Neisseria gonorrhoeae isolated from disseminated and localised infections in pre-penicillin era. Auxotypes and antibacterial drug resistances

MetQ of Neisseria gonorrhoeae Is a Surface-Expressed Antigen That Elicits Bactericidal and Functional Blocking Antibodies

Neisseria gonorrhoeae, the causative agent of the sexually transmitted infection (STI) gonorrhea, is a growing public health threat for which a vaccine is urgently needed. We characterized the functional role of the gonococcal MetQ protein, which is the methionine binding component of an ABC transporter system, and assessed its potential as a candidate antigen for inclusion in a gonococcal vaccine. MetQ has been found to be highly conserved in all strains investigated to date, it is localized on the bacterial surface, and it binds l-methionine with a high affinity. MetQ is also involved in gonococcal adherence to cervical epithelial cells. Mutants lacking MetQ have impaired survival in human monocytes, macrophages, and serum. Furthermore, antibodies raised against MetQ are bactericidal and are able to block gonococcal adherence to epithelial cells. These data suggest that MetQ elicits both bactericidal and functional blocking antibodies and is a valid candidate antigen for additional investigation and possible inclusion in a vaccine for prevention of gonorrhea.

An insight into the drug resistance profile & mechanism of drug resistance in Neisseria gonorrhoeae

Among the aetiological agents of treatable sexually transmitted diseases (STDs), Neissseria gonorrhoeae is considered to be most important because of emerging antibiotic resistant strains that compromise the effectiveness of treatment of the disease - gonorrhoea. In most of the developing countries, treatment of gonorrhoea relies mainly on syndromic management rather than the aetiological based therapy. Gonococcal infections are usually treated with single-dose therapy with an agent found to cure > 95 per cent of cases. Unfortunately during the last few decades, N. gonorrhoeae has developed resistance not only to less expensive antimicrobials such as sulphonamides, penicillin and tetracyclines but also to fluoroquinolones. The resistance trend of N. gonorrhoeae towards these antimicrobials can be categorised into pre-quinolone, quinolone and post-quinolone era. Among the antimicrobials available so far, only the third-generation cephalosporins could be safely recommended as first-line therapy for gonorrhoea globally. However, resistance to oral third-generation cephalosporins has also started emerging in some countries. Therefore, it has become imperative to initiate sustained national and international efforts to reduce infection and misuse of antibiotics so as to prevent further emergence and spread of antimicrobial resistance. It is necessary not only to monitor drug resistance and optimise treatment regimens, but also to gain insight into how gonococcus develops drug resistance. Knowledge of mechanism of resistance would help us to devise methods to prevent the occurrence of drug resistance against existing and new drugs. Such studies could also help in finding out new drug targets in N. gonorrhoeae and also a possibility of identification of new drugs for treating gonorrhoea.

The use of cephalosporins for gonorrhea: the impending problem of resistance

Gonorrhea remains an important clinical and public health problem throughout the world. Gonococcal infections have historically been diagnosed by Gram stain and culture but are increasingly diagnosed through nucleic acid tests, thereby eliminating the opportunity for antimicrobial susceptibility testing. Gonococcal infections are typically treated with single-dose therapy with an agent found to cure > 95% of cases. Unfortunately, the gonococcus has repeatedly developed resistance to antimicrobials including sulfonamides, penicillin, tetracyclines and fluoroquinolones. This has now left third-generation cephalosporins as the lone class of antimicrobials recommended as first-line therapy for gonorrhea in some regions. However, resistance to oral third-generation cephalosporins has emerged and spread in Asia, Australia and elsewhere. The mechanism of this resistance seems to be associated with a mosaic penicillin binding protein (penA) in addition to other chromosomal mutations previously found to confer resistance to beta-lactam antimicrobials (ponA, mtrR, penB, pilQ). Few good options exist or are in development for treating cephalosporin-resistant isolates, as most have had multidrug resistance. Preventing the spread of resistant isolates will depend on ambitious antimicrobial management programs, strengthening and expanding surveillance networks, and through effective sexually transmitted disease control and prevention.

Antimicrobial susceptibility testing of Neisseria gonorrhoeae and implications for epidemiology and therapy

Antimicrobial susceptibility testing (AST) of Neisseria gonorrhoeae has been under development since the early days of antimicrobial agents. However, it is rarely applied to clinical isolates today. The history of the various in vitro tests to determine the susceptibility of N. gonorrhoeae to antibiotics is rich with evidence that these results predict response to therapy for almost all agents tested. Further, AST is a useful and important aspect of strain characterization and disease epidemiology in conjunction with the more specific but laborious techniques of auxotyping, serotyping, and plasmid analysis. Current technology has overcome many of the objections to AST for N. gonorrhoeae with standardization of test media and the development of an accurate disk diffusion AST method that is suited to most clinical laboratories regardless of volume or level of technical expertise. Ironically, the very low level of resistance to the current primary treatment strategy in the United States, ceftriaxone or another potent cephalosporin, makes the use of AST somewhat superfluous.

Beta-lactamase plasmids and chromosomally mediated antibiotic resistance in pathogenic Neisseria species

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Mutation in a locus linked to penB-nmp causes suppression of the Mtr phenotype of Neisseria gonorrhoeae

The chromosomal locus mtr, which encodes low-level resistance to multiple antibacterial agents in Neisseria gonorrhoeae, is subject to phenotypic suppression by env mutations that increase the permeability of the envelope. We have identified a new locus, mom (for modifier of Mtr), which is located on the chromosome very close to penB and nmp, loci known to be linked to each other and to spc. Phenotypic suppression of Mtr was recognized by reductions of resistance to benzylpenicillin and also to oxacillin and the hydrophobic agents novobiocin and erythromycin. The resistance to each of these antibiotics returned to the Mtr levels in mom+ transformants isolated by selection for increased resistance to either novobiocin or erythromycin; the accompanying change of the outer membrane protein I seroreactions confirmed the proximity of nmp and mom. Thus, some mutant gonococci display wild-type antibiotic susceptibilities but can express multiple resistance following a mom+ mutation that releases the suppressed Mtr phenotype.

High-level tetracycline resistance in Neisseria gonorrhoeae is result of acquisition of streptococcal tetM determinant

Recently, strains of Neisseria gonorrhoeae have been isolated which are highly resistant to tetracycline (MICs of 16 to 64 micrograms/ml). This resistance was due to the acquisition of the resistance determinant tetM, a transposon-borne determinant initially found in the genus Streptococcus and more recently in Mycoplasma hominis, Ureaplasma urealyticum, and Gardnerella vaginalis. In N. gonorrhoeae, the tetM determinant was located on a 25.2-megadalton plasmid. This plasmid arose from the insertion of tetM into the 24.5-megadalton gonococcal conjugative plasmid. The tetM determinant could be transferred to suitable recipient strains of N. gonorrhoeae by both genetic transformation and conjugation.

Vancomycin hypersusceptibility in Neisseria gonorrhoeae isolated from patients involves diverse mutations

We investigated the genetic determinants of hypersusceptibility to vancomycin and erythromycin found in Neisseria gonorrhoeae strains isolated from patients. In terms of resistance (highest concentration of antibiotic permitting growth), the levels of vancomycin resistance of six strains ranged from 0.2 to 1.0 microgram/ml, and the level of erythromycin resistance of these strains was 0.02 or 0.05 micrograms/ml. DNA from these strains was used to introduce their hypersusceptibility determinants into partially isogenic derivatives of N. gonorrhoeae 89 which initially had wild-type levels of resistance to vancomycin (greater than or equal to 3.0 micrograms/ml) and erythromycin (greater than or equal to 0.1 microgram/ml). The recombination frequencies found in reciprocal transformation tests of six isogenic strains indicated that the mutations responsible for vancomycin hypersusceptibility were located at different sites. The transformants selected for increased resistance to vancomycin were also resistant to erythromycin. This evidence, together with DNA concentration-response curves, indicated that the mutations affected either one gene locus or closely linked loci. The recombination indices obtained in crosses between our hypersusceptible strains and DNAs from reference strains carrying the envelope mutations env-1, env-2, env-3, and env-10 showed that the mutation (designated env-12) responsible for erythromycin hypersusceptibility in one strain (89-954) was located in close proximity to env-2. The determinant of vancomycin hypersusceptibility in strain 89-954 was distinct from env-12, but the two were linked. In the other five isogenic strains, the hypersusceptibilities to both vancomycin and erythromycin could be annulled by spontaneous mutations in a locus provisionally designated vel because of its likely effects on the envelope. Vel+ mutants obtained by selection with either vancomycin alone or erythromycin alone gained increased resistance to both antibiotics.

Epidemiological studies on Neisseria gonorrhoeae isolated in the United Kingdom

Seven hundred and seventy nine isolates of Neisseria gonorrhoeae from the County of Avon, United Kingdom, were examined by auxotyping and penicillin susceptibility testing. Prototrophic strains which were heterogeneous as judge by penicillin susceptibility were the most commonly isolated and increased in prevalence over the three year period. The group most generally susceptible to penicillin required ArgHypUra for growth and decreased in prevalence over the three year period. Ten strains failed to grow on the auxotyping medium. Serogrouping was undertaken on 408 isolates. All strains reacting with the WI reagents were ArgHypUra requiring. However auxotypically similar strains (ArgHypUra) reacted with WII/WIII reagents suggesting a distinct and separately evolved group. Twenty four strains did not type with the serogrouping reagents. Using contact pairs, W-class serology was found to be a stable marker during natural transmission. However auxotypes were found to be unstable in 22 of 104 contact pairs and of these 18 involved a single requirement for proline. This very high incidence of instability with respect to this marker means it is not possible to reliably differentiate between the prototrophic group and the group with a single requirement for proline.

Auxotypes and antibacterial resistance to gonococci with differing susceptibilities to vancomycin

The responses to vancomycin and 11 other antibacterial drugs and the nutritional requirements of gonococci recovered from two selective media were determined. Single urogenital specimens from 508 patients attending a social hygiene clinic in 1975 yielded 97 strains of Neisseria gonorrhoeae; 95 were recovered on VCNT (a modification of Thayer-Martin medium), always inoculated first, and 69 on LC medium containing lincomycin (4 micrograms/ml) and colistin (5 micrograms/ml). The two drugs at these concentrations in LC medium were not inhibitory for isolates from either medium. Unexpectedly, three isolates on VCNT were susceptible to vancomycin at the concentrations (3 micrograms/ml) in VCNT medium; these three were typically sensitive to penicillins but were hypersusceptible to erythromycin (inhibited by less than or greater than 0.05 micrograms/ml) and rifampin (less than or equal to 0.02 micrograms/ml). Resistance to streptomycin (greater than or equal to 500 micrograms/ml) (22% of the strains) was correlated with increased resistance to penicillins, erythromycin, and rifampin in most instances. All streptomycin-resistant gonococci required proline, or arginine, or none of the test compounds. Strains requiring arginine, hypoxanthine, and uracil were uniformly sensitive to antibiotics but not hypersusceptible. In contrast, six strains of N gonorrhoeae isolated in Denmark required arginine (not satisfied by ornithine), hypoxanthine, and uracil and were hypersusceptible to vancomycin (inhibited by 0.5 micrograms/ml), erythromycin, and rifampin. DNA-mediated transformation showed that all three hypersusceptibilities of one Danish strain were introduced together into a wild-type gonococcus, suggesting that a mutation of an env (envelope) locus might be responsible for the atypical permeability.