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Birhanu M, Abegaz WE, Schröder D, Mihret A, Abebe T, Jacobsson S, Tasew G, Addis T, Abdeta A, Alem Y, Desalegn Z, Ademe M, Teka B, Yohannes M, Yigeremus M, Golparian D, Gebre-Selassie S, Unemo M. Antimicrobial susceptibility in Neisseria gonorrhoeae and epidemiological data of gonorrhoea patients in five cities across Ethiopia, 2021-22. JAC Antimicrob Resist 2024; 6:dlae002. [PMID: 38304725 PMCID: PMC10833647 DOI: 10.1093/jacamr/dlae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/04/2024] [Indexed: 02/03/2024] Open
Abstract
Introduction Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a global public health concern and enhanced global gonococcal AMR surveillance is imperative. As in many African countries, regular, representative and quality-assured gonococcal AMR is lacking in Ethiopia. We describe the AMR in gonococcal isolates from five cities across Ethiopia, 2021-22, and patient epidemiological data. Methods Urethral discharge from males and cervical discharge from females were collected from October 2021 to September 2022. Epidemiological data were collected using a questionnaire. MIC determination (ETEST; eight antimicrobials) was performed on gonococcal isolates and EUCAST breakpoints (v13.1) were used. Results From 1142 urogenital swab samples, 299 species-identified gonococcal isolates were identified; 78.3% were from males and 21.7% from females. The median age for males and females was 25 and 23 years, respectively. Most isolates (61.2%) were identified in Addis Ababa, followed by Gondar (11.4%), Adama (10.4%), Bahir Dar (10.0%) and Jimma (7.0%). The resistance level to ciprofloxacin, tetracycline and benzylpenicillin was 97.0%, 97.0% and 87.6%, respectively, and 87.6% of isolates were producing β-lactamase. All isolates were susceptible to ceftriaxone, cefixime, azithromycin and spectinomycin. Recommended therapy [ceftriaxone (250 mg) plus azithromycin (1 g)] was used for 84.2% of patients. Conclusions We present the first national quality-assured gonococcal AMR data from Ethiopia. Resistance levels to ciprofloxacin, tetracycline and benzylpenicillin were exceedingly high. However, all isolates were susceptible to ceftriaxone, cefixime, azithromycin and spectinomycin. In Ethiopia, it is essential to strengthen the gonococcal AMR surveillance by including further epidemiological data, more isolates from different cities, and WGS.
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Affiliation(s)
- Muluken Birhanu
- Department of Medical Laboratory Science, College of Health Science, Assosa University, Assosa, Ethiopia
- Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Woldaregay Erku Abegaz
- Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Daniel Schröder
- Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and Other STIs, Örebro University, Örebro, Sweden
| | - Adane Mihret
- Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Bacteriology, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Tamrat Abebe
- Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Susanne Jacobsson
- Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and Other STIs, Örebro University, Örebro, Sweden
| | - Geremew Tasew
- National Clinical Bacteriology and Mycology Reference Laboratory, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Tesfa Addis
- National Clinical Bacteriology and Mycology Reference Laboratory, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Abera Abdeta
- National Clinical Bacteriology and Mycology Reference Laboratory, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Yonas Alem
- Department of Medical Laboratory Sciences, Ambo University, Ambo, Ethiopia
| | - Zelealem Desalegn
- Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Muluneh Ademe
- Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Birhanu Teka
- Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Meron Yohannes
- Department of Medical Laboratory Science, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mahlet Yigeremus
- Department of Gynecology and Obstetrics, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Daniel Golparian
- Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and Other STIs, Örebro University, Örebro, Sweden
| | - Solomon Gebre-Selassie
- Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Magnus Unemo
- Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and Other STIs, Örebro University, Örebro, Sweden
- Institute for Global Health, University College London (UCL), London, UK
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Jünger C, Imkamp F, Balakrishna S, Gysin M, Haldimann K, Brugger SD, Scheier TC, Hampel B, Hobbie SN, Günthard HF, Braun DL. Phenotypic and genotypic characterization of Neisseria gonorrhoeae isolates among individuals at high risk for sexually transmitted diseases in Zurich, Switzerland. Int J STD AIDS 2024:9564624241230266. [PMID: 38297880 DOI: 10.1177/09564624241230266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND While ceftriaxone resistance remains scarce in Switzerland, global Neisseria gonorrhoeae (NG) antimicrobial resistance poses an urgent threat. This study describes clinical characteristics in MSM (men who have sex with men) diagnosed with NG infection and analyses NG resistance by phenotypic and genotypic means. METHODS Data of MSM enrolled in three clinical cohorts with a positive polymerase chain reaction test (PCR) for NG were analysed between January 2019 and December 2021 and linked with antibiotic susceptibility testing. Bacterial isolates were subjected to whole genome sequencing (WGS). RESULTS Of 142 participants, 141 (99%) were MSM and 118 (84%) living with HIV. Participants were treated with ceftriaxone (N = 79), azithromycin (N = 2), or a combination of both (N = 61). No clinical or microbiological failures were observed. From 182 positive PCR samples taken, 23 were available for detailed analysis. Based on minimal inhibitory concentrations (MICs), all isolates were susceptible to ceftriaxone, gentamicin, cefixime, cefpodoxime, ertapenem, zoliflodacin, and spectinomycin. Resistance to azithromycin, tetracyclines and ciprofloxacin was observed in 10 (43%), 23 (100%) and 11 (48%) of the cases, respectively. Analysis of WGS data revealed combinations of resistance determinants that matched with the corresponding phenotypic resistance pattern of each isolate. CONCLUSION Among the MSM diagnosed with NG mainly acquired in Switzerland, ceftriaxone MICs were low for a subset of bacterial isolates studied and no treatment failures were observed. For azithromycin, high occurrences of in vitro resistance were found. Gentamicin, cefixime, cefpodoxime, ertapenem, spectinomycin, and zoliflodacin displayed excellent in vitro activity against the 23 isolates underscoring their potential as alternative agents to ceftriaxone.
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Affiliation(s)
- Christian Jünger
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Frank Imkamp
- Institute of Medical Microbiology, University of Zurich, Zurich, Switzerland
| | - Suraj Balakrishna
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marina Gysin
- Institute of Medical Microbiology, University of Zurich, Zurich, Switzerland
| | - Klara Haldimann
- Institute of Medical Microbiology, University of Zurich, Zurich, Switzerland
| | - Silvio D Brugger
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Thomas C Scheier
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Sven N Hobbie
- Institute of Medical Microbiology, University of Zurich, Zurich, Switzerland
| | - Huldrych F Günthard
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Dominique L Braun
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Golparian D, Jacobsson S, Holley CL, Shafer WM, Unemo M. High-level in vitro resistance to gentamicin acquired in a stepwise manner in Neisseria gonorrhoeae. J Antimicrob Chemother 2023; 78:1769-1778. [PMID: 37253051 PMCID: PMC10517096 DOI: 10.1093/jac/dkad168] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/10/2023] [Indexed: 06/01/2023] Open
Abstract
OBJECTIVES Gentamicin is used in several alternative treatments for gonorrhoea. Verified clinical Neisseria gonorrhoeae isolates with gentamicin resistance are mainly lacking and understanding the mechanisms for gonococcal gentamicin resistance is imperative. We selected gentamicin resistance in gonococci in vitro, identified the novel gentamicin-resistance mutations, and examined the biofitness of a high-level gentamicin-resistant mutant. METHODS Low- and high-level gentamicin resistance was selected in WHO X (gentamicin MIC = 4 mg/L) on gentamicin-gradient agar plates. Selected mutants were whole-genome sequenced. Potential gentamicin-resistance fusA mutations were transformed into WT strains to verify their impact on gentamicin MICs. The biofitness of high-level gentamicin-resistant mutants was examined using a competitive assay in a hollow-fibre infection model. RESULTS WHO X mutants with gentamicin MICs of up to 128 mg/L were selected. Primarily selected fusA mutations were further investigated, and fusAR635L and fusAM520I + R635L were particularly interesting. Different mutations in fusA and ubiM were found in low-level gentamicin-resistant mutants, while fusAM520I was associated with high-level gentamicin resistance. Protein structure predictions showed that fusAM520I is located in domain IV of the elongation factor-G (EF-G). The high-level gentamicin-resistant WHO X mutant was outcompeted by the gentamicin-susceptible WHO X parental strain, suggesting lower biofitness. CONCLUSIONS We describe the first high-level gentamicin-resistant gonococcal isolate (MIC = 128 mg/L), which was selected in vitro through experimental evolution. The most substantial increases of the gentamicin MICs were caused by mutations in fusA (G1560A and G1904T encoding EF-G M520I and R635L, respectively) and ubiM (D186N). The high-level gentamicin-resistant N. gonorrhoeae mutant showed impaired biofitness.
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Affiliation(s)
- Daniel Golparian
- Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Örebro University, Örebro, Sweden
| | - Susanne Jacobsson
- Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Örebro University, Örebro, Sweden
| | - Concerta L Holley
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA
| | - William M Shafer
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA
- The Emory Antibiotic Resistance Center, Emory University School of Medicine, Atlanta, GA, USA
- Laboratories of Bacterial Pathogenesis, Veterans Affairs Medical Center, Decatur, GA, USA
| | - Magnus Unemo
- Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Örebro University, Örebro, Sweden
- Institute for Global Health, University College London (UCL), London, UK
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Bazan JA, Tzeng YL, Bischof KM, Satola SW, Stephens DS, Edwards JL, Carter A, Snyder B, Turner AN. Antibiotic Susceptibility Profile for the US Neisseria meningitidis Urethritis Clade. Open Forum Infect Dis 2023; 10:ofac661. [PMID: 36655188 PMCID: PMC9835751 DOI: 10.1093/ofid/ofac661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
The US Neisseria meningitidis urethritis clade (US_NmUC) harbors gonococcal deoxyribonucleic acid alleles and causes gonorrhea-like urogenital tract disease. A large convenience sample of US_NmUC isolates (N = 122) collected between January 2015 and December 2019 in Columbus, Ohio demonstrated uniform susceptibility to antibiotics recommended for gonorrhea treatment and meningococcal chemoprophylaxis.
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Affiliation(s)
- Jose A Bazan
- Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Sexual Health Clinic, Columbus Public Health, Columbus, Ohio, USA
| | - Yih-Ling Tzeng
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Katarina M Bischof
- Division of Epidemiology, The Ohio State University College of Public Health, Columbus, Ohio, USA
| | - Sarah W Satola
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David S Stephens
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jennifer L Edwards
- Department of Pediatrics, The Research Institute at Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Alexandria Carter
- Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Brandon Snyder
- Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Abigail Norris Turner
- Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Division of Epidemiology, The Ohio State University College of Public Health, Columbus, Ohio, USA
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Kakooza F, Kiggundu R, Mboowa G, Kateete PD, Nsangi OT, Kabahita JM, Ssentalo Bagaya B, Golparian D, Unemo M. Antimicrobial susceptibility surveillance and antimicrobial resistance in Neisseria gonorrhoeae in Africa from 2001 to 2020: A mini-review. Front Microbiol 2023; 14:1148817. [PMID: 37089569 PMCID: PMC10117771 DOI: 10.3389/fmicb.2023.1148817] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/15/2023] [Indexed: 04/25/2023] Open
Abstract
Antimicrobial resistance (AMR) in Neisseria gonorrhoeae (NG), compromising gonorrhea treatment, is a global public health concern. Improved, quality-assured NG AMR monitoring at the global level is essential. This mini-review examined NG AMR susceptibility surveillance and AMR data from the African continent from 2001 to 2020. Eligible peer-reviewed publications (n = 30) containing NG AMR data for antimicrobials currently recommended for gonorrhea treatment were included. Overall, very limited NG surveillance and AMR data was available. Furthermore, the NG AMR surveillance studies varied greatly regarding surveillance protocols (e.g., populations and samples tested, sample size, antimicrobials examined), methodologies (e.g., antimicrobial susceptibility testing method [agar dilution, minimum inhibitory concentration (MIC) gradient strip test, disc diffusion test] and interpretative criteria), and quality assurance (internal quality controls, external quality assessments [EQA], and verification of AMR detected). Moreover, most studies examined a suboptimal number of NG isolates, i.e., less than the WHO Global Gonococcal Antimicrobial Surveillance Program (GASP) and WHO Enhanced GASP (EGASP) recommendations of ≥100 isolates per setting and year. The notable inter-study variability and frequently small sample sizes make appropriate inter-study and inter-country comparisons of AMR data difficult. In conclusion, it is imperative to establish an enhanced, standardized and quality-assured NG AMR surveillance, ideally including patient metadata and genome sequencing as in WHO EGASP, in Africa, the region with the highest gonorrhea incidence globally. This will enable the monitoring of AMR trends, detection of emerging AMR, and timely refinements of national and international gonorrhea treatment guidelines. To achieve this aim, national and international leadership, political and financial commitments are imperative.
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Affiliation(s)
- Francis Kakooza
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Immunology and Molecular Biology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Reuben Kiggundu
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Kampala, Uganda
| | - Gerald Mboowa
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Immunology and Molecular Biology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Patrick David Kateete
- Department of Immunology and Molecular Biology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Olga Tendo Nsangi
- Department of Immunology and Molecular Biology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jupiter Marina Kabahita
- Department of Immunology and Molecular Biology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Bernard Ssentalo Bagaya
- Department of Immunology and Molecular Biology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Örebro University, Örebro, Sweden
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Örebro University, Örebro, Sweden
- Institute for Global Health, University College London (UCL), London, United Kingdom
- *Correspondence: Magnus Unemo,
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Golparian D, Kittiyaowamarn R, Paopang P, Sangprasert P, Sirivongrangson P, Franceschi F, Jacobsson S, Wi T, Unemo M. Genomic surveillance and antimicrobial resistance in Neisseria gonorrhoeae isolates in Bangkok, Thailand in 2018. J Antimicrob Chemother 2022; 77:2171-2182. [PMID: 35542983 DOI: 10.1093/jac/dkac158] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 04/20/2022] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a substantial global public health problem. Gonococcal infections acquired in or from Asia represent most verified ceftriaxone treatment failures, and several ceftriaxone-resistant strains have emerged in Asia and subsequently spread globally. Additionally, in Thailand the gonorrhoea incidence remains high. Herein, we investigate the genomic diversity, AMR and AMR determinants in gonococcal isolates cultured in 2018 in Bangkok, Thailand. METHODS Gonococcal isolates from males (n = 37) and females (n = 62) were examined by Etest and WGS. AMR determinants and molecular epidemiological STs were characterized. For phylogenomic comparison, raw sequence data were included from China (432 isolates), Japan (n = 270), Vietnam (n = 229), Thailand (n = 3), a global dataset (n = 12 440) and the 2016 WHO reference strains plus WHO Q (n = 15). RESULTS In total, 88, 66 and 41 different NG-MAST, NG-STAR and MLST STs, respectively, and 31 different NG-STAR clonal complexes were found. A remarkably high frequency (88%) of β-lactamase TEM genes was detected and two novel TEM alleles were found. The phylogenomic analysis divided the isolates into the previously described lineages A and B, with a large proportion of Thai isolates belonging to the novel sublineage A3. CONCLUSIONS We describe the first molecular epidemiological study using WGS on gonococcal isolates from Thailand. The high prevalence of AMR and AMR determinants for ciprofloxacin, tetracycline and benzylpenicillin, and some strains belonging to clones/clades especially in sublineage A2 that are prone to develop resistance to extended-spectrum cephalosporins (ESCs) and azithromycin, should prompt continued and strengthened AMR surveillance, including WGS, of N. gonorrhoeae in Thailand.
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Affiliation(s)
- Daniel Golparian
- World Health Organization Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Rossaphorn Kittiyaowamarn
- Bangrak STIs Center, Division of AIDS and STIs, Department of Disease Control, Ministry of Public Health, Bangkok, Thailand
| | - Porntip Paopang
- Bangrak STIs Center, Division of AIDS and STIs, Department of Disease Control, Ministry of Public Health, Bangkok, Thailand
| | - Pongsathorn Sangprasert
- Bangrak STIs Center, Division of AIDS and STIs, Department of Disease Control, Ministry of Public Health, Bangkok, Thailand
| | | | - Francois Franceschi
- Global Antibiotic Research & Development Partnership (GARDP), Geneva, Switzerland
| | - Susanne Jacobsson
- World Health Organization Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Teodora Wi
- Department of the Global HIV, Hepatitis and STI programmes, World Health Organization, Geneva, Switzerland
| | - Magnus Unemo
- World Health Organization Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Institute for Global Health, University College London, London, UK
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Machado HDM, Martins JM, Schörner MA, Gaspar PC, Bigolin A, Ramos MC, Ferreira WA, Pereira GFM, Miranda AE, Unemo M, Bazzo ML, de Carvalho SVF, Costa MRR, Dias LG, Porto ER, da Fonseca Andrade L, de Castro e Caldo Lima GR, Lozano VF, Bazzo ML, de Rocco F, Barazzetti FH, Kerber G, de Melo Machado H, Martins JM, Buss K, Scheffer MC, Schörner MA, Zonta R, Ramos MC, Nicola MRC, Cecconi MC, de Noronha BSS, Santos CAD, Lopes FM, de Souza Gomes J, Saif JILPJPTC, Ferreira WA, Freire M, Ramos A, Carvalho FNM, Politano A, da Silva RJC, de Araújo; Claudio Campos do Porto S, Bocalon RAL, de Oliveira Machado de Souza U, Mialski R, da Silva Nogueira K, Bay MB, do Monte Alves M, Campos JC, Junior LFA, de Oliveira Camargo L, de Souza Neves LA, Paes APL, Barufaldi F, Reis HDO, Rocha LSD, Ribeiro MIC, da Silva P, Amaral FR, de Figueiroa FJ, Barbosa AMS, Araujo AA, Varejão MG, de França Mendes FG, Cavalcanti VO, Ribeiro PGL, Ishigami B, Caheté L, Zoccoli CM. National surveillance of Neisseria gonorrhoeae antimicrobial susceptibility and epidemiological data of gonorrhoea patients across Brazil, 2018–20. JAC Antimicrob Resist 2022; 4:dlac076. [PMID: 35795244 PMCID: PMC9252985 DOI: 10.1093/jacamr/dlac076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives To (i) describe the nationwide antimicrobial susceptibility of Neisseria gonorrhoeae (NG) isolates cultured across Brazil in 2018–20 and compare it with NG antimicrobial resistance data from 2015–16, and (ii) present epidemiological data of the corresponding gonorrhoea patients in 2018–20. Methods Twelve representative sentinel sites cultured NG isolates from men with urethral discharge. Susceptibility to eight antimicrobials was examined using agar dilution method, according to WHO standards. The consenting participants were invited to provide epidemiological data. Results In total, 633 NG isolates (one isolate per participant) were analysed, and 449 (70.9%) questionnaires were answered. Heterosexual (68.2%) and homosexual (23.1%) sexual orientations were common, and most prevalent types of unprotected sexual intercourse were vaginal insertive (69.9%), oral giving (56.6%) and anal insertive (47.4%). The levels of in vitro NG resistance to ciprofloxacin, tetracycline, benzylpenicillin, azithromycin, cefixime, gentamicin, spectinomycin and ceftriaxone were 67.3%, 40.0%, 25.7%, 10.6%, 0.3%, 0%, 0% and 0%, respectively. Compliance with the recommended first-line ceftriaxone 500 mg plus azithromycin 1 g therapy was high (90.9%). Conclusions Compared with 2015–16, ciprofloxacin resistance has remained high and azithromycin and cefixime resistance rates have increased in Brazil. Resistance remained lacking to ceftriaxone, gentamicin and spectinomycin, which all are gonorrhoea treatment options. The increasing azithromycin resistance in Brazil and internationally may threaten the future use of azithromycin in dual regimens for treatment of gonorrhoea. Consequently, continued and enhanced quality-assured surveillance of gonococcal AMR, and ideally also treatment failures and including WGS, is imperative in Brazil and worldwide.
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Affiliation(s)
- Hanalydia de Melo Machado
- Molecular Biology, Microbiology and Serology Laboratory (LBMMS), Federal University of Santa Catarina , Florianópolis , Brazil
| | - Jéssica Motta Martins
- Molecular Biology, Microbiology and Serology Laboratory (LBMMS), Federal University of Santa Catarina , Florianópolis , Brazil
| | - Marcos André Schörner
- Molecular Biology, Microbiology and Serology Laboratory (LBMMS), Federal University of Santa Catarina , Florianópolis , Brazil
| | - Pamela Cristina Gaspar
- Department of Chronic Diseases and STI, Brazilian Ministry of Health , Brasília , Brazil
- Public Health Postgraduate Program, Brasilia University , Brasilia , Brazil
| | - Alisson Bigolin
- Department of Chronic Diseases and STI, Brazilian Ministry of Health , Brasília , Brazil
| | | | | | | | | | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University , Örebro , Sweden
- Institute for Global Health, University College London (UCL) , London , UK
| | - Maria Luiza Bazzo
- Molecular Biology, Microbiology and Serology Laboratory (LBMMS), Federal University of Santa Catarina , Florianópolis , Brazil
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de Vries HJC, de Laat M, Jongen VW, Heijman T, Wind CM, Boyd A, de Korne-Elenbaas J, van Dam AP, Schim van der Loeff MF, Bruisten S, Hoornenborg E, Knol M, Mathôt RA, Prins JM. Efficacy of ertapenem, gentamicin, fosfomycin, and ceftriaxone for the treatment of anogenital gonorrhoea (NABOGO): a randomised, non-inferiority trial. THE LANCET INFECTIOUS DISEASES 2022; 22:706-717. [DOI: 10.1016/s1473-3099(21)00625-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/06/2021] [Accepted: 09/24/2021] [Indexed: 12/26/2022]
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Martins JM, Scheffer MC, de Melo Machado H, Schörner MA, Golfetto L, Santos TM, Barazzetti FH, de Albuquerque VCB, Bazzo ML. Spectinomycin, gentamicin, and routine disc diffusion testing: An alternative for the treatment and monitoring of multidrug-resistant Neisseria gonorrhoeae? J Microbiol Methods 2022; 197:106480. [DOI: 10.1016/j.mimet.2022.106480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/29/2022] [Accepted: 04/29/2022] [Indexed: 11/29/2022]
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A Single Amino Acid Substitution in Elongation Factor G Can Confer Low-Level Gentamicin Resistance in Neisseria gonorrhoeae. Antimicrob Agents Chemother 2022; 66:e0025122. [PMID: 35465683 PMCID: PMC9112995 DOI: 10.1128/aac.00251-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The continued emergence of Neisseria gonorrhoeae isolates which are resistant to first-line antibiotics has reinvigorated interest in alternative therapies such as expanded use of gentamicin (Gen). We hypothesized that expanded use of Gen promotes emergence of gonococci with clinical resistance to this aminoglycoside. To understand how decreased susceptibility of gonococci to Gen might develop, we selected spontaneous low-level Gen-resistant (GenR) mutants (Gen MIC = 32 μg/mL) of the Gen-susceptible strain FA19. Consequently, we identified a novel missense mutation in fusA, which encodes elongation factor G (EF-G), causing an alanine (A) to valine (V) substitution at amino acid position 563 in domain IV of EF-G; the mutant allele was termed fusA2. Transformation analysis showed that fusA2 could increase the Gen MIC by 4-fold. While possession of fusA2 did not impair either in vitro gonococcal growth or protein synthesis, it did result in a fitness defect during experimental infection of the lower genital tract in female mice. Through bioinformatic analysis of whole-genome sequences of 10,634 international gonococcal clinical isolates, other fusA alleles were frequently detected, but genetic studies revealed that they could not decrease Gen susceptibility in a similar manner to fusA2. In contrast to these diverse international fusA alleles, the fusA2-encoded A563V substitution was detected in only a single gonococcal clinical isolate. We hypothesize that the rare occurrence of fusA2 in N. gonorrhoeae clinical isolates is likely due to a fitness cost during infection, but compensatory mutations which alleviate this fitness cost could emerge and promote GenR in global strains.
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11
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Matoga M, Chen JS, Krysiak R, Ndalama B, Massa C, Bonongwe N, Mathiya E, Kamtambe B, Jere E, Chikaonda T, Golparian D, Unemo M, Cohen MS, Hobbs MM, Hoffman IF. Gentamicin Susceptibility in Neisseria gonorrhoeae and Treatment Outcomes for Urogenital Gonorrhea After 25 Years of Sustained Gentamicin Use in Malawi. Sex Transm Dis 2022; 49:251-256. [PMID: 34772893 PMCID: PMC8940620 DOI: 10.1097/olq.0000000000001580] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gentamicin has been used for the treatment of gonorrhea in Malawi since 1993. However, declining clinical cure rates have been suspected. We evaluated current Neisseria gonorrhoeae susceptibility to gentamicin in vitro and clinically. METHODS Men with acute urethritis were recruited at the Bwaila District Hospital STI Clinic in Lilongwe, Malawi, between January 2017 and August 2019. All men provided urethral swabs for etiological testing at enrollment and test of cure (TOC), 1 week later, using Gram-stained microscopy and culture. We used Etest to determine minimum inhibitory concentrations (MICs) of gentamicin, azithromycin, cefixime, ceftriaxone, ciprofloxacin, and spectinomycin; disc diffusion for tetracycline susceptibility; and whole-genome sequencing (WGS) to verify/refute treatment failure. RESULTS Among 183 N. gonorrhoeae culture-positive men enrolled, 151 (82.5%) had a swab taken for TOC. Of these 151 men, 16 (10.6%) had a positive culture at TOC. One hundred forty-one baseline isolates were tested for gentamicin susceptibility using Etest: 2 (1.4%), MIC = 2 μg/mL; 111 (78.7%), MIC = 4 μg/mL; and 28 (19.9%), MIC = 8 μg/mL. All isolates were susceptible to azithromycin, cefixime, ceftriaxone, and spectinomycin, whereas 63.1% had intermediate susceptibility or resistance to ciprofloxacin. Almost all (96.1%) isolates were resistant to tetracycline. All examined isolates cultured at TOC (n = 13) had gentamicin MICs ≤8 μg/mL. Ten men had pretreatment and posttreatment isolates examined by whole-genome sequencing; 2 (20%) were verified new infections (4119 and 1272 single-nucleotide polymorphisms), whereas 8 (80%) were confirmed treatment failures (0-1 single-nucleotide polymorphism). CONCLUSIONS Gentamicin MICs poorly predict gonorrhea treatment outcome with gentamicin, and treatment failures are verified with gonococcal strains with in vitro susceptibility to gentamicin. The first-line treatment of gonorrhea in Malawi should be reassessed.
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Affiliation(s)
| | - Jane S Chen
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, USA
| | - Robert Krysiak
- UNC Project Malawi, Lilongwe, Malawi
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, USA
| | | | | | | | | | - Blessing Kamtambe
- Bwaila District Hospital, Lilongwe District Health Office, Lilongwe, Malawi
| | | | | | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Örebro University Hospital and Örebro University, Örebro, Sweden
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Örebro University Hospital and Örebro University, Örebro, Sweden
| | - Myron S Cohen
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, USA
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Marcia M Hobbs
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Irving F Hoffman
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, USA
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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12
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Iwuji C, Pillay D, Shamu P, Murire M, Nzenze S, Cox LA, Mullick S. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:2074-2093. [PMID: 35578892 PMCID: PMC9333409 DOI: 10.1093/jac/dkac159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/23/2022] [Indexed: 11/12/2022] Open
Abstract
Objectives Limited antimicrobial resistance (AMR) surveillance coupled with syndromic management of sexually transmitted infections (STIs) in sub-Saharan Africa (SSA) could be contributing to an increase in AMR in the region. This systematic review aimed to synthesize data on the prevalence of AMR in common STIs in SSA and identify some research gaps that exist. Methods We searched three electronic databases for studies published between 1 January 2000 and 26 May 2020. We screened the titles and abstracts for studies that potentially contained data on AMR in SSA. Then we reviewed the full text of these studies to identify articles that reported data on the prevalence of AMR in Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and Mycoplasma genitalium in SSA. We summarized the data using a narrative synthesis. Results The 40 included studies reported on AMR data from 7961 N. gonorrhoeae isolates from 15 countries in SSA and 350 M. genitalium specimens from South Africa. All four SSA regions reported very high rates of ciprofloxacin, tetracycline and penicillin resistance in N. gonorrhoeae. Resistance to cefixime or ceftriaxone was observed in all regions except West Africa. Azithromycin resistance, recommended as part of dual therapy with an extended-spectrum cephalosporin for gonorrhoea, was reported in all the regions. Both macrolide and fluoroquinolone-associated resistance were reported in M. genitalium in South Africa. Studies investigating AMR in C. trachomatis and T. vaginalis were not identified. Conclusions There is a need to strengthen AMR surveillance in SSA for prompt investigation and notification of drug resistance in STIs.
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Affiliation(s)
| | - Diantha Pillay
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Patience Shamu
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Mercy Murire
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Susan Nzenze
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Laura Ashleigh Cox
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Saiqa Mullick
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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13
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Lahra MM, Hogan TR, Shoushtari M, Armstrong BH. Australian Gonococcal Surveillance Programme Annual Report, 2020. ACTA ACUST UNITED AC 2021; 45. [PMID: 34711144 DOI: 10.33321/cdi.2021.45.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Abstract The Australian Gonococcal Surveillance Programme (AGSP), established in 1981, has continuously monitored antimicrobial resistance in clinical isolates of Neisseria gonorrhoeae for more than 40 years. In 2020, a total of 7,222 clinical isolates of gonococci from patients in the public and private sectors, in all jurisdictions, were tested for in vitro antimicrobial susceptibility by standardised methods. Current treatment recommendations for gonorrhoea, for the majority of Australia, continues to be dual therapy with ceftriaxone and azithromycin. In 2020, decreased susceptibility (DS) to ceftriaxone (minimum inhibitory concentration [MIC] value ≥ 0.06 mg/L) was found nationally in 0.9% of isolates. There was one isolate, reported from Victoria in 2020, that was resistant to ceftriaxone (MIC value ≥ 0.25 mg/L). Resistance to azithromycin (MIC value ≥ 1.0 mg/L) was found nationally in 3.9% of N. gonorrhoeae isolates, continuing a downward trend observed and reported since 2017. Isolates with high-level resistance to azithromycin (MIC value ≥ 256 mg/L) are identified sporadically in Australia; in 2020, there was one such isolate reported in Queensland. In 2020, penicillin resistance was found in 27% of gonococcal isolates nationally, and ciprofloxacin resistance in 36%; however, there is considerable variation by jurisdiction. In some remote settings, penicillin resistance remains low, and this drug continues to be recommended as part of an empiric therapy strategy. In 2020, in remote Northern Territory, no penicillin resistance was reported, and in remote Western Australia 5/116 of gonococcal isolates (4.3%) were penicillin resistant. There was one ciprofloxacin-resistant isolate reported from remote Northern Territory, and ciprofloxacin resistance rates remain comparatively low in remote Western Australia (4/116; 3.4%).
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Affiliation(s)
- Monica M Lahra
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia.,School of Medical Sciences, Faculty of Medicine, The University of New South Wales, NSW, 2052, Australia
| | - Tiffany R Hogan
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Masoud Shoushtari
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Benjamin H Armstrong
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia.,School of Medical Sciences, Faculty of Medicine, The University of New South Wales, NSW, 2052, Australia.,Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead, NSW, 2145, Australia
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14
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Cameron-McDermott SM, Barrow GJ, Webster AM, De La Haye CO, Wood DHE, Lewis VM, Nicholson A, Reynolds-Campbell GY, Thoms-Rodriguez CAA, Roye-Green KJ, Otto-Stewart N, Miller ZN, Tomlinson JA, Skyers N, Unemo M, Anzinger JJ. Antimicrobial susceptibility of Neisseria gonorrhoeae isolates and syndromic treatment of men with urethral discharge in Kingston, Jamaica, 2018-19. J Antimicrob Chemother 2021; 77:218-222. [PMID: 34557895 PMCID: PMC8730701 DOI: 10.1093/jac/dkab340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/20/2021] [Indexed: 01/16/2023] Open
Abstract
Objectives To quantitatively determine the antimicrobial susceptibility of clinical Neisseria gonorrhoeae isolates from men with urethral discharge in Jamaica and to describe the syndromic treatment therapies administered. Methods Urethral eSwabs (Copan) were collected from 175 men presenting with urethral discharge to the Comprehensive Health Centre STI Clinic, Kingston, Jamaica. Clinical information was collected and MICs of eight antimicrobials were determined for N. gonorrhoeae isolates (n = 96) using Etest and interpreted using CLSI criteria. Results The median age of the subjects was 28 years (range: 18–73 years) with a median of 2 sexual partners (range: 1–25) per male in the previous 3 months. All examined N. gonorrhoeae isolates were susceptible to ceftriaxone (96/96), azithromycin (91/91), cefixime (91/91) and spectinomycin (91/91). For ciprofloxacin and gentamicin, respectively, 98.9% (91/92) and 91.3% (84/92) of the isolates were susceptible and 1.1% (1/92) and 8.7% (8/92) showed intermediate susceptibility/resistance. For tetracycline and benzylpenicillin, respectively, 38.0% (35/92) and 22.0% (20/91) of the isolates were susceptible, 52.2% (48/92) and 74.7% (68/91) showed intermediate susceptibility/resistance and 9.8% (9/92) and 3.3% (3/91) were resistant. Syndromic treatment was administered as follows: 93.1% received 250 mg of ceftriaxone intramuscularly plus 100 mg of doxycycline orally q12h for 1–2 weeks and 6.9% received 500 mg of ciprofloxacin orally plus 100 mg of doxycycline orally q12h for 1 week. Conclusions Ceftriaxone (250 mg) remains appropriate for gonorrhoea treatment in the examined population of men in Kingston, Jamaica. Surveillance of N. gonorrhoeae AMR should be expanded in Jamaica and other Caribbean countries to guide evidence-based treatment guidelines.
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Affiliation(s)
- Suzette M Cameron-McDermott
- Department of Microbiology, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston, Jamaica
| | - Geoffrey J Barrow
- Department of Medicine, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston, Jamaica
| | | | | | | | - Violet M Lewis
- Comprehensive Health Centre STI Clinic, Kingston, Jamaica
| | - Alison Nicholson
- Department of Microbiology, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston, Jamaica
| | - Glendee Y Reynolds-Campbell
- Department of Microbiology, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston, Jamaica
| | | | - Karen J Roye-Green
- Department of Microbiology, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston, Jamaica
| | - Nakeisha Otto-Stewart
- Department of Microbiology, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston, Jamaica
| | - Zahra N Miller
- Epidemiology Unit, Ministry of Health and Wellness, Kingston, Jamaica
| | - Jennifer A Tomlinson
- HIV/STI/TB Unit, Ministry of Health and Wellness, Kingston, Jamaica.,Jamaica AIDS Support for Life, Kingston, Jamaica
| | - Nicola Skyers
- HIV/STI/TB Unit, Ministry of Health and Wellness, Kingston, Jamaica
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Örebro University and University Hospital, Örebro, Sweden
| | - Joshua J Anzinger
- Department of Microbiology, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston, Jamaica
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15
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Salmerón P, Viñado B, Arando M, Alcoceba E, Romero B, Menéndez B, Bernal S, Idigoras P, Colomina J, Martin-Saco G, Leal-Negredo Á, Torreblanca A, Martínez O, Serra-Pladevall J. Neisseria gonorrhoeae antimicrobial resistance in Spain: a prospective multicentre study. J Antimicrob Chemother 2021; 76:1523-1531. [PMID: 33569588 DOI: 10.1093/jac/dkab037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/19/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Gonococcal infection is one of the most reported sexually transmitted infections and antimicrobial resistance in Neisseria gonorrhoeae (NG) is challenging for the treatment of this infection. This observational study aimed to describe antimicrobial resistance of NG and epidemiological data from patients with gonococcal infection in eight regions of Spain, for updating the local therapeutic guidelines. METHODS MICs of penicillin, cefixime, ceftriaxone, azithromycin, ciprofloxacin, fosfomycin and gentamicin were determined by Etest for all NG isolates recovered from 1 April 2018 to 30 September 2019 from 10 hospitals in Spain. Resistance determinants were identified using logistic regression analysis. Differences with a P value <0.05 were considered statistically significant. RESULTS Antimicrobial susceptibility testing was performed for 2571 gonococci isolated from 2429 patients. 44.5% (945/2124) of patients were MSM. The resistance rate to extended-spectrum cephalosporins was low, with 0.2% (6/2561) of isolates resistant to ceftriaxone and 1.7% (44/2517) of isolates resistant to cefixime. The overall azithromycin resistance rate was 12.1% (310/2560), but differed greatly depending on the area. 56.2% (1366/2429) of the strains studied were ciprofloxacin resistant. MIC50 and MIC90 values of gentamicin and fosfomycin were 4 and 8 mg/L and 24 and 48 mg/L, respectively. CONCLUSIONS Our study shows that NG susceptibility to extended-spectrum cephalosporins remains high in Spain. The azithromycin resistance rate questions the suitability of dual therapy. This study provides data of interest for updating the national treatment guidelines and highlights the need to develop and implement a national sentinel gonococcal antimicrobial susceptibility programme.
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Affiliation(s)
- Paula Salmerón
- Microbiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.,Sexually Transmitted Infections Study Group (GEITS), Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Madrid, Spain.,Department of Genetics and Microbiology, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Belén Viñado
- Microbiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Maider Arando
- Sexually Transmitted Infections Study Group (GEITS), Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Madrid, Spain.,Drassanes-Vall d'Hebron Sexually Transmitted Infections Unit, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Eva Alcoceba
- Microbiology Department, Son Espases Hospital Universitari, Mallorca, Spain
| | - Beatriz Romero
- Microbiology Department, Ramón y Cajal Hospital Universitario, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Blanca Menéndez
- Sexually Transmitted Infections Study Group (GEITS), Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Madrid, Spain.,Sandoval Health Centre, San Carlos Hospital Clínico, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Samuel Bernal
- Sexually Transmitted Infections Study Group (GEITS), Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Madrid, Spain.,Microbiology Department, Virgen de Valme Hospital Universitario, Sevilla, Spain
| | - Pedro Idigoras
- Microbiology Department, Donostia Hospital Universitario, San Sebastián, Spain
| | - Javier Colomina
- Microbiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Gloria Martin-Saco
- Sexually Transmitted Infections Study Group (GEITS), Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Madrid, Spain.,Microbiology Department, Miguel Servet Hospital Universitario, Zaragoza, Spain
| | - Álvaro Leal-Negredo
- Sexually Transmitted Infections Study Group (GEITS), Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Madrid, Spain.,Microbiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Aurora Torreblanca
- Sexually Transmitted Infections Study Group (GEITS), Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Madrid, Spain.,Microbiology Department, Cabueñes Hospital Universitario, Gijón, Spain
| | - Olalla Martínez
- Microbiology Department, La Ribera Hospital Universitario, Valencia, Spain
| | - Judit Serra-Pladevall
- Microbiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.,Sexually Transmitted Infections Study Group (GEITS), Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Madrid, Spain.,Department of Genetics and Microbiology, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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16
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Kularatne R, Kufa T, Gumede L, Maseko V. Comparison of gentamicin MICs by agar dilution and Etest for clinical isolates of Neisseria gonorrhoeae. J Antimicrob Chemother 2021; 75:2599-2604. [PMID: 32544235 DOI: 10.1093/jac/dkaa202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/26/2020] [Accepted: 04/21/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In South Africa, Neisseria gonorrhoeae (NG) is the predominant cause of male urethritis syndrome (MUS). The national MUS treatment guidelines recommend gentamicin as salvage therapy for ceftriaxone treatment failures. We ascertained and compared gentamicin MICs obtained by agar dilution and Etest for clinical isolates of NG. METHODS Gentamicin MICs for NG culture isolates obtained from 272 MUS cases in 2017 were determined using agar dilution, as per CLSI agar dilution methods, and Etest® (bioMérieux, Marcy-l'Étoile, France). Previously published interpretive criteria were used: MIC ≤4 mg/L, susceptible (S); MIC 8-16 mg/L, intermediately resistant (IR); and MIC ≥32 mg/L, resistant (R). WHO 2008 NG reference strains were used as comparison standards. RESULTS Gentamicin agar dilution versus Etest MIC results (mg/L) were as follows: MIC50 = 16 versus 4; MIC90 = 16 versus 8; minimum MIC = 4 versus 1; and maximum MIC = 32 versus 16. Interpretive categories for agar dilution versus Etest were as follows: S, 4.4% versus 86.8%; IR, 86.0% versus 13.4%; and R, 9.6% versus 0%. The gentamicin MIC50 by agar dilution was significantly higher than by Etest (sign test P value <0.001); overall MIC agreement was 7.4% [kappa statistic (κ) = -0.014 (95% CI -0.039 to 0.010)]. Correlation with expected MICs for WHO reference strains was consistently better with Etest than with agar dilution. CONCLUSIONS There was a significant discordance between NG gentamicin MICs by agar dilution versus Etest. NG gentamicin AST methodology must be standardized and interpretive criteria established to optimize the monitoring of susceptibility trends.
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Affiliation(s)
- Ranmini Kularatne
- Centre for HIV & STIs, National Institute for Communicable Diseases, Johannesburg, South Africa.,Department of Clinical Microbiology & Infectious Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Tendesayi Kufa
- Centre for HIV & STIs, National Institute for Communicable Diseases, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Lindy Gumede
- Centre for HIV & STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Venessa Maseko
- Centre for HIV & STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
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17
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Karymbaeva S, Boiko I, Jacobsson S, Mamaeva G, Ibraeva A, Usupova D, Golparian D, Unemo M. Antimicrobial resistance and molecular epidemiological typing of Neisseria gonorrhoeae isolates from Kyrgyzstan in Central Asia, 2012 and 2017. BMC Infect Dis 2021; 21:559. [PMID: 34118893 PMCID: PMC8195719 DOI: 10.1186/s12879-021-06262-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/01/2021] [Indexed: 04/04/2023] Open
Abstract
Background Gonorrhoea and antimicrobial resistance (AMR) in Neisseria gonorrhoeae are significant public health concerns globally. Nearly no gonococcal AMR data are available from Central Asia, and no data from Kyrgyzstan has been published. We examined, for the first time, AMR and molecular epidemiology of N. gonorrhoeae isolates cultured in Kyrgyzstan in 2012 and 2017, in order to inform refinements of the Kyrgyz national gonorrhoea management guidelines. Methods N. gonorrhoeae isolates cultured in 2012 (n = 84) and 2017 (n = 72) in Kyrgyzstan were examined. MICs of nine antimicrobials were determined using Etest and, where available, clinical breakpoints from the EUCAST were applied. N. gonorrhoeae multiantigen sequence typing (NG-MAST) was also performed. Results The overall resistance levels were high to ciprofloxacin (88.5%), tetracycline (56.9%), benzylpenicillin (39.1%), and kanamycin (4.7%). Resistance to cefixime (0.6%, n = 1 isolate), azithromycin (0.6%, n = 1), and gentamicin (0.6%, n = 1) was rare. No resistance to ceftriaxone or spectinomycin was found. However, the proportion of isolates with decreased susceptibility (MIC = 0.125 mg/L) to ceftriaxone and cefixime was 12.8 and 11.5%, respectively. Gonococcal isolates were assigned 69 sequence types, of which 52 (75.4%) were new. Conclusions The gonococcal population in Kyrgyzstan in 2012 and 2017 showed a high genetic diversity. Ceftriaxone, 500–1000 mg, in combination with azithromycin 2 g or doxycycline, particularly when chlamydial infection has not been excluded, should be recommended as empiric first-line treatment. Spectinomycin 2 g could be an alternative treatment, and given with azithromycin 2 g if pharyngeal gonorrhoea has not been excluded. Fluoroquinolones, aminoglycosides, benzylpenicillin, or tetracyclines should not be used for empiric treatment of gonorrhoea in Kyrgyzstan. Timely updating and high compliance to national gonorrhoea treatment guidelines based on quality-assured AMR data is imperative. Expanded and improved gonococcal AMR surveillance in Kyrgyzstan is crucial.
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Affiliation(s)
- Saliya Karymbaeva
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University Hospital, SE-701 85, Örebro, Sweden
| | - Iryna Boiko
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University Hospital, SE-701 85, Örebro, Sweden.,Department of Functional and Laboratory Diagnostics, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Susanne Jacobsson
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University Hospital, SE-701 85, Örebro, Sweden
| | - Galina Mamaeva
- Republican Dermatovenerological Centre, Bishkek, Kyrgyzstan
| | | | - Dilara Usupova
- Republican Dermatovenerological Centre, Bishkek, Kyrgyzstan
| | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University Hospital, SE-701 85, Örebro, Sweden
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University Hospital, SE-701 85, Örebro, Sweden.
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18
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Cole MJ, Tan W, Fifer H, Brittain C, Duley L, Hepburn T, Lawrence T, Montgomery AA, Sprange K, Thandi S, Churchward C, Tripodo F, Woodford N, Ross JDC. Gentamicin, azithromycin and ceftriaxone in the treatment of gonorrhoea: the relationship between antibiotic MIC and clinical outcome. J Antimicrob Chemother 2021; 75:449-457. [PMID: 31670808 DOI: 10.1093/jac/dkz436] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 09/05/2019] [Accepted: 09/23/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To investigate the relationship between MIC and clinical outcome in a randomized controlled trial that compared gentamicin 240 mg plus azithromycin 1 g with ceftriaxone 500 mg plus azithromycin 1 g. MIC analysis was performed on Neisseria gonorrhoeae isolates from all participants who were culture positive before they received treatment. METHODS Viable gonococcal cultures were available from 279 participants, of whom 145 received ceftriaxone/azithromycin and 134 received gentamicin/azithromycin. Four participants (6 isolates) and 14 participants (17 isolates) did not clear infection in the ceftriaxone/azithromycin and gentamicin/azithromycin arms, respectively. MICs were determined by Etest on GC agar base with 1% Vitox. The geometric mean MICs of azithromycin, ceftriaxone and gentamicin were compared using logistic and linear regression according to treatment received and N. gonorrhoeae clearance. RESULTS As the azithromycin MIC increased, gentamicin/azithromycin treatment was less effective than ceftriaxone/azithromycin at clearing N. gonorrhoeae. There was a higher geometric mean MIC of azithromycin for isolates from participants who had received gentamicin/azithromycin and did not clear infection compared with those who did clear infection [ratio 1.95 (95% CI 1.28-2.97)], but the use of categorical MIC breakpoints did not accurately predict the treatment response. The geometric mean MIC of azithromycin was higher in isolates from the pharynx compared with genital isolates. CONCLUSIONS We found that categorical resistance to azithromycin or ceftriaxone in vitro, and higher gentamicin MICs in the absence of breakpoints, were poorly predictive of treatment failure.
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Affiliation(s)
| | - Wei Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Clare Brittain
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Tessa Lawrence
- University Hospitals Birmingham NHS Foundation Trust, Whittall Street Clinic, Birmingham, UK
| | - Alan A Montgomery
- 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
| | | | | | | | - Jonathan D C Ross
- University Hospitals Birmingham NHS Foundation Trust, Whittall Street Clinic, Birmingham, UK
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19
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Antimicrobial resistance in Neisseria gonorrhoeae isolates and gonorrhoea treatment in the Republic of Belarus, Eastern Europe, 2009-2019. BMC Infect Dis 2021; 21:520. [PMID: 34078300 PMCID: PMC8173742 DOI: 10.1186/s12879-021-06184-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 05/14/2021] [Indexed: 11/22/2022] Open
Abstract
Background Limited antimicrobial resistance (AMR) data for Neisseria gonorrhoeae are available in Eastern Europe. We investigated AMR in N. gonorrhoeae isolates in the Republic of Belarus from 2009 to 2019, antimicrobial treatment recommended nationally, and treatment given to patients with gonorrhoea. Methods N. gonorrhoeae isolates (n = 522) cultured in three regions of Belarus in 2009–2019 were examined. Determination of minimum inhibitory concentrations (MICs) of eight antimicrobials was performed using Etest. Resistance breakpoints from the European Committee on Antimicrobial Susceptibility Testing were applied where available. A Nitrocefin test identified β-lactamase production. Gonorrhoea treatment for 1652 patients was also analysed. Statistical significance was determined by the Z-test, Fisher’s exact test, or Mann-Whitney U test with p-values of < 0.05 indicating significance. Results In total, 27.8% of the N. gonorrhoeae isolates were resistant to tetracycline, 24.7% to ciprofloxacin, 7.0% to benzylpenicillin, 2.7% to cefixime, and 0.8% to azithromycin. No isolates were resistant to ceftriaxone, spectinomycin, or gentamicin. However, 14 (2.7%) isolates had a ceftriaxone MIC of 0.125 mg/L, exactly at the resistance breakpoint (MIC > 0.125 mg/L). Only one (0.2%) isolate, from 2013, produced β-lactamase. From 2009 to 2019, the levels of resistance to ciprofloxacin and tetracycline were relatively high and stable. Resistance to cefixime was not identified before 2013 but peaked at 22.2% in 2017. Only sporadic isolates with resistance to azithromycin were found in 2009 (n = 1), 2012 (n = 1), and 2018–2019 (n = 2). Overall, 862 (52.2%) patients received first-line treatment according to national guidelines (ceftriaxone 1 g). However, 154 (9.3%) patients received a nationally recommended alternative treatment (cefixime 400 mg or ofloxacin 400 mg), and 636 (38.5%) were given non-recommended treatment. Conclusions The gonococcal resistance to ciprofloxacin and tetracycline was high, however, the resistance to azithromycin was low and no resistance to ceftriaxone was identified. Ceftriaxone 1 g can continuously be recommended as empiric first-line gonorrhoea therapy in Belarus. Fluoroquinolones should not be prescribed for treatment if susceptibility has not been confirmed by testing. Timely updating and high compliance with national evidence-based gonorrhoea treatment guidelines based on quality-assured AMR data are imperative. The need for continued, improved and enhanced surveillance of gonococcal AMR in Belarus is evident.
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20
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Matoga M, Chen JS, Kudowa E, Kamanga G, Mapanje C, Massa C, Ndalama B, Bonongwe N, Nyirenda N, Mathiya E, Jere E, Ngoma E, Chagomerana M, Phiri S, Powers KA, Miller WC, Cohen MS, Hoffman IF. Syndromes Associated with Sexually Transmitted Infections in Lilongwe, Malawi: Burden and Trends, 2006 to 2015. Sex Transm Dis 2021; 48:e68-e72. [PMID: 32925596 DOI: 10.1097/olq.0000000000001278] [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: 11/26/2022]
Abstract
ABSTRACT Monitoring the burden of and trends in sexually transmitted infection syndromes is useful in informing syndromic management guidelines. Among sexually transmitted infection clinic patients in Lilongwe, Malawi, between 2006 and 2015, genital discharge, lower abdominal pain, and genital ulcer syndromes were common. Prevalence of most syndromes remained stable during the 10-year period.
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Affiliation(s)
| | - Jane S Chen
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health Chapel Hill, NC
| | | | | | | | | | | | | | | | | | | | | | | | - Sam Phiri
- The Lighthouse Trust, Lilongwe, Malawi
| | - Kimberly A Powers
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health Chapel Hill, NC
| | - William C Miller
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH
| | - Myron S Cohen
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Irving F Hoffman
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
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21
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Kakooza F, Musinguzi P, Workneh M, Walwema R, Kyambadde P, Mande E, Lubega C, Nakasi JM, Kiggundu R, Hamill MM, Bagaya BS, Lamorde M, Unemo M, Manabe YC. Implementation of a standardised and quality-assured enhanced gonococcal antimicrobial surveillance programme in accordance with WHO protocols in Kampala, Uganda. Sex Transm Infect 2021; 97:312-316. [PMID: 33082237 DOI: 10.1136/sextrans-2020-054581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/16/2020] [Accepted: 08/29/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The emergence of multidrug-resistant Neisseria gonorrhoeae (NG) is a major global health threat necessitating response and control measures. NG antimicrobial resistance (AMR) surveillance data from sub-Saharan countries is exceedingly limited. This paper aims to describe the establishment, design and implementation of a standardised and quality-assured gonococcal surveillance programme and to describe the susceptibility patterns of the cultured gonococcal isolates in Kampala, Uganda. METHODS From March 2018 to September 2019, using the WHO Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) protocol, consecutive males with urethral discharge syndrome were recruited from 10 surveillance sites in Kampala City, Uganda, in collaboration with the Ministry of Health. Males completed a questionnaire and provided a urethral swab specimen. Culture, identification and antimicrobial susceptibility testing (Etest) were performed. RESULTS Of the 1013 males recruited, 73.1% (740/1013) had a positive Gram stain and 51.1% (n=518) were culture-positive for NG. Using Etest (458 isolates), the resistance to ciprofloxacin was 99.6%. Most isolates were susceptible to azithromycin, cefoxitin and gentamicin, that is, 99.8%, 98.5% and 92.4%, respectively, and all isolates were susceptible to ceftriaxone and cefixime. CONCLUSIONS We established a standardised, quality-assured WHO EGASP. Using Etest, 458 isolates were characterised, with associated epidemiological surveillance data, in 1.5 years, which by far exceed the minimum 100 isolates per year and country requested in the WHO Global GASP, to detect AMR levels with confidence. These isolates with the epidemiological data can be used to develop population level interventions.
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Affiliation(s)
- Francis Kakooza
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Immunology and Molecular Biology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Patrick Musinguzi
- Ministry of Health, National Sexually Transmitted Infections Control Program, Kampala, Uganda
| | - Meklit Workneh
- Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Richard Walwema
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter Kyambadde
- Ministry of Health, National Sexually Transmitted Infections Control Program, Kampala, Uganda
| | - Emmanuel Mande
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Christopher Lubega
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jhamira M Nakasi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Reuben Kiggundu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Matthew M Hamill
- Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Bernard S Bagaya
- Department of Immunology and Molecular Biology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine Clinic of Microbiology, Faculty of Medicine and Health, Örebro University, Orebro, Sweden
| | - Yukari C Manabe
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
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22
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Lahra MM, Hogan TR, Shoushtari M, Armstrong BH. Australian Gonococcal Surveillance Programme Annual Report, 2020. ACTA ACUST UNITED AC 2021; 45. [PMID: 33934693 DOI: 10.33321/cdi.2021.45.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Abstract The Australian Gonococcal Surveillance Programme (AGSP), established in 1981, has continuously monitored antimicrobial resistance in clinical isolates of Neisseria gonorrhoeae for more than 40 years. In 2020, a total of 7,219 clinical isolates of gonococci from patients in the public and private sectors, in all jurisdictions, were tested for in vitro antimicrobial susceptibility by standardised methods. Current treatment recommendations for gonorrhoea, for the majority of Australia, continues to be dual therapy with ceftriaxone and azithromycin. In 2020, decreased susceptibility (DS) to ceftriaxone (minimum inhibitory concentration [MIC] value ≥ 0.06 mg/L) was found nationally in 0.9% of isolates. There was one isolate, reported from Victoria in 2020, that was resistant to ceftriaxone (MIC value ≥ 0.25 mg/L). Resistance to azithromycin (MIC value ≥ 1.0 mg/L) was found nationally in 3.9% of N. gonorrhoeae isolates, continuing a downward trend observed and reported since 2017. Isolates with high-level resistance to azithromycin (MIC value ≥ 256 mg/L) are identified sporadically in Australia; in 2020, there was one such isolate reported in Queensland. In 2020, penicillin resistance was found in 27% of gonococcal isolates nationally, and ciprofloxacin resistance in 36%; however, there is considerable variation by jurisdiction. In some remote settings, penicillin resistance remains low, and this drug continues to be recommended as part of an empiric therapy strategy. In 2020, in remote Northern Territory, no penicillin resistance was reported, and in remote Western Australia 5/116 of gonococcal isolates (4.3%) were penicillin resistant. There was one ciprofloxacin-resistant isolate reported from remote Northern Territory, and ciprofloxacin resistance rates remain comparatively low in remote Western Australia (4/116; 3.4%).
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Affiliation(s)
- Monica M Lahra
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia.,School of Medical Sciences, Faculty of Medicine, The University of New South Wales, NSW, 2052, Australia
| | - Tiffany R Hogan
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Masoud Shoushtari
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Benjamin H Armstrong
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney. New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, 2031, Australia.,School of Medical Sciences, Faculty of Medicine, The University of New South Wales, NSW, 2052, Australia.,Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead, NSW, 2145, Australia
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23
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Barbee LA, Soge OO, Morgan J, Leclair A, Bass T, Werth BJ, Hughes JP, Golden MR. Gentamicin Alone Is Inadequate to Eradicate Neisseria Gonorrhoeae From the Pharynx. Clin Infect Dis 2021; 71:1877-1882. [PMID: 31712813 DOI: 10.1093/cid/ciz1109] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/08/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Centers for Disease Control and Prevention (CDC) guidelines recommend 240 mg gentamicin plus 2 g azithromycin for the treatment of gonorrhea in cephalosporin-allergic patients. The efficacy of gentamicin alone in the treatment of pharyngeal gonorrhea is uncertain. METHODS Between September 2018 and March 2019, we enrolled men who have sex with men with nucleic acid amplification test-diagnosed pharyngeal gonorrhea in a single-arm, unblinded clinical trial. Men received a single 360-mg intramuscular dose of gentamicin and underwent test of cure by culture 4-7 days later. The study measured creatinine at enrollment and test of cure, serum gentamicin concentration postdose to establish peak concentration (Cmax), and standard antimicrobial minimum inhibitory concentrations (MICs) by agar dilution. The trial was designed to establish a point estimate for gentamicin's efficacy for pharyngeal gonorrhea. We planned to enroll 50 evaluable participants; assuming gentamicin was 80% efficacious, the trial would establish a 95% confidence interval (CI) of 66%-90%. We planned interim analyses at n = 10 and n = 25. RESULTS The study was stopped early due to poor efficacy. Of 13 enrolled men, 10 were evaluable, and only 2 (20% [95% CI, 2.5%-55.6%]) were cured. Efficacy was not associated with gentamicin Cmax or MIC. No participants experienced renal insufficiency. The mean creatinine percentage change was +5.2% (range, -6.7% to 21.3%). Six (46%) participants experienced headache, all deemed unrelated to treatment. CONCLUSIONS Gentamicin alone failed to eradicate Neisseria gonorrhoeae from the pharynx. Clinicians should use caution when treating gonorrhea with the CDC's current alternative regimen (gentamicin 240 mg plus azithromycin 2 g) given increases in azithromycin resistance and gentamicin's poor efficacy at the pharynx. CLINICAL TRIALS REGISTRATION NCT03632109.
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Affiliation(s)
- Lindley A Barbee
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA.,Human Immunodeficiency Virus/Sexually Transmitted Disease Program, Public Health-Seattle & King County, Seattle, Washington, USA
| | - Olusegun O Soge
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Jennifer Morgan
- Human Immunodeficiency Virus/Sexually Transmitted Disease Program, Public Health-Seattle & King County, Seattle, Washington, USA
| | - Angela Leclair
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Tamara Bass
- Human Immunodeficiency Virus/Sexually Transmitted Disease Program, Public Health-Seattle & King County, Seattle, Washington, USA
| | - Brian J Werth
- Department of Pharmacy, University of Washington, Seattle, Washington, USA
| | - James P Hughes
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Matthew R Golden
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA.,Human Immunodeficiency Virus/Sexually Transmitted Disease Program, Public Health-Seattle & King County, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
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24
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Armstrong BH, Limnios A, Lewis DA, Hogan T, Kundu R, Ray S, Shoushtari M, El Nasser J, Driscoll T, Lahra MM. Is gentamicin a viable therapeutic option for treating resistant Neisseria gonorrhoeae in New South Wales? ACTA ACUST UNITED AC 2021; 45. [PMID: 33632090 DOI: 10.33321/cdi.2021.45.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract The key issues with Neisseria gonorrhoeae infections, in Australia and elsewhere, are coincident increases in disease rates and in antimicrobial resistance (AMR), although these factors have not been shown to be correlated. Despite advances in diagnosis, control of this disease remains elusive, and incidence in Australia continues to increase. Of the Australian jurisdictions, New South Wales (NSW) has the highest N. gonorrhoeae notifications, and over the five-year period 2015-2019, notifications in NSW have increased above the national average (by 116% versus 85%, respectively). Gonococcal disease control is reliant on effective antibiotic regimens. However, escalating AMR in N. gonorrhoeae is a global health priority, as the collateral injury of untreated infections has substantive impacts on sexual and newborn health. Currently, our first-line therapy for gonorrhoea is also our last line, with no ideal alternative identified. Despite some limitations, gentamicin is licensed and readily available in Australia, and is proposed for treatment of resistant N. gonorrhoeae in national guidelines; however, supportive published microbiological data are lacking. Analysis of gonococcal resistance patterns within Australia for the period 1991-2019, including 35,000 clinical isolates from NSW, illustrates the establishment and spread of population-level resistance to all contemporaneous therapies. An analysis of gentamicin susceptibility on 2,768 N. gonorrhoeae clinical isolates from NSW, for the period 2015-2020, demonstrates that the median minimum inhibitory concentration (MIC) for gentamicin in NSW has remained low, at 4.0 mg/L, and resistance was not detected in any isolate. There has been no demonstration of MIC drift over time (p = 0.91, Kruskal-Wallis test), nor differences in MIC distributions according to patients' sex or site of specimen collection. This is the first large-scale evaluation of gentamicin susceptibility in N. gonorrhoeae in Australia. No gentamicin resistance was detected in clinical isolates, 2015-2020, hence this is likely to be an available treatment option for resistant gonococcal infections in NSW.
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Affiliation(s)
- Benjamin H Armstrong
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia.,School of Medical Sciences, Faculty of Medicine, The University of New South Wales, NSW 2052, Australia
| | - Athena Limnios
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - David A Lewis
- Western Sydney Sexual Health Centre, Western Sydney Local Health District, Parramatta, NSW 2150, Australia.,Westmead Clinical School and Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Westmead , NSW 2145, Australia
| | - Tiffany Hogan
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Ratan Kundu
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Sanghamitra Ray
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Masoud Shoushtari
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Jasmin El Nasser
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Tim Driscoll
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Monica M Lahra
- Neisseria Reference Laboratory and World Health Organization Collaborating Centre for STI and AMR, Sydney; New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW 2031, Australia.,School of Medical Sciences, Faculty of Medicine, The University of New South Wales, NSW 2052, Australia
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25
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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.
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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
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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.
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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
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Riedel S, Vijayakumar D, Berg G, Kang AD, Smith KP, Kirby JE. Evaluation of apramycin against spectinomycin-resistant and -susceptible strains of Neisseria gonorrhoeae. J Antimicrob Chemother 2020; 74:1311-1316. [PMID: 30689929 DOI: 10.1093/jac/dkz012] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/11/2018] [Accepted: 01/03/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The emergence of Neisseria gonorrhoeae resistant to all currently available antimicrobial therapies poses a dire public health threat. New antimicrobial agents with activity against N. gonorrhoeae are urgently needed. Apramycin is an aminocyclitol aminoglycoside with broad-spectrum in vitro activity against MDR Gram-negative pathogens and Staphylococcus aureus. However, its activity against N. gonorrhoeae has not been described. OBJECTIVES The activity spectrum of apramycin against a collection of MDR N. gonorrhoeae was assessed. Isolates tested included those susceptible and resistant to the structurally distinct aminocyclitol, spectinomycin. RESULTS The modal MICs for apramycin and spectinomycin were 16 mg/L and 32 mg/L, respectively. The epidemiological cut-off (ECOFF) for apramycin was 64 mg/L. No strains among 77 tested had an MIC above this ECOFF, suggesting very low levels of acquired apramycin resistance. In time-kill analysis, apramycin demonstrated rapid bactericidal activity comparable to that of spectinomycin. CONCLUSIONS Apramycin has broad-spectrum, rapidly bactericidal activity against N. gonorrhoeae. Future pharmacokinetic and pharmacodynamic studies will be needed to determine whether apramycin and/or apramycin derivatives hold promise as new therapeutics for N. gonorrhoeae infection.
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Affiliation(s)
- Stefan Riedel
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Gretchen Berg
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Anthony D Kang
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Pathology and Ancillary Laboratory Services, Carl R. Darnall Army Medical Center, Fort Hood, TX, USA
| | - Kenneth P Smith
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - James E Kirby
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Boiko I, Golparian D, Jacobsson S, Krynytska I, Frankenberg A, Shevchenko T, Unemo M. Genomic epidemiology and antimicrobial resistance determinants of
Neisseria gonorrhoeae
isolates from Ukraine, 2013–2018. APMIS 2020; 128:465-475. [DOI: 10.1111/apm.13060] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/11/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Iryna Boiko
- Department of Functional and Laboratory Diagnostics I. Horbachevsky Ternopil National Medical University Ternopil Ukraine
- WHO Collaborating Centre for Gonorrhoea and other STIs National Reference Laboratory for STIs Department of Laboratory Medicine Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and other STIs National Reference Laboratory for STIs Department of Laboratory Medicine Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Susanne Jacobsson
- WHO Collaborating Centre for Gonorrhoea and other STIs National Reference Laboratory for STIs Department of Laboratory Medicine Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Inna Krynytska
- Department of Functional and Laboratory Diagnostics I. Horbachevsky Ternopil National Medical University Ternopil Ukraine
| | | | - Tetiana Shevchenko
- Department of General Medicine with a Course of Physical Therapy Faculty of Medical Technologies of Diagnostics and Rehabilitation Oles Honchar Dnipro National University Dnipro Ukraine
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and other STIs National Reference Laboratory for STIs Department of Laboratory Medicine Faculty of Medicine and Health Örebro University Örebro Sweden
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29
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Workneh M, Hamill MM, Kakooza F, Mande E, Wagner J, Mbabazi O, Mugasha R, Kajumbula H, Walwema R, Zenilman J, Musinguzi P, Kyambadde P, Lamorde M, Manabe YC. Antimicrobial Resistance of Neisseria Gonorrhoeae in a Newly Implemented Surveillance Program in Uganda: Surveillance Report. JMIR Public Health Surveill 2020; 6:e17009. [PMID: 32519969 PMCID: PMC7315362 DOI: 10.2196/17009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 04/18/2020] [Accepted: 04/20/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Neisseria gonorrhoeae (commonly known as gonorrhea) has developed resistance to all first-line therapy in Southeast Asia. East Africa has historically had absent or rudimentary gonorrhea surveillance programs and, while the existence of antimicrobial-resistant gonorrhea is recognized, the extent of its resistance is largely unknown. In 2016, the World Health Organization's Enhanced Gonococcal Antimicrobial Surveillance Program (EGASP) was initiated in Uganda to monitor resistance trends. OBJECTIVE This study characterizes gonorrhea and antibiotic resistance in a large surveillance program of men with urethral discharge syndrome from Kampala, Uganda. METHODS Men attending sentinel clinics with urethritis provided demographic information, behavior data, and a urethral swab in line with the World Health Organization's EGASP protocols for culture, identification, and antibiotic-sensitivity testing using 2 methods-disk diffusion (Kirby-Bauer test) and Etest (BioMérieux Inc). A subset of samples underwent detailed antimicrobial resistance testing. RESULTS Of 639 samples collected from September 2016 to February 2018, 400 (62.6%) were culture-positive though 414 (64.8%) had microscopic evidence of gonorrhea. The mean age of the men from whom the samples were collected was 26.9 (SD 9.6) years and 7.2% (46/639) reported having HIV. There was high-level resistance to ciprofloxacin, tetracycline, and penicillin (greater than 90%) by Kirby-Bauer disk diffusion and 2.1% (4/188) had reduced azithromycin sensitivity by Etest. Of the early isolates that underwent detailed characterization, 60.3% (70/116) were culture-positive, 94% (66/69) isolates were either ciprofloxacin-resistant or ciprofloxacin-intermediate by Etest, 96% (65/68) were azithromycin-sensitive, and 96% (66/69) were gentamicin-sensitive. Resistance profiles were comparable between methods except for ceftriaxone (disk diffusion: 68/69, 99%; Etest: 67/69, 97%) and for gentamicin (disk diffusion: 2/8, 25%; Etest: 66/69, 96%) sensitivity. CONCLUSIONS This is the first report from a systematic gonorrhea surveillance program in Uganda. Findings demonstrated resistance or increased minimum inhibitory concentration to all key antigonococcal antibiotics. There was evidence of poor antibiotic stewardship, near-universal resistance to several antibiotics, and emerging resistance to others. Individuals in the population sampled were at exceptionally high risk of STI and HIV infection requiring intervention. Ongoing surveillance efforts to develop interventions to curtail antimicrobial-resistant gonorrhea are needed.
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Affiliation(s)
- Meklit Workneh
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Matthew M Hamill
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | | | | | - Jessica Wagner
- Bayview Pediatric Unit, Johns Hopkins University, Baltimore, MD, United States
| | | | | | | | | | - Jonathan Zenilman
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Patrick Musinguzi
- AIDS Control Program, Division of Sexually Transmitted Infections, Ministry of Health, Kampala, Uganda
| | - Peter Kyambadde
- AIDS Control Program, Division of Sexually Transmitted Infections, Ministry of Health, Kampala, Uganda
| | | | - Yukari C Manabe
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, United States.,Infectious Disease Institute, Kampala, Uganda
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30
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Fifteen years of a nationwide culture collection of Neisseria gonorrhoeae antimicrobial resistance in Portugal. Eur J Clin Microbiol Infect Dis 2020; 39:1761-1770. [PMID: 32494956 DOI: 10.1007/s10096-020-03907-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/07/2020] [Indexed: 10/23/2022]
Abstract
Neisseria gonorrhoeae antimicrobial resistance (AMR) and gonorrhea disease burden remain major public health concerns worldwide. To contribute to the supranational demands to monitor and manage the spread of antimicrobial-resistant N. gonorrhoeae, the Portuguese NIH promoted the creation of the National Laboratory Network for Neisseria gonorrhoeae Collection (PTGonoNet). The present study reports the N. gonorrhoeae major AMR trends observed from 2003 up to 2018. All isolates described in the present study constitute the opportunistic ongoing N. gonorrhoeae isolate collection supported by the National Reference Laboratory for Sexually Transmitted Infections of the Portuguese NIH, enrolling strains isolated in 35 different public and private laboratories. Minimum inhibitory concentrations were determined using E-tests for azithromycin, benzylpenicillin, cefixime, ceftriaxone, ciprofloxacin, gentamicin, spectinomycin and tetracycline. Molecular typing was determined using NG-MAST. AMR data of 2596 country-spread isolates show that 87.67% of all N. gonorrhoeae isolates presented decreased susceptibility to at least one antimicrobial. A continuous decreased susceptibility and resistance to penicillin, tetracycline and ciprofloxacin can be observed along the years. However, no decreased susceptibility to cephalosporins was observed until 2018, while for azithromycin, this was always low. The most common observed NG-MAST genogroups were G1407, G7445, G225, G2, and G1034. This study evidences the advantages of a nationwide collection of isolates and of centralized AMR testing to respond to supranational (EURO-GASP) requirements while providing unprecedented data on AMR in the context of 15 years of surveillance.
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Establishment of a Gonococcal Antimicrobial Surveillance Programme, in Accordance With World Health Organization Standards, in Côte d'Ivoire, Western Africa, 2014-2017. Sex Transm Dis 2020; 46:179-184. [PMID: 30461598 DOI: 10.1097/olq.0000000000000943] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is compromising the treatment of gonorrhea globally. Recent AMR data are extremely limited in Africa, and mainly totally lacking in Western Africa, including Côte d'Ivoire. This study (i) established a quality-assured gonococcal antimicrobial surveillance program, according to World Health Organization quality criteria, (ii) investigated the AMR to 8 therapeutic antimicrobials in gonococcal isolates from 2014 to 2017, and (iii) provided evidence for updating the National Sexually Transmitted Disease Syndromic Management Guidelines in Côte d'Ivoire. METHODS During 2014 to 2017, gonococcal isolates were obtained from sexually active symptomatic or asymptomatic males and females in 14 sites in Côte d'Ivoire. It was a special focus on symptomatic males, and their sexual partners, due to the higher culture positivity rates in symptomatic males. Patient metadata were collected, including age, gender, sexual orientation, and symptoms. Minimum inhibitory concentrations of 8 antimicrobials were determined by Etest and interpreted using European Committee on Antimicrobial Susceptibility Testing breakpoints. β-lactamase production was detected using cefinase disks. RESULTS The level of resistance, examining 212 gonococcal isolates, was as follows: 84.9% to tetracycline, 68.9% to benzylpenicillin, 62.7% to ciprofloxacin, 6.1% to azithromycin, and 1.4% to gentamicin. All isolates were susceptible to ceftriaxone, cefixime and spectinomycin. CONCLUSIONS We provide the first gonococcal AMR data, quality assured according to World Health Organization standards, from Côte d'Ivoire since more than 20 years. The high ciprofloxacin resistance, which informed a revision of the national syndromic management guideline during study, and relatively high resistance to azithromycin demand an improved gonococcal antimicrobial surveillance program and increased awareness when prescribing treatment in Côte d'Ivoire.
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Yang F, Yan J, Zhang J, van der Veen S. Evaluation of alternative antibiotics for susceptibility of gonococcal isolates from China. Int J Antimicrob Agents 2019; 55:105846. [PMID: 31760083 DOI: 10.1016/j.ijantimicag.2019.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 09/03/2019] [Accepted: 11/13/2019] [Indexed: 11/24/2022]
Abstract
The efficacy of the currently recommended first-line treatments for gonococcal infections - ceftriaxone monotherapy or ceftriaxone/azithromycin dual therapy - is waning rapidly, and efficient alternative antimicrobials are needed urgently to ensure that future treatment of gonorrhoea remains available. As such, the aim of this study was to screen alternative clinically approved antimicrobials for in-vitro activity against Neisseria gonorrhoeae. The susceptibility levels of 504 clinical isolates from Zhejiang Province, China to ertapenem, tigecycline, gentamicin, fosfomycin, gemifloxacin, doxycycline and rifampicin were investigated using the agar dilution method. The presence of resistance determinants was identified by polymerase chain reaction and sequencing. The minimum inhibitory concentration inhibiting 90% of growth (MIC90) was 0.06 mg/L for ertapenem, 0.25 mg/L for tigecycline, 16 mg/L for doxycycline, 4 mg/L for gemifloxacin, 16 mg/L for gentamicin, 32 mg/L for fosfomycin and 128 mg/L for rifampicin. All strains appeared to be susceptible to tigecycline (MIC ≤0.5 mg/L), while a poor correlation between tigecycline and tetracycline susceptibility was observed, indicating that tetracycline resistance determinants have little impact on tigecycline susceptibility. For ertapenem, 30 isolates showed an MIC >0.125 mg/L, but the correlation between ertapenem and ceftriaxone susceptibility was low and only two strains showed an MIC >0.125 mg/L for both antibiotics. Therefore, it appeared that most ceftriaxone-resistant isolates were still susceptible to ertapenem. In conclusion, tigecycline and ertapenem showed good activity against N. gonorrhoeae and limited cross-resistance with previously used antibiotics. Therefore, they might be interesting candidates for further evaluation of their suitability as alternative antigonococcal therapies.
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Affiliation(s)
- Fan Yang
- Department of Microbiology and Parasitology, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jing Yan
- Department of Microbiology and Parasitology, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianglin Zhang
- Department of Microbiology and Parasitology, School of Medicine, Zhejiang University, Hangzhou, China
| | - Stijn van der Veen
- Department of Microbiology and Parasitology, School of Medicine, Zhejiang University, Hangzhou, China; Department of Dermatology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China; State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Centre for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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Epidemiology, molecular characterisation and antimicrobial susceptibility of Neisseria gonorrhoeae isolates in Madrid, Spain, in 2016. Epidemiol Infect 2019; 147:e274. [PMID: 31547889 PMCID: PMC6805738 DOI: 10.1017/s095026881900150x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
With the aim to elucidate gonococcal antimicrobial resistance (AMR)–risk factors, we undertook a retrospective analysis of the molecular epidemiology and AMR of 104 Neisseria gonorrhoeae isolates from clinical samples (urethra, rectum, pharynx and cervix) of 94 individuals attending a sexually transmitted infection clinic in Madrid (Spain) from July to October 2016, and explored potential links with socio-demographic, behavioural and clinical factors of patients. Antimicrobial susceptibility was determined by E-tests, and isolates were characterised by N. gonorrhoeae multi-antigen sequence typing. Penicillin resistance was recorded for 15.4% of isolates, and most were susceptible to tetracycline, cefixime and azithromycin; a high incidence of ciprofloxacin resistance (~40%) was found. Isolates were grouped into 51 different sequence types (STs) and 10 genogroups (G), with G2400, ST5441, ST2318, ST12547 and G2992 being the most prevalent. A significant association (P = 0.015) was evident between HIV-positive MSM individuals and having a ciprofloxacin-resistant strain. Likewise, a strong association (P = 0.047) was found between patient age of MSM and carriage of isolates expressing decreased susceptibility to azithromycin. A decrease in the incidence of AMR gonococcal strains and a change in the strain populations previously reported from other parts of Spain were observed. Of note, the prevalent multi-drug resistant genogroup G1407 was represented by only three strains in our study, while the pan-susceptible clones such as ST5441, and ST2318, associated with extragenital body sites were the most prevalent.
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Berenger BM, Demczuk W, Gratrix J, Pabbaraju K, Smyczek P, Martin I. Genetic Characterization and Enhanced Surveillance of Ceftriaxone-Resistant Neisseria gonorrhoeae Strain, Alberta, Canada, 2018. Emerg Infect Dis 2019; 25:1660-1667. [PMID: 31407661 PMCID: PMC6711210 DOI: 10.3201/eid2509.190407] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In July 2018, a case of Neisseria gonorrhoeae associated with ceftriaxone treatment failure was identified in Alberta, Canada. We identified the isolate and nucleic acid amplification testing (NAAT) specimen as the ceftriaxone-resistant strain multilocus sequence type 1903/NG-MAST 3435/NG-STAR 233, originally identified in Japan (FC428), with the same penA 60.001 mosaic allele and genetic resistance determinants. Core single-nucleotide variant (SNV) analysis identified 13 SNVs between this isolate and FC428. Culture-independent surveillance by PCR for the A311V mutation in the penA allele and N. gonorrhoeae multiantigen sequence typing directly from NAAT transport media positive for N. gonorrhoeae by NAAT did not detect spread of the strain. We identified multiple sequence types not previously detected in Alberta by routine surveillance. This case demonstrates the benefit of using culture-independent methods to enhance detection, public health investigations, and surveillance to address this global threat.
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Liu JW, Xu WQ, Zhu XY, Dai XQ, Chen SC, Han Y, Liu J, Chen XS, Yin YP. Gentamicin susceptibility of Neisseria gonorrhoeae isolates from 7 provinces in China. Infect Drug Resist 2019; 12:2471-2476. [PMID: 31496761 PMCID: PMC6691950 DOI: 10.2147/idr.s214059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/12/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose Gentamicin is a promising antimicrobial for the treatment of gonorrhea. The study aimed to evaluate gentamicin minimum inhibitory concentrations (MICs) of Neisseria gonorrhoeae isolates in China. Methods In this study, the agar dilution method was used to determine the MICs of 470 isolates collected in 2016 to four effective antimicrobials (gentamicin, azithromycin, ceftriaxone, and spectinomycin). Results Gentamicin MICs ranged from 1 to 8 mg/L. No isolate was resistant to gentamicin. Of seven isolates simultaneously resistant to azithromycin and ceftriaxone, 6 isolates demonstrated MICs of 4 mg/L or less to gentamicin. No cross relationships were found between MICs of gentamicinand susceptibility profiles of azithromycin, ceftriaxone, and spectinomycin. Conclusion The in vitro results suggest that gentamicin can be a promising treatment option for gonococcal infections in China. Clinical trials to evaluate the therapeutic efficacy of gentamicin are required.
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Affiliation(s)
- Jing-Wei Liu
- Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, People's Republic of China.,National Center for Sexually Transmitted Diseases Control, Chinese Center for Disease Control and Prevention, Nanjing, People's Republic of China
| | - Wen-Qi Xu
- Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, People's Republic of China.,National Center for Sexually Transmitted Diseases Control, Chinese Center for Disease Control and Prevention, Nanjing, People's Republic of China
| | - Xiao-Yu Zhu
- Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, People's Republic of China.,National Center for Sexually Transmitted Diseases Control, Chinese Center for Disease Control and Prevention, Nanjing, People's Republic of China
| | - Xiu-Qin Dai
- Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, People's Republic of China.,National Center for Sexually Transmitted Diseases Control, Chinese Center for Disease Control and Prevention, Nanjing, People's Republic of China
| | - Shao-Chun Chen
- Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, People's Republic of China.,National Center for Sexually Transmitted Diseases Control, Chinese Center for Disease Control and Prevention, Nanjing, People's Republic of China
| | - Yan Han
- Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, People's Republic of China.,National Center for Sexually Transmitted Diseases Control, Chinese Center for Disease Control and Prevention, Nanjing, People's Republic of China
| | - Jun Liu
- SYNAPSE Center, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Xiang-Sheng Chen
- Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, People's Republic of China.,National Center for Sexually Transmitted Diseases Control, Chinese Center for Disease Control and Prevention, Nanjing, People's Republic of China
| | - Yue-Ping Yin
- Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, People's Republic of China.,National Center for Sexually Transmitted Diseases Control, Chinese Center for Disease Control and Prevention, Nanjing, People's Republic of China
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Ross JDC, Brittain C, Cole M, Dewsnap C, Harding J, Hepburn T, Jackson L, Keogh M, Lawrence T, Montgomery AA, Roberts TE, Sprange K, Tan W, Thandi S, White J, Wilson J, Duley L. Gentamicin compared with ceftriaxone for the treatment of gonorrhoea (G-ToG): a randomised non-inferiority trial. Lancet 2019; 393:2511-2520. [PMID: 31056291 PMCID: PMC6620599 DOI: 10.1016/s0140-6736(18)32817-4] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 10/12/2018] [Accepted: 10/25/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gonorrhoea is a common sexually transmitted infection for which ceftriaxone is the current first-line treatment, but antimicrobial resistance is emerging. The objective of this study was to assess the effectiveness of gentamicin as an alternative to ceftriaxone (both combined with azithromycin) for treatment of gonorrhoea. METHODS G-ToG was a multicentre, parallel-group, pragmatic, randomised, non-inferiority trial comparing treatment with gentamicin to treatment with ceftriaxone for patients with gonorrhoea. The patients, treating physician, and assessing physician were masked to treatment but the treating nurse was not. The trial took place at 14 sexual health clinics in England. Adults aged 16-70 years were eligible for participation if they had a diagnosis of uncomplicated genital, pharyngeal, or rectal gonorrhoea. Participants were randomly assigned to receive a single intramuscular dose of either gentamicin 240 mg (gentamicin group) or ceftriaxone 500 mg (ceftriaxone group). All participants also received a single 1 g dose of oral azithromycin. Randomisation (1:1) was stratified by clinic and performed using a secure web-based system. The primary outcome was clearance of Neisseria gonorrhoeae at all initially infected sites, defined as a negative nucleic acid amplification test 2 weeks post treatment. Primary outcome analyses included only participants who had follow-up data, irrespective of the baseline visit N gonorrhoeae test result. The margin used to establish non-inferiority was a lower confidence limit of 5% for the risk difference. This trial is registered with ISRCTN, number ISRCTN51783227. FINDINGS Of 1762 patients assessed, we enrolled 720 participants between Oct 7, 2014, and Nov 14, 2016, and randomly assigned 358 to gentamicin and 362 to ceftriaxone. Primary outcome data were available for 306 (85%) of 362 participants allocated to ceftriaxone and 292 (82%) of 358 participants allocated to gentamicin. At 2 weeks after treatment, infection had cleared for 299 (98%) of 306 participants in the ceftriaxone group compared with 267 (91%) of 292 participants in the gentamicin group (adjusted risk difference -6·4%, 95% CI -10·4% to -2·4%). Of the 328 participants who had a genital infection, 151 (98%) of 154 in the ceftriaxone group and 163 (94%) of 174 in the gentamicin group had clearance at follow-up (adjusted risk difference -4·4%, -8·7 to 0). For participants with a pharyngeal infection, a greater proportion receiving ceftriaxone had clearance at follow-up (108 [96%] in the ceftriaxone group compared with 82 [80%] in the gentamicin group; adjusted risk difference -15·3%, -24·0 to -6·5). Similarly, a greater proportion of participants with rectal infection in the ceftriaxone group had clearance (134 [98%] in the ceftriaxone group compared with 107 [90%] in the gentamicin group; adjusted risk difference -7·8%, -13·6 to -2·0). Thus, we did not find that a single dose of gentamicin 240 mg was non-inferior to a single dose of ceftriaxone 500 mg for the treatment of gonorrhoea, when both drugs were combined with a 1 g dose of oral azithromycin. The side-effect profiles were similar between groups, although severity of pain at the injection site was higher for gentamicin (mean visual analogue pain score 36 of 100 in the gentamicin group vs 21 of 100 in the ceftriaxone group). INTERPRETATION Gentamicin is not appropriate as first-line treatment for gonorrhoea but remains potentially useful for patients with isolated genital infection, or for patients who are allergic or intolerant to ceftriaxone, or harbour a ceftriaxone-resistant isolate. Further research is required to identify and test new alternatives to ceftriaxone for the treatment of gonorrhoea. FUNDING UK National Institute for Health Research.
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Affiliation(s)
- Jonathan D C Ross
- Department of Sexual Health and HIV, Birmingham University Hospitals NHS Foundation Trust, Birmingham, UK.
| | - Clare Brittain
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Michelle Cole
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, Public Health England, London, UK
| | - Claire Dewsnap
- Sexual Health Clinic, Sheffield Royal Hallamshire Hospital, Sheffield, UK
| | - Jan Harding
- Department of Sexual Health and HIV, Birmingham University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Louise Jackson
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Matthew Keogh
- Patient and public involvement representative, Birmingham, UK
| | - Tessa Lawrence
- Department of Sexual Health and HIV, Birmingham University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Tracy E Roberts
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Wei Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Sukhwinder Thandi
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - John White
- Sexual Health Clinic, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Janet Wilson
- Sexual Health Clinic, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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Boiko I, Golparian D, Krynytska I, Bezkorovaina H, Frankenberg A, Onuchyna M, Jacobsson S, Unemo M. Antimicrobial susceptibility of Neisseria gonorrhoeae isolates and treatment of gonorrhoea patients in Ternopil and Dnipropetrovsk regions of Ukraine, 2013-2018. APMIS 2019; 127:503-509. [PMID: 30903707 DOI: 10.1111/apm.12948] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/17/2019] [Indexed: 12/23/2022]
Abstract
Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a major public health concern globally. However, recent gonococcal AMR data from Eastern Europe are extremely limited and no AMR data for strains spreading in Ukraine have ever been internationally published. We investigated the AMR of N. gonorrhoeae isolates in two regions of Ukraine (Ternopil 2013-2018, Dnipropetrovsk 2013-2014), and, where information was available, the treatment administered to the corresponding gonorrhoea patients. Determination of minimum inhibitory concentration (MIC) of eight antimicrobials was performed using Etest and resistance breakpoints from the European Committee on Antimicrobial Susceptibility Testing (EUCAST) were applied. Overall, 9.3% of the examined 150 isolates were resistant to ciprofloxacin, 6.0% to tetracycline, 2.0% to azithromycin, and 0.7% to benzylpenicillin. No isolates were resistant to ceftriaxone, cefixime, spectinomycin, or gentamicin. However, one (0.7%) isolate showed a MIC value of 0.125 mg/L for both ceftriaxone and cefixime, i.e., bordering resistance. Eighty-eight (67.2%) of 131 patients were administered dual therapy (ceftriaxone 1 g plus doxycycline/clarithromycin/azithromycin/ofloxacin) and 22 (16.8%) ceftriaxone 1 g monotherapy. Worryingly, 21 (16.0%) patients received monotherapy with clarithromycin/doxycycline/azithromycin/ofloxacin/benzylpenicillin. In conclusion, the antimicrobial susceptibility of gonococcal strains spreading in Ternopil and Dnipropetrovsk, Ukraine during 2013-2018 was high. Low levels of resistance to ciprofloxacin, tetracycline, azithromycin, and benzylpenicillin were found, but no resistance to the internationally recommended ceftriaxone, cefixime, or spectinomycin. Ceftriaxone 1 g should remain as empiric first-line treatment, in dual therapy with azithromycin or doxycycline or in monotherapy. Continued and expanded gonococcal AMR surveillance in Ukraine is essential to monitor the susceptibility to particularly extended-spectrum cephalosporins, azithromycin and doxycycline.
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Affiliation(s)
- Iryna Boiko
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Clinical Laboratory Department, Ternopil Regional Clinical Dermatovenerologic Dispensary, Ternopil, Ukraine
| | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Inna Krynytska
- Department of Functional and Laboratory Diagnostics, I. Horbachevsky Ternopil State Medical University, Ternopil, Ukraine
| | - Halyna Bezkorovaina
- Outpatient Department, Ternopil Regional Clinical Dermatovenerologic Dispensary, Ternopil, Ukraine
| | - Arkadii Frankenberg
- Dnipropetrovsk Regional Clinical Dermatovenerologic Dispensary, Dnipro, Ukraine
| | - Margarita Onuchyna
- Clinical Laboratory Department, Dnipropetrovsk Regional Clinical Dermatovenerologic Dispensary, Dnipro, Ukraine
| | - Susanne Jacobsson
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Martin I, Sawatzky P, Allen V, Lefebvre B, Hoang LMN, Naidu P, Minion J, Van Caeseele P, Haldane D, Gad RR, Zahariadis G, Corriveau A, German G, Tomas K, Mulvey MR. Multidrug-resistant and extensively drug-resistant Neisseria gonorrhoeae in Canada, 2012-2016. CANADA COMMUNICABLE DISEASE REPORT = RELEVE DES MALADIES TRANSMISSIBLES AU CANADA 2019; 45:45-53. [PMID: 31015818 PMCID: PMC6461123 DOI: 10.14745/ccdr.v45i23a01] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
BACKGROUND Neisseria gonorrhoeae have acquired resistance to many antimicrobials, including third generation cephalosporins and azithromycin, which are the current gonococcal combination therapy recommended by the Canadian Guidelines on Sexually Transmitted Infections. OBJECTIVE To describe antimicrobial susceptibilities for N. gonorrhoeae circulating in Canada between 2012 and 2016. METHODS Antimicrobial resistance profiles were determined using agar dilution of N. gonorrhoeae isolated in Canada 2012-2016 (n=10,167) following Clinical Laboratory Standards Institute guidelines. Data were analyzed by applying multidrug-resistant gonococci (MDR-GC) and extensively drug-resistant gonococci (XDR-GC) definitions. RESULTS Between 2012 and 2016, the proportion of MDR-GC increased from 6.2% to 8.9% and a total of 19 cases of XDR-GC were identified in Canada (0.1%, 19/18,768). The proportion of isolates with decreased susceptibility to cephalosporins declined between 2012 and 2016 from 5.9% to 2.0% while azithromycin resistance increased from 0.8% to 7.2% in the same period. CONCLUSION While XDR-GC are currently rare in Canada, MDR-GC have increased over the last five years. Azithromycin resistance in N. gonorrhoeae is established and spreading in Canada, exceeding the 5% level at which the World Health Organization states an antimicrobial should be reviewed as an appropriate treatment. Continued surveillance of antimicrobial susceptibilities of N. gonorrhoeae is necessary to inform treatment guidelines and mitigate the impact of resistant gonorrhea.
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Affiliation(s)
- I Martin
- Bacterial Pathogens Division, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB
| | - P Sawatzky
- Bacterial Pathogens Division, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB
| | - V Allen
- Public Health Ontario Laboratories, Toronto, ON
| | - B Lefebvre
- Laboratoire de santé publique du Québec, Ste-Anne-de-Bellevue, QC
| | - LMN Hoang
- British Columbia Centre for Disease Control Public Health Laboratory, Vancouver, BC
| | - P Naidu
- Provincial Laboratory for Public Health, Edmonton, AB
| | - J Minion
- Roy Romanow Provincial Laboratory, Regina, SK
| | | | - D Haldane
- Queen Elizabeth II Health Sciences Centre, Halifax, NS
| | - RR Gad
- New Brunswick Department of Health, Fredericton, NB
| | - G Zahariadis
- Newfoundland and Labrador Public Health Laboratory, St. John’s, NL
| | - A Corriveau
- Department of Health and Social Services, Government of the Northwest Territories, Yellowknife, NT
| | | | - K Tomas
- Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, ON
| | - MR Mulvey
- Bacterial Pathogens Division, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB
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In Vitro Synergy Testing of Gentamicin, an Old Drug Suggested as Future Treatment Option for Gonorrhoea, in Combination With Six Other Antimicrobials Against Multidrug-Resistant Neisseria gonorrhoeae Strains. Sex Transm Dis 2019; 45:127-131. [PMID: 28876284 DOI: 10.1097/olq.0000000000000708] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) Neisseria gonorrhoeae is a serious concern and combination therapy has been recommended to delay the onset of treatment failures. Gentamicin, an old and inexpensive antibiotic, is recommended in combination with azithromycin for treatment failures cases with the first-line regimen as per the latest Centers for Disease Control and Prevention sexually transmitted disease treatment guidelines. However, not much literature is available on in vitro and in vivo efficacy of this combination. Therefore, this study was carried out to evaluate the in vitro synergy of gentamicin in combination with azithromycin and 5 other antimicrobials. METHODS In vitro synergy of gentamicin in combination with cefixime, ceftriaxone, spectinomycin, azithromycin, moxifloxacin, and ertapenem was determined by Etest for 75 N. gonorrhoeae strains, of which 65 were MDR and one was XDR. Fractional inhibitory concentration index (FICI) of ≤0.5 and >4.0 denoted synergy and antagonism respectively. RESULTS Maximum efficacy of gentamicin was observed in combination with ertapenem (geometric mean FICI, 0.56) followed by cefixime (FICI, 0.87). There was no antagonism for both these combinations. However, antagonism was demonstrated in 5.3%, 8%, 8%, and 10.7% strains when gentamicin was paired with spectinomycin (FICI, 1.34), ceftriaxone (FICI, 1.13), azithromycin (FICI, 1.49), and moxifloxacin (FICI, 1.30), respectively. CONCLUSIONS The findings suggest that gentamicin significantly enhances the in vitro therapeutic potency of ertapenem and cefixime which will be potentially effective to control the spread of MDR and XDR N. gonorrhoeae. The study warrants more in vitro studies and clinical trials for gentamicin + azithromycin and other 3 combinations because of considerable antagonism.
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Susceptibility of Neisseria gonorrhoeae to Gentamicin-Gonococcal Isolate Surveillance Project, 2015-2016. Sex Transm Dis 2019; 45:96-98. [PMID: 29324629 DOI: 10.1097/olq.0000000000000693] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The gentamicin minimum inhibitory concentrations (MICs) of Neisseria gonorrhoeae isolates were determined. Seventy-three percent of isolates demonstrated an MIC range of 8 to 16 μg/mL, and 27% demonstrated an MIC of 4 μg/mL or less. Significant associations between gentamicin MIC and resistance or reduced susceptibility to other antimicrobials were found.
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Jönsson A, Jacobsson S, Foerster S, Cole MJ, Unemo M. Performance characteristics of newer MIC gradient strip tests compared with the Etest for antimicrobial susceptibility testing of Neisseria gonorrhoeae. APMIS 2018; 126:822-827. [PMID: 30191618 DOI: 10.1111/apm.12887] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 08/07/2018] [Indexed: 11/28/2022]
Abstract
For Neisseria gonorrhoeae susceptibility testing, Etest, comparable to agar dilution, is frequently used. In recent years, newer MIC gradient strip tests have been commercialized. However, these tests have not been appropriately evaluated for gonococci. We evaluated the sensitivity, specificity, accuracy, quality, availability of antimicrobials and cost of the MIC Test Strip (Liofilchem), M.I.C.Evaluator (Oxoid) and Ezy MIC Strip (HiMedia), compared to the reference Etest (bioMérieux), for gonococcal susceptibility testing. The MICs of eight antimicrobials in 103 gonococcal international reference strains (n = 29) and clinical isolates (n = 74) were examined. Coefficient of determination (R2 ), complete agreement, essential agreement, SIR categorical agreement, sensitivity, specificity and accuracy were calculated. R2 of the MICs for the antimicrobials ranged between 0.674-0.996, 0.617-0.993, and 0.643-0.994 for the MIC Test Strip, M.I.C.Evaluator strips and Ezy MIC Strips respectively. The essential agreement (SIR categorical agreement) was 99.6% (88.6%), 100% (87.1%) and 93.0% (83.1%) respectively. M.I.C.Evaluator strips for gonococcal key antimicrobials were lacking and the Ezy MIC Strips showed an inconsistent accuracy, quality and some strips were contaminated. The Liofilchem MIC Test Strips had limitations, but might be relatively accurate alternatives to Etest for gonococci. Strict quality assurance (at manufacturing and testing laboratory), including quality controls, are required.
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Affiliation(s)
- Agnez Jönsson
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Susanne Jacobsson
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Sunniva Foerster
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Michelle J Cole
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Antimicrobial Susceptibility of Neisseria gonorrhoeae Isolates in Baltimore, Maryland, 2016: The Importance of Sentinel Surveillance in the Era of Multi-Drug-Resistant Gonorrhea. Antibiotics (Basel) 2018; 7:antibiotics7030077. [PMID: 30126088 PMCID: PMC6165464 DOI: 10.3390/antibiotics7030077] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/01/2018] [Accepted: 08/14/2018] [Indexed: 12/12/2022] Open
Abstract
The increasing rates of gonorrhea infections and the global emergence and spread of multi-drug-resistant Neisseria gonorrhoeae (NG) threaten the successful management of gonorrhea. In the era of nucleic acid amplification tests (NAATs), surveillance projects are urgently needed to monitor prevalence and trends in the antimicrobial susceptibility of NG. In this study, we retrospectively determined the susceptibility profile of NG isolates to previously and currently prescribed antimicrobials. NG isolates collected in Baltimore, Maryland between January and October 2016 were evaluated by the E-test method and/or molecular methods for susceptibility to ceftriaxone, azithromycin, ciprofloxacin, tetracycline, gentamicin, and penicillin. One-hundred and forty-three NG isolates from African-American males (98.6%), primarily heterosexual (88.8%), ranging in age from 15 to 69 years of age were included in the study. Ciprofloxacin resistance was observed in 44.1% of isolates. Plasmid-mediated resistance to penicillin and tetracycline resistance was detected in 22.4% and 10.1% of isolates, respectively. Three isolates (2.1%) displayed high-level resistance to azithromycin (minimum inhibitory concentration (MIC) > 256 μg/mL). Forty-three percent of isolates were resistant or had decreased susceptibility to three antimicrobials (ciprofloxacin, tetracycline, and penicillin). All isolates were susceptible to ceftriaxone and gentamicin. Overall, the epidemiology of antimicrobial resistant NG in Baltimore continues to evolve, and the emergence of azithromycin resistance in this population emphasizes the need for continued sentinel surveillance programs to monitor susceptibility trends and aid in treatment recommendations.
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Gianecini R, Oviedo C, Irazu L, Rodríguez M, Galarza P. Comparison of disk diffusion and agar dilution methods for gentamicin susceptibility testing of Neisseria gonorrhoeae. Diagn Microbiol Infect Dis 2018; 91:299-304. [PMID: 29709312 DOI: 10.1016/j.diagmicrobio.2018.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/24/2018] [Accepted: 03/07/2018] [Indexed: 11/28/2022]
Abstract
Gentamicin is a promising antibiotic for the treatment of multidrug-resistant gonorrhea. The aim of this study was to analyze the suitability and reliably of disk diffusion to monitor the susceptibility to gentamicin. We studied 237 Neisseria gonorrhoeae isolates obtained in 2013 and 2015. Reference MICs were correlated with inhibition zone diameters (in millimeters) of gentamicin 10 µg disks manufactured by BBL and Oxoid. The Pearson correlation between disk diffusion and agar dilution was r = -.68 (P < 0.001) for BBL disk and r = -.71 (P < 0.001) for Oxoid disk. No very major or major discrepancies were detected. However, a high percentage of minor discrepancies was observed (44.7%, BBL disk) and (21.9%, Oxoid disk). By adjusting the susceptible breakpoint to S ≥ 17 mm, the minor discrepancies rate was reduced to 19.4% (BBL disk) and 10.1% (Oxoid disk). The disk diffusion may be a screening method in clinical laboratories to detect the gentamicin susceptibility of N. gonorrhoeae.
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Affiliation(s)
- Ricardo Gianecini
- Servicio de Enfermedades de Transmisión Sexual, Departamento de Bacteriología, Instituto Nacional de Enfermedades Infecciosas (INEI)-ANLIS "Dr. Carlos G. Malbrán", Ciudad Autónoma de Buenos Aires, Argentina.
| | - Claudia Oviedo
- Servicio de Enfermedades de Transmisión Sexual, Departamento de Bacteriología, Instituto Nacional de Enfermedades Infecciosas (INEI)-ANLIS "Dr. Carlos G. Malbrán", Ciudad Autónoma de Buenos Aires, Argentina.
| | - Lucia Irazu
- Equipo Operacional de Gestión de Calidad, Departamento de Parasitología, Instituto Nacional de Enfermedades Infecciosas (INEI)-ANLIS "Dr. Carlos G. Malbrán", Ciudad Autónoma de Buenos Aires, Argentina.
| | - Marcelo Rodríguez
- Equipo Operacional de Gestión de Calidad, Departamento de Parasitología, Instituto Nacional de Enfermedades Infecciosas (INEI)-ANLIS "Dr. Carlos G. Malbrán", Ciudad Autónoma de Buenos Aires, Argentina.
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- Gonococcal Antimicrobial Susceptibility Surveillance Programme-Argentina (GASSP-AR)
| | - Patricia Galarza
- Servicio de Enfermedades de Transmisión Sexual, Departamento de Bacteriología, Instituto Nacional de Enfermedades Infecciosas (INEI)-ANLIS "Dr. Carlos G. Malbrán", Ciudad Autónoma de Buenos Aires, Argentina.
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Singh V, Bala M, Bhargava A, Kakran M, Bhatnagar R. In vitro efficacy of 21 dual antimicrobial combinations comprising novel and currently recommended combinations for treatment of drug resistant gonorrhoea in future era. PLoS One 2018; 13:e0193678. [PMID: 29509792 PMCID: PMC5839552 DOI: 10.1371/journal.pone.0193678] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 02/15/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recent WHO guidelines recommend dual therapy with ceftriaxone or cefixime plus azithromycin for gonorrhea. Azithromycin in combination with gentamicin or spectinomycin has been recommended in treatment failure cases. Due to emergence of multi-drug resistant (MDR) and extensively-drug resistant (XDR) Neisseria gonorrhoeae strains, it is important to look for efficacy of these combinations and also of others that might be used in future. Therefore, we aimed to evaluate in vitro synergy of 21 dual combinations including current and alternative WHO recommended treatment regimens and other dual combinations. METHODS AND FINDINGS The potential utility of in-vitro interactions of 21 combinations was investigated against 95 N. gonorrhoeae strains including 79 MDR and one XDR strain collected during March 2013 to July 2017 and fractional inhibitory concentration index (FICI) was calculated. These 21 combinations comprised of two WHO currently recommended (cefixime+azithromycin, ceftriaxone+azithromycin); two WHO recommended in treatment failure cases (azithromycin+gentamicin, spectinomycin+azithromycin) and other 17 combinations. RESULTS FICI of the four WHO recommended antimicrobial combinations were higher (>1.0) than the five novel combinationbreeds (FICI range 0.603-0.951) in the study i.e. gentamicin+ertapenem, moxifloxacin+ertapenem, spectinomycin+ertapenem, azithromycin+ moxifloxacin, cefixime+gentamicin. No antagonistic effect of the above four WHO recommended combinations except spectinomycin+azithromycin (FICI = 4.25) was observed for the XDR strain. Out of above five novel combinations, four combinations produced high synergistic effects in overall 95 strains and also for the XDR strain with FICI of 0.13 to 0.38. Antagonistic effects varying from 3.2 to 12.6% were observed for 10 out of 21 tested combinations (azithromycin in combination with gentamicin and spectinomycin; ceftriaxone with moxifloxacin, gentamicin, spectinomycin and ertapenem; spectinomycin with moxifloxacin and gentamicin; cefixime and gentamicin combination with moxifloxacin). CONCLUSION WHO recommended cefixime+azithromycin, ceftriaxone+azithromycin combinations having no antagonism indicates their continuing clinical utility. Highest antagonism without any synergistic effect for the WHO recommended spectinomycin+azithromycin in treatment failure cases suggests that this combination should be evaluated further both in vitro and in vivo. Highest synergistic or additive effect without any antagonistic effect of the above five novel combinations suggests that these may be recommended for treatment in future.
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Affiliation(s)
- Vikram Singh
- Apex Regional STI Training, Research and Reference Laboratory, VMMC & Safdarjung Hospital, New Delhi, India
- SunRise University, Rajasthan, India
| | - Manju Bala
- Apex Regional STI Training, Research and Reference Laboratory, VMMC & Safdarjung Hospital, New Delhi, India
- * E-mail:
| | - Aradhana Bhargava
- Apex Regional STI Training, Research and Reference Laboratory, VMMC & Safdarjung Hospital, New Delhi, India
| | - Monika Kakran
- Apex Regional STI Training, Research and Reference Laboratory, VMMC & Safdarjung Hospital, New Delhi, India
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Unemo M, Jensen JS. Antimicrobial-resistant sexually transmitted infections: gonorrhoea and Mycoplasma genitalium. Nat Rev Urol 2017; 14:139-152. [PMID: 28072403 DOI: 10.1038/nrurol.2016.268] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The emergence of antimicrobial resistance (AMR) is a major concern worldwide and already compromises treatment effectiveness and control of several bacterial sexually transmitted infections (STIs). Neisseria gonorrhoeae and Mycoplasma genitalium are evolving into so-called superbugs that can become resistant, both in vitro and clinically, to essentially all antimicrobials available for treatment, causing exceedingly difficult-to-treat or untreatable STIs and threatening global public health. Widespread AMR in these bacteria is likely to persist and even worsen in the future, owing to the high number of infections, widespread and uncontrolled use of antimicrobials, limited surveillance of AMR and clinical failures, as well as the extraordinary capacity of these bacteria to develop AMR. This development would not only result in an increased prevalence of N. gonorrhoeae and M. genitalium infections but also in a considerably increasing number of severe complications affecting reproductive health. To combat this threat, clinicians need to be aware of the current guidelines on diagnostic procedures, recommended treatment regimens, as well as therapeutic options for multidrug-resistant bacteria. AMR testing needs to be more frequently performed, inform treatment decisions and elucidate how AMRs compromise treatment effectiveness, guiding research for effective future therapies.
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Affiliation(s)
- Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, SE-701 85 Örebro, Sweden
| | - Jorgen S Jensen
- Department of Microbiology and Infection Control, Sexually Transmitted Infections, Research and Development, Statens Serum Institut, Artillerivej 5, DK-2300 Copenhagen S, Denmark
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Brittain C, Childs M, Duley L, Harding J, Hepburn T, Meakin G, Montgomery AA, Tan W, Ross JDC. Gentamicin versus ceftriaxone for the treatment of gonorrhoea (G-TOG trial): study protocol for a randomised trial. Trials 2016; 17:558. [PMID: 27881151 PMCID: PMC5122193 DOI: 10.1186/s13063-016-1683-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 11/05/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gonorrhoea is a common sexually transmitted infection which causes genital pain and discomfort; in women it can also lead to pelvic inflammatory disease and infertility, and in men to epididymo-orchitis. Current treatment is with ceftriaxone, but there is increasing evidence of antimicrobial resistance which is reducing its effectiveness against gonorrhoea. A small, but increasing, number of patients have already been found to have highly resistant strains of gonorrhoea which has been associated with clinical failure. This trial aims to determine whether gentamicin is not clinically worse than ceftriaxone in the treatment of gonorrhoea. METHODS/DESIGN This is a blinded, two-arm, multicentre, noninferiority randomised trial. Patients are eligible if they are aged 16-70 years with a diagnosis of genital, pharyngeal and/or rectal gonorrhoea. Exclusion criteria are: known concurrent sexually transmitted infection(s) (excluding chlamydia); bacterial vaginosis and/or Trichomonas vaginalis infection; contraindications or an allergy to gentamicin, ceftriaxone, azithromycin or lidocaine; pregnancy or breastfeeding; complicated gonorrhoeal infection; weight under 40 kg; use of ceftriaxone, gentamicin or azithromycin within the preceding 28 days. Randomisation is to receive a single intramuscular injection of either gentamicin or ceftriaxone, all participants receive 1 g oral azithromycin as standard treatment. The estimated sample size is 720 participants (noninferiority limit 5%). The primary outcome is clearance of Neisseria gonorrhoeae at all infected sites by a negative Nucleic Acid Amplification Test, 2 weeks post treatment. Secondary outcomes include clinical resolution of symptoms, frequency of adverse events, tolerability of therapy, relationship between clinical effectiveness and antibiotic minimum inhibitory concentration for N. gonorrhoeae, and cost-effectiveness. DISCUSSION The options for future treatment of gonorrhoea are limited. Results from this randomised trial will demonstrate whether gentamicin is not clinically worse than ceftriaxone for the treatment of gonorrhoea. This will inform clinical practice and policy for the treatment of gonorrhoea when current therapy with cephalosporins is no longer effective, or is contraindicated. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number - ISRCTN51783227 , Registered on 18 September 2014. Current protocol version 2.0 17 June 2015.
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Affiliation(s)
- Clare Brittain
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Queen’s Medical Centre, C Floor South Block, Nottingham, NG7 2UH UK
| | - Margaret Childs
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Queen’s Medical Centre, C Floor South Block, Nottingham, NG7 2UH UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Queen’s Medical Centre, C Floor South Block, Nottingham, NG7 2UH UK
| | - Jan Harding
- University Hospitals Birmingham NHS Foundation Trust, Whittall Street Clinic, Whittall Street, Birmingham, B4 6DH UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Queen’s Medical Centre, C Floor South Block, Nottingham, NG7 2UH UK
| | - Garry Meakin
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Queen’s Medical Centre, C Floor South Block, Nottingham, NG7 2UH UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Queen’s Medical Centre, C Floor South Block, Nottingham, NG7 2UH UK
| | - Wei Tan
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Queen’s Medical Centre, C Floor South Block, Nottingham, NG7 2UH UK
| | - Jonathan D. C. Ross
- University Hospitals Birmingham NHS Foundation Trust, Whittall Street Clinic, Whittall Street, Birmingham, B4 6DH UK
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Gentamicin Susceptibility among a Sample of Multidrug-Resistant Neisseria gonorrhoeae Isolates in India. Antimicrob Agents Chemother 2016; 60:7518-7521. [PMID: 27736753 DOI: 10.1128/aac.01907-16] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 09/29/2016] [Indexed: 11/20/2022] Open
Abstract
Antimicrobial susceptibility testing of 258 Neisseria gonorrhoeae isolates by Etest determined that 60.1% were multidrug resistant (MDR), while 5% of the strains had decreased susceptibility to currently recommended extended-spectrum cephalosporins (ESCs). Among these, 84.5% of MDR strains and 76.9% of strains that had decreased susceptibility to ESCs were susceptible to gentamicin. No MDR isolate was resistant to gentamicin. These in vitro results suggest that gentamicin might be an effective treatment option for the MDR strains and in dual therapy for gonorrhea. However, further research regarding the clinical treatment outcomes is essential.
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Lee H, Lee K, Chong Y. New treatment options for infections caused by increasingly antimicrobial-resistant Neisseria gonorrhoeae. Expert Rev Anti Infect Ther 2016; 14:243-56. [PMID: 26690658 DOI: 10.1586/14787210.2016.1134315] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The emergence of high-level resistance to ceftriaxone is giving rise to serious concern about absence of effective treatment options to cure gonococcal infections. Increasing the dosage regimen can be applied to ceftriaxone and azithromycin, but the emergence of high-level resistance has already been reported. Spectinomycin is another active drug but has low efficacy in the treatment of pharyngeal gonorrhoea. Conventional antibiotics could be introduced for gonococcal treatment, but they have some limitations, such as the absence of clinical trials and breakpoint. Combining antibiotics is another promising method to cure patients and to prevent the emergence of resistance. The most important strategy to maintain the efficacy of antibiotics is rapid detection and dissemination control of novel resistant isolate.
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Affiliation(s)
- Hyukmin Lee
- a Department of Laboratory Medicine , International St. Mary's Hospital, Catholic Kwandong University College of Medicine , Incheon , Korea
| | - Kyungwon Lee
- b Department of Laboratory Medicine and Research Institute of Bacterial Resistance , Yonsei University College of Medicine , Seoul , Korea
| | - Yunsop Chong
- b Department of Laboratory Medicine and Research Institute of Bacterial Resistance , Yonsei University College of Medicine , Seoul , Korea
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