Emergence of high-level azithromycin resistance in Neisseria gonorrhoeae in England and Wales.

OBJECTIVES: This study aimed to investigate the origin of high-level azithromycin resistance that emerged in isolates of Neisseria gonorrhoeae in England and Wales in 2007, and to establish methods for identifying high-level azithromycin resistance. METHODS: The Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) data from 2001-07 were examined for emerging trends in azithromycin susceptibility. Further to the identification of six high-level azithromycin-resistant isolates in GRASP 2007, an additional 102 isolates were selected on the basis of azithromycin susceptibility and geographic origin from the GRASP 2006 and 2007 collections. Susceptibility testing by Etest and disc diffusion was performed on all 108 isolates and 75 of these were typed by N. gonorrhoeae multiantigen sequence typing. RESULTS: A slight drift towards higher MICs of azithromycin was observed in the gonococcal population since 2001. Of greater concern was the first example of a shift to high-level resistance observed in six isolates in 2007. All six isolates were sequence type 649, which was not observed in any of the lower-level azithromycin-resistant isolates from 2007 or in any isolates tested from the same geographical locations. Contact tracing data for one patient suggested a link with Scotland. Disc diffusion testing of all 108 isolates showed that azithromycin, but not erythromycin, discs can differentiate between low-level and high-level resistance. CONCLUSIONS: High-level azithromycin resistance has emerged in England and Wales. Contact tracing and typing data suggest this may have originated from Scotland. Surveillance of azithromycin resistance will be key in controlling its further dissemination.

Survey of prioritizing/triaging of appointments in genitourinary medicine clinics in the UK: a British Co-operative Clinical Group survey.

A questionnaire was circulated to all lead genitourinary (GU) medicine physicians in the UK in November 2003 to obtain data on access, waiting times and triaging. Of the 143 responders, 92.3% departments had limited access to some or all GU medicine clinics. Where access was limited, 5.3% had no identifiable process in place to see urgent patients. The mean waiting times in clinics with an open appointment system only for a routine female and male appointment were 2.9 weeks and 2.8 weeks (range 2 days-10 weeks), respectively, and for an urgent appointment, two days (range same day-14 days), for both sexes. The survey has raised concerns that a number of departments did not consider as urgent for prioritizing, patients with documented untreated gonorrhoea, syphilis, or HIV, or contacts of patients with these conditions. This survey has highlighted a need for the national specialist society to provide guidance on prioritizing patients where access is limited.

Molecular epidemiology of endemic ciprofloxacin-resistant Neisseria gonorrhoeae in Liverpool.

Ciprofloxacin-resistant Neisseria gonorrhoeae had been rarely detected on Merseyside and when found was associated with beta-lactamase producing strains, imported from abroad. However, in August 2000, two cases of infection with ciprofloxacin-resistant beta-lactamase-negative strains occurred in sexually unrelated patients with no history of foreign travel. Over the next 18 months a total of 120 patients presented with ciprofloxacin-resistant gonococci, from which 99 patient strains were available for study. Gonococcal DNA was subjected to molecular fingerprinting by polymerase chain reaction amplification followed by Taq1 digestion of their opa genes. Twelve differing opa-types were found, but 79 patients were infected with a single genotype, opa-type 1. The sexual histories of the majority of this group indicated acquisition in Merseyside. This endemic strain was further characterized by having the same amino acid substitutions on gyrA and parC genes. An endemic clone of ciprofloxacin-resistant N. gonorrhoeae has been established on Merseyside necessitating the introduction of ceftriaxone as first-line treatment. Despite the presence of 11 other clones in the city, opa type-1 strains have not yet been displaced, raising the possibility that this strain is endowed with added virulence/endemicity traits or that a number of source patients have not yet been found.

Treatment of bacterial vaginosis with a three day course of 2% clindamycin vaginal cream: a pilot study.

OBJECTIVE: To evaluate the efficacy and safety of a 3 day course of 2% clindamycin cream in the treatment of bacterial vaginosis. DESIGN: A prospective, randomised, double blind, placebo controlled study. SETTING: Department of Genitourinary Medicine, Royal Liverpool University Hospital. SUBJECTS: 55 female patients aged 18 years and over, and premenopausal, who spontaneously or after questioning complained of symptoms of bacterial vaginosis. RESULTS: 55 patients were enrolled. 44 patients were evaluable at Visit 1 when among the 23 who received clindamycin cream bacterial vaginosis was not present in 22 (95.6%) and only one failed treatment. Of the 21 patients in the placebo group only one (4.8%) patient was cured and 20 (95.2%) were failures. Of the 17 patients evaluable at Visit 2 in the clindamycin group, bacterial vaginosis was not present in 14 (82.4%) and had recurred in three. No serious adverse events were noted in either group. CONCLUSION: This pilot study provides encouraging evidence of the efficacy and safety of a 3 day course of 2% clindamycin cream in bacterial vaginosis.

Outcome of cold coagulation for the treatment of cervical intraepithelial neoplasia in a department of genitourinary medicine.

OBJECTIVE: To evaluate the outcome of "cold coagulation" as a treatment modality for major grade cervical pathology, cervical intraepithelial neoplasia (CIN 2 and 3) in a department of genitourinary medicine. DESIGN: Prospective programme trial with 18 month follow-up of patients undergoing "cold coagulation" of the cervical transformation zone following colposcopic assessment and biopsy. SETTING: A genitourinary medicine colposcopy clinic. PATIENTS: 125 female patients with histologically proven major cervical pathology (CIN 2 and 3). The mean age of the patients was 24.5 years; 73% were unmarried, 43% currently smoked and 62% had a history of exposure to the human papilloma virus. MAIN OUTCOME MEASURES: Eradication of cervical abnormality with cytological findings at 4, 8 and 12 months and colposcopy at 18 months, with intervention colposcopic assessment if follow-up cytology was abnormal. RESULTS: Eradication of CIN was achieved in 96.5% of patients, the majority of treatment failures being detected at first cytology. Attendance for follow-up was good, with only a 16% default rate. Final colposcopy yielded five treatment failures. No major complications were noted. CONCLUSION: These results confirm that "cold coagulation" provides an acceptable, efficient and effective, low cost consumer friendly treatment for CIN 2 and CIN 3 in an out-patient genitourinary medicine colposcopy clinic.

Survey of colposcopy service provided by genito-urinary medicine in England and Wales.

OBJECTIVE: To investigate the expansion of colposcopy services within genito-urinary medicine (GUM) in England and Wales since 1985. DESIGN: Data collected by postal and verbal communication from 189 genito-urinary medicine clinics in England and Wales in January 1990. SUBJECTS: Consultant and junior genito-urinary physicians practising colposcopy. MAIN OUTCOME MEASURES: Number of clinics providing colposcopy service; indication for colposcopy, treatment facilities available, waiting lists and training opportunities, compared with that in 1985. RESULTS: Of the 189 genito-urinary medicine clinics contacted, 60 provided a colposcopy service and 55 of these returned completed questionnaires. There has been a 67% increase in the number of colposcopies in use and over 50% of clinics have the facilities to treat cervical pathology. Waiting lists were minimal for both examination and treatment. Both men and women are examined with the colposcope for a variety of indications. At present, 52% of career grade GUM physicians practise colposcopy compared to 24% in 1985 and 94% of senior registrars compared with 42% in 1985 were in training or trained in colposcopy.

Screening for cervical dysplasia in department of genitourinary medicine.

In 632 patients attending a sexually transmitted disease (STD) clinic who were colposcoped because they were in certain high risk groups for cervical neoplasia, and irrespective of cytological findings, 13 out of 51 biopsied had false negative cytology results. Human papilloma virus (HPV) was the most important sexually transmitted agent associated with cervical intraepithelial neoplasia (CIN), but HPV was also present in most patients with false negative (11/13) and false positive (11/14) cytology results. Screening by colposcopy, as well as cervical cytology, is therefore mandatory and must be available for certain STD clinic patients.

In-vitro and in-vivo activity of metronidazole against Gardnerella vaginalis, Bacteroides spp. and Mobiluncus spp. in bacterial vaginosis.

An open, randomized, culture-controlled clinical study was designed to compare the efficacy of a single 2 g dose of metronidazole (Elyzol) with standard 7-day therapy in the treatment of bacterial vaginosis (BV). Forty-one of 47 (87%) patients given the single dose and 30 of 33 (91%) given the 7-day treatment were found to be cured seven days after treatment. At final assessment, 24 of 34 (71%) patients given the single dose and 22 of 28 (79%) given the 7-day treatment remained cured. The two regimes were equally efficaceous in eradicating Gardnerella vaginalis, Bacteroides spp. and Mobiluncus spp. (anaerobic curved rods) from vaginal specimens from patients with BV. The in-vitro activity of metronidazole and its hydroxy metabolite was determined for 11 strains of Gard. vaginalis, 17 strains of Bacteroides spp. and 14 strains of Mobiluncus spp. which had been isolated from patients prior to treatment. The MIC of metronidazole against Gard. vaginalis varied between 2 and greater than or equal to 128 mg/l (median MIC 32 mg/l), but the hydroxy metabolite showed a markedly increased activity against eight of the strains tested (median MIC 4 mg/l). The MIC of metronidazole against the Mobiluncus spp. varied between 0.5 and greater than or equal to 128 mg/l (median MIC 16 mg/l) and the hydroxy metabolite showed little increased activity (median MIC also 16 mg/l). The Bacteroides organisms were highly susceptible to metronidazole and to the hydroxy metabolite, each having a median MIC of 1 mg/l.

Screening for cervical intraepithelial neoplasia and cancer in the Sheffield STD clinic.

I undertook a prospective study of the incidence of histologically confirmed cervical intraepithelial neoplasia (CIN) and cancer in women attending a sexually transmitted disease (STD) clinic, and correlated the findings to cervical cytology reports, age, and history of STD of the affected women. Of 2017 women screened, 75 (3.7%) had dyskaryotic cervical smears. Colposcopically directed biopsy tests gave an overall detection rate of 0.55% for CIN3, which was similar to the national average. The false negative rate was 2.9% and cytology tests alone underestimated the degree of pathological change in 12 (30%) of 40 women with mild dyskaryosis. Women under 20 years old made up 43% of those with CIN1 and 38% of those with CIN2. The detection rate of CIN3 was 0.65% for women aged 15-34, which was higher than the national average and suggested earlier onset of CIN3 in our clinic population. There was a high association between genital warts and cervical precancer. This preliminary study confirms the need for routine non-selective screening of women attending STD clinics by cervical cytology tests, colposcopic examination, and biopsy tests where indicated.