Increased incidences of multidrug-resistant gonorrhea in Taiwanese men: Experiences from a single institute

ObjectivesOur objective was to examine the detection rate of routine urine cultures and genital discharge swab cultures for the detection of gonococcal urethritis in male patients. In addition, we evaluated the results of urinalysis for gonococcal infections and investigated the drug sensitivity of Neisseria gonorrhoeae strains isolated from these patients.Materials and methodsFrom August 2009 to October 2015, 202 men diagnosed with gonococcal infection, based on the results of a urine culture or genital discharge swab culture, were enrolled in this study. Initial clinical symptoms and urinalysis results were collected. The susceptibility of N. gonorrhoeae to penicillin, cefmetazole, cefotaxime, ceftazidime, cefuroxime, ceftriaxone, and ofloxacin were determined using agar plate dilution method.ResultsThe mean age of the patients was 29.67 ± 10.39 years, and 157 of the 202 male patients (87.6%) were aged between 15 years and 34 years. We determined that the diagnostic value of genital discharge swab culture was significantly higher than that of the urine culture (90.9% vs. 67.4%, respectively). Genital or urethral discharge is the major symptom in these patients (88.89%). The susceptibility of N. gonorrhoeae to cefuroxime, cefmetazole, cefotaxime, ceftazidime, penicillin, and ciproxin revealed an increasing prevalence of resistant strains in recent years.ConclusionGenital discharge swab culture is a more effective method than urine culture to detect gonorrhea in patients with dysuria and urethral discharge. The increasing numbers of antibiotic-resistant N. gonorrhoeae strains is a major problem in treating gonococcal urethritis.     

The emergence of penicillinase-producing strains of Neisseria gonorrhoeae in Durban

Gonorrhoea was diagnosed in 179 (87%) of 206 Black males who presented with urethritis at a sexually transmitted disease clinic at the King Edward VIII Hospital, Durban. Penicillinase-producing strains of Neisseria gonorrhoeae were detected in 7 (5%) of 140 gonococcal isolates, and a further 13 strains were relatively resistant to penicillin. Microscopic examination of Gram-stained smears provided a rapid presumptive diagnosis of gonorrhoea in 162 cases. The modified Thayer-Martin medium proved marginally superior to chocolate agar for the isolation of N. gonorrhoeae from urethral exudates. The causation and laboratory diagnosis of urethritis in males and the antibiotic susceptibility pattern of the gonococcal isolates are discussed.     

An unusual case of gonococcal arthritis of the finger

Gonococcal arthritis is the most common acute septic arthritis in sexually active young adults. It is caused by the gram-negative diplococcus Neisseria gonorrhoeae. In 0.5–3% an untreated mucosal infection disseminates throughout the system and affects mostly big joints like the knee, elbows, and ankles. N. gonorrhoeae is a fragile microorganism which is difficult to culture. Penicillin resistance has developed worldwide in recent years, therefore, patients should be treated by a third generation Cephalosporin. In this article, we describe the unexpected finding of septic arthritis in the proximal interphalangeal joint of a 50-year-old patient. The septic arthritis was caused by N. gonorrhoeae. Susanne B. Thomas and Frank Unglaub contributed equally.     

Antibiotic susceptibility of Neisseria gonorrhoeae isolated in Johannesburg.

The susceptibility of 175 clinical isolates of Neisseria gonorrhoeae to penicillin G, ampicillin, erythromycin, tetracycline and spectinomycin was determined. Almost one-fifth of strains were relatively resistant to penicillin G. Relative resistance to penicillin G was significantly correlated with resistance to ampicillin, tetracycline and erythromycin, but not with resistance to spectinomycin. No penicillinase-producing or spectinomycin-resistant strains were encountered in this study. The relevance of the findings to the management of gonococcal urethritis is discussed.     

Detection of penicillinase-producing Neisseria gonorrhoeae from male patients with urethritis

Eighty-nine isolates of Neisseria gonorrhoeae from 89 male urethritis patients were studied for beta-lactamases (penicillinase) production, and their susceptibilities to benzylpenicillin, amoxicillin, piperacillin, clavulanic acid/amoxicillin (Augmentin), cephalexin, cefotaxime, spectinomycin and minocycline were determined by an agar plate-dilution method. Penicillinase activity was tested by a chromogenic cephalosporin method with nitrocefin as substrate (CefinaseTM discs, BBL, USA) and by a paper strip acidimetric method with benzylpenicillin as substrate (beta-Lactamase detection papers, Oxoid, UK). In addition, 60 of the 89 patients were examined for Chlamydia trachomatis, using fluorescein-labeled monoclonal antibodies (Direct specimen test; Micro TrakTM, Syva Co., USA). Penicillinase-producing N. gonorrhoeae (PPNG) were found in 12 of the 89 strains (13.5%). Although all these strains of PPNG were highly resistant to benzylpenicillin and amoxicillin, the minimum inhibitory concentrations (MICs) of Augmentin markedly decreased. Piperacillin was highly active against not only non-PPNG but also PPNG strains. More than half the isolates were resistant to cephalexin (MICs greater than or equal to 12.5 micrograms/ml) while all strains including non-PPNG and PPNG were fully sensitive to cefotaxime (MICs less than or equal to 0.20 microgram/ml). Spectinomycin and minocycline had MIC ranges of 6.25 to 25 micrograms/ml and 0.01 to 3.13 micrograms/ml, respectively; the ranges for non-PPNG and PPNG strains were fairly similar. C. trachomatis was detected in 11 (18.3%) out of 60 patients examined. The increasing incidence of PPNG and coexisting chlamydial infection should be taken into account in the treatment of gonococcal urethritis.     

Mycoplasma genitalium in male urethritis: Diagnosis and treatment in Japan

Male urethritis is a common disease for urologists, with the most common pathogens being, Chlamydia trachomatis and Neisseria gonorrhoeae. When the tests fail to detect these pathogens, the presented urethritis is called non‐chlamydial non‐gonococcal urethritis. Mycoplasma genitalium is one of the pathogens for non‐chlamydial non‐gonococcal urethritis. The test for detecting M. genitalium, which is commercially available in Japan, is not accepted by the Japanese insurance system now. The detection rate of M. genitalium from patients with non‐gonococcal urethritis is 10–20% in Japan. Antimicrobial susceptibility testing for M. genitalium showed that macrolide has the strongest activity and the minimum inhibitory concentrations of tetracyclines were not substantially lower. Some kinds of fluoroquinolones, such as sitafloxacin and moxifloxacin, have stronger activities against M. genitalium. For non‐gonococcal urethritis, macrolides and tetracycline are recommended in some guidelines. In clinical studies, tetracyclines are less effective against M. genitalium than azithromycin, and azithromycin regimens including 1 g stat or 2 g stat are now recommended for urethritis with M. genitalium. However, macrolide‐resistant M. genitalium strains have recently emerged and are spreading worldwide. This macrolide‐resistance is closely related to mutations on the 23S rRNA gene. Sitafloxacin and moxifloxacin have shown good efficacies for M. genitalium in some clinical studies. If the azithromycin regimens fail, we must consider the use of fluoroquinolones, such as sitafloxacin, in Japan. The most important issues include the acceptance of M. genitalium examinations by the national insurance system and the individual treatment of C. trachomatis and M. genitalium in the not‐too‐distant future.     

Epidemiologic and therapeutic study on gonococcal infections--clinical efficacy of norfloxacin

We studied the basic and clinical effects of norfloxacin (NFLX) in 120 patients with gonococcal infections (110 men with urethritis and 10 women with cervicitis)--all residents at Sapporo City; and epidemiologically analyzed the sources of their infections. The male patients were between 16 and 67 years old and the female patients were between 20 and 61 years old, with a peak in the early 20s both for sexes. 70.6% of the male patients in their 10s were infected from their girl friends or so-called pick-up friends and 50% of the female patients from their husbands. The other half of the female were workers serving at so-called special massage parlors. The minimum inhibitory concentration (MIC) of NFLX against N. gonorrhoeae distributed was 0.0125 approximately 3.13 micrograms/ml, with a peak at 0.025 micrograms/ml. NFLX inhibited 93.3% of the clinical strains of this species at less than 0.1 microgram/ml and 96.2% at less than 1 microgram/ml, where the inoculation was 10(6) CFU/ml. Twenty one (20.2%) of the 104 N. gonorrhoeae strains were penicillinase-producing one (PPNG). NFLX inhibited 18 of these PPNG (85.7%) at less than 0.1 microgram/ml and the other 3 strains at 1.56 approximately 3.13 micrograms/ml. Oral administration of 200 mg NFLX showed the average peak serum level of 0.72 micrograms/microliter in 2 hours and the average peak level in the urethral secretions of 0.5 micrograms/ml in one hour. These two concentrations of NFLX covered 95.2% of the MIC distribution against N. gonorrhoeae. The clinical efficacy of 600 mg NFLX (peros) was 97.4 and 93.1% for a 3-and 7-day treatment for male urethritis; and 100% for both 3-and 7-day treatment for female cervicitis. Complicated urethritis with C. trachomatis was noticed in 32.7% of the male urethritis and in 20% of the female cervicitis cases. Urethral secretions among about half of these patients were observed even after treatment with NFLX. As a subsequent treatment, another effective chemotherapeutic is required against C. trachomatis. No adverse reactions were detected with NFLX. All the above results demonstrate that NFLX is a highly effective and safe chemotherapeutic agent for treatment of gonorrhoea.     

Urethritis in white men--a microbiological appraisal.

The incidence of infections with Neisseria gonorrhoeae, Chlamydia trachomatis and mycoplasmas has been assessed in White men with urethritis who were attending a Johannesburg clinic for sexually transmitted diseases. Infection with N. gonorrhoeae was demonstrated in 54% of 212 patients with urethritis. C. trachomatis was isolated from 37% of patients with non-gonococcal urethritis, and from 25% with proven gonococcal infection. Although T-mycoplasmas were isolated significantly more often from patients with urethritis (41%) than from controls (23%) (P less than 0,05) their role in the aetiology of urethritis is uncertain.     

Efficacy of various single-dose regimens of ceftriaxone in uncomplicated acute gonococcal urethritis in adult males

The therapeutic efficacy of single intramuscular doses of ceftriaxone (Rocephin; Roche) (62.5, 125 and 250 mg), administered without probenecid, was evaluated in 167 adult males with uncomplicated acute gonococcal urethritis. Cure rates of 100% were achieved at 62.5 mg and 250 mg. In the 125 mg dose group, Neisseria gonorrhoeae was isolated from 1 patient at follow-up after therapy. Reinfection was suspected, since this patient returned on day 10 and admitted to sexual contact 2 days previously. Side-effects were minimal, and patient acceptance was better for ceftriaxone dissolved in lignocaine than in sterile water. Chlamydia trachomatis was detected at follow-up in 14.4% patients, confirming that ceftriaxone has no significant effect on chlamydial infection and additional treatment is necessary for patients with coexistent infection.     

The importance and frequency of mixed infections with Chlamydia trachomatis and mycoplasmas in acute gonococcal urethritis

Chlamydia trachomatis, Ureaplasma urealyticum and Mycoplasma hominis are frequently involved in gonococcal urethritis. We investigated 143 male White and Black patients with gonococcal urethritis (average age 22,5 years). Of these 29% had coexisting Chlam. trachomatis infection, 34% U. urealyticum infection and 13% Mycoplasma hominis infection. Conventional penicillin therapy did not affect Chlam. trachomatis, U. urealyticum or Mycoplasma hominis, which persisted in the lower urogenital tract, causing a so-called 'post-gonococcal urethritis.' Additional therapy with tetracycline or erythromycin was successful in most cases.     

Gonococcie rectale: mise au point à l’heure de la résistance aux antibiotiques

Neisseria gonorrhoeae is a sexually transmitted infection with potential serious complications if not treated properly. Ciprofloxacin resistances raised 43% of the isolates in 2006 in France. These resistances are responsible of inefficient treatment and widespread of contaminations. The treatment recommended is a single intramuscular or intravenous dose of ceftriaxone. Twenty to 40% of patients are not symptomatic. High-risk patients must be identified and tested, especially men who have sex with men, HIV-positive patients and the young women.     

Prevalence of genital mycoplasmas and ureaplasmas in men younger than 40 years-of-age with acute epididymitis

Objectives: Acute epididymitis is often associated with urethritis. Mycoplasma genitalium and Ureaplasma urealyticum have been considered as pathogens of urethritis. The aim of the present study was to determine the prevalence of these microorganisms in men with acute epididymitis. Method: A total of 56 men younger than 40 years‐of‐age with acute epididymitis were enrolled in the present study between January 2006 and June 2010. First‐void urine specimens were subjected to culture of aerobic bacterial species, and examined for the presence of Chlamydia trachomatis, M. genitalium, M. hominis, U. parvum and U. urealyticum by polymerase chain reaction‐based assays. Urethral swabs were cultured for Neisseria gonorrhoeae. Results: The number and percentage of patients positive for each microorganism were as follows: Gram‐negative bacilli, 2% and 3.6%; Gram‐positive cocci, 23% and 41.1%; N. gonorrhoeae, 3% and 5.4%; C. trachomatis, 28% and 50.0%; M. genitalium, 5% and 8.9%; M. hominis, 6% and 10.7%; U. parvum, 6% and 10.7%; and U. urealyticum, 5% and 8.9%. Among 25 men with non‐chlamydial non‐gonococcal epididymitis, who were negative for Gram‐negative bacilli, M. genitalium or U. urealyticum was detected in one man each (4.0%), and M. hominis and/or U. parvum was detected in five (20.0%). Conclusion: In men younger than 40 years‐of‐age with acute epididymitis, C. trachomatis is a major pathogen. The prevalence of genital mycoplasmas and ureaplasmas are lower, and the role of genital mycoplasmas and ureaplasmas in the development of acute epididymitis remains to be determined.     

Antibiotic susceptibility patterns of Neisseria gonorrhoeae isolates in Port Elizabeth.

OBJECTIVE: To survey the antibiotic susceptibility of Neisseria gonorrhoeae isolates. DESIGN: This was a cohort analytical study. SETTING: Three clinics serving different areas in Port Elizabeth. Outcome measures. Prevalence of antibiotic-resistant N. gonorrhoeae isolates. RESULTS: Twenty-one of the 35 isolates (60%) were resistant to ciprofloxacin, while 28 (80%) showed resistance to erythromycin, 17 (48.6%) to penicillin, 3 (8.6%) to doxycycline, 11 (31.4%) to spectinomycin and 33 (94.3%) to tetracycline. CONCLUSION: To ensure effective treatment of gonorrhoea, continued surveillance of antimicrobial susceptibility is necessary.     

Disseminated gonococcal infection involving the foot

The patient had two features of N. gonorrhoeae infection, which were urogenital inflammation and pharyngitis. At first, the urogenital inflammation was denied and so delayed the correct diagnosis. The patient had been treated initially with oral penicillin for the pharyngitis, but without effect. The result was because of the increase in penicillin-resistant strains. This created DGI with initial migratory polyarthralgia from his left shoulder to the right midfoot. Acute arthritis formed in the midfoot. Once the correct diagnosis was made and appropriate antibiotics started, the infection responded rapidly and completely.     

A microbiological study of failed penicillin therapy for gonococcal urethritis in Durban

Seventy-five men presenting with persistent urethral discharge after penicillin therapy were investigated for sexually transmitted pathogens during July - September 1987. The major aetiological agent isolated was Neisseria gonorrhoeae (58 patients (77.3%]. Penicillinase-producing N. gonorrhoeae (PPNG) accounted for 58.6% of 58 isolates. Chlamydia trachomatis was detected in 10.7% of patients and Trichomonas vaginalis in 14.7% of patients. When there is a high prevalence of PPNG, the use of penicillin as a first-line agent for therapy should be discontinued in favour of an agent active against PPNG and non-PPNG strains. Furthermore, in view of the relatively high prevalence of T. vaginalis, patients returning with persistent urethral discharge should be investigated and treated for infection with this protozoan.     

Epidermal growth factor vs platelet‐rich plasma: Activity against chronic wound microbiota

The objective was to evaluate Staphylococcus aureus and Pseudomonas aeruginosa colonisation of wounds treated with recombinant epidermal growth factor (EGF) and platelet‐rich plasma (PRP); to analyse the susceptibility profiles of S. aureus and P. aeruginosa isolates from wounds treated with EGF and PRP; and to describe the presence of infection in EGF‐treated and PRP‐treated wounds. Experimental study was performed using clinical specimens collected with swabs. Patients were treated with PRP and EGF in the outpatient clinic of a university hospital. Forty‐three isolates were obtained from 31 patients, 41.9% (13/31) of whom had been treated with EGF and 58.0% (18/31) with PRP. Ten of the 43 isolates were identified as S. aureus, 60.0% (6/10) of which were isolated from PRP‐treated wounds. Among the 33 P. aeruginosa isolates, 66.6% (22/33) were isolated from PRP‐treated wounds. Regarding antimicrobial susceptibility, only one strain isolated from an EGF‐treated wound was identified as methicillin‐resistant S. aureus (MRSA). Among the P. aeruginosa isolates, one obtained from a patient treated with EGF was multidrug‐resistant. Patients treated with EGF had no infections during the follow‐up period, and there was a significant difference between the 1st and 12th week in wound infection improvement in patients treated with PRP (P = .0078).     

Clinical evaluation of norfloxacin in gonococcal urethritis

Norfloxacin, a new quinolinecarboxylic acid derivative, was administered to 30 male patients with gonococcal urethritis at a daily dose of 600 mg for 7-21 days. The clinical response was evaluated after administration of 7 days as excellent; Negative culture of N. gonorrhoeae. WBC less than 3/hpf in first voided urine sediment, good; Negative culture, WBC greater than or equal to 3/hpf, and poor; Positive culture. The result was excellent in 14 cases and good in 16 cases. No subjective side effects were observed. The minimum inhibitory concentration (MIC) distribution against the clinically isolated 30 strains of N. gonorrhoeae ranged from 0.0096 micrograms/ml to 0.34 micrograms/ml. Seven of thirty strains were resistant to ABPC. The MIC of these 7 strains ranged from 0.018 micrograms/ml to 0.18 micrograms/ml. Seven cases with ABPC resistant strains had a similar clinical response to other cases. Twelve patients (40%) developed post gonococcal urethritis for 7-14 days after treatment. Clinical observation of this series suggests that a 7 day therapy of Norfloxacin for the patients with gonococcal urethritis is sufficiently effective and that treatment should be changed to other antibacterial agents in the case of post gonococcal urethritis, since continuous administration for more than 7 days of Norfloxacin is not so effective.     

Epidemiological and therapeutic studies on gonococcal infections--one shot therapy by spectinomycin--[Sapporo Clinical Research Group for STD]

From January through March of 1985, the Sapporo Clinical Research Group for STD treated 69 cases of gonococcal infections (61 cases of male gonococcal urethritis and 8 cases of female gonococcal cervicitis) at its facilities in Sapporo City. The therapeutic efficacy of one shot therapy of Spectinomycin (SPCM) was investigated, and an epidemiological study on the cases and bacteriological studies on the isolated strains of Neisseria gonorrhoeae were made. The male patients were between 19 and 55 years old, with a peak age distribution in the younger half of the twenties. The female patients were between 18 and 40 years old. The major source of infections was a so-called special massage parlor which accounted for 36.1% of male cases. The isolation rate of PPNG were 16.7% (11/66). The MIC (inoculum size; 10(6) CFU/ml) of SPCM ranged from 3.13 to 25 micrograms/ml regardless of beta-lactamase production. In male patients, the eradication rate (efficacy rate) of N. gonorrhoeae by SPCM was 94.7% on the first day, 93.6% on the third day and 100% on the seventh day after 2 g one shot therapy. In female patients, the rate was 100% on the third and seventh day after 2 g one shot therapy, and 75% on the first day, 66.7% on third day and 100% on seventh day after 4 g one shot therapy. We considered that one shot therapy of SPCM was effective for gonococcal infection also in the present time. Especially SPCM was effective for infections by PPNG, since it was not resolved by beta-lactamase of N. gonorrhoeae. Positive rate of Chlamydia trachomatis was 16.3% in male gonococcal urethritis, and the serous discharge tended to remain longer in the positive patients than in the negative patients. There was only one side effect (1.4%), therefore SPCM was recognized to be a safely administrated antimicrobial agent.     

Meningococcal infections in hospitalised patients in Pretoria

We report on 13 patients diagnosed with meningococcal infections in patients attending state-owned hospitals serving an indigent population in Pretoria in 2009. The case fatality rate was 27%. Ceftriaxone was the main antibiotic (9 out of 13 patients) for therapy. Five isolates (39%) were serogroup B and 4 (31%) serogroup W135. Most isolates (12/13) were fully susceptible to penicillin (MIC range 0.016 - 0.047 μg/ml). A single isolate was intermediately resistant to penicillin (MIC, 0.125 μg/ml) while all isolates were uniformly susceptible to ceftriaxone, ciprofloxacin and rifampicin. This pattern reveals a shift in serogroups with an increase of serogroup B disease in the Pretoria region, and the need for ongoing monitoring of antimicrobial susceptibility profiles and the value of ceftriaxone for favourable therapeutic outcome.     

Gonorrhoe

Infection with Neisseria gonorrhoeae is a frequent occurrence. It is almost always transmitted via sexual intercourse and the risk of infection is markedly higher for women than for men. Purulent secretion characterizes the clinical picture. After an incubation period of 2-6 days, for the most part urethritis, cervicitis, proctitis, pharyngitis, or conjunctivitis usually develops. Condoms offer good protection against gonococcal infection. The treatment of choice in Central Europe is a single dose of Cefixime.