Penicillinase-producing Neisseria gonorrhoeae in Great Britain, 1977-81: alarming increase in incidence and recent development of endemic transmission.

Since penicillinase-producing Neisseria gonorrhoeae appeared five years ago in West Africa and South-east Asia reported cases have doubled annually in Great Britain, primarily as a result of increasing importation. Importation of penicillinase-producing Neisseria gonorrhoeae has increased exponentially because dramatic expansion of these strains in their regions of origin has led to increasing infection of male air travellers. From 1977 to 1980 infections acquired in Great Britain played only a minor part in the exponential increase. During 1981 the number of indigenous cases increased much more rapidly than imported cases, indicating that these strains have become truly endemic in Great Britain. Currently, identification of patients at high risk and initial treatment with penicillinase-resistant antibiotics offers the best hope of containing the strains. The emergence and rapid spread of penicillinase-producing Neisseria gonorrhoeae shows the international consequences of the abuse of antibiotics.     

Penicillinase-producing Neisseria gonorrhoeae conjunctivitis on some Nigerian children.

During 21 month study of bacterial conjunctivitis among 121 children in two health care centres in Calabar, Nigeria, a total of 90 (74.4%) cases were culturally confirmed. Neonates had the highest age-specific attack rates with 48 (53.3%) cases. Neisseria gonorrhoeae, the predominant pathogen, was recovered from 32 (35.6%) infections; 21 (65.6%) of them from neonates. Cultures of genital swabs of consenting parents of infected neonates as well as those of three female children aged 2-12 years with concurrent vulvo-vaginitis yielded N. gonorrhoeae. Younger women, mostly primi-gravidae were more frequently found to have benefited from peri-natal health care services than older multi-gravidae. Nevertheless, such access to health care services did not appear to influence the frequency of gonococcal conjunctivitis in neonates from the two maternal groups (P < 0.01). Sexual abuse and contaminated fomites were the possible modes of gonococcal infection transmission to older children. Overall, 22 (68.8%) strains of gonococci were resistant to penicillin; 19 (59.4%) were penicillinase-producing Neisseria gonorrhoeae (PPNG), while 5 (15.6%) had chromosomally-mediated resistance. All isolates were sensitive to erythromycin. This study recommends a review of gonorrhoea surveillance in pregnancy to include routine examination of cervical swabs just before delivery.     

Penicillinase-producing Neisseria gonorrhoeae in Canada.

The incidence of infection with penicillinase-producing Neisseria gonorrhoeae (PPNG) reported to the Laboratory Centre for Disease Control in Ottawa has steadily increased since the first Canadian isolation of such a strain in 1976. As of September 1980 a total of 66 PPNG isolates had been referred for biological and genetic characterization as well as for central documentation of the epidemiologic aspects of each case. Over 90% of the infections were firmly traced to patients or contacts who had acquired the infection abroad; this indicates that Canada does not, as yet, have an epidemic focus of PPNG infection. This report includes a synopsis of the biological characteristics of these isolates and an analysis of the results of primary antibiotic treatment that illustrates the importance of considering spectinomycin as the antibiotic of choice for PPNG infections.     

Microflocculation Assay for Gonococcal Antibody

An antigen suspension consisting of cholesterol-lecithin particles sensitized with an extract of gonococci was used in a flocculation assay for the detection of human antibodies to Neisseria gonorrhoeae. With culturally and clinically diagnosed cases of uncomplicated gonorrhea, sera from 70 (49.6%) of 141 males and 207 (79.0%) of 262 females were reactive in the assay. Sera from four (7.3%) of 55 males and 11 (5.4%) of 203 females, all presumed normal, were reactive. The assay utilized equipment available in most clinical and public health laboratories.     

Antibiotic resistant N. gonorrhoeae in Trinidad and Tobago.

We tested the susceptibility patterns of 128 N. gonorrhoeae isolates to six antimicrobials; penicillin, tetracycline, spectinomycin, ceftriaxone, ciprofloxacin and azithromycin, and examined whether certain demographic or behavioral factors related to antibiotic use increased the likelihood of infection by a resistant strain. There was a low rate of resistance to penicillin; penicillinase-producing and chromosomal-mediated penicillin resistant gonorrhea were estimated to be 0.8%. A much higher proportion of isolates were resistant to tetracycline (up to 15%). All isolates were sensitive to spectinomycin, ciprofloxacin and ceftriaxone. However, less than 2% of isolates displayed intermediate resistance to both ciprofloxacin and ceftriaxone, and 9% exhibited intermediate resistance to spectinomycin. Patients who had obtained medication before attending the clinic and had taken all of the medication were more likely (p = 0.03) to be infected with a resistant strain of gonococcus. Also, patients who were asked by a clinic doctor to return for a test of cure during an earlier clinic visit, but who did not return were more likely to be infected with a resistant organism (p = 0.006) compared to those who returned at the doctor's request. These findings have important implications for antibiotic use and educational programs in Trinidad and Tobago.     

Lactobacillus crispatus and its enolase and glutamine synthetase influence interactions between Neisseria gonorrhoeae and human epithelial cells

Journal of Microbiology - Neisseria gonorrhoeae, an obligatory human pathogen causes the sexually transmitted disease gonorrhea, which remains a global health problem. N. gonorrhoeae primarily...     

Sexually transmitted diseases (STDs) in the world.

Sexually transmitted diseases (STDs) represent a major public health problem in the world and the advent and increase of human immunodeficiency virus infection during the last decade has highlighted the importance of infections spread by the sexual route. The World Health Organization estimates that the global incidence in 1995 of new cases of selected curable STDs, which are gonorrhea, chlamydial infection, syphilis and trichomoniasis, was 333 million. Control programs for STDs must prevent the acquisition of STDs, their complications and sequelae and interrupt and reduce transmission.     

Evaluating spatially adaptive guidelines for the treatment of gonorrhea to reduce the incidence of gonococcal infection and increase the effective lifespan of antibiotics

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 markers as a monitoring index of gonorrhoea in Thailand

Multiplex PCR was applied to explore the antimicrobial-resistance profiles of 145 gonococci isolated from Bangrak Hospital, Thailand in 2007. All isolates were clearly identified for the plasmid-mediated resistant types of penicillin (Asia, Africa and Toronto) and tetracycline (American and Dutch). This method can also predict the decreased susceptibility to ciprofloxacin by detection of Ser-91 mutation. Prevalence rates of penicillinase-producing Neisseria gonorrhoeae (PPNG) and high-level tetracycline-resistance N. gonorrhoeae (TRNG) were shown to be high as 82.1% and 84.1%, respectively. Most PPNG carried the Africa-type (78.2%) while the American-type (61.8%) was harboured in most TRNG. Mono- and triple-resistance patterns were presented in 2.6% and 79.5% of male, 20.7% and 62.1% of men who have sex with men (MSM), 0% and 75.0% of female, and 10% and 70% of female sex workers (FSW). Additionally, the rate of the Dutch type was high in patients among the age of 35-44 years (57.1%) and female patients (43.8%). The changing types of plasmids have been noticed during the time period of study. The multi-resistance patterns of the gonococcal isolates can be used as an epidemiological index of gonorrhoea and human sexual behaviours. This information will support the management of individual patients as well as the public health surveillance.     

Cefonicid as Therapy for Uncomplicated Gonococcal Urethritis Caused by Penicillinase-Producing Neisseria gonorrhoeae

Young men with uncomplicated gonococcal urethritis were treated with 1 gram of cefonicid given intramuscularly plus 1 gram of probenecid by mouth. Of 53 evaluable patients, 33 (62%) had penicillinase-producing Neisseria gonorrhoeae. All but one of these patients were cured. All men who had penicillin-sensitive infections were cured. Cefonicid was highly effective in the treatment of both penicillin-sensitive and penicillin-resistant N gonorrhoeae. Other than moderate pain at the site of injection, there were no adverse side effects. Cefonicid can be added to the group of newer cephalosporins that are effective in the treatment of gonococcal urethritis caused by either penicillin-sensitive or penicillin-resistant strains.     

Gonorrhea in homosexual men.

Extragenital gonorrhea was seen in 65% of 54 cases of gonorrhea in 43 homosexual men attending a venereal diseases clinic between 1974 and 1977; in 21 cases the infection was extragenital only. This type of gonorrhea was often asymptomatic and was associated with a high rate of failure of initial treatment in 6 of the 50 cases in which the patient returned for follow-up assessment, and in 5 of the 6 the persistent infection was extragenital. Syphillis was seen concomitantly or had previously occurred in 6 of the 54 cases. Fifteen of 28 cases of primary, secondary or early latent syphilis seen in men during the same study period had occurred in homosexuals. Appropriate testing for extragenital gonorrhea and for syphilis is important in homosexual men who present for examination, and homosexuality with the possibility of extragenital gonorrhea should be considered in a man with syphilis of recent onset.     

Microbial causative agents of male urethritis.

The incidence of Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, Neisseria gonorrhoeae and Trichomonas vaginalis was studied in men with urethritis. Out of 150 examined men 48.7% had the positive isolation of U. urealyticum, 26.0% C. trachomatis, 22.7% N. gonorrhoeae, 18.7% M. hominis and in one (0.7%) patient T. vaginalis was found. None of the above mentioned microorganisms was detected in 24.7% of examined men. In 43.3% cases only one agent was isolated. In 23.3% of the men the combination of two agents, in 8.0% the combination of three and in 0.7% even the combination of four studied microorganisms was observed. C. trachomatis was most frequently observed in combination with N. gonorrhoeae (15 cases) and U. urealyticum (14 cases). M. hominis and U. urealyticum occurred simultaneously in 22 examined men.N.gonorrhoeae was most frequently found together with U. urealyticum (16 cases). Concerning the occurrence of other bacteria and yeasts, no significant difference was found between the groups positive and negative for the above mentioned microorganisms.     

Spectinomycin as initial treatment for gonorrhoea.

The prevalence of penicillinase producing Neisseria gonorrhoeae at this hospital increased exponentially from less than 0.5% in 1978 to 6.5% of all isolates in 1982. In January 1983 first line treatment for uncomplicated heterosexual anogenital gonorrhoea was therefore changed from ampicillin and probenecid to spectinomycin. This subsequently cured 95% of cases seen at the Praed Street Clinic. Although there was an initial fall in the monthly isolation rate of penicillinase producing N gonorrhoeae after the introduction of spectinomycin, this was not maintained. The exponential increase in the prevalence of the strain did slow in 1983, rising to only 8.7%. This, however, may have reflected a general decline in the rate of increase of penicillinase producing N gonorrhoeae throughout Britain. The failure to influence the prevalence of penicillinase producing N gonorrhoeae to any great degree may have been due in part to spectinomycin resistance in both penicillinase producing and non-penicillinase-producing N gonorrhoeae. All of the isolates appeared identical, apart from the presence of the 4.4 megadalton plasmid in penicillinase producing N gonorrhoeae, but they could not be linked epidemiologically. Changing treatment in only one of the many venereal diseases clinics in London, where patients have open access to all such clinics, is unlikely to affect the prevalence of penicillinase producing N gonorrhoeae. This has probably been more important than spectinomycin resistance in limiting the effectiveness of spectinomycin in reducing the prevalence of the strain.     

Measles epidemic from failure to immunize.

During 1988 through 1990, California experienced its worst measles epidemic in more than a decade, with 16,400 reported cases, 3,390 hospital admissions, and 75 deaths. More than half of the patients were younger than 5 years; the highest incidence was among infants younger than 12 months. The epidemic centered in low-income Hispanic communities in southern and central California. The major cause of the epidemic was low immunization levels among preschool-aged children and young adults. Rates of complications, admission to hospital, and death were surprisingly high. Outbreak control efforts met with indeterminate success. Problems with these efforts included insufficient funding early in the epidemic and disappointing public response to community-based immunization campaigns. The cost of medical care and outbreak control for the epidemic is conservatively estimated at $30.9 million. Unless the level of immunization in preschool-aged children is increased, this type of epidemic will probably recur.     

Rheumatic fever and rheumatic heart disease; incidence in California

The statistics quoted in this and other published reports appear to substantiate the impression that rheumatic fever in California, although still an important public health problem which varies widely from one locality to another, is of lower incidence and perhaps of more benign character than in most other parts of the United States. It also appears that in California aortic insufficiency may be of higher relative incidence and occurs more frequently as a clinically diagnosable sequel of rheumatic fever than does classical mitral stenosis. Congenital defects of the heart constitute a large proportion of the cases of organic heart disease in children and young adults in this state.     

Evaluation of four methods for detecting the beta-lactamase activity in Neisseria gonorrhoeae isolated in Cuba

Four methods (chromogenic, acidimetric, inhibition, and iodometric) for demonstration of the beta-lactamase production by 70 isolates of Neisseria gonorrhoeae, were evaluated in Cuba. There was 100% correlation between all beta-lactamase methods and the standardized penicillin dilution susceptibility test for penicillinase-non-producing N. gonorrhoeae. For penicillinase-producing N. gonorrhoeae strains, there was a perfect correlation between the chromogenic method and penicillin susceptibility testing, but one and two strains failed to give a positive result for beta-lactamase with the inhibition/acidimetric and the iodometric methods, respectively. There was a high concordance between the chromogenic method, considered as gold standard and the rest of penicillinase tests evaluated: Kappa Index (KI) = 0.98 for inhibition/acidimetric methods and KI = 0.97 for the iodometric method. The four methods evaluated were accurate, reproducible, easily readable, economical, and ease to use for screening primary isolates of N. gonorrhoeae in Cuba. We recommended the use of the inhibition method, when testing the penicillinase activity in gonococcal isolates in provincial and municipal reference laboratories.     

Evaluation of Internet-Based Dengue Query Data: Google Dengue Trends

Dengue is a common and growing problem worldwide, with an estimated 70–140 million cases per year. Traditional, healthcare-based, government-implemented dengue surveillance is resource intensive and slow. As global Internet use has increased, novel, Internet-based disease monitoring tools have emerged. Google Dengue Trends (GDT) uses near real-time search query data to create an index of dengue incidence that is a linear proxy for traditional surveillance. Studies have shown that GDT correlates highly with dengue incidence in multiple countries on a large spatial scale. This study addresses the heterogeneity of GDT at smaller spatial scales, assessing its accuracy at the state-level in Mexico and identifying factors that are associated with its accuracy. We used Pearson correlation to estimate the association between GDT and traditional dengue surveillance data for Mexico at the national level and for 17 Mexican states. Nationally, GDT captured approximately 83% of the variability in reported cases over the 9 study years. The correlation between GDT and reported cases varied from state to state, capturing anywhere from 1% of the variability in Baja California to 88% in Chiapas, with higher accuracy in states with higher dengue average annual incidence. A model including annual average maximum temperature, precipitation, and their interaction accounted for 81% of the variability in GDT accuracy between states. This climate model was the best indicator of GDT accuracy, suggesting that GDT works best in areas with intense transmission, particularly where local climate is well suited for transmission. Internet accessibility (average ∼36%) did not appear to affect GDT accuracy. While GDT seems to be a less robust indicator of local transmission in areas of low incidence and unfavorable climate, it may indicate cases among travelers in those areas. Identifying the strengths and limitations of novel surveillance is critical for these types of data to be used to make public health decisions and forecasting models.     

RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE—Incidence in California

The statistics quoted in this and other published reports appear to substantiate the impression that rheumatic fever in California, although still an important public health problem which varies widely from one locality to another, is of lower incidence and perhaps of more benign character than in most other parts of the United States. It also appears that in California aortic insufficiency may be of higher relative incidence and occurs more frequently as a clinically diagnosable sequel of rheumatic fever than does classical mitral stenosis. Congenital defects of the heart constitute a large proportion of the cases of organic heart disease in children and young adults in this state.     

A spatial analysis of county-level variation in syphilis and gonorrhea in Guangdong Province, China

Background

Sexually transmitted infections (STI) have made a resurgence in many rapidly developing regions of southern China, but there is little understanding of the social changes that contribute to this spatial distribution of STI. This study examines county-level socio-demographic characteristics associated with syphilis and gonorrhea in Guangdong Province.

Methods/Principal Findings

This study uses linear regression and spatial lag regression to determine county-level (n = 97) socio-demographic characteristics associated with a greater burden of syphilis, gonorrhea, and a combined syphilis/gonorrhea index. Data were obtained from the 2005 China Population Census and published public health data. A range of socio-demographic variables including gross domestic product, the Gender Empowerment Measure, standard of living, education level, migrant population and employment are examined. Reported syphilis and gonorrhea cases are disproportionately clustered in the Pearl River Delta, the central region of Guangdong Province. A higher fraction of employed men among the adult population, higher fraction of divorced men among the adult population, and higher standard of living (based on water availability and people per room) are significantly associated with higher STI cases across all three models. Gross domestic product and gender inequality measures are not significant predictors of reported STI in these models.

Conclusions/Significance

Although many ecological studies of STIs have found poverty to be associated with higher reported STI, this analysis found a greater number of reported syphilis cases in counties with a higher standard of living. Spatially targeted syphilis screening measures in regions with a higher standard of living may facilitate successful control efforts. This analysis also reinforces the importance of changing male sexual behaviors as part of a comprehensive response to syphilis control in China.