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Martins JM, Scheffer MC, de Melo Machado H, Schörner MA, Golfetto L, Santos TM, Barazzetti FH, de Albuquerque VCB, Bazzo ML. Spectinomycin, gentamicin, and routine disc diffusion testing: An alternative for the treatment and monitoring of multidrug-resistant Neisseria gonorrhoeae? J Microbiol Methods 2022; 197:106480. [DOI: 10.1016/j.mimet.2022.106480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/29/2022] [Accepted: 04/29/2022] [Indexed: 11/29/2022]
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Salmerón P, Moreno-Mingorance A, Trejo J, Amado R, Viñado B, Cornejo-Sanchez T, Alberny M, Barbera MJ, Arando M, Pumarola T, Hoyos-Mallecot Y, Serra-Pladevall J, González-López JJ. Emergence and dissemination of three mild outbreaks of Neisseria gonorrhoeae with high-level resistance to azithromycin in Barcelona, 2016-18. J Antimicrob Chemother 2021; 76:930-935. [PMID: 33367806 DOI: 10.1093/jac/dkaa536] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/02/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Neisseria gonorrhoeae (NG) isolates with high-level azithromycin resistance (HL-AziR) have emerged worldwide in recent decades, threatening the sustainability of current dual-antimicrobial therapy. OBJECTIVES This study aimed to characterize the first 16 NG isolates with HL-AziR in Barcelona between 2016 and 2018. METHODS WGS was used to identify the mechanisms of antimicrobial resistance, to establish the MLST ST, NG multiantigen sequence typing (NG-MAST) ST and NG sequence typing for antimicrobial resistance (NG-STAR) ST and to identify the clonal relatedness of the isolates with other closely related NG previously described in other countries based on a whole-genome SNP analysis approach. The sociodemographic characteristics of the patients included in the study were collected by comprehensive review of their medical records. RESULTS Twelve out of 16 HL-AziR isolates belonged to the MLST ST7823/NG-MAST ST5309 genotype and 4 to MLST ST9363/NG-MAST ST3935. All presented the A2059G mutation in all four alleles of the 23S rRNA gene. MLST ST7823/NG-MAST ST5309 isolates were only identified in men who have sex with women and MLST ST9363/NG-MAST ST3935 were found in MSM. Phylogenomic analysis revealed the presence of three transmission clusters of three different NG strains independently associated with sexual behaviour. CONCLUSIONS Our findings support the first appearance of three mild outbreaks of NG with HL-AziR in Spain. These results highlight the continuous capacity of NG to develop antimicrobial resistance and spread among sexual networks. The enhanced resolution of WGS provides valuable information for outbreak investigation, complementing the implementation of public health measures focused on the prevention and dissemination of MDR NG.
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Affiliation(s)
- P Salmerón
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.,Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain
| | - A Moreno-Mingorance
- Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain.,Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - J Trejo
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - R Amado
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - B Viñado
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.,Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain
| | - T Cornejo-Sanchez
- Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - M Alberny
- Institut Català de Salut (ICS), Barcelona, Spain
| | - M J Barbera
- Drassanes-Vall d'Hebron Sexually Transmitted Infections Unit, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain
| | - M Arando
- Drassanes-Vall d'Hebron Sexually Transmitted Infections Unit, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - T Pumarola
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.,Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain.,Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Y Hoyos-Mallecot
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - J Serra-Pladevall
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.,Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain.,Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - J J González-López
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.,Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain.,Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
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3
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The JAID/JSC guidelines to Clinical Management of Infectious Disease 2017 concerning male urethritis and related disorders. J Infect Chemother 2021; 27:546-554. [PMID: 33516669 DOI: 10.1016/j.jiac.2019.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 10/24/2019] [Accepted: 12/03/2019] [Indexed: 11/24/2022]
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Zhang J, van der Veen S. Neisseria gonorrhoeae 23S rRNA A2059G mutation is the only determinant necessary for high-level azithromycin resistance and improves in vivo biological fitness. J Antimicrob Chemother 2020; 74:407-415. [PMID: 30376120 DOI: 10.1093/jac/dky438] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/28/2018] [Indexed: 12/13/2022] Open
Abstract
Objectives The global emergence of Neisseria gonorrhoeae isolates displaying high-level azithromycin resistance is a major concern for the currently recommended azithromycin/ceftriaxone dual therapy. N. gonorrhoeae high-level azithromycin resistance has been associated with an A2059G mutation in 23S rRNA. Here we investigated the specific contribution of this 23S rRNA A2059G mutation to high-level azithromycin resistance and its impact on biological fitness. Methods A2059G/G2059A alleles were specifically cloned into all four genomic copies of 23S rDNA of an azithromycin-susceptible isolate and a high-level azithromycin-resistant isolate. WT and mutant strains were subsequently investigated for azithromycin susceptibility using the agar dilution method. In addition, their biological fitness was studied by comparative liquid growth in the presence of hydrophobic and amphipathic compounds, by competition assays in a mouse vaginal tract infection model and by competition assays for invasion and intracellular survival. Results Azithromycin susceptibility analyses showed that the 23S rRNA A2059G mutation is the only genetic determinant required for N. gonorrhoeae to display the high-level azithromycin resistance phenotype. Further analysis of biological fitness showed that strains containing 2059G outcompeted isogenic strains containing 2059A for colonization in the mouse vaginal tract infection model and for invasion of HeLa cervical epithelial cells. Furthermore, the A2059G mutation enhanced growth in the presence of lithocholic acid or Triton X-100. Conclusions Our findings that the 23S rRNA A2059G mutation is sufficient for high-level azithromycin resistance and that this mutation generally enhanced the biological fitness of N. gonorrhoeae have important implications for the currently recommended treatment policies and antimicrobial stewardship programmes.
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Affiliation(s)
- Jianglin Zhang
- Department of Microbiology and Parasitology, School of Medicine, Zhejiang University, Hangzhou, China
| | - Stijn van der Veen
- Department of Microbiology and Parasitology, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Dermatology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 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, China
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Yan J, Xue J, Chen Y, Chen S, Wang Q, Zhang C, Wu S, Lv H, Yu Y, van der Veen S. Increasing prevalence of Neisseria gonorrhoeae with decreased susceptibility to ceftriaxone and resistance to azithromycin in Hangzhou, China (2015-17). J Antimicrob Chemother 2020; 74:29-37. [PMID: 30329062 DOI: 10.1093/jac/dky412] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/13/2018] [Indexed: 12/31/2022] Open
Abstract
Objectives Development of resistance in Neisseria gonorrhoeae to ceftriaxone monotherapy or ceftriaxone plus azithromycin dual therapy is a global public health concern. The aim of this study was to analyse the trend in antimicrobial resistance in Hangzhou, China, over the period 2015-17. Methods In total, 379 clinical isolates were collected from seven hospitals and antimicrobial susceptibility was determined using the agar dilution method. Isolates showing resistance to ceftriaxone, azithromycin or cefixime were analysed for the presence of resistance determinants. STs were determined with the N. gonorrhoeae multiantigen sequence typing (NG-MAST) method and phylogenetic analysis and strain clustering was determined using porB and tbpB sequences. Results Ceftriaxone resistance, decreased susceptibility to ceftriaxone and azithromycin resistance were observed in 3%, 17% and 21% of the isolates, respectively. This resulted in 5% of the isolates showing both decreased susceptibility to ceftriaxone and azithromycin resistance. Importantly, resistance levels to ceftriaxone and azithromycin increased over the study period, resulting in 5% ceftriaxone resistance, 27% decreased susceptibility to ceftriaxone and 35% azithromycin resistance in 2017 and 11% of the isolates showing both decreased susceptibility to ceftriaxone and azithromycin resistance. Phylogenetic and cluster analysis showed the emergence and expansion in 2017 of a clonally related cluster containing strains with high abundance of decreased susceptibility to ceftriaxone and/or cefixime, which was related to the presence of the mosaic penA allele X. Co-resistance to azithromycin was also observed in this cluster. Conclusions Our findings have major implications for the future reliability of ceftriaxone monotherapy and ceftriaxone plus azithromycin dual therapy in China.
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Affiliation(s)
- Jing Yan
- Department of Microbiology and Parasitology, School of Medicine, Zhejiang University, Hangzhou, China
| | - Juan Xue
- Department of Microbiology and Parasitology, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yan Chen
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shi Chen
- Clinical Laboratory Department, Hangzhou Third Hospital, Hangzhou, China
| | - Qiang Wang
- Department of Clinical Laboratory, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Chuanling Zhang
- Clinical Laboratory, Zhejiang Xiaoshan Hospital, Hangzhou, China
| | - Shenghai Wu
- Department of Laboratory, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huoyang Lv
- Centre of Laboratory Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Stijn van der Veen
- Department of Microbiology and Parasitology, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Dermatology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 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, China
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8
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Carannante A, Ciammaruconi A, Vacca P, Anselmo A, Fillo S, Palozzi AM, Fortunato A, Lista F, Stefanelli P. Genomic Characterization of Gonococci from Different Anatomic Sites, Italy, 2007-2014. Microb Drug Resist 2019; 25:1316-1324. [PMID: 31219400 DOI: 10.1089/mdr.2018.0371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In recent decades, Neisseria gonorrhoeae has developed resistance to several antimicrobial classes. Molecular epidemiology approaches are useful for detecting emerging, often resistant, gonococcal clones. In this study, 67 N. gonorrhoeae isolates from different anatomic sites, collected over 8 years in Italy, were analyzed by whole genome sequencing (WGS). WGS was performed using the Illumina NextSeq 500 platform. Phylogenetic analysis was based on core single nucleotide polymorphism (SNP) and core genome multilocus sequence typing (cgMLST). N. gonorrhoeae multi-antigen sequence typing (NG-MAST), MLST, and N. gonorrhoeae sequence typing for antimicrobial resistance (NG-STAR) were carried out in silico using WGS data. Antimicrobial susceptibility against a four-drug panel was evaluated using a gradient diffusion method. Overall, gonococci clustered in accordance with NG-MAST, MLST, NG-STAR, and antimicrobials susceptibility profiles, but not with the site of isolation, HIV status, and patient sexual orientation. Phylogenetic analysis identified nine clades: two of them were the predominant and including gonococci of G1407 and G2400 genogroups.
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Affiliation(s)
- Anna Carannante
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | | | - Paola Vacca
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Anna Anselmo
- Scientific Department, Army Medical Center, Rome, Italy
| | - Silvia Fillo
- Scientific Department, Army Medical Center, Rome, Italy
| | | | | | | | - Paola Stefanelli
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
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9
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Thakur SD, Levett PN, Horsman GB, Dillon JAR. High levels of susceptibility to new and older antibiotics in Neisseria gonorrhoeae isolates from Saskatchewan (2003-15): time to consider point-of-care or molecular testing for precision treatment? J Antimicrob Chemother 2018; 73:118-125. [PMID: 29029217 DOI: 10.1093/jac/dkx333] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 08/11/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives The antimicrobial susceptibility of Neisseria gonorrhoeae isolates from Saskatchewan was determined retrospectively (2003-15) to ascertain temporal trends to both current and older antimicrobials used for treatment. Method The agar dilution method was used to test the antimicrobial susceptibilities of 685 isolates to seven antibiotics. Results Over the period, only three (0.4%) gonococcal isolates had reduced susceptibility to cefixime and/or ceftriaxone. All isolates were susceptible to spectinomycin. Over 95% of the isolates tested were susceptible to azithromycin except in 2010 and 2013 (27.6% and 7.2% resistant, respectively). One isolate was resistant to both azithromycin and cefixime. Ciprofloxacin resistance was seen in < 5% of isolates prior to 2010, but in > 5% thereafter. From 2006 to 2012, and in 2015, penicillin resistance was detected in < 5% (0%-4.0%) of isolates, but in > 5% for the rest of the study period. Tetracycline resistance remained >5% (11.8%-89.1%) throughout the study. Plasmid-mediated resistance to tetracycline fluctuated between 0% and 17.5% of isolates tested. Four isolates were MDR and two isolates were XDR. Conclusions N. gonorrhoeae isolates were largely susceptible (∼85%) to antibiotics no longer recommended for treatment, such as penicillin and ciprofloxacin. Gonorrhoea in Saskatchewan is primarily (>95%) diagnosed by nucleic acid amplification testing, which does not permit antimicrobial susceptibility testing. The development of molecular testing, or point-of-care tests, to evaluate antimicrobial susceptibility, would enhance knowledge of true levels of resistance and allow discretion as to whether older but still effective antibiotics could be used in individual patient care.
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Affiliation(s)
- Sidharath D Thakur
- Department of Microbiology and Immunology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Vaccine and Infectious Disease Organization - International Vaccine Centre (VIDO-InterVac), University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Paul N Levett
- Saskatchewan Disease Control Laboratory, Regina, Saskatchewan, Canada
| | - Gregory B Horsman
- Saskatchewan Disease Control Laboratory, Regina, Saskatchewan, Canada
| | - Jo-Anne R Dillon
- Department of Microbiology and Immunology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Vaccine and Infectious Disease Organization - International Vaccine Centre (VIDO-InterVac), University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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10
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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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Town K, Bolt H, Croxford S, Cole M, Harris S, Field N, Hughes G. Neisseria gonorrhoeae molecular typing for understanding sexual networks and antimicrobial resistance transmission: A systematic review. J Infect 2018; 76:507-514. [PMID: 29698633 PMCID: PMC5999358 DOI: 10.1016/j.jinf.2018.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 02/11/2018] [Accepted: 02/19/2018] [Indexed: 11/19/2022]
Abstract
Combined molecular and epidemiological data can describe the spread of gonorrhoea. Sexual networks can be inferred from molecular clusters of infection. Gender and sexual orientation are commonly used to characterise these networks. Application of these data within gonorrhoea control interventions is limited. Future studies should focus on evaluating molecular typing data in practice.
Objectives Neisseria gonorrhoeae (NG) is a significant global public health concern due to rising diagnoses rates and antimicrobial resistance. Molecular combined with epidemiological data have been used to understand the distribution and spread of NG, as well as relationships between cases in sexual networks, but the public health value gained from these studies is unclear. We conducted a systematic review to examine how molecular epidemiological studies have informed understanding of sexual networks and NG transmission, and subsequent public health interventions. Methods Five research databases were systematically searched up to 31st March 2017 for studies that used sequence-based DNA typing methods, including whole genome sequencing, and linked molecular data to patient-level epidemiological data. Data were extracted and summarised to identify common themes. Results Of the 49 studies included, 82% used NG Multi-antigen Sequence Typing. Gender and sexual orientation were commonly used to characterise sexual networks that were inferred using molecular clusters; clusters predominantly of one patient group often contained a small number of isolates from other patient groups. Suggested public health applications included using these data to target interventions at specific populations, confirm outbreaks, and inform partner management, but these were mainly untested. Conclusions Combining molecular and epidemiological data has provided insight into sexual mixing patterns, and dissemination of NG, but few studies have applied these findings to design or evaluate public health interventions. Future studies should focus on the application of molecular epidemiology in public health practice to provide evidence for how to prevent and control NG.
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Affiliation(s)
- Katy Town
- National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London in partnership with Public Health England and in collaboration with the London School of Hygiene and Tropical Medicine, Mortimer Market Centre, Third Floor, Capper Street, London WC1E 6JB, UK; Centre for Molecular Epidemiology and Translational Research, Institute for Global Health, University College London, Mortimer Market Centre, Capper Street, London WC1E 6JB, UK.
| | - Hikaru Bolt
- HIV/STI Department, National Infection Service, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Sara Croxford
- HIV/STI Department, National Infection Service, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Michelle Cole
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Simon Harris
- The Wellcome Trust Sanger Institute, Genome Campus, Cambridge CB10 1SA, UK
| | - Nigel Field
- Centre for Molecular Epidemiology and Translational Research, Institute for Global Health, University College London, Mortimer Market Centre, Capper Street, London WC1E 6JB, UK
| | - Gwenda Hughes
- National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London in partnership with Public Health England and in collaboration with the London School of Hygiene and Tropical Medicine, Mortimer Market Centre, Third Floor, Capper Street, London WC1E 6JB, UK; HIV/STI Department, National Infection Service, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
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12
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Buder S, Dudareva S, Jansen K, Loenenbach A, Nikisins S, Sailer A, Guhl E, Kohl PK, Bremer V. Antimicrobial resistance of Neisseria gonorrhoeae in Germany: low levels of cephalosporin resistance, but high azithromycin resistance. BMC Infect Dis 2018; 18:44. [PMID: 29343220 PMCID: PMC5772720 DOI: 10.1186/s12879-018-2944-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 01/03/2018] [Indexed: 11/15/2022] Open
Abstract
Background The widespread antimicrobial resistance of Neisseria gonorrhoeae is a serious problem for the treatment and control of gonorrhoea. Many of the previously effective therapeutic agents are no longer viable. Because N. gonorrhoeae infections are not reportable in Germany, only limited data on disease epidemiology and antimicrobial susceptibility patterns are available. The Gonococcal Resistance Network (GORENET) is a surveillance project to monitor trends in the antimicrobial susceptibility of N. gonorrhoeae in Germany in order to guide treatment algorithms and target future prevention strategies. Methods Between April 2014 and December 2015, data on patient-related information were collected from laboratories nationwide, and susceptibility testing was performed on 537 N. gonorrhoeae isolates forwarded from the network laboratories to the Conciliar Laboratory for gonococci. Susceptibility results for cefixime, ceftriaxone, azithromycin, ciprofloxacin and penicillin were defined according to EUCAST 4.0 standards. Percentages, medians and interquartile ranges (IQR) were calculated. Results Altogether, 90% of isolates were from men. The median age was 32 (IQR 25–44) years for men and 25 (IQR 22–40) years for women (p-value < 0.001). The most frequently tested materials among men were urethral (96.1%) and rectal swabs (1.7%), and among women, it was mainly endocervical and vaginal swabs (84.3%). None of the isolates were resistant to ceftriaxone. Furthermore, 1.9% (in 2014) and 1.4% (in 2015) of the isolates were resistant to cefixime, 11.9% and 9.8% showed resistance against azithromycin, 72.0% and 58.3% were resistant to ciprofloxacin, and 29.1% and 18.8% were resistant to penicillin. Conclusions Resistance to ceftriaxone was not detected, and the percentage of isolates with resistance to cefixime was low, whereas azithromycin resistance showed high levels during the observation period. The rates of ciprofloxacin resistance and penicillin resistance were very high across Germany. Continued surveillance of antimicrobial drug susceptibilities for N. gonorrhoeae remains highly important to ensure efficient disease management.
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Affiliation(s)
- Susanne Buder
- German Consiliary Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany.
| | - Sandra Dudareva
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany. .,Charité University Medicine Berlin, Berlin, Germany.
| | - Klaus Jansen
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Anna Loenenbach
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Sergejs Nikisins
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.,Department of Infectious Diseases, Robert Koch Institute, Berlin, Germany.,European Public Health Microbiology Training (EUPHEM) programme, European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Andrea Sailer
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Eva Guhl
- German Consiliary Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany
| | - Peter K Kohl
- German Consiliary Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany
| | - Viviane Bremer
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
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Evaluation of the Microbiological Efficacy of a Single 2-Gram Dose of Extended-Release Azithromycin by Population Pharmacokinetics and Simulation in Japanese Patients with Gonococcal Urethritis. Antimicrob Agents Chemother 2017; 62:AAC.01409-17. [PMID: 29038284 DOI: 10.1128/aac.01409-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 10/05/2017] [Indexed: 11/20/2022] Open
Abstract
The objective of this study was to analyze the relationship between the pharmacokinetic (PK)/pharmacodynamic (PD) parameters of a single 2-g dose of extended-release formulation of azithromycin (AZM-SR) and its microbiological efficacy against gonococcal urethritis. Fifty male patients with gonococcal urethritis were enrolled in this study. In 36 patients, the plasma AZM concentrations were measured using liquid chromatography-tandem mass spectrometry, the AZM MIC values for the Neisseria gonorrhoeae isolates were determined, and the microbiological outcomes were assessed. AZM-SR monotherapy eradicated N. gonorrhoeae in 30 (83%) of the 36 patients. AZM MICs ranged from 0.03 to 2 mg/liter. The mean value of the area under the concentration-time curve (AUC), estimated by population PK analysis using a two-compartment model, was 20.8 mg · h/liter. Logistic regression analysis showed that the PK/PD target value required to predict an N. gonorrhoeae eradication rate of ≥95% was a calculated AUC/MIC of ≥59.5. The AUC/MIC value was significantly higher in patients who achieved microbiological cure than in patients who achieved microbiological failure. Monte Carlo simulation using this MIC distribution revealed that the probability that AZM-SR monotherapy would produce an AUC/MIC exceeding the AUC/MIC target of 59.5 was 47%. Furthermore, the MIC distribution for strains isolated in this study was mostly consistent with that for strains currently circulating in Japan. In conclusion, in Japan, AZM-SR monotherapy may not be effective against gonococcal urethritis. Therefore, use of a single 2-g dose of AZM-SR either with or without other antibiotics could be an option to treat gonococcal urethritis if patients are allergic to ceftriaxone and spectinomycin or are diagnosed to be infected with an AZM-sensitive strain.
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Stefanelli P, Vescio MF, Landini MP, Dal Conte I, Matteelli A, Cristaudo A, Gaino M, Cusini M, Barbui AM, Mencacci A, De Nittis R, Ghisetti V, Stroppiana E, Carannante A. Time trend analysis (2009-2016) of antimicrobial susceptibility in Neisseria gonorrhoeae isolated in Italy following the introduction of the combined antimicrobial therapy. PLoS One 2017; 12:e0189484. [PMID: 29240786 PMCID: PMC5730201 DOI: 10.1371/journal.pone.0189484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 11/27/2017] [Indexed: 12/02/2022] Open
Abstract
Introduction Neisseria gonorrhoeae (NG) antimicrobial susceptibility trends to azithromycin, cefixime and ceftriaxone were analyzed, from 2009 to 2016, to monitor changing antimicrobial susceptibility concomitant with the change in prescribing practice in 2012 from cefixime, or ceftriaxone, to ceftriaxone plus azithromycin. Patient characteristics predictive to be infected by antibiotic resistant N. gonorrhoeae were estimated. Finally, the protocol for the treatment of gonorrhoea, in comparison with the international guidelines, was also evaluated. Materials and methods Data on NG antimicrobial resistance were obtained from a network of sexually transmitted diseases clinics and other laboratories in 12 cities in Italy. We tested the 1,433 gonococci for antimicrobial susceptibility to azithromycin, cefixime and ceftriaxone using a gradient diffusion method. Logistic-regression methods with cluster robust standard errors were used to investigate the association of resistance categories with demographic and clinical patient characteristics and to assess changes in prescribing practices. To minimize bias due to missing data, all statistical models were fitted to data with forty rounds of multiple imputation, using chained equations. Results The percentage of isolates resistant to cefixime was 17.10% in 2009 and declined up to 1.39% in 2016; at the same time, those resistant to azithromycin was 23.68% in 2009 and 3.00% in 2012. Starting from 2013, azithromycin resistant gonococci tended to increase up to 7.44% in 2016. No ceftriaxone resistant isolates were observed. By multivariate analysis, the men who have sex with women (MSW) and women had a proportional adjusted OR of resistance of 1.25 (95%CI: 0.90; 1.73) and 1.67 (95%CI: 1.16; 2.40), respectively, in comparison with men who have sex with men (MSM). An aOR of resistance of 0.48 (95%CI: 0.21; 1.12) among NG isolated in the pharynx, compared with those isolated in genital sites, was calculated. The proportional aOR of resistance was 0.58 (95%CI: 0.38; 0.89) for presence vs absence of co-infection and 2.00 (95%CI: 1.36; 2.96) for past history vs no history of gonorrhoea.Finally, at least for the period 2013–2016, the older, subjects with anorectal or pharyngeal gonorrhoea infection, subjects with a co-infection, subjects with a previous gonorrhoea infection were not always correctly treated. Conclusions Overall, our findings suggest the shifts in N. gonorrhoeae susceptibility to cefixime and azithromycin in the time frame period. First of all, the increasing rate of azithromycin resistance in 2015–2016 in NG isolated in the country need to be monitor in the future. Finally, extensive information on treatment regimens may be useful to asses treatment adherence particularly for the older subjects, subjects with an anorectal or pharyngeal infection, subjects with a co-infection and subjects with a previous history of gonorrhoea. Gonorrhoea treatment strategy should be based on the evidence obtained by the local antimicrobial surveillance system and data about treatment failures.
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Affiliation(s)
- Paola Stefanelli
- Department Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
- * E-mail:
| | | | - Maria Paola Landini
- Unit of Clinical Microbiology, University Hospital S.Orsola-Malpighi, Bologna, Italy
| | - Ivano Dal Conte
- STI Clinic, Dept. of Infectious Diseases, Amedeo di Savoia Hospital, Turin, Italy
| | - Alberto Matteelli
- Clinic of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy
| | | | - Marina Gaino
- Microbiology and Virology Laboratory, Santa Chiara Hospital, Trento, Italy
| | - Marco Cusini
- Foundation IRCCS Ca’ Granda ‘Ospedale Maggiore Policlinico Milano’, Milan, Italy
| | - Anna Maria Barbui
- Microbiology and Virology Laboratory, Molinette Hospital, Turin, Italy
| | - Antonella Mencacci
- Medical Microbiology Section, Dept. of Medicine, University of Perugia, Perugia, Italy
| | - Rosella De Nittis
- Department of Clinical Pathology, ‘Azienda Ospedaliero-Universitaria OORR’, Foggia, Italy
| | - Valeria Ghisetti
- Laboratory of Microbiology and Virology, Amedeo di Savoia Hospital, Turin, Italy
| | - Elena Stroppiana
- Dermatologic Clinic, ‘A.O.U. Città della Salute e della Scienza’, Turin, Italy
| | - Anna Carannante
- Department Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
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15
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Abstract
BACKGROUND Gonococcal infections are difficult to treat because of their multidrug antimicrobial resistance. The outbreak of antimicrobial-resistant Neisseria gonorrhoeae has begun in Asia and particularly in Japan. Therefore, it is very important that we understand the trend of antimicrobial resistance of N. gonorrhoeae in Asia including Japan. Our surveillance of the antimicrobial susceptibility of N. gonorrhoeae began in 2000 under the guidance of the Department of Urology, Gifu University. We report our surveillance data from 2000 to 2015. METHODS We collected N. gonorrhoeae strains isolated from patients with gonococcal infections who visited our cooperating medical institutions in Japan from 2000 to 2015. MICs of penicillin G, cefixime, ceftriaxone, tetracycline, spectinomycin, azithromycin, and levofloxacin were determined by the agar dilution method approved by the Clinical and Laboratory Standards Institute. RESULTS From 2000 to 2015, 2471 isolates of N. gonorrhoeae were collected in Japan. High rates of nonsusceptibility to penicillin, tetracycline, levofloxacin, cefixime, and azithromycin were shown. Around 5% to 10% of the strains isolated had a 0.25-mg/L MIC of ceftriaxone in each year, and 6 strains (0.24%) with a 0.5-mg/L MIC of ceftriaxone were isolated throughout the study period. Approximately 5% to 10% of the strains were resistant to each of ceftriaxone, azithromycin, and levofloxacin according to European Committee on Antimicrobial Susceptibility Testing breakpoints, and the rate has not increased significantly. CONCLUSIONS From this study and previous pharmacodynamic analyses, a single 1-g dose of ceftriaxone is recommended to treat gonorrhea. As strains with high-level ceftriaxone resistance continue to spread, higher doses of ceftriaxone in monotherapy or multiple doses of ceftriaxone should be considered.
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16
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Antimicrobial Resistance and Neisseria gonorrhoeae Multiantigen Sequence Typing Profile of Neisseria gonorrhoeae in New Delhi, India. Sex Transm Dis 2017; 43:506-16. [PMID: 27414684 DOI: 10.1097/olq.0000000000000471] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Molecular epidemiology of 100 consecutive gonococcal isolates collected between April 2010 and October 2013 from New Delhi was investigated using Neisseria gonorrhoeae multiantigen sequence typing (NG-MAST) along with its association with antimicrobial resistance profiles. Neisseria gonorrhoeae isolates were assigned into 60 different sequence types and 43 (71.6%) were novel. Sole representation was seen in 76.6% sequence types. There was significant association between ST6058 and resistance to penicillin (P = 0.00) and tetracycline (P = 0.002).
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Abrams AJ, Trees DL. Genomic sequencing of Neisseria gonorrhoeae to respond to the urgent threat of antimicrobial-resistant gonorrhea. Pathog Dis 2017; 75:3106325. [PMID: 28387837 PMCID: PMC6956991 DOI: 10.1093/femspd/ftx041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 04/04/2017] [Indexed: 01/02/2023] Open
Abstract
The development of resistance of Neisseria gonorrhoeae to available first-line antibiotics, including penicillins, tetracyclines, fluoroquinolones and cephalosporins, has led to the circulation of multidrug-resistant gonorrhea at a global scale. Advancements in high-throughput whole-genome sequencing (WGS) provide useful tools that can be used to enhance gonococcal detection, treatment and management capabilities, which will ultimately aid in the control of antimicrobial resistant gonorrhea worldwide. In this minireview, we discuss the application of WGS of N. gonorrhoeae to strain typing, phylogenomic, molecular surveillance and transmission studies. We also examine the application of WGS analyses to the public health sector as well as the potential usage of WGS-based transcriptomic and epigenetic methods to identify novel gonococcal resistance mechanisms.
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Affiliation(s)
- A. Jeanine Abrams
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta, GA 30333, USA
| | - David L. Trees
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta, GA 30333, USA
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18
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Regnath T, Mertes T, Ignatius R. Antimicrobial resistance of Neisseria gonorrhoeae isolates in south-west Germany, 2004 to 2015: increasing minimal inhibitory concentrations of tetracycline but no resistance to third-generation cephalosporins. ACTA ACUST UNITED AC 2017; 21:30335. [PMID: 27632642 PMCID: PMC5048714 DOI: 10.2807/1560-7917.es.2016.21.36.30335] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/28/2015] [Indexed: 11/20/2022]
Abstract
Increasing antimicrobial resistance of Neisseria gonorrhoeae, particularly to third-generation cephalosporins, has been reported in many countries. We examined the susceptibility (determined by Etest and evaluated using the breakpoints of the European Committee on Antimicrobial Susceptibility Testing) of 434 N. gonorrhoeae isolates collected from 107 female and 327 male patients in Stuttgart, south-west Germany, between 2004 and 2015. During the study period, high proportions of isolates were resistant to ciprofloxacin (70.3%), tetracycline (48.4%; increasing from 27.5% in 2004/2005 to 57.7% in 2014/2015; p = 0.0002) and penicillin (25.6%). The proportion of isolates resistant to azithromycin was low (5.5%) but tended to increase (p = 0.08). No resistance and stable minimum inhibitory concentrations were found for cefixime, ceftriaxone, and spectinomycin. High-level resistance was found for ciprofloxacin (39.6%) and tetracycline (20.0%) but not for azithromycin; 16.3% of the isolates produced betalactamase. Thus, cephalosporins can still be used for the treatment of gonorrhoea in the study area. To avoid further increasing resistance to azithromycin, its usage should be limited to patients allergic to cephalosporins, or (in combination with cephalosporins) to patients for whom no susceptibility testing could be performed or those co-infected with chlamydiae.
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Ellington MJ, Ekelund O, Aarestrup FM, Canton R, Doumith M, Giske C, Grundman H, Hasman H, Holden MTG, Hopkins KL, Iredell J, Kahlmeter G, Köser CU, MacGowan A, Mevius D, Mulvey M, Naas T, Peto T, Rolain JM, Samuelsen Ø, Woodford N. The role of whole genome sequencing in antimicrobial susceptibility testing of bacteria: report from the EUCAST Subcommittee. Clin Microbiol Infect 2016; 23:2-22. [PMID: 27890457 DOI: 10.1016/j.cmi.2016.11.012] [Citation(s) in RCA: 317] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 11/18/2016] [Indexed: 12/11/2022]
Abstract
Whole genome sequencing (WGS) offers the potential to predict antimicrobial susceptibility from a single assay. The European Committee on Antimicrobial Susceptibility Testing established a subcommittee to review the current development status of WGS for bacterial antimicrobial susceptibility testing (AST). The published evidence for using WGS as a tool to infer antimicrobial susceptibility accurately is currently either poor or non-existent and the evidence / knowledge base requires significant expansion. The primary comparators for assessing genotypic-phenotypic concordance from WGS data should be changed to epidemiological cut-off values in order to improve differentiation of wild-type from non-wild-type isolates (harbouring an acquired resistance). Clinical breakpoints should be a secondary comparator. This assessment will reveal whether genetic predictions could also be used to guide clinical decision making. Internationally agreed principles and quality control (QC) metrics will facilitate early harmonization of analytical approaches and interpretive criteria for WGS-based predictive AST. Only data sets that pass agreed QC metrics should be used in AST predictions. Minimum performance standards should exist and comparative accuracies across different WGS laboratories and processes should be measured. To facilitate comparisons, a single public database of all known resistance loci should be established, regularly updated and strictly curated using minimum standards for the inclusion of resistance loci. For most bacterial species the major limitations to widespread adoption for WGS-based AST in clinical laboratories remain the current high-cost and limited speed of inferring antimicrobial susceptibility from WGS data as well as the dependency on previous culture because analysis directly on specimens remains challenging. For most bacterial species there is currently insufficient evidence to support the use of WGS-inferred AST to guide clinical decision making. WGS-AST should be a funding priority if it is to become a rival to phenotypic AST. This report will be updated as the available evidence increases.
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Affiliation(s)
- M J Ellington
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK
| | - O Ekelund
- Department of Clinical Microbiology and the EUCAST Development Laboratory, Kronoberg Region, Central Hospital, Växjö, Sweden
| | - F M Aarestrup
- National Food Institute, Research Group for Genomic Epidemiology, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark
| | - R Canton
- Servicio de Microbiología, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - M Doumith
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK
| | - C Giske
- Department of Laboratory Medicine, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - H Grundman
- University Medical Centre Freiburg, Infection Prevention and Hospital Hygiene, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - H Hasman
- Statens Serum Institute, Department of Microbiology and Infection Control, Copenhagen, Denmark
| | - M T G Holden
- School of Medicine, Medical & Biological Sciences, North Haugh, University of St Andrews, UK
| | - K L Hopkins
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK
| | - J Iredell
- Westmead Institute for Medical Research, University of Sydney and Marie Bashir Institute, Sydney, NSW, Australia
| | - G Kahlmeter
- Department of Clinical Microbiology and the EUCAST Development Laboratory, Kronoberg Region, Central Hospital, Växjö, Sweden
| | - C U Köser
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - A MacGowan
- Department of Medical Microbiology, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - D Mevius
- Central Veterinary Institute (CVI) part of Wageningen University and Research Centre (WUR), Lelystad, The Netherlands; Department of Infectious Diseases and Immunology, Utrecht University, Utrecht, The Netherlands
| | - M Mulvey
- National Microbiology Laboratory, Winnipeg, Manitoba, Canada
| | - T Naas
- French National Reference Centre for Antibiotic Resistance, Bacteriology-Hygiene unit, Hôpital Bicêtre, APHP, LabEx LERMIT, University Paris Sud, Le Kremlin-Bicêtre, France
| | - T Peto
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - J-M Rolain
- PU-PH des Disciplines Pharmaceutiques, 1-URMITE CNRS IRD UMR 6236, IHU Méditerranée Infection, Valorization and Transfer, Aix Marseille Université, Faculté de Médecine et de Pharmacie, Marseille, France
| | - Ø Samuelsen
- Norwegian National Advisory Unit on Detection of Antimicrobial Resistance, University Hospital of North Norway, Department of Microbiology and Infection Control, Tromsø, Norway
| | - N Woodford
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK.
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Lee H, Lee K, Chong Y. New treatment options for infections caused by increasingly antimicrobial-resistant Neisseria gonorrhoeae. Expert Rev Anti Infect Ther 2016; 14:243-56. [PMID: 26690658 DOI: 10.1586/14787210.2016.1134315] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The emergence of high-level resistance to ceftriaxone is giving rise to serious concern about absence of effective treatment options to cure gonococcal infections. Increasing the dosage regimen can be applied to ceftriaxone and azithromycin, but the emergence of high-level resistance has already been reported. Spectinomycin is another active drug but has low efficacy in the treatment of pharyngeal gonorrhoea. Conventional antibiotics could be introduced for gonococcal treatment, but they have some limitations, such as the absence of clinical trials and breakpoint. Combining antibiotics is another promising method to cure patients and to prevent the emergence of resistance. The most important strategy to maintain the efficacy of antibiotics is rapid detection and dissemination control of novel resistant isolate.
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Affiliation(s)
- Hyukmin Lee
- a Department of Laboratory Medicine , International St. Mary's Hospital, Catholic Kwandong University College of Medicine , Incheon , Korea
| | - Kyungwon Lee
- b Department of Laboratory Medicine and Research Institute of Bacterial Resistance , Yonsei University College of Medicine , Seoul , Korea
| | - Yunsop Chong
- b Department of Laboratory Medicine and Research Institute of Bacterial Resistance , Yonsei University College of Medicine , Seoul , Korea
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Brunner A, Nemes-Nikodem E, Jeney C, Szabo D, Marschalko M, Karpati S, Ostorhazi E. Emerging azithromycin-resistance among the Neisseria gonorrhoeae strains isolated in Hungary. Ann Clin Microbiol Antimicrob 2016; 15:53. [PMID: 27646968 PMCID: PMC5029006 DOI: 10.1186/s12941-016-0166-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 09/13/2016] [Indexed: 11/10/2022] Open
Abstract
Background In the 1990s, azithromycin became the drug of choice for many infectious diseases but emerging resistance to the drug has only been reported in the last decade. In the last 5 years, the National Neisseria gonorrhoeae Reference Laboratory of Hungary (NNGRLH) has also observed an increased number of N. gonorrhoeae strains resistant to azithromycin. The aim of this study was to determine the most frequent sequence types (ST) of N. gonorrhoeae related to elevated levels of azithromycin MIC (minimal inhibitory concentration). Previously and currently isolated azithromycin-resistant strains have been investigated for the existence of molecular relationship. Methods Maldi-Tof technic was applied for the identification of the strains isolated from outpatients attending the reference laboratory. Testing antibiotic susceptibility of azithromycin, cefixime, ceftriaxone, tetracycline, spectinomycin and ciprofloxacin was carried out for all the identified strains, using MIC strip test Liofilchem®. N. gonorrhoeae multiantigen sequence typing (NG-MAST) was performed exclusively on azithromycin-resistant isolates. A phylogenetic tree was drawn using MEGA6 (Molecular Evolutionary Genetics Analysis Version 6.0) Neighbour-Joining method. Results Out of 192 N. gonorrhoeae isolates, 30.0 % (58/192) proved resistant to azithromycin (MIC > 0.5 mg/L). Of the azithromycin-resistant isolates, ST1407, ST4995 and ST11064 were the most prevalent. Based on the phylogenetic analysis, the latter two STs are closely related. Conclusions In contrast to West-European countries, in our region, resistance to azithromycin has increased up to 30 % in the last 5 years, so the recommendation of the European Guideline −500 mg of ceftriaxone combined with 2 g of azithromycin as first choice therapy against N. gonorrhoeae- should be seriously considered in case of Hungary. Electronic supplementary material The online version of this article (doi:10.1186/s12941-016-0166-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandra Brunner
- Department of Dermatology, Venerology and Dermatooncology, Semmelweis University, 41 Mária Street, Budapest, Hungary
| | - Eva Nemes-Nikodem
- Department of Laboratory Medicine, Semmelweis University, 41 Mária Street, Budapest, Hungary
| | - Csaba Jeney
- Institute of Medical Microbiology, Semmelweis University, 4 Nagyvárad Square, Budapest, Hungary
| | - Dora Szabo
- Institute of Medical Microbiology, Semmelweis University, 4 Nagyvárad Square, Budapest, Hungary
| | - Marta Marschalko
- Department of Dermatology, Venerology and Dermatooncology, Semmelweis University, 41 Mária Street, Budapest, Hungary
| | - Sarolta Karpati
- Department of Dermatology, Venerology and Dermatooncology, Semmelweis University, 41 Mária Street, Budapest, Hungary
| | - Eszter Ostorhazi
- Institute of Medical Microbiology, Semmelweis University, 4 Nagyvárad Square, Budapest, Hungary.
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Kidd S, Workowski KA. Management of Gonorrhea in Adolescents and Adults in the United States. Clin Infect Dis 2016; 61 Suppl 8:S785-801. [PMID: 26602618 DOI: 10.1093/cid/civ731] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Gonorrhea is the second most commonly reported notifiable disease in the United States and is associated with serious health sequelae, including pelvic inflammatory disease, infertility, and ectopic pregnancy. Treatment for gonorrhea has been complicated by antimicrobial resistance. Neisseria gonorrhoeae has developed resistance to each of the antimicrobials that were previously recommended as first-line treatment regimens, and current treatment options are severely limited. This article summarizes the key questions and data that were discussed at the Sexually Transmitted Diseases (STD) Treatment Guidelines Expert Consultation meeting in April 2013, and the rationale for the 2015 Centers for Disease Control and Prevention STD treatment guidelines for gonococcal infections in adolescents and adults. Key issues addressed include whether to change the dosage of ceftriaxone and azithromycin used in the recommended dual treatment regimen, whether to continue to list dual treatment with cefixime and azithromycin as an alternative treatment regimen, and management of gonococcal infections in persons with severe cephalosporin allergy or suspected treatment failure.
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Affiliation(s)
- Sarah Kidd
- Division of STD Prevention, Centers for Disease Control and Prevention
| | - Kimberly A Workowski
- Division of STD Prevention, Centers for Disease Control and Prevention Division of Infectious Diseases, Emory University, Atlanta, Georgia
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Jacobsson S, Golparian D, Cole M, Spiteri G, Martin I, Bergheim T, Borrego MJ, Crowley B, Crucitti T, Van Dam AP, Hoffmann S, Jeverica S, Kohl P, Mlynarczyk-Bonikowska B, Pakarna G, Stary A, Stefanelli P, Pavlik P, Tzelepi E, Abad R, Harris SR, Unemo M. WGS analysis and molecular resistance mechanisms of azithromycin-resistant (MIC >2 mg/L) Neisseria gonorrhoeae isolates in Europe from 2009 to 2014. J Antimicrob Chemother 2016; 71:3109-3116. [PMID: 27432597 DOI: 10.1093/jac/dkw279] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/06/2016] [Accepted: 06/09/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To elucidate the genome-based epidemiology and phylogenomics of azithromycin-resistant (MIC >2 mg/L) Neisseria gonorrhoeae strains collected in 2009-14 in Europe and clarify the azithromycin resistance mechanisms. METHODS Seventy-five azithromycin-resistant (MIC 4 to >256 mg/L) N. gonorrhoeae isolates collected in 17 European countries during 2009-14 were examined using antimicrobial susceptibility testing and WGS. RESULTS Thirty-six N. gonorrhoeae multi-antigen sequence typing STs and five phylogenomic clades, including 4-22 isolates from several countries per clade, were identified. The azithromycin target mutation A2059G (Escherichia coli numbering) was found in all four alleles of the 23S rRNA gene in all isolates with high-level azithromycin resistance (n = 4; MIC ≥256 mg/L). The C2611T mutation was identified in two to four alleles of the 23S rRNA gene in the remaining 71 isolates. Mutations in mtrR and its promoter were identified in 43 isolates, comprising isolates within the whole azithromycin MIC range. No mutations associated with azithromycin resistance were found in the rplD gene or the rplV gene and none of the macrolide resistance-associated genes [mef(A/E), ere(A), ere(B), erm(A), erm(B), erm(C) and erm(F)] were identified in any isolate. CONCLUSIONS Clonal spread of relatively few N. gonorrhoeae strains accounts for the majority of the azithromycin resistance (MIC >2 mg/L) in Europe. The four isolates with high-level resistance to azithromycin (MIC ≥256 mg/L) were widely separated in the phylogenomic tree and did not belong to any of the main clades. The main azithromycin resistance mechanisms were the A2059G mutation (high-level resistance) and the C2611T mutation (low- and moderate-level resistance) in the 23S rRNA gene.
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Affiliation(s)
| | | | | | | | - Irene Martin
- Public Health Agency of Canada, Winnipeg, Canada
| | | | | | | | | | - Alje P Van Dam
- Public Health Service Amsterdam, Amsterdam, The Netherlands
| | | | - Samo Jeverica
- Institute of Microbiology and Immunology, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Kohl
- Vivantes Klinikum Neukölln, Berlin, Germany
| | | | | | - Angelika Stary
- Outpatients' Centre for Infectious Venereodermatological Diseases, Vienna, Austria
| | | | | | | | - Raquel Abad
- Institute of Health Carlos III, Madrid, Spain
| | - Simon R Harris
- Pathogen Genomics, The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridgeshire, UK
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Unemo M, del Rio C, Shafer WM. Antimicrobial Resistance Expressed by Neisseria gonorrhoeae: A Major Global Public Health Problem in the 21st Century. Microbiol Spectr 2016; 4:10.1128/microbiolspec.EI10-0009-2015. [PMID: 27337478 PMCID: PMC4920088 DOI: 10.1128/microbiolspec.ei10-0009-2015] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Indexed: 12/24/2022] Open
Abstract
Neisseria gonorrhoeae is a strictly human pathogen that is typically transmitted by sexual contact. The associated disease gonorrhea has plagued humankind for thousands of years, with a current estimated incidence of 78 million cases per year. Advances in antimicrobial discovery in the 1920s and 1930s leading to the discovery of sulfonamides and penicillin begun the era of effective antimicrobial treatment of gonorrhea. Unfortunately, the gonococcus developed decreased susceptibility or even resistance to these initially employed antibiotics, a trend that continued over subsequent decades with each new antibiotic that was brought into clinical practice. As this pattern of resistance has continued into the 21st century, there is now reason for great concern, especially in an era when few new antibiotics have prospects for use as treatment of gonorrhea. Here, we review the history of gonorrhea treatment regimens and gonococcal resistance to antibiotics, the mechanisms of resistance, resistance monitoring schemes that exist in different international settings, global responses to the challenge of resistance, and prospects for future treatment regimens in the 21st century.
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Affiliation(s)
- Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, SE-701 85 Örebro, Sweden
| | - Carlos del Rio
- Hubert Department of Global Health, Rollins School of Public Health of Emory University and Department of Medicine, Division of Infectious Diseases, Emory University Schol of Medicine. 1518 Clifton Rd. NE. CNR Building, Room 7011. Atlanta, GA 30322, USA
| | - William M. Shafer
- Department of Microbiology and Immunology, 1510 Clifton Road, Emory University School of Medicine, Atlanta, GA 30322, USA
- Veterans Affairs Medical Center (Atlanta), 1670 Clairmont Road, Decatur, GA 30033, USA
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High Prevalence of Azithromycin-Resistant Neisseria gonorrhoeae Isolates With a Multidrug Resistance Phenotype in Fukuoka, Japan. Sex Transm Dis 2016; 42:337-41. [PMID: 25970312 DOI: 10.1097/olq.0000000000000279] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The current guidelines recommend a combination of ceftriaxone and azithromycin as a first-line treatment of gonorrhea in the United States and Europe. Despite not being recommended as a first-line regimen in Japan, an oral 2-g dose of azithromycin did become available for gonococcal infections in 2009. Recently, the emergence of azithromycin-resistant Neisseria gonorrhoeae isolates has been reported in several countries, including Japan. METHODS Antimicrobial susceptibility testing was performed on a total of 677 clinical isolates of N. gonorrhoeae obtained from January 2010 to December 2013 in Fukuoka, Japan. A molecular analysis by N. gonorrhoeae multiantigen sequence typing was conducted on the azithromycin-resistant isolates. RESULTS The proportion of azithromycin-resistant isolates (minimum inhibitory concentration > 0.5 μg/mL) increased significantly from 1.8% in 2010 to 22.6% in 2013 (P < 0.001). Among 50 azithromycin-resistant isolates, 30 (60%) exhibited a resistant phenotype to multiple drugs including cefixime. The 2 predominant sequence types (STs) identified by N. gonorrhoeae multiantigen sequence typing were ST6798 (por allele 4033 and tbpB allele 110) and ST1407 (por allele 908 and tbpB allele 110) at 40.0% (20/50) and 12.0% (6/50), respectively. There was a statistically significant increase of the proportion of ST6798 from 0% (0/19) in 2010-2012 to 64.5% (20/31) in 2013 (P < 0.001). CONCLUSIONS Over the previous 4 years, an increasing prevalence of azithromycin-resistant N. gonorrhoeae isolates with a multidrug-resistant phenotype was observed. Furthermore, the azithromycin-resistant isolates seemed to belong to 2 predominant STs. As a result, continued surveillance of gonococci resistant to antimicrobial agents, including azithromycin in Fukuoka, Japan, is necessary.
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Liang JY, Cao WL, Li XD, Bi C, Yang RD, Liang YH, Li P, Ye XD, Chen XX, Zhang XB. Azithromycin-resistant Neisseria gonorrhoeae isolates in Guangzhou, China (2009-2013): coevolution with decreased susceptibilities to ceftriaxone and genetic characteristics. BMC Infect Dis 2016; 16:152. [PMID: 27080231 PMCID: PMC4832481 DOI: 10.1186/s12879-016-1469-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 03/14/2016] [Indexed: 11/10/2022] Open
Abstract
Background The recent emergence of azithromycin-resistant (AZM-R) N. gonorrhoeae isolates that have coevolved decreased susceptibility to extended-spectrum cephalosporins has caused great concern. Here we investigated the prevalence of decreased susceptibility to ceftriaxone (CROD) in AZM-R isolates and genetically characterized AZM-R isolates in Guangzhou, China from 2009 to 2013. Methods The minimum inhibitory concentration (MIC) of AZM and ceftriaxone was determined using an agar-dilution method. All AZM-R isolates were screened for mutations in 23S rRNA, mtrR and penA genes and genotyped using N. gonorrhoeae multi-antigen sequence typing (NG-MAST). Results Of the 485 identified N. gonorrhoeae isolates, 445 (91.8 %) were isolated from male urethritis subjects, and 77 (15.9 %) were AZM-R (MIC ≥ 1 mg/L), including 33 (6.8 %) with AZM low-level resistant (AZM-LLR, MIC = 1 mg/L) and 44 (9.1 %) with AZM middle-level resistant (AZM-MLR, MIC ≥ 2 mg/L). Significantly more CROD (MIC ≥ 0.125 mg/L) showed in AZM-MLR isolates (43.2 %, 19/44) as compared with that in AZM-LLR isolates (18.2 %, 6/33) (p < 0.05). For the 23S rRNA, mtrR, penA or combined 23S rRNA/MtrR/penA mutations, no significant difference was found between AZM-LLR isolates and AZM-MLR isolates (P > 0.05); similar results were detected between combined AZM-LLR/CROD isolates and combined AZM-MLR/CROD isolates (P > 0.05). No mutation A2059G or AZM high-level resistant (AZM-HLR, MIC ≥ 256 mg/L) isolate was detected. Among 77 AZM-R isolates, 67 sequence types (STs) were identified by NG-MAST, of which 30 were novel. Most STs were represented by a single isolate. Conclusions The AZM-R together CROD isolates are now present in Guangzhou, China, which deserve continuous surveillance and the mechanism of concurrent resistance needs further study. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1469-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jing-Yao Liang
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Wen-Ling Cao
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Xiao-Dong Li
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Chao Bi
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Ri-Dong Yang
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Yan-Hua Liang
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Ping Li
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Xing-Dong Ye
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Xiao-Xiao Chen
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Xi-Bao Zhang
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China. .,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China.
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Genomic Epidemiology and Molecular Resistance Mechanisms of Azithromycin-Resistant Neisseria gonorrhoeae in Canada from 1997 to 2014. J Clin Microbiol 2016; 54:1304-13. [PMID: 26935729 DOI: 10.1128/jcm.03195-15] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 02/19/2016] [Indexed: 01/06/2023] Open
Abstract
The emergence of Neisseria gonorrhoeae strains with decreased susceptibility to cephalosporins and azithromycin (AZM) resistance (AZM(r)) represents a public health threat of untreatable gonorrhea infections. Genomic epidemiology through whole-genome sequencing was used to describe the emergence, dissemination, and spread of AZM(r) strains. The genomes of 213 AZM(r) and 23 AZM-susceptible N. gonorrhoeae isolates collected in Canada from 1989 to 2014 were sequenced. Core single nucleotide polymorphism (SNP) phylogenomic analysis resolved 246 isolates into 13 lineages. High-level AZM(r) (MICs ≥ 256 μg/ml) was found in 5 phylogenetically diverse isolates, all of which possessed the A2059G mutation (Escherichia coli numbering) in all four 23S rRNA alleles. One isolate with high-level AZM(r) collected in 2009 concurrently had decreased susceptibility to ceftriaxone (MIC = 0.125 μg/ml). An increase in the number of 23S rRNA alleles with the C2611T mutations (E. coli numbering) conferred low to moderate levels of AZM(r) (MICs = 2 to 4 and 8 to 32 μg/ml, respectively). Low-level AZM(r) was also associated with mtrR promoter mutations, including the -35A deletion and the presence of Neisseria meningitidis-like sequences. Geographic and temporal phylogenetic clustering indicates that emergent AZM(r) strains arise independently and can then rapidly expand clonally in a region through local sexual networks.
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28
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Trembizki E, Buckley C, Donovan B, Chen M, Guy R, Kaldor J, Lahra MM, Regan DG, Smith H, Ward J, Whiley DM. Direct real-time PCR-based detection of Neisseria gonorrhoeae 23S rRNA mutations associated with azithromycin resistance. J Antimicrob Chemother 2015; 70:3244-9. [PMID: 26338048 DOI: 10.1093/jac/dkv274] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 08/10/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Surveillance for Neisseria gonorrhoeae azithromycin resistance is of growing importance given increasing use of ceftriaxone and azithromycin dual therapy for gonorrhoea treatment. In this study, we developed two real-time PCR methods for direct detection of two key N. gonorrhoeae 23S rRNA mutations associated with azithromycin resistance. METHODS The real-time PCR assays, 2611-PCR and 2059-PCR, targeted the gonococcal 23S rRNA C2611T and A2059G mutations, respectively. A major design challenge was that gonococcal 23S rRNA sequences have high sequence homology with those of commensal Neisseria species. To limit the potential for cross-reaction, 'non-template' bases were utilized in primer sequences. The performance of the methods was initially assessed using a panel of gonococcal (n = 70) and non-gonococcal (n = 28) Neisseria species. Analytical specificity was further assessed by testing N. gonorrhoeae nucleic acid amplification test (NAAT)-negative clinical samples (n = 90), before being applied to N. gonorrhoeae NAAT-positive clinical samples (n = 306). RESULTS Cross-reactions with commensal Neisseria strains remained evident for both assays; however, cycle threshold (Ct) values were significantly delayed, indicating reduced sensitivity for non-gonococcal species. For the N. gonorrhoeae NAAT-negative clinical samples, 7/21 pharyngeal samples provided evidence of cross-reaction (Ct values >40 cycles); however, the remaining urogenital and rectal swab samples were negative. In total, the gonococcal 2611 and 2059 23S rRNA nucleotides were both successfully characterized in 266/306 (87%) of the N. gonorrhoeae NAAT-positive clinical specimens. CONCLUSIONS Real-time PCR detection of gonococcal 23S rRNA mutations directly from clinical samples is feasible and may enhance culture- and non-culture-based N. gonorrhoeae resistance surveillance.
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Affiliation(s)
- Ella Trembizki
- Queensland Paediatric Infectious Diseases (QPID) Laboratory, Queensland Children's Medical Research Institute, Brisbane, Queensland 4029, Australia UQ Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland 4029, Australia
| | - Cameron Buckley
- Queensland Paediatric Infectious Diseases (QPID) Laboratory, Queensland Children's Medical Research Institute, Brisbane, Queensland 4029, Australia UQ Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland 4029, Australia
| | - Basil Donovan
- Kirby Institute, UNSW Australia, Sydney, New South Wales 2052, Australia Sydney Sexual Health Centre, Sydney Hospital, Sydney, New South Wales 2000, Australia
| | - Marcus Chen
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria 3053, Australia Central Clinical School, Monash University, Melbourne, Victoria 3800, Australia
| | - Rebecca Guy
- Kirby Institute, UNSW Australia, Sydney, New South Wales 2052, Australia
| | - John Kaldor
- Kirby Institute, UNSW Australia, Sydney, New South Wales 2052, Australia
| | - Monica M Lahra
- WHO Collaborating Centre for STD, Microbiology Department, South Eastern Area Laboratory Services, Prince of Wales Hospital, Sydney, New South Wales 2031, Australia
| | - David G Regan
- Kirby Institute, UNSW Australia, Sydney, New South Wales 2052, Australia
| | - Helen Smith
- Public Health Microbiology, Public and Environmental Health, Queensland Health Forensic and Scientific Services, Archerfield, Queensland 4107, Australia
| | - James Ward
- South Australian Health and Medical Research Institute, Adelaide, South Australia 5000, Australia
| | - David M Whiley
- Queensland Paediatric Infectious Diseases (QPID) Laboratory, Queensland Children's Medical Research Institute, Brisbane, Queensland 4029, Australia UQ Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland 4029, Australia
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Unemo M. Current and future antimicrobial treatment of gonorrhoea - the rapidly evolving Neisseria gonorrhoeae continues to challenge. BMC Infect Dis 2015; 15:364. [PMID: 26293005 PMCID: PMC4546108 DOI: 10.1186/s12879-015-1029-2] [Citation(s) in RCA: 188] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 07/16/2015] [Indexed: 11/18/2022] Open
Abstract
Neisseria gonorrhoeae has developed antimicrobial resistance (AMR) to all drugs previously and currently recommended for empirical monotherapy of gonorrhoea. In vitro resistance, including high-level, to the last option ceftriaxone and sporadic failures to treat pharyngeal gonorrhoea with ceftriaxone have emerged. In response, empirical dual antimicrobial therapy (ceftriaxone 250–1000 mg plus azithromycin 1–2 g) has been introduced in several particularly high-income regions or countries. These treatment regimens appear currently effective and should be considered in all settings where local quality assured AMR data do not support other therapeutic options. However, the dual antimicrobial regimens, implemented in limited geographic regions, will not entirely prevent resistance emergence and, unfortunately, most likely it is only a matter of when, and not if, treatment failures with also these dual antimicrobial regimens will emerge. Accordingly, novel affordable antimicrobials for monotherapy or at least inclusion in new dual treatment regimens, which might need to be considered for all newly developed antimicrobials, are essential. Several of the recently developed antimicrobials deserve increased attention for potential future treatment of gonorrhoea. In vitro activity studies examining collections of geographically, temporally and genetically diverse gonococcal isolates, including multidrug-resistant strains particularly with resistance to ceftriaxone and azithromycin, are important. Furthermore, understanding of effects and biological fitness of current and emerging (in vitro induced/selected and in vivo emerged) genetic resistance mechanisms for these antimicrobials, prediction of resistance emergence, time-kill curve analysis to evaluate antibacterial activity, appropriate mice experiments, and correlates between genetic and phenotypic laboratory parameters, and clinical treatment outcomes, would also be valuable. Subsequently, appropriately designed, randomized controlled clinical trials evaluating efficacy, ideal dose, toxicity, adverse effects, cost, and pharmacokinetic/pharmacodynamics data for anogenital and, importantly, also pharyngeal gonorrhoea, i.e. because treatment failures initially emerge at this anatomical site. Finally, in the future treatment at first health care visit will ideally be individually-tailored, i.e. by novel rapid phenotypic AMR tests and/or genetic point of care AMR tests, including detection of gonococci, which will improve the management and public health control of gonorrhoea and AMR. Nevertheless, now is certainly the right time to readdress the challenges of developing a gonococcal vaccine.
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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, Microbiology, Faculty of Medicine and Health, Örebro University Hospital, Örebro University, SE-701 85, Örebro, Sweden.
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Ezewudo MN, Joseph SJ, Castillo-Ramirez S, Dean D, Del Rio C, Didelot X, Dillon JA, Selden RF, Shafer WM, Turingan RS, Unemo M, Read TD. Population structure of Neisseria gonorrhoeae based on whole genome data and its relationship with antibiotic resistance. PeerJ 2015; 3:e806. [PMID: 25780762 PMCID: PMC4358642 DOI: 10.7717/peerj.806] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 02/08/2015] [Indexed: 01/08/2023] Open
Abstract
Neisseria gonorrhoeae is the causative agent of gonorrhea, a sexually transmitted infection (STI) of major importance. As a result of antibiotic resistance, there are now limited options for treating patients. We collected draft genome sequence data and associated metadata data on 76 N. gonorrhoeae strains from around the globe and searched for known determinants of antibiotics resistance within the strains. The population structure and evolutionary forces within the pathogen population were analyzed. Our results indicated a cosmopolitan gonoccocal population mainly made up of five subgroups. The estimated ratio of recombination to mutation (r/m = 2.2) from our data set indicates an appreciable level of recombination occurring in the population. Strains with resistance phenotypes to more recent antibiotics (azithromycin and cefixime) were mostly found in two of the five population subgroups.
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Affiliation(s)
- Matthew N Ezewudo
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine , Atlanta, GA , USA
| | - Sandeep J Joseph
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine , Atlanta, GA , USA
| | - Santiago Castillo-Ramirez
- Programa de Genómica Evolutiva, Centro de Ciencias Genómicas, Universidad Nacional Autónoma de México , Cuernavaca, Morelos , México
| | - Deborah Dean
- Children's Hospital Oakland Research Institute , Oakland, CA , USA ; University of San Francisco at California, Division of Infectious Diseases , San Francisco, CA , USA
| | - Carlos Del Rio
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine , Atlanta, GA , USA ; Hubert Department of Global Health, Rollins School of Public Health of Emory University , Atlanta, GA , USA
| | - Xavier Didelot
- Department of Infectious Disease Epidemiology, Imperial College London , London , UK
| | - Jo-Anne Dillon
- Department of Microbiology and Immunology, College of Medicine, Vaccine and Infectious Disease Organization International Vaccine Centre, University of Saskatchewan , Saskatoon, Saskatchewan , Canada
| | | | - William M Shafer
- Department of Microbiology and Immunology, Emory University School of Medicine , Atlanta, GA , USA ; Laboratories of Bacterial Pathogenesis, Veterans Affairs Medical Center , Decatur, GA , USA
| | | | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and other STIs, Örebro University Hospital , Örebro , Sweden
| | - Timothy D Read
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine , Atlanta, GA , USA
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31
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Antimicrobial resistance in Neisseria gonorrhoeae in the 21st century: past, evolution, and future. Clin Microbiol Rev 2015; 27:587-613. [PMID: 24982323 DOI: 10.1128/cmr.00010-14] [Citation(s) in RCA: 773] [Impact Index Per Article: 85.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Neisseria gonorrhoeae is evolving into a superbug with resistance to previously and currently recommended antimicrobials for treatment of gonorrhea, which is a major public health concern globally. Given the global nature of gonorrhea, the high rate of usage of antimicrobials, suboptimal control and monitoring of antimicrobial resistance (AMR) and treatment failures, slow update of treatment guidelines in most geographical settings, and the extraordinary capacity of the gonococci to develop and retain AMR, it is likely that the global problem of gonococcal AMR will worsen in the foreseeable future and that the severe complications of gonorrhea will emerge as a silent epidemic. By understanding the evolution, emergence, and spread of AMR in N. gonorrhoeae, including its molecular and phenotypic mechanisms, resistance to antimicrobials used clinically can be anticipated, future methods for genetic testing for AMR might permit region-specific and tailor-made antimicrobial therapy, and the design of novel antimicrobials to circumvent the resistance problems can be undertaken more rationally. This review focuses on the history and evolution of gonorrhea treatment regimens and emerging resistance to them, on genetic and phenotypic determinants of gonococcal resistance to previously and currently recommended antimicrobials, including biological costs or benefits; and on crucial actions and future advances necessary to detect and treat resistant gonococcal strains and, ultimately, retain gonorrhea as a treatable infection.
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Lebedzeu F, Golparian D, Titov L, Pankratava N, Glazkova S, Shimanskaya I, Charniakova N, Lukyanau A, Domeika M, Unemo M. Antimicrobial susceptibility/resistance and NG-MAST characterisation of Neisseria gonorrhoeae in Belarus, Eastern Europe, 2010-2013. BMC Infect Dis 2015; 15:29. [PMID: 25637258 PMCID: PMC4316755 DOI: 10.1186/s12879-015-0755-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 01/15/2015] [Indexed: 11/16/2022] Open
Abstract
Background Gonorrhoea and widely spread antimicrobial resistance (AMR) in its etiological agent Neisseria gonorrhoeae are major public health concerns worldwide. Gonococcal AMR surveillance nationally and internationally, to identify emerging resistance and inform treatment guidelines, is imperative for public health purposes. In 2009, AMR surveillance was initiated in Belarus, Eastern Europe because no gonococcal AMR data had been available for at least two decades. Herein, the prevalence and trends of gonococcal AMR and molecular epidemiological characteristics of N. gonorrhoeae strains from 2010 to 2013 in Belarus, are described. Methods N. gonorrhoeae isolates (n=193) obtained in the Mogilev (n=142), Minsk (n=36) and Vitebsk (n=15) regions of Belarus in 2010 (n=72), 2011 (n=6), 2012 (n=75) and 2013 (n=40) were analyzed in regards to AMR using the Etest method and for molecular epidemiology with N. gonorrhoeae multi-antigen sequence typing (NG-MAST). Results During 2010–2013, the proportions of resistant N. gonorrhoeae isolates were as follows: tetracycline 36%, ciprofloxacin 28%, penicillin G 9%, azithromycin 5%, and cefixime 0.5%. Only one (0.5%) β-lactamase producing isolate was detected. No isolates resistant to ceftriaxone and spectinomycin were identified. Overall, the resistance levels to tetracycline, ciprofloxacin and penicillin G were relatively stable. Interestingly, the level of resistance to azithromycin declined from 12% in 2010 to 0% in 2013 (P < 0.05). In total, 70 NG-MAST STs were identified. The predominant STs were ST1993 (n=53), ST807 (n=13), ST285 (n=8) and ST9735 (n=8). Many novel STs (n=43, 61%), representing 41% of all isolates, were found. Conclusions During 2010–2013, the N. gonorrhoeae population in Belarus displayed high and relatively stable resistance levels to tetracycline, ciprofloxacin, and penicillin G, while the resistance to azithromycin declined. One isolate was resistant to cefixime, but no resistance to ceftriaxone or spectinomycin was found. The results of the present surveillance initiated in 2009 were also used to replace penicillin G with ceftriaxone (1 g single dose intramuscularly) as the first-line drug for empiric treatment of gonorrhoea in the national treatment guidelines in Belarus in late 2009. It is essential to further strengthen the surveillance of gonococcal AMR and ideally survey also treatment failures and molecular epidemiological genotypes in Belarus.
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Affiliation(s)
- Fiodar Lebedzeu
- The Republican Research and Practical Center for Epidemiology and Microbiology (RRPCEM), Minsk, Belarus.
| | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Swedish Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
| | - Leonid Titov
- The Republican Research and Practical Center for Epidemiology and Microbiology (RRPCEM), Minsk, Belarus.
| | | | - Slavyana Glazkova
- The Republican Research and Practical Center for Epidemiology and Microbiology (RRPCEM), Minsk, Belarus.
| | | | | | | | - Marius Domeika
- Department of Prevention and Control of Communicable Diseases, Uppsala County Council, Uppsala, Sweden.
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Swedish Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
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Stevens K, Zaia A, Tawil S, Bates J, Hicks V, Whiley D, Limnios A, Lahra MM, Howden BP. Neisseria gonorrhoeae isolates with high-level resistance to azithromycin in Australia. J Antimicrob Chemother 2014; 70:1267-8. [DOI: 10.1093/jac/dku490] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Bercot B, Belkacem A, Goubard A, Mougari F, Sednaoui P, La Ruche G, Cambau E. High-level azithromycin-resistant Neisseria gonorrhoeae clinical isolate in France, March 2014. ACTA ACUST UNITED AC 2014; 19. [PMID: 25394255 DOI: 10.2807/1560-7917.es2014.19.44.20951] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the first case in France of a high-level azithromycin-resistant Neisseria gonorrhoeae (minimum inhibitory concentration (MIC) = 96 mg/L) assigned to MLST7363 (NG-MAST ST6360), also resistant to ciprofloxacin and tetracycline but susceptible to ceftriaxone. The patient was a 51 year-old heterosexual man who returned following 1g azithromycin monotherapy. Mechanisms of azithromycin resistance were a C2599T mutation in the four copies of the rrl gene and a novel mutation in the promoter of the mtrR gene.
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Affiliation(s)
- B Bercot
- APHP, Lariboisiere-St Louis-Fernand Widal Hospital, Laboratory of Bacteriology-Virology, Associated Laboratory for the National Reference Centre for gonococci, Paris, France
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Kubanova A, Kubanov A, Frigo N, Solomka V, Semina V, Vorobyev D, Khairullin R, Unemo M. Russian gonococcal antimicrobial susceptibility programme (RU-GASP)--resistance in Neisseria gonorrhoeae during 2009-2012 and NG-MAST genotypes in 2011 and 2012. BMC Infect Dis 2014; 14:342. [PMID: 24947981 PMCID: PMC4075497 DOI: 10.1186/1471-2334-14-342] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 06/12/2014] [Indexed: 11/17/2022] Open
Abstract
Background Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a major concern worldwide and gonococcal AMR surveillance globally is imperative for public health purposes. In Eastern Europe, gonococcal AMR surveillance is exceedingly rare. However, in 2004 the Russian gonococcal antimicrobial susceptibility programme (RU-GASP) was initiated. The aims of this study were to describe the prevalence and trends of gonococcal AMR from 2009 to 2012, and molecular epidemiological genotypes in 2011 and 2012 in Russia. Methods Gonococcal isolates from 12–46 surveillance sites distributed across Russia, obtained in 2009 (n = 1200), 2010 (n = 407), 2011 (n = 423), and 2012 (n = 106), were examined for antimicrobial susceptibility using agar dilution method. Gonococcal isolates from 2011 and 2012 were investigated with N. gonorrhoeae multi-antigen sequence typing (NG-MAST). Results During 2009–2012, the proportions of gonococcal isolates resistant to ciprofloxacin, penicillin G, azithromycin and spectinomycin ranged from 25.5% to 44.4%, 9.6% to 13.2%, 2.3% to 17.0% and 0.9% to 11.6%, respectively. Overall, the resistance level to penicillin G was stable, the resistance level to ciprofloxacin was decreasing, however, the level of resistance to azithromycin increased. All isolates were susceptible to ceftriaxone using the US CLSI breakpoints. However, using the European breakpoints 58 (2.7%) of the isolates were resistant to ceftriaxone. Interestingly, this proportion was decreasing, i.e. from 4.8% in 2009 to 0% in 2012. Conclusions In Russia, the diversified gonococcal population showed a high resistance to ciprofloxacin, penicillin G and azithromycin. In general, the MICs of ceftriaxone were relatively high, however, they were decreasing from 2009 to 2012. Ceftriaxone should be the first-line for empiric antimicrobial monotherapy of gonorrhoea in Russia. It is essential to further strengthen the surveillance of gonococcal AMR (ideally also gonorrhoea treatment failures) in Russia.
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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, Microbiology, Örebro University Hospital, SE-701 85 Örebro, Sweden.
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Bignell C, Unemo M. 2012 European guideline on the diagnosis and treatment of gonorrhoea in adults. Int J STD AIDS 2014; 24:85-92. [PMID: 24400344 DOI: 10.1177/0956462412472837] [Citation(s) in RCA: 315] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Gonorrhoea is a major public health concern globally. Of particularly grave concern is that resistance to the extended-spectrum cephalosporins has emerged during the most recent years. This guideline provides recommendations regarding the diagnosis and treatment of gonorrhoea in Europe. Compared to the outdated 2009 European gonorrhoea guideline, this 2012 European gonorrhoea guideline provides up-to-date guidance on, broader indications for testing and treatment of gonorrhoea;the introduction of dual antimicrobial therapy (ceftriaxone 500 mg and azithromycin 2 g) for uncomplicated gonorrhoea when the antimicrobial sensitivity is unknown; recommendation of test of cure in all gonorrhoea cases to ensure eradication of infection and identify emerging resistance; and recommendations to identify, verify and report failures with recommended treatment regimens. Optimisations of the testing, diagnostics, antimicrobial treatment and follow-up of gonorrhoea patients are crucial in controlling the emergent spread of cephalosporin-resistant and multidrug-resistant gonorrhoea.
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Allen VG, Seah C, Martin I, Melano RG. Azithromycin resistance is coevolving with reduced susceptibility to cephalosporins in Neisseria gonorrhoeae in Ontario, Canada. Antimicrob Agents Chemother 2014; 58:2528-34. [PMID: 24514092 PMCID: PMC3993249 DOI: 10.1128/aac.02608-13] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 02/02/2014] [Indexed: 11/20/2022] Open
Abstract
Azithromycin (AZM) is routinely recommended as a component of dual therapy for gonorrhea in combination with third-generation cephalosporins (3GC). In this study, we examined the prevalence of AZM-resistant (AZM(r)) Neisseria gonorrhoeae from July 2010 to February 2013, assessed the rate of concurrent cephalosporin resistance under the current treatment recommendations, and analyzed the clonal distribution of AZM(r) isolates in Ontario, Canada. Nineteen AZM(r) clinical isolates (one per patient; MIC, ≥2 μg/ml) were included in the study. Susceptibility profiles of these isolates to 11 antibiotics, molecular typing, characterization of macrolide resistance mechanisms, and penicillin-binding protein 2 (PBP2) patterns were determined for all the isolates. Two groups were defined based on AZM(r) level; group A isolates displayed high-level resistance (MIC, ≥2,048 μg/ml) due to mutations (A2143G) in the four copies of the 23S rRNA rrl gene, and group B isolates had moderate resistance to AZM (MICs, 2 to 8 μg/ml, C2599T mutation in the rrl gene), with a subgroup belonging to sequence type 3158 (ST3158) (n = 8), which also showed reduced susceptibility to 3GC (MICs, 0.12 to 0.25 μg/ml, PBP2 pattern XXXIV). This AZM(r) phenotype was not observed in previous provincial surveillance in 2008 (the ST3158 clone was found, with AZM MICs of 0.25 to 0.5 μg/ml associated with mtrR mutations). We hypothesized that the AZM mutant prevention concentration (MPC) in the ST3158 subpopulation we found in 2008 was higher than the MPC in wild-type isolates (AZM MIC, ≤0.031 μg/ml), increasing the chances of additional selection of AZM(r) mutations. Full AZM resistance is now emerging in this clone together with reduced susceptibility to 3GC, threatening the future efficacy of these antibiotics as therapeutic options for treatment of gonorrhea.
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Affiliation(s)
- Vanessa G. Allen
- Public Health Ontario Laboratories, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Christine Seah
- Public Health Ontario Laboratories, Toronto, Ontario, Canada
| | - Irene Martin
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Roberto G. Melano
- Public Health Ontario Laboratories, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Mount Sinai Hospital, Toronto, Ontario, Canada
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Takahashi S, Kiyota H, Ito S, Iwasawa A, Hiyama Y, Uehara T, Ichihara K, Hashimoto J, Masumori N, Sunaoshi K, Takeda K, Suzuki N, Hosobe T, Goto H, Suzuki H, Onodera S. Clinical Efficacy of a Single Two Gram Dose of Azithromycin Extended Release for Male Patients with Urethritis. Antibiotics (Basel) 2014; 3:109-20. [PMID: 27025738 PMCID: PMC4790393 DOI: 10.3390/antibiotics3020109] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 02/26/2014] [Accepted: 03/04/2014] [Indexed: 12/02/2022] Open
Abstract
To clarify the clinical efficacy of a single oral 2 g dose of azithromycin extended-release for heterosexual male patients with urethritis, and the current antimicrobial sensitivity of Neisseria gonorrhoeae to azithromycin, a prospective clinical trial was conducted from 2011-2013. In patients with gonococcal urethritis, the eradication rate was 90.9% (30 of 33). The susceptibility rates of isolated Neisseria gonorrhoeae strains to ceftriaxone, spectinomycin, cefixime and azithromycin were 100%, 100%, 95.3% (41/43) and 37.2% (16/43), respectively. In the patients with nongonococcal urethritis, the eradication rate was 90.0% (45 of 50). The microbiological eradication rates for the pathogens were 90.9% (30/33) for Neisseria gonorrhoeae, 91.5% (43/47) for Chlamydia trachomatis, 71.4% (5/7) for Mycoplasma genitalium, and 100% (13/13) for Ureaplasma urealyticum. The main adverse event was diarrhea and its manifestation rate was 35.2% (32 of 120). The symptom of diarrhea was mostly temporary and resolved spontaneously. The conclusion was that the treatment regimen with a single oral 2 g dose of azithromycin extended-release would be effective for patients with urethritis. However, the antimicrobial susceptibilities of Neisseria gonorrhoeae and Mycoplasma genitalium should be carefully monitored because of possible treatment failure.
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Affiliation(s)
- Satoshi Takahashi
- Department of Urology, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0608543, Japan.
| | - Hiroshi Kiyota
- Department of Urology, the Jikei University Katsushika Medical Center, 6-41-2 Aoto Katsushika-ku, Tokyo 1258506, Japan.
| | - Shin Ito
- iClinic, 5-9-6, Nagamachi, Taihaku-ku, Sendai, Miyagi 9820011, Japan.
| | - Akihiko Iwasawa
- Iwasawa Clinic, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0600061, Japan.
| | - Yoshiki Hiyama
- Department of Urology, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0608543, Japan.
| | - Teruhisa Uehara
- Department of Urology, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0608543, Japan.
| | - Koji Ichihara
- Department of Urology, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0608543, Japan.
| | - Jiro Hashimoto
- Department of Urology, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0608543, Japan.
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0608543, Japan.
| | - Kenichi Sunaoshi
- Teine Urologic Clinic, 1-12, Maeda 6-7, Teine-ku, Sapporo 0060816, Japan.
| | - Koichi Takeda
- Teine Urologic Clinic, 1-12, Maeda 6-7, Teine-ku, Sapporo 0060816, Japan.
| | - Nobukazu Suzuki
- Teine Urologic Clinic, 1-12, Maeda 6-7, Teine-ku, Sapporo 0060816, Japan.
| | - Takahide Hosobe
- Hosobe Clinic, 1-1-15, Nezu, Bunkyo-ku, Tokyo 1130031, Japan.
| | - Hirokazu Goto
- Department of Urology, Fuji City General Hospital, 50 Takashima-Cho, Fuji, Shizuoka 4178567, Japan.
| | - Hidenori Suzuki
- Department of Urology, Fuji City General Hospital, 50 Takashima-Cho, Fuji, Shizuoka 4178567, Japan.
| | - Shoichi Onodera
- Department of Urology, Fuji City General Hospital, 50 Takashima-Cho, Fuji, Shizuoka 4178567, Japan.
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Takayama Y, Nakayama SI, Shimuta K, Morita-Ishihara T, Ohnishi M. Characterization of azithromycin-resistant Neisseria gonorrhoeae isolated in Tokyo in 2005-2011. J Infect Chemother 2014; 20:339-41. [PMID: 24571786 DOI: 10.1016/j.jiac.2014.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 12/26/2013] [Accepted: 01/15/2014] [Indexed: 11/27/2022]
Abstract
A total of 122 Neisseria gonorrhoeae isolated in the Tokyo metropolitan area in 2005-2011 were collected and analyzed by N. gonorrhoeae multiantigen sequence typing (NG-MAST) and for their susceptibility to azithromycin and ceftriaxone. All 122 strains were susceptible to ceftriaxone, but 8 strains were azithromycin-resistant, defined as an azithromycin MIC ≥ 1 μg/ml. The 8 azithromycin-resistant strains were in 6 NG-MAST types, 3 strains in NG-MAST type 1407 and each of the other 5 strains in a different NG-MAST type. NG-MAST type 1407 strains are multidrug-resistant and are disseminated worldwide.
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Affiliation(s)
| | - Shu-ichi Nakayama
- Department of Bacteriology I, National Institute of Infectious Diseases, Japan.
| | - Ken Shimuta
- Department of Bacteriology I, National Institute of Infectious Diseases, Japan
| | | | - Makoto Ohnishi
- Department of Bacteriology I, National Institute of Infectious Diseases, Japan
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Ison CA, Alexander S. Antimicrobial resistance inNeisseria gonorrhoeaein the UK: surveillance and management. Expert Rev Anti Infect Ther 2014; 9:867-76. [DOI: 10.1586/eri.11.103] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Chico RM, Hack BB, Newport MJ, Ngulube E, Chandramohan D. On the pathway to better birth outcomes? A systematic review of azithromycin and curable sexually transmitted infections. Expert Rev Anti Infect Ther 2013; 11:1303-32. [PMID: 24191955 PMCID: PMC3906303 DOI: 10.1586/14787210.2013.851601] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The WHO recommends the administration of sulfadoxine-pyrimethamine (SP) to all pregnant women living in areas of moderate (stable) to high malaria transmission during scheduled antenatal visits, beginning in the second trimester and continuing to delivery. Malaria parasites have lost sensitivity to SP in many endemic areas, prompting the investigation of alternatives that include azithromycin-based combination (ABC) therapies. Use of ABC therapies may also confer protection against curable sexually transmitted infections and reproductive tract infections (STIs/RTIs). The magnitude of protection at the population level would depend on the efficacy of the azithromycin-based regimen used and the underlying prevalence of curable STIs/RTIs among pregnant women who receive preventive treatment. This systematic review summarizes the efficacy data of azithromycin against curable STIs/RTIs.
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Affiliation(s)
- R Matthew Chico
- London School of Hygiene and Tropical Medicine Keppel Street, London, WC1E 7HT,UK
| | - Berkin B Hack
- Brighton and Sussex Medical School,Brighton, East Sussex, BN1 9PX,UK
| | - Melanie J Newport
- Brighton and Sussex Medical School,Brighton, East Sussex, BN1 9PX,UK
| | - Enesia Ngulube
- London School of Hygiene and Tropical Medicine Keppel Street, London, WC1E 7HT,UK
| | - Daniel Chandramohan
- London School of Hygiene and Tropical Medicine Keppel Street, London, WC1E 7HT,UK
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Abstract
The delivery of effective antimicrobial therapy is essential for public health control of gonorrhoea, in the absence of a suitable vaccine. The antimicrobial agent chosen should have high efficacy and quality, lack toxicity and give >95% success when given empirically. Guidelines, which are informed by surveillance data, are used to aid clinicians in their choice of appropriate agent. Historically, gonorrhoea treatment has been delivered as a single, directly observed dose but this has resulted in failure of successive antimicrobial agents which have been replaced by a new antimicrobial to which resistance has been rare or non-existing. Following the drift towards decreased susceptibility and treatment failure to the extended spectrum cephalosporins, and the lack of 'new' alternative antimicrobials, the threat of difficult to treat or untreatable gonorrhoea has emerged. The challenge of maintaining gonorrhoea as a treatable infection has resulted in national, regional and global response or action plans. This review discusses different approaches to the future treatment of gonorrhoea including; use of ceftriaxone, the injectable cephalosporin at increased dosage; dual antimicrobial therapy; use of drugs developed for other infections and use of older agents, directed by rapid point of care tests, to susceptible infections. Finally, it is considered whether the time is right to readdress the possibility of developing an effective gonococcal vaccine, given the major advances in our understanding of natural infection, molecular pathogenesis and the revolution in molecular biology techniques.
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Affiliation(s)
- Catherine A Ison
- Sexually Transmitted Bacteria Reference Unit, Microbiological Services, Public Health England, , London, UK
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Hançali A, Ndowa F, Bellaji B, Bennani A, Kettani A, Charof R, El Aouad R. Antimicrobial resistance monitoring in Neisseria gonorrhoeae and strategic use of funds from the Global Fund to set up a systematic Moroccan gonococcal antimicrobial surveillance programme. Sex Transm Infect 2013; 89 Suppl 4:iv24-7. [PMID: 24037141 DOI: 10.1136/sextrans-2013-051166] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The aims of this study were to assess antimicrobial resistance in Neisseria gonorrhoeae infections and update the treatment in the national guidelines for the syndromic management of sexually transmitted infections in Morocco. METHODS 171 men complaining of urethral discharge were recruited from basic health services during 2009. Urethral swab samples were collected and N gonorrhoeae identification was performed by culture. Antimicrobial susceptibility testing was performed using the Etest method and the antimicrobial agents tested were ciprofloxacin, penicillin, spectinomycin, tetracycline, ceftriaxone and cefixime. RESULTS A total of 72 isolates were examined. Significant resistance to tetracycline (92.8%) and ciprofloxacin (86.8%), which was used as first-line treatment in gonococcal infections, was noted. No resistance to spectinomycin, ceftriaxone or cefixime was detected in all the isolates. CONCLUSIONS Following these results the Ministry of Health of Morocco replaced ciprofloxacin and introduced ceftriaxone 250 mg as a single dose in the treatment of gonococcal infections. Using funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), a surveillance programme was set up for antimicrobial resistance testing in N gonorrhoeae.
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Affiliation(s)
- Amina Hançali
- STIs Laboratory, National Institute of Hygiene, , Ministry of Health, Morocco
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Martin I, Sawatzky P, Liu G, Allen V, Lefebvre B, Hoang L, Lovgren M, Haldane D, Caeseele PV, Horsman G, Garceau R, Ratnam S, Wong T, Gilmour M. Antimicrobial susceptibilities and distribution of sequence types of Neisseria gonorrhoeae isolates in Canada: 2010. Can J Microbiol 2013; 59:671-8. [PMID: 24102220 DOI: 10.1139/cjm-2013-0357] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The monitoring of antimicrobial susceptibilities in Neisseria gonorrhoeae isolates and characterization of N. gonorrhoeae multiantigen sequence types (NG-MAST, ST) provide important surveillance data as resistance rates continue to rise. A total of 2970 N. gonorrhoeae isolates were collected by Canadian provincial public health laboratories in 2010, and 1233 were submitted to the National Microbiology Laboratory for testing. The NG-MAST and minimum inhibitory concentration (MIC) by agar dilution were determined for each isolate. Of the 2970 isolates, 25.1% were resistant to penicillin, 34.6% resistant to tetracycline, 31.5% resistant to erythromycin, 35.9% resistant to ciprofloxacin, and 1.2% resistant to azithromycin. Decreased susceptibility to cefixime (MIC ≥ 0.25 mg/L) and ceftriaxone (MIC ≥ 0.125 mg/L) was identified in 3.2% and 7.3% of the isolates, respectively. The most common STs found in Canada were ST1407 (13.3%), ST3150 (11.3%), and ST3158 (9.0%), with 249 different STs identified among the isolates. Within the ST1407 group, 19.5% and 43.3% isolates have decreased susceptibility to cefixime and ceftriaxone, respectively. ST1407, the most prevalent NG-MAST in Canada in 2010, has been associated with high-level ceftriaxone MICs and with cefixime treatment failure cases worldwide. Identification and monitoring of STs and corresponding antimicrobial resistance profiles may be useful in surveillance programs and be used to inform public health actions.
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Affiliation(s)
- Irene Martin
- a Bacteriology and Enteric Diseases Program, National Microbiology Laboratory, Public Health Agency of Canada, 1015 Arlington Street, Winnipeg, MB R3E 3R2, Canada
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Martin I, Jayaraman G, Wong T, Liu G, Gilmour M. Trends in antimicrobial resistance in Neisseria gonorrhoeae isolated in Canada: 2000-2009. Sex Transm Dis 2013; 38:892-8. [PMID: 21934558 DOI: 10.1097/olq.0b013e31822c664f] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Canada conducts surveillance of penicillin, tetracycline, erythromycin, spectinomycin, ciprofloxacin, cefixime, and ceftriaxone susceptibilities in Neisseria gonorrhoeae isolates to support development of national treatment guidelines for sexually transmitted infections. METHODS N. gonorrhoeae isolates were collected by Canadian provincial public health laboratories and included isolates from males and females ranging in age from 1 to 86 years. Minimum inhibitory concentrations (MICs) were determined by agar dilution at the National Microbiology Laboratory, Public Health Agency of Canada, and MIC interpretations were based on the criteria of the Clinical Laboratory Standards Institute. RESULTS From 2000 to 2009, 40,875 isolates of N. gonorrhoeae were tested by provincial laboratories and 10,993 of these were characterized by the Public Health Agency of Canada. There was an increasing incidence of N. gonorrhoeae isolates that were chromosomally resistant to penicillin, tetracycline, and erythromycin while the plasmid-mediated resistance strains (penicillinase-producing N. gonorrhoeae, tetracycline-resistant N. gonorrhoeae, and PP/tetracycline-resistant N. gonorrhoeae strain all had a declining trend. The percentage of isolates resistant to ciprofloxacin significantly increased from 1.3% in 2000 to 25.5% in 2009. Only 0.17% of isolates tested were azithromycin resistant. Between 2000 and 2009, the modal MICs for ceftriaxone increased from 0.016 μg/mL to 0.063 μg/mL. CONCLUSIONS Ciprofloxacin resistance in N. gonorrhoeae within Canada has increased to a level where quinolones are no longer the preferred drugs for the treatment of gonococcal infections and the modal MICs for the third-generation cephalosporins have increased over time. Close monitoring of antibiotic susceptibilities are required to inform treatment options.
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Affiliation(s)
- Irene Martin
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada.
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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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Vidovic S, Thakur SD, Horsman GB, Levett PN, Anvari V, Dillon JAR. Longitudinal analysis of the evolution and dissemination of Neisseria gonorrhoeae strains (Saskatchewan, Canada, 2005 to 2008) reveals three major circulating strains and convergent evolution of ciprofloxacin and azithromycin resistance. J Clin Microbiol 2012; 50:3823-30. [PMID: 22972828 PMCID: PMC3502962 DOI: 10.1128/jcm.01402-12] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Accepted: 08/30/2012] [Indexed: 12/28/2022] Open
Abstract
A longitudinal study combining multilocus sequence typing with molecular evolutionary analysis determined the distribution, population structure, and evolution of antibiotic resistance in Neisseria gonorrhoeae isolates in Saskatchewan that were collected between 2005 and 2008. Of 195 gonococcal isolates examined, 29 sequence types (STs) were identified with 3 major circulating strains (ST-1 through ST-3) comprising 52% of all gonococcal isolates studied. The prevalences, persistence, distribution patterns, and clonalities of these isolates strongly suggest that gonorrhea endemicity within this broad geographic region was driven by these 3 circulating strains. ST-1 exhibited a significantly (P = 0.001) higher prevalence throughout the study than did the others, accounting for ∼25% of the tested isolates each year. The spatial distributions of the gonococcal strains indicated that ST-1 in 2007 entered a linear component of the sexual network, reaching the remote north and resulting in the further spread and maintenance of infection. Ciprofloxacin and azithromycin resistances were observed in distantly related gonococcal lineages, clearly indicating the convergent acquisition of these antibiotic-resistant phenotypes. In addition, all ciprofloxacin- and azithromycin-resistant lineages were found at the edges of the minimum spanning tree, far from the major lineages, suggesting that these antibiotic phenotypes were most likely introduced into the province. In contrast, resistance to penicillin was found mostly in the endemic gonococcal lineages, suggesting that penicillin resistance was probably acquired in Saskatchewan as a result of spontaneous mutations in already-established lineages. Tetracycline resistance was present in all STs except one, indicating its ubiquitous nature in the gonococcal population studied.
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Affiliation(s)
- Sinisa Vidovic
- Vaccine and Infectious Disease Organization, Saskatoon, Saskatchewan, Canada
| | - Sidharath D. Thakur
- Vaccine and Infectious Disease Organization, Saskatoon, Saskatchewan, Canada
| | - Greg B. Horsman
- Saskatchewan Disease Control Laboratory, Regina, Saskatchewan, Canada
| | - Paul N. Levett
- Saskatchewan Disease Control Laboratory, Regina, Saskatchewan, Canada
| | | | - Jo-Anne R. Dillon
- Vaccine and Infectious Disease Organization, Saskatoon, Saskatchewan, Canada
- Department of Biology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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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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Prosthetic valve endocarditis due to Neisseria skkuensis, a novel Neisseria species. J Clin Microbiol 2012; 50:2820-2. [PMID: 22675133 DOI: 10.1128/jcm.00676-12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We describe the first reported case of endocarditis due to Neisseria skkuensis. The organism from the blood cultures taken on admission day was identified initially as unidentified Gram-negative cocci by Vitek2. Finally, it was identified as Neisseria skkuensis by 16 rRNA gene sequence analysis.
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