Emergence and spread of drug resistant Neisseria gonorrhoeae is global concern. We evaluated trends of antimicrobial resistance in Neisseria gonorrhoeae over years 1992–2009 in Pakistan. Resistance rates were compared between years (2007–2009) and (1992–2006). Antimicrobial susceptibility testing was performed and interpreted according to Clinical Laboratory Standards Institute (CLSI) criteria using the disk diffusion methodology against penicillin, ceftriaxone, tetracycline and ofloxacin. Additional antibiotics tested in 100 strains isolated during 2007–2009, included cefotaxime, cefoxitin, cefuroxime, cefipime, ceftazidime, ceftizoxime, cefixime, cefpodoxime, spectinomycin and azithromycin. Neisseria gonorrhoeae ATCC 49226 was used as control. Chi-square for trend analysis was conducted to assess resistance trend over the study period. During study period significant increase in combined resistance to penicillin, tetracycline and ofloxacin was observed (P value ). Resistance rates during the two study period also increased significantly (P value ). Ceftriaxone resistance was not observed. None of the isolates were found to be resistant or with intermediate sensitivity to additional antibiotics. Our findings suggest that penicillin, ciprofloxacin, tetracycline should not be used in the empirical treatment of gonorrhea in Pakistan. Ceftriaxone and cefixime should be the first line therapy; however periodic MICs should be determined to identify emergence of strains with reduced susceptibility. 1. Introduction Gonorrhea continues to be a public health problem with the emergence of multidrug resistant strains [1]. Accurate diagnosis with effective treatment to prevent further transmission is one of the essential elements for control of gonococcal infections [2]. Treatment strategies should be devised to utilize appropriate and preferably single-dose therapy that could be conveniently administered at the time of diagnosis [3]. Surveillance of Neisseria gonorrhoeae antimicrobial resistance is crucial in guiding empirical therapy in any individual setting as resistance may vary in different countries [4]. Neisseria gonorrhoeae infections have been reported from Pakistan as a cause of sexually transmitted infections, but unfortunately national surveillance data is not available to assess its prevalence or antimicrobial resistance [5, 6]. Due to limited resources and lack of trained technologist and microbiologists, most of the laboratories do not report Neisseria gonorrhoeae. Therefore, existing antimicrobial resistance data from the country is limited and
References
[1]
J. W. Tapsall, F. Ndowa, D. A. Lewis, and M. Unemo, “Meeting the public health challenge of multidrug- and extensively drug-resistant Neisseria gonorrhoeae,” Expert Review of Anti-Infective Therapy, vol. 7, no. 7, pp. 821–834, 2009.
[2]
J. W. Tapsall, “Monitoring antimicrobial resistance for public health action,” Communicable Diseases Intelligence, supplement 27, pp. s70–s74, 2003.
[3]
G. R. Burstein and K. A. Workowski, “Sexually transmitted diseases treatment guidelines,” Current Opinion in Pediatrics, vol. 15, no. 4, pp. 391–397, 2003.
[4]
J. Tapsall, “Current concepts in the management of gonorrhoea,” Expert Opinion on Pharmacotherapy, vol. 3, no. 2, pp. 147–157, 2002.
[5]
S. Hawkes, M. Collumbien, L. Platt et al., “HIV and other sexually transmitted infections among men, transgenders and women selling sex in two cities in Pakistan: a cross-sectional prevalence survey,” Sexually Transmitted Infections, vol. 85, pp. ii8–ii16, 2009.
[6]
A. Altaf, N. Z. Janjua, S. Kristensen et al., “High-risk behaviours among juvenile prison inmates in Pakistan,” Public Health, vol. 123, no. 7, pp. 470–475, 2009.
[7]
K. Jabeen, E. Khan, and R. Hasan, “Emergence of quinolone-resistant Neisseria gonorrhoeae in Pakistan,” International Journal of STD and AIDS, vol. 17, no. 1, pp. 30–33, 2006.
[8]
A. Zafar and K. Jabeen, “Antimicrobial resistance in Neisseria gonorrhoeae and limited treatment options,” Journal of the Pakistan Medical Association, vol. 57, no. 7, pp. 333–334, 2007.
[9]
E. W. Koneman, S. D. Allen, W. M. Janda, P. C. Schereckenberger, and J. W. C. Winn, Color Atlas and Text Book of Diagnostic Microbiology, Lippincott, Philadelphia, Pa, USA, 5th edition, 1997.
[10]
Clinical Laboratory Standards Institute, “Performance standards for antimicrobial susceptibility testing,” Sixteen informational supplement, M100-S16 (M7-A7), 2006.
[11]
“British Society of Antimicrobial Chemotherapy Methods for Antimicrobial Susceptibility Testing,” Version 8, January 2009.
[12]
J. W. Tapsall, Antibiotic Resistance in Neisseria Gonorrhoeae, Word Health Organization, Geneva, Switzerland, 2001.
[13]
J. W. Tapsall, “Antibiotic resistance in Neisseria gonorrhoeae,” Clinical Infectious Diseases, vol. 41, no. 4, pp. S263–S268, 2005.
[14]
J. W. Tapsall, “Implications of current recommendations for third-generation cephalosporin use in the WHO Western Pacific Region following the emergence of multiresistant gonococci,” Sexually Transmitted Infections, vol. 85, no. 4, pp. 256–258, 2009.
[15]
A. Sutrisna, O. Soebjakto, F. S. Wignall et al., “Increasing resistance to ciprofloxacin and other antibiotics in Neisseria gonorrhoeae from East Java and Papua, Indonesia, in 2004—Implications for treatment,” International Journal of STD and AIDS, vol. 17, no. 12, pp. 810–812, 2006.
[16]
WHO Western Pacific Programme, South East Asian Gonococcal Antimicrobial Surveillance Programme, J. W. Tapsall et al., “Surveillance of antibiotic resistance in Neisseria gonorrhoeae in the WHO Western Pacific and South East Asian regions, 2007-2008,” Communicable Diseases Intelligence, vol. 34, no. 1, pp. 1–7, 2010.
[17]
K. Jabeen, A. Zafar, S. Irfan, E. Khan, V. Mehraj, and R. Hasan, “Increase in isolation of extended spectrum beta lactamase producing multidrug resistant non typhoidal Salmonellae in Pakistan,” BMC Infectious Diseases, vol. 10, article 101, 2010.
[18]
E. Khan, K. Jabeen, M. Ejaz, J. Siddiqui, M. F. Shezad, and A. Zafar, “Trends in antimicrobial resistance in Shigella species in Karachi, Pakistan,” Journal of Infection in Developing Countries, vol. 3, no. 10, pp. 798–802, 2009.
[19]
R. M. Ramus, J. S. Sheffield, J. A. Mayfield, and G. D. Wendel Jr., “A randomized trial that compared oral cefixime and intramuscular ceftriaxone for the treatment of gonorrhea in pregnancy,” American Journal of Obstetrics and Gynecology, vol. 185, no. 3, pp. 629–632, 2001.
[20]
R. P. Das, K. Jones, A. J. Robinson, and D. J. Timmins, “Cefuroxime axetil to treat gonorrhea,” Genitourinary Medicine, vol. 64, no. 6, p. 394, 1988.
[21]
G. R. Kinghorn, R. C. Spencer, T. K. Smith, P. D. Woolley, R. Patel, and A. J. Robinson, “Comparative study of cefuroxime axetil and procaine penicillin in the treatment of uncomplicated gonorrhoea,” International Journal of STD and AIDS, vol. 1, no. 4, pp. 285–287, 1990.
[22]
Centers for Disease Control and Prevention, “Oral alternatives to cefixime for the treatment of uncomplicated Neisseria gonorrhoeae urogential infections,” http://www.cdc.gov/std/treatment/cefixime.htm.
[23]
Centers for Disease Control and Prevention, “Updated recommended treatment regimens for gonococcal infections and associated conditions,” http://www.cdc.gov/std/treatment/2006/updated-regimens.htm.
[24]
K. A. Workowski and S. M. Berman, “Sexually transmitted diseases treatment guidelines,” The MMWR Recommendations and Reports, vol. 55, no. 11, pp. 1–94, 2006.
[25]
S. Starnino and P. Stefanelli, “Azithromycin-resistant Neisseria gonorrhoeae strains recently isolated in Italy,” Journal of Antimicrobial Chemotherapy, vol. 63, no. 6, pp. 1200–1204, 2009.
[26]
P. G. Galarza, B. Alcalá, C. Salcedo et al., “Emergence of high level azithromycin-resistant Neisseria gonorrhoeae strain isolated in Argentina,” Sexually Transmitted Diseases, vol. 36, no. 12, pp. 787–788, 2009.
