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Tongtoyai J, Cherdtrakulkiat T, Girdthep N, Masciotra S, Winaitham S, Sangprasert P, Daengsaard E, Puangsoi A, Kittiyaowamarn R, Dunne EF, Sirivongrangson P, Hickey AC, Weston E, Frankson RM. Data quality assessment of the Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP), Thailand, 2015-2021. PLoS One 2024; 19:e0305296. [PMID: 38968209 PMCID: PMC11226028 DOI: 10.1371/journal.pone.0305296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 05/27/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Quality assessments of gonococcal surveillance data are critical to improve data validity and to enhance the value of surveillance findings. Detecting data errors by systematic audits identifies areas for quality improvement. We designed and implemented an internal audit process to evaluate the accuracy and completeness of surveillance data for the Thailand Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP). METHODS We conducted a data quality audit of source records by comparison with the data stored in the EGASP database for five audit cycles from 2015-2021. Ten percent of culture-confirmed cases of Neisseria gonorrhoeae were randomly sampled along with any cases identified with elevated antimicrobial susceptibility testing results and cases with repeat infections. Incorrect and incomplete data were investigated, and corrective action and preventive actions (CAPA) were implemented. Accuracy was defined as the percentage of identical data in both the source records and the database. Completeness was defined as the percentage of non-missing data from either the source document or the database. Statistical analyses were performed using the t-test and the Fisher's exact test. RESULTS We sampled and reviewed 70, 162, 85, 68, and 46 EGASP records during the five audit cycles. Overall accuracy and completeness in the five audit cycles ranged from 93.6% to 99.4% and 95.0% to 99.9%, respectively. Overall, completeness was significantly higher than accuracy (p = 0.017). For each laboratory and clinical data element, concordance was >85% in all audit cycles except for two laboratory data elements in two audit cycles. These elements significantly improved following identification and CAPA implementation. DISCUSSION We found a high level of data accuracy and completeness in the five audit cycles. The implementation of the audit process identified areas for improvement. Systematic quality assessments of laboratory and clinical data ensure high quality EGASP surveillance data to monitor for antimicrobial resistant Neisseria gonorrhoeae in Thailand.
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Affiliation(s)
- Jaray Tongtoyai
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Thailand Ministry of Public Health, U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Thitima Cherdtrakulkiat
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Thailand Ministry of Public Health, U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Natnaree Girdthep
- Department of Disease Control, Thailand Ministry of Public Health, Nonthaburi, Thailand
| | - Silvina Masciotra
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Thailand Ministry of Public Health, U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Santi Winaitham
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Thailand Ministry of Public Health, U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | | | - Ekkachai Daengsaard
- Department of Disease Control, Thailand Ministry of Public Health, Nonthaburi, Thailand
| | - Anuparp Puangsoi
- Department of Disease Control, Thailand Ministry of Public Health, Nonthaburi, Thailand
| | | | - Eileen F. Dunne
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Thailand Ministry of Public Health, U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | | | - Andrew C. Hickey
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Thailand Ministry of Public Health, U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Emily Weston
- Division of STD Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Rebekah M. Frankson
- Division of STD Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Jensen JS, Unemo M. Antimicrobial treatment and resistance in sexually transmitted bacterial infections. Nat Rev Microbiol 2024; 22:435-450. [PMID: 38509173 DOI: 10.1038/s41579-024-01023-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 03/22/2024]
Abstract
Sexually transmitted infections (STIs) have been part of human life since ancient times, and their symptoms affect quality of life, and sequelae are common. Socioeconomic and behavioural trends affect the prevalence of STIs, but the discovery of antimicrobials gave hope for treatment, control of the spread of infection and lower rates of sequelae. This has to some extent been achieved, but increasing antimicrobial resistance and increasing transmission in high-risk sexual networks threaten this progress. For Neisseria gonorrhoeae, the only remaining first-line treatment (with ceftriaxone) is at risk of becoming ineffective, and for Mycoplasma genitalium, for which fewer alternative antimicrobial classes are available, incurable infections have already been reported. For Chlamydia trachomatis, in vitro resistance to first-line tetracyclines and macrolides has never been confirmed despite decades of treatment of this highly prevalent STI. Similarly, Treponema pallidum, the cause of syphilis, has remained susceptible to first-line penicillin.
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Affiliation(s)
- Jorgen S Jensen
- Department of Bacteria, Parasites and Fungi, Research Unit for Reproductive Microbiology, Statens Serum Institut, Copenhagen, Denmark.
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, 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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3
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Unemo M, Sánchez-Busó L, Golparian D, Jacobsson S, Shimuta K, Lan PT, Eyre DW, Cole M, Maatouk I, Wi T, Lahra MM. The novel 2024 WHO Neisseria gonorrhoeae reference strains for global quality assurance of laboratory investigations and superseded WHO N. gonorrhoeae reference strains-phenotypic, genetic and reference genome characterization. J Antimicrob Chemother 2024:dkae176. [PMID: 38889110 DOI: 10.1093/jac/dkae176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 05/15/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVES MDR and XDR Neisseria gonorrhoeae strains remain major public health concerns internationally, and quality-assured global gonococcal antimicrobial resistance (AMR) surveillance is imperative. The WHO global Gonococcal Antimicrobial Surveillance Programme (GASP) and WHO Enhanced GASP (EGASP), including metadata and WGS, are expanding internationally. We present the phenotypic, genetic and reference genome characteristics of the 2024 WHO gonococcal reference strains (n = 15) for quality assurance worldwide. All superseded WHO gonococcal reference strains (n = 14) were identically characterized. MATERIAL AND METHODS The 2024 WHO reference strains include 11 of the 2016 WHO reference strains, which were further characterized, and four novel strains. The superseded WHO reference strains include 11 WHO reference strains previously unpublished. All strains were characterized phenotypically and genomically (single-molecule PacBio or Oxford Nanopore and Illumina sequencing). RESULTS The 2024 WHO reference strains represent all available susceptible and resistant phenotypes and genotypes for antimicrobials currently and previously used (n = 22), or considered for future use (n = 3) in gonorrhoea treatment. The novel WHO strains include internationally spreading ceftriaxone resistance, ceftriaxone resistance due to new penA mutations, ceftriaxone plus high-level azithromycin resistance and azithromycin resistance due to mosaic MtrRCDE efflux pump. AMR, serogroup, prolyliminopeptidase, genetic AMR determinants, plasmid types, molecular epidemiological types and reference genome characteristics are presented for all strains. CONCLUSIONS The 2024 WHO gonococcal reference strains are recommended for internal and external quality assurance in laboratory examinations, especially in the WHO GASP, EGASP and other GASPs, but also in phenotypic and molecular diagnostics, AMR prediction, pharmacodynamics, epidemiology, research and as complete reference genomes in WGS analysis.
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Affiliation(s)
- Magnus Unemo
- Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Microbiology, Örebro University, Örebro, Sweden
- Institute for Global Health, University College London (UCL), London, UK
| | - Leonor Sánchez-Busó
- Joint Research Unit 'Infection and Public Health', FISABIO-University of Valencia, Institute for Integrative Systems Biology (I2SysBio), Valencia, Spain
- CIBERESP, ISCIII, Madrid, Spain
| | - Daniel Golparian
- Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Microbiology, Örebro University, Örebro, Sweden
| | - Susanne Jacobsson
- Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Microbiology, Örebro University, Örebro, Sweden
| | - Ken Shimuta
- Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan
| | - Pham Thi Lan
- Hanoi Medical University, National Hospital of Dermatology and Venereology, Hanoi, Vietnam
| | - David W Eyre
- Big Data Institute, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Ismael Maatouk
- Department of the Global HIV, Hepatitis and STI Programmes, WHO, Geneva, Switzerland
| | - Teodora Wi
- Department of the Global HIV, Hepatitis and STI Programmes, WHO, Geneva, Switzerland
| | - Monica M Lahra
- WHO Collaborating Centre for Sexually Transmitted Infections and Antimicrobial Resistance, New South Wales Health Pathology, Microbiology, Randwick, NSW, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, Australia
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4
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Unemo M, Golparian D, Oxelbark J, Kong FYS, Brown D, Louie A, Drusano G, Jacobsson S. Pharmacodynamic evaluation of ceftriaxone single-dose therapy (0.125-1 g) to eradicate ceftriaxone-susceptible and ceftriaxone-resistant Neisseria gonorrhoeae strains in a hollow fibre infection model for gonorrhoea. J Antimicrob Chemother 2024; 79:1006-1013. [PMID: 38497988 DOI: 10.1093/jac/dkae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/22/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Antimicrobial resistance in Neisseria gonorrhoeae is threatening the gonorrhoea treatment, and optimizations of the current ceftriaxone-treatment regimens are crucial. We evaluated the pharmacodynamics of ceftriaxone single-dose therapy (0.125-1 g) against ceftriaxone-susceptible and ceftriaxone-resistant gonococcal strains, based on EUCAST ceftriaxone-resistance breakpoint (MIC > 0.125 mg/L), in our hollow fibre infection model (HFIM) for gonorrhoea. METHODS Gonococcal strains examined were WHO F (ceftriaxone-susceptible, MIC < 0.002 mg/L), R (ceftriaxone-resistant, MIC = 0.5 mg/L), Z (ceftriaxone-resistant, MIC = 0.5 mg/L) and X (ceftriaxone-resistant, MIC = 2 mg/L). Dose-range HFIM 7 day experiments simulating ceftriaxone 0.125-1 g single-dose intramuscular regimens were conducted. RESULTS Ceftriaxone 0.125-1 g single-dose treatments rapidly eradicated WHO F (wild-type ceftriaxone MIC). Ceftriaxone 0.5 and 1 g treatments, based on ceftriaxone human plasma pharmacokinetic parameters, eradicated most ceftriaxone-resistant gonococcal strains (WHO R and Z), but ceftriaxone 0.5 g failed to eradicate WHO X (high-level ceftriaxone resistance). When simulating oropharyngeal gonorrhoea, ceftriaxone 0.5 g failed to eradicate all the ceftriaxone-resistant strains, while ceftriaxone 1 g eradicated WHO R and Z (low-level ceftriaxone resistance) but failed to eradicate WHO X (high-level ceftriaxone resistance). No ceftriaxone-resistant mutants were selected using any ceftriaxone treatments. CONCLUSIONS Ceftriaxone 1 g single-dose intramuscularly cure most of the anogenital and oropharyngeal gonorrhoea cases caused by the currently internationally spreading ceftriaxone-resistant gonococcal strains, which should be further confirmed clinically. A ceftriaxone 1 g dose (±azithromycin 2 g) should be recommended for first-line empiric gonorrhoea treatment. This will buy countries some time until novel antimicrobials are licensed. Using ceftriaxone 1 g gonorrhoea treatment, the EUCAST ceftriaxone-resistance breakpoint is too low.
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Affiliation(s)
- Magnus Unemo
- Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Sexually Transmitted Infections, Örebro University, Örebro, Sweden
- Institute for Global Health, University College London (UCL), London, UK
| | - Daniel Golparian
- Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Sexually Transmitted Infections, Örebro University, Örebro, Sweden
| | - Joakim Oxelbark
- Division of Clinical Chemistry, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Fabian Y S Kong
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - David Brown
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Arnold Louie
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Gainesville, FL, USA
| | - George Drusano
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Susanne Jacobsson
- Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Sexually Transmitted Infections, Örebro University, Örebro, Sweden
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Golparian D, Bazzo ML, Ahlstrand J, Schörner MA, Gaspar PC, de Melo Machado H, Martins JM, Bigolin A, Ramos MC, Ferreira WA, Pereira GFM, Miranda AE, Unemo M. Recent dynamics in Neisseria gonorrhoeae genomic epidemiology in Brazil: antimicrobial resistance and genomic lineages in 2017-20 compared to 2015-16. J Antimicrob Chemother 2024; 79:1081-1092. [PMID: 38517452 DOI: 10.1093/jac/dkae075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 03/01/2024] [Indexed: 03/23/2024] Open
Abstract
OBJECTIVES Regular quality-assured WGS with antimicrobial resistance (AMR) and epidemiological data of patients is imperative to elucidate the shifting gonorrhoea epidemiology, nationally and internationally. We describe the dynamics of the gonococcal population in 11 cities in Brazil between 2017 and 2020 and elucidate emerging and disappearing gonococcal lineages associated with AMR, compare to Brazilian WGS and AMR data from 2015 to 2016, and explain recent changes in gonococcal AMR and gonorrhoea epidemiology. METHODS WGS was performed using Illumina NextSeq 550 and genomes of 623 gonococcal isolates were used for downstream analysis. Molecular typing and AMR determinants were obtained and links between genomic lineages and AMR (determined by agar dilution/Etest) examined. RESULTS Azithromycin resistance (15.6%, 97/623) had substantially increased and was mainly explained by clonal expansions of strains with 23S rRNA C2611T (mostly NG-STAR CC124) and mtr mosaics (mostly NG-STAR CC63, MLST ST9363). Resistance to ceftriaxone and cefixime remained at the same levels as in 2015-16, i.e. at 0% and 0.2% (1/623), respectively. Regarding novel gonorrhoea treatments, no known zoliflodacin-resistance gyrB mutations or gepotidacin-resistance gyrA mutations were found. Genomic lineages and sublineages showed a phylogenomic shift from sublineage A5 to sublineages A1-A4, while isolates within lineage B remained diverse in Brazil. CONCLUSIONS Azithromycin resistance, mainly caused by 23S rRNA C2611T and mtrD mosaics/semi-mosaics, had substantially increased in Brazil. This mostly low-level azithromycin resistance may threaten the recommended ceftriaxone-azithromycin therapy, but the lack of ceftriaxone resistance is encouraging. Enhanced gonococcal AMR surveillance, including WGS, is imperative in Brazil and other Latin American and Caribbean countries.
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Affiliation(s)
- Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, SE-701 85, Örebro, Sweden
| | - Maria Luiza Bazzo
- Molecular Biology, Microbiology and Serology Laboratory, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Josefine Ahlstrand
- WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, SE-701 85, Örebro, Sweden
| | - Marcos André Schörner
- Molecular Biology, Microbiology and Serology Laboratory, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Pamela Cristina Gaspar
- Department of HIV/AIDS, Tuberculosis, and Sexually Transmitted Infection, Secretariat of Health Surveillance and Environment, Ministry of Health of Brazil, Brasília, Brazil
| | - Hanalydia de Melo Machado
- Molecular Biology, Microbiology and Serology Laboratory, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Jéssica Motta Martins
- Molecular Biology, Microbiology and Serology Laboratory, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Alisson Bigolin
- Department of HIV/AIDS, Tuberculosis, and Sexually Transmitted Infection, Secretariat of Health Surveillance and Environment, Ministry of Health of Brazil, Brasília, Brazil
| | | | | | - Gerson Fernando Mendes Pereira
- Department of HIV/AIDS, Tuberculosis, and Sexually Transmitted Infection, Secretariat of Health Surveillance and Environment, Ministry of Health of Brazil, Brasília, Brazil
| | - Angelica Espinosa Miranda
- Department of HIV/AIDS, Tuberculosis, and Sexually Transmitted Infection, Secretariat of Health Surveillance and Environment, Ministry of Health of Brazil, Brasília, Brazil
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, SE-701 85, Örebro, Sweden
- Institute for Global Health, University College London (UCL), London, UK
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Santana BDM, Armentano GM, Ferreira DAS, de Freitas CS, Carneiro-Ramos MS, Seabra AB, Christodoulides M. In Vitro Bactericidal Activity of Biogenic Copper Oxide Nanoparticles for Neisseria gonorrhoeae with Enhanced Compatibility for Human Cells. ACS APPLIED MATERIALS & INTERFACES 2024; 16:21633-21642. [PMID: 38632674 DOI: 10.1021/acsami.4c02357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Resistance to antibiotics and antimicrobial compounds is a significant problem for human and animal health globally. The development and introduction of new antimicrobial compounds are urgently needed, and copper oxide nanoparticles (CuO NPs) have found widespread application across various sectors including biomedicine, pharmacy, catalysis, cosmetics, and many others. What makes them particularly attractive is the possibility of their synthesis through biogenic routes. In this study, we synthesized biogenic green tea (GT, Camellia sinensis)-derived CuO NPs (GT CuO NPs) and examined their biophysical properties, in vitro toxicity for mammalian cells in culture, and then tested them against Neisseria gonorrhoeae, an exemplar Gram-negative bacterium from the World Health Organization's Priority Pathogen List. We compared our synthesized GT CuOP NPs with commercial CuO NPs (Com CuO NPs). Com CuO NPs were significantly more cytotoxic to mammalian cells (IC50 of 7.32 μg/mL) than GT CuO NPs (IC50 of 106.1 μg/mL). GT CuO NPs showed no significant increase in bax, bcl2, il6, and il1β mRNA expression from mammalian cells, whereas there were notable rises after treatment with Com CuO NPs. GT-CuO NPs required concentrations of 0.625 and 3.125 μg/mL to kill 50 and 100% of bacteria, respectively, whereas Com-CuO NPs needed concentrations of 15.625 and 30 μg/mL to kill 50 and 100% of bacteria, and the antibiotic ceftriaxone killed 50 and 100% with 3.125 and 30 μg/mL. Gonococci could be killed within 30 min of exposure to GT CuO NPs and the NPs could kill up to 107 within 1 h. In summary, this is the first report to our knowledge that describes the bioactivity of biogenic CuO NPs against N. gonorrhoeae. Our data suggest that biogenic nanoparticle synthesis has significant advantages over traditional chemical routes of synthesis and highlights the potential of GT-CuO NPs in addressing the challenges posed by multidrug-resistant Neisseria gonorrhoeae infections.
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Affiliation(s)
- Bianca de Melo Santana
- Center for Natural and Human Sciences (CCNH), Federal University of ABC (UFABC), Avenida dos Estados 5001, Santo André, São Paulo 09210-580, Brazil
- Neisseria Research Laboratory, Molecular Microbiology, School of Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, Tremona Road, Southampton SO16 6YD, U.K
| | - Giovana Marchini Armentano
- Center for Natural and Human Sciences (CCNH), Federal University of ABC (UFABC), Avenida dos Estados 5001, Santo André, São Paulo 09210-580, Brazil
| | - Dayana Agnes Santos Ferreira
- Neisseria Research Laboratory, Molecular Microbiology, School of Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, Tremona Road, Southampton SO16 6YD, U.K
- Laboratory of Pathophysiology, Butantan Institute, Av. Vital Brazil, 1500, São Paulo, SP 05503-900, Brazil
| | - Camila Simões de Freitas
- Neisseria Research Laboratory, Molecular Microbiology, School of Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, Tremona Road, Southampton SO16 6YD, U.K
- Postgraduate Program in Health Sciences: Infectious Diseases and Tropical Medicine, Faculty of Medicine, Federal University of Minas Gerais, Av. Prof. Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Marcela Sorelli Carneiro-Ramos
- Center for Natural and Human Sciences (CCNH), Federal University of ABC (UFABC), Avenida dos Estados 5001, Santo André, São Paulo 09210-580, Brazil
| | - Amedea Barozzi Seabra
- Center for Natural and Human Sciences (CCNH), Federal University of ABC (UFABC), Avenida dos Estados 5001, Santo André, São Paulo 09210-580, Brazil
| | - Myron Christodoulides
- Neisseria Research Laboratory, Molecular Microbiology, School of Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, Tremona Road, Southampton SO16 6YD, U.K
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Colón Pérez J, Villarino Fernández RA, Domínguez Lago A, Treviño Castellano MM, Pérez del Molino Bernal ML, Sánchez Poza S, Torres-Sangiao E. Addressing Sexually Transmitted Infections Due to Neisseria gonorrhoeae in the Present and Future. Microorganisms 2024; 12:884. [PMID: 38792714 PMCID: PMC11124187 DOI: 10.3390/microorganisms12050884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/16/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024] Open
Abstract
It was in the 1800s when the first public publications about the infection and treatment of gonorrhoea were released. However, the first prevention programmes were only published a hundred years later. In the 1940s, the concept of vaccination was introduced into clinical prevention programmes to address early sulphonamide resistance. Since then, tons of publications on Neisseria gonorrhoeae are undisputed, around 30,000 publications today. Currently, the situation seems to be just as it was in the last century, nothing has changed or improved. So, what are we doing wrong? And more importantly, what might we do? The review presented here aims to review the current situation regarding the resistance mechanisms, prevention programmes, treatments, and vaccines, with the challenge of better understanding this special pathogen. The authors have reviewed the last five years of advancements, knowledge, and perspectives for addressing the Neisseria gonorrhoeae issue, focusing on new therapeutic alternatives.
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Affiliation(s)
- Julia Colón Pérez
- Servicio de Microbiología y Parasitología Clínica, Complexo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain; (J.C.P.); (A.D.L.); (M.M.T.C.); (M.L.P.d.M.B.)
- Grupo Microbiología, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Rosa-Antía Villarino Fernández
- Departamento de Microbiología, Facultad de Farmacia, Universidad de Santiago de Compostela, 15782 Santiago de Compostela, Spain;
| | - Adrián Domínguez Lago
- Servicio de Microbiología y Parasitología Clínica, Complexo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain; (J.C.P.); (A.D.L.); (M.M.T.C.); (M.L.P.d.M.B.)
- Grupo Microbiología, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - María Mercedes Treviño Castellano
- Servicio de Microbiología y Parasitología Clínica, Complexo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain; (J.C.P.); (A.D.L.); (M.M.T.C.); (M.L.P.d.M.B.)
- Grupo Microbiología, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - María Luisa Pérez del Molino Bernal
- Servicio de Microbiología y Parasitología Clínica, Complexo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain; (J.C.P.); (A.D.L.); (M.M.T.C.); (M.L.P.d.M.B.)
- Grupo Microbiología, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Sandra Sánchez Poza
- Departamento de Microbiología, Facultad de Farmacia, Universidad de Santiago de Compostela, 15782 Santiago de Compostela, Spain;
| | - Eva Torres-Sangiao
- Servicio de Microbiología y Parasitología Clínica, Complexo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain; (J.C.P.); (A.D.L.); (M.M.T.C.); (M.L.P.d.M.B.)
- Grupo Microbiología, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
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8
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Sangprasert P, Golparian D, Paopang P, Girdthep N, Lawung R, Gopinath D, Thammawijaya P, Kittiyaowanarn R, Unemo M. Complete reference genomes of two ceftriaxone-resistant Neisseria gonorrhoeae strains identified in routine surveillance in Bangkok, Thailand, using Nanopore Q20+ chemistry, VolTRAX V2b, and Illumina sequencing. Microbiol Resour Announc 2024; 13:e0123123. [PMID: 38299807 PMCID: PMC10927671 DOI: 10.1128/mra.01231-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/24/2024] [Indexed: 02/02/2024] Open
Abstract
Ceftriaxone-resistant Neisseria gonorrhoeae strains, mostly associated with Asia, threaten gonorrhea treatment. We report the reference genomes of two ceftriaxone-resistant isolates found in routine surveillance in Bangkok, Thailand. The genomes belonged to the more antimicrobial-susceptible genomic lineage B, illustrating that both ceftriaxone-resistant strains and the mosaic penA-60.001 ceftriaxone-resistance determinant are spreading.
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Affiliation(s)
- Pongsathorn Sangprasert
- Division of AIDS and STIs, Department of Disease Control and Prevention, Bangrak STIs Center, Thailand Ministry of Public Health, Bangkok, Thailand
| | - Daniel Golparian
- Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, World Health Organization (WHO) Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Örebro University, Örebro, Sweden
| | - Porntip Paopang
- Division of AIDS and STIs, Department of Disease Control and Prevention, Bangrak STIs Center, Thailand Ministry of Public Health, Bangkok, Thailand
| | - Natnaree Girdthep
- Division of AIDS and STIs, Department of Disease Control and Prevention, Bangrak STIs Center, Thailand Ministry of Public Health, Bangkok, Thailand
| | - Ratana Lawung
- Department of Clinical Microbiology and Applied Technology, Faculty of Medical Technology, Mahidol University, Bangkok, Thailand
| | - Deyer Gopinath
- World Health Organization (WHO), Country Office, Nonthaburi, Thailand
| | | | - Rossaphorn Kittiyaowanarn
- Division of AIDS and STIs, Department of Disease Control and Prevention, Bangrak STIs Center, Thailand Ministry of Public Health, Bangkok, Thailand
| | - Magnus Unemo
- Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, World Health Organization (WHO) Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Örebro University, Örebro, Sweden
- Institute for Global Health, University College London (UCL), London, United Kingdom
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9
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Street TL, Sanderson ND, Barker L, Kavanagh J, Cole K, Llewelyn M, Eyre DW. Target enrichment improves culture-independent detection of Neisseria gonorrhoeae and antimicrobial resistance determinants direct from clinical samples with Nanopore sequencing. Microb Genom 2024; 10:001208. [PMID: 38529900 PMCID: PMC10995632 DOI: 10.1099/mgen.0.001208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/10/2024] [Indexed: 03/27/2024] Open
Abstract
Multi-drug-resistant Neisseria gonorrhoeae infection is a significant public health risk. Rapidly detecting N. gonorrhoeae and antimicrobial-resistant (AMR) determinants by metagenomic sequencing of urine is possible, although high levels of host DNA and overgrowth of contaminating species hamper sequencing and limit N. gonorrhoeae genome coverage. We performed Nanopore sequencing of nucleic acid amplification test-positive urine samples and culture-positive urethral swabs with and without probe-based target enrichment, using a custom SureSelect panel, to investigate whether selective enrichment of N. gonorrhoeae DNA improves detection of both species and AMR determinants. Probes were designed to cover the entire N. gonorrhoeae genome, with tenfold enrichment of probes covering selected AMR determinants. Multiplexing was tested in a subset of samples. The proportion of sequence bases classified as N. gonorrhoeae increased in all samples after enrichment, from a median (IQR) of 0.05 % (0.01-0.1 %) to 76 % (42-82 %), giving a corresponding median improvement in fold genome coverage of 365 times (112-720). Over 20-fold coverage, required for robust AMR determinant detection, was achieved in 13/15(87 %) samples, compared to 2/15(13 %) without enrichment. The four samples multiplexed together also achieved >20-fold genome coverage. Coverage of AMR determinants was sufficient to predict resistance conferred by changes in chromosomal genes, where present, and genome coverage also enabled phylogenetic relationships to be reconstructed. Probe-based target enrichment can improve N. gonorrhoeae genome coverage when sequencing DNA extracts directly from urine or urethral swabs, allowing for detection of AMR determinants. Additionally, multiplexing prior to enrichment provided enough genome coverage for AMR detection and reduces the costs associated with this method.
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Affiliation(s)
- Teresa L. Street
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- National Institute for Health Research Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Nicholas D. Sanderson
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- National Institute for Health Research Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Leanne Barker
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - James Kavanagh
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Kevin Cole
- Department of Microbiology and Infection, University Hospitals Sussex NHS Trust, Brighton, UK
| | - The GonFast Investigators Group
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- National Institute for Health Research Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Department of Microbiology and Infection, University Hospitals Sussex NHS Trust, Brighton, UK
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Martin Llewelyn
- Department of Microbiology and Infection, University Hospitals Sussex NHS Trust, Brighton, UK
| | - David W. Eyre
- National Institute for Health Research Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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10
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Buder S. [Urethritis-spectrum of pathogens, diagnostics and treatment]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2023; 74:835-850. [PMID: 37847382 DOI: 10.1007/s00105-023-05230-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 10/18/2023]
Abstract
A broad spectrum of bacteria, fungi, protozoa and viruses can cause urethritis. In particular, N. gonorrhoeae, C. trachomatis, M. genitalium and T. vaginalis are the focus of diagnostic considerations as classic pathogens associated with sexually transmitted infections (STI). A step-by-step procedure is needed to make a definitive diagnosis. Microscopy with a staining preparation provides an initial differentiation between gonoccocal and non-gonococcal urethritis in symptomatic men as a point-of-care (POC) test. Nucleic acid amplification technology (NAAT) is used for specific and sensitive pathogen detection and, as a multiplex diagnostic test, offers the possibility of detecting several organisms from the same sample. In addition, compared to culture, no vital organisms are required, which allows the collection and use of more diverse and less invasive biological samples (e.g. first stream urine in men or vaginal swabs). Susceptibility testing by culture remains essential for N. gonorrhoeae as resistance is emerging. The treatment of urethritis depends on the suspected or proven pathogen according to the current guidelines. Treatment failure can be caused by many factors (coinfection, lack of therapy adherence, reinfection or resistance of the pathogen) and requires a repeated diagnostic and therapeutic procedure and differentiated approach.
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Affiliation(s)
- Susanne Buder
- Klinik für Dermatologie und Venerologie, Vivantes Klinikum Berlin Neukölln, Rudower Str. 48, 12351, Berlin, Deutschland.
- Konsiliarlabor für Gonokokken, Robert Koch-Institut, Seestr. 10, 13353, Berlin, Deutschland.
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11
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Mortimer TD, Grad YH. A Genomic Perspective on the Near-term Impact of Doxycycline Post-exposure Prophylaxis on Neisseria gonorrhoeae Antimicrobial Resistance. Clin Infect Dis 2023; 77:788-791. [PMID: 37138444 PMCID: PMC10495131 DOI: 10.1093/cid/ciad279] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/27/2023] [Accepted: 05/02/2023] [Indexed: 05/05/2023] Open
Abstract
Pre-existing tetracycline resistance in Neisseria gonorrhoeae limits the effectiveness of post-exposure prophylaxis (PEP) with doxycycline against gonorrhea, and selection for tetracycline resistance may influence prevalence of multi-drug resistant strains. Using genomic and antimicrobial susceptibility data from N. gonorrhoeae, we assessed the near-term impact of doxycycline PEP on N. gonorrhoeae resistance.
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Affiliation(s)
- Tatum D Mortimer
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Yonatan H Grad
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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12
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Wang D, Wang Y, Li Y, Xiu L, Yong G, Yang Y, Gu W, Peng J. Identification of ceftriaxone-resistant Neisseria gonorrhoeae FC428 clone and isolates harboring a novel mosaic penA gene in Chengdu in 2019-2020. Ann Clin Microbiol Antimicrob 2023; 22:73. [PMID: 37592240 PMCID: PMC10436653 DOI: 10.1186/s12941-023-00614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/23/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Antimicrobial resistance in gonorrhea has become a growing global public health burden. Neisseria gonorrhoeae isolates with resistance to ceftriaxone, the last remaining first-line option, represent an emerging threat of untreatable gonorrhea. METHODS A total of ten ceftriaxone-resistant N. gonorrhoeae FC428 isolates and two isolates harboring a novel mosaic penA-232.001 allele from 160 gonococcal isolates in Chengdu in 2019-2020 was described in the present study. Multilocus sequence typing (MLST) and N. gonorrhoeae sequence typing for antimicrobial resistance (NG-STAR) were performed to characterize the isolates. Whole genome sequencing and maximum-likelihood method were performed to infer how the genetic phylogenetic tree of these isolates looks like. Recombination analysis was performed using the RDP4 software. This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100048771, registration date: 20210716). RESULTS The genetic phylogeny showed that the ten FC428 isolates sporadically clustered into different phylogenetic clades, suggesting different introductions and local transmission of FC428. Two isolates showed close genetic relatedness to ceftriaxone-resistant clone A8806, which was only reported from Australia in 2013. Homologous recombination events were detected in penA between Neisseria gonorrhoeae and commensal Neisseria species (N. perflava and N. polysaccharea), providing evidence of commensal Neisseria species might serve as reservoirs of ceftriaxone resistance-mediating penA sequences in clinical gonococcal strains. CONCLUSIONS Our results demonstrate further dissemination of FC428 in China and resurgence risks of sporadic ceftriaxone-resistant A8806 to become the next clone to spread.
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Affiliation(s)
- Di Wang
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Key Laboratory of Respiratory Disease Pathogenomics, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Youwei Wang
- Institute of Dermatology and Venereology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Yamei Li
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Key Laboratory of Respiratory Disease Pathogenomics, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Laboratory Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Leshan Xiu
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Key Laboratory of Respiratory Disease Pathogenomics, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- School of Global Health, Chinese Center for Tropical Diseases Research, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gang Yong
- Institute of Dermatology and Venereology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Yang Yang
- Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
| | - Weiming Gu
- Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Junping Peng
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
- Key Laboratory of Respiratory Disease Pathogenomics, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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13
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Kakooza F, Golparian D, Matoga M, Maseko V, Lamorde M, Krysiak R, Manabe YC, Chen JS, Kularatne R, Jacobsson S, Godreuil S, Hoffman I, Bercot B, Wi T, Unemo M. Genomic surveillance and antimicrobial resistance determinants in Neisseria gonorrhoeae isolates from Uganda, Malawi and South Africa, 2015-20. J Antimicrob Chemother 2023; 78:1982-1991. [PMID: 37352017 DOI: 10.1093/jac/dkad193] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/06/2023] [Indexed: 06/25/2023] Open
Abstract
OBJECTIVES Global antimicrobial resistance (AMR) surveillance in Neisseria gonorrhoeae is essential. In 2017-18, only five (10.6%) countries in the WHO African Region reported to the WHO Global Gonococcal Antimicrobial Surveillance Programme (WHO GASP). Genomics enhances our understanding of gonococcal populations nationally and internationally, including AMR strain transmission; however, genomic studies from Africa are extremely scarce. We describe the gonococcal genomic lineages/sublineages, including AMR determinants, and baseline genomic diversity among strains in Uganda, Malawi and South Africa, 2015-20, and compare with sequences from Kenya and Burkina Faso. METHODS Gonococcal isolates cultured in Uganda (n = 433), Malawi (n = 154) and South Africa (n = 99) in 2015-20 were genome-sequenced. MICs were determined using ETEST. Sequences of isolates from Kenya (n = 159), Burkina Faso (n = 52) and the 2016 WHO reference strains (n = 14) were included in the analysis. RESULTS Resistance to ciprofloxacin was high in all countries (57.1%-100%). All isolates were susceptible to ceftriaxone, cefixime and spectinomycin, and 99.9% were susceptible to azithromycin. AMR determinants for ciprofloxacin, benzylpenicillin and tetracycline were common, but rare for cephalosporins and azithromycin. Most isolates belonged to the more antimicrobial-susceptible lineage B (n = 780) compared with the AMR lineage A (n = 141), and limited geographical phylogenomic signal was observed. CONCLUSIONS We report the first multi-country gonococcal genomic comparison from Africa, which will support the WHO GASP and WHO enhanced GASP (EGASP). The high prevalence of resistance to ciprofloxacin (and empirical use continues), tetracycline and benzylpenicillin, and the emerging resistance determinants for azithromycin show it is imperative to strengthen the gonococcal AMR surveillance, ideally including genomics, in African countries.
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Affiliation(s)
- Francis Kakooza
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Golparian
- Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Örebro University, Örebro, Sweden
| | | | - Venessa Maseko
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Yuka C Manabe
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jane S Chen
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ranmini Kularatne
- Labtests Laboratory and Head Office, Mt Wellington, Auckland, New Zealand
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Susanne Jacobsson
- Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Örebro University, Örebro, Sweden
| | - Sylvain Godreuil
- Laboratoire de Bactériologie, Centre Hospitalier Universitaire de Montpellier, and MIVEGEC, Université de Montpellier, CNRS, IRD, Montpellier, France
| | - Irving Hoffman
- UNC Project Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Beatrice Bercot
- Infectious Agents Department, French National Reference Centre for Bacterial STIs, Associated Laboratory for Gonococci, and APHP, Saint Louis Hospital, Paris, France
| | - Teodora Wi
- Department of the Global HIV, Hepatitis and STI Programmes, WHO, Geneva, Switzerland
| | - Magnus Unemo
- Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Örebro University, Örebro, Sweden
- Institute for Global Health, University College London, London, UK
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