Emergence and Spread of Drug Resistant Neisseria gonorrhoeae

2023 Korean Association of Urogenital Tract Infection and Inflammation guidelines for gonococcal infection

The incidence of gonorrhea has increased significantly in recent years in the United States, especially among sexually active twenty-year-olds. Although the incidence of gonorrhea has decreased in Korea since the early 2000s, it is still common among people in their twenties. Nucleic acid amplification test (NAAT) is the most sensitive diagnostic test for detecting gonococcal infection. Gram-staining is a simple and useful laboratory test for diagnosing symptomatic male gonococcal urethritis. Although bacterial culture can be used to detect antimicrobial susceptibility, its sensitivity is lower than that of NAAT. Treatment for uncomplicated gonorrhea infection is a single intramuscular injection of ceftriaxone 500 mg. Doxycycline (100 mg twice daily for 7 days) is added if there is a possibility of co-infection with chlamydia. If ceftriaxone is difficult to use, spectinomycin 2 g can be injected intramuscularly in Korea. Patients with gonorrhea should have repeated examinations within three months at the exposure site because of a high risk of re-infection. A person diagnosed with gonorrhea should discuss the nature of the infection, the importance of informing partners, when sexual activity can resume, and how to reduce the risk of sexually transmitted infections.

Antimicrobial Stewardship in the Hospital Setting: A Narrative Review

The increasing global threat of antibiotic resistance, which has resulted in countless fatalities due to untreatable infections, underscores the urgent need for a strategic action plan. The acknowledgment that humanity is perilously approaching the "End of the Miracle Drugs" due to the unjustifiable overuse and misuse of antibiotics has prompted a critical reassessment of their usage. In response, numerous relevant medical societies have initiated a concerted effort to combat resistance by implementing antibiotic stewardship programs within healthcare institutions, grounded in evidence-based guidelines and designed to guide antibiotic utilization. Crucial to this initiative is the establishment of multidisciplinary teams within each hospital, led by a dedicated Infectious Diseases physician. This team includes clinical pharmacists, clinical microbiologists, hospital epidemiologists, infection control experts, and specialized nurses who receive intensive training in the field. These teams have evidence-supported strategies aiming to mitigate resistance, such as conducting prospective audits and providing feedback, including the innovative 'Handshake Stewardship' approach, implementing formulary restrictions and preauthorization protocols, disseminating educational materials, promoting antibiotic de-escalation practices, employing rapid diagnostic techniques, and enhancing infection prevention and control measures. While initial outcomes have demonstrated success in reducing resistance rates, ongoing research is imperative to explore novel stewardship interventions.

Implications of new understandings of gliomas in children and adults with NF1: report of a consensus conference

Gliomas are the most common primary central nervous system tumors occurring in children and adults with neurofibromatosis type 1 (NF1). Over the past decade, discoveries of the molecular basis of low-grade gliomas (LGGs) have led to new approaches for diagnosis and treatments. However, these new understandings have not been fully applied to the management of NF1-associated gliomas. A consensus panel consisting of experts in NF1 and gliomas was convened to review the current molecular knowledge of NF1-associated low-grade “transformed” and high-grade gliomas; insights gained from mouse models of NF1-LGGs; challenges in diagnosing and treating older patients with NF1-associated gliomas; and advances in molecularly targeted treatment and potential immunologic treatment of these tumors. Next steps are recommended to advance the management and outcomes for NF1-associated gliomas.

In Silico Approach for Phytocompound-Based Drug Designing to Fight Efflux Pump-Mediated Multidrug-Resistant Mycobacterium tuberculosis

Tuberculosis (TB), caused by the bacteria Mycobacterium tuberculosis, is one of the principal causes of death in the world despite the existence of a significant number of antibiotics aimed against it. This is mainly due to the drug resistance mechanisms present in the bacterium, which leads to multidrug-resistant tuberculosis (MDR-TB). Additionally, the development of new antibiotics has become limited over the years. Although there are various drug resistance mechanisms present, efflux pumps are of utmost importance because they extrude out several dissimilar antitubercular drugs out of the cell. There are many efflux pump proteins present in Mycobacterium tuberculosis. Therefore, blocking these efflux pumps by inhibitors can raise the efficacy of the existing antibiotics and may also pave the path for the discovery and synthesis of new drugs. Plant compounds can act as a resource for the development of efflux pump inhibitors (EPIs), which may eventually replace or augment the current therapeutic options. This is mainly because plants have been traditionally used for ages for food or treatment and are considered safe with little or no side effects. Various computational tools are available which are used for the virtual screening of a large number of phytocompounds within a short span of time. This review aims to highlight the mechanism and appearance of drug resistance in Mycobacterium tuberculosis with emphasis on efflux pumps along with the significance of phytochemicals as inhibitors of these pumps and their screening strategy by computational approaches.

Assuring Adequate Treatment for Persons Diagnosed With Gonorrhea in New York State

BACKGROUND

From November 2014 to May 2016, 57 local health departments in New York State (NYS) excluding New York City were offered a performance incentive (PI) to promote adherence to federally recommended treatment guidelines for gonorrhea. The rationale of the PI was to delay antibiotic resistance and disrupt transmission through attaining a high percentage of treatment adherence.

METHODS

Surveillance data from the NYS Communicable Disease Electronic Surveillance System were used for analysis. We evaluated adherence per Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines for persons 12 years and older reported with uncomplicated gonorrhea during 4 time frames: Pre-PI, PI One, PI Two, and Post-PI. We measured adherence per the Centers for Disease Control and Prevention sexually transmitted disease treatment guidelines during each respective time frame and conducted χ tests to test for the association between treatment adequacy and time frame.

RESULTS

During the Pre-PI, treatment was adequate in 82.0% of persons diagnosed with gonorrhea. After program implementation, treatment adequacy increased significantly (92.1% of diagnosed persons during PI One, 90.4% during PI Two, and 90.5% during the Post-PI; P ≤ 0.0001). The most common reason for inadequate or missing treatment was patient lost to follow-up.

CONCLUSIONS

Public health intervention by the NYS Department of Health improved local health department adherence to federally recommended gonorrhea treatment guidelines, and improvements were maintained after the completion of the PI.

Current status of Neisseria gonorrhoeae cervicitis in pregnant women in Japan

We evaluated the current prevalence of gonococcal cervicitis among pregnant women in institutes that either do or do not routinely screen for gonococcal infection in Japan. We requested 2,330 obstetrical facilities to provide information on Neisseria gonorrhoeae cervicitis in pregnant women. A total of 1,876 (80.5%) of them responded. The universal screening test for gonococcal cervicitis, involving nucleic acid amplification for all pregnant women, was performed in 281 institutes (13.9% of institutes across Japan). The total rate of pregnant women with gonococcal cervicitis was 1.3% in the institutes performing the screening test during pregnancy, while it was only 0.2% (p < 0.01) in those not performing it. This suggests that 84% of infected women may have been missed in the institutes that do not routinely perform the screening test for gonococcal cervicitis. It may be time to examine the cost-effectiveness of providing gonococcal screening for all pregnant women in Japan.

Loop-mediated isothermal amplification of Neisseria gonorrhoeae porA pseudogene: a rapid and reliable method to detect gonorrhea

BACKGROUND AND OBJECTIVE

Gonorrhea is a sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae. Rapid detection is crucial for effective prevention and treatment. This study developed and tested a low-cost effective method for detecting N. gonorrhoeae, especially in developing countries.

METHODS

DNA from a N. gonorrhoeae standard strain, as well as from 26 genital secretion samples of gonorrhea patients, were isolated and used for loop-mediated isothermal amplification (LAMP) assay, which was conducted using either an automatic real-time PCR analyzer or a water bath. The amplified porA pseudogene sequence was compared with the NCBI database and the LAMP results were compared with that of the traditional culture method for its sensitivity and specificity.

RESULTS

LAMP was able to detect Neisseria DNA at a concentration as low as 1 pg/µL (1 × 10³ CFU/mL cells). The LAMP assay results obtained using an automatic real-time PCR analyzer was similar to that of the water bath. Relative to traditional culture, the sensitivity and specificity of the LAMP assay were 94.7 and 85.7%, respectively.

CONCLUSION

LAMP was sensitive and reliable for detecting the porA gene of N. gonorrhoeae. It could be used as a rapid, low cost, and effective method for detecting N. gonorrhoeae.

Effect of lipopolysaccharide on the expression of inflammatory mRNAs and microRNAs in the mouse oviduct

Infection with Gram-negative bacteria is a major cause of aberrant inflammation in the oviduct; consequences can include tubal-based infertility and/or ectopic pregnancy. Understanding the inflammatory response is necessary for the development of novel treatment options that counter inflammation-induced infertility. The aim of the present study was to determine the effect of intraperitoneal (i.p.) administration of Escherichia coli-derived lipopolysaccharide (LPS) on the acute expression of inflammatory mRNAs and microRNAs (miRNAs) in the oviduct. On the day of oestrus, 6- to 8-week-old CD1 mice were injected i.p. with 0, 2 or 10µg LPS in 100μL phosphate-buffered saline. Mice were killed 24h later and the oviducts collected for gene expression analyses. The effect of treatment on the expression of mRNAs and miRNAs was evaluated by one-way analysis of variance (ANOVA), with treatment means of differentially expressed (P<0.05) transcripts separated using Scheffé's test. LPS treatment affected 49 of 179 targeted inflammatory mRNAs and 51 of 578 miRNAs (P<0.05). The identity of differentially expressed miRNAs predicted as regulators of chemokine and interleukin ligand mRNAs was then extracted using the microRNA.org database. The results of the present study indicate that systemic treatment with LPS induces a robust inflammatory response in the oviducts of mice, and identify key mRNAs and putative miRNAs modulating this effect.

Verifying Treatment of Reported Cases of Gonorrhea

BACKGROUND

Verifying correct treatment of reported cases of gonorrhea may slow antibiotic resistance, but verification remains challenging for many sexually transmitted disease (STD) programs due to increased laboratory case reporting and decreased provider reporting. The objectives of this study were to document current reported levels of correct treatment of gonorrhea and to identify approaches and barriers to verifying treatment.

METHODS

We reviewed funding opportunity reports for the Centers for Disease Control and Prevention's directly funded STD programs and conducted key-informant interviews to elicit further treatment verification details.

RESULTS

Among STD programs containing at least one high-morbidity area, a median of 63.0% of gonorrhea cases were reported as treated correctly with a Centers for Disease Control and Prevention-recommended regimen, although the range reported was wide (11.2%-95.2%). Among cases with some type of documented treatment information, the proportion treated correctly was higher (median, 82.2%) but the use of correct treatment was quite variable among STD programs (range, 56.4%-98.5%). Approaches to verifying gonorrhea treatment included modifying outdated surveillance systems and educating providers about case reporting to enhance the passive capture of treatment information as well as active approaches that supported routine and immediate communication with providers regarding cases missing treatment information. Barriers to treatment verification included low levels of provider reporting, outdated surveillance systems, and human and financial resource constraints.

CONCLUSIONS

Baseline assessments revealed that levels of correct gonorrhea treatment vary widely, even after accounting for those cases missing treatment information. Baseline data can help determine whether the active verification of treatment of all cases is warranted.

In-silico Hierarchical Approach for the Identification of Potential Universal Vaccine Candidates (PUVCs) from Neisseria gonorrhoeae

OBJECTIVES

Resistance to the currently recommended extended-spectrum cephalosporins, which is used to treat Gonorrhea, is increasing continuously and leading to a threat of untreatable infection. It is, therefore, becoming extremely essential to search for new therapeutic strategies to control Gonorrhea. Vaccination may be considered as an effective control measure to control this disease, which is caused by Neisseria gonorrhoeae.

METHODS

In-silico hierarchical approach was used to help identify candidate proteins of N. gonorrhoeae that might contribute significantly in vaccine research. In contrast to the conventional vaccine research which requires at least 10-12 years, the present approach would reduce the time period drastically and help to identify Potential Universal Vaccine Candidates (PUVCs). These proteins were further analyzed for the presence of T-cell and linear B-cell epitopes, by using HLAPred and ABCpred servers respectively, in order to facilitate the identification of Multi Epitope Peptide Vaccine Constructs.

RESULTS

We have identified 23 non-host candidate proteins, using the proteomic information of four sequenced strains of N. gonorrhoeae namely FA 1090, TCDC_NG08107, NCCP11945 and MS11 and labeled them as PUVCs. Since all these identified 23 PUVCs contained both T cell and B cell epitopes, these have been further reiterated as PUVCs which could be used as promising leads for vaccine development.

CONCLUSIONS

This hierarchical approach is the first comprehensive study to identify potential vaccine candidates which once utilized for vaccine development would surely serve as promising tools for effective control of Gonorrhea.

Comparison of bacteria isolated from emergency department patients versus hospitalized patients

PURPOSE

The frequencies and corresponding susceptibilities of bacteria isolated from patients in the emergency department (ED) were compared with those from hospitalized patients.

METHODS

A microbiology laboratory report of all positive bacterial cultures obtained in the ED, regardless of the source (e.g., blood, urine, sputum), was obtained. In the case of duplicate cultures, only the first isolate cultured from a single patient was included. Colonization-site cultures (e.g., nasal swabs) and culture reports identified by the laboratory as contaminant organisms were excluded from the evaluation. Antimicrobial susceptibility results were then compiled into a standardized ED-specific antibiogram. Antimicrobial susceptibilities for each pathogen in the ED antibiogram were compared with those in the hospitalwide antibiogram. If there was a difference of ≥5% between the susceptibility of a single antimicrobial agent, chi-square tests were conducted, and unadjusted odds ratios were calculated. Pathogens with fewer than 30 isolates were excluded from the susceptibility comparison.

RESULTS

A total of 3140 cultures were evaluated (1417 from the ED, 1723 from the hospital). The frequencies of pathogens isolated in the ED and hospitalwide were similar, with the exception of Escherichia coli, which were more commonly isolated in ED patients, and Enterococcus species and Pseudomonas aeruginosa, which were more common in hospitalized patients. Significant differences in susceptibility profiles were identified for Staphylococcus aureus, coagulase-negative Staphylococcus, Enterococcus faecalis, E. coli, Klebsiella pneumoniae, and P. aeruginosa.

CONCLUSION

Significant differences in the frequencies of bacteria isolated and corresponding susceptibilities were found in cultures obtained in ED patients compared with those obtained in hospitalized patients.

Gonococcal antimicrobial resistance in the Western Pacific Region

OBJECTIVE

To outline the current situation of gonococcal antimicrobial resistance (AMR) in the Western Pacific region and factors that impact on this.

BACKGROUND

The Western Pacific region is densely populated with many living in poverty. There are high rates of infectious diseases, and a disproportionate burden of gonococcal disease. In many countries there is uncontrolled antimicrobial use: these are ideal conditions for the emergence of AMR.

METHODS

Gonococcal AMR in this region has been monitored for more than 20 years. Clinical isolates, predominantly from unselected patients attending sexually transmitted diseases clinics, are tested against a panel of antibiotics. Quality assurance and control strategies are in place.

RESULTS

There is widespread, high level resistance to penicillin and ciprofloxacin. Decreased susceptibility to ceftriaxone (MIC ≥ 0.06 mg/L) is reported in high levels from some countries in the region. Low numbers of isolates tested in some countries reflect capacity for testing, and are suboptimal for surveillance.

CONCLUSION

The raised MIC values to ceftriaxone, and the emergence and spread of ceftriaxone resistant strains regionally is alarming. Sustaining and enhancing surveillance is critical; however obtaining an adequate sample size is a long-standing issue. The implementation of molecular surveillance strategies could provide broader information on the spread and threat of AMR.

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

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.

Multiplex bead suspension array for screening Neisseria gonorrhoeae antibiotic resistance genetic determinants in noncultured clinical samples

The increasing threat of antibiotic-resistant Neisseria gonorrhoeae highlights the need for new diagnostic options. A high-throughput multiplex bead suspension array assay was developed for profiling 29 N. gonorrhoeae genomic mutations and 2 plasmid genes conferring resistance to 6 antimicrobial agents: penicillin, ciprofloxacin, cefixime, tetracycline, azithromycin, and spectinomycin. The three steps of this assay include amplification of 12 N. gonorrhoeae chromosomal and plasmid loci, multiplex allele-specific primer extension reaction, and multiplex bead suspension array detection. Antibiotic resistance genetic determinants were identified successfully in 239 cervicovaginal N. gonorrhoeae-positive noncultured swab samples. This molecular assay can be used for detection of gonococci in clinical specimens, molecular typing, mutation profiling, and predictive assessment of N. gonorrhoeae susceptibility to antibiotics without the need for culture.

Secretory leukocyte protease inhibitor binds to Neisseria gonorrhoeae outer membrane opacity protein and is bactericidal

PROBLEM

Secretory leukocyte protease inhibitor (SLPI) is an innate immune peptide present on the genitourinary tract mucosa that has antimicrobial activity. In this study, we investigated the interaction of SLPI with Neisseria gonorrhoeae.

METHOD OF STUDY

ELISA and far-Western blots were used to analyze binding of SLPI to gonococci. The binding site for SLPI was identified by tryptic digests and mass spectrometry. Antimicrobial activity of SLPI for gonococci was determined using bactericidal assays. SLPI protein levels in cell supernatants were measured by ELISA, and SLPI mRNA levels were assessed by quantitative RT-PCR.

RESULTS

SLPI bound directly to the gonococcal Opa protein and was bactericidal. Epithelial cells from the reproductive tract constitutively expressed SLPI at different levels. Gonococcal infection of cells did not affect SLPI expression.

CONCLUSION

We conclude that SLPI is bactericidal for gonococci and is expressed by reproductive tract epithelial cells and thus is likely to play a role in the pathogenesis of gonococcal infection.

Emergence of fluoroquinolone resistance in Neisseria gonorrhoeae isolates from four clinics in three regions of Kenya

We have recently reported high levels of fluoroquinolone resistance in a single region of Kenya. In this article, we report high prevalence of fluoroquinolone resistance (53.2%) in Neisseria gonorrhoeae isolates from 4 clinics in 3 additional regions of Kenya. These findings highlight the need to change first-line treatment in these settings and the need to evaluate empirical management guidelines for treatment of gonococcal infection in Kenya.

Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS)

Antimicrobial resistance has emerged as a significant healthcare quality and patient safety issue in the twenty-first century that, combined with a rapidly dwindling antimicrobial armamentarium, has resulted in a critical threat to the public health of the United States. Antimicrobial stewardship programs optimize antimicrobial use to achieve the best clinical outcomes while minimizing adverse events and limiting selective pressures that drive the emergence of resistance and may also reduce excessive costs attributable to suboptimal antimicrobial use. Therefore, antimicrobial stewardship must be a fiduciary responsibility for all healthcare institutions across the continuum of care. This position statement of the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society of America outlines recommendations for the mandatory implementation of antimicrobial stewardship throughout health care, suggests process and outcome measures to monitor these interventions, and addresses deficiencies in education and research in this field as well as the lack of accurate data on antimicrobial use in the United States.

Hematopoetic prostaglandin D synthase: an ESR1-dependent oviductal epithelial cell synthase

Oviductal disease is a primary cause of infertility, a problem that largely stems from excessive inflammation of this key reproductive organ. Our poor understanding of the mechanisms regulating oviductal inflammation restricts our ability to diagnose, treat, and/or prevent oviductal disease. Using mice, our objective was to determine the spatial localization, regulatory mechanism, and functional attributes of a hypothesized regulator of oviductal inflammation, the hematopoietic form of prostaglandin D synthase (HPGDS). Immunohistochemistry revealed specific localization of HPGDS to the oviduct's epithelium. In the isthmus, expression of HPGDS was consistent. In the ampulla, expression of HPGDS appeared dependent upon stage of the estrous cycle. HPGDS was expressed in the epithelium of immature and cycling mice but not in the oviducts of estrogen receptor α knockouts. Two receptor subtypes bind PGD₂: PGD₂ receptor and G protein-coupled receptor 44. Expression of mRNA for Ptgdr was higher in the epithelial cells (EPI) than in the stroma (P < 0.05), whereas mRNA for Gpr44 was higher in the stroma than epithelium (P < 0.05). Treatment of human oviductal EPI with HQL-79, an inhibitor of HPGDS, decreased cell viability (P < 0.05). Treatment of mice with HQL-79 increased mRNA for chemokine (C-C motif) ligands 3, 4, and 19; chemokine (C-X-C motif) ligands 11 and 12; IL-13 and IL-17B; and TNF receptor superfamily, member 1b (P < 0.02 for each mRNA). Overall, these results suggest that HPGDS may play a role in the regulation of inflammation and EPI health within the oviduct.

Infectious proctitis: when to suspect it is not inflammatory bowel disease

BACKGROUND

Proctitis is a common problem and is most frequently associated with inflammatory bowel diseases. However, the incidence of infectious proctitis appears to be rising, especially in men who have sex with men. This may be due to the rise of people participating in receptive anal sex as well as the increase in sexually transmitted infections. The most frequently reported pathogens include Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, and herpes simplex.

DIAGNOSIS

Symptoms of infectious proctitis can include rectal blood and mucous discharge, anorectal pain, ulcers, and occasionally lymphadenopathy and fever. History and physical examination are crucial in establishing a diagnosis, supported by endoscopy, histology, serology, culture and PCR.

TREATMENT

Treatment with antibiotics or antivirals is usually initiated, either empirically or after establishing a diagnosis. Co-infections, HIV testing, and treatment of sexual partners should always be considered.

Molecular analyses of TEM genes and their corresponding penicillinase-producing Neisseria gonorrhoeae isolates in Bangkok, Thailand

Neisseria gonorrhoeae is a major public health problem globally, especially because the bacterium has developed resistance to most antimicrobials introduced for first-line treatment of gonorrhea. In the present study, 96 N. gonorrhoeae isolates with high-level resistance to penicillin from 121 clinical isolates in Thailand were examined to investigate changes related to their plasmid-mediated penicillin resistance and their molecular epidemiological relationships. A β-lactamase (TEM) gene variant, bla(TEM-135), that may be a precursor in the transitional stage of a traditional bla(TEM-1) gene into an extended-spectrum β-lactamase (ESBL), possibly causing high resistance to all extended-spectrum cephalosporins in N. gonorrhoeae, was identified. Clonal analysis using multilocus sequence typing (MLST) and N. gonorrhoeae multiantigen sequence typing (NG-MAST) revealed the existence of a sexual network among patients from Japan and Thailand. Molecular analysis of the bla(TEM-135) gene showed that the emergence of this allele might not be a rare genetic event and that the allele has evolved in different plasmid backgrounds, which results possibly indicate that it is selected due to antimicrobial pressure. The presence of the bla(TEM-135) allele in the penicillinase-producing N. gonorrhoeae population may call for monitoring for the possible emergence of ESBL-producing N. gonorrhoeae in the future. This study identified a bla(TEM) variant (bla(TEM-135)) that is a possible intermediate precursor for an ESBL, which warrants international awareness.

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

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