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Quilter LAS, St Cyr SB, Barbee LA. The Management of Gonorrhea in the Era of Emerging Antimicrobial Resistance: What Primary Care Clinicians Should Know. Med Clin North Am 2024; 108:279-296. [PMID: 38331480 DOI: 10.1016/j.mcna.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
Gonorrhea rates continue to rise in the United States and Neisseria gonorrhoeae's propensity to develop resistance to all therapies used for treatment has complicated the management of gonorrhea. Ceftriaxone is the only remaining highly effective recommended regimen for gonococcal treatment and few new anti-gonococcal antimicrobials are being developed. The 2021 CDC STI Treatment Guidelines increased the dose of ceftriaxone to 500 mg (1 g if ≥ 150 kg) for uncomplicated infections. It is recommended that all clinicians should be aware of antimicrobial resistant gonorrhea and be able to appropriately manage any suspected gonorrhea treatment failure case.
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Affiliation(s)
- Laura A S Quilter
- Division of STD Prevention, Centers of Disease Control and Prevention, 1600 Clifton Road Northeast, MS H24-4, Atlanta, GA 30329, USA.
| | - Sancta B St Cyr
- Division of STD Prevention, Centers of Disease Control and Prevention, 1600 Clifton Road Northeast, MS H24-4, Atlanta, GA 30329, USA
| | - Lindley A Barbee
- Division of STD Prevention, Centers of Disease Control and Prevention, 1600 Clifton Road Northeast, MS H24-4, Atlanta, GA 30329, USA
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Reimche JL, Clemons AA, Chivukula VL, Joseph SJ, Schmerer MW, Pham CD, Schlanger K, St Cyr SB, Kersh EN, Gernert KM. Genomic analysis of 1710 surveillance-based Neisseria gonorrhoeae isolates from the USA in 2019 identifies predominant strain types and chromosomal antimicrobial-resistance determinants. Microb Genom 2023; 9. [PMID: 37171855 DOI: 10.1099/mgen.0.001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
This study characterized high-quality whole-genome sequences of a sentinel, surveillance-based collection of 1710 Neisseria gonorrhoeae (GC) isolates from 2019 collected in the USA as part of the Gonococcal Isolate Surveillance Project (GISP). It aims to provide a detailed report of strain diversity, phylogenetic relationships and resistance determinant profiles associated with reduced susceptibilities to antibiotics of concern. The 1710 isolates represented 164 multilocus sequence types and 21 predominant phylogenetic clades. Common genomic determinants defined most strains' phenotypic, reduced susceptibility to current and historic antibiotics (e.g. bla TEM plasmid for penicillin, tetM plasmid for tetracycline, gyrA for ciprofloxacin, 23S rRNA and/or mosaic mtr operon for azithromycin, and mosaic penA for cefixime and ceftriaxone). The most predominant phylogenetic clade accounted for 21 % of the isolates, included a majority of the isolates with low-level elevated MICs to azithromycin (2.0 µg ml-1), carried a mosaic mtr operon and variants in PorB, and showed expansion with respect to data previously reported from 2018. The second largest clade predominantly carried the GyrA S91F variant, was largely ciprofloxacin resistant (MIC ≥1.0 µg ml-1), and showed significant expansion with respect to 2018. Overall, a low proportion of isolates had medium- to high-level elevated MIC to azithromycin ((≥4.0 µg ml-1), based on C2611T or A2059G 23S rRNA variants). One isolate carried the penA 60.001 allele resulting in elevated MICs to cefixime and ceftriaxone of 1.0 µg ml-1. This high-resolution snapshot of genetic profiles of 1710 GC sequences, through a comparison with 2018 data (1479 GC sequences) within the sentinel system, highlights change in proportions and expansion of select GC strains and the associated genetic mechanisms of resistance. The knowledge gained through molecular surveillance may support rapid identification of outbreaks of concern. Continued monitoring may inform public health responses to limit the development and spread of antibiotic-resistant gonorrhoea.
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Affiliation(s)
- Jennifer L Reimche
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Oak Ridge Institute for Science and Education Research Participation and Fellowship Program, Oak Ridge, TN, USA
| | - Arvon A Clemons
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Oak Ridge Institute for Science and Education Research Participation and Fellowship Program, Oak Ridge, TN, USA
| | - Vasanta L Chivukula
- Oak Ridge Institute for Science and Education Research Participation and Fellowship Program, Oak Ridge, TN, USA
- Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sandeep J Joseph
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Matthew W Schmerer
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Cau D Pham
- Antimicrobial Resistance Coordination and Strategy Unit, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Karen Schlanger
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sancta B St Cyr
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ellen N Kersh
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kim M Gernert
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Nielsen KE, St Cyr SB, Pham CD, Kreisel KM. Assessing the National Representativeness of Estimates of Antimicrobial-Resistant Urogenital Neisseria gonorrhoeae in US Men, Gonococcal Isolate Surveillance Project, 2008-2018. Sex Transm Dis 2023; 50:196-202. [PMID: 36538365 DOI: 10.1097/olq.0000000000001755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The percentage of Neisseria gonorrhoeae (GC) isolates with resistance or elevated minimum inhibitory concentrations to antimicrobials has steadily increased. Current estimates are based on the Gonococcal Isolate Surveillance Project (GISP), a sentinel surveillance study of male GC in the United States. This analysis seeks to assess for adjustment before treating aggregated GISP estimates as nationally representative of all reported male urogenital infections. METHODS We used multilevel regression with poststratification (MRP) to compute national estimates of the proportion of antimicrobial resistance (AMR) (defined as exceeding minimum inhibitory concentration thresholds) in male GC using data from 2008 to 2018 GISP and case reports. Sensitivity analyses investigated the impact of analysis assumptions and unmeasured variables. We additionally produced estimates of 2018 AMR GC cases among US men. RESULTS National estimates were consistent with unweighted estimates. The estimated proportion of incident AMR GC infections in men with urogenital GC in 2018 was 51.5% (95% confidence interval [CI], 50.1%-52.9%), equating to an estimated 366,300 incident AMR GC infections in US men aged 15 to 39 years. Estimates of AMR for tested antimicrobials in male GC infections in 2018 ranged from 0.16% (95% CI, 0.08%-0.24%) for ceftriaxone to 29.9% (95% CI, 28.6%-31.1%) for ciprofloxacin. Sensitivity analyses revealed that unmeasured data on sex of sex partners could substantially impact weighted estimates. CONCLUSIONS Antimicrobial resistance among reported incident male urogenital GC infections remains rare for ceftriaxone, the current standard of care. Aggregated GISP data are generally representative of men in the US who are reported with urogenital gonorrhea.
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Affiliation(s)
| | - Sancta B St Cyr
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Cau D Pham
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kristen M Kreisel
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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Barbee LA, St Cyr SB. Management of Neisseria gonorrhoeae in the United States: Summary of Evidence From the Development of the 2020 Gonorrhea Treatment Recommendations and the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infection Treatment Guidelines. Clin Infect Dis 2022; 74:S95-S111. [PMID: 35416971 DOI: 10.1093/cid/ciac043] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Neisseria gonorrhoeae has developed resistance to all first-line recommended therapies, making gonococcal antimicrobial resistance a major public health concern given limited antibiotic options currently and an even smaller antimicrobial development pipeline. Since the release of the Centers for Disease Control and Prevention (CDC) 2015 STD Treatment Guidelines, azithromycin, part of the 2015 dual-drug treatment regimen, has had a rapid rise in resistance. The 2020 CDC Gonorrhea Treatment Recommendations and the 2021 Sexually Transmitted Infections (STI) Treatment Guidelines were developed weighing the priorities of treating the individual, protecting the population, and preventing antimicrobial resistance. METHODS Gonorrhea subject matter experts (SME) generated 8 key questions and conducted a literature review of updated data from 2013 to 2019 on gonorrhea antimicrobial resistance, treatment failures, clinical trials, and other key topics. More than 2200 abstracts were assessed, and 248 clinically relevant articles were thoroughly reviewed. SMEs also evaluated N gonorrhoeae antimicrobial resistance data from the Gonococcal Isolate Surveillance Project (GISP). EVIDENCE Although there have been reports of ceftriaxone treatment failures internationally, GISP data suggest that ceftriaxone minimal inhibitory concentrations (MICs) have remained stable in the United States, with < 0.1% exhibiting an "alert value" MIC (> 0.25 mcg/mL). However, GISP documented a rapid rise in the proportion of isolates with an elevated MIC (≥ 2.0 mcg/mL) to azithromycin-nearly 5% in 2018. At the same time, new pharmacokinetic/pharmacodynamic data are available, and there is greater recognition of the need for antimicrobial stewardship. SUMMARY The 2021 CDC STI Treatment Guidelines now recommend 500mg ceftriaxone intramuscularly once for the treatment of uncomplicated gonorrhea at all anatomic sites. If coinfection with chlamydia has not been excluded, cotreatment with doxycycline 100mg twice daily for 7 days should be added. Few alternative therapies exist for persons with cephalosporin allergies; there are no recommended alternative therapies for N gonorrhoeae infection of the throat.
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Affiliation(s)
- Lindley A Barbee
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,University of Washington, Seattle, Washington, USA.,Public Health - Seattle & King County HIV/STD Program, Seattle, Washington, USA
| | - Sancta B St Cyr
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Yaesoubi R, Cohen T, Hsu K, Gift TL, St. Cyr SB, Salomon JA, Grad YH. Evaluating spatially adaptive guidelines for the treatment of gonorrhea to reduce the incidence of gonococcal infection and increase the effective lifespan of antibiotics. PLoS Comput Biol 2022; 18:e1009842. [PMID: 35139073 PMCID: PMC8863219 DOI: 10.1371/journal.pcbi.1009842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 02/22/2022] [Accepted: 01/16/2022] [Indexed: 11/19/2022] Open
Abstract
In the absence of point-of-care gonorrhea diagnostics that report antibiotic susceptibility, gonorrhea treatment is empiric and determined by standardized guidelines. These guidelines are informed by estimates of resistance prevalence from national surveillance systems. We examined whether guidelines informed by local, rather than national, surveillance data could reduce the incidence of gonorrhea and increase the effective lifespan of antibiotics used in treatment guidelines. We used a transmission dynamic model of gonorrhea among men who have sex with men (MSM) in 16 U.S. metropolitan areas to determine whether spatially adaptive treatment guidelines based on local estimates of resistance prevalence can extend the effective lifespan of hypothetical antibiotics. The rate of gonorrhea cases in these metropolitan areas was 5,548 cases per 100,000 MSM in 2017. Under the current strategy of updating the treatment guideline when the prevalence of resistance exceeds 5%, we showed that spatially adaptive guidelines could reduce the annual rate of gonorrhea cases by 200 cases (95% uncertainty interval: 169, 232) per 100,000 MSM population while extending the use of a first-line antibiotic by 0.75 (0.55, 0.95) years. One potential strategy to reduce the incidence of gonorrhea while extending the effective lifespan of antibiotics is to inform treatment guidelines based on local, rather than national, resistance prevalence. Antimicrobial resistance threatens the effective treatment of a growing number of infections worldwide. In the absence of rapid point-of-care diagnostics that determine antibiotic susceptibility, the treatment of several infections caused by bacteria (e.g., gonorrhea and tuberculosis) remain empiric and informed by guidelines. These guidelines are usually determined at the national level and based on the estimated resistance prevalence nationally. Here, we show that more cases of gonorrhea could be prevented and the effective lifespan of antibiotics suitable for the treatment of gonorrhea could be extended if treatment guidelines are determined locally and based on the regional resistance prevalence rather than on a single nationwide recommendation. Our analysis provides evidence to highlight the importance of 1) maintaining local surveillance systems of antimicrobial resistance and 2) engaged policymakers who use the data from these surveillance systems to inform timely and effective decisions at the local level.
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Affiliation(s)
- Reza Yaesoubi
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, United States of America
- * E-mail:
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Katherine Hsu
- Massachusetts Department of Public Health, Boston, Massachusetts, United States of America
| | - Thomas L. Gift
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Sancta B. St. Cyr
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Joshua A. Salomon
- Department of Health Policy, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Yonatan H. Grad
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Raphael BH, Pham CD, Sharpe S, Mauk K, Harvey A, Khubbar M, Triplett L, Soge OO, Denny M, Palavecino EL, Finney R, Olsen A, Carlson J, St. Cyr SB, Schlanger K, Kersh EN. Implementation and Evaluation of Gradient Strip Antimicrobial Susceptibility Testing in US Public Health Laboratories to Respond to Resistant Gonorrhea. Sex Transm Dis 2021; 48:S157-S160. [PMID: 34433794 PMCID: PMC10210089 DOI: 10.1097/olq.0000000000001535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Gradient strip antimicrobial susceptibility testing using Etest is conducted by local public health jurisdictions participating in the Strengthening the US Response to Resistant Gonorrhea (SURRG) program to inform public health responses to resistant gonorrhea. Proficiency testing results across the participating laboratories were analyzed and a comparison of Etest with the agar dilution method was conducted. METHODS Laboratories participating in SURRG performed Etest for azithromycin (AZM), cefixime (CFX), and ceftriaxone (CRO). Concurrence between minimum inhibitory concentrations (MICs) obtained with Etest versus the agar dilution method using corresponding isolates was defined as ±1 double dilution. Specific levels of reduced susceptibility were termed "alerts" and included isolates with the following MICs: ≥2.0 μg/mL (AZM), ≥0.25 μg/mL (CFX), and ≥0.125 μg/mL (CRO). Categorical (alert/nonalert) agreement was calculated for MICs determined using Etest and agar dilution methods. RESULTS Strengthening the US Response to Resistant Gonorrhea laboratories had high proficiency testing scores (≥98%) and low levels of interlaboratory variations in MICs. The overall concurrence of MICs (essential agreement) determined using agar dilution, and Etest was 96% (CRO), 96% (CFX), and 95% (AZM). Depending on the antibiotic tested, between 27% and 66% of isolates with alert MICs determined by Etest also had alert MICs using the reference agar dilution methodology; however, most of these alert MICs were detected at threshold levels. CONCLUSIONS This study demonstrates that MICs produced by SURRG laboratories using Etest have a high level of concurrence with agar dilution. Although confirmation of specific alert MICs varied, Etest facilities rapid detection and response to emerging resistant gonorrhea.
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Affiliation(s)
- Brian H. Raphael
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Cau D. Pham
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Samera Sharpe
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kerry Mauk
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Alesia Harvey
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Laura Triplett
- City of Milwaukee Public Health Laboratory, Milwaukee, WI
| | - Olusegun O. Soge
- Public Health-Seattle & King County, King County
- Department of Global Health, University of Washington, Seattle, WA
| | | | - Elizabeth L. Palavecino
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem
- Guilford County Department of Health, Greensboro, NC
| | - Rose Finney
- Indiana State Department of Health, Indianapolis, IN
| | - Aaron Olsen
- New York City Department of Health and Mental Hygiene, New York City, NY
| | | | - Sancta B. St. Cyr
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Karen Schlanger
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ellen N. Kersh
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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Town K, Learner ER, Chivukula VL, Mauk K, Reimche JL, Schmerer MW, Black J, Pathela P, Bhattacharyya S, Kerani RP, Gieseker KE, Fukuda A, Sankaran M, McNeil CJ, Spicknall IH, Raphael BH, St Cyr SB, Bernstein K, Kersh EN, Kirkcaldy RD, Schlanger K, Gernert KM. Exploring and Comparing the Structure of Sexual Networks Affected by Neisseria gonorrhoeae Using Sexual Partner Services Investigation and Genomic Data. Sex Transm Dis 2021; 48:S131-S136. [PMID: 34310528 DOI: 10.1097/olq.0000000000001520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sexual networks are difficult to construct because of incomplete sexual partner data. The proximity of people within a network may be inferred from genetically similar infections. We explored genomic data combined with partner services investigation (PSI) data to extend our understanding of sexual networks affected by Neisseria gonorrhoeae (NG). METHODS We used 2017-2019 PSI and whole-genome sequencing (WGS) data from 8 jurisdictions participating in Centers for Disease Control and Prevention's Strengthening the US Response to Resistant Gonorrhea (SURRG) project. Clusters were identified from sexual contacts and through genetically similar NG isolates. Sexual mixing patterns were characterized by describing the clusters by the individual's gender and gender of their sex partners. RESULTS Our study included 4627 diagnoses of NG infection (81% sequenced), 2455 people received a PSI, 393 people were negative contacts of cases, and 495 were contacts with an unknown NG status. We identified 823 distinct clusters using PSI data combined with WGS data. Of cases that were not linked to any other case using PSI data, 37% were linked when using WGS data. Overall, 40% of PSI cases were allocated to a larger cluster when PSI and WGS data were combined compared with PSI data alone. Mixed clusters containing women, men who report sex with women, and men who report sex with men were common when using the WGS data either alone or in combination with the PSI data. CONCLUSIONS Combining PSI and WGS data improves our understanding of sexual network connectivity.
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Affiliation(s)
- Katy Town
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Emily R Learner
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Kerry Mauk
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Matthew W Schmerer
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jamie Black
- Division of HIV/STD/Viral Hepatitis, Indiana Department of Health, Indianapolis, IN
| | - Preeti Pathela
- Bureau of Sexually Transmitted Infections, New York City Department of Health and Mental Hygiene, Queens, NY
| | | | | | - Karen E Gieseker
- Colorado Department of Public Health and Environment, Denver, CO
| | | | | | - Candice J McNeil
- Department of Health, Wake Forest University School of Medicine/Guilford County, NC
| | - Ian H Spicknall
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Brian H Raphael
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sancta B St Cyr
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kyle Bernstein
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ellen N Kersh
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Robert D Kirkcaldy
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Karen Schlanger
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kim M Gernert
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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Schlanger K, Learner ER, Pham CD, Mauk K, Golden M, Wendel KA, Amsterdam L, McNeil CJ, Johnson K, Nguyen TQ, Holderman JL, Hasty GL, St. Cyr SB, Town K, Nash EE, Kirkcaldy RD. Strengthening the US Response to Resistant Gonorrhea: An Overview of a Multisite Program to Enhance Local Response Capacity for Antibiotic-Resistant Neisseria gonorrhoeae. Sex Transm Dis 2021; 48:S97-S103. [PMID: 34475362 PMCID: PMC10275356 DOI: 10.1097/olq.0000000000001545] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In 2016, Centers for Disease Control and Prevention initiated Strengthening the US Response to Resistant Gonorrhea (SURRG) in multiple jurisdictions to enhance antibiotic resistant gonorrhea rapid detection and response infrastructure and evaluate the impact of key strategies. METHODS Eight jurisdictions were funded to establish or enhance local gonococcal culture specimen collection in sexually transmitted disease and community clinics, conduct rapid antimicrobial susceptibility testing (AST) in local laboratories, modify systems for enhanced data collection and rapid communication of results, and initiate enhanced partner services among patients with gonorrhea demonstrating elevated minimum inhibitory concentrations (MICs) to ceftriaxone, cefixime or azithromycin. RESULTS Grantees incorporated genital, pharyngeal, and rectal gonococcal culture collection from all genders at participating clinics. During 2018 to 2019, grantees collected 58,441 culture specimens from 46,822 patients and performed AST on 10,814 isolates (representing 6.8% [3412] and 8.9% [4883] of local reported cases in 2018 and 2019, respectively). Of isolates that underwent AST, 11% demonstrated elevated azithromycin MICs; fewer than 0.5% demonstrated elevated ceftriaxone or cefixime MICs. Among patients whose infections demonstrated elevated MICs, 81.7% were interviewed for partner elicitation; however, limited new cases were identified among partners and contacts. CONCLUSIONS As a public health model to build capacity to slow the spread of emerging resistance, SURRG successfully expanded culture collection, implemented rapid AST, and implemented an enhanced partner services investigation approach in participating jurisdictions. Findings from SURRG may enhance preparedness efforts and inform a longer-term, comprehensive, and evidence-based public health response to emerging gonococcal resistance. Continued development of innovative approaches to address emerging resistance is needed.
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Affiliation(s)
| | | | - Cau D. Pham
- Centers for Disease Control and Prevention, Atlanta GA
| | - Kerry Mauk
- Centers for Disease Control and Prevention, Atlanta GA
| | - Matthew Golden
- University of Washington/Public Health-Seattle & King County, Seattle, WA
| | | | | | - Candice J. McNeil
- Guilford County Department of Health, Greensboro
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - Kimberly Johnson
- New York City Department of Health and Mental Hygiene, Long Island City, NY
| | | | - Justin L. Holderman
- Centers for Disease Control and Prevention, Atlanta GA
- Indiana Department of Health, Indianapolis IN
| | | | | | - Katy Town
- Centers for Disease Control and Prevention, Atlanta GA
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Quilter LAS, St Cyr SB, Hong J, Asbel L, Bautista I, Carter B, Casimir Y, Denny M, Ervin M, Gomez R, Harvey A, Holderman JL, Johnson K, Kohn RP, Learner ER, Mauk K, Menza T, Mettenbrink C, Nettleton WD, Nicosia KR, Pham CD, Ried C, Schlanger K, Schneider A, Soge OO, Tabidze I, Taylor SN, Tilghman W, Toler C, Weinstock H, Torrone EA. Antimicrobial Susceptibility of Urogenital and Extragenital Neisseria gonorrhoeae Isolates Among Men Who Have Sex With Men: Strengthening the US Response to Resistant Gonorrhea and Enhanced Gonococcal Isolate Surveillance Project, 2018 to 2019. Sex Transm Dis 2021; 48:S111-S117. [PMID: 34475363 DOI: 10.1097/olq.0000000000001548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We investigated differences in gonococcal antimicrobial susceptibility by anatomic site among cisgender men who have sex with men (MSM) using specimens collected through the Centers for Disease Control and Prevention's enhanced Gonococcal Isolate Surveillance Project and Strengthening the US Response to Resistant Gonorrhea. METHODS During the period January 1, 2018-December 31, 2019, 12 enhanced Gonococcal Isolate Surveillance Project and 8 Strengthening the US Response to Resistant Gonorrhea sites collected urogenital, pharyngeal, and rectal isolates from cisgender MSM in sexually transmitted disease clinics. Gonococcal isolates were sent to regional laboratories for antimicrobial susceptibility testing by agar dilution. To account for correlated observations, linear mixed-effects models were used to calculate geometric mean minimum inhibitory concentrations (MICs), and mixed-effects logistic regression models were used to calculate the proportion of isolates with elevated or resistant MICs; comparisons were made across anatomic sites. RESULTS Participating clinics collected 3974 urethral, 1553 rectal, and 1049 pharyngeal isolates from 5456 unique cisgender MSM. There were no significant differences in the geometric mean MICs for azithromycin, ciprofloxacin, penicillin, and tetracycline by anatomic site. For cefixime and ceftriaxone, geometric mean MICs for pharyngeal isolates were higher compared with anogenital isolates (P < 0.05). The proportion of isolates with elevated ceftriaxone MICs (≥0.125 μg/mL) at the pharynx (0.67%) was higher than at rectal (0.13%) and urethral (0.18%) sites (P < 0.05). CONCLUSIONS Based on data collected from multijurisdictional sentinel surveillance projects, antimicrobial susceptibility patterns of Neisseria gonorrhoeae isolates may differ among MSM at extragenital sites, particularly at the pharynx. Continued investigation into gonococcal susceptibility patterns by anatomic site may be an important strategy to monitor and detect the emergence of antimicrobial resistant gonorrhea over time.
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Affiliation(s)
| | - Sancta B St Cyr
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jaeyoung Hong
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lenore Asbel
- Philadelphia Department of Public Health, Philadelphia, PA
| | | | | | | | | | | | | | - Alesia Harvey
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Kimberly Johnson
- New York City Department of Mental Health and Hygiene, New York City, NY
| | - Robert P Kohn
- San Francisco Department of Public Health, San Francisco, CA
| | - Emily R Learner
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kerry Mauk
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | | | - Cau D Pham
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Karen Schlanger
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | | | - Winston Tilghman
- County of San Diego Health & Human Services Agency, San Diego, CA
| | - Cindy Toler
- Guilford County Public Health, Greensboro, NC
| | - Hillard Weinstock
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Elizabeth A Torrone
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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Pham CD, Pettus K, Nash EE, Liu H, St Cyr SB, Schlanger K, Papp J, Gartin J, Dorji T, Akullo K, Kersh EN. Utility of MALDI-TOF MS for differentiation of Neisseria gonorrhoeae isolates with dissimilar azithromycin susceptibility profiles. J Antimicrob Chemother 2021; 75:3202-3208. [PMID: 32737509 DOI: 10.1093/jac/dkaa303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/09/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Antibiotic-resistant gonorrhoea has been a chronic public health burden since the mid-1930s. Recent emergence of isolates resistant to the current recommended antibiotics for gonorrhoea further magnifies the threat of untreatable gonorrhoea. The lack of new, effective antibiotics highlights the need for better understanding of the population structure of Neisseria gonorrhoeae in order to provide greater insight on how to curtail the spread of antimicrobial-resistant N. gonorrhoeae. OBJECTIVES To explore a potential application of MALDI-TOF MS to differentiate N. gonorrhoeae displaying different levels of susceptibility to the antibiotic azithromycin. METHODS We conducted MALDI-TOF MS using the Bruker Biotyper on 392 N. gonorrhoeae isolates collected through the Gonococcal Isolate Surveillance Project (GISP) and/or the Strengthening the United States Response to Resistant Gonorrhea (SURRG) project. The MALDI-TOF MS spectra were visually analysed to assess the presence of distinctive peak(s). Statistical analysis was performed to assess the relationship between gonococcal isolates with the distinct protein peak and antibiotic susceptibility. RESULTS In this study, we were able to differentiate N. gonorrhoeae isolates into two distinct subpopulations using MALDI-TOF MS. Isolates were distinguished by the presence or absence of a spectral peak at 11 300 Da. Notably, these two groups exhibited different levels of susceptibility to azithromycin. CONCLUSIONS We have shown that in addition to its ability to identify N. gonorrhoeae, MALDI-TOF MS could also be used to differentiate gonococcal isolates with different levels of susceptibility to azithromycin.
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Affiliation(s)
- Cau D Pham
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kevin Pettus
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Evelyn E Nash
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Hsi Liu
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sancta B St Cyr
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Karen Schlanger
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John Papp
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jarrett Gartin
- Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tandin Dorji
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA.,Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | | | - Ellen N Kersh
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
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11
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Thomas JC, Joseph SJ, Cartee JC, Pham CD, Schmerer MW, Schlanger K, St Cyr SB, Kersh EN, Raphael BH. Phylogenomic analysis reveals persistence of gonococcal strains with reduced-susceptibility to extended-spectrum cephalosporins and mosaic penA-34. Nat Commun 2021; 12:3801. [PMID: 34155204 PMCID: PMC8217231 DOI: 10.1038/s41467-021-24072-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 05/28/2021] [Indexed: 12/03/2022] Open
Abstract
The recent emergence of strains of Neisseria gonorrhoeae associated with treatment failures to ceftriaxone, the foundation of current treatment options, has raised concerns over a future of untreatable gonorrhea. Current global data on gonococcal strains suggest that several lineages, predominately characterized by mosaic penA alleles, are associated with elevated minimum inhibitory concentrations (MICs) to extended spectrum cephalosporins (ESCs). Here we report on whole genome sequences of 813 N. gonorrhoeae isolates collected through the Gonococcal Isolate Surveillance Project in the United States. Phylogenomic analysis revealed that one persisting lineage (Clade A, multi-locus sequence type [MLST] ST1901) with mosaic penA-34 alleles, contained the majority of isolates with elevated MICs to ESCs. We provide evidence that an ancestor to the globally circulating MLST ST1901 clones potentially emerged around the early to mid-20th century (1944, credibility intervals [CI]: 1935-1953), predating the introduction of cephalosporins, but coinciding with the use of penicillin. Such results indicate that drugs with novel mechanisms of action are needed as these strains continue to persist and disseminate globally.
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Affiliation(s)
- Jesse C Thomas
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Sandeep J Joseph
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John C Cartee
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Cau D Pham
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Matthew W Schmerer
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Karen Schlanger
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sancta B St Cyr
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ellen N Kersh
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Brian H Raphael
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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12
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Abstract
BACKGROUND The most recent prevalence and incidence estimates for chlamydia and gonorrhea, the 2 most reported sexually transmitted infections in the United States, were for 2008. We present updated estimates of the number of prevalent and incident chlamydial and gonococcal infections for 2018. METHODS We estimated chlamydial prevalence directly from the 2015 to 2018 cycles of the National Health and Nutrition Examination Survey and chlamydial incidence using a mathematical model primarily informed by National Health and Nutrition Examination Survey and case report data. Total and antimicrobial-resistant gonococcal prevalence and incidence were estimated using mathematical models primarily informed by case report and Gonococcal Isolate Surveillance Program data. Estimates were calculated for the total population, all women, and all men aged 15 to 39 years, stratified by age group. Primary estimates represent medians and uncertainty intervals represent the 25th (Q1) and 75th (Q3) percentiles of the empirical frequency distributions of prevalence and incidence for each infection. RESULTS Among persons aged 15 to 39 years in the United States in 2018, we estimate 2.35 (Q1, 2.20; Q3, 2.51) million prevalent and 3.98 (Q1, 3.77; Q3, 4.22) million incident chlamydial infections, and an estimated 209,000 (Q1, 183,000; Q3, 241,000) prevalent and 1.57 (Q1, 1.44; Q3, 1.72) million incident gonococcal infections. Of all gonococcal infections, there were 107,000 (Q1, 94,000; Q3, 124,000) prevalent and 804,000 (Q1, 738,000; Q3, 883,000) incident infections demonstrating antimicrobial resistance or elevated minimum inhibitory concentrations to selected antibiotics. CONCLUSIONS Chlamydia and gonorrhea were very common in the United States in 2018. Estimates show that more than 800,000 newly acquired gonococcal infections in 2018 demonstrated resistance or elevated minimum inhibitory concentrations to currently or previously recommended antibiotics.
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Affiliation(s)
- Kristen M Kreisel
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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13
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Kreisel KM, Spicknall IH, Gargano JW, Lewis FMT, Lewis RM, Markowitz LE, Roberts H, Johnson AS, Song R, St Cyr SB, Weston EJ, Torrone EA, Weinstock HS. Sexually Transmitted Infections Among US Women and Men: Prevalence and Incidence Estimates, 2018. Sex Transm Dis 2021; 48:208-214. [PMID: 33492089 PMCID: PMC10245608 DOI: 10.1097/olq.0000000000001355] [Citation(s) in RCA: 179] [Impact Index Per Article: 59.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The most recent estimates of the number of prevalent and incident sexually transmitted infections (STIs) in the United States were for 2008. We provide updated estimates for 2018 using new methods. METHODS We estimated the total number of prevalent and incident infections in the United States for 8 STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus, sexually transmitted hepatitis B, and sexually transmitted HIV. Updated per-capita prevalence and incidence estimates for each STI were multiplied by the 2018 full resident population estimates to calculate the number of prevalent and incident infections. STI-specific estimates were combined to generate estimates of the total number of prevalent and incident STIs overall, and by sex and age group. Primary estimates are represented by medians, and uncertainty intervals are represented by the 25th (Q1) and 75th (Q3) percentiles of the empirical frequency distributions of prevalence and incidence for each STI. RESULTS In 2018, there were an estimated 67.6 (Q1, 66.6; Q3, 68.7) million prevalent and 26.2 (Q1, 24.0; Q3, 28.7) million incident STIs in the United States. Chlamydia, trichomoniasis, genital herpes, and human papillomavirus comprised 97.6% of all prevalent and 93.1% of all incident STIs. Persons aged 15 to 24 years comprised 18.6% (12.6 million) of all prevalent infections; however, they comprised 45.5% (11.9 million) of all incident infections. CONCLUSIONS The burden of STIs in the United States is high. Almost half of incident STIs occurred in persons aged 15 to 24 years in 2018. Focusing on this population should be considered essential for national STI prevention efforts.
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Affiliation(s)
- Kristen M Kreisel
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
| | - Ian H Spicknall
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
| | - Julia W Gargano
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention
| | | | - Rayleen M Lewis
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention
| | - Lauri E Markowitz
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention
| | | | - Anna Satcher Johnson
- HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ruiguang Song
- HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sancta B St Cyr
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
| | - Emily J Weston
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
| | - Elizabeth A Torrone
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
| | - Hillard S Weinstock
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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14
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Picker MA, Knoblock RJ, Hansen H, Bautista I, Griego R, Barber L, Bendik W, Lam K, Adelman E, Qiu-Shultz Z, Raphael BH, Pham CD, Kersh EN, Weinstock H, St. Cyr SB. Notes from the Field: First Case in the United States of Neisseria gonorrhoeae Harboring Emerging Mosaic penA60 Allele, Conferring Reduced Susceptibility to Cefixime and Ceftriaxone. MMWR Morb Mortal Wkly Rep 2020; 69:1876-1877. [PMID: 33301430 PMCID: PMC7737691 DOI: 10.15585/mmwr.mm6949a5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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