for 18.5%, 12.5%, 19%, and 16% of the isolates, respectively; much higher proportions of strains were intermediately susceptible to these antibiotics. Spectinomycin and cefotaxime were active against all gonococci studied. A shift to IB serovars and to sporadic types of strains was noted from previous years among the non-PPNG isolates. This is compatible with the marked increase in the rate of imported cases of infection caused by n on-PPNG strains.

CONCLUSIONS

The emergence of high-level resistance to tetracycline and resistance to fluoroquinolones was ascertained. At the present, however, the main problem with gonococcal resistance in Greece seems to ensue from the increasing rates of chromosomally resistant strains. Moreover, the increasing frequency of imported gonococci underlines the necessity for continuous epidemiologic surveillance.

Increasing resistance of Neisseria gonorrhoeae in west and central Africa. Consequence on therapy of gonococcal infection

BACKGROUND AND OBJECTIVES

Antimicrobial resistant strains of Neisseria gonorrhoeae have spread with remarkable rapidity in many African countries. Chromosomal resistance to penicillin, tetracycline, and thiamphenicol is frequent now, and reported prevalences of penicillinase-producing N. gonorrhoeae isolates vary between 15% and 80%. Plasmid-mediated tetracycline-resistant N. gonorrhoeae isolates have been observed in several African countries.

GOALS

To characterize gonococcal isolates from three sites in West and Central Africa, to determine antimicrobial susceptibility patterns, to document the spread of plasmid-mediated resistance to penicillin and tetracycline in these three sites, and to discuss the consequences of rising antimicrobial resistance on the management of gonococcal infection in Africa.

STUDY DESIGN

Over time, a total of 2,288 gonococcal isolates were obtained from Abidjan, Ivory Coast (1992-1993, n = 251), from Kigali, Rwanda (1988-1993, n = 952), and from Kinshasa, Zaire (1988-1990, n = 1,085). The isolates were characterized by auxotyping and serotyping. Plasmid-mediated resistance to penicillin and to tetracycline was determined. Antimicrobial susceptibility testing to ceftriaxone, ciprofloxacin, penicillin, spectinomycin, tetracycline, and thiamphenicol was performed with an agar dilution method.

RESULTS

The prevalence of penicillinase-producing N. gonorrhoeae increased significantly over time from 44% to 57% in Kigali and remained stable at a high level in Abidjan (73%) and in Kinshasa (67%). The frequency of tetracycline-resistant N. gonorrhoeae increased significantly during the observation periods in all three sites: from 20% to 65% in Abidjan, from 0% to 64% in Kigali, and from 14% to 41% in Kinshasa. Chromosomal resistance to penicillin was common in Kigali and Kinshasa, and chromosomal resistance to tetracycline and thiamphenicol was frequent in all three sites. All gonococcal isolates were susceptible to ceftriaxone, ciprofloxacin, and spectinomycin. Prototrophic and proline requiring strains were predominant, and IA-6 was the most common serovar in the three sites. IB-specific serovars were more common among penicillinase-producing N. gonorrhoeae and IA-specific serovars were more frequent among tetracycline-resistant N. gonorrhoeae, but there was no evidence for a clonal spread of resistant strains.

CONCLUSIONS

This study illustrates the high frequency of resistant gonococci in Africa and shows that tetracycline-resistant N. gonorrhoeae have become highly endemic in different geographic areas of the continent. The use of effective drugs is essential to reduce gonorrhea transmission. Surveillance of temporal changes in antimicrobial resistance in gonococcal strain populations should be part of sexually transmitted diseases control programs.

Antibiotic susceptibility patterns and plasmid profiles of penicillinase-producing Neisseria gonorrhoeae strains in Durban, South Africa, 1990-1993

BACKGROUND AND OBJECTIVES

The appearance of strains of Neisseria gonorrhoeae resistant, both chromosomally and plasmid-mediated, to penicillin and other antibiotics makes this versatile pathogen difficult to treat. There is, therefore, a need for surveillance of N. gonorrhoeae strains to determine the efficacy of current therapeutic measures.

GOALS

To survey the antibiotic susceptibilities and plasmid profiles of penicillinase-producing N. gonorrhoeae strains isolated over a 4-year period.

STUDY DESIGN

Penicillinase-producing N. gonorrhoeae strains were detected by the chromogenic cephalosporin test. Minimum inhibitory concentrations to penicillin G, tetracycline, ceftriaxone, and ciprofloxacin were determined using the E-test. Plasmid DNA was obtained by the alkaline lysis method and profiles generated.

RESULTS

Penicillinase-producing N. gonorrhoeae strains increased from 16.4% to 19.0% in the period from 1990 through 1993. Although all strains were resistant to penicillin, strains were susceptible to varying levels of ciprofloxacin, ceftriaxone, and even tetracycline. All penicillinase-producing N. gonorrhoeae strains possessed the 2.6-megadalton cryptic plasmid, and in addition 87.7% contained the 24.5-megadalton conjugative plasmid. Of the six known gonococcal beta-lactamase plasmids, the 4.4-megadalton Asian and 3.2-megadalton African plasmids were predominant. The most prevalent plasmid profile contained the 2.6-megadalton cryptic, 24.5-megadalton conjugative, and 4.4-megadalton Asian plasmids.

CONCLUSIONS

To ensure effective treatment of gonorrhea, continued surveillance of the antimicrobial susceptibilities and plasmid profiles of penicillinase-producing N. gonorrhoeae strains is necessary.

Tetracycline resistance determinants: mechanisms of action, regulation of expression, genetic mobility, and distribution

Tetracycline-resistant bacteria were first isolated in 1953 from Shigella dysenteriae, a bacterium which causes bacterial dysentery. Since then tetracycline-resistant bacterial have been found in increasing numbers of species and genera. This has resulted in reduced effectiveness of tetracycline therapy over time. Tetracycline resistance is normally due to the acquisition of new genes often associated with either a mobile plasmid or a transposon. These tetracycline resistance determinants are distinguishable both genetically and biochemically. Resistance is primarily due to either energy-dependent efflux of tetracycline or protection of the ribosomes from the action of tetracycline. Gram-negative tetracycline efflux proteins are linked to repressor proteins which in the absence of tetracycline block transcription of the repressor and structural efflux genes. In contrast, expression of the Gram-positive tetracycline efflux genes and some of the ribosomal protection genes appears to be regulated by attenuation of mRNA transcription. Specific tetracycline resistance genes have been identified in 32 Gram-negative and 22 Gram-positive genera. Tetracycline-resistant bacteria are found in pathogens, opportunistic and normal flora species. Tetracycline-resistant bacteria can be isolated from man, animals, food, and the environment. The nonpathogens in each of these ecosystems may play an important role as reservoirs for the antibiotic resistance genes. It is clear that if we are to reverse the trend toward increasingly antibiotic-resistant pathogenic bacteria we will need to change how antibiotics are used in both human and animal health and food production.

Tetracycline-resistant Neisseria gonorrhoeae. Characteristics of patients and isolates at a London Genitourinary Medicine Clinic

OBJECTIVES

To compare auxotypes, serovars, and antibiograms of tetracycline-resistant Neisseria gonorrhoeae (TRNG) and non-TRNG isolated from patients attending an East London Genitourinary Medicine (GUM) Clinic. To obtain plasmid profiles for penicillinase-producing gonococci (PPNG) as well as presumptive TRNG. To identify differences in patient characteristics for the TRNG and non-TRNG patient groups.

STUDY DESIGN

Gonococcal isolates were collected from 400 patients attending the GUM clinic at the Royal London Hospital GUM Clinic over a 1-year period. Isolates (378) were tested for susceptibility to various antibiotics, auxotyped, and serotyped. Plasmid profiles were obtained for PPNG and isolates exhibiting high-level tetracycline resistance (TRNG). The presence of the tet M determinant was confirmed using the polymerase chain reaction (PCR). The PCR product was digested with the restriction endonuclease (RE) Hpa II and electrophoresed on a 2.5% agarose gel to determine an "RE pattern." Patient data were collected by retrospective case-note review.

RESULTS

TRNG (n = 42) accounted for 11% of the 378 isolates tested, and the remaining 336 (89%) isolates were non-TRNG. Non-requiring auxotrophy and P1B-2 serovar expression occurred more frequently among TRNG. PPNG accounted for 31% of TRNG and 5% of non-TRNG. Chromosomal resistance to penicillin (CMRNG) was absent among TRNG but accounted for 11% of non-TRNG. One TRNG isolate showed decreased susceptibility to ciprofloxacin (MIC 0.25 mg/l). All isolates were sensitive to cefotaxime, cefixime, spectinomycin, and azithromycin. All TRNG possessed the 25.2 MDa plasmid and produced a PCR product of appropriate size after tet M gene sequence amplification. RE digests of the PCR product gave a single pattern. None of the TRNG in contrast to 18% of the non-TRNG were acquired homosexually. Ethnic distribution differed between the patients with TRNG and patients without non-TRNG (Afro-Caribbean 81% versus 58%; white 19% versus 36%). Most TRNG were acquired in the United Kingdom.

CONCLUSIONS

TRNG differ from the non-TRNG in their auxotype and serovar distribution. PPNG are more common among the TRNG isolates, whereas CMRNG appear absent. TRNG are isolated more commonly from Afro-Caribbean patients and were not represented among homosexually acquired isolates.

Antimicrobial agents and gonorrhoea: therapeutic choice, resistance and susceptibility testing

INTRODUCTION

Neisseria gonorrhoeae, the causative agent of gonorrhoea is a particularly well adapted pathogen that has continued to evolve mechanisms to evade treatment with antimicrobial agents.

THERAPEUTIC CHOICE

The choice of antibiotic for use in the first-line treatment of gonorrhoea should be made with knowledge of the susceptibility of the isolates of N gonorrhoeae to be encountered.

RESISTANCE

High-level resistance to penicillin and tetracycline in N gonorrhoeae is plasmid-mediated and a major therapeutic problem. Penicillinase-producing N gonorrhoeae, first described in 1976, have now spread worldwide and tetracycline-resistant N gonorrhoeae, described in 1985, are becoming increasingly prevalent. Chromosomal resistance to penicillin is low-level and affects a range of antibiotics. High-level resistance to spectinomycin has been sporadic and has not limited its use whereas the emergence of resistance to ciprofloxacin will have a significant impact on its use for gonorrhoea.

SUSCEPTIBILITY TESTING

A variety of methods are available including disc diffusion, breakpoint agar dilution technique, E-test and determination of the minimum inhibitory concentration (MIC). The choice of methodology will depend on the number and type of isolates and the facilities available for testing.

DISCUSSION

Surveillance programmes to monitor levels of antibiotic resistant isolates are essential to ensure therapeutic success.

Distribution of tet(H) among Pasteurella isolates from the United States and Canada

Tetracycline-resistant isolates of Pasteurella multocida and Pasteurella haemolytica obtained from various locations in the United States and Canada were studied to determine the distribution of the tet(H) gene. Of the 31 isolates examined, 25 were found to contain the tet(H) gene. Chromosomal or plasmid DNA obtained from those that did not contain the tet(H) gene did not hybridize with probes specific for classes A through G, though chromosomal DNA from one isolate lacking tet(H) hybridized with a probe specific for class M. The tet(H) gene was found on plasmid as well as on chromosomal DNA, suggesting that it is carried on a transposable element.

Gonococcal susceptibility to antimicrobials in Baltimore, 1988-1994. What was the impact of ciprofloxacin as first-line therapy for gonorrhea?

BACKGROUND

Single-dose, oral quinolones have been a recommended treatment option for gonorrhea since 1989 and have since been used as first-line therapy for gonorrhea in Baltimore.

METHODS

The impact of this strategy on antimicobial susceptibility patterns in Neisseria gonorrhoeae was assessed utilizing data collected as part of the National Gonococcal Isolate Surveillance system. This system evaluates a systematically collected sample. Minimum inhibitory concentrations to penicillin, tetracycline, ceftriaxone, and ciprofloxacin were determined by agar dilution.

RESULTS

Between January 1988 and September 1994, 1,846 gonococcal isolates were evaluated. The proportion of isolates with plasmid-mediated resistance (penicillinase-producing Neisseria gonorrhoeae or tetracycline-resistant Neisseria gonorrhoeae) increased from 22% in 1988 to 46% in 1992 and then dropped to 20% in 1994. In contrast, the prevalence of chromosomally mediated resistant isolates ranged between 3% and 10%. Between 1988 and 1994, the geometric mean penicillin and tetracycline minimum inhibitory concentrations decreased slightly (penicillin: from 0.509 microgram/ml to 0.369 microgram/ml; tetracycline: from 1.01 micrograms/ml to 0.767 microgram/ml). The mean ceftriaxone MIC increased from 0.005 microgram/ml in 1988 to 0.021 microgram/ml in 1992, and then abruptly decreased. Ciprofloxacin minimum inhibitory concentrations did not change substantially during the study period. Concurrent studies performed in this community suggest that quinolones were infrequently used for infections other than sexually transmitted ones during this time period.

CONCLUSIONS

Single-dose quinolone therapy does not appear to foster development of resistant gonococcal isolates. However, resistance may develop as a result of complex ecological interactions with the community, underscoring the need for continued surveillance.