Plasmid patterns and antimicrobial susceptibilities of Neisseria gonorrhoeae in Bandung, Indonesia.

Antimicrobial susceptibilities of Neisseria gonorrhoeae isolates from female sex workers and from men with urethritis in Bandung, Indonesia, were determined by an agar dilution technique. Typing of the Tet M plasmid in tetracycline-resistant isolates (TRNG) was performed using a polymerase chain reaction (PCR) technique and plasmid profiles of penicillinase-producing isolates (PPNG) were determined. All PPNG possessed the 4.4 MDa beta-lactamase plasmid and all TRNG showed a PCR fragment characteristic of the 'Dutch' type Tet M plasmid. Of the 50 gonococci isolates tested, all were resistant to tetracycline; 47 were TRNG, 26 were PPNG, and 6 were resistant to thiamphenicol. Chromosomal resistance to penicillin was not detected. All isolates were susceptible to ceftriaxone, ciprofloxacin, norfloxacin, ofloxacin, kanamycin, spectinomycin, and trimethoprim/sulfamethoxazole. Spectinomycin and fluoroquinolones are useful primary drugs for treatment of gonococcal infection in Bandung. Continued surveillance of antimicrobial resistance should be part of gonorrhoea control in Indonesia.

Evaluation of syndromic patient management algorithm for urethral discharge.

OBJECTIVE: To determine feasibility, validity, and cost effectiveness of the syndromic approach to male patients with urethral discharge in Bandung, Indonesia. METHODS: The WHO algorithm on urethral discharge with no microscopy available was evaluated. Patients presented with a complaint of urethral discharge and if discharge was confirmed the algorithm was applied. Treatment covered gonococcal and chlamydial infection (ciprofloxacin 500 mg single oral dose plus doxycycline 100 mg, twice daily orally for 7 days). The gold standard for validation was gonococcal culture and chlamydia antigen detection. RESULTS: 140 male patients with a complaint of urethral discharge were enrolled; 119 had confirmed discharge and entered the decision tree: 107 were followed and 104 (97%) were clinically cured. Of the three patients with persistent discharge, one had a purulent urethral discharge, diagnosed as gonococcal urethritis and he was probably reinfected; two patients had a serous discharge and microbiological tests were negative. Overall, 106 out of 107 patients (99%) were microbiologically cured. Sensitivity of the algorithm is 100% and its positive predictive value (PPV) is 75% or 97% if validated against gold standard microbiological tests or Gram stain, respectively. Cost per patient is rupiah (Rp)5.894 ($US2.56) for the algorithm compared with Rp43.024 ($18.70) for full microbiological diagnosis. The cost estimate for an algorithm of urethral discharge with microscopy available is Rp6.432 ($2.80) CONCLUSION: The "symptom and sign" algorithm is fully adapted to the prevailing situation in primary healthcare settings, is acceptable to healthcare workers and patients (who are effectively treated at their first visit), is highly cost effective, is 100% sensitive (no false negatives, which is not the case with microbiological diagnosis), and has a high PPV, between 75% and 97%. It is an excellent patient management tool and a sound basis for partner notification so that it should have a major impact on STD/HIV control and prevention in both men and women.