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Bazzo ML, Machado HDM, Martins JM, Schörner MA, Buss K, Barazzetti FH, Gaspar PC, Bigolin A, Benzaken A, de Carvalho SVF, Andrade LDF, Ferreira WA, Figueiroa F, Fontana RM, da Silva MFDCR, Silva RJC, Aires Junior LF, Neves LADS, Miranda AE, Network BG. Aetiological molecular identification of sexually transmitted infections that cause urethral discharge syndrome and genital ulcer disease in Brazilian men: a nationwide study. Sex Transm Infect 2024; 100:133-137. [PMID: 38360847 DOI: 10.1136/sextrans-2023-055950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/13/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Little is known about the aetiology of urethral discharge syndrome (UDS) and genital ulcer disease (GUD) in Brazil due to limited access to laboratory tests and treatment based mainly on the syndromic approach. OBJECTIVES To update Brazilian treatment guidelines according to the current scenario, the first nationwide aetiological study for UDS and GUD was performed. METHODS Male participants with urethral discharge (UD) and/or genital ulcer (GU) reports were enrolled. Sample collection was performed by 12 sentinel sites located in the five Brazilian regions. Between 2018 and 2020, 1141 UD and 208 GU samples were collected in a Universal Transport Medium-RT (Copan). A multiplex quantitative PCR kit (Seegene) was used to detect UD: Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), M. hominis (MH), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV), Ureaplasma parvum (UP), U. urealyticum (UU) and another kit to detect GU: cytomegalovirus (CMV), Haemophilus ducreyi (HD), herpes simplex virus type 1 (HSV1), herpes simplex virus type 2 (HSV2), lymphogranuloma venereum (LGV), Treponema pallidum (TP) and varicella-zoster virus (VZV). RESULTS In UD samples, the frequency of pathogen detection was NG: 78.38%, CT: 25.6%, MG: 8.3%, UU: 10.4%, UP: 3.5%, MH: 3.5% and TV: 0.9%. Coinfection was assessed in 30.9% of samples, with 14.3% of NG/CT coinfection. The most frequent pathogen identified in GU was HSV2, present in 40.8% of the samples, followed by TP at 24.8%, LGV and CMV at 1%, and HSV1 at 0.4%. Coinfection of TP/HSV2 was detected in 4.4% of samples. VZV and HD were not detected. In 27.7% of the GU samples, no pathogen was detected. CONCLUSION This study provided the acquisition of unprecedented data on the aetiology of UDS and GUD in Brazil, demonstrated the presence of a variety of pathogens in both sample types and reaffirmed the aetiologies known to be most prevalent globally.
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Affiliation(s)
- Maria Luiza Bazzo
- Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
- Pharmacy Post Graduate Program, Molecular Biology, Microbiology and Serology Laboratory-LBMMS, Florianópolis, Brazil
| | - Hanalydia de Melo Machado
- Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
- Pharmacy Post Graduate Program, Molecular Biology, Microbiology and Serology Laboratory-LBMMS, Florianópolis, Brazil
| | - Jessica Motta Martins
- Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
- Pharmacy Post Graduate Program, Molecular Biology, Microbiology and Serology Laboratory-LBMMS, Florianópolis, Brazil
| | - Marcos André Schörner
- Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
- Pharmacy Post Graduate Program, Molecular Biology, Microbiology and Serology Laboratory-LBMMS, Florianópolis, Brazil
| | - Ketlyn Buss
- Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
- Pharmacy Post Graduate Program, Molecular Biology, Microbiology and Serology Laboratory-LBMMS, Florianópolis, Brazil
| | - Fernando Hartmann Barazzetti
- Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
- Pharmacy Post Graduate Program, Molecular Biology, Microbiology and Serology Laboratory-LBMMS, Florianópolis, Brazil
| | - Pamela Cristina Gaspar
- Department of Surveillance, Prevention and Control of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis, Secretariat of Health Surveillance, Ministry of Health, Brasília, Distrito Federal, Brazil
| | - Alisson Bigolin
- Department of Surveillance, Prevention and Control of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis, Secretariat of Health Surveillance, Ministry of Health, Brasília, Distrito Federal, Brazil
| | - Adele Benzaken
- Leônidas e Maria Deane Institute Fiocruz Amazonas, Manaus, Amazonas, Brazil
- AIDS Healthcare Foundation, Los Angeles, California, USA
| | | | | | | | | | | | | | | | | | | | - Angelica Espinosa Miranda
- Department of Surveillance, Prevention and Control of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis, Secretariat of Health Surveillance, Ministry of Health, Brasília, Distrito Federal, Brazil
- Federal University of Espirito Santo, Vitoria, Brazil
| | - Brazilian-Gasp Network
- Department of Surveillance, Prevention and Control of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis, Secretariat of Health Surveillance, Ministry of Health, Brasília, Distrito Federal, Brazil
- Brazilian GASP, Florianópolis, Brazil
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Kitano H, Teishima J, Shigemura K, Ohge H, Fujisawa M, Matsubara A. Current status of countermeasures for infectious diseases and resistant microbes in the field of urology. Int J Urol 2019; 26:1090-1098. [PMID: 31382322 DOI: 10.1111/iju.14087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/17/2019] [Indexed: 12/12/2022]
Abstract
A worldwide increase in antimicrobial-resistant microbes due to the improper use of antimicrobial agents, along with a lack of progress in developing new antimicrobials, is becoming a societal problem. Although carbapenem-resistant Enterobacteriaceae, which are resistant to carbapenem antimicrobials, first appeared in 1993, treatment options remain limited. Mechanisms behind antimicrobial resistance involve changes to microbial outer membranes, drug efflux pump abnormalities, β-lactamase production and the creation of biofilms around cell bodies. Genetic information related to these forms of antimicrobial resistance exists on chromosomes and plasmids, and when located on the latter can easily be transmitted to other strains, no matter the species, which creates a risk of antimicrobial resistance spreading exceptionally rapidly. To prevent the spread of antimicrobial resistance, the World Health Organization in 2015 published an action plan on antimicrobial resistance, based on which World Health Organization member countries have laid out specific policies and targets. Urinary tract infections are a type of healthcare-associated infection, and the sexually transmitted disease pathogen, Neisseria gonorrhoeae, has been included in a list of microbes that pose a risk to human health published by the US Centers for Disease Control and Prevention. Urologists face numerous problems when attempting to use antimicrobials properly, which is one method of dealing with antimicrobial resistance. Therefore, this article describes the current state of resistant microbes associated with urinary tract infections and countermeasures for antimicrobial resistance, including new antimicrobials.
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Affiliation(s)
- Hiroyuki Kitano
- Department of Urology, Hiroshima University, Hiroshima City, Hiroshima, Japan.,Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima City, Hiroshima, Japan
| | - Jun Teishima
- Department of Urology, Hiroshima University, Hiroshima City, Hiroshima, Japan
| | | | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima City, Hiroshima, Japan
| | - Masato Fujisawa
- Department of Urology, Kobe University, Kobe City, Hyogo, Japan
| | - Akio Matsubara
- Department of Urology, Hiroshima University, Hiroshima City, Hiroshima, Japan
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An Illustration of the Potential Health and Economic Benefits of Combating Antibiotic-Resistant Gonorrhea. Sex Transm Dis 2019; 45:250-253. [PMID: 29465709 DOI: 10.1097/olq.0000000000000725] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Preventing the emergence of ceftriaxone-resistant Neisseria gonorrhoeae can potentially avert hundreds of millions of dollars in direct medical costs of gonorrhea and gonorrhea-attributable HIV infections. In the illustrative scenario we examined, emerging ceftriaxone resistance could lead to 1.2 million additional N. gonorrhoeae infections within 10 years, costing $378.2 million.
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Taylor SN, Marrazzo J, Batteiger BE, Hook EW, Seña AC, Long J, Wierzbicki MR, Kwak H, Johnson SM, Lawrence K, Mueller J. Single-Dose Zoliflodacin (ETX0914) for Treatment of Urogenital Gonorrhea. N Engl J Med 2018; 379:1835-1845. [PMID: 30403954 DOI: 10.1056/nejmoa1706988] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Antibiotic-resistant Neisseria gonorrhoeae has prompted the development of new therapies. Zoliflodacin is a new antibiotic that inhibits DNA biosynthesis. In this multicenter, phase 2 trial, zoliflodacin was evaluated for the treatment of uncomplicated gonorrhea. METHODS We randomly assigned eligible men and women who had signs or symptoms of uncomplicated urogenital gonorrhea or untreated urogenital gonorrhea or who had had sexual contact in the preceding 14 days with a person who had gonorrhea to receive a single oral dose of zoliflodacin (2 g or 3 g) or a single 500-mg intramuscular dose of ceftriaxone in a ratio of approximately 70:70:40. A test of cure occurred within 6±2 days after treatment, followed by a safety visit 31±2 days after treatment. The primary efficacy outcome measure was the proportion of urogenital microbiologic cure in the microbiologic intention-to-treat (micro-ITT) population. RESULTS From November 2014 through December 2015, a total of 179 participants (167 men and 12 women) were enrolled. Among the 141 participants in the micro-ITT population who could be evaluated, microbiologic cure at urogenital sites was documented in 55 of 57 (96%) who received 2 g of zoliflodacin, 54 of 56 (96%) who received 3 g of zoliflodacin, and 28 of 28 (100%) who received ceftriaxone. All rectal infections were cured in all 5 participants who received 2 g of zoliflodacin and all 7 who received 3 g, and in all 3 participants in the group that received ceftriaxone. Pharyngeal infections were cured in 4 of 8 participants (50%), 9 of 11 participants (82%), and 4 of 4 participants (100%) in the groups that received 2 g of zoliflodacin, 3 g of zoliflodacin, and ceftriaxone, respectively. A total of 84 adverse events were reported: 24 in the group that received 2 g of zoliflodacin, 37 in the group that received 3 g of zoliflodacin, and 23 in the group that received ceftriaxone. According to investigators, a total of 21 adverse events were thought to be related to zoliflodacin, and most such events were gastrointestinal. CONCLUSIONS The majority of uncomplicated urogenital and rectal gonococcal infections were successfully treated with oral zoliflodacin, but this agent was less efficacious in the treatment of pharyngeal infections. (Funded by the National Institutes of Health and Entasis Therapeutics; ClinicalTrials.gov number, NCT02257918 .).
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Affiliation(s)
- Stephanie N Taylor
- From the Louisiana State University Health Sciences Center, New Orleans (S.N.T.); University of Alabama at Birmingham, Birmingham (J. Marrazzo, E.W.H.); University of Washington, Seattle (J. Marrazzo); Indiana University, Indianapolis (B.E.B.); University of North Carolina, Chapel Hill (A.C.S.), and FHI 360, Durham (S.M.J.) - both in North Carolina; Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Disease, Bethesda (J.L.), and Emmes, Rockville (M.R.W., H.K.) - both in Maryland; and Entasis Therapeutics, Waltham, MA (K.L., J. Mueller)
| | - Jeanne Marrazzo
- From the Louisiana State University Health Sciences Center, New Orleans (S.N.T.); University of Alabama at Birmingham, Birmingham (J. Marrazzo, E.W.H.); University of Washington, Seattle (J. Marrazzo); Indiana University, Indianapolis (B.E.B.); University of North Carolina, Chapel Hill (A.C.S.), and FHI 360, Durham (S.M.J.) - both in North Carolina; Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Disease, Bethesda (J.L.), and Emmes, Rockville (M.R.W., H.K.) - both in Maryland; and Entasis Therapeutics, Waltham, MA (K.L., J. Mueller)
| | - Byron E Batteiger
- From the Louisiana State University Health Sciences Center, New Orleans (S.N.T.); University of Alabama at Birmingham, Birmingham (J. Marrazzo, E.W.H.); University of Washington, Seattle (J. Marrazzo); Indiana University, Indianapolis (B.E.B.); University of North Carolina, Chapel Hill (A.C.S.), and FHI 360, Durham (S.M.J.) - both in North Carolina; Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Disease, Bethesda (J.L.), and Emmes, Rockville (M.R.W., H.K.) - both in Maryland; and Entasis Therapeutics, Waltham, MA (K.L., J. Mueller)
| | - Edward W Hook
- From the Louisiana State University Health Sciences Center, New Orleans (S.N.T.); University of Alabama at Birmingham, Birmingham (J. Marrazzo, E.W.H.); University of Washington, Seattle (J. Marrazzo); Indiana University, Indianapolis (B.E.B.); University of North Carolina, Chapel Hill (A.C.S.), and FHI 360, Durham (S.M.J.) - both in North Carolina; Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Disease, Bethesda (J.L.), and Emmes, Rockville (M.R.W., H.K.) - both in Maryland; and Entasis Therapeutics, Waltham, MA (K.L., J. Mueller)
| | - Arlene C Seña
- From the Louisiana State University Health Sciences Center, New Orleans (S.N.T.); University of Alabama at Birmingham, Birmingham (J. Marrazzo, E.W.H.); University of Washington, Seattle (J. Marrazzo); Indiana University, Indianapolis (B.E.B.); University of North Carolina, Chapel Hill (A.C.S.), and FHI 360, Durham (S.M.J.) - both in North Carolina; Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Disease, Bethesda (J.L.), and Emmes, Rockville (M.R.W., H.K.) - both in Maryland; and Entasis Therapeutics, Waltham, MA (K.L., J. Mueller)
| | - Jill Long
- From the Louisiana State University Health Sciences Center, New Orleans (S.N.T.); University of Alabama at Birmingham, Birmingham (J. Marrazzo, E.W.H.); University of Washington, Seattle (J. Marrazzo); Indiana University, Indianapolis (B.E.B.); University of North Carolina, Chapel Hill (A.C.S.), and FHI 360, Durham (S.M.J.) - both in North Carolina; Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Disease, Bethesda (J.L.), and Emmes, Rockville (M.R.W., H.K.) - both in Maryland; and Entasis Therapeutics, Waltham, MA (K.L., J. Mueller)
| | - Michael R Wierzbicki
- From the Louisiana State University Health Sciences Center, New Orleans (S.N.T.); University of Alabama at Birmingham, Birmingham (J. Marrazzo, E.W.H.); University of Washington, Seattle (J. Marrazzo); Indiana University, Indianapolis (B.E.B.); University of North Carolina, Chapel Hill (A.C.S.), and FHI 360, Durham (S.M.J.) - both in North Carolina; Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Disease, Bethesda (J.L.), and Emmes, Rockville (M.R.W., H.K.) - both in Maryland; and Entasis Therapeutics, Waltham, MA (K.L., J. Mueller)
| | - Hannah Kwak
- From the Louisiana State University Health Sciences Center, New Orleans (S.N.T.); University of Alabama at Birmingham, Birmingham (J. Marrazzo, E.W.H.); University of Washington, Seattle (J. Marrazzo); Indiana University, Indianapolis (B.E.B.); University of North Carolina, Chapel Hill (A.C.S.), and FHI 360, Durham (S.M.J.) - both in North Carolina; Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Disease, Bethesda (J.L.), and Emmes, Rockville (M.R.W., H.K.) - both in Maryland; and Entasis Therapeutics, Waltham, MA (K.L., J. Mueller)
| | - Shacondra M Johnson
- From the Louisiana State University Health Sciences Center, New Orleans (S.N.T.); University of Alabama at Birmingham, Birmingham (J. Marrazzo, E.W.H.); University of Washington, Seattle (J. Marrazzo); Indiana University, Indianapolis (B.E.B.); University of North Carolina, Chapel Hill (A.C.S.), and FHI 360, Durham (S.M.J.) - both in North Carolina; Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Disease, Bethesda (J.L.), and Emmes, Rockville (M.R.W., H.K.) - both in Maryland; and Entasis Therapeutics, Waltham, MA (K.L., J. Mueller)
| | - Kenneth Lawrence
- From the Louisiana State University Health Sciences Center, New Orleans (S.N.T.); University of Alabama at Birmingham, Birmingham (J. Marrazzo, E.W.H.); University of Washington, Seattle (J. Marrazzo); Indiana University, Indianapolis (B.E.B.); University of North Carolina, Chapel Hill (A.C.S.), and FHI 360, Durham (S.M.J.) - both in North Carolina; Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Disease, Bethesda (J.L.), and Emmes, Rockville (M.R.W., H.K.) - both in Maryland; and Entasis Therapeutics, Waltham, MA (K.L., J. Mueller)
| | - John Mueller
- From the Louisiana State University Health Sciences Center, New Orleans (S.N.T.); University of Alabama at Birmingham, Birmingham (J. Marrazzo, E.W.H.); University of Washington, Seattle (J. Marrazzo); Indiana University, Indianapolis (B.E.B.); University of North Carolina, Chapel Hill (A.C.S.), and FHI 360, Durham (S.M.J.) - both in North Carolina; Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Disease, Bethesda (J.L.), and Emmes, Rockville (M.R.W., H.K.) - both in Maryland; and Entasis Therapeutics, Waltham, MA (K.L., J. Mueller)
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Taylor SN, Morris DH, Avery AK, Workowski KA, Batteiger BE, Tiffany CA, Perry CR, Raychaudhuri A, Scangarella-Oman NE, Hossain M, Dumont EF. Gepotidacin for the Treatment of Uncomplicated Urogenital Gonorrhea: A Phase 2, Randomized, Dose-Ranging, Single-Oral Dose Evaluation. Clin Infect Dis 2018; 67:504-512. [PMID: 29617982 PMCID: PMC6070052 DOI: 10.1093/cid/ciy145] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/23/2018] [Indexed: 11/28/2022] Open
Abstract
Background In this phase 2 study, we evaluated the efficacy and safety of oral gepotidacin, a novel triazaacenaphthylene bacterial type II topoisomerase inhibitor, for the treatment of uncomplicated urogenital gonorrhea. Methods Adult participants with suspected urogenital gonorrhea were enrolled and completed baseline (day 1) and test-of-cure (days 4-8) visits. Pretreatment and posttreatment urogenital swabs were collected for Neisseria gonorrhoeae (NG) culture and susceptibility testing. Pharyngeal and rectal swab specimens were collected if there were known exposures. Participants were stratified by gender and randomized 1:1 to receive a 1500-mg or 3000-mg single oral dose of gepotidacin. Results The microbiologically evaluable population consisted of 69 participants, with NG isolated from 69 (100%) urogenital, 2 (3%) pharyngeal, and 3 (4%) rectal specimens. Microbiological eradication of NG was achieved by 97%, 95%, and 96% of participants (lower 1-sided exact 95% confidence interval bound, 85.1%, 84.7%, and 89.1%, respectively) for the 1500-mg, 3000-mg, and combined dose groups, respectively. Microbiological cure was achieved in 66/69 (96%) urogenital infections. All 3 failures were NG isolates that demonstrated the highest observed gepotidacin minimum inhibitory concentration of 1 µg/mL and a common gene mutation. At the pharyngeal and rectal sites, 1/2 and 3/3 NG isolates, respectively, demonstrated microbiological cure. There were no treatment-limiting adverse events for either dose. Conclusions This study demonstrated that single, oral doses of gepotidacin were ≥95% effective for bacterial eradication of NG in adult participants with uncomplicated urogenital gonorrhea. Clinical Trials Registration NCT02294682.
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Affiliation(s)
- Stephanie N Taylor
- Section of Infectious Disease, Louisiana State University Health Sciences Center, New Orleans
| | | | - Ann K Avery
- Department of Medicine, Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio
| | - Kimberly A Workowski
- Department of Medicine, Division of Infectious Diseases, Emory University Department of Medicine, Atlanta, Georgia
| | - Byron E Batteiger
- Department of Medicine, Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis
| | | | - Caroline R Perry
- Research & Development, GlaxoSmithKline, Collegeville, Pennsylvania
| | | | | | - Mohammad Hossain
- Research & Development, GlaxoSmithKline, Collegeville, Pennsylvania
| | - Etienne F Dumont
- Research & Development, GlaxoSmithKline, Collegeville, Pennsylvania
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Wu X, Qin X, Huang J, Wang F, Li M, Wu Z, Liu X, Pei J, Wu S, Chen H, Guo C, Xue Y, Tang S, Fang M, Lan Y, Ou J, Xie Z, Yu Y, Yang J, Chen W, Zhao Y, Zheng H. Determining the in vitro susceptibility of Neisseria gonorrhoeae isolates from 8 cities in Guangdong Province through an improved microdilution method. Diagn Microbiol Infect Dis 2018; 92:325-331. [PMID: 30292397 DOI: 10.1016/j.diagmicrobio.2018.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 05/27/2018] [Accepted: 06/06/2018] [Indexed: 10/14/2022]
Abstract
A microdilution method for the antibiotic susceptibility testing of Neisseria gonorrhoeae was established and improved, and the antibiotic resistance of N. gonorrhoeae samples isolated from 8 cities of Guangdong in 2016 was determined. The improved microdilution method was compared with the agar dilution method recommend by the World Health Organization (WHO) Western Pacific Region by testing the susceptibility of 100 clinical N. gonorrhoeae isolates. The essential agreement (EA), categorical agreement (CA), very major error (VME), major error (ME), and minor error (MIE) levels of the two methods were analyzed; the acceptable performance rates were measured as follows: ≥90% for EA or CA, ≤3% for VME or ME, and ≤7% for MIE. The EA, CA, VME, ME, and MIE of each method for 7 antibiotics, penicillin, tetracycline, ciprofloxacin, spectinomycin, ceftriaxone, cefixime, and azithromycin, were 96%-100%, 94%-100%, 0%-3%, 0%-2%, and 0%-6%, respectively. The Wilcoxon signed-rank test results indicated 94%-100% agreement between the 2 methods after excluding off-scale values (P > 0.05). The susceptibility of 634 N. gonorrhoeae strains to the 7 antibiotics above were tested through the microdilution method. The resistant rates of the isolates against ciprofloxacin, tetracycline, penicillin, and azithromycin were 99.8%, 88.3%, 53.8%, and 11%, and the percentages of the isolates with decreased susceptibility to ceftriaxone (minimum inhibitory concentration [MIC] ≥0.125 μg/mL) and cefixime (MIC ≥0.25 μg/mL) were 2.1% and 12%, respectively, in Guangdong. Among 8 cities, Shenzhen had the highest rates of resistance against penicillin (77.8%) and decreased susceptibility against ceftriaxone (5.6%). Zhuhai had the highest rates of decreased susceptibility against cefixime (30.1%), and Jiangmen had the highest azithromycin-resistant isolates (16.8%). The findings from this study indicated that the improved microdilution method is an alternative for testing the antimicrobial susceptibility of N. gonorrhoeae. The resistance rates of N. gonorrhoeae against penicillin, tetracycline, and ciprofloxacin were high. While ceftriaxone, cefixime, and spectinomycin remained effective against N. gonorrhoeae, their effectiveness seemed to be decreasing over time. Azithromycin therapy requires timely susceptibility test results.
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Affiliation(s)
- Xingzhong Wu
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Xiaolin Qin
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Jinmei Huang
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Feng Wang
- Shenzhen Center for Chronic Diseases Control, Shenzhen, Guangdong 518020, China
| | - Ming Li
- The fifth People's Hospital of Dongguan, Dongguan, Guangdong 523903, China
| | - Zhizhou Wu
- Jiangmen Dermatology Hospital, Jiangmen, Guangdong 529000, China
| | - Xiaofeng Liu
- Zhuhai Center for Chronic Diseases Control, Zhuhai, Guangdong 519099, China
| | - Junming Pei
- Shantou Dermatology Hospital, Shantou, Guangdong 515041, China
| | - Shanghua Wu
- Shaoguan Center for Chronic Diseases Control, Shaoguan, Guangdong 512026, China
| | - Heyong Chen
- Maoming Center for Chronic Diseases Control, Maoming, Guangdong 525099, China
| | - Chixing Guo
- Panyu Center for Chronic Diseases Control, Guangzhou, Guangdong 511400, China
| | - Yaohua Xue
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Sanmei Tang
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Mingheng Fang
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Yinyuan Lan
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Jiangli Ou
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Zhenmou Xie
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Yuqi Yu
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Jieyi Yang
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Wentao Chen
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Yunhu Zhao
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Heping Zheng
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China.
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Management of Gonorrhea. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00065-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Anaene M, Soyemi K, Caskey R. Factors associated with the over-treatment and under-treatment of gonorrhea and chlamydia in adolescents presenting to a public hospital emergency department. Int J Infect Dis 2016; 53:34-38. [PMID: 27771470 DOI: 10.1016/j.ijid.2016.10.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/16/2016] [Accepted: 10/14/2016] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES The purpose of this study was to measure the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) and the rates and factors associated with their over-treatment (OT) and under-treatment (UT). METHODS A retrospective chart review was performed of patients aged 13-24 years who were screened for GC/CT in the emergency department (ED) of a public hospital. Descriptive statistics were obtained for all variables, and multivariate log binomial regression was performed to ascertain the factors associated with OT and UT. RESULTS Seven hundred and ninety-seven adolescents and young adults were screened for GC/CT. The overall sexually transmitted infection (STI) positivity rate was 21.6%; 136 (21.6%) subjects were over-treated and 74 (43.4%) subjects were under-treated. Patients presenting with STI exposure or genito-urinary symptoms were more likely to be OT. Additionally, females aged 18-19 years or with a prior history of STIs were more likely to be OT. Females (83.6%) were more likely to be UT, while STI exposure, genito-urinary symptoms, and a prior history of STI were protective of UT . CONCLUSION Adolescents and young adults screened for STIs have a high prevalence of GC/CT. A significant proportion of these patients end up over-treated and an even higher proportion are under-treated.
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Affiliation(s)
- Mutimbwa Anaene
- Department of Pediatrics (MC 856), The University of Illinois at Chicago, 840 S. Wood Street, Chicago, IL 60612, USA.
| | - Kenneth Soyemi
- Pediatric Emergency Room, John H. Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - Rachel Caskey
- Department of Internal Medicine, The University of Illinois at Chicago, Chicago, Illinois, USA
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Abstract
The genus Neisseria contains two pathogenic species of prominant public health concern: Neisseria gonorrhoeae and Neisseria meningitidis. These pathogens display a notable ability to undergo frequent programmed recombination events. The recombination-mediated pathways of transformation and pilin antigenic variation in the Neisseria are well-studied systems that are critical for pathogenesis. Here we will detail the conserved and unique aspects of transformation and antigenic variation in the Neisseria. Transformation will be followed from initial DNA binding through recombination into the genome with consideration to the factors necessary at each step. Additional focus is paid to the unique type IV secretion system that mediates donation of transforming DNA in the pathogenic Neisseria. The pilin antigenic variation system uses programmed recombinations to alter a major surface determinant, which allows immune avoidance and promotes infection. We discuss the trans- and cis- acting factors which facilitate pilin antigenic variation and present the current understanding of the mechanisms involved in the process.
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Chen SC, Yin YP, Dai XQ, Unemo M, Chen XS. First nationwide study regarding ceftriaxone resistance and molecular epidemiology of Neisseria gonorrhoeae in China. J Antimicrob Chemother 2015; 71:92-9. [PMID: 26472770 DOI: 10.1093/jac/dkv321] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/05/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a major public health concern worldwide. This is the first nationwide study, performed within the China Gonococcal Antimicrobial Susceptibility Programme (China-GASP), regarding AMR, including ceftriaxone genetic resistance determinants, and molecular epidemiology of gonococci in China. METHODS Gonococcal isolates (n = 1257) from consecutive patients were collected at 11 sentinel sites distributed across China during 2012-13. Susceptibility to ceftriaxone, spectinomycin, ciprofloxacin and tetracycline was determined using the agar dilution method. Ceftriaxone resistance determinants penA and penB were examined using sequencing. N. gonorrhoeae multiantigen sequence typing (NG-MAST) was performed for molecular epidemiology. RESULTS Among isolates, 0.2% were resistant to spectinomycin, 4.4% to ceftriaxone, 42.9% to tetracyclines (high-level resistance) and 99.8% to ciprofloxacin. Among 890 sequenced isolates, 16 (1.8%) possessed a penA mosaic allele; 4 of these isolates belonged to the MDR internationally spread NG-MAST genogroup G1407 (first description in China). Non-mosaic penA alleles with an A501T mutation and an A102D alteration in porB1b were statistically associated with decreased susceptibility/resistance to ceftriaxone. NG-MAST G10339, G1424 and G1053 were associated with decreased susceptibility/resistance to ceftriaxone. CONCLUSIONS In China, ceftriaxone and spectinomycin can continue to be recommended for gonorrhoea treatment, with the possible exception of Hainan and Sichuan provinces where ceftriaxone resistance exceeded 5% and AMR surveillance needs to be strengthened. Molecular approaches including genotyping and AMR determinant analysis can be valuable to supplement and enhance conventional surveillance of gonococcal AMR in China.
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Affiliation(s)
- Shao-Chun Chen
- National Center for STD Control, Chinese Center for Disease Control and Prevention, and Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, and Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China
| | - Yue-Ping Yin
- National Center for STD Control, Chinese Center for Disease Control and Prevention, and Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, and Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China
| | - Xiu-Qin Dai
- National Center for STD Control, Chinese Center for Disease Control and Prevention, and Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, and Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Xiang-Sheng Chen
- National Center for STD Control, Chinese Center for Disease Control and Prevention, and Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, and Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China
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Holley CE, Van Pham T, Mezzadra HM, Willis GC, Witting MD. Overtreatment of gonorrhea and chlamydial infections in 2 inner-city emergency departments. Am J Emerg Med 2015; 33:1265-8. [PMID: 26119905 DOI: 10.1016/j.ajem.2015.06.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 06/04/2015] [Accepted: 06/04/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Infections with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) are the most commonly reported sexually transmitted diseases in the United States. OBJECTIVES The primary objective of this study was to estimate the incidence of overtreatment of GC and CT infections in the emergency department (ED). The secondary objective was to determine if there are clinical variables that predict infection with GC and CT. METHODS A retrospective medical record review was performed at 2 inner-city hospitals. Records were obtained from the evaluation of female patients who presented to the ED between January 1, 2012, and December 31, 2012, who were tested for GC and CT infection. A standardized form was used to extract specific information from each medical record. RESULTS Data were extracted from 538 medical records. Of the 522 ED visits, 32 (6%) yielded test results positive for either GC or CT, including 3 that were positive for both. Treatment was administered to 101 patients (19%) and declined by an additional 9 (2%). Of those receiving antibiotics, 87 of 101 (0.86; 95% confidence interval, 0.77-0.92) had negative test results. Of those not offered antibiotics, 17 of 412 (0.04; 95% confidence interval, 0.02-0.07) had positive test results. The overtreatment proportion was similar at hospitals (55/66 [0.83] and 32/35 [0.91], respectively). Of clinical variables that were considered, only age less than 19 years was statistically associated with a positive test result for GC and CT. CONCLUSION The rate of overtreatment for GC and CT was 86%. The practice of empirical treatment should be reconsidered.
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Affiliation(s)
| | - Thuy Van Pham
- University of Maryland, School of Medicine, Baltimore, MD
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Chesson HW, Kirkcaldy RD, Gift TL, Owusu-Edusei K, Weinstock HS. Ciprofloxacin resistance and gonorrhea incidence rates in 17 cities, United States, 1991-2006. Emerg Infect Dis 2014; 20:612-9. [PMID: 24655615 PMCID: PMC3966369 DOI: 10.3201/eid2004.131288] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Antimicrobial drug resistance can hinder gonorrhea prevention and control efforts. In this study, we analyzed historical ciprofloxacin resistance data and gonorrhea incidence data to examine the possible effect of antimicrobial drug resistance on gonorrhea incidence at the population level. We analyzed data from the Gonococcal Isolate Surveillance Project and city-level gonorrhea incidence rates from surveillance data for 17 cities during 1991–2006. We found a strong positive association between ciprofloxacin resistance and gonorrhea incidence rates at the city level during this period. Their association was consistent with predictions of mathematical models in which resistance to treatment can increase gonorrhea incidence rates through factors such as increased duration of infection. These findings highlight the possibility of future increases in gonorrhea incidence caused by emerging cephalosporin resistance.
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Blomquist PB, Miari VF, Biddulph JP, Charalambous BM. Is gonorrhea becoming untreatable? Future Microbiol 2014; 9:189-201. [PMID: 24571073 DOI: 10.2217/fmb.13.155] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
An estimated 498 million new cases of curable sexually transmitted infections occur worldwide annually. Of these, 106 million are gonococcal infections, rendering gonorrhea the second most prevalent bacterial sexually transmitted infection after chlamydia. A decline in susceptibility to extended-spectrum cephalosporins, as well as treatment failures, have been identified worldwide. This, together with the associated epidemiological and socioeconomic burden, is of increasing concern. Currently, the effectiveness of antibiotic resistance control measures is limited. Barriers include the lack of therapeutic options, the difficulties of reducing high-risk sexual behavior and Neisseria gonorrhoeae's propensity to rapidly acquire resistance determinants. While the disease remains treatable for the moment, we need to anticipate and be prepared for the arrival and spread of untreatable gonorrhea by using a multifaceted approach and search for other, perhaps novel control strategies.
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Affiliation(s)
- Paula Bianca Blomquist
- University College London Medical School Centre for Clinical Microbiology, Royal Free Campus, University College London, Rowland Hill Street, London, NW3 2PF, UK
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Kirkcaldy RD, Weinstock HS, Moore PC, Philip SS, Wiesenfeld HC, Papp JR, Kerndt PR, Johnson S, Ghanem KG, Hook EW. The efficacy and safety of gentamicin plus azithromycin and gemifloxacin plus azithromycin as treatment of uncomplicated gonorrhea. Clin Infect Dis 2014; 59:1083-91. [PMID: 25031289 DOI: 10.1093/cid/ciu521] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ceftriaxone is the foundation of currently recommended gonorrhea treatment. There is an urgent need for backup treatment options for patients with cephalosporin allergy or infections due to suspected cephalosporin-resistant Neisseria gonorrhoeae. We evaluated the efficacy and tolerability of 2 combinations of existing noncephalosporin antimicrobials for treatment of patients with urogenital gonorrhea. METHODS We conducted a randomized, multisite, open-label, noncomparative trial in 5 outpatient sexually transmitted disease clinic sites in Alabama, California, Maryland, and Pennsylvania. Patients aged 15-60 years diagnosed with uncomplicated urogenital gonorrhea were randomly assigned to either gentamicin 240 mg intramuscularly plus azithromycin 2 g orally, or gemifloxacin 320 mg orally plus azithromycin 2 g orally. The primary outcome was microbiological cure of urogenital infections (negative follow-up culture) at 10-17 days after treatment among 401 participants in the per protocol population. RESULTS Microbiological cure was achieved by 100% (lower 1-sided exact 95% confidence interval [CI] bound, 98.5%) of 202 evaluable participants receiving gentamicin/azithromycin, and 99.5% (lower 1-sided exact 95% CI bound, 97.6%) of 199 evaluable participants receiving gemifloxacin/azithromycin. Gentamicin/azithromycin cured 10 of 10 pharyngeal infections and 1 of 1 rectal infection; gemifloxacin/azithromycin cured 15 of 15 pharyngeal and 5 of 5 rectal infections. Gastrointestinal adverse events were common in both arms. CONCLUSIONS Gentamicin/azithromycin and gemifloxacin/azithromycin were highly effective for treatment of urogenital gonorrhea. Gastrointestinal adverse events may limit routine use. These non-cephalosporin-based regimens may be useful alternative options for patients who cannot be treated with cephalosporin antimicrobials. Additional treatment options for gonorrhea are needed. Clinical Trials Registration. NCT00926796.
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Affiliation(s)
- Robert D Kirkcaldy
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Hillard S Weinstock
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Page C Moore
- Department of Biostatistics, University of Arkansas Medical Sciences, Little Rock
| | | | - Harold C Wiesenfeld
- University of Pittsburgh and Allegheny County Health Department, Pennsylvania
| | - John R Papp
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Peter R Kerndt
- County of Los Angeles, Department of Public Health, California
| | | | - Khalil G Ghanem
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward W Hook
- University of Alabama at Birmingham Jefferson County Department of Health, Birmingham, Alabama
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Chen SC, Yin YP, Dai XQ, Unemo M, Chen XS. Antimicrobial resistance, genetic resistance determinants for ceftriaxone and molecular epidemiology of Neisseria gonorrhoeae isolates in Nanjing, China. J Antimicrob Chemother 2014; 69:2959-65. [PMID: 25011655 DOI: 10.1093/jac/dku245] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a major problem worldwide. This study investigated the AMR, genetic ceftriaxone resistance determinants and molecular epidemiology of N. gonorrhoeae in Nanjing, China. METHODS N. gonorrhoeae isolates were collected in 2007 (n = 198) and 2012 (n = 80). The susceptibility to ceftriaxone, spectinomycin, ciprofloxacin and tetracycline was determined using an agar-dilution method. The ceftriaxone resistance determinants penA, mtrR and penB were examined using sequencing. N. gonorrhoeae multi-antigen sequence typing (NG-MAST) was performed for molecular epidemiology. RESULTS All isolates were resistant to ciprofloxacin, 42.4% produced β-lactamase and 34.9% showed high-level resistance to tetracycline (MIC ≥16 mg/L). In total, 5.4% of isolates were resistant to ceftriaxone; however, all of these isolates were obtained in 2007 and the susceptibility to ceftriaxone appeared to have increased. All isolates were susceptible to spectinomycin. No penA mosaic alleles were found. Non-mosaic penA alleles with A501T and G542S alterations, an H105Y alteration in mtrR and an A102D/N alteration in porB1b were statistically associated with decreased susceptibility or resistance to ceftriaxone. The most prevalent NG-MAST sequence types (STs) were ST568 (n = 13), ST270 (n = 9) and ST421 (n = 7). ST270 was the most common ST in isolates with decreased susceptibility or resistance to ceftriaxone. CONCLUSIONS Ceftriaxone, ideally 500 mg and together with azithromycin (1-2 g), should be recommended for treatment of gonorrhoea in Nanjing, China. However, N. gonorrhoeae strains with resistance to ceftriaxone have been found in Nanjing. NG-MAST and ceftriaxone resistance determinant analysis can be valuable to supplement the antimicrobial resistance surveillance in China, which needs to be further strengthened.
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Affiliation(s)
- Shao-Chun Chen
- National Center for STD Control, Chinese Center for Disease Control and Prevention, and Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, and Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China
| | - Yue-Ping Yin
- National Center for STD Control, Chinese Center for Disease Control and Prevention, and Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, and Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China
| | - Xiu-Qin Dai
- National Center for STD Control, Chinese Center for Disease Control and Prevention, and Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, and Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden
| | - Xiang-Sheng Chen
- National Center for STD Control, Chinese Center for Disease Control and Prevention, and Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, and Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China
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Jeverica S, Golparian D, Hanzelka B, Fowlie AJ, Matičič M, Unemo M. High in vitro activity of a novel dual bacterial topoisomerase inhibitor of the ATPase activities of GyrB and ParE (VT12-008911) against Neisseria gonorrhoeae isolates with various high-level antimicrobial resistance and multidrug resistance. J Antimicrob Chemother 2014; 69:1866-72. [PMID: 24651828 DOI: 10.1093/jac/dku073] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Clinical resistance to the currently recommended extended-spectrum cephalosporins (ESCs), the last remaining options for empirical antimicrobial monotherapy of gonorrhoea globally, has been reported. New antimicrobials are essential to avoid the emergence of untreatable gonorrhoea. We have investigated the in vitro activity of a novel dual bacterial topoisomerase inhibitor of the ATPase activities of GyrB and ParE (Vertex aminobenzimidazole VT12-008911), compared with antimicrobials currently or previously recommended for gonorrhoea treatment. METHODS MICs were determined using agar dilution (VT12-008911) or Etest (seven antimicrobials) for international reference strains (n = 28) and clinical Neisseria gonorrhoeae isolates (n = 220). The latter included three extensively drug-resistant isolates with high-level ceftriaxone resistance, additional isolates with clinical ESC resistance and a high number of isolates with ciprofloxacin resistance and multidrug resistance. RESULTS The MIC(50), MIC(90) and MIC range of VT12-008911 were 0.064, 0.125 and ≤0.002-0.25 mg/L, respectively. One-hundred and seventy (69%) isolates were ciprofloxacin resistant; however, only 54 of those isolates had a VT12-008911 MIC >0.064 mg/L (47 and 7 with MIC = 0.125 mg/L and MIC = 0.25 mg/L, respectively). The in vitro activity of VT12-008911 was superior to that of ciprofloxacin and all additional antimicrobials investigated. Time-kill curve analysis showed that VT12-008911 exhibited potent time-dependent bactericidal activity, at or very close to the MIC, against N. gonorrhoeae. CONCLUSIONS In vitro results suggest that VT12-008911 might be an effective treatment option for gonorrhoea. However, it will be important to detail the pharmacokinetics/pharmacodynamics, toxicity, selection and mechanisms of VT12-008911 resistance in N. gonorrhoeae and, finally, to perform well-designed in vivo randomized clinical trials.
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Affiliation(s)
- Samo Jeverica
- Institute for Microbiology and Immunology, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden
| | | | | | - Mojca Matičič
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden
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Grad YH, Kirkcaldy RD, Trees D, Dordel J, Harris SR, Goldstein E, Weinstock H, Parkhill J, Hanage WP, Bentley S, Lipsitch M. Genomic epidemiology of Neisseria gonorrhoeae with reduced susceptibility to cefixime in the USA: a retrospective observational study. THE LANCET. INFECTIOUS DISEASES 2014; 14:220-6. [PMID: 24462211 PMCID: PMC4030102 DOI: 10.1016/s1473-3099(13)70693-5] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The emergence of Neisseria gonorrhoeae with decreased susceptibility to extended spectrum cephalosporins raises the prospect of untreatable gonorrhoea. In the absence of new treatments, efforts to slow the increasing incidence of resistant gonococcus require insight into the factors that contribute to its emergence and spread. We assessed the relatedness between isolates in the USA and reconstructed likely spread of lineages through different sexual networks. METHODS We sequenced the genomes of 236 isolates of N gonorrhoeae collected by the Centers for Disease Control and Prevention's Gonococcal Isolate Surveillance Project (GISP) from sentinel public sexually transmitted disease clinics in the USA, including 118 (97%) of the isolates from 2009-10 in GISP with reduced susceptibility to cefixime (cef(RS)) and 118 cefixime-susceptible isolates from GISP matched as closely as possible by location, collection date, and sexual orientation. We assessed the association between antimicrobial resistance genotype and phenotype and correlated phylogenetic clustering with location and sexual orientation. FINDINGS Mosaic penA XXXIV had a high positive predictive value for cef(RS). We found that two of the 118 cef(RS) isolates lacked a mosaic penA allele, and rechecking showed that these two were susceptible to cefixime. Of the 116 remaining cef(RS) isolates, 114 (98%) fell into two distinct lineages that have independently acquired mosaic penA allele XXXIV. A major lineage of cef(RS) strains spread eastward, predominantly through a sexual network of men who have sex with men. Eight of nine inferred transitions between sexual networks were introductions from men who have sex with men into the heterosexual population. INTERPRETATION Genomic methods might aid efforts to slow the spread of antibiotic-resistant N gonorrhoeae through augmentation of gonococcal outbreak surveillance and identification of populations that could benefit from increased screening for asymptomatic infections.
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Affiliation(s)
- Yonatan H Grad
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA; Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | | | - David Trees
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Edward Goldstein
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | | | | | - William P Hanage
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Stephen Bentley
- Wellcome Trust Sanger Institute, Hinxton, UK; Department of Medicine, University of Cambridge, Addenbrookes Hospital, Cambridge, UK
| | - Marc Lipsitch
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA, USA
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19
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Molecular approaches to enhance surveillance of gonococcal antimicrobial resistance. Nat Rev Microbiol 2014; 12:223-9. [PMID: 24509781 DOI: 10.1038/nrmicro3217] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The best available data indicate that the world is heading towards a pandemic of extensively drug-resistant Neisseria gonorrhoeae. At the same time, clinical microbiology laboratories have moved away from using culture-based methods to diagnose gonorrhoea, thus undermining our ability to detect antimicrobial resistance (AMR) using current technologies. In this Opinion article, we discuss the problem of N. gonorrhoeae AMR, particularly emerging resistance to the cephalosporin ceftriaxone, outline current concerns about the surveillance of N. gonorrhoeae AMR and propose the use of molecular methods on a large scale to systematically enhance surveillance.
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20
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Gose S, Nguyen D, Lowenberg D, Samuel M, Bauer H, Pandori M. Neisseria gonorrhoeae and extended-spectrum cephalosporins in California: surveillance and molecular detection of mosaic penA. BMC Infect Dis 2013; 13:570. [PMID: 24305088 PMCID: PMC4235022 DOI: 10.1186/1471-2334-13-570] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 11/28/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The spread of Neisseria gonorrhoeae strains with mosaic penA alleles and reduced susceptibility to extended-spectrum cephalosporins is a major public health problem. While much work has been performed internationally, little is known about the genetics or molecular epidemiology of N. gonorrhoeae isolates with reduced susceptibility to extended-spectrum cephalosporins in the United States. The majority of N. gonorrhoeae infections are diagnosed without a live culture. Molecular tools capable of detecting markers of extended-spectrum cephalosporin resistance are needed. METHODS Urethral N. gonorrhoeae isolates were collected from 684 men at public health clinics in California in 2011. Minimum inhibitory concentrations (MICs) to ceftriaxone, cefixime, cefpodoxime and azithromycin were determined by Etest and categorized according to the U.S. Centers for Disease Control 2010 alert value breakpoints. 684 isolates were screened for mosaic penA alleles using real-time PCR (RTPCR) and 59 reactive isolates were subjected to DNA sequencing of their penA alleles and Neisseria gonorrhoeae multi-antigen sequence typing (NG-MAST). To increase the specificity of the screening RTPCR in detecting isolates with alert value extended-spectrum cephalosporin MICs, the primers were modified to selectively amplify the mosaic XXXIV penA allele. RESULTS Three mosaic penA alleles were detected including two previously described alleles (XXXIV, XXXVIII) and one novel allele (LA-A). Of the 29 isolates with an alert value extended-spectrum cephalosporin MIC, all possessed the mosaic XXXIV penA allele and 18 were sequence type 1407, an internationally successful strain associated with multi-drug resistance. The modified RTPCR detected the mosaic XXXIV penA allele in urethral isolates and urine specimens and displayed no amplification of the other penA alleles detected in this study. CONCLUSION N. gonorrhoeae isolates with mosaic penA alleles and reduced susceptibility to extended-spectrum cephalosporins are currently circulating in California. Isolates with the same NG-MAST ST, penA allele and extended-spectrum cephalosporin MICs have caused treatment failures elsewhere. The RTPCR assay presented here may be useful for the detection of N. gonorrheoae isolates and clinical specimens with reduced extended-spectrum cephalosporin MICs in settings where antimicrobial susceptibility testing is unavailable. In an era of increasing antimicrobial resistance and decreasing culture capacity, molecular assays capable of detecting extended-spectrum cephalosporin of resistance are essential to public health.
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Affiliation(s)
- Severin Gose
- San Francisco Department of Public Health, 101 Grove St. Rm. 419, San Francisco, CA 94102, USA
| | - Duylinh Nguyen
- San Francisco Department of Public Health, 101 Grove St. Rm. 419, San Francisco, CA 94102, USA
| | - Daniella Lowenberg
- California Polytechnic State University at San Luis Obispo, 1 Grand Ave, San Luis Obispo, CA 93405, USA
- Currently at PharmGKB, Standford University, CA, Stanford University 1501 California Avenue, Palo Alto, CA 94304, USA
| | - Michael Samuel
- Sexually Transmitted Disease Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, 850 Marina Bay Pkwy, Richmond, CA 94804, USA
| | - Heidi Bauer
- Sexually Transmitted Disease Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, 850 Marina Bay Pkwy, Richmond, CA 94804, USA
| | - Mark Pandori
- San Francisco Department of Public Health, 101 Grove St. Rm. 419, San Francisco, CA 94102, USA
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Abstract
Gonorrhea is the second most common bacterial sexually transmitted infection in the United States. It continues to be a major cause of morbidity for women and has been linked to infertility and pelvic inflammatory disease. In 2012, the Centers for Disease Control and Prevention revised the current treatment guidelines for gonorrhea in response to the rising rates of antibiotic resistance. This column will discuss the new guidelines, including the rationale for the change as well as nursing implications to support timely and effective treatment of gonorrhea.
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Affiliation(s)
- Heidi Collins Fantasia
- Department of Nursing, School of Health and Environment, University of Massachusetts, Lowell, MA, USA. Heidi_Fantasia@ uml.edu
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Utility of specimens positive for Neisseria gonorrhoeae by the Aptima Combo 2 assay for assessment of strain diversity and antibiotic resistance. J Clin Microbiol 2013; 51:4156-60. [PMID: 24108603 DOI: 10.1128/jcm.01694-13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In our jurisdiction, the Aptima Combo 2 assay (Gen-Probe, Inc.) is used to detect Neisseria gonorrhoeae from specimens collected at clinics for sexually transmitted infections (STI) and from select community patients. In addition, swabs are also collected for N. gonorrhoeae culture, susceptibility testing, and sequence typing (ST). Since only a small proportion of samples from provincial cases undergo culture, the available trends in antimicrobial susceptibility and predominant strain types may not be representative of all N. gonorrhoeae infections. Due to the limitations facing the use of N. gonorrhoeae culture to understand these trends in the general community, we performed a molecular analysis for markers of cephalosporin resistance and ST determination by using nucleic acid extracts of specimens sent for Aptima testing. Thirty-four samples submitted for both Aptima testing and N. gonorrhoeae culture from the same anatomic location (within 24 h) were included in the study. Sequence type was determined based on the sequence of the por and tbpB genes, and amino acid changes in the PBP 2 protein, encoded by the penA gene, were considered representative for the assessment of antimicrobial susceptibility. Sequence identity of 100% was observed between the sequences obtained from Aptima-analyzed samples and culture samples. Sequencing results showed an association between decreased susceptibility to extended-spectrum cephalosporins (ESC(ds)), tbp allele 110, ST 1407, and amino acid changes (G545S, I312M, and V316T) in the PBP 2 protein. Our data, generated based on a few representative genes, suggest that gonococcal samples positive by Aptima testing can be used to determine single nucleotide polymorphisms associated with ESC(ds) and the sequence type based on molecular strain typing. Confirmation of these findings may obviate the need for gonorrhea culture in the future.
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Kidd S, Lee MVC, Maningas E, Komeya A, Kunimoto G, O'Connor N, Katz AR, Wasserman GM, Kirkcaldy RD, Whelen AC. Gonococcal susceptibility to cephalosporins--Hawaii, 2003 to 2011. Sex Transm Dis 2013; 40:756-9. [PMID: 23949591 PMCID: PMC4580131 DOI: 10.1097/01.olq.0000431357.18959.30] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Among gonococcal isolates examined at the Hawaii State Laboratory Division from 2003 to 2011, the prevalence of elevated cefixime minimum inhibitory concentrations (MICs; ≥0.064 μg/mL) and elevated cefpodoxime MICs (≥0.19 μg/mL) increased over time. In contrast, few isolates exhibited elevated ceftriaxone MICs (≥0.094 μg/mL), and the prevalence of elevated ceftriaxone MICs did not change.
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Affiliation(s)
- Sarah Kidd
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Antimicrobial resistance and molecular typing of Neisseria gonorrhoeae isolates in Kyoto and Osaka, Japan, 2010 to 2012: intensified surveillance after identification of the first strain (H041) with high-level ceftriaxone resistance. Antimicrob Agents Chemother 2013; 57:5225-32. [PMID: 23939890 DOI: 10.1128/aac.01295-13] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In 2009, the first high-level ceftriaxone-resistant Neisseria gonorrhoeae strain (H041) was isolated in Kyoto, Japan. The present study describes an intensified surveillance (antimicrobial resistance and molecular typing) of Neisseria gonorrhoeae isolates in Kyoto and its neighboring prefecture Osaka, Japan, in 2010 to 2012, which was initiated after the identification of H041. From April 2010 to March 2012, 193 N. gonorrhoeae isolates were collected and the MICs (μg/ml) to six antimicrobials, including ceftriaxone, were determined. All isolates showed susceptibility to ceftriaxone and cefixime (MIC values, <0.5 μg/ml), and spectinomycin. The rates of resistance (intermediate susceptibility) to azithromycin, penicillin G, and ciprofloxacin were 3.6% (19.7%), 24.4% (71.0%), and 78.2% (0.5%), respectively. Multilocus sequence typing (MLST) showed that 40.9%, 19.2%, and 17.1% of isolates belonged to ST1901, ST7359, and ST7363, respectively. Furthermore, N. gonorrhoeae multiantigen sequence typing (NG-MAST) revealed that 12 (63%) of the 19 isolates with decreased susceptibility to ceftriaxone (MIC > 0.064 μg/ml) were of ST1407. NG-MAST ST1407 was also the most prevalent ST (16.1%; 31 of 193 isolates). In those NG-MAST ST1407 strains, several mosaic type penA alleles were found, including SF-A type (penicillin binding protein 2 allele XXXIV) and its derivatives. These were confirmed using transformation of the penA mosaic alleles as critical determinants for enhanced cefixime and ceftriaxone MICs. The intensified surveillance in Kyoto and Osaka, Japan, did not identify any dissemination of the high-level ceftriaxone-resistant N. gonorrhoeae strain H041, suggesting that H041 might have caused only a sporadic case and has not spread further.
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Johnson MB, Criss AK. Neisseria gonorrhoeae phagosomes delay fusion with primary granules to enhance bacterial survival inside human neutrophils. Cell Microbiol 2013; 15:1323-40. [PMID: 23374609 PMCID: PMC3713093 DOI: 10.1111/cmi.12117] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 01/11/2013] [Accepted: 01/27/2013] [Indexed: 12/21/2022]
Abstract
Symptomatic infection with Neisseria gonorrhoeae (Gc) promotes inflammation driven by polymorphonuclear leucocytes (PMNs, neutrophils), yet some Gc survive PMN exposure during infection. Here we report a novel mechanism of gonococcal resistance to PMNs: Gc phagosomes avoid maturation into phagolysosomes by delayed fusion with primary (azurophilic) granules, which contain antimicrobial components including serine proteases. Reduced phagosome-primary granule fusion was observed in gonorrheal exudates and human PMNs infected ex vivo. Delayed phagosome-granule fusion could be overcome by opsonizing Gc with immunoglobulin. Using bacterial viability dyes along with antibodies to primary granules revealed that Gc survival in PMNs correlated with early residence in primary granule-negative phagosomes. However, when Gc was killed prior to PMN exposure, dead bacteria were also found in primary granule-negative phagosomes. These results suggest that Gc surface characteristics, rather than active bacterial processes, influence phagosome maturation and that Gc death inside PMNs occurs after phagosome-granule fusion. Ectopically increasing primary granule-phagosome fusion, by immunoglobulin opsonization or PMN treatment with lysophosphatidylcholine, reduced intracellular Gc viability, which was attributed in part to serine protease activity. We conclude that one method for Gc to avoid PMN clearance in acute gonorrhoea is by delaying primary granule-phagosome fusion, thus preventing formation of a degradative phagolysosome.
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Affiliation(s)
- M. Brittany Johnson
- Department of Microbiology, Immunology, and Cancer Biology, University of Virginia, Charlottesville, Virginia, USA
| | - Alison K. Criss
- Department of Microbiology, Immunology, and Cancer Biology, University of Virginia, Charlottesville, Virginia, USA
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Sethi S, Golparian D, Bala M, Dorji D, Ibrahim M, Jabeen K, Unemo M. Antimicrobial susceptibility and genetic characteristics of Neisseria gonorrhoeae isolates from India, Pakistan and Bhutan in 2007-2011. BMC Infect Dis 2013; 13:35. [PMID: 23347339 PMCID: PMC3565906 DOI: 10.1186/1471-2334-13-35] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 01/22/2013] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Knowledge on antimicrobial drug resistance and genetic characteristics of Neisseria gonorrhoeae isolates circulating in India, Pakistan, and Bhutan is sorely lacking. In this paper, we describe the prevalence of antimicrobial resistance and molecular characteristics of N. gonorrhoeae isolates from India, Pakistan, and Bhutan in 2007-2011. METHODS Antimicrobial susceptibility and β-lactamase production were tested for 65 N. gonorrhoeae isolates from India (n=40), Pakistan (n=18) and Bhutan (n=7) using Etest methodology (eight antimicrobials) and nitrocefin solution, respectively. Resistance determinants, i.e. penA, mtrR, porB1b, gyrA, and parC, were sequenced. N. gonorrhoeae multiantigen sequence typing (NG-MAST) was performed for molecular epidemiology. RESULTS The highest resistance level was observed for ciprofloxacin (94%), followed by penicillin G (68%), erythromycin (62%), tetracycline (55%), and azithromycin (7.7%). All the isolates were susceptible to ceftriaxone, cefixime, and spectinomycin. Thirty-four (52%) of the isolates were producing β-lactamase. No penA mosaic alleles or A501-altered alleles of penicillin-binding protein 2 were identified. Forty-nine NG-MAST STs were identified, of which 42 STs have not been previously described worldwide. CONCLUSIONS Based on this study, ceftriaxone, cefixime, and spectinomycin can be used as an empirical first-line therapy for gonorrhoea in India, Pakistan, and Bhutan, whereas ciprofloxacin, penicillin G, tetracycline, erythromycin, and azithromycin should not be. It is imperative to strengthen the laboratory infrastructure in this region, as well as to expand the phenotypic and genetic surveillance of antimicrobial resistance, emergence of new resistance, particularly, to extended-spectrum cephalosporins, and molecular epidemiology.
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Affiliation(s)
- Sunil Sethi
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, SE-701 85, Örebro, Sweden
| | - Manju Bala
- WHO GASP SEAR Regional Reference Laboratory, Apex Regional STD Teaching, Training & Research Centre, VMMC & Safdarjang Hospital, New Delhi, India
| | | | - Muhammad Ibrahim
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, SE-701 85, Örebro, Sweden
| | | | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, SE-701 85, Örebro, Sweden
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Unemo M, Nicholas RA. Emergence of multidrug-resistant, extensively drug-resistant and untreatable gonorrhea. Future Microbiol 2012; 7:1401-22. [PMID: 23231489 PMCID: PMC3629839 DOI: 10.2217/fmb.12.117] [Citation(s) in RCA: 320] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The new superbug Neisseria gonorrhoeae has retained resistance to antimicrobials previously recommended for first-line treatment and has now demonstrated its capacity to develop resistance to the extended-spectrum cephalosporin, ceftriaxone, the last remaining option for first-line empiric treatment of gonorrhea. An era of untreatable gonorrhea may be approaching, which represents an exceedingly serious public health problem. Herein, we review the evolution, origin and spread of antimicrobial resistance and resistance determinants (with a focus on extended-spectrum cephalosporins) in N. gonorrhoeae, detail the current situation regarding verified treatment failures with extended-spectrum cephalosporins and future treatment options, and highlight essential actions to meet the large public health challenge that arises with the possible emergence of untreatable gonorrhea. Essential actions include: implementing action/response plans globally and nationally; enhancing surveillance of gonococcal antimicrobial resistance, treatment failures and antimicrobial use/misuse; and improving prevention, early diagnosis and treatment of gonorrhea. Novel treatment strategies, antimicrobials (or other compounds) and, ideally, a vaccine must be developed.
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Affiliation(s)
- Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea & Other STIs, National Reference Laboratory for Pathogenic Neisseria, Örebro University Hospital, SE-701 85 Örebro, Sweden.
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Abraham S, Poehlmann C, Spornraft-Ragaller P. Gonorrhea: Data on antibiotic resistance and accompanying infections at the University Hospital Dresden over a 10-year time period. J Dtsch Dermatol Ges 2012. [PMID: 23194411 DOI: 10.1111/j.1610-0387.2012.08044.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Over the last years, growing resistance of gonorrhea to quinolones has emerged worldwide. Currently, cases with resistance to oral and parenteral third-generation cephalosporins are increasingly reported. Because gonorrhea is not a notifiable infection in Germany, data on epidemiology and antimicrobial surveillance of gonorrhea are scarce. We present the results of N. gonorrhoea testing at the University Hospital Dresden over the course of ten years. PATIENTS AND METHODS The results of cultural and nucleic acid amplification testing of gonorrhea and accompanying infections of 1,850 smears between 2001 and 2010 were analyzed retrospectively. RESULTS Among 181 patients (mean age 30.4 years) 159 had positive PCR analyses for gonorrhea and 50 positive cultures of Neisseria gonorrhoea. The rate of ciprofloxacin resistance was high (in 46% of all isolates), primarily in men. Resistance to cefotaxime and ceftriaxone could not be detected so far. In 40% of the cases at least one accompanying urogenital infection occurred, predominantly with Chlamydia trachomatis. CONCLUSIONS Similar to other regions of Germany, a high percentage of resistance to quinolones was found in gonorrhea, but not to cephalosporins. Additionally, accompanying infections were frequent and warrant screening. In the light of recent cases of resistance to cephalosporins currently emerging in Europe, cultural diagnosis of gonorrhea should definitely be intensified by all means. The results should be integrated into a surveillance system.
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Affiliation(s)
- Susanne Abraham
- Department of Dermatology, University Hospital Carl Gustav Carus, Technical University Dresden, Germany.
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Genome sequencing of a Neisseria gonorrhoeae isolate of a successful international clone with decreased susceptibility and resistance to extended-spectrum cephalosporins. Antimicrob Agents Chemother 2012; 56:5633-41. [PMID: 22908152 DOI: 10.1128/aac.00636-12] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The recent emergence of Neisseria gonorrhoeae strains with decreased susceptibility to extended-spectrum cephalosporins is a major concern globally. We sequenced the genome of an N. gonorrhoeae multiantigen sequence typing (NG-MAST) ST1407 isolate (SM-3) with decreased susceptibility and resistance to oral extended-spectrum cephalosporins. The isolate was cultured in 2008 in San Francisco, CA, and possessed mosaic penA allele XXXIV, which is associated with an international clone that possesses decreased susceptibility as well as resistance to oral extended-spectrum cephalosporins globally. The genome sequence of strain NCCP11945 was used as a scaffold, and our assembly resulted in 91 contigs covering 2,029,064 bp (91%; >150× coverage) of the genome. Numerous instances of suspected horizontal genetic transfer events with other Neisseria species were identified, and two genes, opa and txf, acquired from nongonococcal Neisseria species, were identified. Strains possessing mosaic penA alleles (n = 108) and nonmosaic penA alleles (n = 169) from the United States and Europe (15 countries), cultured in 2002 to 2009, were screened for the presence of these genes. The opa gene was detected in most (82%) penA mosaic-containing isolates (mainly from 2007 to 2009) but not in any penA nonmosaic isolates. The txf gene was found in all strains containing opa but also in several (18%) penA nonmosaic strains. Using opa and txf as genetic markers, we identified a strain that possesses mosaic penA allele XXXIV, but the majority of its genome is not genetically related to strain SM-3. This implies that penA mosaic allele XXXIV was transferred horizontally. Such isolates also possessed decreased susceptibility and resistance to oral extended-spectrum cephalosporins. These findings support that genetic screening for particular penA mosaic alleles can be a valuable method for tracking strains with decreased susceptibility as well as resistance to oral extended-spectrum cephalosporins worldwide and that screening using only NG-MAST may not be sufficient.
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Kidd S, Kirkcaldy R, Weinstock H, Bolan G. Tackling multidrug-resistant gonorrhea: how should we prepare for the untreatable? Expert Rev Anti Infect Ther 2012; 10:831-3. [DOI: 10.1586/eri.12.69] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Unemo M, Golparian D, Limnios A, Whiley D, Ohnishi M, Lahra MM, Tapsall JW. In vitro activity of ertapenem versus ceftriaxone against Neisseria gonorrhoeae isolates with highly diverse ceftriaxone MIC values and effects of ceftriaxone resistance determinants: ertapenem for treatment of gonorrhea? Antimicrob Agents Chemother 2012; 56:3603-9. [PMID: 22547617 PMCID: PMC3393402 DOI: 10.1128/aac.00326-12] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/23/2012] [Indexed: 12/24/2022] Open
Abstract
Clinical resistance to the currently recommended extended-spectrum cephalosporins (ESCs), the last remaining treatment options for gonorrhea, is being reported. Gonorrhea may become untreatable, and new treatment options are crucial. We investigated the in vitro activity of ertapenem, relative to ceftriaxone, against N. gonorrhoeae isolates and the effects of ESC resistance determinants on ertapenem. MICs were determined using agar dilution technique or Etest for international reference strains (n = 17) and clinical N. gonorrhoeae isolates (n = 257), which included the two extensively drug-resistant (XDR) strains H041 and F89 and additional isolates with high ESC MICs, clinical ESC resistance, and other types of clinical high-level and multidrug resistance (MDR). Genetic resistance determinants for ESCs (penA, mtrR, and penB) were sequenced. In general, the MICs of ertapenem (MIC(50) = 0.032 μg/ml; MIC(90) = 0.064 μg/ml) paralleled those of ceftriaxone (MIC(50) = 0.032 μg/ml; MIC(90) = 0.125 μg/ml). The ESC resistance determinants mainly increased the ertapenem MIC and ceftriaxone MIC at similar levels. However, the MIC ranges for ertapenem (0.002 to 0.125 μg/ml) and ceftriaxone (<0.002 to 4 μg/ml) differed, and the four (1.5%) ceftriaxone-resistant isolates (MIC = 0.5 to 4 μg/ml) had ertapenem MICs of 0.016 to 0.064 μg/ml. Accordingly, ertapenem had in vitro advantages over ceftriaxone for isolates with ceftriaxone resistance. These in vitro results suggest that ertapenem might be an effective treatment option for gonorrhea, particularly for the currently identified ESC-resistant cases and possibly in a dual antimicrobial therapy regimen. However, further knowledge regarding the genetic determinants (and their evolution) conferring resistance to both antimicrobials, and clear correlates between genetic and phenotypic laboratory parameters and clinical treatment outcomes, is essential.
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Affiliation(s)
- Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden
| | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden
| | - Athena Limnios
- WHO Collaborating Centre for STD, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - David Whiley
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, Children's Health Service District, Brisbane, Queensland, Australia
| | | | - Monica M. Lahra
- WHO Collaborating Centre for STD, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - John W. Tapsall
- WHO Collaborating Centre for STD, Prince of Wales Hospital, Sydney, New South Wales, Australia
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Stoltey JE, Barry PM. The use of cephalosporins for gonorrhea: an update on the rising problem of resistance. Expert Opin Pharmacother 2012; 13:1411-20. [PMID: 22646654 PMCID: PMC4079034 DOI: 10.1517/14656566.2012.690396] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Over the last several years, Neisseria gonorrhoeae has developed decreased susceptibility to extended-spectrum cephalosporins worldwide. Gonococcal antimicrobial surveillance programs in multiple regions have documented the rise in N. gonorrhoeae isolates' minimum inhibitory concentrations to cephalosporins, and the first cases of ceftriaxone treatment failure have been reported. These developments have prompted the use of the term 'superbug' and concerns about the emergence of untreatable gonococcal infections. AREAS COVERED Since the publication of the last detailed review of the use of cephalosporins for gonorrhea in 2009, several new developments have occurred, which are detailed in this review. A variety of treatment strategies have been proposed in response to this 'superbug' threat, including increasing the dose or providing multiple doses of cephalosporins, multidrug therapy, rotating therapeutic regimens and individualized treatment based on susceptibility testing. EXPERT OPINION A robust public health response is needed that includes better diagnosis and treatment of pharyngeal gonorrhea, improved surveillance of antimicrobial resistance, informed treatment approaches and reduction of the global burden of gonococcal infections.
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Affiliation(s)
- Juliet E Stoltey
- San Francisco Department of Public Health STD Prevention and Control Services, University of California-San Francisco, Division of Infectious Diseases, 513 Parnassus Avenue, Box 0654, San Francisco, CA 94143, USA.
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Buono S, Wu A, Hess DC, Carlson JS, Rauch L, Philip SS, Barry P, Bernstein K, Klausner JD, Pandori MW. Using the Neisseria gonorrhoeae multiantigen sequence-typing method to assess strain diversity and antibiotic resistance in San Francisco, California. Microb Drug Resist 2012; 18:510-7. [PMID: 22686196 DOI: 10.1089/mdr.2011.0229] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Urogenital Neisseria gonorrhoeae isolates (266) collected in San Francisco, CA, in 2009 were analyzed for antimicrobial susceptibility and were subsequently genotyped by N. gonorrhoeae multiantigen sequence typing (NG-MAST). Isolates of identical or closely related sequence types were found to possess highly similar phenotypes with regard to drug susceptibility. Isolates containing decreased susceptibility to oral cephalosporins were detected in 2009 and were found to contain the mosaic penA allele (XXXIV) found previously to be associated with decreased susceptibility to cephalosporins. A better understanding of the relationships between phenotypic and genotypic markers for antimicrobial resistance may be helpful to the development of effective surveillance systems for drug-resistant N. gonorrhoeae.
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Affiliation(s)
- Sean Buono
- San Francisco Department of Public Health Laboratory, San Francisco, California 94102, USA
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Unemo M, Shafer WM. Antibiotic resistance in Neisseria gonorrhoeae: origin, evolution, and lessons learned for the future. Ann N Y Acad Sci 2012; 1230:E19-28. [PMID: 22239555 DOI: 10.1111/j.1749-6632.2011.06215.x] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The strict human pathogen Neisseria gonorrhoeae has caused gonorrhea for thousands of years, and currently gonorrhea is the second most prevalent bacterial sexually transmitted infection worldwide. Given the ancient nature of N. gonorrhoeae and its unique obligate relationship with humankind over the millennia, its remarkable ability to adapt to the host immune system and cause repeated infections, and its propensity to develop resistance to all clinically useful antibiotics, the gonococcus is an ideal pathogen on which to study the evolution of bacterial pathogenesis, including antimicrobial resistance, over the long term and within the host during infection. Recently, the first gonococcus displaying high-level resistance to ceftriaxone, identified in Japan, was characterized in detail. Ceftriaxone is the last remaining option for empirical first-line treatment, and N. gonorrhoeae now seems to be evolving into a true "superbug." In the near future, gonorrhea may become untreatable in certain circumstances. Herein, the history of antibiotics used for treatment of gonorrhea, the evolution of resistance emergence in N. gonorrhoeae, the linkage between resistance and biological fitness of N. gonorrhoeae, lessons learned, and future perspectives are reviewed and discussed.
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Affiliation(s)
- Magnus Unemo
- National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
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In vitro activity of the new fluoroketolide solithromycin (CEM-101) against a large collection of clinical Neisseria gonorrhoeae isolates and international reference strains, including those with high-level antimicrobial resistance: potential treatment option for gonorrhea? Antimicrob Agents Chemother 2012; 56:2739-42. [PMID: 22354296 DOI: 10.1128/aac.00036-12] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Gonorrhea may become untreatable, and new treatment options are essential. We investigated the in vitro activity of the first fluoroketolide, solithromycin. Clinical Neisseria gonorrhoeae isolates and reference strains (n = 246), including the two extensively drug-resistant strains H041 and F89 and additional isolates with clinical cephalosporin resistance and multidrug resistance, were examined. The activity of solithromycin was mainly superior to that of other antimicrobials (n = 10) currently or previously recommended for gonorrhea treatment. Solithromycin might be an effective treatment option for gonorrhea.
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High-level cefixime- and ceftriaxone-resistant Neisseria gonorrhoeae in France: novel penA mosaic allele in a successful international clone causes treatment failure. Antimicrob Agents Chemother 2011; 56:1273-80. [PMID: 22155830 DOI: 10.1128/aac.05760-11] [Citation(s) in RCA: 475] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Recently, the first Neisseria gonorrhoeae strain (H041) highly resistant to the expanded-spectrum cephalosporins (ESCs) ceftriaxone and cefixime, which are the last remaining options for first-line gonorrhea treatment, was isolated in Japan. Here, we confirm and characterize a second strain (F89) with high-level cefixime and ceftriaxone resistance which was isolated in France and most likely caused a treatment failure with cefixime. F89 was examined using six species-confirmatory tests, antibiograms (33 antimicrobials), porB sequencing, N. gonorrhoeae multiantigen sequence typing (NG-MAST), multilocus sequence typing (MLST), and sequencing of known gonococcal resistance determinants (penA, mtrR, penB, ponA, and pilQ). F89 was assigned to MLST sequence type 1901 (ST1901) and NG-MAST ST1407, which is a successful gonococcal clone that has spread globally. F89 has high-level resistance to cefixime (MIC = 4 μg/ml) and ceftriaxone (MIC = 1 to 2 μg/ml) and resistance to most other antimicrobials examined. A novel penA mosaic allele (penA-CI), which was penA-XXXIV with an additional A501P alteration in penicillin-binding protein 2, was the primary determinant for high-level ESC resistance, as determined by transformation into a set of recipient strains. N. gonorrhoeae appears to be emerging as a superbug, and in certain circumstances and settings, gonorrhea may become untreatable. Investigations of the biological fitness and enhanced understanding and monitoring of the ESC-resistant clones and their international transmission are required. Enhanced disease control activities, antimicrobial resistance control and surveillance worldwide, and public health response plans for global (and national) perspectives are also crucial. Nevertheless, new treatment strategies and/or drugs and, ideally, a vaccine are essential to develop for efficacious gonorrhea management.
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Is Neisseria gonorrhoeae initiating a future era of untreatable gonorrhea?: detailed characterization of the first strain with high-level resistance to ceftriaxone. Antimicrob Agents Chemother 2011; 55:3538-45. [PMID: 21576437 DOI: 10.1128/aac.00325-11] [Citation(s) in RCA: 493] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Recently, the first Neisseria gonorrhoeae strain (H041) that is highly resistant to the extended-spectrum cephalosporin (ESC) ceftriaxone, the last remaining option for empirical first-line treatment, was isolated. We performed a detailed characterization of H041, phenotypically and genetically, to confirm the finding, examine its antimicrobial resistance (AMR), and elucidate the resistance mechanisms. H041 was examined using seven species-confirmatory tests, antibiograms (30 antimicrobials), porB sequencing, N. gonorrhoeae multiantigen sequence typing (NG-MAST), multilocus sequence typing (MLST), and sequencing of ESC resistance determinants (penA, mtrR, penB, ponA, and pilQ). Transformation, using appropriate recipient strains, was performed to confirm the ESC resistance determinants. H041 was assigned to serovar Bpyust, MLST sequence type (ST) ST7363, and the new NG-MAST ST4220. H041 proved highly resistant to ceftriaxone (2 to 4 μg/ml, which is 4- to 8-fold higher than any previously described isolate) and all other cephalosporins, as well as most other antimicrobials tested. A new penA mosaic allele caused the ceftriaxone resistance. In conclusion, N. gonorrhoeae has now shown its ability to also develop ceftriaxone resistance. Although the biological fitness of ceftriaxone resistance in N. gonorrhoeae remains unknown, N. gonorrhoeae may soon become a true superbug, causing untreatable gonorrhea. A reduction in the global gonorrhea burden by enhanced disease control activities, combined with wider strategies for general AMR control and enhanced understanding of the mechanisms of emergence and spread of AMR, which need to be monitored globally, and public health response plans for global (and national) perspectives are important. Ultimately, the development of new drugs for efficacious gonorrhea treatment is necessary.
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