Single dose (direct observed) azithromycin therapy for Neisseria gonorrhoeae and Chlamydia trachomatis in STD clinic attenders with genital discharge in Trinidad and Tobago

The purpose of this study was to determine the prevalence and to assess the efficacy of a single one gram oral dose of azithromycin under direct observed therapy of genital discharge due to Neisseria gonorrhoeae and Chlamydia trachomatis infections in STD clinic attenders in Trinidad and Tobago. All patients with genital discharge and their contacts were given one gram oral dose of azithromycin under direct supervision after collection of urethral and cervical swabs for N gonorrhoeae culture and smear and for C trachomatis antigen detection by ELISA. Clinical and microbiological evaluation was done on those who returned after 7 to 10 days for follow up. Of the 735 patients who were enrolled in the study, 319 (43.4 percent) had N gonorrhoeae and 100 (13.6 percent) had C trachomatis. Only 151 (36 percent) of the 419 patients with a pathogeneic isolate returned for clinical and microbiological assessment. The remaining 268 (64 percent) of the 419 patients were lost to follow up. One hundred and forty three patients (94.7 percent) had total abatement of signs and symptoms after taking azithromycin. One patient (0.65 percent), who had both N gonorrhoeae and C trachomatis, improved clinically with the drug. Seven patients (six with N gonorrhoeae and one with C trachomatis) failed to respond clinically to azithromycin. Microbiological eradication was achieved in 115 (100 percent) patients who had single infection with N gonorrhoeae and in 23 patients (96 percent) with C trachomatis infections, N gonorrhoeae and C trachomatis were eradicated in 10 and 12 patients, respectively, after initial treatment. In two patients with combined infection, N gonorrhoeae continued to be isolated after treatment with azithromycin. A single one gram oral dose of azithromycin under direct supervision is useful in the treatment of uncomplicated genital infection with N gonorrhoeae and C trachomatis in STD clinic attenders in Trinidad. (AU)

Chlamydial and gonococcal infections in Curacao: prevalence and determinants

OBJECTIVE: To determine prevalence and determinants of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections among asymptomatic women and men in Curacao. DESIGN AND METHODS: This was a cross-sectional population-based study. Urine samples (n=579) were collected from Antillean people, > 18 years, randomly selected from participants of a 1994 population survey (the Curacao Health Study, n=2,248). For the detection of CT and Erasmus Medical Center, Rotterdam. RESULTS: CT and NG infections were found in 6.1 percent and 1.0 percent of samples, respectively. Concomitant CT and NG infection did not occur. Most CT infections were found in persons <44 years of age, the highest prevalence was found in the 18-24 year age group, 17.4 percent (13/75). In contrast, most NG infections were found in persons >44 years. CT infection, but not NG infection, was correlated with indices of low socio-economic status. Multiple regression confirmed the association of CT infection with age and socio-economic class. CONCLUSION: In Curacao, CT and NG infections are not epidemiologically linked. CT infection is highly prevalent and calls for a screening-intervention model based on prevalence and risk factors. (Au)

Epidemiology of non-ulcerative sexually transmitted diseases in a high risk population in Jamaica

The role of ulcerative STDs such as syphilis in facilitating the transmission and acquisition of HIV is well established. Non-ulcerative STDs such as gonorrhoea and Chlamydia infection are considered facilitators of HIV transmission. This study was designed to determine the types of non-ulcerative sexually transmitted diseases and associated risk factors among high-risk Jamaican men and women. A cross-sectional survey was conducted including 510 clients attending an STD clinic in Kingston. A standardised questionnaire was administered and microbiological investigations performed on urethral or cervical swab specimens obtained from each participant. All the subjects were symptomatic; 377 (74 percent) had genital discharge and 197 (39 percent) had dysuria with or without discharge. There were 309 cases of NGU; 115 cases of Candidiasis, 275 confirmed gonococcal infections and 226 cases of Trichomoniasis. Men were two times more likely to have gonococcal infection than women (69 percent vs. 50 percent; p<0.01). History of smoking marijuana was significantly associated with a positive test for gonorrhoea (69 percent vs. 52 percent; p<0.01). Forty one percent of women reported that their partners never used condoms (41 percent vs. 19 percent; p<0.01). Only nine men acknowledged consistent condom use. Those who were first time attendees at the STD clinic (n=263) were more likely to report never using condoms (38 percent vs. 27 percent; p<0.01). These data highlight the need for priority targetting in this high-risk group for counselling and health education in controlling, STD and HIV infection in Jamaica.(AU)

High burden of antimicrobial resistance in Neisseria gonorrhoeae in the Caribbean, 1994-96: implication for the National STD Prevention and Control Programme

Gonorrhoea remains an important source of morbidity in the Caribbean. Despite decreasing rates of gonococcal infection, the proportion of isolates which are resistant to antimicrobials has increased dramatically in developing and developed countries. The objective of this study was to obtain reliable data on trends in antimicrobial susceptibility patterns and to identify new resistant strains through the surveillance network for gonococcal antimicrobial resistance patterns in the Caribbean. The prevalence rate of penicillinase producing N. gonorrhoeae (PPNG) ranged between 4 percent and 64 percent in isolates from 1994 to 1996 in 12 countries surveyed. High rates of PPNG were recorded in Suriname (70 percent), Guyana (77 percent), Bahamas (62 percent) and Barbados (57 percent). St Lucia was the only country not reporting the presence of PPNG. High levels of tetracycline resistant N. gonorrhoeae (TRNG) were present in four countries. Fifty-seven percent of N. gonorrhoeae isolates in Guyana were TRNG. The MIC50 and 90 to ciprofloxacin and ceftriaxone were 2-4 times higher in PPNG isolates than MICs for susceptible strains in three countries. The total burden of antibiotic resistance (penicillin and tetracycline) ranged from 42.5 to 92.9 percent in three countries. This study clearly demonstrates the need for monitoring of antimicrobial susceptibility pattern of N. gonorrhoeae for successful implementation of national guidelines for the treatment of genital discharge syndrome.(AU)

Antibiotic susceptibility of Neisseria gonorrhoeae in Trinidad and Tobago

Treatment failures with standard doses of penicillin have been observed in the Sexually Transmitted Diseases (STD) clinics in Trindad and Tobago. In the absence of an ongoing surveillance system, the antimicrobial susceptibility of 518 Neisseria gonorrhoeae strains was determined in order to guide treatment. 39 (7.6 percent) strains were resistant to penicillin, including 27 (5.2 percent) positive for beta-lactamase; that is penicillinase-producing Neisseria gonorrhoeae (PPNG). 51 (10 percent) strains were resistant to tetracycline, with 26 (5.0 percent) of these exhibiting high levels of resistance compatible with tetracycline resistant Neisseria gonorrhoeae (TRNG). Six strains showed evidence of having both PPNG and TRNG plasmids, and five strains showed chromosomally-mediated resistance to both penicillin and tetracycline. The overall resistance rate to penicillin and tetracycline was 17.7 percent. There was no resistance to spectinomycin, cefuroxine, ceftriaxone and norfloxacin. The resistance rates demonstrated in this study are sufficently significant to preclude the use of penicillin and tetracycline in the STD clinics and to justify the use of newer antimicrobials. It is essential that resistance patterns be monitored by continued surveillance.(AU)

Sexual mixing patterns of patients with Gonorrhoea: is there a core group?

BACKGROUND: Epidemics of sexually transmitted infections are maintained by high level transmission amongst `core groups' of individuals, raising the basic reproductive rate to greater than unity. Assortative sexual mixing, that is, choosing partners who are like, rather than unlike, with respect to certain characteristics contributes to the persistent infection with a core group. We have reported high rates of gonorrhoea amongst people from black minority ethnic groups residing in Lambeth, Southwark and Lewisham. OBJECTIVES: To examine assortiveness of sexual mixing according to demographic characteristics of patients with heterosexually acquired gonorrohoea. SETTING: The Caldecot Centre, Department of Genitourinary Medicine, King's Healthcare. SUBJECTS: 287 heterosexual clinic attendees participating in contact tracing interviews for microscopy or culture proven gonorrhoea from 06/03/95 to 12/01/96 MAIN OUTCOME MEASURES: Matrices formed by cross-tabulation of ethnicity, residence and social class of gonorrhoea index cases and their most recent sexual partner. Assortativeness measured by Q1, a value ranging from zero (random mixing) to one (completely assortative). RESULTS: there were 120 (42 percent) female and 167 male respondents. 67 percent of female cases and 74 percent of male cases were of self-reported black Caribbean ethnicity. 48 percent of relationships with the most recent partner were temporarily concurrent with another partnership (48 percent of black cases versus 29 percent of white cases, p=0.19). Values of Q in women and men, respectively were: ethnicity, 0.64 and 0.60: borough of residence, 0.56 and 0.53; social class, 0.39 and 0.35; age group 0.37 and 0.47. CONCLUSIONS: Concurrency of sexual partnerships is common in individuals with gonorrhoea with a trend towards increased concurrency amongst those from black ethnic groups. Assortativeness in the selection of sexual partners is most evident for ethnic group and geographic area. These factors may contribute to the disproportionate number of individuals of black Caribbean ethnicity with gonorrhoea in South East London. Further work is required to examine the attitudes and practices with members of different ethnic groups with respect to sexual relationships and behaviours. Culturally appropriate interventions to reduce the burden of sexually transmitted infections should be targeted to high risk geographic areas.(AU)

Antibiotic sensitivity of neisseria gonorrhoeae isolates in Barbados; longitudinal surveillance 1990-1994

The antimicrobial susceptibility of 775 isolates of Neisseria gonorrhoeae, recovered in Barbados over a five-year period, was studied by disc diffusion. Sensitivity to penicillin declined from 56 percent in 1990 to 38 percent in 1994. The prevalence of á-lactamase production rose from 30 percent to 50 percent during this period and sensitivity to tetracycline declined from 96 percent to 46 percent, while co-trimoxazole and spectinomycin sensitivities varied. Ceftriaxone, norfloxacin and erythromycin were the only compounds tested to which sensitivity remained uniform. The results confirm the current recommendations by several agencies that ceftriaxone or an oral fluoroquinolone should be considered the drug of choice for the empirical treatment of gonorrhoea (AU)

Antimicrobial sensitivities of Neisseria gonorrhoeae isolates in Barbados - abstract

Treatment of gonorrhoeae is almost invariably accomplished with a single dose regimen, because of the nature of the STD population. A knowledge of gonococcal sensitivities is therefore important, particularly if resistance to the standard treatment regimes occurs. Strains of Neisseria gonorrhoeae islolated at the Barbados Public Health laboratory are tested routinely for sensitivity to a range of agents by disc diffusion. The compounds tested include penicillin, erythromycin, tetracycline, co-trimoxazole and spectinomycin. Since 1990, ceftriaxone, norfloxacin and cefuroxime have been added. In addition, production of the plasmid-mediated á-lactamase was detected using a chromogenic substrate. During the four-year-period 1990 - 1993, sensitivity to penicillin varied between 35 percent and 56 percent. The prevalence of penicillinase-producing Neisseria gonorrhoeae (PPNG) was high, exceeding 40 percent in 1992 and 1993. During the period of this study, there was a marked increase in the prevalence of resistance to tetracycline and a concomitant increase in sensitivity to co-trimoxazole. Significant in vitro resistance to spectinomycin was encountered. All isolates were sensitive to erythromycin, norfloxacin, cefuroxime and ceftriaxone. These findings emphasise that penicillin or ampicillin are not good choices for empirical therapy of gonorrhoea in Barbados. A á-lactamase stable cephalosporin or a fluoroquinolone should be the drug of choice (AU)

Susceptibility of neisseria gonorrhoeae to selected antimicrobial agents in Trinidad and Tobago - abstract

Treatment failures of 20 percent with standard doses of penicillin have been observed in our sexually transmitted disease (STD) clinics in the treatment of gonorrhoea. A large number of Neisseria gonorrhoeae strains (547) from various STD clinics were tested against selected antimicrobials in order to determine the most appropriate alternative treatment regimen. Using an agar dilution technique and testing for the presence of beta-lactamase production, it was determined that less than 1 percent of Neisseria gonorrhoeae strains were sensitive to penicillin, 85 percent were moderately sensitive and 15 percent were completely resistant to penicillin. More than 5 percent of the strains produced beta-lactamase. Tetracycline resistance was seen in 57 percent of the strains, and 7.3 percent of the strains were resistant to cefuroxime. There was no resistance to spectinomycin, ceftriaxone or norfloxacin. STD clinics in Trinidad and Tobago can no longer rely on penicillin and tetracycline in the treatment gonorrhoea. Protocols will have to include spectinomycin, ceftriaxone or norfloxacin (AU)

Chlamydial infections in selected populations in Jamaica

The importance of Chlamydia trachomatis as a cause of genital tract infection in Caribbean countries is largely unknown. Two hundred and sixteen cervical and urethral specimens were collected from patients with cervicitis and urethritis attending a Sexually Transmitted Diseases (STD) Clinic, a Gynaecology Clinic and a Family Planing Clinic in Kingston. Specimens were tested for chlamydiae by direct immunofluorescence and cell culture methods. They were also investigated for N. gonorrhoeae infections. Seventy-two of 138 patients (52.2 percent) at the STD Clinic were positive for chlamydiae; 28 of 50 ((56.0 percent ) from the Gynaecology Clinic and 11 of 28 (39.3 percent) from the Family Planning Clinic were positive. The prevalence of C. trachomatis (52.3 percent) was higher than that of N. gonorrhoeae (11.1 percent) in all groups. The results indicate that C. trachomatis is a common cause of genital tract infections in Jamaica(AU)

Treatment of gonorrhoea and susceptibility to antimicrobials of PPNG and non-PPNG strains in Jamaica

Of 1400 patients in Jamaica screened for uncomplicated gonorrhoea, 54 percent (753 patients) were culture positive. Of the 459 patients who complied with the terms of the study, 97 percent (211/218) of those treated with ampicillin G were cured compared with 94 percent (227/241) of those treated with ampicillin. Penicillinase producing Neisseria gonorrhoeae (PPNG) strains were identified for the first time during the study, and 10 patients infected with PPNG strains (two treated with penicillin, eight with ampicillin) contributed to the 21 treatment failures. The in vitro susceptibility of eight antimicrobial agents for 629 non-PPNG and 20 PPNG strains was estimated. Of the non-PPNG isolates, 8 percent had an Mic of 1mg/1 or more of pencillin, 11 percent were resistant to this concentration of cefuroxime 32 percent to tetracycline, and under 1 percent to the same concentration of cefuroxime and erythromycin. Fever than 2 percent of the isolates were resistant to 2 mg/1 or more thiamphenicol, and all isolates were susceptible to spectinomycin and trimethiprimsulphamethoxazole (at a ratio of 1:19). Significantly more strains from the 21 treatment failures were resistant to penicillin (52 percent) or ampicillin (62 percent) compared with 7 percent strains resistant to pencillin and 4 percent to ampicillin from the successfully treated group.(AU)

Auxotypes, plasmid contents, and serovars of gonococcal strains (PPNG and non-PPNG) from Jamaica.

The analysis of the auxotypes and plasmid profiles of 459 non-PPNG strains from Jamaica suggest that strains have been imported to the island. Unlike in many developing countries where strains are differentiated by only a few auxotypes, 13 different auxotypes were identified in the non-PPNG strains. In Jamaica over 10 percent of the strains were plasmid free and required proline, citrulline, and uracil (PCU-)for growth. These isolates predominate in Canada and are increasingly reported from areas of the United States of America and Europe. The serological analysis of 168 of the non-PPNG strains indicated that most (76 percent, 128) were from serogroup WII/III. Serogroup WII/III strains comprised 17 serovar combinations with GS and PH reagents, whereas serogroup WI strains included only four serovars. Unusually, most WI Aedgkih non-PPNG strains were wild type or proline requiring. Strains of serovar Aedg were especially noted (in 93 percent, 13/14) for carriage of the transfer plasmid. The first 20 PPNG strains isolated in Jamaica proved to have multiple origins as they had eight variations of auxotype, serovar, and plasmid content. Most (60 percent, 12/20) of those isolated were typed as serogroup WI, and 10 of these isolated were serovar Aedfkih. Although most (70 percent, 14/20) PPNG strains harboured African type plasmids with or without transfer plasmids, six also carried Asian type plasmids (with the transfer plasmid).(AU)

Antibiotic resistance of N. gonorrhoeae in Jamaica - abstract

A total of 885 women and 515 men, who were symptomatic, were screened by culture for gonorrhoea. Men were screened initially with Gram stain. Of these, 313 women and 440 men were proven to have uncomplicated gonorrhoea and were randomly assigned to treatment with procaine penicillin (4.8 mega units) or ampicillin (3.5g) each with probenecid (1g). Of this number, 61 women and 120 men were subsequently excluded from the study, leaving 252 women and 320 men for analysis. In this report, only the first 148 men are analysed. Test of cure (TOC) was performed 3-7 days post-treatment. One hundred and eighty women and 129 men completed treatment and follow-up within this period. The TOC was done after 7 days in 72 women and 19 men; these late returnees were analysed separately. Eliminating the late TOC cases, the total failure rates for penicillin and ampicillin were 4.8 percent and 4.3 percent respectively; for men 5.2 percent and 7.0 percent, for women 4.5 percent and 2.2 percent. Of the 14 failures to both regimes followed up within 7 days, 5 had PPNG infections, 2 were reinfections and 1 had pelvic complications. Urethral swabs from males and endocervical swabs from females were inoculated on to Thayer-Martin medium and gonococcal isolattes were identified by standard methods. Isolates were tested for penicillinase production using chromogenic cephahalosporin. Using the agar dilution technique and supplemented Protease No. 3 agar, the MICs to penicillin, ampicillin, spectinomycin, tetracycline, erythromycin, sulfamethoxazole-trimethoprim (19:1), cefuroxime and thiamphenicol were determined on isolates from these patients. Preliminary data on the determination of auxotype indicated that the prototrophic and proline-requiring groups comprised over 60 percent of the isolates tested to date. However, several other auxotype groups, especially Orn- and Pro-Cit-Ura-, were prevalent as well. Plasmid analysis of the strains indicated that all the Pro-Cit-Ura- isolates were plasmid-free, a result noted by others, and that 26 percent of the isolates carried transfer plasmids. To date, 16 PPNG cases have been detected among the 440 male cases, and 1 among 277 female cases. The PPNG isolates harboured either the African (3.2 Md) or the Asian (4.8 Md) penicillinase-producing plasmids. This is the first time that PPNG strains have been identified in Jamaica (AU)

Antibiotic resistance of Neisseria gonorrhoeae in Jamaica compared with the United States

The antibiotic sensitivity of 113 strains of N. gonorrhoeae collected in Kingston and Montego Bay in 1978 was compared to that of 26 strains collected in Kingston in 1971. In 1971, 38 percent of the gonococcal isolates in Jamaica grew in the presence of >0.25 æg/ml of penicillin (0.4 units) compared to only 8.9 percent in 1978. A similar decrease in the level of tetracycline resistance (MIC>1.0 æg/ml) was also seen from 1971, when 31 percent of gonococcal isolates were resistant, to 1977 when only 13.4 percent were resistant. The percentage of antibiotic resistance of strains of N. gonorrhoeae in Jamaica was higher than were contemporary isolates from the United States in both 1971 and 1978. The level of penicillin and tetracycline resistance of the 1978 strains were less than those of the 1971 strains, but were higher as a group than contemporary gonococci isolated in the United States (AU)

Penicillin and tetracycline sensitivity of Jamaican strains of gonococci

The sensitivity of penicillin and tetracycline of 53 strains of gonococci isolated in the Summer of 1971 from routine cases in a clinic in Kingston, Jamaica, has been determined. The level of sensitivity of Jamaican strains to these antibiotics was remarkably similar to the sensitivity to these antibiotics of routine strains isolated over the United States in 1970-71. There was a remarkable correlation of sensitivities to penicillin and tetracycline of individual strains. The similarity of sensitivity of strains in Jamaica to the sensitivity of strains in the United States and the good correlation of the degree of sensitivity of individual strains to the two drugs lend support to the hypothesis of Sparling (1972) and of Maness and Sparling (1973) of a common genetic pathway responsible for the development of most cases of resistance to these antibodies (AU)

Gonococcaemia with arthritis, dermatitis and myocarditis

Six cases of gonococcaemia seen at the University Hospital of the West Indies are described. All presented with polyarthritis and all but one had skin lesions. They varied widely in severity and chronicity and included one case with rigors and myocarditis. Emphasis is placed on the diagnostic value of the scanty skin lesions, and the importance of repeated examination of cervical swabs (Summary)

Clinical gonorrhoea in the female: laboratory findings

The practice of treating females with vaginal discharges and other pelvic symptoms, on the basis of a presumptive diagnosis of "Clinical gonorrhoea" without attempting to obtain adequate laboratory tests for N. Gonorrhoea, T. Vaginalis and C. Albican in female patients. All of whom had reported to a V. D. Clinic, (some because they were reported as contacts of male gonorrhoea patients), and who had been selected for penicillin treatment. All had vaginal discharges and other evidence of genital disease. The study was carried out at the Comphrensive Health Centre in Kingston, Jamaica. Tests for Gonorrhoea included cervical and vaginal gram-stained smears and cervical cultures. Due to shortages of media and personnel, cultures for the comparison of smear and cultures involved, for about half of the female studied, a single Transgrow bottle culture from the cervix and for the other half a Transgrow bottle culture and also a small (5.5cm) Thayer-Martin plate. Other patients had a rectal culture on a small Thayer-Martin plate also. These were included not alo in the comparison of results with overall tests for N. Gonorrhoea, E. Baginalis and C. Albicans. Transgrow cultures were incubated immediately. Tests for T. Vaginalis included wet preparations and cultures on "Trichomonas medium". Tests for C. Albicans involved cultures on Sabouraud's agar with yeast identified as C. Albicans by the germination test as described by Taschdjian and associates. A total of 107 or 45.9 percent of 233 females had positive tests for gonorrhoea. (In three of these the test were doubtful). 104 or 44.6 percent had positive tests for T. Vaginalis; 72 or 30.9 percent had positive tests for C. Albicans. Overall, 187 patients or 80.2 percent were positive (or doubtful) to one or more tests and 46 or 19.8 percent were negative to all three. Patients with mixed infections were: N. gonorrhoea + T. Vaginalis - 15.4 percent, n. gonorrhoea + C. Albicans - 7.3 percent, N. gonorrhoea + C. Albicans T. Vaginalis - 6.4 percent, T. Vaginalis + C. Albicans - 5.6 percent. Of 92 or 41.8 percent of a total of 220 females studied, and who were positive or doubtful, only 40 or 18.2 percent of the total had positive or doubtful smears, while 52 or 23.6 percent of the total had only positive cultures. The latter would have been missed had smears alone been done. (i.e. 56.5 percent of cases). Of 94 or 44.3 percent of 212 females studied by T-M and Transgrow media, 76 had both tests positive. A total of 18 had one test positive, 7 with Transgrow and 11 with T-M. Of 104 patients who had both rectal and cervical cultures, 8 or 7.7 percent had only the rectal culture positive. There were 23 positive rectal cultures compared with 51 cervical positives out of a total of 59 with positive cultures. Of 140 patients with Trichomonal infestation, 107 had positive wet preparations while 114 had positive cultures. The advantage of culture over wet preparation is therefore but slight. It is clear that smears are inadeqate as anything more than supplementary diagnostic aids and that cultures for gonorrhoea are absolutely essential in the diagnosis of gonorrhoea in the female. Rectal cultures were found to add substantial increase (15.7 percent) to the number of positive cases when used in conjunction with cervical cultures. This must be clear to all physicians and cultures made available for their use(AU)