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July 2007, Volume 57, Issue 7

Editorial

Antimicrobial Resistance in Neisseria gonorrhoeae and Limited Treatment Options

Afia Zafar  ( Department of Pathology Microbiology, Aga Khan University Hospital, Karachi, Pakistan. )
Kauser Jabeen  ( Department of Pathology Microbiology, Aga Khan University Hospital, Karachi, Pakistan. )

Neisseria gonorrhoeae is an important cause of sexually transmitted infections (STI) worldwide. The global incidence of gonorrhoeae is approximately 62 million casesper year. In developing countries it still remains a major cause of infection. The importance of this disease is notlimited to its numerical frequency but also concerns the complications it may cause and its ability to assist the transmission of other STIs including HIV. By and large, infections in men are detected early enough to prevent serious sequelae. In females, it causes cervicitis, urethritis, pelvic inflammatory disease and infertility and remains an asymptomatic (carrier) infectionin early stage.1 Therefore infection in females facilitates dissemination of the disease in the community. Moreover the frequency of pelvic inflammatory disease and infertilityis so common that early and appropriate treatment ismandatory.The prevalence of gonococcal infections varies widely among communities and patient populations. In Pakistan, incidence or prevalence data are not available to give an accurate picture of the disease distribution.However infection is common and treatment is expensive,for primary as well as complicated cases.2 Given the scale of public health importance of gonorrhea, selection of appropriate therapy is crucial. Early treatment rapidly reduces infectivity and helps in disease control. Therefore it is important that early, appropriate, and effective therapy is provided to each case. The most useful therapy against gonococcal infections should be a safe,affordable and single dose regimen. Single dose oraltherapy is preferred to ensure compliance, and low cost and to reduce risk of infections associated with parenteral therapy.3 Unfortunately N. gonorrhoeae is one of thecommunity-acquired bacterial pathogens that are currently causing problem of multidrug-resistance. High rate ofantimicrobial resistance against the conventional drugs suchas penicillins, tetracyclines and macrolides has limited theiruse.4Consequently, fluoroquinolones have become the most appropriate and cost effective alternative. Globally treatment of gonorrhoeae with this group of drugs iscomplicated by exponential rise in antimicrobial resistance.Quinolone resistant N. gonorrhoeae (QRNG) continued tospread, in response to which center of diseases control and prevention (CDC) recommended that quinolones should notbe used for the treatment of gonorrhea in areas with increased prevalence of QRNG (>5%) in 2006.5 In Pakistan ciprofloxacin and ofloxacin are the most frequently used antimicrobial agents to treat gonococcal infections. However, previously Jabeen et al have reported a high rate of quinolone resistance in clinical isolates fromthe years 1992-2002.6 The association of in vitro resistance with a high rate of treatment failure was a cause of majorconcern. In recent years a further rise in resistance (76%,unpublished AKUH laboratory data) excludes their use asempirical agent in the management of gonococcalinfections.Ceftriaxone resistance is not yet detected in localgonococcal isolates and presently it remains the drug ofchoice, though cost and parenteral mode of administration limits its use. However it is highly desirable that public and private sector laboratories should look for the emergence ofresistance against ceftriaxone as strains with reduced susceptibility have been reported in the past.7 In search of alternative oral agents, recent studieshave evaluated efficacy of azithromycin, cefixime,cefuroxime, cefpodoxime, levofloxacin and gatifloxacin.7To date antimicrobial susceptibility of these drugs has not been evaluated locally. Seeing that previously recommended antibiotics have lost their efficacy, we stress that it is vital to search for a suitable oral agent which can effectively treat gonococcal infections. Finally, we recommend that to prevent further dissemination of antimicrobial resistance and for an early response, federal health department must take the lead andwith the collaboration of NIH, Islamabad and clinical laboratories establish an infrastructure for the national surveillance program to monitor emergence ofantimicrobial resistance not only for N. gonorrhoeae butalso for other bacterial pathogens.

References

1.Mandell, Bennet and Dolin. Principals and practices of infectious diseases.6th Ed. Elsvier,  Churchil Livingstone 2005; pp 2514-9.

2.Rehan N. Profile of men suffering from sexually transmitted infections inPakistan. J Pak Med Assoc. 2006; 56:S60-5.

3.Guidelines for the management of sexually transmitted infections. Geneva,Switzerland: World Health Organization, 2003

.4.Taspall J. Antimicrobial resistance in Neisseria gonorrhoeae. Geneva,Switzerland: World Health Organization, 2001.

5.Jabeen K, Khan E, Hasan R.  Emergence of quinolone-resistant Neisseriagonorrhoeae in Pakistan. Int J STD AIDS. 2006; 17:30-3.

6.Centers for Disease Control and Prevention, Workowski KA, Berman SM.Sexually transmitted diseases treatment guidelines, 2006. MMWR RecommRep 2006; 55: 1-94.

7.Newman LM, Moran JS, Workowski KA. Update on the management ofgonorrhea in adults in the United States. Clin Infect Dis 2007; 44: S84-101.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: