Neisseria Gonorrhoae And Their Antimicrobial .
Yeshanew and Geremew Antimicrobial Resistance and Infection Control(2018) RCHOpen AccessNeisseria Gonorrhoae and theirantimicrobial susceptibility patterns amongsymptomatic patients from Gondar town,north West EthiopiaAddisu Gize Yeshanew* and Rozina Ambachew GeremewAbstractBackground: Neisseria gonorrhoeae, the causative agent of gonorrhoea, is a Gram negative, coffee-bean shapedfacultative intracellular diplococcus bacterium, the classical sexually transmitted bacteria. Nowadays, N. gonorrhoeaehas developed high-level resistance to all traditional antimicrobials used for the treatment of gonorrhoea andmakes the treatment complicated. So, the aim of this study was to determine magnitude and antimicrobialresistance patterns of N. gonorrhoeae.Methods: A cross sectional study was conducted between April and August 2016 among STI clinic clients inGondar town hospitals and health centers. Urethral swab and cervical swab specimens were inoculated to ThayerMartin media (OXOID, UK) plates. Observation of Gram-negative intracellular diplococcic was a presumptivediagnosis of gonococcal infection. Finally, antimicrobial susceptibility was assessed by using a modified Kirby-Bauerdisk diffusion test, with results indicating susceptible, intermediate or resistant. Data were entered and analyzedusing SPSS version 20.Results: The overall prevalence of laboratory confirmed N. gonorrhoeae was 25(20.8%). The isolated N. gonorrhoeaewas resistant 100% to tetracycline, penicillin and 80% percent was multidrug resistant.Conclusion: Prevalence and drug resistance of N. gonorrhoeae were high in the study area. A large study is neededin order to know the magnitude in the community as well as to increase awareness of both regional healthbureaus and the Ministry of Health about the treatment guide-lines.Keywords: N. Gonorrhoeae, Antimicrobial sensitivity testBackgroundNeisseria gonorrhoeae is a Gram negative, coffee-beanshaped intracellular diplococcus bacterium responsiblefor gonorrhoea which is one of the classical sexuallytransmitted infections (STIs) [1]. The causative organismis highly adapted to the genital tract and often causingasymptomatic and undetected infection [2]. Gonorrhoeais acquired by unsafe sex practices and also can be transmitted from mother to child during delivery [1], whichhas medically significant implications if not treated early.* Correspondence: addisu.gize@sphmmc.edu.et; konjoaddisu@gmail.comDepartment of Microbiology, St. Paul’s Hospital Millennium Medical College,Addis Ababa, EthiopiaUntreated gonorrhoea can lead infertility, inflammationleading to acute and chronic abdominal pain in women,ectopic pregnancy and maternal death, first trimesterabortion, severe neonatal eye infection that lead toblindness, a fivefold increase in HIV transmission,disseminated gonococcal infection which results in localized septic arthritis, endocarditis, and meningitis[1, 3, 4]. Therefore, accurate efforts should be made tooffer routine endocervical cultures for N. gonorrhoeae toall women who have risk behavior of STIs to prevent thisinfection [5]. Gonorrhoea treatment is complicated byN.gonorrhoeae’s ability to develop antimicrobial resistance[6]. Since the introduction of antimicrobials to treat N.gonorrhoeae infection 70–80 years ago, N. gonorrhoeae The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication o/1.0/) applies to the data made available in this article, unless otherwise stated.
Yeshanew and Geremew Antimicrobial Resistance and Infection Control (2018) 7:85has progressively developed resistance to most antimicrobial previously recommended for treatment, including sulfonamides, penicillin, tetracycline, and fluoroquinoloneantibiotics [7]. In European Surveillance of combined antimicrobial susceptibility data, the resistance was found tobe high to ciprofloxacin (30.9%), penicillin (21.3%) andtetracycline (59.8%), and Neisseria gonorrhoeae strain(H041) that is highly resistant to the extended-spectrumcephalosporin (ESC) ceftriaxone [8, 9].In many parts of the developing world, the absence ofetiologic diagnostic capacity due to constraints imposedby cost, lack of equipment or trained personnel, andtime management has forced health care providers torely on a syndrome based approach to STI management,because many STIs have common symptoms or areasymptomatic and therefore undetected and untreated[10]. Therefore, this study primarily aimed to determinethe prevalence N. gonorrhoeae and their antimicrobialsusceptibility pattern among STI clinics attendants atGondar town, North West of Ethiopia.Materials and methodsA cross-sectional study was conducted from April 1 toAugust 30, 2016 in Gondar town hospitals and healthcenters, Gondar town, Northwest Ethiopia. The Town is725 km away from Addis Ababa, Ethiopia, located in theNorth Gondar Zone of the Amhara Region. Based onfigures from 2011 Central Statistical Agency (CSA) ofEthiopia, Gondar town has a total population of 207,044,of whom 98,120 are men and 108,924 women. There aretwo hospital (1 governmental and 1 private) and 5 healthcenters in the town.Patients who visited Gondar town hospitals and healthcenters during the study period serve as the sourcepopulation, whereas, all STI suspected patients attendingin the STI clinic were included as the case of the study.However, patients under antibiotic treatment during7 days before the enrolment and female patients whowere on menstruation at the time of examination wereexcluded from the study. Descriptive statistics, includingsocio-demographics factors and known risk factors forSTI were performed.Sample size and sampling techniqueSample size was calculated based on the single population proportion formula considering the prevalence rateof 8.5% from the previous study conducted in Bahirdar,Northwest Ethiopia. Expected margin of error (d) was0.05 and confidence interval (z) was 95%. One hundredtwenty consecutive consenting patients, who attendedGondar town hospitals and health centers STI clinic,with one or more of the complaints as stated by WHOin its syndrome approach for the diagnosis of STI wereincluded [5].Page 2 of 7Data collection procedureSocio-demographic characteristicsAfter taking written informed consent from each studyparticipant, a semi-structured questionnaire was used tocollect socio-demographic and clinical data needed inthis study. Data were collected by trained nurses.Sample collectionUrethral and cervical specimenExternal inspections of the genital area were made, andthe characteristics of any local changes such as;erythema, abrasions, ulceration, urethral discharge andvaginal discharge were noted, including color, amount,odor and consistency. In the absence of visible urethraldischarge, the patient was asked to milk the urethra.Specimens of discharge were obtained at or just withinthe urethral meatus for male and cervical swabs weretaken for female. Two swabs were taken; one for Gramstaining and the other were put on Amies transportmedia for N. gonorrhoeae culture at Gondar UniversityHospital laboratory. This laboratory, according toEthiopian National Accreditation Office (ENAO), whichestablished the Stepwise Laboratory (Quality) Improvement Process towards Accreditation (SLIPTA), has got 3stars (75–84%) ranked from 5 stars ( 95%). ENAO givesrecognition based on progress towards meeting requirements set by international standards and on laboratoryperformance during the 12 months preceding theSLIPTA audit, relying on complete and accurate data, toimprove quality of public health laboratories in developing countries to achieve ISO 15189 standards.Laboratory methodIsolation and identification of N. GonorrhoeaeIdentification was made by observing polymorphonuclearleucocytes (PMNLs) with Gram-negative intracellulardiplococci as a presumptive diagnosis of gonococcal infection. Specimens inoculated directly into the modifiedThayer Martin medium (MTM) (OXOID, UK) plates contained vancomycin, colistin, nistatin and trimetoprin andincubated at 36.5 C for 24–48 h. Then isolates was identified as N. gonorrhoeae on the basis of colony morphology,Gram staining, oxidase test, and carbohydrate utilizationtest [11]. N. gonorrhoeae is observed as Gram negativediplococci when Gram stained, positive for oxidase,ferments only glucose, and is resistant to colisin [12].Antibiotic susceptibility testingFrom a pure culture, 3–5 selected colonies of bacteriawere transferred to a tube with a straight wire and prepared in a suspension of 2.5 ml normal saline and incubated at 36.5 C until the turbidity of the suspensionbecome adjusted to a McFarland 0.5. A sterile swab wasused to distribute the bacteria evenly over the entire
Yeshanew and Geremew Antimicrobial Resistance and Infection Control (2018) 7:85surface of MTM agar. The susceptibility to the followingantimicrobial agents (OXOID, UK) were assessed: penicillin (P 10 IU), tetracycline (TE 30 μg), ciprofloxacin(CIP 5 μg), ceftriaxone (CRO 30 μg), Cefotaxime(30 μg), Cefoxitin (FOX 30 μg), Clindmycin (CLI 2 μg).The criteria used to select the antimicrobial agentstested were based on their availability and frequent prescriptions for the management of gonococcal infectionand the national list of medicines by Food, Medicine andHealth- Care Administration and Control Authority(FMHACA) Ethiopia in 2010 to treat infections, and thesyndromic management package for the management ofsexually transmitted infections guideline from theFederal Ministry of Health.Finally, antimicrobial susceptibility testing was performed for all isolates according to the criteria of Clinicaland Laboratory Standard Institute (CLSI) by the modifiedKirby-Bauer disk diffusion method on Thayer Martinmedium plates, results as to susceptible or resistant werebased on the M100-S24 Performance Standards for Antimicrobial Susceptibility Testing [12].Data quality controlThe questionnaire was pre-tested on 15 outpatient department patients for comprehensiveness, effectiveness,reliability and validity. Training was given for data collectors on data collection procedures with support froman investigator, venereologist and gynecologist. Culturemedia sterility was ensured by incubating 5% of eachbatch of the prepared media at 37oc for 24 h. Performance of prepared media was also checked by inoculatingwith control strains N. gonorrhoeae ATCCTM 49226(10) [13].Page 3 of 7ResultsSocio-demographic characteristicsA total of 120 patients, 21 (17.5%) males and 99 (82.5%)females, were enrolled in the study. The mean SD ageof the study participants was 27.8 7.2 years. The majority (66.6%) of the study participants were in the agegroup below 30 years old. Fifty eight (48.3%) weremarried. The majority of the patients 74 (61.7%) wereliterate. Regarding their occupation, house wives numbered 26(21.7%), and in terms of economic status, 37(30.8%) participants reported not to receiving income oftheir own (Table 1).Prevalence of N. GonorrhoeaeThe overall prevalence of laboratory confirmed N. gonorrhoeae pathogens among suspected attendees of Gondartown hospitals and health centers was 25(20.8%). N.gonorrhoeae infections were higher among females andage groups 15-29 yrs. The majority of the respondents82(68.3%) had multiple sexual partners, and 69(57.5%)had never used condoms (Table 1).Antimicrobial susceptibility pattern of N. GonorrhoeaestrainsThe antimicrobial susceptibility pattern of all isolates ofN. gonorrhoeae is shown in Table 2. All isolates of N.gonorrhoeae showed resistance to at least one antimicrobial agent. The susceptibility pattern of isolates showsthere were a hundred percent non-susceptibility fortetracycline, 76% non-susceptibility and 24% intermediate resistant for penicillin. The isolated N. gonorrhoeaewas resistant 52% to ciprofloxacin, 48% to ceftriaxone,44% to cefoxitin, 29% to cefotaxime, and 28% to clindmycin. Most of the isolates (80%) showed multiple drugresistance and 11(44%) of the isolates showednon-susceptibility to both ciprofloxacin and ceftriaxone.Data analysisData were entered and analyzed using SPSS version 20. Descriptive statistics was applied to determine the distributionof the socio-demographic and clinical characteristics.Ethical considerationThe proposed study was approved by the research andethics committee of the School of Biomedical and Laboratory Sciences of the University of Gondar. Officialpermission was obtained from each of the health facilities. The aim and details of the study was explained toeach study participant before obtaining their writtenconsent for specimen collection. Confidentiality wasmaintained at all levels of the study by using codes rather than names of the study participants. The results ofall positive individuals were reported to the respectivehealth facilities for better management of the patients.DiscussionThe overall prevalence of laboratory confirmed N. gonorrhoeae was 25(20.8%). This prevalence rate was comparable with studies from Mozambique (22.5%) [14], Egypt(26%) [15] and southwestern Nigeria (25%) [16]. However it was higher than the value reported from previousfindings of studies done in Hawassa, Southern Ethiopia(5.1%) [2] as well as the Northern part of Ethiopia [17].Again the present finding was higher than the studiesconducted in other countries: for example, 11% inMongolia [18], 6% United States [19], 1.4% in Colombia[20], 6% in India and 1% from Nigeria [21]. These discrepancies might be due to the lack of advancement inboth early diagnosis and treatment in our country, whichcan lead to an increased number of untreated patients.A lack of differential diagnosis for resource poor settingscan lead to an increased number of untreated patients
Yeshanew and Geremew Antimicrobial Resistance and Infection Control (2018) 7:85Page 4 of 7Table 1 Prevalence of N. gonorrhoeae described by socio-demographic characteristics and known risk factors for STI, Gondar town,North West Ethiopia from April–August 2016CharacteristicsTotal N (%), n 120N. gonorrhoeae ve (%),n 25N. gonorrhoeae- ve (%), n 95Male21(17.5)6 (29)15 )7(23)24(77)SexAgeMarital statusEducational statusOccupationGovernment employedHouse (30.8)7(19)30(81)Income ) 160027(22.5)6(22)21(78)Knowledge about 5)7(15)37(84)One partner38(31.6)7(18)31(82)More than one partner82(68.3)18(22)64(78)Alcohol useKhat chewingSmokingHistory of abortionSexual partner
Yeshanew and Geremew Antimicrobial Resistance and Infection Control (2018) 7:85Page 5 of 7Table 1 Prevalence of N. gonorrhoeae described by socio-demographic characteristics and known risk factors for STI, Gondar town,North West Ethiopia from April–August 2016 (Continued)CharacteristicsTotal N (%), n 120N. gonorrhoeae ve (%),n 25N. gonorrhoeae- ve (%), n 9569(57.5)13(19)56(81)Condom )Males sexual contact with prostitute womenHistory of STICommonly using toillet & washing materialsContact new person the last 3 monthsHIV status ve infected with N. gonorrhoeae, , ve non-infected with N. gonorrhoeae, S/Rarely sometimes or rarely, CSW Commercial Sex Workers, STI Sexual TransmittedInfection, HIV Human Immunodeficiency Virusand a poor partner tracing system and using a syndromic approach, especially in the study area, might bethe possible causes for this high prevalence rate.The main reason for the rapid increase of N. gonorrhoeaeresistance rates to Penicillin, Tetracycline and Ciprofloxacinafter they had been recommended for clinical use is likelytheir indiscriminate use. Patients tend to administer antimicrobial treatment by themselves or visit non-formalmedical institutions such as unregistered private clinics.Table 2 Antimicrobial susceptibility pattern of N. gonorrhoeaeisolates from STI clinic attendants in Gondar town, North WestEthiopia from April–May 2016Antibiotic#S (%)# I (%)# R 4)Clindmycin18(72)*7(28)# S number of sensitive, # I number of intermediate, # R number of resistance,* have no intermediate rangeMoreover, some patients do not complete the full treatmentcourse, increasing the chance for antimicrobial resistanceto develop. For example, patients could buy antimicrobialsin drug stores without a prescription. Indeed, an associationbetween self-prescribed antimicrobial use and gonococcalAMR may be high.Gonococcal infection was observed in 6(29%) of malesand, patients having multiple sexual partners 18(22%)and previous history of STI 16(24%). This prevalencerate may be attributed to less condom usage by femalesand having a history of STI which leads to the infection.The same factors were shown to increase the exposureand prevalence rate of gonococcal infection in otherstudies as well [22, 23].In addition, it was observed infection in both the agegroups of 15–29 & 30–45 years old. The finding on thetarget group was also supported by other studies [24, 25].The antimicrobial resistance patterns ranged from7(28%) for Cefotaxime and Clindmycin up to 100% inTetracycline. This Tetracycline resistance pattern wassimilar with the study done in Gambella hospital,Ethiopia [1]. The present study showed a high level ofresistance to Tetracycline 25(100%) and Ciprofloxacin13(52%) compared to the study done in North West
Yeshanew and Geremew Antimicrobial Resistance and Infection Control (2018) 7:85Ethiopia (92.6, 40.9%) (15), Southern Ethiopia (55, 18%)[2] and United States (25.3, 19.2%) [4].Most researchers are worried gonorrhoea will soonbecome untreatable with those antibiotics. This maybe true in resource limited countries because of alack of proper usage of antibiotics and application ofantimicrobials as therapeutic agents for syndromatictreatment or may be due to the emergence of new resistant beta-lactamase producing strains over a periodof time.The resistance of Cefotaxime 7(28%) and Cefoxitin11(44%) in the current study is also higher than thestudy conducted in Gambella hospital, Ethiopia [1]and Southern Ethiopia [2] but lower as compared toTetracycline, Penicillin, Ciprofloxacin. The reasonmight be these drugs are expensive, not intensivelyused and not easily available outside the health institution, plus these drugs are newer compared to theothers. Low resistance pattern of these drugs in ourstudy may make these drugs excellent choices asfirst-line treatment.ConclusionHigh prevalence of N. gonorrhoeae and drug resistanceamong symptomatic clients who attended the STI clinicsin the study area was observed. This should cause alarmand should lead to a large community based study andincreased awareness of both regional health bureaus andthe Ministry of He
Gram staining, oxidase test, and carbohydrate utilization test [11]. N. gonorrhoeae is observed as Gram negative diplococci when Gram stained, positive for oxidase, ferments only glucose, and is resistant to colisin [12]. Antibiotic susceptibility testing From a pure culture, 3–5 selected colonies of bacteria
Reference strains listed in this brochure are quality control (QC) strains for the agar-dilution, disk diffusion, and Etest susceptibility procedures used to determine the antimicrobial susceptibilities of isolates of Neisseria gonorrhoeae. These strains may be used to assess the quality of susceptibilities of N.
NEISSERIA Of the eleven species of Neisseria that colonize humans, only two are pathogens. 1N. gonorrhoeae (the gonococcus) is the causative agent of gonorrhoea and is transmitted via sexual contact. Symptoms of infection with N. gonorrhoeae differ depending on the site of infection. Infection of the genitals can result in a purulent (or pus-like) discharge from the
Antimicrobials, Aspergillus fumigatus, Antimicrobial Peptides 1. Introduction 1.1. Antimicrobial Peptides and Proteins It is notable that antimicrobial peptides particularly cationic ones play a signifi-cant role within the natural immunity of animal defences against topical and general microbes altogether species of life. These antimicrobial .
Chapter 5: Antimicrobial stewardship education for clinicians 123 Acronyms and abbreviations 126 5.1 Introduction 127 5.2 Key elements of antimicrobial stewardship education 128 5.2.1 Audiences 128 5.2.2 Principles of education on antimicrobial stewardship 129 5.2.3 Antimicrobial stewardship competencies and standards 129
Antimicrobial Peptides 2 ANTIMICROBIAL PEPTIDES OFFERED BY BACHEM Ribosomally synthesized antimicrobial peptides (AMPs) constitute a structurally diverse group of molecules found virtually in all organisms. Most antimicrobial peptides contain less than 100 amino acid residues, have a net positive charge, and are membrane active. They are major
activity mechanisms, and their antimicrobial activity against a broad spectrum of microorganisms, such as gram-positive and gram-negative bacteria as well as fungi, parasites and viruses (23-25 ). 1.2. Antimicrobial peptides - a new class of antibi otics? Antimicrobial peptides are part of the innate immune system and play an important
Several groups in the 1970s and 1980s reported antimicrobial peptides produced from leukocytes, including α-defensins from rabbits and humans [10]. One important landmark in the history of antimicrobial peptides is the work of Boman et al. in 1981. Boman injected bacteria into pupae of a silk moth and isolated the antimicrobial peptides
latino lgbt people in the criminal justice system, but limited DATA PAINT A PICTURE OF BIAS AND OVERREPRESENTATION. Sources: U.S. Census Bureau, "Annual Estimates of the Resident Population by Sex, Age, Race, and Hispanic Origin for the United States and States: April 1, 2010 to July 1, 2014," June 2015; Gary J. Gates and Frank Newport, “Special Report: 3.4% of U.S. Adults Identify
