Background Antimicrobial resistance in Neisseria gonorrhoeae is a global concern, with the ongoing emergence of ceftriaxone and azithromycin resistance threatening current treatment paradigms. To monitor the emergence of antimicrobial resistance in N. gonorrhoeae, the World Health Organization (WHO) Gonococcal Antimicrobial Surveillance Programme (GASP) has operated in the Western Pacific and South East Asian regions since 1992. The true burden of antimicrobial resistance remains unknown. In response, the objective of this study was to survey ceftriaxone and azithromycin susceptibility in N. gonorrhoeae across the western Pacific and south-east Asia, and interlink this data with systematically reviewed reports of ceftriaxone and azithromycin resistance. Methods and findings The WHO Collaborating Centre for Sexually Transmitted Infections and Antimicrobial Resistance, Sydney, coordinated annual surveys of gonococcal susceptibilities with participating laboratories, and additionally undertook a systematic review of reports detailing gonococcal ceftriaxone and azithromycin susceptibility data for locations geographically in the Asia Pacific from 2011 to 2016. It was found that surveillance of gonococcal antimicrobial resistance remains limited in the Asia Pacific, with weaker surveillance of azithromycin versus ceftriaxone. Ninety-three published reports were identified (including national reports) which documented susceptibility data for ceftriaxone and azithromycin. GASP survey data was available for 21 countries, territories or areas, and suggested MICs are increasing for ceftriaxone and azithromycin. Between 2011 and 2016, the percentage of locations reporting >5% of gonococcal isolates with MICs to ceftriaxone meeting WHO’s definition of decreased susceptibility (MIC 0.125 mg/L) increased from 14.3% to 35.3% and the percentage of locations reporting >5% of gonococcal isolates with azithromycin resistance (MIC 1 mg/L) increased from 14.3% to 38.9%. Published reports were available for several countries that did not provide GASP surveillance responses for ceftriaxone (n = 5) and azithromycin (n = 3) respectively. Over the study period, there was a 183% increase in the number of countries providing surveillance data for GASP for both ceftriaxone and azithromycin, and a 30.6% increase in ceftriaxone MIC testing across the Asia Pacific facilitated by this project. Conclusion This study provides the first comprehensive illustration of increasing MICs to ceftriaxone in the Asia Pacific. The survey and literature review additionally detail increasing resistance to azithromycin. Further surveillance system strengthening is required to monitor these trends in order to address and curb gonococcal AMR in the region.

/pdf/systematic-review-and-survey-of-neisseria-gonorrhoeae-3566ipuxth.pdf

Systematic review and survey of Neisseria gonorrhoeae ceftriaxone and azithromycin susceptibility data in the Asia Pacific, 2011 to 2016.

Background Neisseria gonorrhoeae (N. gonorrhoeae) is now recognized as a commonly reported sexually transmitted pathogen, and the increasing drug resistance of N. gonorrhoeae has become a serious public health problem. The accuracy of molecular detection for detecting moderate-level azithromycin resistance is not well-established. We summarized the data from studies of the N. gonorrhoeae 23S rRNA mutation at position 2611 with azithromycin resistance to determine the relationship between the mutation and resistance. Methods and findings In this systematic review and meta-analysis, two researchers independently searched six databases for studies with data for the azithromycin minimum inhibitory concentrations (MICs) and the 23S rRNA mutation C2611T of each N. gonorrhoeae isolate. Since the breakpoint of moderate-level resistance to azithromycin (ML-AzmR) was not determined, we divided the moderate level into two groups according to the range of MICs (moderate resistance limited to 2-128 mg/L or 4-128 mg/L) for data extraction. A random-effects model was used to calculate the pooled sensitivity rate, the specificity rate, the pooled positive likelihood ratio (PLR), the negative likelihood ratio (NLR), and the diagnostic odds ratio (DOR). Meta-regression analyses by detection method, isolates sampling (a random sample or not), location, and sample size were performed to explore the possible causes of heterogeneity. The potential publication bias of the included studies was conducted by the Deeks' test. We included 20 studies in our study: 20 studies have data of N. gonorrhoeae with MICs between 2 and 128 mg/L with mutation or without mutation at position 2611(4759 samples), and 14 studies have data of N. gonorrhoeae with MICs between 4 and 128 mg/L (3367 samples). In the group with the moderate level of 2-128 mg/L, the pooled sensitivity rate of the molecular assays was determined to be 71.9% (95% CI, 67.6-74%), the pooled specificity rate was 98.7% (95% CI, 98.2-99.0%), and the DOR ranged from 55.0 to 351.3 (mean, 139.1). In the 4-128 mg/L group, the pooled sensitivity rate was 91.9% (95% CI, 88.9-94.2%), the pooled specificity rate was 95.9% (95% CI, 95.1-96.6%), and the DOR ranged from 41.9 to 364.1 (mean, 123.6). Conclusion Through this meta-analysis, we found that the C2611T mutation of 23S rRNA is valuable for the molecular diagnostic of moderate-level azithromycin resistance (ML-AzmR) in N. gonorrhoeae, especially when the moderate level is set at 4-128 mg/L. This rapid molecular detection method can be used for the rapid identification of ML-AzmR isolates in the clinic.

The Accuracy of Molecular Detection Targeting the Mutation C2611T for Detecting Moderate-Level Azithromycin Resistance in Neisseria gonorrhoeae: A Systematic Review and Meta-Analysis.

Background Neisseria gonorrhoeae resistance to azithromycin has become a significant public health concern globally, and high-level azithromycin-resistant (HL-AzmR) isolates have emerged frequently. However, high-level azithromycin resistance is considered to be caused by mutated alleles of 23S rRNA gene at position 2059, and identification of HL-AzmR isolates mainly relies on agar dilution method or E-test method. This study aimed to assess the accuracy of the molecular assays targeting the mutation A2059G for identifying HL-AzmR isolates and thereby determine the association between the mutation and high-level azithromycin resistance. Methods Two researchers independently searched six databases to identify studies published from the launch of each database to October 15, 2017. The fixed effects model was used to estimate the pooled sensitivity rate, specificity rate, positive predictive value (PPV), and negative predictive value (NPV). Summary receiver operating characteristic curves were generated, and the area under the curve (AUC) was determined to estimate the overall performance of the assays. The Deeks' test was conducted to evaluate potential publication bias. Results Ten relevant studies were included in the meta-analysis to assess the synthetic accuracy of the molecular assays. The molecular assays had the synthetic sensitivity rate of 97.8% and the synthetic specificity rate of 99.1%. And the aggregated PPV and NPV were 96.4% and 99.5%, respectively. AUC was 0.99, suggesting a close relation existing between the mutation A2059G and high-level azithromycin resistance. This indicated that the molecular assays targeting the mutation A2059G have relatively high overall accuracy for identifying HL-AzmR N. gonor-rhoeae isolates. Publication bias was statistically significant. Conclusion The mutation A2059G is the critical factor causing high-level azithromycin resistance. Hence, molecular methods are recommended to be put into clinical practice by commercialization, which will assist clinicians to prescribe more precisely.

/pdf/evaluation-of-the-accuracy-of-molecular-assays-targeting-the-2pgfy5nzhw.pdf

Evaluation of the accuracy of molecular assays targeting the mutation A2059G for detecting high-level azithromycin resistance in Neisseria gonorrhoeae: a systematic review and meta-analysis.

Objective
To investigate the prevalence, molecular mechanism and genetic characteristics of azithromycin-resistant Neisseria gonorrhoeae (N.gonorrhoeae) strains isolated in Shenzhen.


Methods
N. gonorrhoeae strains were collected in Shenzhen from 2011 to 2015. Agar dilution method and E-test were used to detect the minimum inhibitory concentrations (MIC) of these strains to azithromycin. All azithromycin-resistant (AZM-R) strains (MIC≥2 μg/ml) and some azithromycin-sensitive strains (MIC≤0.25 μg/ml) which were randomly selected as the control group were screened for mutations in 23S rRNA, mtrR and erm genes and genotyped by using N. gonorrhoeae multi-antigen sequence typing (NG-MAST).


Results
A total of 788 N. gonorrhoeae strains were collected, 148 (18.8%) of which were AZM-R strains (MIC≥1 μg/ml). Eighteen out of 21 high-level AZM-R (AZM-HLR) strains had A2143G mutations in the four copies of the 23S rRNA gene. Twelve out of 29 middle-level AZM-R (AZ-MLR) strains had missense mutations, among which C2611T mutations in the four copies of the 23S rRNA were detected in 10 strains. Incidence of G45D/Y105H mutation in AZM-HLR strains was higher than that in AZM-MLR (χ2=12.702, P=0.000) or AZ-S (χ2=4.462, P=0.035) strains according to the analysis of the promoter and coding region of mtrR gene. PCR analysis revealed that only one strain carried ermB gene (MIC=2 μg/ml). The 788 N. gonorrhoeae strains were typed into 81 sequence types (STs) by NG-MAST, most of which were represented by one strain only. STs of ST3356 and ST1866 that were identified in the AZ-R strains in the current study had been noted in a previous report of emerging AZM-R N. gonorrhoeae strains in Nanjing, Chongqing and Guangzhou. Neighbor-joining (NJ) phylogenetic tree showed that the resistant strains did not form a separate cluster.


Conclusion
Currently, it is not suitable to use azithromycin as a monotherapy for gonorrhea in Shenzhen. Mutations of A2059G and C2611T in 23S rRNA of N. gonorrhoeae were respectively responsible for high-level and middle-level resistance to azithromycin. Repeated emergence of ST1866 and ST3356 will help us monitor and analyze the epidemiological characteristics of N. gonorrhoeae strains resistant to azithromycin in Shenzhen.


Key words: 
Neisseria gonorrhoeae; Azithromycin; Resistance gene; NG-MAST

Antibiotic resistant mechanism and epidemiological characteristics of azithromycin-resistant Neisseria gonorrhoeae strains in Shenzhen

Objective To investigate the genotype and characteristics of Neisseria gonorrhoeae (N.gonorrhoeae) isolates with reduced susceptibility to ceftriaxone in Shenzhen from 2009 to 2011.Methods A total of 296 N.gonorrhoeae isolates were collected in Shenzhen from 2009 to 2011.ceftriaxone strains (minimum inhibitory concentration between 0.06 and 0.50 μg/ml) were determined by agar dilution method.Logistic regression was used to analyze the associated factors of ceftriaxone N.gonorrhoeae infection.Neighbor-joining(NJ) phylogenetic tree analysis and N.gonorrhoeae multiantigen sequence typing (NG-MAST) were performed on all ceftriaxone isolates and susceptible control isolates randomly selected in accordance with the principle of 1 ∶ 1 sampling.Results No isolates displayed resistance to ceftriaxone,whereas 53 (17.9％) showed reduced susceptibility to ceftriaxone among 296 isolates.Only antibiotic use in recent two months was associated with ceftriaxone isolates infection(OR =3.080,95％ CI:1.376-6.894).Among the ceftriaxone isolates,48 different ST were identified including 5 STs (ST1768,ST3927,ST641,ST7076 and ST7078) containing 2 isolates and 43 single STs.There were 26 STs previously reported from HongKong in China.Low sensitive strains clustering was not observed by NJ phylogenetic tree.Conclusion The proportion of ceftriaxone strains among the 296 N.gonorrhoeae isolates collected from 2009 to 2011 in Shenzhen is high.The STs of ceftriaxone strains may have unique epidemic features in Shenzhen.

Key words: 
Neisseria gonorrhoeae ;  Ceftriaxone ;  Molecular epidemiology

Molecular characteristics of Neisseria gonorrhoeae isolates with decreased susceptibilities to ceftriaxone in Shenzhen from 2009 to 2011

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Antibiotic resistant mechanism and epidemiological characteristics of azithromycin-resistant Neisseria gonorrhoeae strains in Shenzhen

Molecular characteristics of Neisseria gonorrhoeae isolates with decreased susceptibilities to ceftriaxone in Shenzhen from 2009 to 2011