Received on 26.06.2015 Modified on 18.07.2015

Research J. Pharm. and Tech. 8(9): Sept, 2015; Page 1217-1220

DOI: 10.5958/0974-360X.2015.00222.X

INTRODUCTION^1-10:

According to World Health Organization (WHO) estimates, Gonorrhoea is one of the most common sexually transmitted infections (STIs) in developing countries¹. Although Gonorrhoea is easily curable, but if remains undetected, untreated can lead to complications like pelvic inflammatory disease, ectopic pregnancy, tubal factor infertility, adverse pregnancy outcomes in females, and testicular and prostate infections and infertility in males. Infection in pregnant women may lead to crucial perforation and blindness in the newborn. Gonococcal infections have also been documented to facilitate acquisition and transmission of HIV and HPV infection^2,3 .

Control of gonococcal infection is becoming increasingly difficult due to emergence of resistant strains to a wide range of antibitiotics. Recent studies have revealed a high level of resistance against antibiotics such as, penicillins and quinolones in several countries, including India⁴. Between 2009 to 2012 penicillinase- producing Neisseria Gonorrhoeae (N. gonorrhoeae). N. gonorrhoeae isolates from WHO South East Asian Region varied from 0% (Pune, Nagpur) to 88.9% (Bhutan), while the rates of resistance to tetracycline and resistance to ciprofloxacin varied from 9.8%-100% and 57%-100%, respectively⁵. Gonococci have been adept at developing resistance to several commonly used antimicrobials.

Another cause of concern is, rate of gonorrhoea and other non-ulcerative STIs are difficult to determine because clinical presentation is not specific enough and facilities, materials, or personnel for laboratory based diagnosis are inadequate. Moreover, there is lack of reporting mechanism and reluctance to report STIs to public health authorities. Periodic Anti-microbial surveillance is, therefore, necessary determine the resistance patterns. There is irrational and injudicious use of antibacterial agents, especially in the developing countries like India and is expected to worsen unless urgent and appropriate steps are initiated. This study was done with an objective to find out the prevalence and antibiotic susceptibility pattern of N. gonorrhoeae

MATERIAL AND METHODS:

This was a prospective study conducted in a tertiary care hospital in South India from June 2013 to May 2015. Samples were collected from patients attending gynecology and STD clinic. All patients in reproductive age group who attended gynecology out patient with suspected STIs were included in the study. Women of reproductive age group (15-44 years) with any one of the sign and symptom for STIs such as pain during sexual intercourse, a painful or burning sensation when urinating and abnormal vaginal discharge were included. Corresponding symptoms in the males were included in the study. Others with symptoms indicating development of Pelvic Inflammatory Disease (PID) like cramps and pain, bleeding between menstrual periods, vomiting, and fever were also included in the study. Patients on recent antibiotic treatment and those who were outside the reproductive age group were excluded from the study.

Clinical examination was done in all patients who were attending gynecological OPD. Two swabs were collected from each patient one for gram stain and the other for culture. The samples were immediately delivered and inoculated to appropriate media in Microbiology Laboratory. Stuart’s transport media was used at times of delay. While one of the two swabs taken from individual patient was used for gram stain the other was inoculated on to nonselective chocolate agar and selective agar modified Thayer-Martin medium. The inoculated plates were incubated at 35-36°C for 48 hrs in a moist atmosphere enriched with 5% CO2 using candle jar. N. gonorrhoeae produces small raised, grey shiny colonies on modified Thayer-Martin medium after overnight incubation. In general all positive cultures were identified by their characteristic appearance on the media, Gram staining reaction and confirmed by the pattern of biochemical reactions using the standard method⁶.

Antimicrobial sensitivity test was performed by Kirby-Bauer disk diffusion method using CLSI guidelines. The susceptibility to the following antimicrobial agents were assessed by: Penicillin (10 IU), Tetracycline (30μg), Ciprofloxacin (5μg), Ceftriaxone (30μg), Cefixime (5μg), Cefoxitin (30μg), Cefotaxime (10μg), Nalidixic acid (30μg). The criteria used to select the antimicrobial agents tested were based on their availability. N. gonorrhoeae ATCC 49226 strain and WHO reference strains A, C, E, G, J, K-Q were used as controls. The information was recorded and analyzed using Microsoft Excel (2007 version) and the results are explained in frequency and percentage.

RESULTS:

A total of 546 samples were analyzed, out of which 49 (9%) were positive for N. gonorrhoeae. The age and sex distribution of the cases is shown in table 1.

Table 1:Age and sex distribution of Neisseria gonorrhoeae.

Age group (years)

Male

Female

Total

15-20

21-25

26-30

31-40

41-45

Total

Maximum number of cases were from females and in age group of 26-30 years.

The patterns of Neisseria gonorrhoeae was isolated is shown in table 2.

Table 2: Patterns of Neisseria gonorrhoeae isolates among males and females.

Specimen	Male (n=17)	Female (n=32)
Urethral discharge	5	0
Vaginal discharge	-	10
Cervical discharge	-	6
Lower abdominal pain syndrome	2	6
Genital ulcer disease	1	3
non‑herpetic
Genital ulcer disease herpetic	4	2
Genital scabies	2	3
Molluscum contagiosum	1	2
Balanoposthitis	2	-

Maximum isolates were from urethral discharge in males and vaginal discharge in females.

The reaction of Neisseria gonorrhoeae to various biochemical tests is shown in table 3.

Table 3: Gram satin, culture and reaction of Neisseria gonorrhoeae to various biochemical tests

Test	Gram stain	Growth on Chocolate agar	Growth on modified Thayer martin media	Oxidase test
Positive	47	48	49	49
Negative	499	498	497	497
Total				546

The antibiogram of Neisseria Gonorrhoeae is shown in table 4.

Table 4: Antibiogram of Neisseria gonorrhoeae. (% resistance) (n=49)

Antibiotic

Number

Percentage

Penicillin

Tetracycline

Ciprofloxacin

Ceftriaxone

Cefotaxime

Cefoxitin

Cefixime

Nalidixic acid

71.4

63.2

48.9

28.5

24.4

55.1

Maximum resistance was seen with Penicillin and no resistance was seen with Ceftriaxone.

DISCUSSION:

Increase in N. gonorrhoeae isolates which are resistant to multiple antimicrobial agents is now a serious problem⁷. In the present study maximum resistance was seen with Penicillin and no resistance was seen with Ceftriaxone and Cefixime. Antimicrobial susceptibility studies are required to monitor changing trends in resistance and helps in identifying new types of resistance. There is a geographical difference in resistance pattern of N. gonorrhoeae, some centres have highlighted an alarming increase in the percentage of Penicillin and Quinolones over the years^8,9. Other studies from Nagpur (0%), Hyderabad (41.9%) and Kolkata (52.6%) have reported a lower percentage of Penicillin, findings similar to our study were reported from another WHO SEAR country, Thailand in 2013⁵.

The prevalence of N. gonorrhoeae in the present study was 9%. The prevalence in this study is higher compared to other reports like Jordan 2.2% and Vietnam 0.7%^10,11. Some studies have reported a higher prevalence^12-14. In the present study there was female preponderance (table 2). A recent study conducted in India has reported only males being affected¹⁵. These variations might be due to geographical differences.

Cefixime is the first-line drug recommended under syndromic management of STIs according to the recent NACO guidelines for treatment of gonorrhea¹⁶. Treatment failure to cefixime has been reported from several countries like Japan, France, Canada, Austria and Norway^17-19. Recently ceftriaxone resistant isolates have been identified in Japan (2009), France (2010) and Spain (2011)^17,20,21. The high rate of resistance among N. gonorrhoeae isolates may be an indicator of inappropriate use of antimicrobials due availability of over-the-counter drugs, prescription by unqualified practitioners or self-medication²². Increase in N. gonorrhoeae isolates which are resistant to multiple antimicrobial agents is now a serious problem⁷. Emergence of N. gonorrhoeae isolates with decreased susceptibility/resistance to ceftriaxone, as a consequence of excess utilisation of oral third-generation cephalosporins for other infectious conditions, may pose a serious threat in the management of gonorrhoea in countries like India.

Antimicrobial surveillance should be done periodically to monitor the current susceptibility patterns in local hospitals. In most of the hospitals, sensitivity reports are not readily available, empirical therapy is often needed to. Regional antibiotic susceptibility studies will help in choosing an appropriate antibiotic for empirical therapy and reduce the mortality and morbidity. Every hospital should regularly conduct antibiogram studies, develop an antibiotic policy to promote rational use of antibiotics and emergence of resistance.

LIMITATIONS OF THE STUDY:

The sample size was small and we did not evaluate co-infection with other STIs. Going forward we plan to conduct a study of gonococcal infection in HIV positive patients and compare the susceptibility bet HIV gonococcal and non HIV gonococcal cases. Future studies should focus on identifying behavioral or environmental factors to address differences in predictors within groups.

CONCLUSION:

In the present study, N. gonorrhoeae isolates showed resistance to commonly used anti-microbials except Ceftriaxone and Cefixime. Research into, and identification of alternate treatment regimens are integral part to prevent emergence of resistance. Results of the study support the current recommendations of NACO for use of third generation as the first choice drugs for the empirical treatment of gonorrhea in India.

ACKNOWLEDGEMENT:

We authors thanks the staff of microbiology laboratory for the help in conducting this study

CONFLICT OF INTEREST:

None

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