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Kersh EN, Allen V, Ransom E, Schmerer M, Cyr S, Workowski K, Weinstock H, Patel J, Ferraro MJ. Rationale for a Neisseria gonorrhoeae Susceptible-only Interpretive Breakpoint for Azithromycin. Clin Infect Dis 2021; 70:798-804. [PMID: 30963175 DOI: 10.1093/cid/ciz292] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 04/04/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Azithromycin (AZI) is recommended with ceftriaxone (CRO) for treatment of uncomplicated gonococcal urethritis and cervicitis in the United States, and an AZI-susceptibility breakpoint is needed. Neither the Food and Drug Administration (FDA) nor the Clinical and Laboratory Standards Institute (CLSI) has set interpretive breakpoints for AZI susceptibility. As a result, AZI antimicrobial susceptibility testing (AST) cannot be interpreted using recognized standards. This has contributed to increasingly unavailable clinical laboratory AST, although gonorrhea is on the rise with >550 000 US gonorrhea cases reported to the Centers for Disease Control and Prevention in 2017, the highest number of cases since 1991. METHODS This article summarizes the rationale data reviewed by the CLSI in June 2018. RESULTS The CLSI decided to set a susceptible-only interpretive breakpoint at the minimum inhibitory concentration of ≤1 µg/mL. This is also the epidemiological cutoff value (ECV) (ie, the end of the wild-type susceptibility distribution). This breakpoint presumes that AZI (1-g single dose) is used in an approved regimen that includes an additional antimicrobial agent (ie, CRO 250 mg, intramuscular single dose). CONCLUSIONS Having a breakpoint can improve patient care and surveillance and allow future development and FDA regulatory approval of modernized AST to guide treatment. The breakpoint coincides with a European Committee on AST decision to remove previously established, differing AZI breakpoints and use the ECV as guidance for testing. The CLSI breakpoint is now the recognized standard that defines AZI susceptibility for gonococcal infections.
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Affiliation(s)
- Ellen N Kersh
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Eric Ransom
- Association of Public Health Laboratories, Silver Spring, Maryland
| | - Matthew Schmerer
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sancta Cyr
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kim Workowski
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.,Emory University, Department of Medicine, Atlanta, Georgia
| | - Hillard Weinstock
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jean Patel
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary Jane Ferraro
- Department of Medicine, Harvard Medical School, Boston.,Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston
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Fletcher-Lartey S, Dronavalli M, Alexander K, Ghosh S, Boonwaat L, Thomas J, Robinson A, Patel Z, Forssman B, Pal N. Trends in Antimicrobial Resistance Patterns in Neisseria Gonorrhoeae in Australia and New Zealand: A Meta-analysis and Systematic Review. Antibiotics (Basel) 2019; 8:E191. [PMID: 31652729 PMCID: PMC6963718 DOI: 10.3390/antibiotics8040191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/14/2019] [Accepted: 10/22/2019] [Indexed: 02/07/2023] Open
Abstract
(1) Background: The widespread development of resistance among Neisseria gonorrhoeae (NG) clinical isolates has been reported by surveillance systems around the world. This meta-analysis estimated the changes in susceptibility patterns among antibiotics under surveillance in Australia and New Zealand. (2) Methods: Articles published in English from 1980-2018, from Australia or New Zealand, that met the selection criteria were included. The meta-analysis was carried out using the R statistical software. (3) Results: In Australia, there has been decreasing susceptibility of gonococcal isolates to selected antimicrobials over time. Azithromycin (Odds Ratio (OR): 0.73; 95% Confidence Interval (CI) 0.64-0.82) and ceftriaxone (OR: 0.69; 95% CI 0.59-0.80) showed decreasing levels of susceptibility each year. Western Australia (OR: 0.76; 95% CI 0.60-0.96) and Victoria (OR: 0.74; 95% CI 0.60-0.90) also had decreasing levels of susceptibility to ceftriaxone over time compared with other states and territories. (4) Conclusions: The results highlight the need for the development of new approaches for managing cases of gonorrhoea. Improved antimicrobial stewardship, enhanced surveillance and contact tracing are needed to identify and respond to changes in antibiotic resistance in a timely manner. Increasing awareness and public health follow-up of cases can help to interrupt the cycle of infection and limit transmission.
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Affiliation(s)
| | - Mithilesh Dronavalli
- Public Health Unit, South Western Sydney Local Health District, Liverpool, NSW 2170, Australia.
| | - Kate Alexander
- Public Health Unit, South Western Sydney Local Health District, Liverpool, NSW 2170, Australia.
| | - Sayontonee Ghosh
- Public Health Unit, South Western Sydney Local Health District, Liverpool, NSW 2170, Australia.
| | - Leng Boonwaat
- Public Health Unit, South Western Sydney Local Health District, Liverpool, NSW 2170, Australia.
| | - Jane Thomas
- Public Health Unit, Nepean Blue Mountains Local Health District, Penrith, NSW 2750, Australia.
| | - Amanda Robinson
- Public Health Unit, Nepean Blue Mountains Local Health District, Penrith, NSW 2750, Australia.
| | - Zeel Patel
- Public Health Unit, South Western Sydney Local Health District, Liverpool, NSW 2170, Australia.
| | - Bradley Forssman
- Public Health Unit, Nepean Blue Mountains Local Health District, Penrith, NSW 2750, Australia.
| | - Naru Pal
- Public Health Unit, South Western Sydney Local Health District, Liverpool, NSW 2170, Australia.
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Mismatch Amplification Mutation Assay-Based Real-Time PCR for Rapid Detection of Neisseria gonorrhoeae and Antimicrobial Resistance Determinants in Clinical Specimens. J Clin Microbiol 2018; 56:JCM.00365-18. [PMID: 29950339 PMCID: PMC6113480 DOI: 10.1128/jcm.00365-18] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 06/25/2018] [Indexed: 01/31/2023] Open
Abstract
Molecular methods are often used for Neisseria gonorrhoeae detection, but complete definition of antimicrobial resistance (AMR) patterns still requires phenotypic tests. We developed an assay that both identifies N. gonorrhoeae and detects AMR determinants in clinical specimens. Molecular methods are often used for Neisseria gonorrhoeae detection, but complete definition of antimicrobial resistance (AMR) patterns still requires phenotypic tests. We developed an assay that both identifies N. gonorrhoeae and detects AMR determinants in clinical specimens. We designed a mismatch amplification mutation assay (MAMA)-based SYBR green real-time PCR targeting one N. gonorrhoeae-specific region (opa); mosaic penA alleles (Asp345 deletion [Asp345del], Gly545Ser) associated with decreased susceptibility to cephalosporins; and alterations conferring resistance to ciprofloxacin (GyrA Ser91Phe), azithromycin (23S rRNA A2059G and C2611T), and spectinomycin (16S rRNA C1192T). We applied the real-time PCR to 489 clinical specimens, of which 94 had paired culture isolates, and evaluated its performance by comparison with the performance of commercial diagnostic molecular and phenotypic tests. Our assay exhibited a sensitivity/specificity of 93%/100%, 96%/85%, 90%/91%, 100%/100%, and 100%/90% for the detection of N. gonorrhoeae directly from urethral, rectal, pharyngeal, cervical, and vaginal samples, respectively. The MAMA strategy allowed the detection of AMR mutations by comparing cycle threshold values with the results of the reference opa reaction. The method accurately predicted the phenotype of resistance to four antibiotic classes, as determined by comparison with the MIC values obtained from 94 paired cultures (sensitivity/specificity for cephalosporins, azithromycin, ciprofloxacin, and spectinomycin resistance, 100%/95%, 100%/100%, 100%/100%, and not applicable [NA]/100%, respectively, in genital specimens and NA/72%, NA/98%, 100%/97%, and NA/96%, respectively, in extragenital specimens). False-positive results, particularly for the penA Asp345del reaction, were observed predominantly in pharyngeal specimens. Our real-time PCR assay is a promising rapid method to identify N. gonorrhoeae and predict AMR directly in genital specimens, but further optimization for extragenital specimens is needed.
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Loenenbach A, Dudareva-Vizule S, Buder S, Sailer A, Kohl PK, Bremer V. [Laboratory practices: diagnostics and antibiotics resistance testing of Neisseria gonorrhoeae in Germany]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016; 58:866-874. [PMID: 26112875 DOI: 10.1007/s00103-015-2191-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Recent years have seen a world-wide increase in antimicrobial resistance (AMR) in cases of infection with Neisseria gonorrhoeae (NG). NG infection is not notifiable in Germany and there is a lack of information available about the spread and AMR of NG infections. The objective of the study was to provide information on diagnostic methods and AMR testing in cases of NG infections in German laboratories. A cross-sectional survey was undertaken in Germany between June and August 2013 using an online questionnaire. Laboratories performing NG diagnostics were identified and described with regard to the diagnostic methods used, the number of tests performed, the antibiotics tested and the AMR observed, in addition to general laboratory information. In total, 188 of the 521 participating laboratories performed NG diagnostics; these were included in the further statistical analysis. 92.6 % of the 188 laboratories performed culture. A median of 60 (IQR 15-270) samples per quarter (SPQ) were tested, with an overall positivity rate of 4.1 and 6.9 % among men. Most (82.1 %) of the 151 laboratories performing NG culture tested for AMR as well. The most frequently tested antibiotics were ciprofloxacin (94.8 %), penicillin (93.1 %), doxycycline (70.0 %) and ceftriaxone (67.2 %). The most frequently observed AMR ever were those against ciprofloxacin (87.1 %), penicillin (78.3 %), doxycycline (56.6 %) and azithromycin (35.1 %; all percentages refer to laboratories). The laboratories used different standards regarding susceptibility criteria. The emergence and spread of AMR shows that it is crucial to assess and monitor the scope and trends of multidrug-resistant gonorrhea. The data collected on diagnostic methods and AMR testing in cases of NG infections in German laboratories constitute an important basis for future monitoring.
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Affiliation(s)
- Anna Loenenbach
- Abteilung für Infektionsepidemiologie, Fachgebiet HIV/AIDS und andere sexuell oder durch Blut übertragbare Infektionen, Robert Koch-Institut, Seestraße 10, 13353, Berlin, Deutschland.
| | - S Dudareva-Vizule
- Abteilung für Infektionsepidemiologie, Fachgebiet HIV/AIDS und andere sexuell oder durch Blut übertragbare Infektionen, Robert Koch-Institut, Seestraße 10, 13353, Berlin, Deutschland
| | - S Buder
- Konsiliarlabor für Gonokokken, Vivantes Klinikum Neukölln, Rudower Straße 48, 12351 Berlin, Deutschland
| | - A Sailer
- Abteilung für Infektionsepidemiologie, Fachgebiet HIV/AIDS und andere sexuell oder durch Blut übertragbare Infektionen, Robert Koch-Institut, Seestraße 10, 13353, Berlin, Deutschland
| | - P K Kohl
- Konsiliarlabor für Gonokokken, Vivantes Klinikum Neukölln, Rudower Straße 48, 12351 Berlin, Deutschland
| | - V Bremer
- Abteilung für Infektionsepidemiologie, Fachgebiet HIV/AIDS und andere sexuell oder durch Blut übertragbare Infektionen, Robert Koch-Institut, Seestraße 10, 13353, Berlin, Deutschland
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Cheng CW, Li LH, Su CY, Li SY, Yen MY. Changes in the six most common sequence types of Neisseria gonorrhoeae, including ST4378, identified by surveillance of antimicrobial resistance in northern Taiwan from 2006 to 2013. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 49:708-716. [PMID: 25442864 DOI: 10.1016/j.jmii.2014.08.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 08/06/2014] [Accepted: 08/23/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND There has been no longitudinal study of drug susceptibility in Neisseria gonorrhoeae in Taiwan since 2006. METHODS We collected 1090 gonococcal isolates from Taipei City Hospital, Taiwan from April 2006 to August 2013. We used a disk diffusion assay to determine the susceptibility to five antibiotics and an E-test to determine the minimum inhibitory concentrations for cefixime and ceftriaxone in isolates with resistance. Neisseria gonorrhoeae-multi Antigen Sequence Typing and DNA sequencing of the por and tbpB genes were used to identify sequence types. RESULTS Among the 1090 isolates, the resistances to penicillin, ciprofloxacin, cefpodoxime, cefixime, and ceftriaxone were 61.01%, 83.39%, 9.63%, 6.70%, and 2.39%, respectively. The highest minimum inhibitory concentrations of cefixime and ceftriaxone were 0.19 mg/L and 0.50 mg/L, respectively. There were 327 sequence types. The four most common sequence types in homosexuals were ST4378, ST359, ST4654, and ST547; the two most common sequence types in heterosexuals were ST421 and ST419. Each of these sequence types had more than 25 isolates. There were significant differences in the sequence types in patients with different sexual orientations (p < 0.001). CONCLUSION Oral cefixime or ceftriaxone injections were used as first-line drugs for the treatment of gonorrhea from 2006 to 2013 because gonorrhea isolates had low minimum inhibitory concentrations for these two drugs. The abrupt emergence of ST4378 (closely related to the notorious ST1407) since 2009 is a cause for alarm. Changes in sexual behavior, including an increase in sexual activity without the use of condoms, may have contributed to the peak in gonorrhea in 2010. Further molecular epidemiological investigations are required.
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Affiliation(s)
- Ching-Wai Cheng
- Department of Internal Medicine, Taipei City Hospital, Ren-Ai Branch, Taipei, Taiwan, ROC
| | - Lan-Hui Li
- Department of Laboratory Medicine, Taipei City Hospital, Kun-Ming Branch, Taipei, Taiwan, ROC
| | - Chen-Yi Su
- Division of Infectious Diseases, Department of Internal Medicine, Taipei City Hospital, Ren-Ai Branch, Taipei, Taiwan, ROC
| | - Shu-Ying Li
- Research and Diagnostic Center, Centers for Disease Control, Taipei, Taiwan, ROC
| | - Muh-Yong Yen
- Division of Infectious Diseases, Department of Internal Medicine, Taipei City Hospital, Kun-Ming Branch, Taipei, Taiwan, ROC.
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Endimiani A, Guilarte YN, Tinguely R, Hirzberger L, Selvini S, Lupo A, Hauser C, Furrer H. Characterization of Neisseria gonorrhoeae isolates detected in Switzerland (1998-2012): emergence of multidrug-resistant clones less susceptible to cephalosporins. BMC Infect Dis 2014; 14:106. [PMID: 24568221 PMCID: PMC3941690 DOI: 10.1186/1471-2334-14-106] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 02/20/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The spread of Neisseria gonorrhoeae (Ng) isolates resistant to the clinically implemented antibiotics is challenging the efficacy of treatments. Unfortunately, phenotypic and molecular data regarding Ng detected in Switzerland are scarce. METHODS We compared the characteristics of Ng detected during 1998-2001 (n = 26) to those detected during 2009-2012 (n = 34). MICs were obtained with the Etest and interpreted as non-susceptible (non-S) according to EUCAST criteria. Sequence type (ST) was achieved implementing the NG-MAST. BlaTEM, ponA, penA, mtrR, penB, tet(M), gyrA, parC, mefA, ermA/B/C/F, rplD, rplV, and 23S rRNA genes were analyzed. RESULTS The following susceptibility results were obtained (period: % of non-S, MIC90 in mg/L): penicillin (1998-2001: 42.3%, 3; 2009-2012: 85.3%, 16), cefixime (1998-2001: 0%, ≤0.016; 2009-2012: 8.8%, 0.125), ceftriaxone (1998-2001: 0%, 0.004; 2009-2012: 0%, 0.047), ciprofloxacin (1998-2001: 7.7%, 0.006; 2009-2012: 73.5%, ≥32), azithromycin (1998-2001: 11.5%, 0.25; 2009-2012: 23.6%, 0.38), tetracycline (1998-2001: 65.4%, 12; 2009-2012: 88.2%, 24), spectinomycin (1998-2001: 0%, 12; 2009-2012: 0%, 8). The prevalence of multidrug-resistant (MDR) isolates increased from 7.7% in 1998-2001 to 70.6% in 2009-2012. International STs and genogroups (G) emerged during 2009-2012 (G1407, 29.4%; G2992, 11.7%; G225, 8.8%). These isolates possessed distinctive mechanisms of resistance (e.g., G1407: PBP1 with L421, PBP2 pattern XXXIV, GyrA with S91F and D95G, ParC with S87R, PorB with G120K and A121N, mtrR promoter with A deletion). CONCLUSIONS The prevalence of penicillin- ciprofloxacin- and tetracycline-resistant Ng has reached dramatic levels, whereas cefixime and ceftriaxone show MICs that tend to increase during time. International MDR clones less susceptible to cephalosporins are rapidly emerging indicating that the era of untreatable gonococcal infections is close.
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Affiliation(s)
- Andrea Endimiani
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland.
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Dalhoff A. Global fluoroquinolone resistance epidemiology and implictions for clinical use. Interdiscip Perspect Infect Dis 2012; 2012:976273. [PMID: 23097666 PMCID: PMC3477668 DOI: 10.1155/2012/976273] [Citation(s) in RCA: 212] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Accepted: 06/26/2012] [Indexed: 12/22/2022] Open
Abstract
This paper on the fluoroquinolone resistance epidemiology stratifies the data according to the different prescription patterns by either primary or tertiary caregivers and by indication. Global surveillance studies demonstrate that fluoroquinolone resistance rates increased in the past years in almost all bacterial species except S. pneumoniae and H. influenzae, causing community-acquired respiratory tract infections. However, 10 to 30% of these isolates harbored first-step mutations conferring low level fluoroquinolone resistance. Fluoroquinolone resistance increased in Enterobacteriaceae causing community acquired or healthcare associated urinary tract infections and intraabdominal infections, exceeding 50% in some parts of the world, particularly in Asia. One to two-thirds of Enterobacteriaceae producing extended spectrum β-lactamases were fluoroquinolone resistant too. Furthermore, fluoroquinolones select for methicillin resistance in Staphylococci. Neisseria gonorrhoeae acquired fluoroquinolone resistance rapidly; actual resistance rates are highly variable and can be as high as almost 100%, particularly in Asia, whereas resistance rates in Europe and North America range from <10% in rural areas to >30% in established sexual networks. In general, the continued increase in fluoroquinolone resistance affects patient management and necessitates changes in some guidelines, for example, treatment of urinary tract, intra-abdominal, skin and skin structure infections, and traveller's diarrhea, or even precludes the use in indications like sexually transmitted diseases and enteric fever.
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Affiliation(s)
- Axel Dalhoff
- Institute for Infection-Medicine, Christian-Albrechts Univerity of Kiel and University Medical Center Schleswig-Holstein, Brunswiker Straße 4, 24105 Kiel, Germany
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Chon SY, Doan HQ, Mays RM, Singh SM, Gordon RA, Tyring SK. Antibiotic overuse and resistance in dermatology. Dermatol Ther 2012; 25:55-69. [PMID: 22591499 DOI: 10.1111/j.1529-8019.2012.01520.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Antibiotics have a significant role in dermatology, treating a wide range of diseases, including acne, rosacea, inflammatory skin conditions and skin structure infections, such as cellulitis, folliculitis, carbuncles, and furuncles. Because of their consistent use, utility, and availability, antibiotics are susceptible to overuse within the medical practice, and, specific to this discussion, in the dermatologic setting. The issue of continuously increasing risk of antibiotic resistance remains an important concern to the dermatologist. The scope of this review will be to provide an overview of the common antibiotics used in the dermatologic setting with an emphasis on identifying areas of overuse, reported bacterial resistance, and discussion of clinical management aimed at decreasing antibiotic resistance.
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Affiliation(s)
- Susan Y Chon
- Department of Dermatology, University of Texas Medical School at Houston, MD Anderson Cancer Center, Houston, TX 77030, USA.
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Biedenbach DJ, Turner LL, Jones RN, Farrell DJ. Activity of JNJ-Q2, a novel fluoroquinolone, tested against Neisseria gonorrhoeae, including ciprofloxacin-resistant strains. Diagn Microbiol Infect Dis 2012; 74:204-6. [PMID: 22819604 DOI: 10.1016/j.diagmicrobio.2012.06.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 06/28/2012] [Indexed: 10/28/2022]
Abstract
JNJ-Q2 is a broad-spectrum fluoroquinolone with activity against Gram-positive and -negative pathogens. The in vitro activity of JNJ-Q2 was evaluated when tested against Neisseria gonorrhoeae isolates, including 31 ciprofloxacin-resistant strains with documented mutations in the quinolone resistance determining region. MIC values were determined using reference agar dilution methods using ciprofloxacin, penicillin, ceftriaxone, tetracycline, and azithromycin as comparators. All isolates were inhibited by ≤0.25 μg/mL of JNJ-Q2 (range, 0.004-0.25 μg/mL; MIC(50/90), 0.03/0.25 μg/mL) which was 8-fold (MIC(50)) and 32-fold more potent (MIC(90)) compared to ciprofloxacin. Few strains were susceptible to penicillin (3.0%) and tetracycline (6.1%), and with the use of the European Committee on Antimicrobial Susceptibility Testing interpretive criteria, 13.6% were resistant to azithromycin. All strains were susceptible to ceftriaxone, the most potent agent (MIC(90), 0.06 μg/mL) followed by JNJ-Q2 (MIC(90), 0.25 μg/mL). JNJ-Q2 appears to be a potent fluoroquinolone when tested against contemporary multidrug-resistant N. gonorrhoeae.
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Livermore DM. Fourteen years in resistance. Int J Antimicrob Agents 2012; 39:283-94. [PMID: 22386741 DOI: 10.1016/j.ijantimicag.2011.12.012] [Citation(s) in RCA: 155] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 12/29/2011] [Indexed: 12/31/2022]
Abstract
Resistance trends have changed greatly over the 14 years (1997-2011) whilst I was Director of the UK Antibiotic Resistance Monitoring and Reference Laboratory (ARMRL). Meticillin-resistant Staphylococcus aureus (MRSA) first rose, then fell with improved infection control, although with the decline of one major clone beginning before these improvements. Resistant pneumococci too have declined following conjugate vaccine deployment. If the situation against Gram-positive pathogens has improved, that against Gram-negatives has worsened, with the spread of (i) quinolone- and cephalosporin-resistant Enterobacteriaceae, (ii) Acinetobacter with OXA carbapenemases, (iii) Enterobacteriaceae with biochemically diverse carbapenemases and (iv) gonococci resistant to fluoroquinolones and, latterly, cefixime. Laboratory, clinical and commercial aspects have also changed. Susceptibility testing is more standardised, with pharmacodynamic breakpoints. Treatments regimens are more driven by guidelines. The industry has fewer big profitable companies and more small companies without sales income. There is good and bad here. The quality of routine susceptibility testing has improved, but its speed has not. Pharmacodynamics adds science, but over-optimism has led to poor dose selection in several trials. Guidelines discourage poor therapy but concentrate selection onto a diminishing range of antibiotics, threatening their utility. Small companies are more nimble, but less resilient. Last, more than anything, the world has changed, with the rise of India and China, which account for 33% of the world's population and increasingly provide sophisticated health care, but also have huge resistance problems. These shifts present huge challenges for the future of chemotherapy and for the edifice of modern medicine that depends upon it.
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Affiliation(s)
- David M Livermore
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK.
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11
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Antimicrobial resistance in sexually transmitted infections in the developed world. Curr Opin Infect Dis 2012; 25:73-8. [DOI: 10.1097/qco.0b013e32834e9a6a] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Abstract
Micro-organisms exist to survive. Even in the absence of antimicrobial agents, many have determinants of resistance that may be expressed phenotypically, should the need arise. With the advent of the antibiotic age, as more and more drugs were developed to treat serious infections, micro-organisms (particularly bacteria) rapidly developed resistance determinants to prevent their own demise.The most important determinants of resistance have been in the Gram-positive and Gram-negative bacteria. Among Gram-positive bacteria, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and penicillin-resistant Streptococcus pneumoniae (PRSP) have taxed researchers and pharmaceutical companies to develop new agents that are effective against these resistant strains. Among the Gram-negative bacteria, extended-spectrum beta-lactamase (ESBL) enzymes, carbapenemases (CREs) and the so-called amp-C enzymes that may be readily transferred between species of enterobacteriaceae and other facultative species have created multi-drug resistant organisms that are difficult to treat. Other resistance determinants have been seen in other clinically important bacterial species such as Neisseria gonorrhoeae, Clostridium difficile, Haemophilus influenzae and Mycobacterium tuberculosis. These issues have now spread to fungal agents of infection.A variety of modalities have been used to stem the tide of resistance. These include the development of niche compounds that target specific resistance determinants. Other approaches have been to find new targets for antimicrobial activity, use of combination agents that are effective against more than one target in the cell, or new delivery mechanism to maximize the concentration of antimicrobial agents at the site of infection without causing toxicity to the host. It is important that such new modalities have been proved effective for clinical therapy. Animal models and non-mammalian systems have been developed to determine if new agents will reach sufficient concentrations at infection sites to predict clinical efficacy without toxicity. It will also be key to consider antimicrobial stewardship as an important component of the continuing battle to prevent the development of antimicrobial resistance.
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Affiliation(s)
- Robert P Rennie
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada.
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