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NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 ORIGINAL RESEARCHGONORRHOEA IN MEN: DIAGNOSTIC ASPECTS AND
CHANGING ANTIBIOTIC SUSCEPTIBILITY PATTERN
Sandeep Nanda1, Sonia Barve1, Chandralekha Bhanujan2, Sachin P Lohra2,
Rupal Patel3, Govind L Ninama4, Kalpesh Mistry4
Author's Affiliation: 1Medical college, Baroda; 2BJ Medical College, Ahmedabad; 3PS Medical College, Karamsad; 4GMERS,
Gotri, Baroda
Correspondence: Dr. Sandeepkumar Nanda, Email: [email protected]
ABSTRACT
Background: Gonorrhea since the ancient times is causing significant morbidity. Though a number of methods are
available for diagnosis in men, culture still remains the gold standard. Gonococci are delicate and fastidious bacteria
but its remarkable ability to develop resistance to a variety of antibiotics makes it a major threat to public health. Objectives: To detect the incidence in symptomatic men and in vitro antimicrobial susceptibility pattern of the
gonococcal isolates. Materials & Methods: - 100 urethral swabs from men with urethritis were screened for presence of gonococci by
gram stain and culture on Chocolate Agar and Modified Thayer-Martin medium. The isolated gonococci were screened for Penicillinase production and susceptibility to antibiotics was subsequently carried out by standard disc diffusion method. Results: - Gonorrhoea was detected in 56 of the urethral swabs giving a incidence of 56%. The difference of
detection in gram stain and culture was insignificant (P>0.05). Of all the isolated gonococci considerable resistance was seen to ciprofloxacin(46.4%), tetracycline(23.2%) and Penicillin(17%) with Incidence of PPNG being 12.5%. All strains were uniformly sensitive to Spectinomycin and Cephalosporins. Conclusions: - Neisseria gonorrhoeae is main etiological agent in urethritis in sexually active men and culture
though time consuming, costly and demands expertise is still better method for diagnosis as gives high isolation rate and observe changing patterns in antibiotic susceptibility to commonly used antimicrobials. Keywords: Gonorrhoea, Men, Antibiotic susceptibility
culture was regarded as difficult and uncertain, but many decades ago the problems were overcome, and Gonorrhea is one of the oldest known bacterial diseases culture became the method of first choice for diagnosis, that was recognized as sexually transmitted infection by and remains the "gold standard" against which other 13th century but still causes significant morbidity among methods are measured. However, culture is by no means sexually active individuals1. Global estimates of disease the only method available for diagnosis of are difficult to obtain but WHO suggests that gonorrhoea.3,4,5. worldwide, 62 million new cases occur annually. The greatest burden of disease falls upon less developed Alternative methods have been evaluated exclusively for countries so the highest incidence and prevalence is the detection of gonococci in clinical specimen such as found in Africa and South-East asia. In India, the ELISA, immunofluorescence, DNA probes, genetic prevalence rate of gonorrhea is 3-19%2. Gonorrhoea transformation, polymerase chain reaction (PCR). caused by Neisseria gonorrhoeae, is diagnosed Though rapid, sensitive and specific, PCR has several presumptively by the presence of intracellular and limitations; it needs costly equipment and reagents, extracellular Gram negative cocci on a Gram stain. experienced technician, and the organism cannot be Culture for the causative organism is considered isolated in this method for further investigation.5,6 On necessary, however, as it dies rapidly if exposed to the other hand, culture, though more time consuming, desiccating or oxidising conditions, so isolation of needs to maintain viable organism till culture is done gonococci requires good specimen collection and and having less sensitivity in some samples, is the bedside inoculation or suitable transport, a moist carbon method of choice for identification of gonococci, dioxide enriched atmosphere and enriched and or particularly in developing countries because is cost selective medium3,4,5. For these reasons diagnosis by effective, high specificity and very important for testing Volume 3│Issue 2│Apr – June 2013 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 the antibiotic sensitivity pattern that is another key 1. A sterile, calcium alginate tipped swab was factor in successful treatment and control of disease3,5. used for collection of discharge or sterile bacteriological Because of continuing drift towards decreased antibiotic loop was passed 3-4 cm into the urethra. One swab was sensitivity of Neisseria gonorrhoeae, effective treatment of used for smear preparation for Gram-staining and gonorrhea is hampered. Emergence of gonococci with microscopical examination. Gram-stained smears of plasmid mediated and chromosomally mediated urethral exudate were examined under x 1000 resistance to penicillin and tetracycline resulted in use of magnification oil immersion for the presence of quinolones for the treatment of gonorrhea. But polymorphonuclear cells and Gram-negative diplococci. Quinolone Resistant N. gonorrheae (QRNG) resulted in The results of the smears were considered positive if the use of expanded spectrum Cephalosporins as the typical Gram-negative diplococci were seen, whether first line of treatment for uncomplicated gonorrhea. located intracellularly or extracellularly. Because of the emergence of resistance to different antibiotics, the in vitro estimation of antimicrobial 2. And the second swab was streaked directly on sensitivity becomes necessary.
to an enriched medium, Chocolate Agar(CA) and 7There has been little published work on gonococcal infection in men since selective medium, Modified Thayer-Martin before the 2nd World War and much that is written media(MTM) having Vancomycin, Colistin, Nystatin reflects received information, passed down from and Trimethoprim as selective agents and incubated for previous authorities.
48 hours in moist environment at 35-36°C in 5-10% carbon dioxide. No cultures for viruses or chlamydiae So this study was carried out in symptomatic male were carried out. A presumptive identification of patients to know the incidence of gonococci in isolates of Neisseria gonorrhoeae was based on urethritis and evaluation of gram stain and culture characteristic colonial morphology, positive oxidase test, methods as well as role of enriched media and selective and the presence of Gram-negative diplococci. Isolates media in diagnosis of gonorrhoea and study antibiotic were further identified as N. gonorrhoeae by typical sugar susceptibility pattern of gonococci. utilization tests. All the isolated gonococci were screened for production of Penicillinase by acidometric method and antibiotic sensitivity testing performed by METHODS AND MATERIAL
disc diffusion method against Penicillin, Tetracycline, Ciprofloxacin, Spectinomycin, Cefuroxime and Male patients with complaint of urethral discharge were examined after informed consent. Those suspected of having gonorrhoea, discharge was collected under sterile conditions and smears were prepared for Gram staining and culture performed bed side on enriched media and selective media. For this purpose two samples were In the present study, gonococci were the etiological taken one for culture and second for smear preparation. agent in 56(56%) of the 100 symptomatic men that presented with urethritis (Table 1). Table 1: Incidence of gonorrhea and Evaluation of Chocolate agar (CA) and Modified Thayer Martin
(MTM) medium in isolation of gonococci
Gonococcal isolates (%)
No. of isolations on specific media
Present study 100 56(56%) Jacob et al9 375 Bonin et al10 6236 Majority of patients (78.6%) with gonorrhea were tetracycline and ciprofloxacin respectively. Resistance to between 15 to 29 yrs of age and 94.6% gave history of penicillin was observed in 10 (17.8%) of the isolates of unprotected sexual exposure to CSWs while 5.4% were which Penicillinase producing Neisseria gonorrhoeae homosexuals. Diagnosis of gonorrhea was established (PPNG) were seen in 7(12.5%) of the isolates (Table 3). by Gram stain in 53% and by culture in 56% of the patients but the difference of positivity is not statistically significant (P>0.05) (Table 2). Table 2: Evaluation of smear in comparison with
Gonococci were isolated on both MTM and CA in 53 culture in diagnosis of gonorrhea
cases, on MTM only in 3 and no isolation on CA only. Authors Positive
by Positive by
So all the isolates grew on MTM and only 3 were not smear (%)
isolated on CA. Though the rate of isolation is higher Present study (n =100) on MTM in comparison to CA, the difference is not Manis et al11 (n=295) statistically significant (P>0.05) (Table 1).All the isolates were susceptible to Spectinomycin, Cefuroxime and Ceftriaxone. While 23.2% and 46.6% were resistant to Volume 3│Issue 2│Apr – June 2013 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Table 3: Antibiotic resistance pattern of gonococci
study Penicillin Ciprofloxacin Spectinomycin Cefuroxime Ceftriaxone Present study (n=56) 3 (5.3) 13(23.2) 26(46.4) Lesmana et al (n=122) Berron et al (n=400) 16 (4) 129(32.2) 26(6.5) DISCUSSION
20-29years of age and gave history of unprotected, multiple, heterosexual exposure to CSWs (94%). As for Among the symptomatic males gonococcal urethritis is establishing diagnosis, though Gram stain is rapid, cost the predominant (56%). Similar results are reported by effective, highly sensitive and specific in symptomatic Jacob et al9 (P>0.05) but the incidence is significantly men we still recommend use of culture along with different with that of Bonin et al10 (P<0.01) (Table 1). Gram stain. Culture though time consuming, costly, This difference is because in present study only cases of requires special set up and technical expertise and viable symptomatic urethritis have been included while Bonin organism for isolation will help in diagnosis in missed et al included all male patients undergoing urethral out cases and perform Antibiotic sensitivity testing culture whether for diagnosis, screening or test of cure. considering changing patterns in the sensitivity profile On comparison with study of Manis et al11, the rate of of organism4. As for choice of culture media whether positivity of smear in diagnosis of gonorrhea is not enriched (CA) or selective (MTM), we recommend statistically significant (P>0.05) (Table 2). Similar results both, because MTM have higher isolation rate but some were reported by Sherrard et al8 94% positivity of smear strains of gonococci are sensitive to Vancomycin and in symptomatic men. These results further confirm that are inhibited on MTM are isolated only on CA. Due to Microscopy of a gram-stained urethral sample is a highly high prevalence PPNG and resistance in gonococci to sensitive examination in diagnosis of gonorrhoea when Penicillin, Ciprofloxacin and Tetracycline it is compared to culture in symptomatic men, although its mandatory to perform antibiotic sensitivity testing and sensitivity is much reduced in asymptomatic men, even observe the changing pattern in antibiotic susceptibility when most of these are presenting as known contacts of pattern. However, because no resistance is observed to gonorrhoea, and the index of suspicion of the Cephalosporins these are the drugs of choice for microscopist is high8. On comparing result of present management of Gonorrhoea. study for isolation on CA and MTM with that of Jacob et al9 and Bonin et al10, it was observed that the difference was not statistically significant (P>0.05, CI 95%). However, in both the studies some isolates (1 in REFERENCES
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