Emerging Infections 10 by W. Michael Scheld

Author:W. Michael Scheld
Language: eng
Format: epub
ISBN: 9781683673217
Publisher: Wiley
Published: 2016-06-13T00:00:00+00:00

GONOCOCCAL ISOLATE SURVEILLANCE PROJECT: AN EXAMPLE OF AN ESSENTIAL RESISTANCE SURVEILLANCE PROGRAM

In the United States, the antimicrobial susceptibility patterns of N. gonorrhoeae have been monitored since 1986 through the Gonococcal Isolate Surveillance Project (GISP), a national sentinel surveillance program and the oldest continuously running antimicrobial susceptibility surveillance program in the world (122). Since its inception, the GISP has provided valuable information that has been used to update the CDC’s Sexually Transmitted Diseases (STD) Treatment Guidelines as well as provided data used by CDC to modify the treatment recommendations for gonorrhea in real time. For example, data from GISP were pivotal in alerting public health officials about the increasing prevalence of gonorrhea among MSM in the late 1990s (123), the recommendation to avoid the use of fluoroquinolones among MSM with gonorrhea in 2004 (74), and, in 2007, the recommendation that fluoroquinolones not be used for any patient that presents with gonorrhea, leaving ESCs as the only remaining class of antimicrobials recommended for treatment of gonorrhea (124). Furthermore, in 2010, due to concerns regarding emergence of ESC resistance, the CDC introduced recommendations for dual antimicrobial therapy. The CDC’s 2010 STD Treatment Guidelines recommended an ESC (ceftriaxone at 250 mg i.m. or cefixime at 400 mg orally) plus azithromycin at 1 g orally or doxycycline at 100 mg orally twice daily for 7 days (125). In 2012, data from the GISP led the CDC to no longer recommend oral cephalosporin for the treatment of gonorrhea. Accordingly, cefixime was excluded from the recommended regimens in the CDC’s STD Treatment Guidelines and cefixime was an alternative regimen (together with azithromycin at 1 g orally) only when ceftriaxone was not available (126). In 2015, due to the high prevalence of tetracycline resistance among GISP isolates, particularly those with elevated cefixime MICs, doxycycline was excluded from the recommended regimen. Consequently, the CDC’s 2015 STD Treatment Guidelines recommend for the treatment of uncomplicated urogenital, anogenital, and pharyngeal gonorrhea only dual therapy with a single i.m. injection of ceftriaxone (250 mg) plus azithromycin at 1 g orally (91). Clearly the emergence and spread of ESC-resistant N. gonorrhoeae would severely limit the treatment options for gonorrhea in the United States and globally. As mentioned above, in response to the threat of ESC-resistant N. gonorrhoeae, the Division of STD Prevention at the CDC has developed a response plan (18) that includes the GISP as a critical component of the surveillance for ESC-resistant N. gonorrhoeae.

GISP is a collaborative project among selected STD clinics, five regional laboratories, and the CDC (Fig. 1). In GISP, N. gonorrhoeae specimens and demographic and clinical data of corresponding patients are collected each month from the first 25 men who attend the participating STD clinics in 26 selected U.S. cities and who have also been diagnosed with urethral gonorrhea (presumptive or confirmed diagnosis). These isolates are then shipped to one of five regional laboratories (Atlanta, GA; Baltimore, MD; Birmingham, AL; Seattle, WA; and Austin, TX), where they are confirmed as N. gonorrhoeae, tested for β-lactamase production using the nitrocefin test, and analyzed for antimicrobial susceptibility by agar dilution.

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