1
|
Jorge-Berrocal A, Vargas-Herrera N, Benites C, Salazar-Quispe F, Mayta-Barrios M, Barrios-Cárdenas YJ, Melano RG, Yagui M. Antimicrobial Susceptibility of Neisseria gonorrhoeae Isolates From Peru, 2018 and 2019. Sex Transm Dis 2022; 49:682-686. [PMID: 35858477 DOI: 10.1097/olq.0000000000001678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Currently, in Latin America, including Peru, the treatment of gonorrhea is still empiric and information regarding antimicrobial resistance is scarce in some countries because of the limited resources, which can contribute to the rising rates of reported multidrug-resistant gonococcal strains. In that context, it is mandatory to continuously monitor and report antimicrobial resistance in N. gonorrhoeae to update treatment recommendations. METHODS This descriptive study analyzed genital and anal samples from symptomatic patients who attended 15 sexually transmitted infections health facilities from 8 different regions in Peru during the years 2018 to 2019 within the framework of Sentinel Surveillance. After establishing the presumptive diagnosis, the isolates were sent to the Laboratory of Sexually Transmitted Bacteria of the National Institute of Health of Peru in Lima where the species were confirmed (N = 165) and susceptibility profiles were determined. RESULTS Among the 165 isolates, 95.2% corresponded to male patients, between 18 and 22 years of age (40.6%), half reported having a sexual partner and being heterosexual. Clinically, 89.7% manifested the presence of urethral exudate. Microbiology showed 95.2% of the isolates resistant to ciprofloxacin and 9.1% non-susceptible to azithromycin. Reduced susceptibility to ceftriaxone and cefixime was observed in 1.2% and 3.6% of the isolates respectively. All strains tested were susceptible to spectinomycin. CONCLUSIONS This study demonstrated that in Peru, fluoroquinolones should not be recommended or used in N. gonorrhoeae infections due to the high percentage of resistant strains. In addition, nationwide access to gonococcal resistance testing, molecular diagnostics and antimicrobial stewardship should be implemented to control the spread of gonococcal antimicrobial resistance.
Collapse
|
2
|
Martins JM, Scheffer MC, de Melo Machado H, Schörner MA, Golfetto L, Santos TM, Barazzetti FH, de Albuquerque VCB, Bazzo ML. Spectinomycin, gentamicin, and routine disc diffusion testing: An alternative for the treatment and monitoring of multidrug-resistant Neisseria gonorrhoeae? J Microbiol Methods 2022; 197:106480. [DOI: 10.1016/j.mimet.2022.106480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/29/2022] [Accepted: 04/29/2022] [Indexed: 11/29/2022]
|
3
|
Cassu-Corsi D, Santos FF, Cayô R, Martins WM, Nodari CS, Almeida LG, Martins RA, Carvalho da Silva RJ, Vasconcelos ATR, Pignatari AC, Gales AC. Genomic analyses of ciprofloxacin-resistant Neisseria gonorrhoeae isolates recovered from the largest South American metropolitan area. Genomics 2022; 114:110287. [DOI: 10.1016/j.ygeno.2022.110287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 11/11/2021] [Accepted: 01/31/2022] [Indexed: 11/04/2022]
|
4
|
Carlos CC, Masim MAL, Lagrada ML, Gayeta JM, Macaranas PKV, Sia SB, Facun MAM, Palarca JFC, Olorosa AM, Cueno GAC, Abrudan M, Abudahab K, Argimón S, Kekre M, Underwood A, Stelling J, Aanensen DM. Genome Sequencing Identifies Previously Unrecognized Klebsiella pneumoniae Outbreaks in Neonatal Intensive Care Units in the Philippines. Clin Infect Dis 2021; 73:S316-S324. [PMID: 34850834 PMCID: PMC8634409 DOI: 10.1093/cid/ciab776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Klebsiella pneumoniae is a critically important pathogen in the Philippines. Isolates are commonly resistant to at least 2 classes of antibiotics, yet mechanisms and spread of its resistance are not well studied. METHODS A retrospective sequencing survey was performed on carbapenem-, extended spectrum beta-lactam-, and cephalosporin-resistant Klebsiella pneumoniae isolated at 20 antimicrobial resistance (AMR) surveillance sentinel sites from 2015 through 2017. We characterized 259 isolates using biochemical methods, antimicrobial susceptibility testing, and whole-genome sequencing (WGS). Known AMR mechanisms were identified. Potential outbreaks were investigated by detecting clusters from epidemiologic, phenotypic, and genome-derived data. RESULTS Prevalent AMR mechanisms detected include blaCTX-M-15 (76.8%) and blaNDM-1 (37.5%). An epidemic IncFII(Yp) plasmid carrying blaNDM-1 was also detected in 46 isolates from 6 sentinel sites and 14 different sequence types (STs). This plasmid was also identified as the main vehicle of carbapenem resistance in 2 previously unrecognized local outbreaks of ST348 and ST283 at 2 different sentinel sites. A third local outbreak of ST397 was also identified but without the IncFII(Yp) plasmid. Isolates in each outbreak site showed identical STs and K- and O-loci, and similar resistance profiles and AMR genes. All outbreak isolates were collected from blood of children aged < 1 year. CONCLUSION WGS provided a better understanding of the epidemiology of multidrug resistant Klebsiella in the Philippines, which was not possible with only phenotypic and epidemiologic data. The identification of 3 previously unrecognized Klebsiella outbreaks highlights the utility of WGS in outbreak detection, as well as its importance in public health and in implementing infection control programs.
Collapse
Affiliation(s)
- Celia C Carlos
- Research Institute for Tropic al Medicine, Muntinlupa, the Philippines
| | | | | | - June M Gayeta
- Research Institute for Tropic al Medicine, Muntinlupa, the Philippines
| | | | - Sonia B Sia
- Research Institute for Tropic al Medicine, Muntinlupa, the Philippines
| | | | | | | | | | - Monica Abrudan
- Centre for Genomic Pathogen Surveillance, Wellcome Genome Campus, Hinxton, Cambridge, UK
| | - Khalil Abudahab
- Centre for Genomic Pathogen Surveillance, Wellcome Genome Campus, Hinxton, Cambridge, UK
| | - Silvia Argimón
- Centre for Genomic Pathogen Surveillance, Wellcome Genome Campus, Hinxton, Cambridge, UK
| | - Mihir Kekre
- Centre for Genomic Pathogen Surveillance, Wellcome Genome Campus, Hinxton, Cambridge, UK
| | - Anthony Underwood
- Centre for Genomic Pathogen Surveillance, Wellcome Genome Campus, Hinxton, Cambridge, UK
- Brigham and Women’s Hospital, Boston, MA, USA
| | | | - David M Aanensen
- Centre for Genomic Pathogen Surveillance, Wellcome Genome Campus, Hinxton, Cambridge, UK
- Centre for Genomic Pathogen Surveillance, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| |
Collapse
|
5
|
Gianecini RA, Poklepovich T, Golparian D, Cuenca N, Tuduri E, Unemo M, Campos J, Galarza P. Genomic Epidemiology of Azithromycin-Nonsusceptible Neisseria gonorrhoeae, Argentina, 2005-2019. Emerg Infect Dis 2021; 27:2369-2378. [PMID: 34424175 PMCID: PMC8386799 DOI: 10.3201/eid2709.204843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Azithromycin-nonsusceptible Neisseria gonorrhoeae strains are an emerging global public health threat. During 2015–2018, the prevalence of azithromycin-nonsusceptible gonococcal infection increased significantly in Argentina. To investigate the genomic epidemiology and resistance mechanisms of these strains, we sequenced 96 nonsusceptible isolates collected in Argentina during 2005–2019. Phylogenomic analysis revealed 2 main clades, which were characterized by a limited geographic distribution, circulating during January 2015–November 2019. These clades included the internationally spreading multilocus sequence types (STs) 1580 and 9363. The ST1580 isolates, which had MICs of 2–4 μg/mL, had mutations in the 23S rRNA. The ST9363 isolates, which had MICs of 2–4 or >256 μg/mL, had mutations in the 23S rRNA, a mosaic mtr locus, or both. Identifying the geographic dissemination and characteristics of these predominant clones will guide public health policies to control the spread of azithromycin-nonsusceptible N. gonorrhoeae in Argentina.
Collapse
|
6
|
Salmerón P, Moreno-Mingorance A, Trejo J, Amado R, Viñado B, Cornejo-Sanchez T, Alberny M, Barbera MJ, Arando M, Pumarola T, Hoyos-Mallecot Y, Serra-Pladevall J, González-López JJ. Emergence and dissemination of three mild outbreaks of Neisseria gonorrhoeae with high-level resistance to azithromycin in Barcelona, 2016-18. J Antimicrob Chemother 2021; 76:930-935. [PMID: 33367806 DOI: 10.1093/jac/dkaa536] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/02/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Neisseria gonorrhoeae (NG) isolates with high-level azithromycin resistance (HL-AziR) have emerged worldwide in recent decades, threatening the sustainability of current dual-antimicrobial therapy. OBJECTIVES This study aimed to characterize the first 16 NG isolates with HL-AziR in Barcelona between 2016 and 2018. METHODS WGS was used to identify the mechanisms of antimicrobial resistance, to establish the MLST ST, NG multiantigen sequence typing (NG-MAST) ST and NG sequence typing for antimicrobial resistance (NG-STAR) ST and to identify the clonal relatedness of the isolates with other closely related NG previously described in other countries based on a whole-genome SNP analysis approach. The sociodemographic characteristics of the patients included in the study were collected by comprehensive review of their medical records. RESULTS Twelve out of 16 HL-AziR isolates belonged to the MLST ST7823/NG-MAST ST5309 genotype and 4 to MLST ST9363/NG-MAST ST3935. All presented the A2059G mutation in all four alleles of the 23S rRNA gene. MLST ST7823/NG-MAST ST5309 isolates were only identified in men who have sex with women and MLST ST9363/NG-MAST ST3935 were found in MSM. Phylogenomic analysis revealed the presence of three transmission clusters of three different NG strains independently associated with sexual behaviour. CONCLUSIONS Our findings support the first appearance of three mild outbreaks of NG with HL-AziR in Spain. These results highlight the continuous capacity of NG to develop antimicrobial resistance and spread among sexual networks. The enhanced resolution of WGS provides valuable information for outbreak investigation, complementing the implementation of public health measures focused on the prevention and dissemination of MDR NG.
Collapse
Affiliation(s)
- P Salmerón
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.,Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain
| | - A Moreno-Mingorance
- Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain.,Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - J Trejo
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - R Amado
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - B Viñado
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.,Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain
| | - T Cornejo-Sanchez
- Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - M Alberny
- Institut Català de Salut (ICS), Barcelona, Spain
| | - M J Barbera
- Drassanes-Vall d'Hebron Sexually Transmitted Infections Unit, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain
| | - M Arando
- Drassanes-Vall d'Hebron Sexually Transmitted Infections Unit, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - T Pumarola
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.,Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain.,Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Y Hoyos-Mallecot
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - J Serra-Pladevall
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.,Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain.,Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - J J González-López
- Department of Microbiology, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.,Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Barcelona, Spain.,Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| |
Collapse
|
7
|
Abstract
We report on the first high-level azithromycin-resistant Neisseria gonorrhoeae isolate (minimum inhibitory concentration, ≥256 μg/mL) in North Carolina isolated from a pharyngeal swab of a 33-year-old HIV-negative man who has sex with men. In addition, the isolate was found to be susceptible to cefixime, ceftriaxone, and penicillin and resistant to tetracycline. By whole-genome sequencing, the strain was assigned as MLST ST9363, NG-MAST ST5035, and a novel NG-STAR sequence type, ST1993.
Collapse
|
8
|
Holderman JL, Thomas JC, Schlanger K, Black JM, Town K, St. Cyr SB, Pham CD, Kirkcaldy RD. Sustained Transmission of Neisseria gonorrhoeae with High-Level Resistance to Azithromycin, in Indianapolis, Indiana, 2017–2018. Clin Infect Dis 2021; 73:808-815. [PMID: 34492693 PMCID: PMC10183473 DOI: 10.1093/cid/ciab132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/11/2021] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Since 2014, Neisseria gonorrhoeae azithromycin (AZM) susceptibility has declined in the United States, but high-level AZM resistance (HL-AZMR) has been infrequent and sporadic. We describe a cluster of 14 N. gonorrhoeae isolates with HL-AZMR identified in Indianapolis over 13 months.
Methods
N. gonorrhoeae culture specimens (genital and extragenital) were collected from attendees of the Bell Flower Clinic. Isolates underwent antimicrobial susceptibility testing (AST) using Etest. AZM minimum inhibitory concentrations ≥256 µg/mL were classified as HL-AZMR. Local disease intervention specialists interviewed patients whose isolates demonstrated HL-AZMR and conducted partner services. Relatedness of isolates was investigated by genomic analyses.
Results
During 2017–2018, AST was performed in 1016 N. gonorrhoeae isolates collected at the Bell Flower Clinic. Fourteen isolates (1.4%) from 12 men collected over 13 months demonstrated HL-AZMR; all were cephalosporin susceptible. Of the 12 men, 9 were white and reported male sex partners. Nine of the men were able to be retested; all were cured with 250-mg ceftriaxone plus 1-g AZM. Two men named each other as partners; no other partners in common were reported. Genomic analysis demonstrated close relatedness of the HL-AZMR isolates and a novel combination of a mosaic-mtrR promoter along with 23S ribosomal RNA mutations that appear to have emerged from circulating strains.
Conclusions
The close genetic relatedness with limited epidemiologic linkages between patients highlights the challenges of gonorrhea partner investigations and suggests undetected local transmission. Local AST, rapid public health action, and epidemiologic investigations combined with genomic analysis provides a multipronged approach to understanding an outbreak of sexually transmitted disease.
Collapse
Affiliation(s)
- Justin L Holderman
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Division of HIV, STD, and Viral Hepatitis Prevention, Indiana Department of Health, Indianapolis, Indiana, USA
| | - Jesse C Thomas
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Karen Schlanger
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jamie M Black
- Division of HIV, STD, and Viral Hepatitis Prevention, Indiana Department of Health, Indianapolis, Indiana, USA
| | - Katy Town
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sancta B St. Cyr
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Cau D Pham
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Robert D Kirkcaldy
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
9
|
The JAID/JSC guidelines to Clinical Management of Infectious Disease 2017 concerning male urethritis and related disorders. J Infect Chemother 2021; 27:546-554. [PMID: 33516669 DOI: 10.1016/j.jiac.2019.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 10/24/2019] [Accepted: 12/03/2019] [Indexed: 11/24/2022]
|
10
|
Atypical Mutation in Neisseria gonorrhoeae 23S rRNA Associated with High-Level Azithromycin Resistance. Antimicrob Agents Chemother 2021; 65:AAC.00885-20. [PMID: 33139288 DOI: 10.1128/aac.00885-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/20/2020] [Indexed: 01/23/2023] Open
Abstract
A2059G mutation in the 23S rRNA gene is the only reported mechanism conferring high-level azithromycin resistance (HL-AZMR) in Neisseria gonorrhoeae Through U.S. gonococcal antimicrobial resistance surveillance projects, we identified four HL-AZMR gonococcal isolates lacking this mutational genotype. Genetic analysis revealed an A2058G mutation of 23S rRNA alleles in all four isolates. In vitro selected gonococcal strains with homozygous A2058G recapitulated the HL-AZMR phenotype. Taken together, we postulate that the A2058G mutation confers HL-AZMR in N. gonorrhoeae.
Collapse
|
11
|
Mensforth S, Ross JDC. Should we still use azithromycin for gonorrhoea treatment? Sex Health 2020; 16:442-448. [PMID: 31207203 DOI: 10.1071/sh19016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 03/07/2019] [Indexed: 11/23/2022]
Abstract
This review presents the evidence for azithromycin in the treatment of gonorrhoea, both as monotherapy and as a component of dual therapy. Uncertainties are explored regarding the efficacy of a dual treatment strategy, combining ceftriaxone and azithromycin, in the context of resistance trends and extra-genital infections. The association between microbiological testing and clinical outcome for the individual patient, and the effect of azithromycin use on other sexually transmissible infections, are considered. Finally, in the absence of imminent new antimicrobials, optimising the dose of azithromycin while maintaining tolerability is discussed.
Collapse
Affiliation(s)
- Sarah Mensforth
- Department of Sexual Health and HIV, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2GW, UK; and Corresponding author.
| | - Jonathan D C Ross
- Department of Sexual Health and HIV, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2GW, UK
| |
Collapse
|
12
|
Ross JD, Harding J, Duley L, Montgomery AA, Hepburn T, Tan W, Brittain C, Meakin G, Sprange K, Thandi S, Jackson L, Roberts T, Wilson J, White J, Dewsnap C, Cole M, Lawrence T. Gentamicin as an alternative to ceftriaxone in the treatment of gonorrhoea: the G-TOG non-inferiority RCT. Health Technol Assess 2020; 23:1-104. [PMID: 31099330 DOI: 10.3310/hta23200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Gonorrhoea is a common sexually transmitted infection that can cause pain and discomfort, affect fertility in women and lead to epididymo-orchitis in men. Current treatment is with ceftriaxone, but there is increasing evidence of antimicrobial resistance reducing its effectiveness. Gentamicin is a potential alternative treatment requiring further evaluation. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of gentamicin as an alternative treatment to ceftriaxone in the treatment of gonorrhoea. DESIGN A multicentre, parallel-group, blinded, non-inferiority randomised controlled trial. SETTING Fourteen sexual health clinics in England. PARTICIPANTS Adults aged 16-70 years with a diagnosis of uncomplicated, untreated genital, pharyngeal or rectal gonorrhoea based on a positive Gram-stained smear on microscopy or a positive nucleic acid amplification test (NAAT). RANDOMISATION AND BLINDING Participants were randomised using a secure web-based system, stratified by clinic. Participants, investigators and research staff assessing participants were blinded to treatment allocation. INTERVENTIONS Allocation was to either 240 mg of gentamicin (intervention) or 500 mg of ceftriaxone (standard treatment), both administered as a single intramuscular injection. All participants also received 1 g of oral azithromycin. MAIN OUTCOME MEASURE The primary outcome measure was clearance of Neisseria gonorrhoeae at all infected sites, confirmed by a negative Aptima Combo 2® (Hologic Inc., Marlborough, MA, USA) NAAT, at 2 weeks post treatment. RESULTS We randomised 720 participants, of whom 81% were men. There were 358 participants in the gentamicin group and 362 in the ceftriaxone group; 292 (82%) and 306 (85%) participants, respectively, were included in the primary analysis. Non-inferiority of gentamicin to ceftriaxone could not be demonstrated [adjusted risk difference for microbiological clearance -6.4%, 95% confidence interval (CI) -10.4% to -2.4%]. Clearance of genital infection was similar in the two groups, at 94% in the gentamicin group and 98% in the ceftriaxone group, but clearance of pharyngeal infection and rectal infection was lower in the gentamicin group (80% vs. 96% and 90% vs. 98%, respectively). Reported pain at the injection site was higher for gentamicin than for ceftriaxone. The side-effect profiles were comparable between the groups. Only one serious adverse event was reported and this was deemed not to be related to the trial medication. The economic analysis found that treatment with gentamicin is not cost neutral compared with standard care, with average patient treatment costs higher for those allocated to gentamicin (£13.90, 95% CI £2.47 to £37.34) than to ceftriaxone (£6.72, 95% CI £1.36 to £17.84). LIMITATIONS Loss to follow-up was 17% but was similar in both treatment arms. Twelve per cent of participants had a negative NAAT for gonorrhoea at their baseline visit but this was balanced between treatment groups and unlikely to have biased the trial results. CONCLUSIONS The trial was unable to demonstrate non-inferiority of gentamicin compared with ceftriaxone in the clearance of gonorrhoea at all infected sites. Clearance at pharyngeal and rectal sites was lower for participants allocated to gentamicin than for those allocated to ceftriaxone, but was similar for genital sites in both groups. Gentamicin was associated with more severe injection site pain. However, both gentamicin and ceftriaxone appeared to be well tolerated. FUTURE WORK Exploration of the genetic determinants of antibiotic resistance in N. gonorrhoeae will help to identify accurate markers of decreased susceptibility. Greater understanding of the immune response to infection can assist gonococcal vaccine development. TRIAL REGISTRATION Current Controlled Trials ISRCTN51783227. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 20. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Jonathan Dc Ross
- Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jan Harding
- Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Wei Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Clare Brittain
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Garry Meakin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Sukhwinder Thandi
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Louise Jackson
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Tracy Roberts
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - John White
- Burrell Street Clinic, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Michelle Cole
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI), National Infection Service, Public Health England, London, UK
| | - Tessa Lawrence
- Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
13
|
Zheng Z, Liu L, Shen X, Yu J, Chen L, Zhan L, Chen H, Lin C, Jiang Y, Xia H, Wang L, Yu F. Antimicrobial Resistance And Molecular Characteristics Among Neisseria gonorrhoeae Clinical Isolates In A Chinese Tertiary Hospital. Infect Drug Resist 2019; 12:3301-3309. [PMID: 31695449 PMCID: PMC6815782 DOI: 10.2147/idr.s221109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/25/2019] [Indexed: 01/15/2023] Open
Abstract
Purpose The resistance of N. gonorrhoeae to antimicrobial agents has been increasing year by year due to the overuse of antibiotics. The primary aims of the present study were to investigate the molecular characteristics of the clinical isolates of Neisseria gonorrhoeae and the resistance to azithromycin in a Chinese tertiary hospital. Methods From January 2014 to May 2017, a total of 55 clinical isolates of N. gonorrhoeae were collected. Genes associated with azithromycin resistance (AZM-R), including mutations in 23S rRNA alleles, the mtrR promoter and coding regions, and rplD and rplV were evaluated by PCR and DNA sequencing. All clinical isolates were subjected to N. gonorrhoeae multiantigen sequence typing (NG-MAST), while the AZM-R isolates were further characterized by multilocus sequence typing (MLST). Results The AZM-R rate in this study was 23.64% (13/55), and a single (A)-nucleotide deletion mutation in the mtrR promoter region, a G45D mutation in the mtrR coding region, a point mutation in rplD, and an A2047G mutation in 23S rRNA alleles were detected in 13, 4, 3 and 4 isolates, respectively; no mutations were found in rplV. There was no significant difference in the mtrR coding region mutation rate between the azithromycin-sensitive and AZM-R groups (P > 0.05); however, there was a significant difference in the mutation rate of the mtrR promoter region (P < 0.05). Among the 55 isolates studied, 43 distinct NG-MAST were determined, while the AZM-R isolates were allocated into 10 distinct MLST/NG-MAST combinations. All three isolates with high-level AZM-R belonged to the sequence types (STs) NG-MAST ST1866 and MLST ST10899. Conclusion N. gonorrhoeae clinical isolates from Wenzhou, eastern China, showed considerable genetic diversity. Measures should be implemented to monitor the spread of the NG-MAST ST1866 and MLST ST10899 N. gonorrhoeae clones, which exhibit high-level AZM-R in eastern China.
Collapse
Affiliation(s)
- Zhou Zheng
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Li Liu
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Xiaofei Shen
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Jingyi Yu
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Lijiang Chen
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Lingling Zhan
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Han Chen
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Chunchan Lin
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Ye Jiang
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Hong Xia
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Liangxing Wang
- Department of Respiratory Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, People's Republic of China
| | - Fangyou Yu
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China.,Department of Laboratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200443, People's Republic of China
| |
Collapse
|
14
|
Bazzo ML, Golfetto L, Gaspar PC, Pires AF, Ramos MC, Franchini M, Ferreira WA, Unemo M, Benzaken AS. First nationwide antimicrobial susceptibility surveillance for Neisseria gonorrhoeae in Brazil, 2015-16. J Antimicrob Chemother 2019; 73:1854-1861. [PMID: 29635367 DOI: 10.1093/jac/dky090] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/26/2018] [Indexed: 11/12/2022] Open
Abstract
Objectives Gonorrhoea and antimicrobial resistance (AMR) in Neisseria gonorrhoeae are major public health concerns globally. Enhanced AMR surveillance for gonococci is essential worldwide; however, recent quality-assured gonococcal AMR surveillance in Latin America, including Brazil, has been limited. Our aims were to (i) establish the first nationwide gonococcal AMR surveillance, quality assured according to WHO standards, in Brazil, and (ii) describe the antimicrobial susceptibility of clinical gonococcal isolates collected from 2015 to 2016 in all five main regions (seven sentinel sites) of Brazil. Methods Gonococcal isolates from 550 men with urethral discharge were examined for susceptibility to ceftriaxone, cefixime, azithromycin, ciprofloxacin, benzylpenicillin and tetracycline using the agar dilution method, according to CLSI recommendations and quality assured according to WHO standards. Results The levels of resistance (intermediate susceptibility) to tetracycline, ciprofloxacin, benzylpenicillin and azithromycin were 61.6% (34.2%), 55.6% (0.5%), 37.1% (60.4%) and 6.9% (8.9%), respectively. All isolates were susceptible to ceftriaxone and cefixime using the US CLSI breakpoints. However, according to the European EUCAST cefixime breakpoints, 0.2% (n = 1) of isolates were cefixime resistant and 6.9% (n = 38) of isolates had a cefixime MIC bordering on resistance. Conclusions This study describes the first national surveillance of gonococcal AMR in Brazil, which was quality assured according to WHO standards. The high resistance to ciprofloxacin (which promptly informed a revision of the Brazilian sexually transmitted infection treatment guideline), emerging resistance to azithromycin and decreasing susceptibility to extended-spectrum cephalosporins necessitate continuous surveillance of gonococcal AMR and ideally treatment failures, and increased awareness when prescribing treatment in Brazil.
Collapse
Affiliation(s)
- M L Bazzo
- Molecular Biology, Microbiology and Serology Laboratory, Federal University of Santa Catarina, Florianópolis, Brazil
| | - L Golfetto
- Molecular Biology, Microbiology and Serology Laboratory, Federal University of Santa Catarina, Florianópolis, Brazil
| | - P C Gaspar
- Department of Surveillance, Prevention and Control of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis, Ministry of Health, Brasilia, Brazil
| | - A F Pires
- Department of Surveillance, Prevention and Control of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis, Ministry of Health, Brasilia, Brazil.,University of Brasilia Postgraduate Program in Collective Health, Brasilia, Brazil
| | - M C Ramos
- Brazilian STD Society, Porto Alegre, Brazil
| | | | | | - M Unemo
- WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - A S Benzaken
- Department of Surveillance, Prevention and Control of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis, Ministry of Health, Brasilia, Brazil
| | | |
Collapse
|
15
|
Emergence and Spread of Neisseria gonorrhoeae Strains with High-Level Resistance to Azithromycin in Taiwan from 2001 to 2018. Antimicrob Agents Chemother 2019; 63:AAC.00773-19. [PMID: 31235631 DOI: 10.1128/aac.00773-19] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/17/2019] [Indexed: 01/17/2023] Open
Abstract
A total of 598 Neisseria gonorrhoeae isolates obtained from patients in Taiwan from 2001 to 2018 were evaluated. The MICs of ceftriaxone (CRO) and azithromycin (AZM) against the isolates were determined by the agar dilution method. N. gonorrhoeae isolates with AZM MICs of ≥1 μg/ml were identified and characterized by the presence of AZM resistance determinants. For high-level AZM-resistant (AZM-HLR) isolates (MIC ≥ 256 μg/ml), genotyping was performed using multilocus sequence typing (MLST) and N. gonorrhoeae multiantigen sequence typing (NG-MAST). Among the N. gonorrhoeae isolates studied, 8.7% (52/598) exhibited AZM MICs of ≥1 μg/ml. Thirteen of the 52 isolates contained A2059G (23S rRNA NG-STAR type 1) or C2611T (23S rRNA NG-STAR type 2) mutations. The prevalence of the A2059G mutation was higher in AZM-HLR isolates (P < 0.001). The -35A deletion in the promoter region of the mtrR gene did not differ between AZM-HLR isolates (100%, 10/10) and the isolates with AZM MICs of 1 μg/ml to 64 μg/ml (95.2%, 40/42) (P = 1.000). The presence of mutations in the mtrR coding region was significantly different between these two groups at 90% (9/10) and 26.2% (11/42), respectively (P < 0.001). The AZM-HLR isolates, all carrying four mutated A2059G alleles, a -35A deletion, and G45D, were classified as MLST 12039/10899 and NG-MAST 1866/16497. In conclusion, Taiwan is among the countries reporting gonococci with high-level resistance to AZM so that a single dose of 1 g ceftriaxone intramuscularly as the first choice for management of N. gonorrhoeae infection should be evaluated.
Collapse
|
16
|
Emergence of Neisseria gonorrhoeae Strains Harboring a Novel Combination of Azithromycin-Attenuating Mutations. Antimicrob Agents Chemother 2019; 63:AAC.02313-18. [PMID: 30917979 DOI: 10.1128/aac.02313-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/03/2019] [Indexed: 12/30/2022] Open
Abstract
The nimbleness of Neisseria gonorrhoeae to evade the effect of antibiotics has perpetuated the fight against antibiotic-resistant gonorrhea for more than 80 years. The ability to develop resistance to antibiotics is attributable to its indiscriminate nature in accepting and integrating exogenous DNA into its genome. Here, we provide data demonstrating a novel combination of the 23S rRNA A2059G mutation with a mosaic-multiple transferable resistance (mosaic-mtr) locus haplotype in 14 N. gonorrhoeae isolates with high-level azithromycin MICs (≥256 μg/ml), a combination that may confer more fitness than in previously identified isolates with high-level azithromycin resistance. To our knowledge, this is the first description of N. gonorrhoeae strains harboring this novel combination of resistance determinants. These strains were isolated at two independent jurisdictions participating in the Gonococcal Isolate Surveillance Project (GISP) and in the Strengthening the U.S. Response to Resistant Gonorrhea (SURRG) project. The data suggest that the genome of N. gonorrhoeae continues to shuffle its genetic material. These findings further illuminate the genomic plasticity of N. gonorrhoeae, which allows this pathogen to develop mutations to escape the inhibitory effects of antibiotics.
Collapse
|
17
|
Sánchez-Busó L, Harris SR. Using genomics to understand antimicrobial resistance and transmission in Neisseria gonorrhoeae. Microb Genom 2019; 5:e000239. [PMID: 30698520 PMCID: PMC6421347 DOI: 10.1099/mgen.0.000239] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 11/16/2018] [Indexed: 12/22/2022] Open
Abstract
Gonorrhoea infections are on the increase and strains that are resistant to all antimicrobials used to treat the disease have been found worldwide. These observations encouraged the World Health Organization to include Neisseria gonorrhoeae on their list of high-priority organisms in need of new treatments. Fortunately, concurrent resistance to both antimicrobials used in dual therapy is still rare. The fight against antimicrobial resistance (AMR) must begin from an understanding of how it evolves and spreads in sexual networks. Genome-based analyses have allowed the study of the gonococcal population dynamics and transmission, giving a novel perspective on AMR gonorrhoea. Here, we will review past, present and future treatment options for gonorrhoea and explain how genomics is helping to increase our understanding of the changing AMR and transmission landscape. This article contains data hosted by Microreact.
Collapse
Affiliation(s)
- Leonor Sánchez-Busó
- Infection Genomics, Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridgeshire, UK
| | - Simon R. Harris
- Infection Genomics, Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridgeshire, UK
| |
Collapse
|
18
|
Wang F, Liu J, Liu H, Huang J, Chen S, Chen X, Yin Y. Evaluation of the accuracy of molecular assays targeting the mutation A2059G for detecting high-level azithromycin resistance in Neisseria gonorrhoeae: a systematic review and meta-analysis. Infect Drug Resist 2018; 12:95-104. [PMID: 30643437 PMCID: PMC6312691 DOI: 10.2147/idr.s183754] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Neisseria gonorrhoeae resistance to azithromycin has become a significant public health concern globally, and high-level azithromycin-resistant (HL-AzmR) isolates have emerged frequently. However, high-level azithromycin resistance is considered to be caused by mutated alleles of 23S rRNA gene at position 2059, and identification of HL-AzmR isolates mainly relies on agar dilution method or E-test method. This study aimed to assess the accuracy of the molecular assays targeting the mutation A2059G for identifying HL-AzmR isolates and thereby determine the association between the mutation and high-level azithromycin resistance. METHODS Two researchers independently searched six databases to identify studies published from the launch of each database to October 15, 2017. The fixed effects model was used to estimate the pooled sensitivity rate, specificity rate, positive predictive value (PPV), and negative predictive value (NPV). Summary receiver operating characteristic curves were generated, and the area under the curve (AUC) was determined to estimate the overall performance of the assays. The Deeks' test was conducted to evaluate potential publication bias. RESULTS Ten relevant studies were included in the meta-analysis to assess the synthetic accuracy of the molecular assays. The molecular assays had the synthetic sensitivity rate of 97.8% and the synthetic specificity rate of 99.1%. And the aggregated PPV and NPV were 96.4% and 99.5%, respectively. AUC was 0.99, suggesting a close relation existing between the mutation A2059G and high-level azithromycin resistance. This indicated that the molecular assays targeting the mutation A2059G have relatively high overall accuracy for identifying HL-AzmR N. gonor-rhoeae isolates. Publication bias was statistically significant. CONCLUSION The mutation A2059G is the critical factor causing high-level azithromycin resistance. Hence, molecular methods are recommended to be put into clinical practice by commercialization, which will assist clinicians to prescribe more precisely.
Collapse
Affiliation(s)
- Feng Wang
- Department of STD Control Laboratory, Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Jingwei Liu
- Department of Reference STD Lab, National Center for STD Control, Chinese Center for Disease Control and Prevention, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China,
| | - Hongye Liu
- Department of Reference STD Lab, National Center for STD Control, Chinese Center for Disease Control and Prevention, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China,
| | - Jing Huang
- Department of STD Control Laboratory, Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Shaochun Chen
- Department of Reference STD Lab, National Center for STD Control, Chinese Center for Disease Control and Prevention, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China,
| | - Xiangsheng Chen
- Department of Reference STD Lab, National Center for STD Control, Chinese Center for Disease Control and Prevention, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China,
| | - Yueping Yin
- Department of Reference STD Lab, National Center for STD Control, Chinese Center for Disease Control and Prevention, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China,
| |
Collapse
|
19
|
Wu X, Qin X, Huang J, Wang F, Li M, Wu Z, Liu X, Pei J, Wu S, Chen H, Guo C, Xue Y, Tang S, Fang M, Lan Y, Ou J, Xie Z, Yu Y, Yang J, Chen W, Zhao Y, Zheng H. Determining the in vitro susceptibility of Neisseria gonorrhoeae isolates from 8 cities in Guangdong Province through an improved microdilution method. Diagn Microbiol Infect Dis 2018; 92:325-331. [PMID: 30292397 DOI: 10.1016/j.diagmicrobio.2018.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 05/27/2018] [Accepted: 06/06/2018] [Indexed: 10/14/2022]
Abstract
A microdilution method for the antibiotic susceptibility testing of Neisseria gonorrhoeae was established and improved, and the antibiotic resistance of N. gonorrhoeae samples isolated from 8 cities of Guangdong in 2016 was determined. The improved microdilution method was compared with the agar dilution method recommend by the World Health Organization (WHO) Western Pacific Region by testing the susceptibility of 100 clinical N. gonorrhoeae isolates. The essential agreement (EA), categorical agreement (CA), very major error (VME), major error (ME), and minor error (MIE) levels of the two methods were analyzed; the acceptable performance rates were measured as follows: ≥90% for EA or CA, ≤3% for VME or ME, and ≤7% for MIE. The EA, CA, VME, ME, and MIE of each method for 7 antibiotics, penicillin, tetracycline, ciprofloxacin, spectinomycin, ceftriaxone, cefixime, and azithromycin, were 96%-100%, 94%-100%, 0%-3%, 0%-2%, and 0%-6%, respectively. The Wilcoxon signed-rank test results indicated 94%-100% agreement between the 2 methods after excluding off-scale values (P > 0.05). The susceptibility of 634 N. gonorrhoeae strains to the 7 antibiotics above were tested through the microdilution method. The resistant rates of the isolates against ciprofloxacin, tetracycline, penicillin, and azithromycin were 99.8%, 88.3%, 53.8%, and 11%, and the percentages of the isolates with decreased susceptibility to ceftriaxone (minimum inhibitory concentration [MIC] ≥0.125 μg/mL) and cefixime (MIC ≥0.25 μg/mL) were 2.1% and 12%, respectively, in Guangdong. Among 8 cities, Shenzhen had the highest rates of resistance against penicillin (77.8%) and decreased susceptibility against ceftriaxone (5.6%). Zhuhai had the highest rates of decreased susceptibility against cefixime (30.1%), and Jiangmen had the highest azithromycin-resistant isolates (16.8%). The findings from this study indicated that the improved microdilution method is an alternative for testing the antimicrobial susceptibility of N. gonorrhoeae. The resistance rates of N. gonorrhoeae against penicillin, tetracycline, and ciprofloxacin were high. While ceftriaxone, cefixime, and spectinomycin remained effective against N. gonorrhoeae, their effectiveness seemed to be decreasing over time. Azithromycin therapy requires timely susceptibility test results.
Collapse
Affiliation(s)
- Xingzhong Wu
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Xiaolin Qin
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Jinmei Huang
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Feng Wang
- Shenzhen Center for Chronic Diseases Control, Shenzhen, Guangdong 518020, China
| | - Ming Li
- The fifth People's Hospital of Dongguan, Dongguan, Guangdong 523903, China
| | - Zhizhou Wu
- Jiangmen Dermatology Hospital, Jiangmen, Guangdong 529000, China
| | - Xiaofeng Liu
- Zhuhai Center for Chronic Diseases Control, Zhuhai, Guangdong 519099, China
| | - Junming Pei
- Shantou Dermatology Hospital, Shantou, Guangdong 515041, China
| | - Shanghua Wu
- Shaoguan Center for Chronic Diseases Control, Shaoguan, Guangdong 512026, China
| | - Heyong Chen
- Maoming Center for Chronic Diseases Control, Maoming, Guangdong 525099, China
| | - Chixing Guo
- Panyu Center for Chronic Diseases Control, Guangzhou, Guangdong 511400, China
| | - Yaohua Xue
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Sanmei Tang
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Mingheng Fang
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Yinyuan Lan
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Jiangli Ou
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Zhenmou Xie
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Yuqi Yu
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Jieyi Yang
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Wentao Chen
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Yunhu Zhao
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China
| | - Heping Zheng
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong 510091, China; Guangdong Provincial Dermatology Hospital, Guangzhou, Guangdong 510091, China; Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou, Guangdong 510091, China.
| |
Collapse
|
20
|
Ryan L, Golparian D, Fennelly N, Rose L, Walsh P, Lawlor B, Mac Aogáin M, Unemo M, Crowley B. Antimicrobial resistance and molecular epidemiology using whole-genome sequencing of Neisseria gonorrhoeae in Ireland, 2014-2016: focus on extended-spectrum cephalosporins and azithromycin. Eur J Clin Microbiol Infect Dis 2018; 37:1661-1672. [PMID: 29882175 DOI: 10.1007/s10096-018-3296-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 05/31/2018] [Indexed: 12/21/2022]
Abstract
High-level resistance and treatment failures with ceftriaxone and azithromycin, the first-line agents for gonorrhoea treatment are reported and antimicrobial-resistant Neisseria gonorrhoeae is an urgent public health threat. Our aims were to determine antimicrobial resistance rates, resistance determinants and phylogeny of N. gonorrhoeae in Ireland, 2014-2016. Overall, 609 isolates from four University Hospitals were tested for susceptibility to extended-spectrum cephalosporins (ESCs) and azithromycin by the MIC Test Strips. Forty-three isolates were whole-genome sequenced based on elevated MICs. The resistance rate to ceftriaxone, cefixime, cefotaxime and azithromycin was 0, 1, 2.1 and 19%, respectively. Seven high-level azithromycin-resistant (HLAzi-R) isolates were identified, all susceptible to ceftriaxone. Mosaic penA alleles XXXIV, X and non-mosaic XIII, and G120K plus A121N/D/G (PorB1b), H105Y (MtrR) and A deletion (mtrR promoter) mutations, were associated with elevated ESC MICs. A2059G and C2611T mutations in 23S rRNA were associated with HLAzi-R and azithromycin MICs of 4-32 mg/L, respectively. The 43 whole-genome sequenced isolates belonged to 31 NG-MAST STs. All HLAzi-R isolates belonged to MLST ST1580 and some clonal clustering was observed; however, the isolates differed significantly from the published HLAzi-R isolates from the ongoing UK outbreak. There is good correlation between previously described genetic antimicrobial resistance determinants and phenotypic susceptibility categories for ESCs and azithromycin in N. gonorrhoeae. This work highlights the advantages and potential of whole-genome sequencing to be applied at scale in the surveillance of antibiotic resistant strains of N. gonorrhoeae, both locally and internationally.
Collapse
Affiliation(s)
- L Ryan
- Department of Clinical Microbiology, St James's Hospital, Dublin, Ireland.
| | - D Golparian
- WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - N Fennelly
- Department of Clinical Microbiology, St James's Hospital, Dublin, Ireland
| | - L Rose
- Department of Clinical Microbiology, St James's Hospital, Dublin, Ireland
| | - P Walsh
- Department of Computing, Cork Institute of Technology, Cork, Ireland
| | - B Lawlor
- Department of Computing, Cork Institute of Technology, Cork, Ireland
| | - M Mac Aogáin
- Department of Clinical Microbiology, Trinity Translational Medicine Institute, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - M Unemo
- WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - B Crowley
- Department of Clinical Microbiology, St James's Hospital, Dublin, Ireland.,Department of Virology, St James's Hospital, Dublin, Ireland
| |
Collapse
|
21
|
Wan C, Li Y, Le WJ, Liu YR, Li S, Wang BX, Rice PA, Su XH. Increasing Resistance to Azithromycin in Neisseria gonorrhoeae in Eastern Chinese Cities: Resistance Mechanisms and Genetic Diversity among Isolates from Nanjing. Antimicrob Agents Chemother 2018; 62:e02499-17. [PMID: 29530847 PMCID: PMC5923098 DOI: 10.1128/aac.02499-17] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 02/23/2018] [Indexed: 12/20/2022] Open
Abstract
Azithromycin resistance (AZM-R) of Neisseria gonorrhoeae is emerging as a clinical and public health challenge. We determined molecular characteristics of recent AZM-R Nanjing gonococcal isolates and tracked the emergence of AZM-R isolates in eastern Chinese cities in recent years. A total of 384 N. gonorrhoeae isolates from Nanjing collected from 2013 to 2014 were tested for susceptibility to AZM and six additional antibiotics; all AZM-R strains were characterized genetically for resistance determinants by sequencing and were genotyped using N. gonorrhoeae multiantigen sequence typing (NG-MAST). Among the 384 isolates, 124 (32.3%) were AZM-R. High-level resistance (MIC, ≥256 mg/liter) was present in 10.4% (40/384) of isolates, all of which possessed the A2143G mutation in all four 23S rRNA alleles. Low- to mid-level resistance (MIC, 1 to 64 mg/liter) was present in 21.9% (84/384) of isolates, 59.5% of which possessed the C2599T mutation in all four 23S rRNA alleles. The 124 AZM-R isolates were distributed in 71 different NG-MAST sequence types (STs). ST1866 was the most prevalent type in high-level AZM-R (HL-AZM-R) isolates (45% [18/40]). This study, together with previous reports, revealed that the prevalence of AZM-R in N. gonorrhoeae isolates in certain eastern Chinese cities has risen >4-fold (7% to 32%) from 2008 to 2014. The principal mechanisms of AZM resistance in recent Nanjing isolates were A2143G mutations (high-level resistance) and C2599T mutations (low- to mid-level resistance) in the 23S rRNA alleles. Characterization of NG-MAST STs and phylogenetic analysis indicated the genetic diversity of N. gonorrhoeae in Nanjing; however, ST1866 was the dominant genotype associated with HL-AZM-R isolates.
Collapse
Affiliation(s)
- Chuan Wan
- STD Clinic, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Yang Li
- STD Clinic, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Wen-Jing Le
- STD Clinic, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Yu-Rong Liu
- STD Clinic, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Sai Li
- STD Clinic, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Bao-Xi Wang
- STD Clinic, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Peter A Rice
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Xiao-Hong Su
- STD Clinic, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
| |
Collapse
|
22
|
Sustained transmission of high-level azithromycin-resistant Neisseria gonorrhoeae in England: an observational study. THE LANCET. INFECTIOUS DISEASES 2018. [PMID: 29523496 DOI: 10.1016/s1473-3099(18)30122-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Between Nov 3, 2014, and Feb 24, 2017, 70 cases of high-level azithromycin-resistant (HL-AziR; minimum inhibitory concentration [MIC] ≥256 mg/L) Neisseria gonorrhoeae were reported from across England. Whole-genome sequencing was done to investigate this outbreak to determine whether the ongoing outbreak represented clonal spread of an HL-AziR N gonorrhoeae strain identified in Leeds. We also wanted to elucidate the molecular mechanisms of azithromycin resistance in N gonorrhoeae in the UK. METHODS In this observational study, whole-genome sequencing was done on the HL-AziR N gonorrhoeae isolates from England. As comparators, 110 isolates from the UK and Ireland with a range of azithromycin MICs were also sequenced, including eight isolates from Scotland with azithromycin MICs ranging from 0·12 mg/L to 1·00 mg/L that were N gonorrhoeae multi-antigen sequence type 9768 (ST9768), which was the sequence type initially responsible for the outbreak. The presence of mutations or genes associated with azithromycin resistance was also investigated. FINDINGS 37 of the 60 HL-AziR isolates from England belonged to ST9768, and were genetically similar (mean 4·3 single-nucleotide polymorphisms). A 2059A→G mutation was detected in three or all four alleles of the 23S rRNA gene. Five susceptible ST9768 isolates had one mutated 23S rRNA allele and one low-level resistant ST9768 isolate had two mutated alleles. INTERPRETATION Sustained transmission of a successful HL-AziR clone was seen across England. Mutation 2059A→G was found in isolates with lower azithromycin MICs. Azithromycin exposure might have provided the selection pressure for one or two mutated copies of the 23S rRNA gene to recombine with wild-type copies, leading to three or four mutated copies and the HL-AziR phenotype. HL-AziR could emerge in isolates with low azithromycin MICs and eliminate the effectiveness of azithromycin as part of dual therapy for the treatment of gonorrhoea. FUNDING Public Health England.
Collapse
|
23
|
Buder S, Dudareva S, Jansen K, Loenenbach A, Nikisins S, Sailer A, Guhl E, Kohl PK, Bremer V. Antimicrobial resistance of Neisseria gonorrhoeae in Germany: low levels of cephalosporin resistance, but high azithromycin resistance. BMC Infect Dis 2018; 18:44. [PMID: 29343220 PMCID: PMC5772720 DOI: 10.1186/s12879-018-2944-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 01/03/2018] [Indexed: 11/15/2022] Open
Abstract
Background The widespread antimicrobial resistance of Neisseria gonorrhoeae is a serious problem for the treatment and control of gonorrhoea. Many of the previously effective therapeutic agents are no longer viable. Because N. gonorrhoeae infections are not reportable in Germany, only limited data on disease epidemiology and antimicrobial susceptibility patterns are available. The Gonococcal Resistance Network (GORENET) is a surveillance project to monitor trends in the antimicrobial susceptibility of N. gonorrhoeae in Germany in order to guide treatment algorithms and target future prevention strategies. Methods Between April 2014 and December 2015, data on patient-related information were collected from laboratories nationwide, and susceptibility testing was performed on 537 N. gonorrhoeae isolates forwarded from the network laboratories to the Conciliar Laboratory for gonococci. Susceptibility results for cefixime, ceftriaxone, azithromycin, ciprofloxacin and penicillin were defined according to EUCAST 4.0 standards. Percentages, medians and interquartile ranges (IQR) were calculated. Results Altogether, 90% of isolates were from men. The median age was 32 (IQR 25–44) years for men and 25 (IQR 22–40) years for women (p-value < 0.001). The most frequently tested materials among men were urethral (96.1%) and rectal swabs (1.7%), and among women, it was mainly endocervical and vaginal swabs (84.3%). None of the isolates were resistant to ceftriaxone. Furthermore, 1.9% (in 2014) and 1.4% (in 2015) of the isolates were resistant to cefixime, 11.9% and 9.8% showed resistance against azithromycin, 72.0% and 58.3% were resistant to ciprofloxacin, and 29.1% and 18.8% were resistant to penicillin. Conclusions Resistance to ceftriaxone was not detected, and the percentage of isolates with resistance to cefixime was low, whereas azithromycin resistance showed high levels during the observation period. The rates of ciprofloxacin resistance and penicillin resistance were very high across Germany. Continued surveillance of antimicrobial drug susceptibilities for N. gonorrhoeae remains highly important to ensure efficient disease management.
Collapse
Affiliation(s)
- Susanne Buder
- German Consiliary Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany.
| | - Sandra Dudareva
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany. .,Charité University Medicine Berlin, Berlin, Germany.
| | - Klaus Jansen
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Anna Loenenbach
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Sergejs Nikisins
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.,Department of Infectious Diseases, Robert Koch Institute, Berlin, Germany.,European Public Health Microbiology Training (EUPHEM) programme, European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Andrea Sailer
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Eva Guhl
- German Consiliary Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany
| | - Peter K Kohl
- German Consiliary Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany
| | - Viviane Bremer
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | | |
Collapse
|
24
|
Abstract
BACKGROUND Gonococcal infections are difficult to treat because of their multidrug antimicrobial resistance. The outbreak of antimicrobial-resistant Neisseria gonorrhoeae has begun in Asia and particularly in Japan. Therefore, it is very important that we understand the trend of antimicrobial resistance of N. gonorrhoeae in Asia including Japan. Our surveillance of the antimicrobial susceptibility of N. gonorrhoeae began in 2000 under the guidance of the Department of Urology, Gifu University. We report our surveillance data from 2000 to 2015. METHODS We collected N. gonorrhoeae strains isolated from patients with gonococcal infections who visited our cooperating medical institutions in Japan from 2000 to 2015. MICs of penicillin G, cefixime, ceftriaxone, tetracycline, spectinomycin, azithromycin, and levofloxacin were determined by the agar dilution method approved by the Clinical and Laboratory Standards Institute. RESULTS From 2000 to 2015, 2471 isolates of N. gonorrhoeae were collected in Japan. High rates of nonsusceptibility to penicillin, tetracycline, levofloxacin, cefixime, and azithromycin were shown. Around 5% to 10% of the strains isolated had a 0.25-mg/L MIC of ceftriaxone in each year, and 6 strains (0.24%) with a 0.5-mg/L MIC of ceftriaxone were isolated throughout the study period. Approximately 5% to 10% of the strains were resistant to each of ceftriaxone, azithromycin, and levofloxacin according to European Committee on Antimicrobial Susceptibility Testing breakpoints, and the rate has not increased significantly. CONCLUSIONS From this study and previous pharmacodynamic analyses, a single 1-g dose of ceftriaxone is recommended to treat gonorrhea. As strains with high-level ceftriaxone resistance continue to spread, higher doses of ceftriaxone in monotherapy or multiple doses of ceftriaxone should be considered.
Collapse
|
25
|
Thakur SD, Araya P, Borthagaray G, Galarza P, Hernandez AL, Payares D, Sanabria Cruz OM, Carvallo MET, Corredor AH, Dillon JAR. Resistance to Ceftriaxone and Azithromycin in Neisseria gonorrhoeae Isolates From 7 Countries of South America and the Caribbean: 2010-2011. Sex Transm Dis 2017; 44:157-160. [PMID: 28178114 DOI: 10.1097/olq.0000000000000587] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Seven countries in Latin America and the Caribbean report on (2010 and 2011) the susceptibility of 2235 isolates of Neisseria gonorrhoeae to 6 antibiotics. Thirteen isolates had ceftriaxone minimum inhibitory concentrations (MICs) of 0.125 to ≥ 0.25 mg/L. The percentage of resistant isolates to the following antibiotics was: azithromycin, 1.0% to 1.7%; ciprofloxacin, 42.1% to 36.2%; penicillin, 31% to 35%; tetracycline, 21.8% to 22.6%.
Collapse
Affiliation(s)
- Sidharath Dev Thakur
- From the *Department of Microbiology, College of Medicine, †Vaccine and infectious Disease Organization-International Vaccine Center, University of Saskatchewan, Saskatchewan, Canada; ‡Instituto de Salud Publica de Chile, Santiago, Chile; §Faculdad de Quimica, Universidad de la Republica, Montivideo, Uruguay; ¶Instituto Nacional de Enfermedades Infecciosas-ANLIS "Dr Carlos Malbrán", Buenos Aires, Argentina; ∥Instituto de Medicina Tropical "Pedro Kouri", Ministerio Salud Publica, Habana, Cuba; **Instituto Nacional Higiene 'Rafael Rangel', Caracas, Venezuela; ††Instituto National de Salud, Bogota, Colombia; and ‡‡Centro Departmental de Vigilancia Information y Referencia, CDVIR La Paz, Bolivia
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Phylogeny and antimicrobial resistance in Neisseria gonorrhoeae isolates from Rio de Janeiro, Brazil. INFECTION GENETICS AND EVOLUTION 2017; 58:157-163. [PMID: 29225148 DOI: 10.1016/j.meegid.2017.12.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/02/2017] [Accepted: 12/05/2017] [Indexed: 11/22/2022]
|
27
|
Costa-Lourenço APRD, Barros Dos Santos KT, Moreira BM, Fracalanzza SEL, Bonelli RR. Antimicrobial resistance in Neisseria gonorrhoeae: history, molecular mechanisms and epidemiological aspects of an emerging global threat. Braz J Microbiol 2017; 48:617-628. [PMID: 28754299 PMCID: PMC5628311 DOI: 10.1016/j.bjm.2017.06.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 06/03/2017] [Accepted: 06/05/2017] [Indexed: 12/31/2022] Open
Abstract
Neisseria gonorrhoeae is the agent of gonorrhea, a sexually transmitted infection with an estimate from The World Health Organization of 78 million new cases in people aged 15-49 worldwide during 2012. If left untreated, complications may include pelvic inflammatory disease and infertility. Antimicrobial treatment is usually effective; however, resistance has emerged successively through various molecular mechanisms for all the regularly used therapeutic agents throughout decades. Detection of antimicrobial susceptibility is currently the most critical aspect for N. gonorrhoeae surveillance, however poorly structured health systems pose difficulties. In this review, we compiled data from worldwide reports regarding epidemiology and antimicrobial resistance in N. gonorrhoeae, and highlight the relevance of the implementation of surveillance networks to establish policies for gonorrhea treatment.
Collapse
Affiliation(s)
| | | | - Beatriz Meurer Moreira
- Institute of Microbiology, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Raquel Regina Bonelli
- Institute of Microbiology, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
| |
Collapse
|
28
|
Ellington MJ, Ekelund O, Aarestrup FM, Canton R, Doumith M, Giske C, Grundman H, Hasman H, Holden MTG, Hopkins KL, Iredell J, Kahlmeter G, Köser CU, MacGowan A, Mevius D, Mulvey M, Naas T, Peto T, Rolain JM, Samuelsen Ø, Woodford N. The role of whole genome sequencing in antimicrobial susceptibility testing of bacteria: report from the EUCAST Subcommittee. Clin Microbiol Infect 2016; 23:2-22. [PMID: 27890457 DOI: 10.1016/j.cmi.2016.11.012] [Citation(s) in RCA: 317] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 11/18/2016] [Indexed: 12/11/2022]
Abstract
Whole genome sequencing (WGS) offers the potential to predict antimicrobial susceptibility from a single assay. The European Committee on Antimicrobial Susceptibility Testing established a subcommittee to review the current development status of WGS for bacterial antimicrobial susceptibility testing (AST). The published evidence for using WGS as a tool to infer antimicrobial susceptibility accurately is currently either poor or non-existent and the evidence / knowledge base requires significant expansion. The primary comparators for assessing genotypic-phenotypic concordance from WGS data should be changed to epidemiological cut-off values in order to improve differentiation of wild-type from non-wild-type isolates (harbouring an acquired resistance). Clinical breakpoints should be a secondary comparator. This assessment will reveal whether genetic predictions could also be used to guide clinical decision making. Internationally agreed principles and quality control (QC) metrics will facilitate early harmonization of analytical approaches and interpretive criteria for WGS-based predictive AST. Only data sets that pass agreed QC metrics should be used in AST predictions. Minimum performance standards should exist and comparative accuracies across different WGS laboratories and processes should be measured. To facilitate comparisons, a single public database of all known resistance loci should be established, regularly updated and strictly curated using minimum standards for the inclusion of resistance loci. For most bacterial species the major limitations to widespread adoption for WGS-based AST in clinical laboratories remain the current high-cost and limited speed of inferring antimicrobial susceptibility from WGS data as well as the dependency on previous culture because analysis directly on specimens remains challenging. For most bacterial species there is currently insufficient evidence to support the use of WGS-inferred AST to guide clinical decision making. WGS-AST should be a funding priority if it is to become a rival to phenotypic AST. This report will be updated as the available evidence increases.
Collapse
Affiliation(s)
- M J Ellington
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK
| | - O Ekelund
- Department of Clinical Microbiology and the EUCAST Development Laboratory, Kronoberg Region, Central Hospital, Växjö, Sweden
| | - F M Aarestrup
- National Food Institute, Research Group for Genomic Epidemiology, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark
| | - R Canton
- Servicio de Microbiología, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - M Doumith
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK
| | - C Giske
- Department of Laboratory Medicine, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - H Grundman
- University Medical Centre Freiburg, Infection Prevention and Hospital Hygiene, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - H Hasman
- Statens Serum Institute, Department of Microbiology and Infection Control, Copenhagen, Denmark
| | - M T G Holden
- School of Medicine, Medical & Biological Sciences, North Haugh, University of St Andrews, UK
| | - K L Hopkins
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK
| | - J Iredell
- Westmead Institute for Medical Research, University of Sydney and Marie Bashir Institute, Sydney, NSW, Australia
| | - G Kahlmeter
- Department of Clinical Microbiology and the EUCAST Development Laboratory, Kronoberg Region, Central Hospital, Växjö, Sweden
| | - C U Köser
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - A MacGowan
- Department of Medical Microbiology, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - D Mevius
- Central Veterinary Institute (CVI) part of Wageningen University and Research Centre (WUR), Lelystad, The Netherlands; Department of Infectious Diseases and Immunology, Utrecht University, Utrecht, The Netherlands
| | - M Mulvey
- National Microbiology Laboratory, Winnipeg, Manitoba, Canada
| | - T Naas
- French National Reference Centre for Antibiotic Resistance, Bacteriology-Hygiene unit, Hôpital Bicêtre, APHP, LabEx LERMIT, University Paris Sud, Le Kremlin-Bicêtre, France
| | - T Peto
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - J-M Rolain
- PU-PH des Disciplines Pharmaceutiques, 1-URMITE CNRS IRD UMR 6236, IHU Méditerranée Infection, Valorization and Transfer, Aix Marseille Université, Faculté de Médecine et de Pharmacie, Marseille, France
| | - Ø Samuelsen
- Norwegian National Advisory Unit on Detection of Antimicrobial Resistance, University Hospital of North Norway, Department of Microbiology and Infection Control, Tromsø, Norway
| | - N Woodford
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK.
| |
Collapse
|
29
|
Kidd S, Workowski KA. Management of Gonorrhea in Adolescents and Adults in the United States. Clin Infect Dis 2016; 61 Suppl 8:S785-801. [PMID: 26602618 DOI: 10.1093/cid/civ731] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Gonorrhea is the second most commonly reported notifiable disease in the United States and is associated with serious health sequelae, including pelvic inflammatory disease, infertility, and ectopic pregnancy. Treatment for gonorrhea has been complicated by antimicrobial resistance. Neisseria gonorrhoeae has developed resistance to each of the antimicrobials that were previously recommended as first-line treatment regimens, and current treatment options are severely limited. This article summarizes the key questions and data that were discussed at the Sexually Transmitted Diseases (STD) Treatment Guidelines Expert Consultation meeting in April 2013, and the rationale for the 2015 Centers for Disease Control and Prevention STD treatment guidelines for gonococcal infections in adolescents and adults. Key issues addressed include whether to change the dosage of ceftriaxone and azithromycin used in the recommended dual treatment regimen, whether to continue to list dual treatment with cefixime and azithromycin as an alternative treatment regimen, and management of gonococcal infections in persons with severe cephalosporin allergy or suspected treatment failure.
Collapse
Affiliation(s)
- Sarah Kidd
- Division of STD Prevention, Centers for Disease Control and Prevention
| | - Kimberly A Workowski
- Division of STD Prevention, Centers for Disease Control and Prevention Division of Infectious Diseases, Emory University, Atlanta, Georgia
| |
Collapse
|
30
|
Jacobsson S, Golparian D, Cole M, Spiteri G, Martin I, Bergheim T, Borrego MJ, Crowley B, Crucitti T, Van Dam AP, Hoffmann S, Jeverica S, Kohl P, Mlynarczyk-Bonikowska B, Pakarna G, Stary A, Stefanelli P, Pavlik P, Tzelepi E, Abad R, Harris SR, Unemo M. WGS analysis and molecular resistance mechanisms of azithromycin-resistant (MIC >2 mg/L) Neisseria gonorrhoeae isolates in Europe from 2009 to 2014. J Antimicrob Chemother 2016; 71:3109-3116. [PMID: 27432597 DOI: 10.1093/jac/dkw279] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/06/2016] [Accepted: 06/09/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To elucidate the genome-based epidemiology and phylogenomics of azithromycin-resistant (MIC >2 mg/L) Neisseria gonorrhoeae strains collected in 2009-14 in Europe and clarify the azithromycin resistance mechanisms. METHODS Seventy-five azithromycin-resistant (MIC 4 to >256 mg/L) N. gonorrhoeae isolates collected in 17 European countries during 2009-14 were examined using antimicrobial susceptibility testing and WGS. RESULTS Thirty-six N. gonorrhoeae multi-antigen sequence typing STs and five phylogenomic clades, including 4-22 isolates from several countries per clade, were identified. The azithromycin target mutation A2059G (Escherichia coli numbering) was found in all four alleles of the 23S rRNA gene in all isolates with high-level azithromycin resistance (n = 4; MIC ≥256 mg/L). The C2611T mutation was identified in two to four alleles of the 23S rRNA gene in the remaining 71 isolates. Mutations in mtrR and its promoter were identified in 43 isolates, comprising isolates within the whole azithromycin MIC range. No mutations associated with azithromycin resistance were found in the rplD gene or the rplV gene and none of the macrolide resistance-associated genes [mef(A/E), ere(A), ere(B), erm(A), erm(B), erm(C) and erm(F)] were identified in any isolate. CONCLUSIONS Clonal spread of relatively few N. gonorrhoeae strains accounts for the majority of the azithromycin resistance (MIC >2 mg/L) in Europe. The four isolates with high-level resistance to azithromycin (MIC ≥256 mg/L) were widely separated in the phylogenomic tree and did not belong to any of the main clades. The main azithromycin resistance mechanisms were the A2059G mutation (high-level resistance) and the C2611T mutation (low- and moderate-level resistance) in the 23S rRNA gene.
Collapse
Affiliation(s)
| | | | | | | | - Irene Martin
- Public Health Agency of Canada, Winnipeg, Canada
| | | | | | | | | | - Alje P Van Dam
- Public Health Service Amsterdam, Amsterdam, The Netherlands
| | | | - Samo Jeverica
- Institute of Microbiology and Immunology, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Kohl
- Vivantes Klinikum Neukölln, Berlin, Germany
| | | | | | - Angelika Stary
- Outpatients' Centre for Infectious Venereodermatological Diseases, Vienna, Austria
| | | | | | | | - Raquel Abad
- Institute of Health Carlos III, Madrid, Spain
| | - Simon R Harris
- Pathogen Genomics, The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridgeshire, UK
| | | |
Collapse
|
31
|
Liang JY, Cao WL, Li XD, Bi C, Yang RD, Liang YH, Li P, Ye XD, Chen XX, Zhang XB. Azithromycin-resistant Neisseria gonorrhoeae isolates in Guangzhou, China (2009-2013): coevolution with decreased susceptibilities to ceftriaxone and genetic characteristics. BMC Infect Dis 2016; 16:152. [PMID: 27080231 PMCID: PMC4832481 DOI: 10.1186/s12879-016-1469-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 03/14/2016] [Indexed: 11/10/2022] Open
Abstract
Background The recent emergence of azithromycin-resistant (AZM-R) N. gonorrhoeae isolates that have coevolved decreased susceptibility to extended-spectrum cephalosporins has caused great concern. Here we investigated the prevalence of decreased susceptibility to ceftriaxone (CROD) in AZM-R isolates and genetically characterized AZM-R isolates in Guangzhou, China from 2009 to 2013. Methods The minimum inhibitory concentration (MIC) of AZM and ceftriaxone was determined using an agar-dilution method. All AZM-R isolates were screened for mutations in 23S rRNA, mtrR and penA genes and genotyped using N. gonorrhoeae multi-antigen sequence typing (NG-MAST). Results Of the 485 identified N. gonorrhoeae isolates, 445 (91.8 %) were isolated from male urethritis subjects, and 77 (15.9 %) were AZM-R (MIC ≥ 1 mg/L), including 33 (6.8 %) with AZM low-level resistant (AZM-LLR, MIC = 1 mg/L) and 44 (9.1 %) with AZM middle-level resistant (AZM-MLR, MIC ≥ 2 mg/L). Significantly more CROD (MIC ≥ 0.125 mg/L) showed in AZM-MLR isolates (43.2 %, 19/44) as compared with that in AZM-LLR isolates (18.2 %, 6/33) (p < 0.05). For the 23S rRNA, mtrR, penA or combined 23S rRNA/MtrR/penA mutations, no significant difference was found between AZM-LLR isolates and AZM-MLR isolates (P > 0.05); similar results were detected between combined AZM-LLR/CROD isolates and combined AZM-MLR/CROD isolates (P > 0.05). No mutation A2059G or AZM high-level resistant (AZM-HLR, MIC ≥ 256 mg/L) isolate was detected. Among 77 AZM-R isolates, 67 sequence types (STs) were identified by NG-MAST, of which 30 were novel. Most STs were represented by a single isolate. Conclusions The AZM-R together CROD isolates are now present in Guangzhou, China, which deserve continuous surveillance and the mechanism of concurrent resistance needs further study. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1469-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Jing-Yao Liang
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Wen-Ling Cao
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Xiao-Dong Li
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Chao Bi
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Ri-Dong Yang
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Yan-Hua Liang
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Ping Li
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Xing-Dong Ye
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Xiao-Xiao Chen
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China.,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China
| | - Xi-Bao Zhang
- Institute of Dermatology, Guangzhou Medical University, Guangzhou, 510095, PR China. .,Department of Dermatology, Guangzhou Institute of Dermatology, 56 Hengfu Road, Guangzhou, 510095, PR China.
| |
Collapse
|
32
|
Genomic Epidemiology and Molecular Resistance Mechanisms of Azithromycin-Resistant Neisseria gonorrhoeae in Canada from 1997 to 2014. J Clin Microbiol 2016; 54:1304-13. [PMID: 26935729 DOI: 10.1128/jcm.03195-15] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 02/19/2016] [Indexed: 01/06/2023] Open
Abstract
The emergence of Neisseria gonorrhoeae strains with decreased susceptibility to cephalosporins and azithromycin (AZM) resistance (AZM(r)) represents a public health threat of untreatable gonorrhea infections. Genomic epidemiology through whole-genome sequencing was used to describe the emergence, dissemination, and spread of AZM(r) strains. The genomes of 213 AZM(r) and 23 AZM-susceptible N. gonorrhoeae isolates collected in Canada from 1989 to 2014 were sequenced. Core single nucleotide polymorphism (SNP) phylogenomic analysis resolved 246 isolates into 13 lineages. High-level AZM(r) (MICs ≥ 256 μg/ml) was found in 5 phylogenetically diverse isolates, all of which possessed the A2059G mutation (Escherichia coli numbering) in all four 23S rRNA alleles. One isolate with high-level AZM(r) collected in 2009 concurrently had decreased susceptibility to ceftriaxone (MIC = 0.125 μg/ml). An increase in the number of 23S rRNA alleles with the C2611T mutations (E. coli numbering) conferred low to moderate levels of AZM(r) (MICs = 2 to 4 and 8 to 32 μg/ml, respectively). Low-level AZM(r) was also associated with mtrR promoter mutations, including the -35A deletion and the presence of Neisseria meningitidis-like sequences. Geographic and temporal phylogenetic clustering indicates that emergent AZM(r) strains arise independently and can then rapidly expand clonally in a region through local sexual networks.
Collapse
|
33
|
Chisholm SA, Wilson J, Alexander S, Tripodo F, Al-Shahib A, Schaefer U, Lythgow K, Fifer H. An outbreak of high-level azithromycin resistant Neisseria gonorrhoeae in England. Sex Transm Infect 2015; 92:365-7. [PMID: 26601852 DOI: 10.1136/sextrans-2015-052312] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/28/2015] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To investigate a potential outbreak of high-level azithromycin resistant (HL-AziR) gonococcal infections diagnosed in eight patients attending a sexual health clinic in Leeds, North England, between November 2014 and March 2015. METHODS Eight cases of infection with gonococci exhibiting azithromycin minimum inhibitory concentrations (MICs) ≥256 mg/L were identified from patients in Leeds as part of the routine service provided by the Sexually Transmitted Bacteria Reference Unit. All patient records were reviewed to collate epidemiological and clinical information including evaluation of patient management. Whole-genome sequencing (WGS) was performed on seven gonococcal isolates to determine Neisseria gonorrhoeae multiantigen sequence type (NG-MAST), WGS comparison and mutations in the 23S rRNA genes. RESULTS All patients were heterosexual (five male, three female) from a range of ethnic backgrounds and from the Leeds area. Three patients were linked by partner notification. All patients were infected at genital sites and two women had pharyngeal infection also. Six patients received the recommended first-line therapy for uncomplicated gonorrhoea, one was treated for pelvic inflammatory disease and one received spectinomycin followed later by ciprofloxacin. Test of cure was achieved in seven patients and confirmed successful eradication. All seven isolates sequenced were identical by NG-MAST and WGS comparison, and contained an A2143G mutation in all four 23S rRNA alleles. CONCLUSIONS Epidemiological and microbiological investigations confirm that an outbreak of a gonococcal strain showing HL-AziR is ongoing in the North of England. Every effort should be made to identify and curtail dissemination of this strain as it presents a significant threat to the current recommended front-line dual therapy.
Collapse
Affiliation(s)
- Stephanie A Chisholm
- Sexually Transmitted Bacteria Reference Unit, Microbiology Services, Public Health England, London, UK
| | - Janet Wilson
- Leeds Sexual Health, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust
| | - Sarah Alexander
- Sexually Transmitted Bacteria Reference Unit, Microbiology Services, Public Health England, London, UK
| | - Francesco Tripodo
- Sexually Transmitted Bacteria Reference Unit, Microbiology Services, Public Health England, London, UK
| | - Ali Al-Shahib
- Infectious Disease Informatics, Microbiology Services, Public Health England, London, UK
| | - Ulf Schaefer
- Infectious Disease Informatics, Microbiology Services, Public Health England, London, UK
| | - Kieren Lythgow
- Infectious Disease Informatics, Microbiology Services, Public Health England, London, UK
| | - Helen Fifer
- Sexually Transmitted Bacteria Reference Unit, Microbiology Services, Public Health England, London, UK
| |
Collapse
|
34
|
Failure of azithromycin 2.0 g in the treatment of gonococcal urethritis caused by high-level resistance in California. Sex Transm Dis 2015; 42:279-80. [PMID: 25868141 DOI: 10.1097/olq.0000000000000265] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We report a treatment failure to azithromycin 2.0 g caused by a urethral Neisseria gonorrhoeae isolate with high-level azithromycin resistance in California. This report describes the epidemiological case investigation and phenotypic and genetic characterization of the treatment failure isolate.
Collapse
|
35
|
Trembizki E, Buckley C, Donovan B, Chen M, Guy R, Kaldor J, Lahra MM, Regan DG, Smith H, Ward J, Whiley DM. Direct real-time PCR-based detection of Neisseria gonorrhoeae 23S rRNA mutations associated with azithromycin resistance. J Antimicrob Chemother 2015; 70:3244-9. [PMID: 26338048 DOI: 10.1093/jac/dkv274] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 08/10/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Surveillance for Neisseria gonorrhoeae azithromycin resistance is of growing importance given increasing use of ceftriaxone and azithromycin dual therapy for gonorrhoea treatment. In this study, we developed two real-time PCR methods for direct detection of two key N. gonorrhoeae 23S rRNA mutations associated with azithromycin resistance. METHODS The real-time PCR assays, 2611-PCR and 2059-PCR, targeted the gonococcal 23S rRNA C2611T and A2059G mutations, respectively. A major design challenge was that gonococcal 23S rRNA sequences have high sequence homology with those of commensal Neisseria species. To limit the potential for cross-reaction, 'non-template' bases were utilized in primer sequences. The performance of the methods was initially assessed using a panel of gonococcal (n = 70) and non-gonococcal (n = 28) Neisseria species. Analytical specificity was further assessed by testing N. gonorrhoeae nucleic acid amplification test (NAAT)-negative clinical samples (n = 90), before being applied to N. gonorrhoeae NAAT-positive clinical samples (n = 306). RESULTS Cross-reactions with commensal Neisseria strains remained evident for both assays; however, cycle threshold (Ct) values were significantly delayed, indicating reduced sensitivity for non-gonococcal species. For the N. gonorrhoeae NAAT-negative clinical samples, 7/21 pharyngeal samples provided evidence of cross-reaction (Ct values >40 cycles); however, the remaining urogenital and rectal swab samples were negative. In total, the gonococcal 2611 and 2059 23S rRNA nucleotides were both successfully characterized in 266/306 (87%) of the N. gonorrhoeae NAAT-positive clinical specimens. CONCLUSIONS Real-time PCR detection of gonococcal 23S rRNA mutations directly from clinical samples is feasible and may enhance culture- and non-culture-based N. gonorrhoeae resistance surveillance.
Collapse
Affiliation(s)
- Ella Trembizki
- Queensland Paediatric Infectious Diseases (QPID) Laboratory, Queensland Children's Medical Research Institute, Brisbane, Queensland 4029, Australia UQ Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland 4029, Australia
| | - Cameron Buckley
- Queensland Paediatric Infectious Diseases (QPID) Laboratory, Queensland Children's Medical Research Institute, Brisbane, Queensland 4029, Australia UQ Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland 4029, Australia
| | - Basil Donovan
- Kirby Institute, UNSW Australia, Sydney, New South Wales 2052, Australia Sydney Sexual Health Centre, Sydney Hospital, Sydney, New South Wales 2000, Australia
| | - Marcus Chen
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria 3053, Australia Central Clinical School, Monash University, Melbourne, Victoria 3800, Australia
| | - Rebecca Guy
- Kirby Institute, UNSW Australia, Sydney, New South Wales 2052, Australia
| | - John Kaldor
- Kirby Institute, UNSW Australia, Sydney, New South Wales 2052, Australia
| | - Monica M Lahra
- WHO Collaborating Centre for STD, Microbiology Department, South Eastern Area Laboratory Services, Prince of Wales Hospital, Sydney, New South Wales 2031, Australia
| | - David G Regan
- Kirby Institute, UNSW Australia, Sydney, New South Wales 2052, Australia
| | - Helen Smith
- Public Health Microbiology, Public and Environmental Health, Queensland Health Forensic and Scientific Services, Archerfield, Queensland 4107, Australia
| | - James Ward
- South Australian Health and Medical Research Institute, Adelaide, South Australia 5000, Australia
| | - David M Whiley
- Queensland Paediatric Infectious Diseases (QPID) Laboratory, Queensland Children's Medical Research Institute, Brisbane, Queensland 4029, Australia UQ Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland 4029, Australia
| |
Collapse
|
36
|
Stevens K, Zaia A, Tawil S, Bates J, Hicks V, Whiley D, Limnios A, Lahra MM, Howden BP. Neisseria gonorrhoeae isolates with high-level resistance to azithromycin in Australia. J Antimicrob Chemother 2014; 70:1267-8. [DOI: 10.1093/jac/dku490] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
|
37
|
Analysis of Neisseria gonorrhoeae azithromycin susceptibility in the United States by the Gonococcal Isolate Surveillance Project, 2005 to 2013. Antimicrob Agents Chemother 2014; 59:998-1003. [PMID: 25451056 DOI: 10.1128/aac.04337-14] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Azithromycin, administered with ceftriaxone, is recommended by the CDC for the treatment of gonorrhea. Many experts have expressed concern about the ease with which Neisseria gonorrhoeae can acquire macrolide resistance. We sought to describe gonococcal azithromycin susceptibility in the United States and to determine whether azithromycin susceptibility has changed over time. We analyzed data from 2005 to 2013 from the Gonococcal Isolate Surveillance Project, a CDC-supported sentinel surveillance network that monitors gonococcal antimicrobial susceptibility. A total of 44,144 N. gonorrhoeae isolates were tested for azithromycin susceptibility by agar dilution methods. The overall azithromycin MIC50 was 0.25 μg/ml, and the MIC90 was 0.5 μg/ml. There were no overall temporal trends in geometric means. Isolates from men who had sex with men had significantly higher geometric mean MICs than isolates from men who had sex exclusively with women. The overall prevalence of reduced azithromycin susceptibility (MIC, ≥2 μg/ml) was 0.4% and varied by year from 0.3% (2006 and 2009) to 0.6% (2013). We did not find a clear temporal trend in gonococcal azithromycin MICs in the United States, and the prevalence of reduced azithromycin susceptibility remains low. These findings support the continued use of azithromycin in a combination therapy regimen for gonorrhea.
Collapse
|
38
|
Bercot B, Belkacem A, Goubard A, Mougari F, Sednaoui P, La Ruche G, Cambau E. High-level azithromycin-resistant Neisseria gonorrhoeae clinical isolate in France, March 2014. ACTA ACUST UNITED AC 2014; 19. [PMID: 25394255 DOI: 10.2807/1560-7917.es2014.19.44.20951] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the first case in France of a high-level azithromycin-resistant Neisseria gonorrhoeae (minimum inhibitory concentration (MIC) = 96 mg/L) assigned to MLST7363 (NG-MAST ST6360), also resistant to ciprofloxacin and tetracycline but susceptible to ceftriaxone. The patient was a 51 year-old heterosexual man who returned following 1g azithromycin monotherapy. Mechanisms of azithromycin resistance were a C2599T mutation in the four copies of the rrl gene and a novel mutation in the promoter of the mtrR gene.
Collapse
Affiliation(s)
- B Bercot
- APHP, Lariboisiere-St Louis-Fernand Widal Hospital, Laboratory of Bacteriology-Virology, Associated Laboratory for the National Reference Centre for gonococci, Paris, France
| | | | | | | | | | | | | |
Collapse
|
39
|
Buono SA, Watson TD, Borenstein LA, Klausner JD, Pandori MW, Godwin HA. Stemming the tide of drug-resistant Neisseria gonorrhoeae: the need for an individualized approach to treatment. J Antimicrob Chemother 2014; 70:374-81. [PMID: 25331059 DOI: 10.1093/jac/dku396] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Drug-resistant Neisseria gonorrhoeae poses a significant public health challenge. In recent years, gonococci resistant to first- and second-line antibiotics have spread worldwide and new strains have developed that are increasingly resistant to third-generation cephalosporins, which are currently our last line of available treatments. Given the timeline required to develop new drugs or an effective vaccine for N. gonorrhoeae, a top priority is to use the drugs that are available as effectively as possible. Currently, clinical management of gonorrhoea is based upon treatment guidelines informed by international gonococcal antimicrobial susceptibility surveillance programmes. This approach, although currently the most practical, is subject to a number of limitations since surveillance data inherently provide population-level information. As a result, basing treatment guidelines on these data can result in the prescription of more aggressive or broader treatment than is needed by individual patients and hence inadvertently contribute to the development and spread of resistance to important drugs. Clearly, methods are needed that provide patient-specific drug susceptibility information in a time frame that would allow clinicians to prescribe individualized treatment regimens for gonorrhoea. Fortunately, in recent years, there have been a number of advances in the development of rapid methods for characterizing both the genotype and the drug resistance phenotype of N. gonorrhoeae strains. Here, we review these advances and propose additional studies that would help facilitate a transition towards an individualized treatment approach for gonorrhoea.
Collapse
Affiliation(s)
- Sean A Buono
- Department of Environmental Health Sciences, Fielding School of Public Health, UCLA, 650 Charles E. Young Drive South, Los Angeles, CA 90095, USA UCLA Global Bio Lab, California Nanosystems Institute, UCLA, 570 Westwood Plaza Building 114, Los Angeles, CA 90095, USA
| | - Tyler D Watson
- Department of Environmental Health Sciences, Fielding School of Public Health, UCLA, 650 Charles E. Young Drive South, Los Angeles, CA 90095, USA
| | - Lee A Borenstein
- UCLA Global Bio Lab, California Nanosystems Institute, UCLA, 570 Westwood Plaza Building 114, Los Angeles, CA 90095, USA Los Angeles County Public Health Laboratory, 12750 Erickson Avenue, Downey, CA 90242, USA
| | - Jeffrey D Klausner
- David Geffen School of Medicine, UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Mark W Pandori
- San Francisco Public Health Laboratory, San Francisco Department of Public Health, 101 Grove Street, Suite 419, San Francisco, CA 94102, USA
| | - Hilary A Godwin
- Department of Environmental Health Sciences, Fielding School of Public Health, UCLA, 650 Charles E. Young Drive South, Los Angeles, CA 90095, USA UCLA Global Bio Lab, California Nanosystems Institute, UCLA, 570 Westwood Plaza Building 114, Los Angeles, CA 90095, USA Institute of the Environment and Sustainability, UCLA, La Kretz Hall, Suite 300, Box 951496, Los Angeles, CA 90095, USA
| |
Collapse
|
40
|
Yasuda M, Ito S, Kido A, Hamano K, Uchijima Y, Uwatoko N, Kusuyama H, Watanabe A, Miyamura R, Miyata K, Deguchi T. A single 2 g oral dose of extended-release azithromycin for treatment of gonococcal urethritis. J Antimicrob Chemother 2014; 69:3116-8. [DOI: 10.1093/jac/dku221] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
41
|
Morita-Ishihara T, Unemo M, Furubayashi KI, Kawahata T, Shimuta K, Nakayama SI, Ohnishi M. Treatment failure with 2 g of azithromycin (extended-release formulation) in gonorrhoea in Japan caused by the international multidrug-resistant ST1407 strain of Neisseria gonorrhoeae. J Antimicrob Chemother 2014; 69:2086-90. [PMID: 24777907 DOI: 10.1093/jac/dku118] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Antimicrobial resistance in Neisseria gonorrhoeae is a major public health concern globally. We report the first verified treatment failure of gonorrhoea with 2 g of azithromycin (extended-release formulation) in Japan and characteristics of the corresponding N. gonorrhoeae isolates. METHODS Pre- and post-treatment isolates (n = 4) were investigated by Etest for antimicrobial susceptibility. The isolates were examined for molecular epidemiology by multilocus sequence typing (MLST), N. gonorrhoeae multi-antigen sequence typing (NG-MAST) and multiple-locus variable-number tandem repeat analysis (MLVA), and for the presence of azithromycin resistance determinants (23S rRNA gene mutations, erm genes and mtrR mutations). RESULTS All isolates were resistant to azithromycin (MIC 4 mg/L) and ciprofloxacin, but remained susceptible to cefixime, ceftriaxone and spectinomycin. All isolates were assigned to MLST ST1901 and NG-MAST ST1407 and three of four isolates possessed MLVA profile 8-3-21-16-1. All isolates contained the previously described C2599T mutation (N. gonorrhoeae numbering) in all four 23S rRNA alleles and the previously described single-nucleotide (A) deletion in the mtrR promoter region. CONCLUSIONS This verified treatment failure occurred in a patient infected with an MLST ST1901/NG-MAST ST1407 strain of N. gonorrhoeae. While this international strain commonly shows resistance or decreased susceptibility to multiple antimicrobials, including extended-spectrum cephalosporins, the strain reported here remained fully susceptible to the latter antimicrobials. Hence, two subtypes of azithromycin-resistant gonococcal MLST ST1901/NG-MAST ST1407 appear to have evolved and to be circulating in Japan. Azithromycin should not be recommended as a single antimicrobial for first-line empirical treatment of gonorrhoea.
Collapse
Affiliation(s)
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and other STIs, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden
| | | | | | - Ken Shimuta
- National Institute of Infectious Diseases, Tokyo, Japan
| | | | | |
Collapse
|
42
|
Takahashi S, Kiyota H, Ito S, Iwasawa A, Hiyama Y, Uehara T, Ichihara K, Hashimoto J, Masumori N, Sunaoshi K, Takeda K, Suzuki N, Hosobe T, Goto H, Suzuki H, Onodera S. Clinical Efficacy of a Single Two Gram Dose of Azithromycin Extended Release for Male Patients with Urethritis. Antibiotics (Basel) 2014; 3:109-20. [PMID: 27025738 PMCID: PMC4790393 DOI: 10.3390/antibiotics3020109] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 02/26/2014] [Accepted: 03/04/2014] [Indexed: 12/02/2022] Open
Abstract
To clarify the clinical efficacy of a single oral 2 g dose of azithromycin extended-release for heterosexual male patients with urethritis, and the current antimicrobial sensitivity of Neisseria gonorrhoeae to azithromycin, a prospective clinical trial was conducted from 2011-2013. In patients with gonococcal urethritis, the eradication rate was 90.9% (30 of 33). The susceptibility rates of isolated Neisseria gonorrhoeae strains to ceftriaxone, spectinomycin, cefixime and azithromycin were 100%, 100%, 95.3% (41/43) and 37.2% (16/43), respectively. In the patients with nongonococcal urethritis, the eradication rate was 90.0% (45 of 50). The microbiological eradication rates for the pathogens were 90.9% (30/33) for Neisseria gonorrhoeae, 91.5% (43/47) for Chlamydia trachomatis, 71.4% (5/7) for Mycoplasma genitalium, and 100% (13/13) for Ureaplasma urealyticum. The main adverse event was diarrhea and its manifestation rate was 35.2% (32 of 120). The symptom of diarrhea was mostly temporary and resolved spontaneously. The conclusion was that the treatment regimen with a single oral 2 g dose of azithromycin extended-release would be effective for patients with urethritis. However, the antimicrobial susceptibilities of Neisseria gonorrhoeae and Mycoplasma genitalium should be carefully monitored because of possible treatment failure.
Collapse
Affiliation(s)
- Satoshi Takahashi
- Department of Urology, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0608543, Japan.
| | - Hiroshi Kiyota
- Department of Urology, the Jikei University Katsushika Medical Center, 6-41-2 Aoto Katsushika-ku, Tokyo 1258506, Japan.
| | - Shin Ito
- iClinic, 5-9-6, Nagamachi, Taihaku-ku, Sendai, Miyagi 9820011, Japan.
| | - Akihiko Iwasawa
- Iwasawa Clinic, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0600061, Japan.
| | - Yoshiki Hiyama
- Department of Urology, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0608543, Japan.
| | - Teruhisa Uehara
- Department of Urology, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0608543, Japan.
| | - Koji Ichihara
- Department of Urology, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0608543, Japan.
| | - Jiro Hashimoto
- Department of Urology, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0608543, Japan.
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University School of Medicine, S. 1, W. 16, Chuo-ku, Sapporo, Hokkaido 0608543, Japan.
| | - Kenichi Sunaoshi
- Teine Urologic Clinic, 1-12, Maeda 6-7, Teine-ku, Sapporo 0060816, Japan.
| | - Koichi Takeda
- Teine Urologic Clinic, 1-12, Maeda 6-7, Teine-ku, Sapporo 0060816, Japan.
| | - Nobukazu Suzuki
- Teine Urologic Clinic, 1-12, Maeda 6-7, Teine-ku, Sapporo 0060816, Japan.
| | - Takahide Hosobe
- Hosobe Clinic, 1-1-15, Nezu, Bunkyo-ku, Tokyo 1130031, Japan.
| | - Hirokazu Goto
- Department of Urology, Fuji City General Hospital, 50 Takashima-Cho, Fuji, Shizuoka 4178567, Japan.
| | - Hidenori Suzuki
- Department of Urology, Fuji City General Hospital, 50 Takashima-Cho, Fuji, Shizuoka 4178567, Japan.
| | - Shoichi Onodera
- Department of Urology, Fuji City General Hospital, 50 Takashima-Cho, Fuji, Shizuoka 4178567, Japan.
| |
Collapse
|
43
|
Takayama Y, Nakayama SI, Shimuta K, Morita-Ishihara T, Ohnishi M. Characterization of azithromycin-resistant Neisseria gonorrhoeae isolated in Tokyo in 2005-2011. J Infect Chemother 2014; 20:339-41. [PMID: 24571786 DOI: 10.1016/j.jiac.2014.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 12/26/2013] [Accepted: 01/15/2014] [Indexed: 11/27/2022]
Abstract
A total of 122 Neisseria gonorrhoeae isolated in the Tokyo metropolitan area in 2005-2011 were collected and analyzed by N. gonorrhoeae multiantigen sequence typing (NG-MAST) and for their susceptibility to azithromycin and ceftriaxone. All 122 strains were susceptible to ceftriaxone, but 8 strains were azithromycin-resistant, defined as an azithromycin MIC ≥ 1 μg/ml. The 8 azithromycin-resistant strains were in 6 NG-MAST types, 3 strains in NG-MAST type 1407 and each of the other 5 strains in a different NG-MAST type. NG-MAST type 1407 strains are multidrug-resistant and are disseminated worldwide.
Collapse
Affiliation(s)
| | - Shu-ichi Nakayama
- Department of Bacteriology I, National Institute of Infectious Diseases, Japan.
| | - Ken Shimuta
- Department of Bacteriology I, National Institute of Infectious Diseases, Japan
| | | | - Makoto Ohnishi
- Department of Bacteriology I, National Institute of Infectious Diseases, Japan
| |
Collapse
|
44
|
Lewis DA. The role of core groups in the emergence and dissemination of antimicrobial-resistant N gonorrhoeae. Sex Transm Infect 2014; 89 Suppl 4:iv47-51. [PMID: 24243880 DOI: 10.1136/sextrans-2013-051020] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Core groups contain individuals who are regularly infected with Neisseria gonorrhoeae and are able to transmit their infection to a large number of sexual partners. Classical core groups, such as sex workers and their male partners, or men who have sex with men (MSM), have contributed to the emergence and spread of antimicrobial-resistant N gonorrhoeae over many years. Sex workers and their clients were the most important core group driving the dissemination of penicillinase-producing N gonorrhoeae in the 1970s. Such individuals have continued to contribute to penicillinase-producing N gonorrhoeae outbreaks as well as to the subsequent emergence of gonococcal resistance to fluoroquinolones, macrolides, spectinomycin and cephalosporins in various settings. MSM have been a very important core group since the 1980s, first with the spread of TetM-expressing N gonorrhoeae and, second, with the dissemination of fluoroquinolone-resistant N gonorrhoeae. MSM-associated sexual networks have most recently been critical to the spread of gonococci resistant to third generation extended spectrum cephalosporins, including cefixime and ceftriaxone. Individuals within other core groups have also been linked to the transmission of antimicrobial-resistant gonorrhoea, such as military personnel, travellers, drug users, young adults, older men and members of street gangs. Understanding core behaviours and their geospatial clustering is essential for an optimal public health response to the rising prevalence of antimicrobial-resistant gonorrhoea. Furthermore, rapid and effective treatment of N gonorrhoeae infections in core individuals and their sexual partners should be a priority for gonorrhoea control programmes.
Collapse
Affiliation(s)
- D A Lewis
- Centre for HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, National Health Laboratory Service, , Johannesburg, South Africa
| |
Collapse
|
45
|
Ison CA, Alexander S. Antimicrobial resistance inNeisseria gonorrhoeaein the UK: surveillance and management. Expert Rev Anti Infect Ther 2014; 9:867-76. [DOI: 10.1586/eri.11.103] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
46
|
Martin I, Sawatzky P, Liu G, Allen V, Lefebvre B, Hoang L, Lovgren M, Haldane D, Caeseele PV, Horsman G, Garceau R, Ratnam S, Wong T, Gilmour M. Antimicrobial susceptibilities and distribution of sequence types of Neisseria gonorrhoeae isolates in Canada: 2010. Can J Microbiol 2013; 59:671-8. [PMID: 24102220 DOI: 10.1139/cjm-2013-0357] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The monitoring of antimicrobial susceptibilities in Neisseria gonorrhoeae isolates and characterization of N. gonorrhoeae multiantigen sequence types (NG-MAST, ST) provide important surveillance data as resistance rates continue to rise. A total of 2970 N. gonorrhoeae isolates were collected by Canadian provincial public health laboratories in 2010, and 1233 were submitted to the National Microbiology Laboratory for testing. The NG-MAST and minimum inhibitory concentration (MIC) by agar dilution were determined for each isolate. Of the 2970 isolates, 25.1% were resistant to penicillin, 34.6% resistant to tetracycline, 31.5% resistant to erythromycin, 35.9% resistant to ciprofloxacin, and 1.2% resistant to azithromycin. Decreased susceptibility to cefixime (MIC ≥ 0.25 mg/L) and ceftriaxone (MIC ≥ 0.125 mg/L) was identified in 3.2% and 7.3% of the isolates, respectively. The most common STs found in Canada were ST1407 (13.3%), ST3150 (11.3%), and ST3158 (9.0%), with 249 different STs identified among the isolates. Within the ST1407 group, 19.5% and 43.3% isolates have decreased susceptibility to cefixime and ceftriaxone, respectively. ST1407, the most prevalent NG-MAST in Canada in 2010, has been associated with high-level ceftriaxone MICs and with cefixime treatment failure cases worldwide. Identification and monitoring of STs and corresponding antimicrobial resistance profiles may be useful in surveillance programs and be used to inform public health actions.
Collapse
Affiliation(s)
- Irene Martin
- a Bacteriology and Enteric Diseases Program, National Microbiology Laboratory, Public Health Agency of Canada, 1015 Arlington Street, Winnipeg, MB R3E 3R2, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Cephalosporin and azithromycin susceptibility in Neisseria gonorrhoeae isolates by site of infection, British Columbia, 2006 to 2011. Sex Transm Dis 2013; 40:46-51. [PMID: 23250301 DOI: 10.1097/olq.0b013e31827bd64c] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Widespread resistance of Neisseria gonorrhoeae to penicillin, tetracycline, and fluoroquinolones has challenged effective treatment and control; recent international case reports of cefixime, ceftriaxone, and azithromycin resistance suggest that the remaining treatment options are now additionally threatened. To explore trends in antimicrobial susceptibility of N. gonorrhoeae, we reviewed provincial laboratory data from British Columbia, 2006 to 2011. METHODS Susceptibility testing was performed for all N. gonorrhoeae isolates detected in-house or forwarded to the reference laboratory. Resistance or intermediate resistance (nonsusceptibility) was defined by standard breakpoints for penicillin, tetracycline, ciprofloxacin, and spectinomycin. Elevated minimum inhibitory concentrations (MICs) at serial dilutions of 0.064 μg/mL or greater were explored for cefixime/ceftriaxone and 0.5 μg/mL or greater for azithromycin. Nonsusceptibility/elevated MIC was compared by year, site of infection, sex, and age. RESULTS A total of 1837 isolates representing 22% of all reported gonorrhea cases were analyzed. Nonsusceptibility to penicillin was established at baseline. Nonsusceptibility to tetracycline and ciprofloxacin increased over the study period, reaching 96% and 36%, respectively, in 2011. Sixteen isolates (1%) had a cefixime MIC of 0.25 μg/mL (none ≥0.5), none had a ceftriaxone MIC of 0.25 μg/mL or greater, and 15 (1%) had an azithromycin MIC of 2.0 μg/mL or greater. Elevated MIC of these agents showed an increasing trend over time. Nonsusceptibility and elevated MIC were consistently highest at the rectal and pharyngeal sites and higher in isolates from males, including when stratified to the pharyngeal site. INTERPRETATION Increases in elevated MIC of cefixime/ceftriaxone/azithromycin were superimposed on a background of established resistance to penicillin, tetracycline, and ciprofloxacin and may signal impending gonococcal resistance to first-line treatments. Ongoing surveillance will inform timely shifts in treatment recommendations.
Collapse
|
48
|
Martin I, Jayaraman G, Wong T, Liu G, Gilmour M. Trends in antimicrobial resistance in Neisseria gonorrhoeae isolated in Canada: 2000-2009. Sex Transm Dis 2013; 38:892-8. [PMID: 21934558 DOI: 10.1097/olq.0b013e31822c664f] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Canada conducts surveillance of penicillin, tetracycline, erythromycin, spectinomycin, ciprofloxacin, cefixime, and ceftriaxone susceptibilities in Neisseria gonorrhoeae isolates to support development of national treatment guidelines for sexually transmitted infections. METHODS N. gonorrhoeae isolates were collected by Canadian provincial public health laboratories and included isolates from males and females ranging in age from 1 to 86 years. Minimum inhibitory concentrations (MICs) were determined by agar dilution at the National Microbiology Laboratory, Public Health Agency of Canada, and MIC interpretations were based on the criteria of the Clinical Laboratory Standards Institute. RESULTS From 2000 to 2009, 40,875 isolates of N. gonorrhoeae were tested by provincial laboratories and 10,993 of these were characterized by the Public Health Agency of Canada. There was an increasing incidence of N. gonorrhoeae isolates that were chromosomally resistant to penicillin, tetracycline, and erythromycin while the plasmid-mediated resistance strains (penicillinase-producing N. gonorrhoeae, tetracycline-resistant N. gonorrhoeae, and PP/tetracycline-resistant N. gonorrhoeae strain all had a declining trend. The percentage of isolates resistant to ciprofloxacin significantly increased from 1.3% in 2000 to 25.5% in 2009. Only 0.17% of isolates tested were azithromycin resistant. Between 2000 and 2009, the modal MICs for ceftriaxone increased from 0.016 μg/mL to 0.063 μg/mL. CONCLUSIONS Ciprofloxacin resistance in N. gonorrhoeae within Canada has increased to a level where quinolones are no longer the preferred drugs for the treatment of gonococcal infections and the modal MICs for the third-generation cephalosporins have increased over time. Close monitoring of antibiotic susceptibilities are required to inform treatment options.
Collapse
Affiliation(s)
- Irene Martin
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada.
| | | | | | | | | | | |
Collapse
|
49
|
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. Sex Transm Dis 2013; 39:813-21. [PMID: 23001269 DOI: 10.1097/olq.0b013e3182631c9f] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
Collapse
|
50
|
Vidovic S, Thakur SD, Horsman GB, Levett PN, Anvari V, Dillon JAR. Longitudinal analysis of the evolution and dissemination of Neisseria gonorrhoeae strains (Saskatchewan, Canada, 2005 to 2008) reveals three major circulating strains and convergent evolution of ciprofloxacin and azithromycin resistance. J Clin Microbiol 2012; 50:3823-30. [PMID: 22972828 PMCID: PMC3502962 DOI: 10.1128/jcm.01402-12] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Accepted: 08/30/2012] [Indexed: 12/28/2022] Open
Abstract
A longitudinal study combining multilocus sequence typing with molecular evolutionary analysis determined the distribution, population structure, and evolution of antibiotic resistance in Neisseria gonorrhoeae isolates in Saskatchewan that were collected between 2005 and 2008. Of 195 gonococcal isolates examined, 29 sequence types (STs) were identified with 3 major circulating strains (ST-1 through ST-3) comprising 52% of all gonococcal isolates studied. The prevalences, persistence, distribution patterns, and clonalities of these isolates strongly suggest that gonorrhea endemicity within this broad geographic region was driven by these 3 circulating strains. ST-1 exhibited a significantly (P = 0.001) higher prevalence throughout the study than did the others, accounting for ∼25% of the tested isolates each year. The spatial distributions of the gonococcal strains indicated that ST-1 in 2007 entered a linear component of the sexual network, reaching the remote north and resulting in the further spread and maintenance of infection. Ciprofloxacin and azithromycin resistances were observed in distantly related gonococcal lineages, clearly indicating the convergent acquisition of these antibiotic-resistant phenotypes. In addition, all ciprofloxacin- and azithromycin-resistant lineages were found at the edges of the minimum spanning tree, far from the major lineages, suggesting that these antibiotic phenotypes were most likely introduced into the province. In contrast, resistance to penicillin was found mostly in the endemic gonococcal lineages, suggesting that penicillin resistance was probably acquired in Saskatchewan as a result of spontaneous mutations in already-established lineages. Tetracycline resistance was present in all STs except one, indicating its ubiquitous nature in the gonococcal population studied.
Collapse
Affiliation(s)
- Sinisa Vidovic
- Vaccine and Infectious Disease Organization, Saskatoon, Saskatchewan, Canada
| | - Sidharath D. Thakur
- Vaccine and Infectious Disease Organization, Saskatoon, Saskatchewan, Canada
| | - Greg B. Horsman
- Saskatchewan Disease Control Laboratory, Regina, Saskatchewan, Canada
| | - Paul N. Levett
- Saskatchewan Disease Control Laboratory, Regina, Saskatchewan, Canada
| | | | - Jo-Anne R. Dillon
- Vaccine and Infectious Disease Organization, Saskatoon, Saskatchewan, Canada
- Department of Biology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| |
Collapse
|