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Gupta N, Kumar D, Das A, Sood S, Malhotra BD. Conductive Ink-Coated Paper-Based Supersandwich DNA Biosensor for Ultrasensitive Detection of Neisseria gonorrhoeae. BIOSENSORS 2023; 13:bios13040486. [PMID: 37185561 PMCID: PMC10136323 DOI: 10.3390/bios13040486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
Herein, we report results of the studies relating to the development of an impedimetric, magnetic bead-assisted supersandwich DNA hybridization assay for ultrasensitive detection of Neisseria gonorrhoeae, the causative agent of a sexually transmitted infection (STI), gonorrhea. First, a conductive ink was formulated by homogenously dispersing carboxylated multiwalled carbon nanotubes (cMWCNTs) in a stable emulsion of terpineol and an aqueous suspension of carboxymethyl cellulose (CMC). The ink, labeled C5, was coated onto paper substrates to fabricate C5@paper conductive electrodes. Thereafter, a magnetic bead (MB)-assisted supersandwich DNA hybridization assay was optimized against the porA pseudogene of N. gonorrhoeae. For this purpose, a pair of specific 5' aminated capture probes (SCP) and supersandwich detector probes (SDP) was designed, which allowed the enrichment of target gonorrheal DNA sequence from a milieu of substances. The SD probe was designed such that instead of 1:1 binding, it allowed the binding of more than one T strand, leading to a 'ladder-like' DNA supersandwich structure. The MB-assisted supersandwich assay was integrated into the C5@paper electrodes for electrochemical analysis. The C5@paper electrodes were found to be highly conductive by a four-probe conductivity method (maximum conductivity of 10.1 S·cm-1). Further, the biosensing assay displayed a wide linear range of 100 aM-100 nM (109 orders of magnitude) with an excellent sensitivity of 22.6 kΩ·(log[concentration])-1. The clinical applicability of the biosensing assay was assessed by detecting genomic DNA extracted from N. gonorrhoeae in the presence of DNA from different non-gonorrheal bacterial species. In conclusion, this study demonstrates a highly sensitive, cost-effective, and label-free paper-based device for STI diagnostics. The ink formulation prepared for the study was found to be highly thixotropic, which indicates that the paper electrodes can be screen-printed in a reproducible and scalable manner.
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Affiliation(s)
- Niharika Gupta
- Department of Biotechnology, Delhi Technological University, Delhi 110042, India
| | - D Kumar
- Department of Applied Chemistry, Delhi Technological University, Delhi 110042, India
| | - Asmita Das
- Department of Biotechnology, Delhi Technological University, Delhi 110042, India
| | - Seema Sood
- Department of Microbiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110016, India
| | - Bansi D Malhotra
- Department of Biotechnology, Delhi Technological University, Delhi 110042, India
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Hanrahan JK, Hogan TR, Buckley C, Trembizki E, Mitchell H, Lau CL, Whiley DM, Lahra MM. Emergence and spread of ciprofloxacin-resistant Neisseria gonorrhoeae in New South Wales, Australia: lessons from history. J Antimicrob Chemother 2020; 74:2214-2219. [PMID: 31170281 DOI: 10.1093/jac/dkz182] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/10/2019] [Accepted: 04/05/2019] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Our aim was to investigate the emergence and spread of ciprofloxacin resistance in clinical Neisseria gonorrhoeae isolates in New South Wales, Australia, from the first reported case in 1991 until ciprofloxacin resistance was sustained at or above the WHO threshold for treatment change of 5% (1999), to inform future strategies for controlling gonococcal antimicrobial resistance. METHODS The index isolate and all subsequent clinical isolates of ciprofloxacin-resistant N. gonorrhoeae in New South Wales from 1991 to 1999 were genotyped using a previously described method on the Agena MassARRAY iPLEX platform. Region of acquisition data, where available, were used to determine whether cases were travel associated. RESULTS In New South Wales, of the 325 ciprofloxacin-resistant N. gonorrhoeae isolates reported from 1991 to 1999, 98% (320/325) were able to be recovered and 100% (320/320) were genotyped. There were 66 different genotypes, comprising 1-99 isolates each. Notably no single clone was found to account for ciprofloxacin resistance being sustained in the population, with considerable variability in genotype prevalence observed throughout the study period. A total of 65% (209/320) of genotyped isolates had information regarding the likely place of acquisition; of these, 44% (93/209) were associated with overseas travel or sexual contact with an overseas visitor. The first ciprofloxacin-resistant N. gonorrhoeae in New South Wales was associated with travel to Thailand. Index cases of each resistant genotype were significantly more likely to have been acquired overseas (51.5%), predominantly in Asia (45%, 30/66). CONCLUSIONS The continued importation of multiple genotypes, rather than the expansion of a single genotype, led to ciprofloxacin-resistant N. gonorrhoeae being established in New South Wales.
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Affiliation(s)
- Jane K Hanrahan
- WHO Collaborating Centre for Sexually Transmitted Infections and Antimicrobial Resistance, NSWHP Microbiology, Prince of Wales Hospital, Sydney, New South Wales 2031, Australia.,School of Biotechnology and Biomolecular Science, The University of New South Wales, Sydney, New South Wales 2052
| | - Tiffany R Hogan
- WHO Collaborating Centre for Sexually Transmitted Infections and Antimicrobial Resistance, NSWHP Microbiology, Prince of Wales Hospital, Sydney, New South Wales 2031, Australia
| | - Cameron Buckley
- Faculty of Medicine, Centre for Clinical Research, The University of Queensland, Herston, Queensland 4029, Australia
| | - Ella Trembizki
- Faculty of Medicine, Centre for Clinical Research, The University of Queensland, Herston, Queensland 4029, Australia
| | - Hazel Mitchell
- School of Biotechnology and Biomolecular Science, The University of New South Wales, Sydney, New South Wales 2052
| | - Colleen L Lau
- Research School of Population Health, The Australian National University, Canberra, ACT 2600, Australia
| | - David M Whiley
- Faculty of Medicine, Centre for Clinical Research, The University of Queensland, Herston, Queensland 4029, Australia.,Pathology Queensland, Microbiology Department, Herston, Queensland 4029, Australia
| | - Monica M Lahra
- WHO Collaborating Centre for Sexually Transmitted Infections and Antimicrobial Resistance, NSWHP Microbiology, Prince of Wales Hospital, Sydney, New South Wales 2031, Australia.,School of Biotechnology and Biomolecular Science, The University of New South Wales, Sydney, New South Wales 2052
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Unemo M, Lahra MM, Cole M, Galarza P, Ndowa F, Martin I, Dillon JAR, Ramon-Pardo P, Bolan G, Wi T. World Health Organization Global Gonococcal Antimicrobial Surveillance Program (WHO GASP): review of new data and evidence to inform international collaborative actions and research efforts. Sex Health 2019; 16:412-425. [PMID: 31437420 PMCID: PMC7035961 DOI: 10.1071/sh19023] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/29/2019] [Indexed: 12/21/2022]
Abstract
Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a serious public health problem, compromising the management and control of gonorrhoea globally. Resistance in N. gonorrhoeae to ceftriaxone, the last option for first-line empirical monotherapy of gonorrhoea, has been reported from many countries globally, and sporadic failures to cure especially pharyngeal gonorrhoea with ceftriaxone monotherapy and dual antimicrobial therapies (ceftriaxone plus azithromycin or doxycycline) have been confirmed in several countries. In 2018, the first gonococcal isolates with ceftriaxone resistance plus high-level azithromycin resistance were identified in England and Australia. The World Health Organization (WHO) Global Gonococcal Antimicrobial Surveillance Program (GASP) is essential to monitor AMR trends, identify emerging AMR and provide evidence for refinements of treatment guidelines and public health policy globally. Herein we describe the WHO GASP data from 67 countries in 2015-16, confirmed gonorrhoea treatment failures with ceftriaxone with or without azithromycin or doxycycline, and international collaborative actions and research efforts essential for the effective management and control of gonorrhoea. In most countries, resistance to ciprofloxacin is exceedingly high, azithromycin resistance is present and decreased susceptibility or resistance to ceftriaxone has emerged. Enhanced global collaborative actions are crucial for the control of gonorrhoea, including improved prevention, early diagnosis, treatment of index patient and partner (including test-of-cure), improved and expanded AMR surveillance (including surveillance of antimicrobial use and treatment failures), increased knowledge of correct antimicrobial use and the pharmacokinetics and pharmacodynamics of antimicrobials and effective drug regulations and prescription policies (including antimicrobial stewardship). Ultimately, rapid, accurate and affordable point-of-care diagnostic tests (ideally also predicting AMR and/or susceptibility), new therapeutic antimicrobials and, the only sustainable solution, gonococcal vaccine(s) are imperative.
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Affiliation(s)
- Magnus Unemo
- World Health Organization Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, SE-701 85 Örebro, Sweden; and Corresponding author.
| | - Monica M Lahra
- World Health Organization Collaborating Centre for Sexually Transmitted Infections and Antimicrobial Resistance, New South Wales Health Pathology, Microbiology, Randwick, NSW, Australia
| | - Michelle Cole
- National Infection Service, Public Health England, London, UK
| | - Patricia Galarza
- National Reference Laboratory for STDs, National Institute of Infectious Diseases - ANLIS 'Dr Carlos G. Malbrán', Buenos Aires, Argentina
| | - Francis Ndowa
- Skin and Genitourinary Medicine Clinic, Harare, Zimbabwe
| | - Irene Martin
- Public Health Agency of Canada, National Microbiology Laboratory, Winnipeg, MB, Canada
| | | | - Pilar Ramon-Pardo
- Communicable Diseases and Environmental Determinants of Health Department Pan American Health Organization/World Health Organization, Washington, DC, USA
| | - Gail Bolan
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Teodora Wi
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Lee H, Suh YH, Lee S, Kim YK, Han MS, Bae HG, Unemo M, Lee K. Emergence and Spread of Cephalosporin-Resistant Neisseria gonorrhoeae with Mosaic penA Alleles, South Korea, 2012-2017. Emerg Infect Dis 2019; 25:416-424. [PMID: 30789143 PMCID: PMC6390772 DOI: 10.3201/eid2503.181503] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
In South Korea, surveillance of antimicrobial drug resistance in Neisseria gonorrhoeae is extremely limited. We describe the emergence and subsequent national spread of N. gonorrhoeae strains with mosaic penA alleles associated with decreased susceptibility and resistance to extended-spectrum cephalosporins. From 2012 through 2017, the proportion of mosaic penA alleles in gonococcal-positive nucleic acid amplification test (NAAT) specimens across South Korea increased from 1.1% to 23.9%. Gonococcal strains with mosaic penA alleles emerged in the international hubs of Seoul in Gyeonggi Province and Busan in South Gyeongsang Province and subsequently spread across South Korea. Most common was mosaic penA-10.001 (n = 572 isolates; 94.7%), which is associated with cefixime resistance. We also identified mosaic penA-34.001 and penA-60.001, both of which are associated with multidrug-resistant gonococcal strains and spread of cefixime and ceftriaxone resistance. Implementation of molecular resistance prediction from N. gonorrhoeae–positive nucleic acid amplification test specimens is imperative in South Korea and internationally.
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Donà V, Low N, Golparian D, Unemo M. Recent advances in the development and use of molecular tests to predict antimicrobial resistance in Neisseria gonorrhoeae. Expert Rev Mol Diagn 2017; 17:845-859. [PMID: 28741392 DOI: 10.1080/14737159.2017.1360137] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The number of genetic tests, mostly real-time PCRs, to detect antimicrobial resistance (AMR) determinants and predict AMR in Neisseria gonorrhoeae is increasing. Several of these assays are promising, but there are important shortcomings and few assays have been adequately validated and quality assured. Areas covered: Recent advances, focusing on publications since 2012, in the development and use of molecular tests to predict gonococcal AMR for surveillance and for clinical use, advantages and disadvantages of these tests and of molecular AMR prediction compared with phenotypic AMR testing, and future perspectives for effective use of molecular AMR tests for different purposes. Expert commentary: Several challenges for direct testing of clinical, especially extra-genital, specimens remain. The choice of molecular assay needs to consider the assay target, quality controls, sample types, limitations intrinsic to molecular technologies, and specific to the chosen methodology, and the intended use of the test. Improved molecular- and particularly genome-sequencing-based methods will supplement AMR testing for surveillance purposes, and translate into point-of-care tests that will lead to personalized treatments, while sparing the last available empiric treatment option (ceftriaxone). However, genetic AMR prediction will never completely replace phenotypic AMR testing, which detects also AMR due to unknown AMR determinants.
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Affiliation(s)
- Valentina Donà
- a Institute for Infectious Diseases, University of Bern , Bern , Switzerland
| | - Nicola Low
- b Institute of Social and Preventive Medicine, University of Bern , Bern , Switzerland
| | - Daniel Golparian
- c WHO Collaborating Centre for Gonorrhoea , Örebro University , Örebro , Sweden
| | - Magnus Unemo
- c WHO Collaborating Centre for Gonorrhoea , Örebro University , Örebro , Sweden
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Molecular tests for the detection of antimicrobial resistant Neisseria gonorrhoeae: when, where, and how to use? Curr Opin Infect Dis 2016; 29:45-51. [PMID: 26658656 DOI: 10.1097/qco.0000000000000230] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Molecular methods for the diagnosis of Neisseria gonorrhoeae are replacing bacterial culture in many settings. This review focuses on recent progress in the development of molecular tests to detect resistant N. gonorrhoeae both to enhance surveillance and to guide decisions about individual patient management. RECENT FINDINGS Assays to enhance surveillance have been developed to detect determinants of resistance for all antibiotics used as first-line gonorrhoea treatment, or to detect specific 'superbug' strains, but few have been applied in clinical practice. The most advanced strategy relevant to individual case management is to identify ciprofloxacin-sensitive strains so that unnecessary use of ceftriaxone can be avoided. Cross-reactivity with pharyngeal commensal Neisseria species reduces specificity and is a challenge for many assays. SUMMARY Progress with laboratory-based molecular tests to detect gonococcal resistance is being made but substantial challenges remain. No laboratory-based assay has been subjected to a field evaluation and no assay so far can be used as a point-of-care test. Given the threat of antimicrobial resistance, now is the time to exploit the molecular technologies used for diagnosis and to invest in the development of molecular gonococcal resistance tests that can be implemented for public health good.
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Abstract
In the last 20 years, nucleic acid amplification tests (NAATs) have gradually replaced traditional methods for the detection of sexually transmitted infections. NAAT technology comes with some considerable benefits for diagnosis, including increased sensitivity, rapid result turnaround and suitability for high throughput screening of asymptomatic individuals using more-readily available specimens. However, the transition to NAAT has not come without its problems. False-negative and false-positive results have been reported owing to various technical issues. Furthermore, increased reliance on NAATs for diagnosis have created the need to develop NAAT-based methods to inform treatment, being an area that presents its own set of challenges. In this review article, we explore NAAT-based detection of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium and Trichomonas vaginalis. In doing so, we consider the benefits and limitations of NAAT-based technology and highlight areas where further research and development is in need.
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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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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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Molecular approaches to enhance surveillance of gonococcal antimicrobial resistance. Nat Rev Microbiol 2014; 12:223-9. [PMID: 24509781 DOI: 10.1038/nrmicro3217] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The best available data indicate that the world is heading towards a pandemic of extensively drug-resistant Neisseria gonorrhoeae. At the same time, clinical microbiology laboratories have moved away from using culture-based methods to diagnose gonorrhoea, thus undermining our ability to detect antimicrobial resistance (AMR) using current technologies. In this Opinion article, we discuss the problem of N. gonorrhoeae AMR, particularly emerging resistance to the cephalosporin ceftriaxone, outline current concerns about the surveillance of N. gonorrhoeae AMR and propose the use of molecular methods on a large scale to systematically enhance surveillance.
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Low N, Unemo M, Skov Jensen J, Breuer J, Stephenson JM. Molecular diagnostics for gonorrhoea: implications for antimicrobial resistance and the threat of untreatable gonorrhoea. PLoS Med 2014; 11:e1001598. [PMID: 24503544 PMCID: PMC3913554 DOI: 10.1371/journal.pmed.1001598] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
This Essay from Nicola Low and colleagues discusses the importance of the nucleic acid amplification tests for rapid detection of N. gonorrhoeae and its resistance determinants, as well as the importance of ensuring their rational use, as priorities for controlling both gonorrhoea and antimicrobial resistance. Please see later in the article for the Editors' Summary
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Affiliation(s)
- Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Magnus Unemo
- World Health Organization Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Örebro University Hospital, Örebro, Sweden
| | - Jørgen Skov Jensen
- Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - Judith Breuer
- MRC-UCL Centre for Medical Molecular Virology, Division of Infection and Immunity, University College London, London, United Kingdom
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Yu RX, Yin Y, Wang GQ, Chen SC, Zheng BJ, Dai XQ, Han Y, Li Q, Zhang GY, Chen X. Worldwide susceptibility rates of Neisseria gonorrhoeae isolates to cefixime and cefpodoxime: a systematic review and meta-analysis. PLoS One 2014; 9:e87849. [PMID: 24498212 PMCID: PMC3909252 DOI: 10.1371/journal.pone.0087849] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 01/02/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Neisseria gonorrhoeae (NG) infection is a serious public health problem. The third-generation extended-spectrum cephalosporins (ESCs) have been used as the first-line treatment for NG infection for almost three decades. However, in recent years, treatment failures with the oral third-generation ESCs have been reported worldwide. This study aimed to estimate worldwide susceptibility rates of NG to cefixime and cefpodoxime by analyzing data from all relevant published studies. METHODOLOGY/PRINCIPAL FINDINGS Two researchers independently searched five databases to identify studies on susceptibilities of NG to cefixime and cefpodoxime published between January 1, 1984 and October 15, 2012. A fixed-effect model was used to perform group analysis, and a χ2 test was employed to make subgroup comparison. Publication bias was assessed with the Begg rank correlation test. The pooled susceptibility rate of NG isolates to cefixime was 99.8% (95% CI: 99.7%-99.8%). The cefixime susceptibility rate of NG isolates from men was significantly lower than that from patients without information of gender or from men and women; the susceptibility rate of NG isolates from Asia was significantly lower than that from other continents; and the susceptibility rate of NG isolates collected before or during 2003 was significantly higher than that after 2003. The pooled susceptibility rate of NG isolates to cefpodoxime was 92.8% (95% CI: 89.0%-95.3%), which was lower than that to cefixime (92.8% vs. 99.8%, χ2 = 951.809, P<0.01). CONCLUSIONS The susceptibility rate of NG isolates to cefixime varied with the gender of patients and geographical location from which NG isolates were collected, and declined with time. The reported lower susceptibility rate of NG isolates to cefixime and associated treatment failures, as well as the emergence of NG strains with cephalosporin resistance call for the more effective control of NG infection and the development of new antibiotics.
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Affiliation(s)
- Rui-xing Yu
- Reference STD Lab, National Center for STD Control, Chinese CDC, Institute of Dermatology, Chinese Academy of Medical Sciences, Peking Union Medical College, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, Jiangsu Province, China
| | - Yueping Yin
- Reference STD Lab, National Center for STD Control, Chinese CDC, Institute of Dermatology, Chinese Academy of Medical Sciences, Peking Union Medical College, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, Jiangsu Province, China
| | - Guan-qun Wang
- Department of STD, Anhui Provincial Institute of Dermatology, Hefei, Anhui Province, China
| | - Shao-chun Chen
- Reference STD Lab, National Center for STD Control, Chinese CDC, Institute of Dermatology, Chinese Academy of Medical Sciences, Peking Union Medical College, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, Jiangsu Province, China
| | - Bing-jie Zheng
- Reference STD Lab, National Center for STD Control, Chinese CDC, Institute of Dermatology, Chinese Academy of Medical Sciences, Peking Union Medical College, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, Jiangsu Province, China
| | - Xiu-qin Dai
- Reference STD Lab, National Center for STD Control, Chinese CDC, Institute of Dermatology, Chinese Academy of Medical Sciences, Peking Union Medical College, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, Jiangsu Province, China
| | - Yan Han
- Reference STD Lab, National Center for STD Control, Chinese CDC, Institute of Dermatology, Chinese Academy of Medical Sciences, Peking Union Medical College, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, Jiangsu Province, China
| | - Qi Li
- Reference STD Lab, National Center for STD Control, Chinese CDC, Institute of Dermatology, Chinese Academy of Medical Sciences, Peking Union Medical College, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, Jiangsu Province, China
| | - Guo-yi Zhang
- Reference STD Lab, National Center for STD Control, Chinese CDC, Institute of Dermatology, Chinese Academy of Medical Sciences, Peking Union Medical College, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, Jiangsu Province, China
| | - Xiangsheng Chen
- Reference STD Lab, National Center for STD Control, Chinese CDC, Institute of Dermatology, Chinese Academy of Medical Sciences, Peking Union Medical College, Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, Jiangsu Province, China
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Lahra MM, Lo YR, Whiley DM. Gonococcal antimicrobial resistance in the Western Pacific Region. Sex Transm Infect 2014; 89 Suppl 4:iv19-23. [PMID: 24243875 DOI: 10.1136/sextrans-2012-050906] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To outline the current situation of gonococcal antimicrobial resistance (AMR) in the Western Pacific region and factors that impact on this. BACKGROUND The Western Pacific region is densely populated with many living in poverty. There are high rates of infectious diseases, and a disproportionate burden of gonococcal disease. In many countries there is uncontrolled antimicrobial use: these are ideal conditions for the emergence of AMR. METHODS Gonococcal AMR in this region has been monitored for more than 20 years. Clinical isolates, predominantly from unselected patients attending sexually transmitted diseases clinics, are tested against a panel of antibiotics. Quality assurance and control strategies are in place. RESULTS There is widespread, high level resistance to penicillin and ciprofloxacin. Decreased susceptibility to ceftriaxone (MIC ≥ 0.06 mg/L) is reported in high levels from some countries in the region. Low numbers of isolates tested in some countries reflect capacity for testing, and are suboptimal for surveillance. CONCLUSION The raised MIC values to ceftriaxone, and the emergence and spread of ceftriaxone resistant strains regionally is alarming. Sustaining and enhancing surveillance is critical; however obtaining an adequate sample size is a long-standing issue. The implementation of molecular surveillance strategies could provide broader information on the spread and threat of AMR.
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Affiliation(s)
- Monica M Lahra
- Microbiology Department, South Eastern Area Laboratory Services, WHO Collaborating Centre for STD, The Prince of Wales Hospital, , Sydney, New South Wales, Australia
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Goire N, Freeman K, Lambert SB, Nimmo GR, Limnios AE, Lahra MM, Nissen MD, Sloots TP, Whiley DM. The influence of target population on nonculture-based detection of markers of Neisseria gonorrhoeae antimicrobial resistance. Sex Health 2013; 9:422-9. [PMID: 23036167 DOI: 10.1071/sh12026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 05/07/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND With treatment options for gonorrhoea (Neisseria gonorrhoeae) diminishing, strengthening antimicrobial resistance (AMR) surveillance is paramount. METHODS In this study, we investigated polymerase chain reaction (PCR) based methods, in parallel with N. gonorrhoeae multi-antigen sequence typing (NG-MAST), for direct detection of four N. gonorrhoeae chromosomal mechanisms associated with emerging resistance to extended spectrum cephalosporins using noncultured samples: an adenine deletion in the mtrR promoter, a mosaic penicillin-binding protein (PBP) 2, an A501V PBP2 mutation, and alterations at positions 120 and 121 of the porB protein. The PCR assays were validated using a panel of characterised N. gonorrhoeae isolates (n=107) and commensal Neisseria (n=100) species. These PCR assays with NG-MAST were then applied to noncultured clinical specimens from distinct populations in Australia with differing levels of N. gonorrhoeae AMR: the Northern Territory (NT), where resistance has a low population prevalence, and Queensland (Qld), with higher AMR prevalence. RESULTS The real-time PCR assays proved highly sensitive and specific. When applied to the noncultured samples, only 1 out of 50 (2%) samples from NT harboured a resistant mechanism, whereas the Qld samples (n=129) collected over different periods showed progressive acquisition of resistant mechanisms, and these were associated with specific NG-MAST types, including Type 225. CONCLUSIONS The results suggest that our PCR-based methods could be used to rapidly pinpoint incursion of resistant strains into previously unaffected populations. Likewise, our results show that for molecular AMR surveillance, the population being investigated is as important as the genetic mechanisms being targeted.
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Affiliation(s)
- Namraj Goire
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, Brisbane, Australia.
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Goire N, Lahra MM, Ohnishi M, Hogan T, Liminios AE, Nissen MD, Sloots TP, Whiley DM. Polymerase chain reaction-based screening for the ceftriaxone-resistant Neisseria gonorrhoeae F89 strain. ACTA ACUST UNITED AC 2013; 18:20444. [PMID: 23594520 DOI: 10.2807/1560-7917.es2013.18.14.20444] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Emergence and spread of Neisseria gonorrhoeae resistant to extended spectrum cephalosporins is a major problem threatening treatment of gonorrhoea and is further highlighted by the recent report of a second ceftriaxone-resistant N. gonorrhoeae strain (F89) in Europe, initially observed in France and subsequently identified in Spain. N. gonorrhoeae antimicrobial resistance (AMR) surveillance has acquired new importance and molecular tools have the potential to enhance bacterial culture-based methods. In this study, we established a polymerase chain reaction (PCR) protocol for direct detection of the F89 strain. A key component of this screening protocol was the development of a hybridisation probe-based melting curve analysis assay (mosaic501-hybPCR) to detect the presence of an A501P substitution on the N. gonorrhoeae mosaic penicillin binding protein 2 (PBP2) sequence, an important characteristic of the F89 strain. The mosaic501-hybPCR was evaluated using plasmid-derived positive controls (n=3) and characterised gonococcal (n=33) and non-gonococcal (n=58) isolates. The protocol was then applied to 159 clinical specimens from Sydney, Australia, collected during the first half of the year 2012 that were N. gonorrhoeae PCR-positive. Overall, the results indicate that the PCR-based protocol is suitable for direct detection of the N. gonorrhoeae F89 strain in non-cultured clinical samples. It therefore provides an additional tool to aid investigations into the potential spread of F89 strain throughout Europe and elsewhere.
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Affiliation(s)
- N Goire
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, The University of Queensland, Queensland, Australia
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Chanal J, Lassau F, Morand P, Janier M, Dupin N. [What's new in the diagnosis and treatment of Neisseria gonorrhoeae]. Presse Med 2013; 42:454-8. [PMID: 23433914 DOI: 10.1016/j.lpm.2012.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 09/17/2012] [Accepted: 09/21/2012] [Indexed: 11/16/2022] Open
Abstract
Bacterial culture remains the gold standard for symptomatic infection. Nucleic Acid Amplification Tests (NAATs) have better sensitivity and specificity for rectal and pharyngeal specimens. A bacterial culture with antibiogram must be done for all NAAT positive specimens in order to modify antibiotics prescription if needed. We must fear a diffusion of extensively drug-resistant Neisseria gonorrhoeae in the future. Nevertheless, ceftriaxone 500 mg intramuscular with 1 g of azithromycin against Chlamydia trachomatis remains the treatment of N. gonorrhoeae infections. Screening of partners of identified cases and other STDs is the main measure to add to the treatment of gonorrhea.
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Affiliation(s)
- Johan Chanal
- Assistance publique-Hôpitaux de Paris, université Paris-5, hôpital Cochin, service de dermatologie, Paris, France.
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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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Whiley DM, Goire N, Lahra MM, Donovan B, Limnios AE, Nissen MD, Sloots TP. The ticking time bomb: escalating antibiotic resistance in Neisseria gonorrhoeae is a public health disaster in waiting. J Antimicrob Chemother 2012; 67:2059-61. [PMID: 22604449 DOI: 10.1093/jac/dks188] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
From a once easily treatable infection, gonorrhoea has evolved into a challenging disease, which in future may become untreatable in certain circumstances. International spread of extensively drug-resistant gonococci would have severe public health implications. It seems clear that under the current treatment pressure from extended-spectrum cephalosporins, and owing to Neisseria gonorrhoeae's remarkable evolutionary adaptability, further rise of ceftriaxone-resistant strains around the world is inevitable. Simply increasing the doses of extended-spectrum cephalosporins will likely prove ineffective in the long run, and has been a lesson learnt for all single-agent therapies used for gonorrhoea to date. We recommend that dual therapy, especially those consisting of extended-spectrum cephalosporins and azithromycin, be adopted more widely and complemented by strengthening of antimicrobial resistance surveillance. Unless there is urgent action at international and local levels to combat the problem of N. gonorrhoeae antimicrobial resistance, we are in for gloomy times ahead in terms of gonorrhoea disease and control.
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Affiliation(s)
- David M Whiley
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, Children's Health Service, Brisbane, Queensland, Australia.
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Stoltey JE, Barry PM. The use of cephalosporins for gonorrhea: an update on the rising problem of resistance. Expert Opin Pharmacother 2012; 13:1411-20. [PMID: 22646654 PMCID: PMC4079034 DOI: 10.1517/14656566.2012.690396] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Over the last several years, Neisseria gonorrhoeae has developed decreased susceptibility to extended-spectrum cephalosporins worldwide. Gonococcal antimicrobial surveillance programs in multiple regions have documented the rise in N. gonorrhoeae isolates' minimum inhibitory concentrations to cephalosporins, and the first cases of ceftriaxone treatment failure have been reported. These developments have prompted the use of the term 'superbug' and concerns about the emergence of untreatable gonococcal infections. AREAS COVERED Since the publication of the last detailed review of the use of cephalosporins for gonorrhea in 2009, several new developments have occurred, which are detailed in this review. A variety of treatment strategies have been proposed in response to this 'superbug' threat, including increasing the dose or providing multiple doses of cephalosporins, multidrug therapy, rotating therapeutic regimens and individualized treatment based on susceptibility testing. EXPERT OPINION A robust public health response is needed that includes better diagnosis and treatment of pharyngeal gonorrhea, improved surveillance of antimicrobial resistance, informed treatment approaches and reduction of the global burden of gonococcal infections.
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Affiliation(s)
- Juliet E Stoltey
- San Francisco Department of Public Health STD Prevention and Control Services, University of California-San Francisco, Division of Infectious Diseases, 513 Parnassus Avenue, Box 0654, San Francisco, CA 94143, USA.
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