Penicillinase-producing Neisseria Gonorrhoeae Infections Research Articles

Diversity of isolates of penicillinase-producing Neisseria gonorrhoeae (PPNG) in Honolulu, Hawaii: 1982-1991.

Gonococcal infections caused by penicillinase-producing Neisseria gonorrhoeae (PPNG) isolates have increased in geographic distribution and prevalence. It was postulated that PPNG strains would become endemic in Honolulu and that, in turn, this city would serve as a reservoir for the introduction of PPNG strains into the continental United States. To assess the role of Honolulu as a reservoir for PPNG strains by assessing the diversity and persistence of PPNG strains between 1982 and 1991. A total of 432 PPNG strains were characterized by auxotype/serovar (A/S) class and plasmid content, and their distribution during the 10-year period was studied. Of 432 isolates, 373 (86.4%) possessed a 4.4-Mdal beta-lactamase plasmid; 39 (9.0%) possessed a 3.2-Mdal beta-lactamase plasmid; and 20 (4.6%) possessed a 3.05-Mdal beta-lactamase plasmid. A total of 53 A/S classes were identified. Asian, African, and Toronto PPNG strains belonged to 49 (92.5%), 15 (28.3%), and 11 (20.7%) A/S classes, respectively. Though all Toronto PPNG strains possessed a 24.5-Mdal conjugative plasmid, these plasmids could not be transferred by conjugation. Although some apparent microepidemics of PPNG strains were identified, most strains were isolated sporadically. A large number of different strains have been associated with PPNG infections in Honolulu, but there was no evidence that any strain persisted endemically during the study period. These observations have important implications for the design and assessment of community gonorrhea control strategies.

Determinants of penicillinase producing Neisseria gonorrhoeae infections in heterosexuals in Amsterdam.

At the STD clinic of the Municipal Health Service in Amsterdam, the annual number of infections with penicillinase-producing Neisseria gonorrhoeae (PPNG) strains remained relatively stable from 1983 until 1990, while the number of non-PPNG infections declined dramatically. To investigate the PPNG and non-PPNG epidemic, a cross sectional study was conducted in 1989 and 1990. The purpose of this study was to assess determinants of PPNG infections among heterosexuals diagnosed with gonorrhoeae. In addition to routinely collected data in new consultations for STDs, information on alcohol use, drug use and sexual behaviour was obtained from patients diagnosed with gonorrhoea. The diagnosis of gonorrhoea was based on a positive culture and isolates were screened for PPNG. Logistic regression analysis was used to assess independent predictors of PPNG infection. Additional information was available of 328 women and 995 heterosexual men diagnosed with gonorrhoea. PPNG was diagnosed in 86/328 (26%) women and in 329/995 (33%) men. Logistic regression analysis identified a Central/South American nationality (odds ratio(OR) = 2.46) and older age (OR = 1.04 per year) as positively associated with PPNG infection in female patients. An inverse relation was found with use of hard drugs (OR = 0.29). Among men diagnosed with gonorrhoea, sexual contacts with window prostitutes (mainly women from Central/South America) (OR = 1.98) and a foreign nationality (OR = 1.78) were positively associated with PPNG infection, and sexual contact with drug using prostitutes (OR = 0.47) inversely. PPNG infections were especially common among Central and South American window prostitutes and their clients, but not among hard-drug addicted prostitutes and their clients. Since window prostitutes originating from Central and South American countries are transient in Amsterdam, prevention activities targeted at these prostitutes and their clients should be continued to limit the spread of PPNG and other STDs within these groups.

The emergence of penicillinase-producing Neisseria gonorrhoeae strains carrying the 4.9 kb (Toronto) plasmid in Denmark and of a novel large plasmid in two nonpenicillinase-producing Neisseria gonorrhoeae strains.

This study comprised plasmid analysis and antimicrobial susceptibility testing of 712 out of a total of 730 penicillinase-producing Neisseria gonorrhoeae (PPNG) and 744 random non-PPNG strains isolated in Denmark between 1985 and 1990. The rate of patients with PPNG infections rose from 1% to 2% during 1985-1987 to 6.9% in 1989, and then decreased to 4.8% in 1990. A decrease in cases of gonorrhea from 9,798 to 1,990 was seen during the same period. Strains harboring the 4.9 kb (Toronto) plasmid first appeared in 1987; in 1988-1990, 65% to 78% of strains from patients with PPNG infections acquired in Denmark contained this plasmid. The majority of these strains seemed to belong to a single clone. Tetracycline-resistant PPNG strains (MIC greater than 32 mg/L) first appeared in Denmark in 1989, and tetracycline-resistant non-PPNG strains carrying a 40 kb plasmid (tetM?) first appeared in 1990. A novel 41-42 kb plasmid appeared in one strain in 1987 and another in 1988. The minimum inhibitory concentration (MIC) of tetracycline for these two strains was 4 mg/l. The significance of this plasmid is yet unknown.

Localized Outbreak of Penicillinase-Producing Neisseria gonorrhoeae

In King County, Washington, penicillinase-producing Neisseria gonorrhoeae infections increased from 0.8% of reported cases of gonorrhea in 1986 to 6.8% of cases in the third quarter of 1987, then stabilized at 2.7% to 3.6% of cases. Of 268 penicillinase-producing N gonorrhoeae isolates tested, 159 (59%) belonged to a single clone, as evidenced by auxotyping, protein-I serotyping, plasmid analysis, and antimicrobial susceptibility testing. As this strain spread, the predominance of cases shifted from whites to blacks and from men to equal numbers of men and women. The proportion of cases associated with illicit drug use rose steadily from 19% in the first quarter of 1987 to 82% in the fourth quarter. Sixty percent of cases occurred in prostitutes or recent sexual contacts of prostitutes. These results suggest that core gonorrhea transmitters in King County are predominantly black illicit drug users, prostitutes, and their sexual partners. These are priority target populations for behavioral intervention and other measures to control the spread of all sexually transmitted diseases, including human immunodeficiency virus infection.

Epidemiologic aspects of control of penicillinase-producing Neisseria gonorrhoeae.

Although first identified in 1976, penicillinase-producing Neisseria gonorrhoeae (PPNG) began to have significant epidemiologic impact in the United States only after 1980. The epidemic curve has been marked by a series of successive sigmoidal increases, the result of staggered epidemic activity in Los Angeles, California, New York, New York, and Miami. The most recent increase and current plateau has led to a provisional total of 16,608 cases for 1986, with the proportion of PPNG isolates as high as 30% in some communities. The intensity of PPNG transmission appears to parallel that of gonorrhea in general, with high attack rates in central city areas (i.e., among core groups) and with a dimmishing gradient outward from the center. The endemicity of PPNG is related in a general way to the size of the inoculum. A county experiencing seven cases in a month at the time of introduction, for example, has less than a 50% probability of reverting to zero cases during the next 12 months. It would appear that the inoculation of PPNG organisms into a community leads to a "take" when high-level transmitters of gonorrhea are affected. Though current projections suggest as many as 35,000-40,000 cases of PPNG infections by 1991, control programs that focus resources on core-group transmitters of gonorrhea may alter that course.

Epidemiology of PPNG infections in the Netherlands: analysis by auxanographic typing and plasmid identification.

We carried out auxanographic typing and plasmid identification on 1380 isolates of penicillinase producing Neisseria gonorrhoeae (PPNG) isolated in the Netherlands in 1982 and found four plasmid patterns and 24 auxotypes with noticeable local or regional variations. Among 756 strains harbouring the 3 X 2 megadalton (Mdal) resistance plasmid ("African" type), with or without the 24 Mdal transfer plasmid, 667 (88%) were non-requiring and inhibited by phenylalanine. This type was endemic in most of the cities or regions we studied. Twenty methionine requiring PPNG strains were found, all harbouring the 3.2 and 24 Mdal plasmid; virtually all of them were isolated or contracted in the region of Groningen. The predominant (443 (71%) auxotype among the 624 PPNG strains containing the 4.5 Mdal plasmid ("Asian" type) (with or without the 24 Mdal plasmid) was proline requiring. This auxotype (with the 4.5 Mdal and 24 Mdal plasmid) caused an outbreak in Amsterdam, and in Groningen replaced the local methionine requiring auxotype which had the 3.2 Mdal and 24 Mdal plasmids. Many auxotypes with the 4.5 Mdal plasmid, and requiring proline only, or proline and isoleucine, circulated in the Hague. Spread of imported strains by prostitution played an important part in the epidemiology of infection with PPNG strains.

Epidemiology of PPNG infections in Amsterdam: analysis by auxanographic typing and plasmid characterisation.

In January 1981 the incidence of penicillinase producing Neisseria gonorrhoeae (PPNG) strains in Amsterdam had increased to 18% of all new cases of gonorrhoea. Auxanographic typing in combination with plasmid determination of 729 PPNG strains showed that in 1981 the predominant and endemic types were those with the Africa plasmid and transfer factor which were non-requiring and inhibited by phenylalanine. In 1982 proline requiring strains with the Asia plasmid and transfer factor increased after being imported and spread by prostitution. Four different plasmid patterns and 12 auxotypes were distinguishable. Unusual auxotypes of both African and Asian plasmid types are frequently imported, some disappearing soon after their introduction into Holland but others providing an opportunity to trace sources and contacts. Prostitution and the biological properties of PPNG strains seem to play an important role in their spread. Only 2.6% of them were isolated from homosexual men. In areas where PPNG strains are prevalent, auxotyping is an important tool in their surveillance.

Epidemiology of penicillinase-producing Neisseria gonorrhoeae in Liverpool from 1977 to 1982

After the 1976 outbreak of penicillinase-producing Neisseria gonorrhoeae (PPNG) infections had been controlled, less than 1 per cent of cases of gonorrhoea in Liverpool in 1977 and 1978 were caused by PPNG. Thereafter the steady increase in PPNG infections to 5.6 per cent of all cases in 1982 was associated with marked changes in epidemiological pattern, plasmids and auxotypes. In 1976 nearly all PPNG infections were acquired by young black males living in the inner city from women frequenting clubs; the PPNG were all of the African 3.2 megadalton (MD) plasmid type and of arginine-requiring auxotype. Between 1977 and 1982 female patients were increasingly ship girl prostitutes associating with seamen who constituted more than 50 per cent of the male patients. These men and other travellers introduced PPNG into Liverpool from the Far East and West Africa. In 1978 PPNG of the Asian type with 4.4 MD plasmid with or without 24.5 MD transfer plasmids were isolated in Liverpool where in 1979 all PPNG carried 4.4 MD and 24.5 MD plasmids. In 1982 strains of the 'new' African type with 3.2 and 24.5 MD plasmids were isolated as were PPNG of the Asian type that had been acquired in West Africa. Auxotyping of the 1982 isolates showed that none were arginine-requiring but three other types were identified: proline-requiring: proline-arginine-requiring; non-requiring. For the control of PPNG, a strategy based on constant vigilance, appropriate diagnostic procedures, rapidly effective treatment and determined contact tracing is needed.

Update on Treatment Recommendations For Gonococcal Infections

Since the Centers for Disease Control (CDC) last established recommendations for treating gonococcal infections in 1979 [1], new information gained from studies recently conducted and from feed-back provided by practitioners has suggested certain revisions. An area of major concern is the treatment of infections caused by penicillinaseproducing Neisseria gonorrhoeae (PPNG). Since these infections and their associated complications are increasing [2], a review of the current alternatives for effective treatment of PPNG infections is particularly important at this time. This paper will be a review of recent English language reports related to the following sections of CDC's 1979 recommended treatment schedules for gonorrhea: uncomplicated gonococcal infections, PPNG infections, and the prevention of gonococcal ophthalmia. Other sections of the 1979 treatment schedules for gonorrhea will be discussed elsewhere in this series of position papers. Recommendations remain essentially the same in four areas: treatment in pregnancy, disseminated gonococcal infection, neonatal disease, and gonorrhea in childhood, although new treatment schedules for PPNG infections in these groups are suggested.

Epidemiology of penicillinase-producing Neisseria gonorrhoeae in Singapore.

The number of infections with penicillinase-producing Neisseria gonorrhoeae (PPNG) strains in Singapore has risen from three in 1976 to 1792 in 1979. In the latter year they formed 19.2% of all infections with gonorrhoea, and 1280 of the strains isolated were from female prostitutes. The prevalence of PPNG infections is analysed according to the different sections of the community and racial groups. Despite energetic control measures PPNG strains are not being contained within Singapore. Thus global dissemination from such a busy port and tourist centre is a real danger.

HR 756--a new cephalosporin in the treatment of gonorrhoea caused by ordinary and penicillinase-producing strains of Neisseria gonorrhoeae.

HR 756, a new cephalosporin, was used in single intramuscular doses of 500 mg to treat 108 men and women with gonorrhoea caused by penicillinase-producing Neisseria gonorrhoeae (PPNG) and non-PPNG. Of 102 patients followed up, 99 (97.05%) were cured. Cure rates for PPNG infections and non-PPNG infections were 98.18% and 95.74% respectively. Few adverse side effects were recorded but possible cross-sensitisation with penicillin was observed. Clinical and laboratory antibiotic susceptibility results correlated well. It is concluded that this drug is safe and effective in treating both PPNG and non-PPNG infectons.