Infectious Disease

First US case of gonorrhea with novel resistance gene recognized in Nevada

December 26, 2020

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The first case of Neisseria gonorrhoeae with the nascent mosaic PenA60 allele, which confers reduced susceptibility to cefixime and ceftriaxone, was identified in the United States, according to a recent study.

Michael A. Picker

“This isolate was captured and tested during routine procedures for the CDC’s Gonococcal Isolate Surveillance Project (GISP).” Michael A. Picker, PhD, Healio said, a microbiology supervisor at the Southern Nevada Public Health Laboratory.

In an MMWR report, Picker and colleagues reported that the urethral isolate was collected in October 2019 from an HIV-negative, heterosexual man with penile discharge and dysuria. They said the man had been treated with the then-recommended ceftriaxone regimen, given intramuscularly plus oral azithromycin. (This combination therapy is no longer recommended. In updated guidelines, the CDC recently recommended giving ceftriaxone alone – without azithromycin – for the treatment of uncomplicated gonorrhea. It is recommended that 100 mg oral doxycycline – not azithromycin – be given twice daily for 7 days, in which a chlamydial co-infection could not be ruled out.)

According to Picker and colleagues, nucleic acid amplification tests (NAATs) and cultures taken from the patient’s rectum and pharynx were negative for N. gonorrhoeae.

After the sensitivity results of the urethral isolate, which showed decreased sensitivity to cefixime and ceftriaxone but was nonetheless susceptible to azithromycin, were confirmed by CDC in late November 2019, additional molecular testing by the CDC revealed the emerging mosaic PenA60 allele, the first in Japan identified in 2018 was identified in 2016 and later in China, Canada, Denmark, Australia, France and the UK.

Picker and colleagues said the results of an investigation showed that the man acquired the infection locally, “but the origin of the isolate remains unclear,” they wrote. The isolate’s minimum inhibitory concentration for ceftriaxone was the highest observed in the 34 years that GISP monitored the susceptibility of ceftriaxone and other antimicrobial agents.

To identify other cases of N. gonorrhoeae with the penA60 allele in southern Nevada, the CDC’s Southern Nevada Health District provided all NAAT-positive samples of N. gonorrhoeae from all of its clinics to the CDC by December 2019. No other cases of culture-independent molecular testing were identified.

“The development of antibiotic resistance in N. gonorrhoeae and other bacterial pathogens in general can adversely affect patient outcomes,” Picker said. “The identification of this antibiotic-resistant strain of N. gonorrhoeae in Nevada in 2019 underscores the utility and importance of surveillance programs such as the GISP as an effective tool for identifying emerging antimicrobial-resistant pathogens.”

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