Rafiq Khanani  ( Department of Pathology, Sindh Medical College, Karachi. )
A. Razak Memon  ( Department of Pathology, Sindh Medical College, Karachi. )
Rasool Bux Shaikh  ( Department of Pathology, Sindh Medical College, Karachi. )
Ghulam Ali  ( Department of Pathology, Sindh Medical College, Karachi. )
Mubashir Shaikh  ( Department of Pathology, Sindh Medical College, Karachi. )
Tariq Sandila  ( Department of Pathology, Skin arid Social Hygiene Centre, Karachi. )
Zahid Hussain  ( Department of Pathology, Sindh Medical College, Karachi. )
Nighat Parveen  ( Department of Pathology, Skin arid Social Hygiene Centre, Karachi. )

Urethral or cervical swab of 255 patients attending Skin and Social Hygiene Centre and found positive for gram negative Intracellular diplococol on direct microscopy were inoculated on Modified New York City (MNYC) medium and chocolate (heated blood) agar for Isolation of neisseria gonorrhea. Growth of N. gonorrhea was obtained in 134(52.5%) cases. These strains were tested for penicillin susceptibility by disc diffusion method and for the production of B-lactamase by rapid penicillinase paper strip test and rapid chromogenic cephalasporin method. Penicillin resistance was found in 31(23%) strains, of which twelve (9%) were B- lactamase producers (PPNG), the remaining 19 (14%) strains were penicillin resistant B-lactamase negative (Pen RB Neg). We conclude that PPNG as well as other penicillin resistant strains (Pen RB Neg) of neisseria gonorrhea are prevalent in our country and appropriate changes In the conventional therapeutic regime are desirable (JPMA 44:70, 1994).

Gonorrhea has become one of the most common bacterial infections worldwide. Among the factors responsible for this gonorrhea pandemic are alleged increase in promiscuity, use of oral or parentral con­traceptive methods rather than protective contraceptive methods, a large and gradually increasing reservoir of asymptomatic females and males who unknowingly transmit the disease to their sexual partners and decreas­ing susceptibility of gonococci to commonly used an­tibiotics¹. During the last 30 years, resistance to penicillin G has gradually risen probably by selection of chromosomal mutants². The problem of resistance of gonococci to penicillins has been further aggravated by emergence of B-lactamase producing gonococci since 1976³. This resistance is plasmid mediated and gonococ­ci might have acquired it from haemophilus or other gram negative organisms⁴ . Focal outbreaks of B-lactamase producing neisseria gonorrhea have been reported from Phillipines, Thailand, California, New York and else­where and endemic foci are being established⁵. This study was conducted to assess the frequency of treatment failures with conventional therapy for gonorrhea.

Origin of strains:
Skin and Social Hygiene Centre is the only hospital in Karachi specifically designated as a centre for sexually transmitted diseases (STD). This study includes 255 patients who presented to this hospital from March, 1989 to January, 1992 with a history of purulent urethral discharge and showing intracellular gram -ye diplococci on direct microscopy of urethral or cervical smears.
Isolation and identification:
Specimens were collected by two sterile calcium alginate swabs - one swab was used for marking well on chocolate agar which was subsequently spread thinly by a sterile wire loop⁶. Second swab was seeded by streaking over the surface of the Modified New York City (MNYC) medium while rotating it to ensure that all surfaces of swabs tip come in contact with the medium. Inoculated plates were incubated immediately in a candle jar with white wax candles, transferred to incubator at 35°C and examined after 24 and 48 hours. Characteristic 0.5-1.0 mm, grey to white, opaque, raised and glistening colonies were subjected to oxidase test. Rapid reacting oxidase positive colonies were picked up for gram staining and biochemical confirmation with rapid carbohydrate degradation tests (oxoid).
Susceptibility to penicillin:
It was determined by picking 5-10 colonies from primary plate, emulsifying it in Muller Hinton broth adjusting inoculum size to 10⁸ organisms/mi with 0.5 McFarland Standard and inoculating it on 1% IsoVitalex supplemented GC agar base plate and applying a 6 ug penicillin disc. It was incubated in a candle jar at 35°C. A zone size of c 20mm in diameter at 24-48 hours was suggestive of a penicillin resistant strain⁷. Control strains obtained from Centres for Disease Control (CDC), Atlanta, Georgia were also included with each batch. All the strains showing resistance to penicillin, i.e., zone diameter of <20 mm were tested for B-lactamase produc­tion.
B-lactamase production:
It was determined by (0 Rapid Penicillinase paper Strip test⁸ and (ii) Rapid Chromogenic Cephalosporin method using nitrocefin impregnated paper discs⁹. Control strains from CDC viz: penicillin resistant f3-lactamase negative (Pen RB Neg) and Penicillin resis­tant B-lactamase positive (Pen RB Pos) were also in­cluded with each batch. Penicillin resistant strains which were found B-lactamase negative were once again sub­jected to penicillin susceptibility test for reconfirmation of its penicillin resistance.

Out of 255 cases, growth of neisseria gonorrhea was obtained in 134 (52.5%) cases. Of these 103 (77%) were sensitive and 31 (23%) resistant to penicillin. Production of B-lactamase was detected in 12 (9%) strains (PPNG; Pen RB Positive). Remaining 19 (14%) strains were penicillin resistant B-lactamase negative (Pen RB Negative).

Sexually transmitted diseases (STD) are hyperen­demic in many developing countries and their incidence is increasing¹⁰. Treatment failures with conventional regimes of penicillin or ampicillin led us to conduct this study to find out susceptibility of neisseria gonorrhea to penicillin, the most widely used drug for treatment of gonorrhea. Present study showed resistance to penicillin in 23% strains, which is similar to 20 to 31% reported in other series^11,13. However, it is much lower than that of 41% reported by Gedebou and Tassew¹⁴ and 62% reported by Ng et al¹⁵. In the present study 12(9%) PPNG strains were isolated. This is comparable to 16% PPNG strains isolated by Chowdhary et al¹⁶ 14.6% reported by Urabe et al¹⁷. . However, the figure is much lower compared to 40-50% PPNG strains reported from USA and Singapore⁵. The case histories of patients included in the present study indicated that eight (Pen RB Positive) strains isolated were acquired within the country and four strains were imported by sailors. However, due to stigma attached to STDs, concealment of facts by patients, lack of education, limited availability of STD clinics and almost non-existence of contact tracing and epidemiological studies, it is difficult to ascertain whether there are established endemic foci of PPNG and other penicillin resistant strains or these represent importation and only occasional secondary cases. Systematic multicentre studies for isolation, iden­tification and susceptibility of neisseria gonorrhea are needed to formulate recommendations for treatment of gonorrhea, as conventional measures in vogue are bound to result in treatment failures leading to spread of disease and increased incidence of complications of gonorrhea.

We sincerely thank Dr. Tahira Naqvi, Director, Skin and Social Hygiene Centre for help and guidance in patient selection. Our thanks are also due to Miss Amna and Mr. Rustam for technical assistance and to Mr. Muhammad Zamiruddin Kauser for typing the manuscript.

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