High percentages of resistance to tetracycline and penicillin and reduced susceptibility to azithromycin characterize the majority of strain types of Neisseria gonorrhoeae isolates in Cuba, 1995-1998

Genomic sequencing of Neisseria gonorrhoeae to respond to the urgent threat of antimicrobial-resistant gonorrhea

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.

Comparison of two disc diffusion methods with minimum inhibitory concentration for antimicrobial susceptibility testing of Neisseria gonorrhoeae isolates

Background:

A few studies are available comparing either minimum inhibitory concentration (MIC) values with the Clinical and Laboratory Standards Institute (CLSI) disc diffusion method or MIC with the Australian Gonococcal Surveillance Program (AGSP) method.

Aim:

This study was conducted with the aim to identify the most feasible and cost-effective method for antimicrobial susceptibility testing of Neisseria gonorrhoeae.

Materials and Methods:

Antimicrobial susceptibility testing of N. gonorrhoeae was performed using, in parallel, the E-test for MIC determination and disc diffusion by CLSI and AGSP techniques, and were compared. Susceptibility to penicillin, ciprofloxacin, tetracycline, ceftriaxone and spectinomycin and cefixime were determined by CSLI and AGSP method and Kappa statistics used to analyse the data with SPSS software.

Results:

All isolates were susceptible to ceftriaxone and spectinomycin by three methods. Ninety-nine (99%) strains were resistant to ciprofloxacin, while 1% showed intermediate susceptibility to ciprofloxacin by all methods. Statistically, there was a moderate level of agreement between the methods for penicillin.

Conclusion:

All three methods gave reproducible results. Although the media used in the disc diffusion by the AGSP method is easy and cheap to prepare, the CLSI method of disc diffusion testing is recommended for susceptibility testing of gonococcal isolates because of its feasibility and 100% accuracy, with MIC by E-test as the reference method.

Two decades of the gonococcal antimicrobial surveillance program in South America and the Caribbean: challenges and opportunities

OBJECTIVES

The WHO has called for a global action plan to control the spread and impact of antibiotic resistant Neisseria gonorrhoeae. We report on key antimicrobial susceptibility (AMS) trends in countries in Latin America and the Caribbean from 1990 to 2011.

METHODS

Data collected between 1990 and 2011 by up to 23 countries in the Latin American and Caribbean region were aggregated and analysed for overall trends in N gonorrhoeae AMS to six antibiotics. Methods for gonococcal identification, susceptibility testing and interpretation were standardised.

RESULTS

More than 21 500 N gonorrhoeae isolates were tested for AMS between 1990 and 2011. The number of countries reporting yearly declined from 17 in the 1990 s to 7 in 2011. The first isolates (0.4%, 20/5171) with reduced susceptibility (minimum inhibitory concentration ≥ 0.125 mg/L) to ceftriaxone were reported between 2007 and 2011. Ciprofloxacin resistance, first noted in the mid-1990 s, ranged from 1.6% of isolates tested in 1997 rising to 42.1% in 2010. Overall, azithromycin resistance reached a high of 25.8% of isolates tested in 2008 falling to 1.0% in 2010. Resistance to penicillin ranged between 24.2% in 2003 to a high of 48.5% in 1993. Tetracycline resistance ranged between a high of 61.1% of isolates tested in 2001 to 21.8% in 2010. Plasmid mediated penicillin and tetracycline resistance declined over the period.

CONCLUSIONS

Gonococcal AMS surveillance initiatives are urgently needed in every country in the region to ensure that effective treatments for gonococcal infections are in place and to better understand emerging trends in gonococcal antimicrobial resistance.

On the pathway to better birth outcomes? A systematic review of azithromycin and curable sexually transmitted infections

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.

Emergence of increased azithromycin resistance during unsuccessful treatment of Neisseria gonorrhoeae infection with azithromycin (Portland, OR, 2011)

We describe the emergence of an azithromycin-resistant Neisseria gonorrhoeae variant in a man from Portland, Oregon, during sole treatment with 2 g azithromycin. This report highlights the ease with which gonococcal macrolide resistance can emerge, the threat of multidrug resistant N. gonorrhoeae, and the need for adherence to Centers for Disease Control and Prevention treatment guidelines.

Retrospective analysis of antimicrobial susceptibility trends (2000-2009) in Neisseria gonorrhoeae isolates from countries in Latin America and the Caribbean shows evolving resistance to ciprofloxacin, azithromycin and decreased susceptibility to ceftriaxone

BACKGROUND

The emergence of resistance and treatment failures to third generation cephalosporins prompted the revitalization of the global Gonococcal Antimicrobial Surveillance Program (GASP) to ensure that information regarding trends of the antimicrobial susceptibility of Neisseria gonorrhoeae isolates is up-to-date. Accordingly, former and potential GASP participants in Latin America and the Caribbean were contacted to reinitiate the GASP network in the region and to undertake a retrospective analysis of the antimicrobial susceptibility of N. gonorrhoeae isolates between 2000 and 2009.

METHODS

Eleven countries participated in this retrospective analysis reporting on the susceptibility of N. gonorrhoeae isolates to up to 6 antibiotics as well as national treatment guidelines over the period. Antimicrobial susceptibility determination was carried out using combination of agar dilution and disk diffusion (Clinical Laboratory and Standards Institute) or Etest. Antimicrobial susceptibility data from each country were aggregated and analyzed for antimicrobial resistance trends in the region.

RESULTS

More than 11,400 N. gonorrhoeae isolates were tested for antimicrobial susceptibility: 6 countries tested N. gonorrhoeae over the entire period and 5 countries tested sporadically. Decreased susceptibility to ceftriaxone was reported from 1 country (7 isolates, MICs >0.25 μg/ml) in 2007. No resistance to spectinomycin was reported. From 2000 to 2009, aggregated ciprofloxacin resistance increased from 2% (19/784) to 31% (311/1015) in 9 countries and azithromycin resistance increased from 6% (39/646) to 23% (225/962) in 4/6 reporting countries. Overall, resistance to penicillin and tetracycline decreased from 35% (441/1241) to 26% (258/975) and from 60% (476/792) to 35% (323/931), respectively.In 2009, resistance to gentamicin (3%, 4/122), chloramphenicol (5%, 6/120), and ofloxacin (2%, 6/120) was reported from 1 country.

CONCLUSIONS

The report of ceftriaxone-resistant isolates coupled with the emergence and spread of resistance to ciprofloxacin and azithromycin in Latin America and the Caribbean in the 2000s indicates the importance of active surveillance of N. gonorrhoeae antimicrobial susceptibility to determine antimicrobial resistance emerging trends so as to promptly inform and guide the development of effective treatment options for gonococcal infections.

Antimicrobial activity of flavonoids from Piper lanceaefolium and other Colombian medicinal plants against antibiotic susceptible and resistant strains of Neisseria gonorrhoeae

BACKGROUND

The successful treatment of Neisseria gonorrhoeae (NG) infections is increasingly problematic because of the resistance of this pathogen to multiple antimicrobial agents. This development underscores the need for new antimicrobial sources. In the current study, 21 crude methanol extracts, from 19 plants used in Colombian traditional medicine for cutaneous infections, were screened for antimicrobial activity against NG.

METHODS

Extracts were screened by disc susceptibility assay. In addition, the minimum inhibitory concentrations of active compounds from P. lanceaefolium were assayed using a panel of 26 NG strains comprising 12 antibiotic-resistant phenotypes.

RESULTS

In all, 71% of the crude extracts exhibited antibacterial activity against the antibiotic susceptible NG strain WHO V, whereas 10% of the extracts inhibited penicillinase-producing NG strain GC1-182. The crude extract of Piper lanceaefolium was the only extract to show significant activity without ultraviolet (UV) light activation. Preliminary screening identified 3 compounds in this plant possessing antimicrobial activity: the flavonoids 5,7-dihydroxyflavanone (pinocembrin), 2',4',6'-trihydroxychalcone (pinocembrin chalcone), and the prenylated benzoic acid derivative cyclolanceaefolic acid methyl ester. Pinocembrin and pinocembrin chalcone inhibited 100% of the NG panel at 64 μg/mL and 128 μg/mL, respectively, whereas cyclolanceaefolic acid methyl ester inhibited 44% of the strains at 128 μg/mL.

CONCLUSIONS

This is the first report of the antibacterial activity of Columbian plants against NG. The activity of the 2 flavonoids, pinocembrin, and pinocembrin chalcone, toward both susceptible and resistant NG strains makes them promising candidates for further research.

Predominant porB1A and porB1B genotypes and correlation of gene mutations with drug resistance in Neisseria gonorrhoeae isolates in Eastern China

BACKGROUND

Variations of porB1A and porB1B genes and their serotypes exist in Neisseria gonorrhoeae isolates from different geographical areas, and some site mutations in the porB1B gene correlate with drug resistance.

METHODS

The β-lactamase production of N. gonorrhoeae isolates was determined by paper acidometric test and nitrocefin discs. The porB1A and porB1B genes of 315 non-penicillinase-producting N. gonorrhoeae (non-PPNG) strains were amplified by PCR for sequencing to determine serotypes and site mutations. A duplex PCR was designed to simultaneously detect both porB1A and porB1B genes. Penicillin and tetracycline resistance was assessed by an in vitro drug sensitivity test.

RESULTS

Of the N. gonorrhoeae isolates, 31.1% tested positive for porB1A and 68.9% for porB1B genes. All the 98 porB1A+ isolates belonging to IA6 serotype with either no mutation at the 120 and 121 sites (88.8%) or a D120G (11.2%) mutation and were no resistance to both penicillin and tetracycline. Among the 217 porB1B+ isolates, 26.7%, 22.6% and 11.5% belonged to IB3, IB3/6 and IB4 serotypes, respectively. Particularly, two novel chimeric serotypes, IB3/6-IB2 and IB2-IB4-IB2, were found in 77 and 8 porB1B+ isolates. Two hundred and twelve (97.7%) of the porB1B+ isolates were presented G120 and/or A121 mutations with 163 (76.9%) at both sites. Interestingly, within the 77 porB1B+ isolates belonging to IB3/6-IB2 serotype, 15 were discovered to possess novel deletions at both A121 and N122 sites. All the replacement mutations at these sites in PorB1B were correlated with resistance and the deletion mutation showed the highest resistance.

CONCLUSION

N. gonorrhoeae isolates circulating in Eastern China include a sole PorB1A serotype (IA6) and five PorB1B serotypes. Multiple mutations in porB1B genes, including novel A121 and N122 deletions, are correlated with high levels of penicillin and tetracycline resistance.

Developing a system to predict laboratory-confirmed chlamydial and/or gonococcal urethritis in adult male emergency department patients

OBJECTIVES

We aimed to create a system for predicting which male emergency department (ED) patients with suspected chlamydial and/or gonococcal urethritis would have laboratory-confirmed infections based on clinical factors available at the initial ED encounter.

METHODS

We used statistical models to develop a system to predict either the presence or absence of laboratory-confirmed chlamydial and/or gonorrheal urethritis based on patient demographics and presenting symptoms. Data for the system were extracted from a retrospective chart review of adult male patients who were suspected of having, and were tested for, chlamydial and/or gonococcal urethritis at an adult, urban, northeastern United States, academic ED from January 1998 to December 2004.

RESULTS

Among the 822 patients tested, 29.2% had chlamydia, gonorrhea, or both infections; 13.8% were infected with chlamydia alone, 12.1% were infected with gonorrhea alone, and 3.3% were infected with both. From the statistical models, the following factors were predictive of a positive laboratory test for chlamydia and/or gonorrhea: age < or = 24 years, penile discharge, sexual contact with someone known to have chlamydia and/or gonorrhea, and not having health care insurance. A system using a hierarchical grouping of these factors based on the predicted probabilities of a laboratory-confirmed chlamydial and/or gonococcal urethritis, paired with baseline ED prevalence of these infections, was confirmed through internal validation testing to modestly predict which patients had or did not have a laboratory-confirmed infection.

CONCLUSIONS

This system of a combination of risk factors available during the clinical encounter in the ED modestly predicts which adult male patients suspected of having chlamydial and/or gonorrheal urethritis are more likely to have or not have a laboratory-confirmed infection. A prospective study is needed to create and validate a clinical prediction rule based on the results of this system.

Strain typing and antimicrobial resistance of fluoroquinolone-resistant Neisseria gonorrhoeae causing a California infection outbreak

Antimicrobial-resistant Neisseria gonorrhoeae is an emerging public health problem as a result of the alarming limitation in treatment options. We examined an outbreak in California of fluoroquinolone-resistant Neisseria gonorrhoeae (QRNG) by evaluation of a combination of routine isolates from the Gonococcal Isolate Surveillance Project and isolates collected by expanded surveillance performed between April 2000 and June 2002. QRNG isolates were characterized by two methods: (i) determination of a combination of antibiogram, auxotype, serovar, Lip type, and patterns of amino acid alteration in the quinolone resistance-determining region of GyrA and ParC (ASLGP) and (ii) pulsed-field gel electrophoresis (PFGE). Strain typing was used to describe the QRNG outbreak strains and the associated antimicrobial resistance profiles. Among 79 isolates that were completely characterized, we identified 20 different ASLGP strain types, and 2 of the types were considered to belong to outbreak strains that comprised 65% (51/79) of the isolates. By PFGE typing, there were 24 different strain types, and 4 of these were considered outbreak types and comprised 66% (52/79) of the isolates. The overall agreement between the typing methods in distinguishing outbreak strains and non-outbreak strains was 84% (66/79). The most common QRNG ASLGP strain type had chromosomally mediated resistance to penicillin and tetracycline and an azithromycin MIC of 0.5 microg/ml. The occurrence of an outbreak caused by QRNG strains that could fail to be eradicated by most antibiotic classes reinforces the serious problem with antimicrobial resistance in Neisseria gonorrhoeae that the public health system faces. Adherence to a regimen with the recommended antibiotics at the appropriate dose is critical, and monitoring for antimicrobial susceptibility needs to be actively maintained to adapt treatment guidelines appropriately.

Emergence of high-level azithromycin resistance in Neisseria gonorrhoeae in England and Wales

OBJECTIVES

This study aimed to investigate the origin of high-level azithromycin resistance that emerged in isolates of Neisseria gonorrhoeae in England and Wales in 2007, and to establish methods for identifying high-level azithromycin resistance.

METHODS

The Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) data from 2001-07 were examined for emerging trends in azithromycin susceptibility. Further to the identification of six high-level azithromycin-resistant isolates in GRASP 2007, an additional 102 isolates were selected on the basis of azithromycin susceptibility and geographic origin from the GRASP 2006 and 2007 collections. Susceptibility testing by Etest and disc diffusion was performed on all 108 isolates and 75 of these were typed by N. gonorrhoeae multiantigen sequence typing.

RESULTS

A slight drift towards higher MICs of azithromycin was observed in the gonococcal population since 2001. Of greater concern was the first example of a shift to high-level resistance observed in six isolates in 2007. All six isolates were sequence type 649, which was not observed in any of the lower-level azithromycin-resistant isolates from 2007 or in any isolates tested from the same geographical locations. Contact tracing data for one patient suggested a link with Scotland. Disc diffusion testing of all 108 isolates showed that azithromycin, but not erythromycin, discs can differentiate between low-level and high-level resistance.

CONCLUSIONS

High-level azithromycin resistance has emerged in England and Wales. Contact tracing and typing data suggest this may have originated from Scotland. Surveillance of azithromycin resistance will be key in controlling its further dissemination.

Diagnosis and treatment of pelvic inflammatory disease

Pelvic inflammatory disease (PID), the infection and inflammation of the female upper genital tract, is a common cause of infertility, chronic pain and ectopic pregnancy. Diagnosis and management are challenging, largely resulting from varying signs and symptoms and a polymicrobial etiology that is not fully delineated. Owing to the potential for serious sequelae, a low threshold for diagnosis and treatment is recommended. As PID has a multimicrobial etiology, including Neisseria gonorrhoeae, Chlamydial trachomatis and anaerobic and mycoplasmal bacteria, treatment of PID should consist of a broad spectrum antibiotic regimen. Recent treatment trials have focused on shorter duration regimens, such as azithromycin, and monotherapies including ofloxacin, but data are sparse. Research comparing sequelae development by differing antimicrobial regimens is extremely limited, but will ultimately shape future treatment guidelines.

Pharyngeal Gonorrhea in Female Sex Workers: Response to a Single 2-g Dose of Azithromycin

OBJECTIVES

A sharp increase in the incidence of gonorrhea has been observed in Tel Aviv, Israel, since 1999. Almost one half of interviewed patients admitted contracting the infection from a sex worker. In two thirds of the cases, oral sex (fellatio) was the most probable route of acquiring the disease. In the current study, we assessed the prevalence of pharyngeal gonorrhea among sex workers in Tel Aviv and evaluated the efficacy of a single 2-g dose of azithromycin in eradicating the infection.

METHODS

Throat specimens were obtained for gonococcal culture from 301 female sex workers practicing in brothels. A questionnaire covering demographic and sexual behavior information was administered to all participants, and a single 2-g dose was administered orally under supervision. Women with positive cultures were reexamined a week later for eradication of Neisseria gonorrhoeae.

RESULTS

N gonorrhoeae was isolated from 27 women (9%). The median age of women with pharyngeal gonorrhea was 23 years (range, 18-32 years); 85% were born in former Soviet Union (mostly Russia, Ukraine, Moldavia). Regular condom use in vaginal sex was reported by 88% of the participants, whereas only 60% reported always using condoms in oral sex. All isolates were susceptible to azithromycin (MIC < or = 0.5 microg/ml). Gonococci were eradicated in 20/21 individuals (95%).

CONCLUSION

A high carriage rate of gonococci in the throat and a low rate of condom use in oral sex were documented among sex workers in Tel Aviv. A single 2 g dose of azithromycin was very effective in eradicating gonococci from the throat.

Epidemiology, pathogenesis and treatment of pelvic inflammatory disease

Pelvic inflammatory disease, the infection and inflammation of the female upper genital tract, is a common cause of infertility, chronic pain and ectopic pregnancy. Diagnosis and management are challenging, due largely to a polymicrobial etiology which is not fully delineated. Signs and symptoms of this syndrome vary widely, further complicating diagnosis and treatment. Due to the potential for serious sequelae, a low threshold for diagnosis and treatment is recommended. Since pelvic inflammatory disease has a multimicrobial etiology including Neisseria gonorrhoeae, Chlamydia trachomatis and anaerobic and mycoplasmal bacteria, treatment of pelvic inflammatory disease should be broad spectrum. Recent treatment trials have focused on shorter duration regimens such as azithromycin and monotherapies including ofloxacin, although data are sparse. Research comparing sequelae development by differing antimicrobial regimens is extremely limited, but will ultimately shape future treatment guidelines. Several promising short-duration and monotherapy antibiotic regimens should be evaluated in pelvic inflammatory disease treatment trials for compliance, microbiological and clinical cure, and reduction of subsequent adverse reproductive and gynecological morbidity.

Molecular epidemiology of Neisseria gonorrhoeae- identification of the first presumed Swedish transmission chain of an azithromycin-resistant strain

In the present study, 10 azithromycin-resistant Neisseria gonorrhoeae isolates from 6 Swedish male patients in 2004, 3 sporadic Swedish azithromycin-resistant N. gonorrhoeae isolates from recent years and one Swedish N. gonorrhoeae isolate from 2003 that was susceptible to azithromycin but assigned the same serological variant (serovar), i.e. IB-37, as the isolates from 2004 were included. The isolates were characterized phenotypically using antibiograms and serovar determination and genetically with pulsed-field gel electrophoresis (PFGE), entire porB gene sequencing and N. gonorrhoeae multiantigen sequence typing (NG-MAST). The epidemiological information and the results of the thorough phenotypic characterisation and genetic characterisation identified the first presumed domestic transmission of one azithromycin-resistant N. gonorrhoeae strain in Sweden in 2004. This stresses the need for continuous surveillance of the antibiotic susceptibility of N. gonorrhoeae in order to identify emergence of new resistance, monitor the changing patterns of the susceptibility, and be able to update treatment recommendations on a regular basis.

Challenges in the control of gonorrhea in South America and the Caribbean: monitoring the development of resistance to antibiotics

OBJECTIVE

: The objective of this study was to ascertain the antimicrobial susceptibility of Neisseria gonorrhoeae isolates from 6 South American and 13 Caribbean countries participating in the Gonococcal Antimicrobial Surveillance Program (GASP) from 1990 to 1999.

STUDY

: A GASP network of laboratories was launched in the Americas and the Caribbean during the 1990s. Standardized methods and interpretative criteria were established for the isolation of N. gonorrhoeae, strain identification, and determination, and quality control of antimicrobial susceptibility.

RESULTS

: Two countries (Argentina and Uruguay) maintained continuous surveillance during the study period. Some countries gathered data periodically and several others were unable to initiate antimicrobial surveillance as a result of lack of resources. The percentage of penicillin-resistant N. gonorrhoeae isolated in the region over the decade varied considerably (1.0-11.9% carried chromosomal resistance and 17.9-38.8% produced beta-lactamase) with an overall trend to declining numbers of penicillin-resistant isolates. For tetracycline, 7.4% to 36.3% carried chromosomal resistance, whereas 12.0% to 27.4% carried plasmid-mediated resistance. There were no reports of ciprofloxacin-resistant isolates, although N. gonorrhoeae with decreased susceptibility to ciprofloxacin and azithromycin as well as spectinomycin-resistant isolates were identified in some countries.

Antimicrobial resistance in developing countries. Part I: recent trends and current status

The global problem of antimicrobial resistance is particularly pressing in developing countries, where the infectious disease burden is high and cost constraints prevent the widespread application of newer, more expensive agents. Gastrointestinal, respiratory, sexually transmitted, and nosocomial infections are leading causes of disease and death in the developing world, and management of all these conditions has been critically compromised by the appearance and rapid spread of resistance. In this first part of the review, we have summarised the present state of resistance in these infections from the available data. Even though surveillance of resistance in many developing countries is suboptimal, the general picture is one of accelerating rates of resistance spurred by antimicrobial misuse and shortfalls in infection control and public health. Reservoirs for resistance may be present in healthy human and animal populations. Considerable economic and health burdens emanate from bacterial resistance, and research is needed to accurately quantify the problem and propose and evaluate practicable solutions. In part II, to be published next month, we will review potential containment strategies that could address this burgeoning problem.

Preliminary studies on activity of Ocimum sanctum, Drynaria quercifolia, and Annona squamosa against Neisseria gonorrhoeae

BACKGROUND

Despite the progressive increase of antimicrobial resistance of Neisseria gonorrhoeae worldwide, there are limited reports of alternative remedies from plants.

GOAL

The aim of the current study was to screen 3 plants, Ocimum sanctum, Drynaria quercifolia, and Annona squamosa, for activity against Neisseria gonorrhoeae.

STUDY

By disc diffusion method, extracts of these 3 plants were screened for activity against Neisseria gonorrhoeae; their antimicrobial activity was calculated as percentage inhibition and compared with penicillin and ciprofloxacin.

RESULTS

The extracts of all 3 plants caused inhibition of Neisseria gonorrhoeae clinical isolates and World Health Organization (WHO) strains, more so than the multidrug resistant Neisseria gonorrhoeae.

CONCLUSION

Neisseria gonorrhoeae clinical isolates and WHO strains were sensitive to extracts of Ocimum sanctum, Drynaria quercifolia, and Annona squamosa. This motivates us to isolate the active component/second from the 3 plants.