1. 100% Ciprofloxacin resistance in gonococcal isolates in patients with or at high risk of HIV acquisition in an urban Ugandan clinic DR EMILY MABONGA KING’S COLLEGE HOSPITAL, LONDON

2. Background  78 million cases of Gonorrhoea (GC) reported worldwide each year  Challenges with resistance to GC Table showing introduction of antibiotics followed by resistance

3. Gonorrhoea in Uganda  Cefixime is the recommended drug (2012)  The sequelae of untreated GC  Increased acquisition and transmission of HIV  Management is syndromic; limited data on asymptomatic patients

4. Aim To determine the resistance pattern of Neisseria gonorrhoeae isolates to antimicrobial agents

5. Study site Katanga

6. Study population Asymptomatic:  Discordant couples  CSW’s (outreach)  MARPs  Pregnant women  Young adults Symptomatic:  All patients IDI  CSW’s (outreach) Participants were recruited from March – August 2015

7. Study procedures  Asymptomatic patients and out-reach patients were not examined  Symptomatic patients were examined  Male patients with discharge and patients with a history of contact with GC had a culture done at the first visit  All samples for GC culture were collected with a Dacron swab and inoculated immediately onto chocolate agar and a microscope slide

8. Laboratory procedures (1) GC confirmation:  Nucleic acid amplification test: BD Probetec ET machine  Gram negative diplococci cultures that tested positive for both oxidase and superoxidase tests were identified as N. gonorrhoeae

9. Laboratory procedures (2) Antimicrobial susceptibility testing:  Kirby-Bauer diffusion method  Zones of inhibition around each disk were measured and compared against reference standards provided by the Clinical and Laboratory Standards Institute (CLSI) guidelines 2012

10. Zone diameter and MIC Interpretive Standard for Neisseria gonorrhoeae Zone diameter (mm) AntibioticResistantIntermediateSusceptible 1.Penicillin G 10 units≤ 2627 - 46≥ 47 2.Ceftriaxone (30 µg)--≥ 35 3.Cefuroxime (30 µg) (parenteral) ≤ 2526 - 30≥ 31 4.Cefoxitin (30 µg)≤ 2324 - 27≥ 28 5.Cefixime (5 µg)--≥ 31 6.Tetracycline (30 µg)≤ 3031 - 37 ≥ 38 7.Ciprofloxacin (5 µg)≤ 2728 - 40≥ 41 8.Ceftazidime (30 µg)--≥ 31

11. 575 participants screened 179 (31.1%) Men 396(68.9%) Women 139 (77.7%) Asymptomatic Total asymptomatic = 454 (79%) Total symptomatic = 121 (21%) 40 (22.3%) Symptomatic 315 (79.5%) Asymptomatic 81 (20.4%) Symptomatic Results

12. 54 STIs (NG/CT/TV) were diagnosed in 52 patients patients Overall prevalence of an STI 9.4% (n=575) GC – 34 (5.9%)  22 symptomatic (9 male; 13 female)  12 asymptomatic (all female) CT -16 (2.8%)  4 symptomatic (all female)  12 asymptomatic (all female of these 3 were recent HIV diagnosis) TV- 4 (0.7) (all symptomatic, all female)

13. Characteristics of participants with GC (n=34) Male (n=9)Female (n=25) Median age (years) 2624.5 Symptom status Symptomatic9 (100%)12 (48%) Asymptomatic013 (52%) HIV status Positive9 (100%)22 (88%) Negative03 (12%)

14. 2 patients not cultured: 1 DNA 1 Rx in community 34 +ve for GC on BD NAAT 32 patients provided specimens for GC culture 17 viable isolates 15 specimens viable isolates: 7 over/ mixed growth 6 lost viability 2 samples discarded (R- CIP; TE; P) Flow diagram from GC +ve NAAT to viable isolates

15. Antimicrobial susceptibility of N.gonorrhoeae by disk diffusion method Susceptible (%)Intermediate (%)Resistant (%)Mean (range) in mm CLIS ref for resistance Penecillin0 (0) 17 (100)8 (6 - 18)≤ 26 Tetracycline0 (0) 17 (100)11 (7 - 18)≤ 30 Ciprofloxacin0 (0) 17 (100)12 (8 – 16)≤ 27 Cefixime10 (58.8)2 (11.8)5 (29.4)20 (15 – 26)< 31 Ceftriaxone12 (70.6)0 (0)5 (29.4)37.2 (15 – 31)< 35 Cefuroxime9 (52.9)6 (35.3)2 (11.8) Cefoxitin3 (17.6)12 (70.6)2 (11.8) Ceftazidine1 (8.4)0 (0)11 (91.6)

16. Treatment  33 / 34 patients received treatment with cefixime  30 (85.7%) returned for TOC  3 were still positive (re-infection)  Of the 5 resistant to cefixime there were no treatment failures

17. Limitations  Small number of isolates  Culture media – chocolate agar  DST for macrolides and spectinomycin not done

18. Discussion  100% GC resistance to ciprofloxacin, tetracycline and penicillin - increase from previous published data in Uganda  % cefixime resistance higher in this study than previous published data CiprofloxacinCefiximeTetracyclinePenicillin This study (Mar – Aug 2015)100%29.4%100% Amito et al; Gulu (Jan 2007- Dec 2011) 23.3%-17.2%23.4% Vandepite et al; Kampala (Apr 2008 – Oct 2009) 83.1%0.7%97.368.2%

19. Discussion  >50% of women with GC were asymptomatic; they would have been missed if only the syndromic approach was utilized  Patients attend every 2 months for HIV care (including treatment of OI) therefore are more exposed to antimicrobials than the general population  Local guidelines were revised – cefixime 400mg stat is first line therapy

20. Summary  Highly resistant gonococcal infections in key populations with HIV or at risk of HIV acquisition  Antimicrobial resistance surveillance for N.gonorrhoeae and other organisms is urgently needed in Uganda to inform emerging patterns of resistance leading to appropriate guidance on treatment options

21. Thanks  Rosalind Parkes-Ratanshi  Sheila Nabweyambo  Olive Mbabazi  Chris Taylor  Charlotte Gaydos  Yuka Manabe

22. Thanks  Becton Dickinson for donation of kits  Johns Hopkins Centre for STD POC tests for payment of lab cost  Staff and patients at IDI  Questions??