Dear BASHH members,
Please find below an urgent clinical alert that has been issued by Public Health England, relating to the recent identification of two cases of infection with extensively-drug-resistant (XDR) Neisseria gonorrhoeae. For treatment advice, please contact firstname.lastname@example.org
BASHH are also working with Public Health England to support the release of updated guidelines for the management of gonorrhoea as soon as possible.
9th January 2019
Two cases of XDR gonorrhoea identified in UK residents
In the last three months, two cases of infection with extensively-drug-resistant (XDR) Neisseria gonorrhoeae (Ng) (1) in heterosexual females have been confirmed by the PHE Reference Laboratory. These cases are from different locations in England and may have links to a party destination in Europe.
The first case presented to a sexual health clinic in October 2018 with genital symptoms and cleared the infection following treatment with ceftriaxone 500mg and azithromycin 1g. The second case presented to a sexual health clinic in November 2018 with anal and genital symptoms. They failed initial treatment with ceftriaxone 1g, and subsequent treatment with gentamicin 240mg and azithromycin 2g. Three days of IV ertapenem cleared the infection.
Microbiology: The two isolates are resistant to ceftriaxone (MIC 1.0mg/L) and have intermediate susceptibility to azithromycin (MIC 0.5mg/L). The isolates are resistant to cefixime, penicillin, ciprofloxacin and tetracycline, but are susceptible to spectinomycin. The isolates are classed as extensively drug resistant but are different to the case in 2018 connected to Thailand, which had high-level azithromycin resistance. The MICs to gentamicin and ertapenem are low, suggesting susceptibility, but the MICs at which resistance occurs is not currently defined. Whole genome sequencing is underway.
Incident management: Identifying the origins of these isolates and the potential for further transmission is a priority. Multidisciplinary teams have been convened to progress the investigations, ensure contacts are traced, and contain spread.
Actions for Clinics and Laboratories:
- Clinics should ensure that before treatment is given, a specimen is taken for culture from all patients with suspected gonorrhoea. It is essential that all cases have a test of cure.
- Anyone with genital gonorrhoea (regardless of gender or reported sexual behaviour) should have pharyngeal sampling if either of the following apply:
- Susceptibility results are not available and the infection may have been acquired in the Asia-Pacific region where there are high levels of antimicrobial resistance that may lead to treatment failure
- Genital infection with a confirmed ceftriaxone resistant strain
- Clinics are requested to ensure that their local microbiology laboratory refers any isolate reported as ceftriaxone resistant to the Reference laboratory at PHE Colindale.
- For treatment advice, please contact email@example.com.
Link to relevant guidance:
- Public Health England. Guidance for the detection of gonorrhoea in England. Public Health England. London. 2014. Available at:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/405293/170215_Gonorrhoea_testing_guidance_REVISED__2_.pdf
- BASHH guideline for the management of gonorrhoea (2011). Available at: https://www.bashhguidelines.org/media/1044/gc-2011.pdf
1.Clifton S, Bolt H, Mohammed H, Town K, Furegato M, Cole M, et al (2018). Prevalence of and factors associated with MDR Neisseria gonorrhoeae in England and Wales between 2004 and 2015: analysis of annual cross-sectional surveillance surveys. J Antimicrob Chemother (30 Jan).
British Association for Sexual Health & HIV (BASHH)