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Allan-Blitz LT, Fifer H, Klausner JD. Managing treatment failure in Neisseria gonorrhoeae infection: current guidelines and future directions. THE LANCET. INFECTIOUS DISEASES 2024; 24:e532-e538. [PMID: 38367636 DOI: 10.1016/s1473-3099(24)00001-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 12/26/2023] [Accepted: 01/04/2024] [Indexed: 02/19/2024]
Abstract
Due to the continued emergence of resistance to extended-spectrum cephalosporin antibiotics, clinicians are increasingly more likely to encounter cases of Neisseria gonorrhoeae treatment failure. The current international treatment guidelines offer few regimens for cases of N gonorrhoeae infection that do not respond to first-line therapy, and there are many complexities that should be considered with such regimens; these include regional variations in resistance to alternative agents, access to different antibiotics, and penetration of those antibiotics within different tissues. Further, such regimens do not account for the challenges of treating pharyngeal infections; many patients who have not responded to treatment with extended-spectrum cephalosporin antibiotics to date have had pharyngeal involvement. In addition, pharyngeal infections play a pivotal role in the emergence and spread of antimicrobial resistance in N gonorrhoeae and are more difficult to treat than urogenital infections because of the unfavourable pharmacokinetics of cephalosporins in pharyngeal tissues. Here, we summarise the current guidelines, provide additional approaches and considerations for clinicians, and highlight knowledge gaps that should be addressed to ensure appropriate therapy in cases of treatment failure.
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Affiliation(s)
- Lao-Tzu Allan-Blitz
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Helen Fifer
- Blood Safety, Hepatitis, STI & HIV Division, UK Health Security Agency, London, UK
| | - Jeffrey D Klausner
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Quilter LAS, St Cyr SB, Barbee LA. The Management of Gonorrhea in the Era of Emerging Antimicrobial Resistance: What Primary Care Clinicians Should Know. Med Clin North Am 2024; 108:279-296. [PMID: 38331480 PMCID: PMC11150008 DOI: 10.1016/j.mcna.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
Gonorrhea rates continue to rise in the United States and Neisseria gonorrhoeae's propensity to develop resistance to all therapies used for treatment has complicated the management of gonorrhea. Ceftriaxone is the only remaining highly effective recommended regimen for gonococcal treatment and few new anti-gonococcal antimicrobials are being developed. The 2021 CDC STI Treatment Guidelines increased the dose of ceftriaxone to 500 mg (1 g if ≥ 150 kg) for uncomplicated infections. It is recommended that all clinicians should be aware of antimicrobial resistant gonorrhea and be able to appropriately manage any suspected gonorrhea treatment failure case.
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Affiliation(s)
- Laura A S Quilter
- Division of STD Prevention, Centers of Disease Control and Prevention, 1600 Clifton Road Northeast, MS H24-4, Atlanta, GA 30329, USA.
| | - Sancta B St Cyr
- Division of STD Prevention, Centers of Disease Control and Prevention, 1600 Clifton Road Northeast, MS H24-4, Atlanta, GA 30329, USA
| | - Lindley A Barbee
- Division of STD Prevention, Centers of Disease Control and Prevention, 1600 Clifton Road Northeast, MS H24-4, Atlanta, GA 30329, USA
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Yang F, Gao S, Yan J, Lin X, van der Veen S. Moenomycin is broadly active against multidrug-resistant Neisseria gonorrhoeae and clears an infection from a murine vaginal tract infection model. J Antimicrob Chemother 2022; 77:2461-2469. [PMID: 35762496 DOI: 10.1093/jac/dkac202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/27/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Ceftriaxone therapy for gonorrhoea has become under increasing pressure due to waning susceptibility levels and emergence of high-level resistant strains such as the FC428 clone. Moenomycin was recently identified to display potent anti-gonococcal activity against some reference strains. Therefore, the aim of this study was to investigate moenomycin in vitro and in vivo antimicrobial activity. METHODS Moenomycin in vitro antimicrobial activity was investigated against 575 clinical isolates, including strains associated with the FC428 clone, using the agar dilution method. Moenomycin in vivo activity was investigated in a mouse vaginal tract gonococcal infection model. RESULTS The moenomycin MIC range for the strain collection was 0.004-0.06 mg/L, with a MIC50 of 0.016 mg/L and a MIC90 of 0.03 mg/L. The correlation between moenomycin and ceftriaxone susceptibility levels was poor (R = 0.13), while the fractional inhibitory concentration index (FICI) resulted in indifference for all tested strains. Therefore, development of cross-resistance between moenomycin and ceftriaxone is unlikely for N. gonorrhoeae. Determination of the moenomycin mode of activity against N. gonorrhoeae by time-kill assays showed that moenomycin is bactericidal, with over 104-fold inactivation observed after 4 h exposure. Finally, an intramuscular moenomycin dose of 10 mg/kg given on 2 consecutive days was able to clear a gonococcal infection in a mouse vaginal tract infection model within 1-3 days after the second dose, which was significantly faster than for mice treated with the vehicle control (P < 0.0001). CONCLUSIONS Moenomycin displays potent in vitro and in vivo antimicrobial activity against N. gonorrhoeae, warranting further exploration as alternative therapy.
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Affiliation(s)
- Fan Yang
- Department of Microbiology, and Department of Dermatology of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Shuai Gao
- Department of Microbiology, and Department of Dermatology of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Jing Yan
- Department of Microbiology, and Department of Dermatology of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Xu'ai Lin
- Department of Microbiology, and Department of Dermatology of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Stijn van der Veen
- Department of Microbiology, and Department of Dermatology of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
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Barbee LA, St Cyr SB. Management of Neisseria gonorrhoeae in the United States: Summary of Evidence From the Development of the 2020 Gonorrhea Treatment Recommendations and the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infection Treatment Guidelines. Clin Infect Dis 2022; 74:S95-S111. [PMID: 35416971 DOI: 10.1093/cid/ciac043] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Neisseria gonorrhoeae has developed resistance to all first-line recommended therapies, making gonococcal antimicrobial resistance a major public health concern given limited antibiotic options currently and an even smaller antimicrobial development pipeline. Since the release of the Centers for Disease Control and Prevention (CDC) 2015 STD Treatment Guidelines, azithromycin, part of the 2015 dual-drug treatment regimen, has had a rapid rise in resistance. The 2020 CDC Gonorrhea Treatment Recommendations and the 2021 Sexually Transmitted Infections (STI) Treatment Guidelines were developed weighing the priorities of treating the individual, protecting the population, and preventing antimicrobial resistance. METHODS Gonorrhea subject matter experts (SME) generated 8 key questions and conducted a literature review of updated data from 2013 to 2019 on gonorrhea antimicrobial resistance, treatment failures, clinical trials, and other key topics. More than 2200 abstracts were assessed, and 248 clinically relevant articles were thoroughly reviewed. SMEs also evaluated N gonorrhoeae antimicrobial resistance data from the Gonococcal Isolate Surveillance Project (GISP). EVIDENCE Although there have been reports of ceftriaxone treatment failures internationally, GISP data suggest that ceftriaxone minimal inhibitory concentrations (MICs) have remained stable in the United States, with < 0.1% exhibiting an "alert value" MIC (> 0.25 mcg/mL). However, GISP documented a rapid rise in the proportion of isolates with an elevated MIC (≥ 2.0 mcg/mL) to azithromycin-nearly 5% in 2018. At the same time, new pharmacokinetic/pharmacodynamic data are available, and there is greater recognition of the need for antimicrobial stewardship. SUMMARY The 2021 CDC STI Treatment Guidelines now recommend 500mg ceftriaxone intramuscularly once for the treatment of uncomplicated gonorrhea at all anatomic sites. If coinfection with chlamydia has not been excluded, cotreatment with doxycycline 100mg twice daily for 7 days should be added. Few alternative therapies exist for persons with cephalosporin allergies; there are no recommended alternative therapies for N gonorrhoeae infection of the throat.
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Affiliation(s)
- Lindley A Barbee
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,University of Washington, Seattle, Washington, USA.,Public Health - Seattle & King County HIV/STD Program, Seattle, Washington, USA
| | - Sancta B St Cyr
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Lahra MM, Hogan TR, Shoushtari M, Armstrong BH. Australian Gonococcal Surveillance Programme Annual Report, 2020. ACTA ACUST UNITED AC 2021; 45. [PMID: 34711144 DOI: 10.33321/cdi.2021.45.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Abstract The Australian Gonococcal Surveillance Programme (AGSP), established in 1981, has continuously monitored antimicrobial resistance in clinical isolates of Neisseria gonorrhoeae for more than 40 years. In 2020, a total of 7,222 clinical isolates of gonococci from patients in the public and private sectors, in all jurisdictions, were tested for in vitro antimicrobial susceptibility by standardised methods. Current treatment recommendations for gonorrhoea, for the majority of Australia, continues to be dual therapy with ceftriaxone and azithromycin. In 2020, decreased susceptibility (DS) to ceftriaxone (minimum inhibitory concentration [MIC] value ≥ 0.06 mg/L) was found nationally in 0.9% of isolates. There was one isolate, reported from Victoria in 2020, that was resistant to ceftriaxone (MIC value ≥ 0.25 mg/L). Resistance to azithromycin (MIC value ≥ 1.0 mg/L) was found nationally in 3.9% of N. gonorrhoeae isolates, continuing a downward trend observed and reported since 2017. Isolates with high-level resistance to azithromycin (MIC value ≥ 256 mg/L) are identified sporadically in Australia; in 2020, there was one such isolate reported in Queensland. In 2020, penicillin resistance was found in 27% of gonococcal isolates nationally, and ciprofloxacin resistance in 36%; however, there is considerable variation by jurisdiction. In some remote settings, penicillin resistance remains low, and this drug continues to be recommended as part of an empiric therapy strategy. In 2020, in remote Northern Territory, no penicillin resistance was reported, and in remote Western Australia 5/116 of gonococcal isolates (4.3%) were penicillin resistant. There was one ciprofloxacin-resistant isolate reported from remote Northern Territory, and ciprofloxacin resistance rates remain comparatively low in remote Western Australia (4/116; 3.4%).
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Affiliation(s)
- Monica M Lahra
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia.,School of Medical Sciences, Faculty of Medicine, The University of New South Wales, NSW, 2052, Australia
| | - Tiffany R Hogan
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Masoud Shoushtari
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Benjamin H Armstrong
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia.,School of Medical Sciences, Faculty of Medicine, The University of New South Wales, NSW, 2052, Australia.,Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead, NSW, 2145, Australia
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6
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Palace SG, Fryling KE, Li Y, Wentworth AJ, Traverso G, Grad YH. Identification of bile acid and fatty acid species as candidate rapidly bactericidal agents for topical treatment of gonorrhoea. J Antimicrob Chemother 2021; 76:2569-2577. [PMID: 34245280 DOI: 10.1093/jac/dkab217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 06/02/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Novel therapeutic strategies are urgently needed for Neisseria gonorrhoeae, given its increasing antimicrobial resistance. Treatment of oropharyngeal N. gonorrhoeae infections has proven particularly challenging, with most reported treatment failures of the first-line drug ceftriaxone occurring at this site and lower cure rates in recent trials of new antibiotics reported for oropharyngeal infections compared with other sites of infection. However, the accessibility of the oropharynx to topical therapeutics provides an opportunity for intervention. Local delivery of a therapeutic at a high concentration would enable the use of non-traditional antimicrobial candidates, including biological molecules that exploit underlying chemical sensitivities of N. gonorrhoeae but lack the potency or pharmacokinetic profiles required for effective systemic administration. METHODS Two classes of molecules that are thought to limit gonococcal viability in vivo, bile acids and short- and medium-chain fatty acids, were examined for rapid bactericidal activity. RESULTS The bile acids deoxycholic acid (DCA) and chenodeoxycholic acid (CDCA), but not other bile acid species, exerted extremely rapid bactericidal properties against N. gonorrhoeae, reducing viability more than 100 000-fold after 1 min. The short-chain fatty acids formic acid and hexanoic acid shared this rapid bactericidal activity. All four molecules are effective against a phylogenetically diverse panel of N. gonorrhoeae strains, including clinical isolates with upregulated efflux pumps and resistance alleles to the most widely used classes of existing antimicrobials. DCA and CDCA are both approved therapeutics for non-infectious indications and are well-tolerated by cultured epithelial cells. CONCLUSIONS DCA and CDCA are attractive candidates for further development as anti-gonococcal agents.
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Affiliation(s)
- Samantha G Palace
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA.,Center for Communicable Disease Dynamics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Kyra E Fryling
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Ying Li
- Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Adam J Wentworth
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA.,Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Giovanni Traverso
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA.,Division of Gastroenterology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Yonatan H Grad
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA.,Center for Communicable Disease Dynamics, Harvard T. H. Chan School of Public Health, Boston, MA, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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7
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Kong FYS, Hatzis CL, Lau A, Williamson DA, Chow EPF, Fairley CK, Hocking JS. Treatment efficacy for pharyngeal Neisseria gonorrhoeae: a systematic review and meta-analysis of randomized controlled trials. J Antimicrob Chemother 2021; 75:3109-3119. [PMID: 32747940 DOI: 10.1093/jac/dkaa300] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/09/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Rising gonorrhoea rates require highly effective treatments to reduce transmission and prevent development of antimicrobial resistance. Currently the most effective treatments for pharyngeal gonorrhoea remain unclear. This review aimed to estimate treatment efficacy for pharyngeal gonorrhoea. METHODS Online bibliographic databases were searched for the period 1 January 2000 to 17 September 2019 for treatments of gonorrhoea. All randomized controlled trials (RCTs) with data on pharyngeal gonorrhoea among participants aged 15 years or above, published in English, were included. Meta-analyses (random effects) were used to estimate the treatment efficacy, defined as microbiological cure, among currently recommended monotherapies and dual therapies, previously recommended but no longer used regimens and emerging drugs under evaluation. Side effects were also summarized. The study protocol was registered on PROSPERO (CRD42020149278). RESULTS There were nine studies that included 452 participants studying 19 treatment regimens. The overall treatment efficacy for pharyngeal gonorrhoea was 98.1% (95% CI: 93.8%-100%; I2 = 57.3%; P < 0.01). Efficacy was similar for single (97.1%; 95% CI: 90.8%-100.0%; I2 = 15.6%; P = 0.29) and dual therapies (98.0%; 95% CI: 91.4%-100%; I2 = 79.1%; P < 0.01). Regimens containing azithromycin 2 g or ceftriaxone were similarly efficacious. The summary efficacy estimate for emerging drugs was 88.8% (95% CI: 76.9%-97.5%; I2 = 11.2%; P = 0.34). Small sample sizes in each trial was a major limitation. CONCLUSIONS Regimens containing ceftriaxone or azithromycin 2 g, alone or as part of dual therapies are the most efficacious for pharyngeal gonorrhoea. Further pharyngeal-specific RCTs with adequate sample sizes are needed.
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Affiliation(s)
- Fabian Y S Kong
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Christina L Hatzis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Andrew Lau
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Deborah A Williamson
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, Victoria, Australia
| | - Eric P F Chow
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jane S Hocking
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
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Antimicrobial Resistance Profiles of Human Commensal Neisseria Species. Antibiotics (Basel) 2021; 10:antibiotics10050538. [PMID: 34066576 PMCID: PMC8148603 DOI: 10.3390/antibiotics10050538] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/23/2021] [Accepted: 04/27/2021] [Indexed: 11/17/2022] Open
Abstract
Pathogenic Neisseria gonorrhoeae causes the sexually transmitted infection gonorrhea. N. gonorrhoeae has evolved high levels of antimicrobial resistance (AR) leading to therapeutic failures even in dual-therapy treatment with azithromycin and ceftriaxone. AR mechanisms can be acquired by genetic transfer from closely related species, such as naturally competent commensal Neisseria species. At present, little is known about the antimicrobial resistance profiles of commensal Neisseria. Here, we characterized the phenotypic resistance profile of four commensal Neisseria species (N. lactamica, N. cinerea, N. mucosa, and N. elongata) against 10 commonly used antibiotics, and compared their profiles to 4 N. gonorrhoeae strains, using disk diffusion and minimal inhibitory concentration assays. Overall, we observed that 3 of the 4 commensals were more resistant to several antibiotics than pathogenic N. gonorrhoeae strains. Next, we compared publicly available protein sequences of known AR genes, including penicillin-binding-protein 2 (PBP2) from commensals and N. gonorrhoeae strains. We found mutations in PBP2 known to confer resistance in N. gonorrhoeae also present in commensal Neisseria sequences. Our results suggest that commensal Neisseria have unexplored antibiotic resistance gene pools that may be exchanged with pathogenic N. gonorrhoeae, possibly impairing drug development and clinical treatment.
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Lahra MM, Hogan TR, Shoushtari M, Armstrong BH. Australian Gonococcal Surveillance Programme Annual Report, 2020. ACTA ACUST UNITED AC 2021; 45. [PMID: 33934693 DOI: 10.33321/cdi.2021.45.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Abstract The Australian Gonococcal Surveillance Programme (AGSP), established in 1981, has continuously monitored antimicrobial resistance in clinical isolates of Neisseria gonorrhoeae for more than 40 years. In 2020, a total of 7,219 clinical isolates of gonococci from patients in the public and private sectors, in all jurisdictions, were tested for in vitro antimicrobial susceptibility by standardised methods. Current treatment recommendations for gonorrhoea, for the majority of Australia, continues to be dual therapy with ceftriaxone and azithromycin. In 2020, decreased susceptibility (DS) to ceftriaxone (minimum inhibitory concentration [MIC] value ≥ 0.06 mg/L) was found nationally in 0.9% of isolates. There was one isolate, reported from Victoria in 2020, that was resistant to ceftriaxone (MIC value ≥ 0.25 mg/L). Resistance to azithromycin (MIC value ≥ 1.0 mg/L) was found nationally in 3.9% of N. gonorrhoeae isolates, continuing a downward trend observed and reported since 2017. Isolates with high-level resistance to azithromycin (MIC value ≥ 256 mg/L) are identified sporadically in Australia; in 2020, there was one such isolate reported in Queensland. In 2020, penicillin resistance was found in 27% of gonococcal isolates nationally, and ciprofloxacin resistance in 36%; however, there is considerable variation by jurisdiction. In some remote settings, penicillin resistance remains low, and this drug continues to be recommended as part of an empiric therapy strategy. In 2020, in remote Northern Territory, no penicillin resistance was reported, and in remote Western Australia 5/116 of gonococcal isolates (4.3%) were penicillin resistant. There was one ciprofloxacin-resistant isolate reported from remote Northern Territory, and ciprofloxacin resistance rates remain comparatively low in remote Western Australia (4/116; 3.4%).
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Affiliation(s)
- Monica M Lahra
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia.,School of Medical Sciences, Faculty of Medicine, The University of New South Wales, NSW, 2052, Australia
| | - Tiffany R Hogan
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Masoud Shoushtari
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Benjamin H Armstrong
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia.,School of Medical Sciences, Faculty of Medicine, The University of New South Wales, NSW, 2052, Australia.,Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead, NSW, 2145, Australia
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10
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Armstrong BH, Limnios A, Lewis DA, Hogan T, Kundu R, Ray S, Shoushtari M, El Nasser J, Driscoll T, Lahra MM. Is gentamicin a viable therapeutic option for treating resistant Neisseria gonorrhoeae in New South Wales? ACTA ACUST UNITED AC 2021; 45. [PMID: 33632090 DOI: 10.33321/cdi.2021.45.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract The key issues with Neisseria gonorrhoeae infections, in Australia and elsewhere, are coincident increases in disease rates and in antimicrobial resistance (AMR), although these factors have not been shown to be correlated. Despite advances in diagnosis, control of this disease remains elusive, and incidence in Australia continues to increase. Of the Australian jurisdictions, New South Wales (NSW) has the highest N. gonorrhoeae notifications, and over the five-year period 2015-2019, notifications in NSW have increased above the national average (by 116% versus 85%, respectively). Gonococcal disease control is reliant on effective antibiotic regimens. However, escalating AMR in N. gonorrhoeae is a global health priority, as the collateral injury of untreated infections has substantive impacts on sexual and newborn health. Currently, our first-line therapy for gonorrhoea is also our last line, with no ideal alternative identified. Despite some limitations, gentamicin is licensed and readily available in Australia, and is proposed for treatment of resistant N. gonorrhoeae in national guidelines; however, supportive published microbiological data are lacking. Analysis of gonococcal resistance patterns within Australia for the period 1991-2019, including 35,000 clinical isolates from NSW, illustrates the establishment and spread of population-level resistance to all contemporaneous therapies. An analysis of gentamicin susceptibility on 2,768 N. gonorrhoeae clinical isolates from NSW, for the period 2015-2020, demonstrates that the median minimum inhibitory concentration (MIC) for gentamicin in NSW has remained low, at 4.0 mg/L, and resistance was not detected in any isolate. There has been no demonstration of MIC drift over time (p = 0.91, Kruskal-Wallis test), nor differences in MIC distributions according to patients' sex or site of specimen collection. This is the first large-scale evaluation of gentamicin susceptibility in N. gonorrhoeae in Australia. No gentamicin resistance was detected in clinical isolates, 2015-2020, hence this is likely to be an available treatment option for resistant gonococcal infections in NSW.
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Affiliation(s)
- Benjamin H Armstrong
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia.,School of Medical Sciences, Faculty of Medicine, The University of New South Wales, NSW 2052, Australia
| | - Athena Limnios
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - David A Lewis
- Western Sydney Sexual Health Centre, Western Sydney Local Health District, Parramatta, NSW 2150, Australia.,Westmead Clinical School and Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Westmead , NSW 2145, Australia
| | - Tiffany Hogan
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Ratan Kundu
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Sanghamitra Ray
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Masoud Shoushtari
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Jasmin El Nasser
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Tim Driscoll
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Monica M Lahra
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia.,School of Medical Sciences, Faculty of Medicine, The University of New South Wales, NSW 2052, Australia
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11
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Chow EPF, Maddaford K, Hocking JS, Bradshaw CS, Wigan R, Chen MY, Howden BP, Williamson DA, Fairley CK. An open-label, parallel-group, randomised controlled trial of antiseptic mouthwash versus antibiotics for oropharyngeal gonorrhoea treatment (OMEGA2). Sci Rep 2020; 10:19386. [PMID: 33168910 PMCID: PMC7652834 DOI: 10.1038/s41598-020-76184-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/26/2020] [Indexed: 12/17/2022] Open
Abstract
New treatments for oropharyngeal gonorrhoea are required to address rising antimicrobial resistance. We aimed to examine the efficacy of a 14-day course of mouthwash twice daily compared to standard treatment (antibiotic) for the treatment of oropharyngeal gonorrhoea. The OMEGA2 trial was a parallel-group and open-labelled randomised controlled trial among men with untreated oropharyngeal gonorrhoea that was conducted between September 2018 and February 2020 at Melbourne Sexual Health Centre in Australia. Men were randomised to the intervention (rinsing, gargling and spraying mouthwash twice daily for 14 days) or control (standard treatment) arm and followed for 28 days. Participants in both arms were advised to abstain from sex and kissing with anyone for 14 days after enrolment. Oropharyngeal swabs were collected at baseline, Day 14 and Day 28 and tested for Neisseria gonorrhoeae by nucleic acid amplification test (NAAT) and culture. The primary outcome was the detection of oropharyngeal N. gonorrhoeae by NAAT at Day 14 after treatment. This trial was registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12618001380280). This trial stopped early due to a high failure rate in the mouthwash arm. Twelve men were randomly assigned to either mouthwash (n = 6) or standard treatment (n = 6). Of the 11 men who returned at Day 14, the cure rate for oropharyngeal gonorrhoea in the mouthwash arm was 20% (95% CI 1-72%; 1/5) and in the standard treatment arm was 100% (95% CI 54-100%; 6/6). A 14-day course of mouthwash failed to cure a high proportion of oropharyngeal gonorrhoea cases.
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Affiliation(s)
- Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia.
- Central Clinical School, Monash University, Melbourne, VIC, Australia.
- Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia.
| | - Kate Maddaford
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
| | - Jane S Hocking
- Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia
| | - Catriona S Bradshaw
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Rebecca Wigan
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
| | - Marcus Y Chen
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Benjamin P Howden
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Deborah A Williamson
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
- Department of Microbiology, Royal Melbourne Hospital, Melbourne Health, Melbourne, VIC, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Monash University, Melbourne, VIC, Australia
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12
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Unemo M, Ross J, Serwin AB, Gomberg M, Cusini M, Jensen JS. 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults. Int J STD AIDS 2020:956462420949126. [PMID: 33121366 DOI: 10.1177/0956462420949126] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gonorrhoea is a major public health concern globally. Increasing incidence and sporadic ceftriaxone-resistant cases, including treatment failures, are growing concerns. The 2020 European gonorrhoea guideline provides up-to-date evidence-based guidance regarding the diagnosis and treatment of gonorrhoea. The updates and recommendations emphasize significantly increasing gonorrhoea incidence; broad indications for increased testing with validated and quality-assured nucleic acid amplification tests and culture; dual antimicrobial therapy including high-dose ceftriaxone and azithromycin (ceftriaxone 1 g plus azithromycin 2 g) OR ceftriaxone 1 g monotherapy (ONLY in well-controlled settings, see guideline for details) for uncomplicated gonorrhoea when the antimicrobial susceptibility is unknown; recommendation of test of cure (TOC) in all gonorrhoea cases to ensure eradication of infection and identify resistance; and enhanced surveillance of treatment failures when recommended treatment regimens have been used. Improvements in access to appropriate testing, test performance, diagnostics, antimicrobial susceptibility surveillance and treatment, and follow-up of gonorrhoea patients are essential in controlling gonorrhoea and to mitigate the emergence and/or spread of ceftriaxone resistance and multidrug-resistant and extensively drug-resistant gonorrhoea. For detailed background, evidence base and discussions, see the background review for the present 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults (Unemo M, et al. Int J STD AIDS. 2020).
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Affiliation(s)
- M Unemo
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Microbiology, Örebro University Hospital and Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jdc Ross
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - A B Serwin
- Department of Dermatology and Venereology, Medical University of Białystok, Białystok, Poland
| | - M Gomberg
- Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology, Moscow, Russia
| | - M Cusini
- Department of Dermatology, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milano, Italy
| | - J S Jensen
- Infection Preparedness, Research Unit for Reproductive Tract Microbiology, Statens Serum Institut, Copenhagen, Denmark
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13
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Rubin DHF, Ross JDC, Grad YH. The frontiers of addressing antibiotic resistance in Neisseria gonorrhoeae. Transl Res 2020; 220:122-137. [PMID: 32119845 PMCID: PMC7293957 DOI: 10.1016/j.trsl.2020.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/08/2020] [Accepted: 02/10/2020] [Indexed: 12/21/2022]
Abstract
The sexually transmitted infection gonorrhea, caused by the Gram-negative bacterium Neisseria gonorrhoeae, can cause urethritis, cervicitis, and systemic disease, among other manifestations. N. gonorrhoeae has rapidly rising incidence along with increasing levels of antibiotic resistance to a broad range of drugs including first-line treatments. The rise in resistance has led to fears of untreatable gonorrhea causing substantial disease globally. In this review, we will describe multiple approaches being undertaken to slow and control this spread of resistance. First, a number of old drugs have been repurposed and new drugs are being developed with activity against Neisseria gonorrhoeae. Second, vaccine development, long an important goal, is advancing. Third, new diagnostics promise rapid detection of antibiotic resistance and a shift from empiric to tailored treatment. The deployment of these new tools for addressing the challenge of antibiotic resistance will require careful consideration to provide optimal care for all patients while extending the lifespan of treatment regimens.
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Affiliation(s)
- Daniel H F Rubin
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jonathan D C Ross
- Department of Sexual Health and HIV, Birmingham University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Yonatan H Grad
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Center for Communicable Disease Dynamics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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14
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Burmeister P, Su S, Smith AJ, Wilby KJ. The Use of Gentamicin for Treatment of Urogenital and Extragenital Gonorrhea: A Systematic Review of Efficacy Data. Ann Pharmacother 2020; 54:1030-1037. [PMID: 32436729 DOI: 10.1177/1060028020927057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To evaluate clinical efficacy data for gentamicin in the treatment of gonorrhea. DATA SOURCES A keyword search of PubMed (1966 to April 2020), EMBASE (1947 to April 2020), and International Pharmaceutical Abstracts (1970 to April 2020) was conducted. The electronic search was supplemented with manual screening of references from identified articles and a search of ClinicalTrials.gov to identify ongoing trials. STUDY SELECTION AND DATA EXTRACTION Comparator and noncomparator studies reporting microbiological outcomes of treatment with gentamicin for gonorrhea in humans were included. Data extracted included study year, authors, aim, setting, population, dosing protocols, and outcome results. Risk of bias was assessed according to the Cochrane Risk of Bias Assessment Tool. DATA SYNTHESIS A total of 407 articles were identified, of which 11 met inclusion criteria. Two studies were randomized controlled trials, and 1 additional randomized noncomparator study was identified. All other studies were nonrandomized and noncomparator in nature. The highest quality evidence suggests that gentamicin is not noninferior to ceftriaxone (both in addition to azithromycin) for treatment of gonorrhea but may achieve cure rates >90%. Conflicting evidence exists regarding the efficacy of gentamicin-based regimens for the specific treatment of extragenital gonorrhea. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Results of this review could affect patient care and clinical practice because they clearly demonstrate the role of gentamicin for the treatment of gonorrhea as a second-line agent. Future research should confirm findings, especially for the role of gentamicin in extragenital infections. CONCLUSIONS Gentamicin-based regimens should be reserved for second-line treatment of urogenital and extragenital gonorrhea infections.
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Affiliation(s)
| | - Simon Su
- University of Otago, Dunedin, New Zealand
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