Resistência de Neisseria gonorrhoeae a antimicrobianos na prática clínica: como está o Brasil? / Antimicrobials resistance of Neisseria gonorrhoeae in clinical practice: where Brazil stands?

Estima-se que um milhão de infecções sexualmente transmissíveis (IST) sejam adquiridas por dia no mundo, segundo a Organização Mundial da Saúde. Elas podem ser causadas por diversos micro-organismos pelo contato sexual. Embora tratáveis, as infecções, como a clamidiana, sífilis, tricomoníase e gonorreia, são responsáveis por 350 milhões de novos casos de IST anualmente no mundo. A gonorreia é a segunda IST bacteriana mais prevalente no planeta e tem chamado atenção nos últimos anos em decorrência da baixa eficácia em seu tratamento. O agente etiológico é a Neisseria gonorrhoeae. Na maioria das mulheres, a infecção por esse micro-organismo é assintomática, dificultando ainda mais seu diagnóstico e tratamento e, portanto, aumentando o risco de desenvolvimento de suas complicações associadas. Mesmo quando diagnosticada, essa infecção está sujeita a um alto índice de insucesso terapêutico que se deve, principalmente, à grande plasticidade genética da N. gonorrhoeae para aquisição de genes cromossômicos ou plasmidiais de resistência. O aumento da resistência desse micro-organismo a antimicrobianos comumente utilizados no tratamento, como penicilina, tetraciclina e ciprofloxacina, tem sido relatado em diversos países. No Brasil, poucos estudos estão disponíveis, mas em alguns estados já foram relatadas linhagens resistentes à ciprofloxacina. Dessa forma, deve-se ressaltar a importância de novos estudos que visem descrever o perfil da resistência da N. gonorrhoeae a antimicrobianos. Tais achados certamente nortearão a implementação de sistemas de vigilância epidemiológica no país visto que, até o momento, as infecções por N. gonorrhoeae sequer estão incluídas na lista nacional de doenças e agravos de notificação compulsória.(AU)

According to the World Health Organization, approximately one million sexually transmitted infections (STI) are acquired daily in the world. These infections can be caused by several microorganisms via contact. The treatable STI, such as chlamydia, syphilis, trichomoniasis and gonorrhea, account for 350 million new cases of STI each year worldwide. Gonorrhoea is caused by Neisseria gonorrhoeae and is the second most common bacterial STI in the world. It has drawn more attention in the last years due to the low efficacy in its treatment. Most women with this infection are asymptomatic, which makes its diagnosis and treatment troublesome increasing the risk for its associated complications. Even when diagnosed, this infection is subject to a high rate of therapeutic failure mainly due to the great genetic plasticity of N. gonorrhoeae for the acquisition of chromosomal or resistance plasmid enes. Increased resistance of this microorganism to antimicrobials commonly used in treatment such as penicillin, tetracycline and ciprofloxacin has been reported in several countries. In Brazil, few studies are available, but in some states strains resistant to ciprofloxacin were alreadyreported. The refore, it is important to highlight the importance of new studies aimed at describing the resistance profile of N. gonorrhoeae to antimicrobials in Brazil context. These findings will certainly guide the implementation of epidemiological surveillance systems in the country, since until now N. gonorrhoeae infections do not figure into the national list of compulsorily notifiable diseases.(AU)

Effectiveness of syndromic management for male patients with urethral discharge symptoms in Amazonas, Brazil

Abstract: Background: Urethral discharge syndrome (UDS) is characterized by the presence of purulent or mucopurulent urethral discharge.The main etiological agents of this syndrome are Neisseria gonorrhoeae and Chlamydia trachomatis. Objectives: To evaluate the effectiveness of the syndromic management to resolve symptoms in male urethral discharge syndrome cases in Manaus, Amazonas, Brazil. Methods: Retrospective cohort of male cases of urethral discharge syndrome observed at a clinic for sexually transmitted disease (STD) in 2013. Epidemiological and clinical data, as well as the results of urethral swabs, bacterioscopy, hybrid capture for C.trachomatis, wet-mount examination, and culture for N.gonorrhoeae, were obtained through medical chart reviews. Results: Of the 800 urethral discharge syndrome cases observed at the STD clinic, 785 (98.1%) presented only urethral discharge syndrome, 633 (79.1%) returned for follow-up, 579 (91.5%) were considered clinically cured on the first visit, 41(6.5 %) were considered cured on the second visit, and 13(2.0%) did not reach clinical cure after two appointments. Regarding the etiological diagnosis, 42.7% of the patients presented a microbiological diagnosis of N.gonorrhoeae, 39.3% of non-gonococcal and non-chlamydia urethritis, 10.7% of C.trachomatis and 7.3% of co-infection with chlamydia and gonococcus. The odds of being considered cured in the first visit were greater in those who were unmarried, with greater schooling, and with an etiological diagnosis of gonorrhea. The diagnosis of non-gonococcal urethritis reduced the chance of cure in the first visit. Study limitation: A study conducted at a single center of STD treatment. Conclusion: Syndromic management of male urethral discharge syndrome performed in accordance with the Brazilian Ministry of Health STD guidelines was effective in resolving symptoms in the studied population. More studies with microbiological outcomes are needed to ensure the maintenance of the syndromic management.

Estado actual de la gonorrea / Current state of gonorrhea

La gonorrea es una infección de transmisión sexual conocida desde la antigüedad que se ha perpetuado en el tiempo. Su agente etiológico, Neisseria gonorrhoeae, fue adquiriendo resistencia a la mayoría de los antimicrobianos utilizados para su tratamiento empírico. Las resistencias emergentes en los últimos años son a fluorquinolonas, macrólidos y cefalosporinas orales y parenterales. Hay aislamientos multirresistentes que plantean un desafío para su tratamiento. En países donde estos hallazgos ocurrieron precedentemente, la experiencia de tratamientos con antibióticos no convencionales, por ejemplo aminoglucósidos, es limitada y también emergieron cepas resistentes. Una de las estrategias utilizadas frente a la sensibilidad disminuida a ceftriaxona es aumentar la dosis o utilizar tratamientos combinados. En el marco actual de la multirresistencia de este microorganismo es importante promover la prevención de la infección, realizar vigilancia epidemiológica y buscar nuevas estrategias para su tratamiento.

Gonorrhea is a sexually transmitted infection known since antiquity that has been perpetuated over time. Its etiologic agent, Neisseria gonorrhoeae, was becoming resistant to most antimicrobials agents used for empiric therapy. Emerging resistance in recent years are fluoroquinolones, macrolides, oral and parenteral cephalosporins. There are multiresistant isolates that represent a challenge for its treatment. In countries where these findings occurred previously, the experience with unconventional treatments such as aminoglycosides is limited and resistant strains have emerged. One of the strategies used against the reduced susceptibility to ceftriaxone is to increase the dose or use combined treatments. In the current context of multidrug resistance of this organism it is important to promote the prevention of infection, epidemiological surveillance and look for new strategies for treatment.

Increasing Incidence of High-Level Tetracycline-Resistant Neisseria gonorrhoeae due to Clonal Spread and Foreign Import

PURPOSE: The detection of high-level tetracycline-resistant strains of Neisseria gonorrhoeae (TRNG) can make important epidemiological contributions that are relevant to controlling infections from this pathogen. In this study, we aimed to determine the incidence of TRNG isolates over time and also to investigate the characteristics and genetic epidemiology of these TRNG isolates in Korea. MATERIALS AND METHODS: The antimicrobial susceptibilities of 601 isolates of N. gonorrhoeae from 2004 to 2011 were tested by standard Clinical and Laboratory Standards Institute methods. To determine the molecular epidemiological relatedness, N. gonorrhoeae multi-antigen sequence typing was performed. RESULTS: The incidence of TRNG increased from 2% in 2004 to 21% in 2011. The minimum inhibitory concentration distributions of ceftriaxone and susceptibility of ciprofloxacin in TRNG were different from non-TRNG and varied according to the year of isolation. Most of the TRNG isolates collected from 2004 to 2007 exhibited genetic relatedness, with sequence type (ST) 1798 being the most common. From 2008 to 2011, the STs of the isolates became more variable and introduction of genetically unrelated TRNG were noted. CONCLUSION: The increased incidence of TRNG strains until 2007 appears to be due, at least in part, to clonal spread. However, we propose that the emergence of various STs since 2008 could be associated with foreign import.

Ceftriaxona 500mg para tratamento da Neisseria gonorrhoeae resistente à ciprofloxacina / Ceftriaxone 500mg for treatment of Neisseria gonorrhoeae resistant to ciprofloxacin

CONTEXTO: A gonorreia é uma das infecções bacterianas mais frequentes e é causada pela Neisseria gonorrhoeae. Encontra-se atualmente entre as cinco principais infecções sexualmente transmissíveis mais notificadas na população masculina. Dentre as mudanças propostas pelo PCDT para Infecções Sexualmente Transmissíveis - IST em discussão, recebe destaque a alteração do esquema terapêutico atualmente em uso para o controle da Neisseria gonorrhoeae no Brasil, que prevê a substituição da ciprofloxacina 500mg, dose única via oral, pela ceftriaxona 500mg, dose única via intramuscular. Essa alteração tem como principal objetivo conter o desenvolvimento de maior resistência bacteriana aos antibióticos disponíveis na rede pública para o tratamento desse agravo. TRATAMENTO: Para a escolha do tratamento da infecção gonocócica a OMS estabelece critérios de eficácia, segurança, custo, adesão e disponibilidade, nos seguintes termos: -Eficácia: os medicamentos utilizados devem ter uma taxa de cura de pelo menos 95%. Esquemas terapêuticos com eficácia entre 85% e 95% devem ser utilizados com cautela e abaixo de 85% são considerados inaceitáveis. -Segurança: a presença de efeitos colaterais é a segunda maior preocupação na escolha dos tratamentos e desempenha papel de extrema relevância em mulheres grávidas ou em aleitamento, portanto, o nível de toxicidade deve permanecer dentro de padrões aceitáveis para a saúde do paciente, do feto e do bebê. -Custo: o custo do medicamento deve ser analisado e comparado aos custos de retratamento, eventuais complicações, e risco de transmissão e resistência. -Observância e aceitabilidade: os tratamentos devem ser de preferência em dose única e administrados por via oral. -Disponibilidade: os tratamentos selecionados devem levar em conta a aprovação sanitária no país. Além desses critérios, devem ser consideradas as co-infecções existentes e o risco de redução da eficácia para outras indicações terapêuticas. A TECNOLOGIA: A ceftriaxona é um antibiótico de terceira geração da família da cefalosporina registrado na ANVISA, por meio da Resolução 252 de 5 de março de 2001. O medicamento está disponível no mercado em diferentes apresentações, todas injetáveis, sendo indicado para o tratamento de eventos de sepsemia; meningite; infecções intra-abdominais (peritonites, infecções do trato gastrintestinal e biliar); infecções ósseas, articulares, tecidos moles, pele e feridas; infecções em pacientes imunocomprometidos; infecções renais e do trato urinário; infecções do trato respiratório, particularmente pneumonia e infecções otorrinolaringológicas; infecções genitais, inclusive gonorreia; profilaxia de infecções pré-operatórias; Borreliose de Lyme (Doença de Lyme). RECOMENDAÇÃO DA CONITEC: Na 34ª Reunião da CONITEC, realizada no dia 2 de abril de 2015, os membros do plenário deliberaram por unanimidade recomendar a incorporação da ceftriaxona 500mg injetável para o tratamento de gonorreia resistente à ciprofloxacina, conforme normas técnicas definidas pelo Ministério da Saúde. Foi assinado o Registro de Deliberação nº 110/2015. DECISÃO: PORTARIA Nº 58, de 1 de outubro de 2015 - Torna pública a decisão de incorporar a ceftriaxona 500mg injetável para o tratamento de gonorreia resistente à ciprofloxacina, conforme normas técnicas definidas pelo Ministério da Saúde, no âmbito do Sistema Único de Saúde - SUS.

Systemic lupus Erythematosus and Neisseria gonorrhoea a case of the arthritis-dermatitis syndrome

Systemic lupus erythematosus (SLE) is a systemic disease characterized by arthritis among other protean manifestations. Occasionally lupus flares occur and is associated with increasing joint pains. In this state, complement is activated and leads to precipitation of immune complexes. Neisserial infections are cleared by complement and so in the presence of deficient complement, these infections will flourish. Disseminated gonococcal infection (DGI) occurs infrequently. A case of Neisseria gonorrhoea presenting as the arthritis-dermatitis syndrome which mimicked a lupus flare is presented and the appropriate literature reviewed.

An insight into the drug resistance profile & mechanism of drug resistance in Neisseria gonorrhoeae.

Among the aetiological agents of treatable sexually transmitted diseases (STDs), Neissseria gonorrhoeae is considered to be most important because of emerging antibiotic resistant strains that compromise the effectiveness of treatment of the disease - gonorrhoea. In most of the developing countries, treatment of gonorrhoea relies mainly on syndromic management rather than the aetiological based therapy. Gonococcal infections are usually treated with single-dose therapy with an agent found to cure > 95 per cent of cases. Unfortunately during the last few decades, N. gonorrhoeae has developed resistance not only to less expensive antimicrobials such as sulphonamides, penicillin and tetracyclines but also to fluoroquinolones. The resistance trend of N. gonorrhoeae towards these antimicrobials can be categorised into pre-quinolone, quinolone and post-quinolone era. Among the antimicrobials available so far, only the third-generation cephalosporins could be safely recommended as first-line therapy for gonorrhoea globally. However, resistance to oral third-generation cephalosporins has also started emerging in some countries. Therefore, it has become imperative to initiate sustained national and international efforts to reduce infection and misuse of antibiotics so as to prevent further emergence and spread of antimicrobial resistance. It is necessary not only to monitor drug resistance and optimise treatment regimens, but also to gain insight into how gonococcus develops drug resistance. Knowledge of mechanism of resistance would help us to devise methods to prevent the occurrence of drug resistance against existing and new drugs. Such studies could also help in finding out new drug targets in N. gonorrhoeae and also a possibility of identification of new drugs for treating gonorrhoea.

Neisseria gonorrhoeae. Resistencia a los antibióticos / Neisseria gonorrhoeae. Antibiotic resistance

Neisseria gonorrhoeae (Ng) adquirio a traves de los años mecanismos de resistencia, lo que provoco que los distintos esquemas de tratamiento que en un comienzo fueron exitosos en tiempos variables, generaran problemas no siempre faciles de resolver. El objetivo de este trabajo es evaluar el perfil de sensibilidad de los aislamientos de Neisseria gonorrhoeae (Ng) frente a siete antibióticos en el periodo 2005-2009. Este estudio se realizo en el Programa de Enfermedades de Transmision Sexual (PETS) del Hospital de Clinicas, Universidad de Buenos Aires, en el período comprendido entre enero de 2005 y diciembre de 2009. Los datos clinicos de este trabajo para la busqueda de Ng fueron tomados de 1.871 pacientes de sexo masculino, de los cuales 802 (43%) eran heterosexuales (HET) y 1.069 (57%) hombres que tenian relaciones sexuales con hombres (HSH). Se incluyeron pacientes con sintomatologia de descarga uretral y disuria. La recoleccion de muestras se realizo en aquellos pacientes que no habian recibido tratamiento antibiotico (ATB) durante las 48 horas previas, mediante hisopado uretral y tomas en region anal y faringea en los que tenian relaciones sexuales con hombres. El 23,7% de los aislamientos presento resistencia cromosómica a penicilina y el 12,6% fue productor de ß-lactamasa.Las primeras fallas de las fluorquinolonas a nivel mundial fue a principios de la decada del 90. La Argentina documento el primer hallazgo en 2000. Actualmente esta resistencia trepo al 31,2-52%. Las cefalosporinas de tercera generacion mantienen aun su efectividad, aunque se han detectado en nuestro medio aislamientos con sensibilidad disminuida a este antibiotico.

Resistencia de Neisseria gonorrhoeae a ciprofloxacina según hábitos sexuales / Ciprofloxacin resistance of Neisseria gonorrhoeae according to sexual habits

En la Argentina los primeros hallazgos de Neisseria gonorrhoeae resistentes a las fluorquinolonas se documentaron en el año 2000. Desde enero de 2005 hasta junio de 2007, se evaluaron 595 hombres que tienen sexo con hombres (HSH) y 571 varones heterosexuales para investigar la presencia de N. gonorrhoeae y la resistencia a los antimicrobianos. La prevalencia de gonorrea en HSH y varones heterosexuales fue 0.091(91/1000) en ambos grupos y el % de N. gonorrhoeae resistente a ciprofloxacina (NGRC) fue 20.0% y 3.8% respectivamente (p: 0.0416). Trece de 106 aislamientos fueron NGRC, correspondieron a 11 HSH y 2 varones heterosexuales. Seis HSH presentaron uretritis, uno de ellos con localización simultánea en recto y cinco pacientes fueron asintomáticos (recto, 2; faringe, 2; uretra, 1). No se pudo demostrar relación epidemiológica entre ellos. Dos varones heterosexuales presentaron uretritis. Los 8 pacientes sintomáticos fueron tratados empíricamente con ciprofloxacina y se documentó fracaso de tratamiento. Estos y los portadores de NGRC recibieron tratamiento con 500 mg de ceftriaxona IM. Los controles postratamiento demostraron la erradicación del microorganismo. Los aislamientos de NGRC presentaron CIM de ciprofloxacina entre 2 y 32 µg/ml, todos fueron beta-lactamasa negativos, 4/13 presentaron resistencia cromosómica a penicilina (CIM= 1 µg/ml), y los rangos de CIM (µg/ml) para los siguientes antibióticos fueron: penicilina: 0.016-1; tetraciclina: 0.125-2; ceftriaxona: 0.004-0.008; eritromicina: 0.032-2; azitromicina: 0.032-0.5; espectinomicina: 8-32. Dado el elevado porcentaje de aislamientos de NGRC en HSH en nuestro hospital, debería utilizarse otro antimicrobiano para el tratamiento empírico en estos pacientes.

The first isolates of Neisseria gonorrhoeae resistant to fluorquinolones in Argentina were reported in 2000. Since January 2005 to June 2007 Neisseria gonorrhoeae was studied in 595 men who have sex with men (MSM) and 571 heterosexual men. The gonorrhea prevalence in MSM and heterosexual men was 0.091(91/1000) and the Neisseria gonorrhoeae ciprofloxacin resistant (CRNG) was 20% in MSM and 3.8% in heterosexual men (p: 0.0416). Thirteen out of 106 isolates from 11 MSM and 2 heterosexual men were CRNG. Six out of eleven MSM had urethritis, one also carried Neisseria gonorrhoeae in rectum and 5 patients were asymptomatic carriers (rectum 2, pharynx 2, urethra 1). No epidemiological relation was found among the patients. Two heterosexual men had urethritis. The 8 symptomatic men were treated with ciprofloxacin but treatment failed in all of them. These patients and the asymptomatic ones were treated with ceftriaxone, 500 mg IM. The post treatment microbiological controls were negative. The CRNG isolates had ciprofloxacin MIC between 2 and 32 (µg/ml), all were negative to penicillinase, 4 out of 13 were chromosomally resistant to penicillin (MIC: 1 µg/ml). The MICs (µg/ml) ranges for several antimicrobial agents were: penicillin: 0.016-1; tetracycline: 0.125-2; ceftriaxone: 0.004-0.008; erythromycin: 0.032-2; azithromycin: 0.032-0.5; spectinomycin: 8-32. Due to the high level of ciprofloxacin-resistant N. gonorrhoeae isolated from MSM in our hospital, another antimicrobial agent for empirical therapy should be used in these patients.

Correlation between In vitro susceptibility and treatment outcome with azithromycin in gonorrhoea: a prospective study.

PURPOSE: This prospective study was carried out to determine the antimicrobial susceptibility of Neisseria gonorrhoeae isolates by disc diffusion method and minimum inhibitory concentration (MIC) by E -test with special reference to azithromycin. Also, the correlation between in vitro susceptibility and treatment outcome with single 2 g oral dose azithromycin was assessed. METHODS: The study included 75 gonococcal isolates from males with urethritis, females with endocervicitis and their sexual contacts. All isolates were subjected to susceptibility testing for penicillin, ciprofloxacin, tetracycline, ceftriaxone, spectinomycin, cefixime and azithromycin. Males with gonococcal urethritis were randomised to receive a single dose of either azithromycin or ceftriaxone. Forty-two men with urethritis received 2 g single oral dose azithromycin, while all other patients were given 250 mg parentral ceftriaxone. All patients were called for follow-up to assess clinical and microbiological cure rates. RESULTS: While all the isolates were susceptible to ceftriaxone, spectinomycin, cefixime and azithromycin; 74 (98.7%), 24 (32%) and 23 (30.7%) strains were resistant to ciprofloxacin, penicillin and tetracycline respectively, by both disc diffusion method and E -test. The MIC range, MIC50 and MIC90 of N. gonorrhoeae strains, to azithromycin were 0.016-0.25, 0.064 and 0.19 microg/mL, respectively. Follow-up attendance of the patients was 52.4 with 100% clinical and microbiological cure rates. CONCLUSIONS: Results of our study indicate that 2 g single oral dose azithromycin is safe and effective in the treatment of uncomplicated gonorrhoea.

Emergence of ciprofloxacin resistant Neisseria gonorrhoeae in north India.

BACKGROUND AND OBJECTIVES: Though quinolones have been recommended as a single dose treatment for uncomplicated gonorrhoea, there have been reports of treatment failure with fluoroquinolones. In this study we determined the antimicrobial susceptibility levels of consecutive isolates of Neisseria gonorrhoeae to examine the emergence of ciprofloxacin resistance N. gonorrhoeae. METHODS: Minimum inhibitory concentration (MIC) of ciprofloxacin and other drugs (penicillin, tetracycline, ciprofloxacin and ceftriaxone) was determined by agar dilution method. MIC was interpreted according to the NCCLS guidelines. beta lactamase production was detected by iodometric method and chromogenic cephalosporin method using nitrocefin disc. RESULTS: A total of 45 consecutive isolates of N. gonorrhoeae were obtained from patients with suspected acute gonococcal uretheritis. Of the 45 isolates, 35 (77.7%) were resistant to ciprofloxacin, 16 (35.5%) showed MIC value greater than 8 microg/ml. All isolates were sensitive to ceftriaxone while 21 isolates (46.6%) were resistant to penicillin and 23 (51%) to tetracycline. Ten isolates (22%) were found to be beta-lactamase producers. INTERPRETATION AND CONCLUSION: Ciprofloxacin resistant N. gonorrhoeae is on the rise in and around Chandigarh (north India). Thus, periodic surveillance of susceptibility levels of N. gonorrhoeae is essential to prevent the dissemination of drug resistant strains in the community.

Decrease in the incidence of tetracycline resistance in strains of Neisseria gonorrhoeae in the nineties

Antibiotic resistance determined by standard disc-diffusion method on GC agar with supplement B in 583 strains of Neisseria gonorrhoeae encountered between 1991 and 1996 at the University Hospital of the West Indies, Kingston, Jamaica, were analyzed. The level of penicillin resistance varied between 40 and 28 over the years. Tetracycline resistance fell from 44.2 in 1991 to 23.9 in 1996. Twenty-one per cent of the isolates were resistant simultaneously to both penicillin and tetracycline in 1991. The percentage of such strains decreased to 6.5 in 1996. Ceftriaxone was introduced as a first line drug in treatment of gonococcal infections in the late 1980s. The declining trend of tetracycline resistance may be due to a decrease in the usage of tetracycline in recent years

Characterization of Neisseria gonorrhoeae strains isolated from patients with conjunctivitis

The conjunctivitis produced by Neisseria gonorrhoeae is the less frequently reported clinical form of gonococcal infection. We aim to phenotypically characterize N. gonorrhoeae isolated from conjunctivae sites. A total of six cases of this disease were notified in the Camagüey province, Cuba. All the strains isolated were penicillin-producing, showed the serogroup WI and exhibited the same antimicrobial susceptibility pattern and plasmid profile (2.6-3.2-24.5). The results contribute to the characterization of N. gonorrhoeae strains circulating in our environment

Tratamiento de la gonorrea en adolescentes y adultos / Gonorrhea treatment in adolescents and adults

La gonorrea continúa siendo una enfermedad frecuente. En Chile 70 porciento de las cepas de neisseria gonorrhoeae son resistentes a penicilina y mantienen 100 porciento de sensibilidad a cefalosporinas de tercera generación y ciprofloxacina. Se revisan los esquemas terapéuticos propuestos para las infecciones gonocóccicas uretrales, cervicales, rectales, faríngeas, conjuntivales, forma diseminada, endocarditis y meningitis. Además se comentan las exigencias del tratamiento en la mujer embarazada, en pacientes infectados por virus de inmunodeficiencia humana, en casos de coexistencia con chlamydia trachomatis y en pacientes alérgicos a b lactámicos

Resistência aos antibióticos em Neisseria gonorrhoeae: dos mecanismos ao monitoramento / Neisseria gonorrhoeae drug resistence: from the mechanisms to monitoring

Gonorréia continua sendo uma infecçäo clinicamente importante, no mundo inteiro cerca de 60 milhöes de casos/ano, mas com uma distribuiçäo geográfica diferente entre os países desenvolvidos e aqueles em desenvolvimento. Embora nos primeiros a doença tenha declinado nos últimos 10 anos, a N. gonorrhoeae permanece como a principal causa de infecçäo e, consequentemente, um sério problema de saúde pública. Nos países subdesenvolvidos, portanto, a gonorréia ainda é motivo de muita preocupacao para os estudiosos das doenças sexualmente transmissíveis -DSTs especialmente, em virtude das complicacoes clínicas que pode causar e pela capacidade que tem de favorecer a transmissäo do vírus da imunodeficiência humana -VIH

Trovafloxacina en ginecologia / Trovafloxacin in gynecology

La infección intraabdominal (IIABD) se define como la presencia de un proceso infeccioso en la cavidad peritoneal. Puede ser local o tener repercusión sistémica, generando disfunción orgánica múltiple. La mayoría de los estudios refieren una mortalidad del 30 por ciento en las IIABD severas. La peritonitis secundaria se produce por pérdida de la integridad del aparato gastrointestinal, que contamina con gérmenes la cavidad peritoneal. Son invariablemente infecciones polimicrobianas, predominando bacilos Gran negativos anaerobios facultativos y anaerobios. El pronóstico de la peritonitis depende de la lucha entre dos fuerzas: la inmunidad local y sistémica del huésped por un lado y el volumen, naturaleza e duración de la contaminación por el otro. Los microorganismos y sus productos estimulan las defensas celulares del huésped y activan numerosos mediadores inflamatorios que son responsable de la sepsis. El tratamiento antibiótico de las peritonitis secundarias debe actuar principalmente sobre Escherichia coli y Bacteroides fragilis. La administracion empírica adecuada y precoz de antibióticos contra estas bacterias está bien establecido. Es necesario considerar si la infección es localizada o generalizada y si se acompaña o no de disfunción orgánica. Debe también considerase en la elección del esquema antibiótico si la peritonitis es extra o intrahospitalaria. En las infecciones leves o moderadas adquiridas en la comunidad pueden utilizarse combinaciones como metronidazol-ceftriaxona, metronidazol-gentamicina o monodroga como ampicilina-sulbactam. En las peritonitis graves intrahospitalarias, el imipenem o la combinación piperacilina-tazobactam son efectivas. Las nuevas quinolonas como trovafloxacina o clinafloxacina, que tienen excelente actividad contra los gérmenes anaerobios y aerobios que producen las IIABD, podrían ser efectivas en su tratamiento. Son necesarios futuros ensayos clínicos para determinar su utilidad. Las peritonitis terciarias representan una respuesta inflamatoria sistémica con falla multiorgánica originada por activación descontrolada de la cascada inflamatoria. Es considerada una inflamación peritoneal y sistémica persistente. Los abtibióticos y las re-intervenciones quirúrgicas parecen tener poca utilidad en esta situación.

Etiología microbiana de la enfermedad inflamatoria pélvica leve y moderada (EIP) / Microbial ethiology of mild and moderate pelvic inflammatory disease

La Enfermedad Inflamatoria Pélvica (EIP) es una de las complicaciones más severas de las Enfermedades de Transmisión Sexual (ETS) se puede deber entre otros eventos al ascenso de la microflora genital femenina o a la infección de gérmenes implicados en ETS como la Chlamydia trachomatis o Neisseria gonorrhoeae. Esto trae como consecuencia serias repercusiones desde el punto de vista gineco-obstétrico. Una de las principales limitaciones a la que se enfrenta el médico es el conocer su etiología. De tal manera que con el presente trabajo, se pretende establecer el tipo de microorganismos involucrados en esta patología a fin de que al identificarlos, mediante el cultivo de endocérvix, endometrio y líquido peritoneal; se otorgue a la paciente el tratamiento adecuado, oportuno y certero, logrando así una mayor eficacia terapéutica

Rabdomiolisis asociada a infeccion gonococcica diseminada en una anciana / Rhabdomyolisis associated to disseminated gonococcal infection in an elderly woman

El síndrome de infección Gonocóccica Diseminada (IGD) es muy infrecuente en pacientes de edad avanzada y su asociación a Rabdomiólisis (RML) no ha sido publicada, por lo cual presentamos un caso de RML secundario a IGD en una mujer geronte. Se presume que el daño muscular en este caso estuvo relacionado directamente con la infección gonocóccica a través de la liberación de endotoxinas y mediadores celulares del sistema mononuclear-fagocítico y/o con la injuria isquémica secundaria al cuadro de severa hipoperfusión tisular. Sugerimos que la infección gonocóccica se agregue a las causas infecciosas de RML y que se incluya en el diagnóstico diferencial inicial de todo paciente que se presente con poliartritis y RML.

Corrimento Vaginal na Infância: Como abordá-lo / Management of vulvovaginitis during childhood

As vulvovaginites, mais especificamente o corrimento vaginal, e uma doença comum na infância e freqüente causa de procura de atençäo médica pediátrica. Essa alta freqüência, deve-se principalmente a higiene precária dos genitais externos, o que coloca as vulvovaginites inespecíficas como a causa mais freqüente de vulvovaginites na infância. É muito importante que na abordagem da criança com corrimento vaginal, seja determinado se o mesmo é fisiológico ou patológico, evitando-se tratamentos desnecessários. Sabe-se ainda, que a maioria dos corrimentos vaginais cessam com uma adequada higiene dos genitais. Nos casos em que o agente etiológico da vulvovaginite é considerado um agente de Doenças Sexualmente transmissíveis e deve ser feita uma investigaçäo para determinar se houve estupro. O sucesso do tratamento, depende além do correto diagnóstico etiológico da patologia, do minucioso esclarecimento à família da importância e conseqüência do mesmo. Fez-se uma abordagem prática de como manusear o corrimento vaginal na infância, apontando suas principais características, seu diagnóstico e o tratamento