Rapid Emergence of Gonococcal Fluoroquinolone Resistance in Men Who Have Sex with Men in King County, WA - PowerPoint PPT Presentation

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Rapid Emergence of Gonococcal Fluoroquinolone Resistance in Men Who Have Sex with Men in King County, WA

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Rapid Emergence of Gonococcal Fluoroquinolone Resistance in Men Who Have Sex with Men in King County, WA WLH Whittington MR Golden KK Winterscheid – PowerPoint PPT presentation

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Title: Rapid Emergence of Gonococcal Fluoroquinolone Resistance in Men Who Have Sex with Men in King County, WA


1
Rapid Emergence of Gonococcal Fluoroquinolone
Resistance in Men Who Have Sex with Men in King
County, WA
  • WLH Whittington
  • MR Golden
  • KK Winterscheid
  • SA Wang
  • KK Holmes
  • HH Handsfield

Department of Medicine, University of Washington,
Public Health--Seattle King County Centers
for Disease Control
2
Background
  • Effective gonorrhea therapy reduces disease
    spread by reducing duration of infection
  • Fluoroquinolone gonococcal resistance has been
    reported in the Pacific rim, including Hawaii
    California
  • Therapy choices limited by discontinuation by the
    manufacturer of adult dosage cefixime
  • In King County, from 1993-2001, prevalence of
    fluoroquinolone resistance was consistently lt1

3
Objectives
  • Assess trends in fluoroquinolone resistance in
    King County, WA
  • Describe contemporary outbreak caused by
    fluoroquinolone resistant gonococci

4
Methods
  • Isolates from private and public clinical
    laboratories in King County (Schwebke et. al.)
  • Antimicrobial susceptibilities determined by agar
    dilution tests (NCCLS)
  • For assessment of contemporary outbreak, disk
    diffusion tests (NCCLS) performed immediately

5
Methods (cont)
  • Fluoroquinolone resistance defined by an agar
    dilution MIC gt1 mg ciprofloxacin/ml
  • Gonococcal phenotypes said to differ if auxotype
    differed or susceptibilities differed by gt2
    dilutions to gt2 classes of antimicrobials
  • Patients isolate characteristics compared
    between those with ciprofloxacin resistant and
    susceptible infections using parametric and
    non-parametric tests logistic regression
    utilized to control for covariates

6
Proportion of infections caused by ciprofloxacin
resistant gonococci1993-2002
isolates (1208) (996)
(726) (624) (815)
By criterion of NCCLS
7
Fluoroquinolone Resistance1993-2002
  • Small outbreak during 1995 associated with
    commercial sex work (Whittington et. al.)
  • Excess cases during 2002 among men, often MSM
  • However, no additional cases detected
    by screening of 240 gonococcal isolates
    from October 2003 through April 2004

8
Proportion of infections caused by ciprofloxacin
resistant gonococci by quarter, 2003
By criterion of NCCLS History suggestive of
acquisition elsewhere
9
Resistance by gender, source of care and sexual
preference

  • (n/total)
  • Source of care
  • STD Clinic 12 (21/171)
  • Other 6
    (7/121)
  • Gender
  • Male 12
    (27/222)
  • Female 1 (1/70)
  • Sexual preference
  • Heterosexual 3 (2/76)
  • MSM 22
    (19/85)
  • STD Clinic patients only
  • Plt0.05

10
Characteristics of infecting gonococci by
fluoroquinolone resistance
  • Resistant
    Susceptible
  • (n28)
    (n264)
  • Different Phenotypes 3
    20
  • Median (range) MIC (mg/ml)
  • Penicillin G 1.0
    (0.25-2.0) 0.25 (0.03-2.0)
  • Tetracycline HCl 1.0 (0.5-4.0)
    0.5 (0.06-4)
  • Erythromycin 1.0 (0.5-2.0)
    0.5 (0.008-16.0)
  • Azithromycin 0.125 (0.06-0.25)
    0.06 (0.008-2.0)
  • Based on antibiogram and auxotype PFGE pending
    1 cipR phenotype dominant
  • Plt0.05

11
Limitations
  • Based only on those infections from which
    isolates were received
  • Previously shown that samples were
    representative of all reported cases
  • However, recent use of NAAT by many
    providers introduces potential for bias,
    e.g. women may be underrepresented

12
Summary Significance
  • Spread was rapidfrom undetected to 16 of
    isolates in lt 6 months
  • Most (86) resistant isolates had ciprofloxacin
    MICs gt4 mg/ml Failure rates of 50 after
    ciprofloxacin therapy (Aplasca et. al.)
    Treatment failure was documented in 4 local
    patients
  • Spread was most efficient among MSM Due
    to behaviors or selective advantage of
    resistant strains (ciprofloxacin resistance or
    macrolide resistance as marker of
    resistance to killing by fecal lipids?)

13
Intervention
  • Immediate disk diffusion testing permitted timely
    identification of this problem
  • Local treatment recommendations changed in
    November 2003 to include cefpodoxime 400mg P.O.
    plus doxycycline or azithromycin
    fluoroquinolones no longer recommended

14
Addendum
  • During January-February 2004, prevalence of
    fluoroquinolone resistant gonococci remained high
    (20, 20/98)
  • Resistant isolates were recovered from 2
    additional women during this period

15
Acknowledgements
  • Sarah Lam for performance of disk diffusion
    susceptibility tests
  • Olusegnu Soge for performance of PFGE
  • Financial support from the CDC and NIAID

16
(No Transcript)
17
Disk diffusion antimicrobial susceptibilities
cefpodoxime and cefixime (n220)
Cefixime
Cefpodoxime (mm)
r0.78
18
Selection of Gonorrhea Therapy
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