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Hicks AL, Kissler SM, Mortimer TD, Ma KC, Taiaroa G, Ashcroft M, Williamson DA, Lipsitch M, Grad YH. Targeted surveillance strategies for efficient detection of novel antibiotic resistance variants. eLife 2020; 9:e56367. [PMID: 32602459 PMCID: PMC7326491 DOI: 10.7554/elife.56367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/17/2020] [Indexed: 12/14/2022] Open
Abstract
Genotype-based diagnostics for antibiotic resistance represent a promising alternative to empiric therapy, reducing inappropriate antibiotic use. However, because such assays infer resistance based on known genetic markers, their utility will wane with the emergence of novel resistance. Maintenance of these diagnostics will therefore require surveillance to ensure early detection of novel resistance variants, but efficient strategies to do so remain undefined. We evaluate the efficiency of targeted sampling approaches informed by patient and pathogen characteristics in detecting antibiotic resistance and diagnostic escape variants in Neisseria gonorrhoeae, a pathogen associated with a high burden of disease and antibiotic resistance and the development of genotype-based diagnostics. We show that patient characteristic-informed sampling is not a reliable strategy for efficient variant detection. In contrast, sampling informed by pathogen characteristics, such as genomic diversity and genomic background, is significantly more efficient than random sampling in identifying genetic variants associated with resistance and diagnostic escape.
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Affiliation(s)
- Allison L Hicks
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public HealthBostonUnited States
| | - Stephen M Kissler
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public HealthBostonUnited States
| | - Tatum D Mortimer
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public HealthBostonUnited States
| | - Kevin C Ma
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public HealthBostonUnited States
| | - George Taiaroa
- Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and ImmunityMelbourneAustralia
| | - Melinda Ashcroft
- Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and ImmunityMelbourneAustralia
| | - Deborah A Williamson
- Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and ImmunityMelbourneAustralia
| | - Marc Lipsitch
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public HealthBostonUnited States
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T.H. Chan School of Public HealthBostonUnited States
| | - Yonatan H Grad
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public HealthBostonUnited States
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical SchoolBostonUnited States
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Establishment of a Gonococcal Antimicrobial Surveillance Programme, in Accordance With World Health Organization Standards, in Côte d'Ivoire, Western Africa, 2014-2017. Sex Transm Dis 2020; 46:179-184. [PMID: 30461598 DOI: 10.1097/olq.0000000000000943] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is compromising the treatment of gonorrhea globally. Recent AMR data are extremely limited in Africa, and mainly totally lacking in Western Africa, including Côte d'Ivoire. This study (i) established a quality-assured gonococcal antimicrobial surveillance program, according to World Health Organization quality criteria, (ii) investigated the AMR to 8 therapeutic antimicrobials in gonococcal isolates from 2014 to 2017, and (iii) provided evidence for updating the National Sexually Transmitted Disease Syndromic Management Guidelines in Côte d'Ivoire. METHODS During 2014 to 2017, gonococcal isolates were obtained from sexually active symptomatic or asymptomatic males and females in 14 sites in Côte d'Ivoire. It was a special focus on symptomatic males, and their sexual partners, due to the higher culture positivity rates in symptomatic males. Patient metadata were collected, including age, gender, sexual orientation, and symptoms. Minimum inhibitory concentrations of 8 antimicrobials were determined by Etest and interpreted using European Committee on Antimicrobial Susceptibility Testing breakpoints. β-lactamase production was detected using cefinase disks. RESULTS The level of resistance, examining 212 gonococcal isolates, was as follows: 84.9% to tetracycline, 68.9% to benzylpenicillin, 62.7% to ciprofloxacin, 6.1% to azithromycin, and 1.4% to gentamicin. All isolates were susceptible to ceftriaxone, cefixime and spectinomycin. CONCLUSIONS We provide the first gonococcal AMR data, quality assured according to World Health Organization standards, from Côte d'Ivoire since more than 20 years. The high ciprofloxacin resistance, which informed a revision of the national syndromic management guideline during study, and relatively high resistance to azithromycin demand an improved gonococcal antimicrobial surveillance program and increased awareness when prescribing treatment in Côte d'Ivoire.
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Attram N, Agbodzi B, Dela H, Behene E, Nyarko EO, Kyei NNA, Larbi JA, Lawson BWL, Addo KK, Newman MJ, Duplessis CA, Adams N, Unemo M, Letizia AG. Antimicrobial resistance (AMR) and molecular characterization of Neisseria gonorrhoeae in Ghana, 2012-2015. PLoS One 2019; 14:e0223598. [PMID: 31600300 PMCID: PMC6786528 DOI: 10.1371/journal.pone.0223598] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 09/24/2019] [Indexed: 12/13/2022] Open
Abstract
Neisseria gonorrhoeae antimicrobial resistance (AMR) surveillance is essential for tracking the emergence and spread of AMR strains in local, national and international populations. This is crucial for developing or refining treatment guidelines. N. gonorrhoeae multiantigen sequence typing (NG-MAST) is beneficial for describing the molecular epidemiology of gonococci at national and international levels. Elucidation of AMR determinants to β-lactam drugs, is a means of monitoring the development of resistance. In Ghana, little is known about the current gonococcal AMR prevalence and no characterization of gonococcal isolates has been previously performed. In this study, gonococcal isolates (n = 44) collected from five health facilities in Ghana from 2012 to 2015, were examined using AMR testing, NG-MAST and sequencing of penA. High rates of resistance were identified to tetracycline (100%), benzylpenicillin (90.9%), and ciprofloxacin (81.8%). One isolate had a high cefixime MIC (0.75 μg/ml). Twenty-eight NG-MAST sequence types (STs) were identified, seventeen of which were novel. The isolate with the high cefixime MIC contained a mosaic penA-34 allele and belonged to NG-MAST ST1407, an internationally spreading multidrug-resistant clone that has accounted for most cefixime resistance in many countries. In conclusion, AMR testing, NG-MAST, and sequencing of the AMR determinant penA, revealed high rates of resistance to tetracycline, benzylpenicillin, and ciprofloxacin; as well as a highly diverse population of N. gonorrhoeae in Ghana. It is imperative to continue with enhanced AMR surveillance and to understand the molecular epidemiology of gonococcal strains circulating in Ghana and other African countries.
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Affiliation(s)
- Naiki Attram
- US Naval Medical Research Unit Number Three, Ghana Laboratory, Legon, Ghana
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
- * E-mail: ,
| | - Bright Agbodzi
- US Naval Medical Research Unit Number Three, Ghana Laboratory, Legon, Ghana
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
| | - Helena Dela
- US Naval Medical Research Unit Number Three, Ghana Laboratory, Legon, Ghana
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
| | - Eric Behene
- US Naval Medical Research Unit Number Three, Ghana Laboratory, Legon, Ghana
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
| | | | | | - John A. Larbi
- Department of Theoretical and Applied Biology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Bernard W. L. Lawson
- Department of Theoretical and Applied Biology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kennedy K. Addo
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
| | - Mercy J. Newman
- Department of Medical Microbiology, School of Biomedical and Allied Health Science, College of Health Sciences, University of Ghana, Accra, Ghana
| | | | - Nehkonti Adams
- US Naval Medical Research Unit Number Three, Ghana Laboratory, Legon, Ghana
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Andrew G. Letizia
- US Naval Medical Research Unit Number Three, Ghana Laboratory, Legon, Ghana
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Antimicrobial Susceptibility of Neisseria gonorrhoeae Isolates in Yaoundé, Cameroon From 2009 to 2014. Sex Transm Dis 2019; 45:e101-e103. [PMID: 30234796 DOI: 10.1097/olq.0000000000000915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We investigated the antimicrobial resistance in gonococci 2009 to 2014 in Yaoundé, Cameroon, and recommend revisions of the Cameroonian treatment guideline. We observed a high resistance to ciprofloxacin (17.6%) but no ceftriaxone resistance. Ceftriaxone should replace ciprofloxacin as the recommended first-line treatment for urethral/vaginal discharge. Enhanced resistance surveillance in Africa is essential.
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Mlynarczyk-Bonikowska B, Malejczyk M, Majewski S, Unemo M. Antibiotic resistance and NG-MAST sequence types of Neisseria gonorrhoeae isolates in Poland compared to the world. Postepy Dermatol Alergol 2018; 35:346-551. [PMID: 30618519 PMCID: PMC6320495 DOI: 10.5114/ada.2018.79780] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/12/2018] [Indexed: 11/17/2022] Open
Abstract
Gonorrhoea is one of the most common sexually transmitted infections and in 2012, the World Health Organization estimated about 78 million of new global urogenital cases among adults per year. The main concern during the latest decade has been the emergence and spread of multidrug-resistant strains of Neisseria gonorrhoeae. Resistance has emerged internationally to the extended-spectrum cephalosporins, ceftriaxone and cefixime, which are the last remaining options for empiric first-line monotherapy of gonorrhoea. In Poland, the levels of resistance to ciprofloxacin, benzylpenicillin and tetracycline are high, and the prevalence of azithromycin resistance has increased. However, no resistance to ceftriaxone has been identified. The currently spread multidrug-resistant strains frequently represent epidemic clones. The present paper reviews and describes the antimicrobial resistance and N. gonorrhoeae multiantigen sequence typing (NG-MAST) sequence types of N. gonorrhoeae strains spreading in Poland compared to the world.
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Affiliation(s)
| | - Magdalena Malejczyk
- Department of Diagnostics of Sexually Transmitted Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Sławomir Majewski
- Department of Diagnostics of Sexually Transmitted Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Magnus Unemo
- World Health Organization (WHO) Collaborating Centre for Gonorrhoea and other STIs, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Latif AS, Gwanzura L, Machiha A, Ndowa F, Tarupiwa A, Gudza-Mugabe M, Shukusho FD, Chakanyuka Musanhu C, Wi T, Unemo M. Antimicrobial susceptibility in Neisseria gonorrhoeae isolates from five sentinel surveillance sites in Zimbabwe, 2015-2016. Sex Transm Infect 2017; 94:62-66. [PMID: 28476914 DOI: 10.1136/sextrans-2016-053090] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/28/2017] [Accepted: 04/18/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Gonorrhoea and antimicrobial resistance (AMR) in Neisseria gonorrhoeae are major public health concerns worldwide. Enhanced AMR surveillance for gonococci is essential globally. In Zimbabwe, very limited gonococcal AMR data were reported. Our aims were to (i) implement quality-assured gonococcal AMR surveillance in Zimbabwe and (ii) investigate gonococcal AMR at five health centres in 2015-2016. METHODS Gonococcal isolates from 104 men with urethral discharge were tested for susceptibility to kanamycin, ceftriaxone, cefixime, ciprofloxacin and azithromycin using Etest. RESULTS All isolates (102 possible to test) were susceptible to ceftriaxone and cefixime. The level of resistance (intermediate resistance) to kanamycin and ciprofloxacin was 2.0% (2.0%) and 18.6% (27.5%), respectively. The two kanamycin-resistant isolates (R≥128 mg/L) had a kanamycin minimum inhibitory concentration (MIC) of >256 mg/L. The ciprofloxacin resistance ranged from 9.5% to 30.8% in the five sentinel sites. Only 10 (9.6%) of the isolates were tested for susceptibility to azithromycin and 1 (10.0%) was resistant (MIC=4 mg/L). CONCLUSIONS The emergence of multidrug-resistant gonorrhoea internationally is a major public health concern and gonococcal AMR surveillance is crucial globally. In Zimbabwe, gonococcal AMR surveillance has now been implemented and quality assured according to WHO standards. The results of this first surveillance will be used to directly inform revisions of the national treatment guidelines. It is imperative to further strengthen the surveillance of gonococcal AMR, and ideally also treatment failures, in Zimbabwe and most countries in the WHO African region, which requires continuous national and international support, including technical support, and political and financial commitment.
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Affiliation(s)
| | - Lovemore Gwanzura
- Department of Medical Laboratory Sciences, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Anna Machiha
- STI, HIV/AIDS and TB Programmes, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Francis Ndowa
- STI, HIV/AIDS and TB Programmes, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Andrew Tarupiwa
- National Microbiology Reference Laboratory, Southerton, Harare, Zimbabwe
| | | | - Fungai D Shukusho
- National Microbiology Reference Laboratory, Southerton, Harare, Zimbabwe
| | | | - Teodora Wi
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Magnus Unemo
- World Health Organization Collaborating Centre for Gonorrhoea and other STIs, Örebro University, Örebro, Sweden
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Giguère K, Alary M. Targeting core groups for gonorrhoea control: feasibility and impact. Sex Transm Infect 2015; 91:241-4. [PMID: 25926404 DOI: 10.1136/sextrans-2014-051732] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/02/2014] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE We aimed to outline why core groups should be targeted in Neisseria gonorrhoeae control and suggest several important and timely interventions to target core groups while highly resistant strains are spreading. METHODS Core group definition, feasibility and impact of gonorrhoea core group interventions as well as gonorrhoea resistance development have been reviewed in the paper. RESULTS Core group interventions have proven effective in gonorrhoea control in the past but are compromised by the spread of highly resistant strains. CONCLUSIONS Worldwide functional Gonorrhoea Antimicrobial Surveillance Program, better screening and better treatment programmes are needed. Prevention through condom promotion aimed at core groups remains essential. More specific treatment guidance for low-income and middle-income countries without resistance data is required in the meantime to achieve a better use of antibiotics.
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Affiliation(s)
- Katia Giguère
- Centre de recherche du CHU de Québec, Québec, Canada Département de médecine sociale et préventive, Université Laval, Québec, Canada
| | - Michel Alary
- Centre de recherche du CHU de Québec, Québec, Canada Département de médecine sociale et préventive, Université Laval, Québec, Canada Institut national de santé publique du Québec, Québec, Canada
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