determination of the antimicrobial susceptibility of neisseria gonorrhoeae trevor winstanley rebecca...
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![Page 1: Determination of the antimicrobial susceptibility of Neisseria gonorrhoeae Trevor Winstanley Rebecca Clarke Department of Microbiology Royal Hallamshire](https://reader030.vdocument.in/reader030/viewer/2022033105/56649e5d5503460f94b56183/html5/thumbnails/1.jpg)
Determination of the antimicrobial susceptibility of
Neisseria gonorrhoeae
Trevor Winstanley Rebecca Clarke
Department of MicrobiologyRoyal Hallamshire Hospital
Sheffield UK29 July 2003 Freeman Hospital
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Gonorrhoea
2nd most common bacterial STD > 22,500 episodes diagnosed in GUM
clinics in England & Wales (2001) Highest incidence
Males 20-24 256/100,000 Females 16-19 198/100,000
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Epidemiology Concentrated within demographic
and behavioural risk groups High-levels of
re-infection concurrent STDs asymptomatic infection
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Public health concern
Increasing incidence Poor reproductive and sexual
health outcomes High prevalence of resistance
onward transmission adverse clinical sequelae
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Antimicrobial resistance 10 -12% of gonococcal isolates are
resistant to some degree inner cities those acquiring infections abroad gay and bisexual men
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Plasmid-mediated
ß-lactamase
Tetracycline
PPNG Positive < 16 mg/L
TRNG Negative 16 mg/L
PP/TRNG Positive 16 mg/L
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Chromosomal
ß-lactamase
PenicillinTetracyclin
e
PenR Negative 1 mg/L < 2 mg/L
TetR Negative < 1 mg/L 2 - 8 mg/L
CMRNG Negative 1 mg/L 2 - 8 mg/L
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Chromosomal
Ciprofloxacin
Intermediate
0.125 < 1 mg/L
Resistant 1 mg/L
Spectinomycin
Resistant 128 mg/L
Ceftriaxone Decreased 0.5 mg/L
Azithromycin Resistant 1 mg/L
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U.K. guidelines Easily treatable
95% cure from 1st line therapy Penicillins Fluoroquinolones
ciprofloxacin, ofloxacin Cephalosporins
ceftriaxone, cefixime (Doxycycline / tetracycline)
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GRASP Gonococcal Resistance to
Antimicrobials Surveillance Programme DoH sentinel surveillance
PHLS Communicable Disease Surveillance Centre (CDSC)
PHLS Genitourinary Infections Reference Laboratory (GUIRL)
Department of Infectious Diseases & Microbiology at Imperial College
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GRASP 2001 (n = 2666)
PenicillinPlasmid 3.0%
Chromosome 5.1%
TetracyclinePlasmid 4.6%
Chromosome 27.9%
CiprofloxacinIntermediate 2.6%
Resistant 3.1%
Azithromycin Resistant 0.3%
SpectinomycinResistant ND
Ceftriaxone
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Cure ratesUncomplicated genital gonorrhoeaRecommended dosage
Susceptible > 95% Intermediate 90-95% Resistant < 90%
WHO; SRGA; NCCLS
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Media
NCCLS SRGA BSAC ARMRL GRASP
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Objectives To validate the BSAC disc diffusion
method for N.gonorrhoeae to translate reference into routine
To confirm or refute tentative breakpoints
To extend the range of interpretive criteria
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Methodology 222 distinct isolates from 5
geographical regions 5 WHO control strains Disc diffusion tests, MICs
BSAC methodology ß-lactamase
Nitrocefin
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0
5
10
15
20
25
30
48464442403836343230282624222018161412108642
Zone diameter (mm)
Nu
mb
er
of
iso
late
s
32
16
8
4
2
1
0.5
0.25
0.125
0.064
0.032
0.016
0.008
0.004
MIC(mg/ L)
Penicillin
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Amoxycillin
0
5
10
15
20
25
30
464442403836343230282624222018161412108642
Zone diameter (mm)
Nu
mb
er
of
iso
late
s
32
16
8
4
2
1
0.5
0.25
0.125
0.064
0.032
0.016
0.008
0.004
MIC(mg/ L)
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Co-amoxyclav
0
5
10
15
20
25
30
50484644424038363432302826242220181614121086
Zone diameter (mm)
Nu
mb
er
of
iso
late
s
32
16
8
4
2
1
0.5
0.25
0.125
0.064
0.032
0.016
0.008
0.004
MIC(mg/ L)
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Ciprofloxacin
0
5
10
15
20
25
30
35
585654525048464442403836343230282624222018161412108642
Zone diameter (mm)
Nu
mb
er
of
iso
late
s
32
16
8
4
2
1
0.5
0.25
0.125
0.064
0.032
0.016
0.008
0.004
MIC(mg/ L)
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Nalidixic acid
0
5
10
15
20
25
30
35
40
45
50
48464442403836343230282624222018161412108642
Zone diameter (mm)
Nu
mb
er
of
iso
late
s
32
16
8
4
2
1
0.5
0.25
0.125
0.064
0.032
0.016
0.008
0.004
MIC(mg/L)
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Tetracycline
0
5
10
15
20
25
30
5048464442403836343230282624222018161412108642
Zone diameter (mm)
Nu
mb
er
of
iso
late
s
16
8
4
2
1
0.5
0.25
MIC (mg/ L)
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Metzler & DeHaan analysis
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AntibioticMIC breakpoint (mg/L)
Disc content
Zone diameter (mm)
R S R S
Spectinomycin 128 64 25 13 14
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Antibiotic
MIC breakpoint (mg/L)Disc
content
Zone diameter (mm)
R Low R S R
Low R S
Spectinomycin 128 - 64 25 13 - 14
Ciprofloxacin 2 0.12-1 0.06 1 14 15-28 29
The MIC breakpoint has been lowered to ensure that isolates with reduced susceptibility to ciprofloxacin are detected.
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AntibioticMIC breakpoint (mg/L)
Disc content
Zone diameter (mm)
R S R S
Spectinomycin 128 64 25 13 14
Ciprofloxacin 2 0.12-1 0.06 1 14 15-28 29
Nalidixic acid - - 30 - -
Quinolone resistance is most reliably detected with nalidixic acid. Strains with reduced susceptibility to fluoroquinolones have no zone of inhibition with nalidixic acid.
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Antibiotic
MIC breakpoint (mg/L)Disc
content
Zone diameter (mm)
R Low R S R
Low R
S
Spectinomycin 128 - 64 25 13 - 14
Ciprofloxacin 2 0.12-1 0.06 1 14 15-28 29
Nalidixic acid - - - 30 - - -
Penicillin 2 0.12-1 0.06 1 unit 17 18-25 26
Test for -lactamase.
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Antibiotic
MIC breakpoint (mg/L)Disc
content
Zone diameter (mm)
R Low R S R
Low R
S
Spectinomycin 128 - 64 25 13 - 14
Ciprofloxacin 2 0.12-1 0.06 1 14 15-28 29
Nalidixic acid - - - 30 - - -
Penicillin 2 0.12-1 0.06 1 unit 17 18-25 26
Cefuroxime 2 - 1 5 19 - 20
Ceftriaxone 0.5 - 0.25 5 34 - 35
Resistance to ceftriaxone has not been described. Isolates with chromosomally encoded penicillin resistance (low level) have slightly reduced zones of inhibition with ceftriaxone but remain susceptible. Confirm by MIC.
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Antibiotic
MIC breakpoint (mg/L)Disc
content
Zone diameter (mm)
R Low R S R
Low R
S
Spectinomycin 128 - 64 25 13 - 14
Ciprofloxacin 2 0.12-1 0.06 1 14 15-28 29
Nalidixic acid - - - 30 - - -
Penicillin 2 0.12-1 0.06 1 unit 17 18-25 26
Cefuroxime 2 - 1 5 19 - 20
Ceftriaxone 0.5 - 0.25 5 34 - 35
Tetracycline 2 - 1 10 13 14-26 27
Use tetracycline result to infer susceptibility to doxycycline. Isolates with plasmid-mediated resistance have no zones of inhibition and those with low-level chromosomal resistance have zones 14-26 mm
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Antibiotic
MIC breakpoint (mg/L)Disc
content
Zone diameter (mm)
R Low R S R
Low R
S
Spectinomycin 128 - 64 25 13 - 14
Ciprofloxacin 2 0.12-1 0.06 1 14 15-28 29
Nalidixic acid - - - 30 - - -
Penicillin 2 0.12-1 0.06 1 unit 17 18-25 26
Cefuroxime 2 - 1 5 19 - 20
Ceftriaxone 0.5 - 0.25 5 34 - 35
Tetracycline 2 - 1 10 13 14-26 27
Erythromycin 1 - 0.5 5 11 - 12
Azithromycin 2 - 1 15 27 - 28
Rifampicin 2 - 1 2 20 - 21
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Antibiotic
MIC breakpoint (mg/L)Disc
content
Zone diameter (mm)
R Low R S R
Low R
S
Spectinomycin 128 - 64 25 13 - 14
Ciprofloxacin 2 0.12-1 0.06 1 14 15-28 29
Nalidixic acid - - - 30 - - -
Penicillin 2 0.12-1 0.06 1 unit 17 18-25 26
Cefuroxime 2 - 1 5 19 - 20
Ceftriaxone 0.5 - 0.25 5 34 - 35
Tetracycline 2 - 1 10 13 14-26 27
Erythromycin 1 - 0.5 5 11 - 12
Azithromycin 2 - 1 15 27 - 28
Rifampicin 2 - 1 2 20 - 21
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Next?
Cefixime
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Clap!