1. Neisseria gonorrhoeae Nealia House

2. Gonorrhea Topic Overview Topic Overview Biology of Neisseria gonorrhoeae Biology of Neisseria gonorrhoeae –Survival Within Host Screening Screening Treatment Treatment Control/Surveillance Control/Surveillance http://www2.chemie.uni- erlangen.de/education/medchem/harnsteine/urs_infektion.html

3. Gonorrhea Sexually transmitted disease Sexually transmitted disease Infection Rate Infection Rate –socioeconomic class –Age Very common infectious disease Very common infectious disease –STI second only to chlamydia Increasing antibacterial resistance Increasing antibacterial resistance Increases efficiency of HIV transmission Increases efficiency of HIV transmission http://www.cat.cc.md.us/courses/bio141/labmanua/lab1/dkngon.html

4. Affected Populations http://www.agi-usa.org/pubs/ib_std.html STI Rates World-Wide

5. Gonorrhea Humans only natural host Humans only natural host –Reproductive tract Infection can be asymptomatic Infection can be asymptomatic –Infertility Several tests available for detection of gonorrhea Several tests available for detection of gonorrhea http://evolution.berkeley.edu/evosite/relevance/images/Ku nkel_97210C.jpg

6. Gonorrhea Topic Overview Topic Overview Biology of Neisseria gonorrhoeae Biology of Neisseria gonorrhoeae –Survival Within Host Screening Screening Treatment Treatment Control/Surveillance Control/Surveillance http://www.nature.com/genomics/images/neisseria_200.jpg

7. Transmission Does not survive in the environment, must be transmitted through contact Does not survive in the environment, must be transmitted through contact –Unprotected sex –Contact with eyes, mouth –Mother to child during birth Neonatal hyperacute purulent conjunctivitis http://www.aafp.org/afp/980215ap/morrow.html

8. Transmission Transmissibility dependent on: Transmissibility dependent on: –Strain –Male to female transmission more effective  Higher number of organisms present in male urethral discharge than female vaginal secretions http://www.biology.arizona.edu/human_bio/problem_sets/stds/graphics/Gonorrhea.gif

9. Structure Diplococcus Diplococcus Gram-negative Gram-negative Fimbriae extend several micrometers from cell surface Fimbriae extend several micrometers from cell surface http://textbookofbacteriology.net/BSRP.html

10. http://gsbs.utmb.edu/microbook/images/fig97_2.JPG

11. http://www.infocompu.com/adolfo_arthur/ingles/gonorrea.htm http://www.dermnet.com/thumbnailIndex.cfm?moduleID=16&module GroupID=234&groupIndex=0&numcols=0 Systemic Infection

12. Infection N. gonorrhoeae attaches to mucosal cells via pili and other surface proteins N. gonorrhoeae attaches to mucosal cells via pili and other surface proteins Induces production of inflammatory cytokines by epithelial cells Induces production of inflammatory cytokines by epithelial cells http://www.brown.edu/Courses/Bio_160/Projects1999/av/gonorrhea.html

13. Infection http://www.ncbi.nlm.nih. gov/books/bv.fcgi?rid=m med.figgrp.898

14. Survival Within Host Evades host immune system by changing surface proteins Evades host immune system by changing surface proteins –Often asymptomatic infection The RdgC protein is required for efficient pilin antigenic variation The RdgC protein is required for efficient pilin antigenic variation http://www.brown.edu/Courses/Bio_160/Projects1999/av/gonorrhea.html

15. Antigenic Variation Pilus promotes attachment of gonococcal cell to host epithelial cell Pilus promotes attachment of gonococcal cell to host epithelial cell –Must retain some consistency Conserved N-terminal and variable C- terminal regions Conserved N-terminal and variable C- terminal regions –Constant regions –Semi-variable regions –Hypervariable regions Phase variation from piliated to non- piliated Phase variation from piliated to non- piliated

16. Immune Memory Infection history did not alter antibody levels in patients with current infection Infection history did not alter antibody levels in patients with current infection –Suggests immunological memory not induced by uncomplicated gonococcal infections Local and systemic immune responses to gonococci extremely modest Local and systemic immune responses to gonococci extremely modest –Slight increase in serum immunoglobulin G (IgG) in infected males –Slight increase in serum IgA1 antibodies in infected females

17. Survival Within Host Pili, outer membrane proteins, lipopolysaccharides Pili, outer membrane proteins, lipopolysaccharides –Binding to epithelial surfaces –Passage through epithelium –Interaction with phagocytes Variations in outer membrane protein (P1, Por) Variations in outer membrane protein (P1, Por) Requires Requires –Carbon dioxide –Sulfur in form of cysteine –Iron http://www.med.monash.edu.au/assets/images/mic robiology/gono.jpg

18. Antimicrobial Resistance Gonococcal strains resistant to: Gonococcal strains resistant to: –Penicillins –Tetracyclines –Spectinomycin –Fluoroquinolones Presently, ciprofloxacin and ofloxacin recommended by CDC for treatment Presently, ciprofloxacin and ofloxacin recommended by CDC for treatment

19. Biotechnology Oligonucleotide chips now used to screen for antimicrobial resistance Oligonucleotide chips now used to screen for antimicrobial resistance –Point mutations in the gyrA and parC genes   Determine the prevalence of ciprofloxacin-resistant strains Results identical to sequencing results Rapid and reliable analysis

20. Gonorrhea Topic Overview Topic Overview Biology of Neisseria gonorrhoeae Biology of Neisseria gonorrhoeae –Survival Within Host Screening Screening Treatment Treatment Control/Surveillance Control/Surveillance http://thailabonline.com/bacteria7.htm

21. Screening “Gold Standard” “Gold Standard” –Nucleic acid amplification assays  Polymerase chain reaction Cell culture to confirm diagnosis Cell culture to confirm diagnosis –Oxidase positive http://education.med.nyu.edu/courses/microbiology/courseware/infect-disease/Gram_Neg_Bacilli5.html

22. Types of Tests Gram-Stained Smear Gram-Stained Smear –Sensitivity reduced in asymptomatic infections –Less that 50% sensitive as cell culture –Not useful in rectal infections http://www.lahey.org/Medical/InfectiousDiseases/ID_Gonorrhea.asp

23. Types of Tests Culture Based Systems Culture Based Systems –High degree of specificity –Expensive –Trained personnel –Media requirements –Presumptive identification  Growth on selective GC agar, gram stain, oxidase and superoxol positivity http://www.asu.edu/it/spotlight/archive/genesis/

24. Types of Tests Antigen Detection and Enzyme Immunoassays Antigen Detection and Enzyme Immunoassays –Extensively investigated  Low/high prevalence  Symptomatic/asymptomatic –Few to no situations for which this assay recommended  Because of antigenic variation http://wfrc.usgs.gov/research/fish%20populations/STMaule5.htm

25. Types of Tests DNA Probe Hybridization DNA Probe Hybridization –Specific chemiluminescent label on probe –Available commercially –85% sensitivity –99% specificity http://www.ebiotrade.com

26. Types of Tests Nucleic Acid-Based Amplification Assays (NAAT) Nucleic Acid-Based Amplification Assays (NAAT) –95% accurate –False positives due to specimen cross- contamination, environmental contamination http://www.biologicalprocedures.com/bpo/arts/1/6/m6.htm

27. Current Screening No test for samples from all major sites of gonococcal infection No test for samples from all major sites of gonococcal infection –Rapid –Inexpensive –Reliable Such a test would improve case-finding Such a test would improve case-finding –Efficient treatment –Disease management

28. Gonorrhea Topic Overview Topic Overview Biology of Neisseria gonorrhoeae Biology of Neisseria gonorrhoeae –Survival Within Host Screening Screening Treatment Treatment Control/Surveillance Control/Surveillance http://neisseria.org/ng/images/

29. Treatment http://www.cdc.gov/STD/treatment/4-2002TG.htm#Gonococcal

30. Treatment Fluoroquinolones Fluoroquinolones http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=mmed.figgrp.686 http://www.m-ww.de/pharmakologie/arzneimittel/antiinfektiva/antibiotika/ofloxacin.html Ofloxacin Ciprofloxacin Levofloxacin http://www.alchemchina.com/products/apis_l.files/Levofloxacin.gif

31. Treatment Ceftriaxone (Rocephin ® ) Ceftriaxone (Rocephin ® ) –Single dose intramuscularly –Introduced as treatment in 1985  Retained resistance –Beta-lactam antibiotic –Action against penicillinase http://www.m-ww.de/pharmakologie/arzneimittel/antiinfektiva/antibiotika/ceftriaxon.html

32. Treatment Possible co-infection with Chlamydia trachomatis Possible co-infection with Chlamydia trachomatis Azithromycin Doxycycline http://www.bmb.leeds.ac.uk/mbiology/ug/ugteach/icu 8/images/antibiotics/azithromycin.gif http://www.cbwinfo.com/Pharmaceuticals/Structures/Doxycycline.gif

33. Vaccine Hard to develop Hard to develop –No animal model No immune memory to Neisseria gonorrhoeae No immune memory to Neisseria gonorrhoeae –Antigenic variation strategy Difficulty finding target common to all strains Difficulty finding target common to all strains Research continues to identify possible vaccine targets Research continues to identify possible vaccine targets –DNA vaccines –Mucosal immunization

34. Gonorrhea Topic Overview Topic Overview Biology of Neisseria gonorrhoeae Biology of Neisseria gonorrhoeae –Survival Within Host Screening Screening Treatment Treatment Control/Surveillance Control/Surveillance http://www.mediscan.co.uk/cfm/img_coll.cfm?action=sear ch&imageID=020864&collectionID=21&name=Electron%2 0Micrographs&log=nk#

35. Prevention Abstinence Abstinence Safe/”smart” sex Safe/”smart” sex Barrier contraceptives Barrier contraceptives Educational programs Educational programs Reduce misuse of antimicrobials Reduce misuse of antimicrobials http://www.pueblo.gsa.gov/cic_text/health/contracept/co ndom.gif

36. Governmental Programs Health Canada Health Canada –Educational plans –STD Screening –Free STD clinics

37. Governmental Programs CDC Gonococcal Isolate Surveillance Project (GISP) CDC Gonococcal Isolate Surveillance Project (GISP)

38. Conclusions More research More research –Reliable, fast screening –Preventative therapeutics Non-biotechnological interventions Non-biotechnological interventions Prudent antimicrobial use Prudent antimicrobial use http://www.agma.med.uni-giessen.de/cfagma/andro/verz.dbm

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