Multi-Drug Resistant Neisseria gonorrhea Among Hotel-Based Sex Workers in Rajshahi, Bangladesh

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1 International Journal of Microbiological Research 4 (2): , 2013 ISSN IDOSI Publications, 2013 DOI: /idosi.ijmr Multi-Drug Resistant Neisseria gonorrhea Among Hotel-Based Sex Workers in Rajshahi, Bangladesh Lutfun Nesa, Abdus Salam, Anwar Ul Islam and Aktar Uzzaman Chouduri 1 Department of Pharmacy, University of Rajshahi, Rajshahi-6205, Bangladesh 2 Department of Pathology, Rajshahi Medical College Hospital, Rajshahi-6000, Bangladesh Abstract: Information on antimicrobial sensitivity pattern of Neisseria gonorrhea among commercial sex workers in worldwide many cities have already been reported but are yet to be investigated in Rajshahi city, Bangladesh. This study aimed to determine the antimicrobial resistance profile in N. gonorrhea among hotel-based sex workers in this city. N. gonorrhea strain was isolated from endocervical swab specimen from sex workers and identified by biochemical analysis. In vitro susceptibility test of gonorrhea isolates was performed by disk diffusion method with traditional and widely used antimicrobials, e.g. penicillin, tetracycline, ciprofloxacin, erythromycin, ceftriaxone and cefixime. Sex workers mean age ranged years having either hidden or obvious gonococcal infection. All isolated N. gonorrhea strains were highly or intermediately resistant against tetracycline, penicillin, ciprofloxacin, ceftriaxone. High-level resistance was found in three isolates against tetracycline, erythromycin and ciprofloxacin. Eythromycin was resistant against three isolates but was highly active against one isolate. Only cefixime was potentially active against all isolates indicating that cefixime is currently the choice of drug for gonorrhea treatment. However, tested antibiotics exhibited a case-specific effectiveness on gonorrhea isolates. Obtained drug resistance pattern varied on the case of individual, some other factors associated with lifestyle of individual and geographic location. Multi-drug resistant N. gonorrhea was in alerting level that bears a risk of transmission of STD to general public. The need of surveillance and counseling to sex workers, prevention and control of infection should be undertaken seriously otherwise it would cause a devastating epidemic in near future. Key words: Sex Workers Gonorrhea Multi-Drug Resistance Bangladesh INTRODUCTION gonorrhea are often susceptible to HIV and tend to show complications [3].Gonococcal infection also increases the Commercial sex workers (CSWs) serve as the risk of HIV transmission by 3-5 folds [4-5]. reservoir of sexually transmitted diseases (STDs). CSWs sustain very high rates of transmission of Gonorrhea is one of the classical STD with human by the STDs; among them, gonorrhea with multiple antibiotic causative microbe, Neisseria gonorrhea. The globally resistance is common [6]. The development of resistance estimated number of gonorrhea cases is 200 million per to antimicrobials in N. gonorrhea is a result of both wide year [1]. Prevalence rate of this disease varies greatly dissemination of resistant clones and the emergence of among countries in the developed and developing world, strains with novel resistance mechanisms [7]. Despite of the highest being in South and Southeast Asia followed a sharp decline in the incidence of gonococcal infection by Africa and Latin America [2]. Many years ago this in developed countries during the last decade, it still disease was easily killed with a shot of penicillin but now remains one of the most common venereal diseases in a day is increasingly becoming a life-threatening microbe. developing countries and a global health problem [1]. Soon, the world may face a version that cannot be killed Several problems are associated with the development of by any existing antibiotic. However, patients infected with resistance such as self-prescription, inappropriate drug Corresponding Author: Aktar Uzzaman Chouduri, Department of Pharmacy, University of Rajshahi Rajshahi-6205, Bangladesh. Tel: , (Office) Cel: , Fax:

2 selection and dose maintenance, lack of surveillance and endocervical swab-samples, one swab smear for Gram monitoring of resistance trends, lack of identifying the staining test and another swab sample in a culture tube emergence of new resistance [8] and so on. Beside these, for cell culture, were collected from SWs. A sterile cottonthere is a lack of reporting in developing countries as wool swab was passed into the endocervix and gently well. rotated against the endocervical wall to obtain a The resistance against almost all antimicrobials in specimen. An expert paramedic technician helped us for N. gonorrhea is rapidly changing now in South and specimen collection process. For each SW a code number Southeast Asian countries [9, 10]. Periodic monitoring of was used in the specimen taken. The swab samples from the antimicrobial susceptibility profile in the high-risk the collection point were brought into the laboratory population can provide the essential clues regarding the under chilling condition. The collected specimens were changing pattern of antimicrobial susceptibilities [11]. instantaneously streaked onto the culture plate. All the Hotel-based sex workers are one of the high risk laboratory works were performed at Microbiology populations for the dissemination of resistant gonorrhea Laboratory, Department of Pharmacy, University of strain to the community level. Rajshahi, Bangladesh. Antimicrobials of fluoroquinolone group, such as ciprofloxacin or ofloxacin, were highly effective agents as Biochemical Tests: Gram staining - Gram staining test treatment for gonococcal infections including those with was performed with swab smear and with a single colony resistance [12, 13]. However, recently the emergence of formed on the primary culture plate of swab specimens to gonococcal isolates with reduced susceptibility or identify whether the specimen contains Gram-negative resistance to fluoroquinolones is a threatening concern in organism. The smear is allowed to dry, then heat-fixed and several countries including Bangladesh [14-17]. Earlier the Gram-stained as described elsewhere. A single colony is treatment failure of gonorrhea with fluoroquinolones has emulsified in a small drop of saline on a glass slide and been reported in Dhaka, Bangladesh [18, 19] but over the stained with same technique. years, the treatment has become more complicated due to Oxidase test - Oxidase reagent, 1% tetramethyl-presistance to a variety of antimicrobials. To date, the phenylenediamine dihydrochloride, was prepared in identification of prevalence, risk factors, antimicrobial aqueous solution. A single colony from primary culture sensitivity pattern of N. gonorrhea is pending in Rajshahi was sub-cultured on a separate chocolate agar plate at City, Bangladesh. Therefore, this study aimed to search 37 C for 24 hr and 1% oxidase test reagent was poured the current resistance profile in N. gonorrhea among onto the culture. A positive reaction by the development hotel-based sex workers in Rajshahi City that would of deep purple color of the culture within few seconds provide updated treatment regimen for resistant confirmed the colony as N. gonorrhea strain. N. gonorrhea strain in Bangladesh. Antimicrobial susceptibility test - Antimicrobial susceptibility tests of isolated N. gonorrhea strains were MATERIALS AND METHODS performed by disc diffusion method on chocolate agar media containing fresh sheep blood as described in Chemicals and Antimicrobial Disks: Blood agar base Bauer et al. [20] using six antibiotics discs; tetracycline was purchased from Sigma-Aldrich, USA; antibiotic disks (30 µg), penicillin (10 IU), ceftriaxone (30 µg), from Oxiod, England. The doses of antibiotics and disc erythromycin (15 µg), ciprofloxacin (5 µg) and cefixime diameters were in accordance with the standards of (5 µg). At first frozen inoculums were sub-cultured onto World Health Organization. agar plates prior to susceptibility testing. A suspension of fresh cells was spread onto a separate agar plate with Study Population: Target people of this study were antibiotic disks followed by the incubation at 37 C for hotel-based sex workers (hereafter termed as SW) in 24 h before the zones of inhibition were measured. Rajshahi city, Bangladesh. A prospective study was N. gonorrhea isolates that demonstrated resistance to conducted among twelve SWs attending in the regular three or more antibiotics were categorized as multi-drug counseling program organized by the regional branch of resistant. a non-governmental organization, HELP, over a period of June 2009 to September RESULTS Specimen Collection: At first, the study population was informed about the purpose of the study in detail and consent from SWs was taken individually with the assurance of maintenance of secrecy. Two separate Isolation and Identification of N. gonorrhea: Three different screening techniques were applied to specimens for the isolation and identification of N. gonorrhea strains described hereunder. 168

3 Table 1: Screening of endocervical swab specimens for N. gonorrhea. Specimen no Gram staining Primary culture Diplococcus character in microscopic examination Oxidase test Remarks SW-01 - SW NG SW-03 +/- + b + - SW NG SW-05 - SW-06 - SW NG SW-08 - SW NG SW-10 - SW-11 - SW-12 a - - a False Gram negative staining of swab smear b Undefined character by microscopic examination SW12 were diagnosed as Gram negative bacteria (Table 1) and one specimen SW3 diagnosed as mixed-type bacteria which exhibited both Gram positive and Gram negative staining. The smear specimens, either Gram negative or mixed-type, were further analyzed by morphological study of cell with the second swab sample collected for cell culturing. Morphological analysis - All specimens were Fig. 1: Microscopic view of gonorrhea isolate of streaked on chocolate agar plate and allowed to grow specimen SW4. A: Fresh sub-culture of specimen at 37 C for 24 to 48 hrs under the CO 2 environment. SW4 was transferred onto glass slide and stained Five specimens, SW2 - SW4, SW7 and SW9 enabled with Gram staining reagent. Dried slide was to form bacterial colonies on culture plates but SW12 viewed under microscope (Rinocular photographic which was Gram negative in smear staining test did not microscope, M2100, Germany, 800 magnification) show any colonies on culture plate (Table 1). A single with a drop of immersion oil. B: A snapshot colony from each specimen was sub-cultured on a captured on microscope monitor showing the separate agar plate and the fresh cell was visualized diplococcal characteristic of gonorrhea strain. under microscope (magnification 800) to test the diplococcus morphology of N. gonorrhea strain. Four typical colonies from specimen SW2, SW4, SW7 and SW9, were identified as Gram negative diplococci (Table 1). Microscopic view of Gram negative staining and diplococcal morphology of specimen SW4 has been shown in Figure 1. One isolates, SW3, which showed a mixed-type character in smear staining test was still unclear in morphological analysis (Table 1). Further biochemical test, oxidase reaction, was conducted with these five presumptive cultures to confirm the identities Fig. 2: Gonorrhea isolate identified by oxidase test. Few of colonies. drops of 1% oxidase test reagent were poured Oxidase test - Few drops of 1% oxidase test reagent onto the fresh culture that turned the culture into were poured onto the fresh sub-culture of each of five deep purple color confirming the N. gonorrhea colonies. Four cultures of specimen SW2, SW4, SW7 strain. and SW9 turned into deep purple color confirming the N. gonorrhea strain while the specimen SW3 was not. Gram staining - N. gonorrhea is most commonly A representative oxidase test result of specimen SW4 has found in the cervix of infected women. Endocervical swab been shown in Figure 2. smears collected from sex workers were subjected to Gram Test results obtained were tabulated (Table 1) and staining test as described in materials and methods. based on the results from three different identification Five specimens coded as SW2, SW4, SW7, SW9 and tests described above four isolates SW2, SW4, SW7 and 169

4 Table 2: Multi-drug resistant N. gonorrhea isolates determined by disc diffusion method Recommended zone of inhibition (mm) for susceptibility test of N. gonorrhea b Tested Disc Mean zone of Incidence Specimen no. drugs potency a inhibition (mm) Resistant Intermediate Susceptible of resistance SW2 Tetracycline 30 µg R Penicillin 10 IU R Ceftriaxone 30 µg I Erythromycin 15 µg I Ciprofloxacin 5 µg I Cefixime 5 µg SW4 Tetracycline 30 µg R Penicillin 10 IU R Ceftriaxone 30 µg I Erythromycin 15 µg I Ciprofloxacin 5 µg R Cefixime 5 µg SW7 Tetracycline 30 µg R Penicillin 10 IU R Ceftriaxone 30 µg I Erythromycin 15 µg Ciprofloxacin 5 µg R Cefixime 5 µg SW9 Tetracycline 30 µg R Penicillin 10 IU I Ceftriaxone 30 µg I Erythromycin 15 µg R Ciprofloxacin 5 µg I Cefixime 5 µg Since at least three drugs were resistant against isolates SW4 and SW7, therefore, these isolates are categorized as multi-drug resistant N. gonorrhea strain. a Each test was done in triplicate and mean value was considered for analysis. b Recommended zone of inhibition for susceptibility test of N. gonorrhea strain is followed as the guideline of District Laboratory Practice in Tropical Countries [22]. N. gonorrhea strains have been shown in Figure 3. Antimicrobial susceptibility test was carried out with these four gonorrhea isolates. Fig. 3: Sub-culture of N. gonorrhea isolates on chocolate agar media. Swab specimens from SWs were inoculated onto chocolate agar media followed by the exposure of inoculums in CO 2 environment provided by candle jar extinction. A: Representative gonorrhea positive culture of specimen SW4 grown at 37 C for 24 h. B: Subculture of four N. gonorrhea isolates on agar plate of specimen SW2, SW4, SW7 and SW9. SW9 were confirmed as N. gonorrhea strain that showed positive reactions in oxidase test and gram-negative diplococci in Gram staining test. One representative culture plate with bacterial colonies and four isolated Multi-Drug Resistant Profile in N. gonorrhea: Tetracycline: Tetracycline is still active drug for the treatment of gonorrhea in developed countries although its activity is decreasing rapidly in third-world countries. Recently, 73.3% tetracycline-resistant N. gonorrhea (TRNG) has been reported in South Africa [21]. We tested tetracycline to check its effectiveness against the isolated N. gonorrhea strains. Based on the diameter of zone inhibition, isolate SW2, SW4 were detected as highly resistant against tetracycline (Figure 4A, 5A and Table 2) whereas isolate SW7, SW9 were on the marginal line of resistance level (Figure 6, 7A, Table 2). All four isolates were tetracycline resistant but one of them SW2 did not show any zone of inhibition (Figure 4A) indicating a high-level resistant phenotype of SW2 against tetracycline. The resistance of gonococci to tetracycline is either chromosome-mediated, which caused low-level resistance to tetracycline or plasmid-mediated which produced high-level resistance to tetracycline. 170

5 Fig. 4: Appearances of inhibitory zones of SW2 isolate. Mean zone diameter of inhibition around discs of A: tetracycline (Tet), penicillin (Pen), ceftriaxone (Ceftri) and B: erythromycin (Ery), ciprofloxacin (Cip), cefixime (Cef) are 0, 20, 20 and 16, 34, 38 mm respectively. The isolate was resistant against tetracycline, penicillin and intermediately resistant against erythromycin, ciprofloxacin (Table 2) Fig. 5: Appearances of inhibitory zones of SW4 isolate. Mean zone diameter of inhibition around discs of A: tetracycline (Tet), penicillin (Pen), ceftriaxone (Ceftri) and B: erythromycins (Ery), ciprofloxacin (Cip), cefixime (Cef) are 10, 20, 26 and 14, 0, 34 mm respectively. The isolate was resistant against tetracycline, penicillin, ciprofloxacin and intermediately resistant against erythromycin (Table 2) Fig. 6: Appearances of inhibitory zones of SW7 isolate. Mean zone diameter of inhibition around discs of tetracycline (Tet), penicillin (Pen), ceftriaxone (Ceftri), erythromycin (Ery), ciprofloxacin (Cip), cefixime (Cef) are 30, 10, 25, 38, 20 and 46 mm respectively. The isolate was resistant against tetracycline, penicillin and ciprofloxacin (Table 2). Fig. 7: Appearances of inhibitory zones of SW9 isolate. Mean zone diameter of inhibition around discs of A: tetracycline (Tet), penicillin (Pen), ceftriaxone (Ceftri) and B: erythromycins (Ery), ciprofloxacin (Cip), cefixime (Cef) are 30, 33, 25 and 0, 35, 35 mm respectively. The isolate was resistant against tetracycline, erythromycin and intermediately resistant against penicillin, ciprofloxacin (Table 2) 171

6 The plasmid-mediated resistance was first reported in the cefixime- and ceftriaxone-resistant N. gonorrhea is United States and latter it was found in other countries as isolated in France [25]. Although cephalosporins are the well. Since with tetracycline 30 µg discs, zone diameter of choice of drug for gonorrhea treatment but in this study 19 mm usually indicate a plasmid-mediated TRNG only cefixime was found to be active against isolated strain [22], therefore, SW2 and SW4, should be the N. gonorrhea strains. plasmid-mediated TRNG and other two, SW7 and SW9, might be the chromosome-mediated TRNG. Two isolates Erythromycin: Erythromycin is a macrolide class of showed high-level of tetracycline resistance in this study. antibiotics. All isolates were treated with erythromycin, where two isolates, SW2 and SW4, were intermediately Penicillin: When penicillin was first used in the 1940s for resistant (Figure 4B, 5B and Table 2) and isolate SW9 was the treatment of gonorrhea, it was effective against most highly resistant to erythromycin (Figure 7B, Table 2) strain. However, with increased use of this antibiotic, the which did not show any zone of inhibition. Only one number of resistant isolates to penicillin has been isolate SW7 was strongly inhibited by erythromycin with increased worldwide in recent years. Prevalence of 38 mm zone diameter where the minimum susceptible penicillin resistant N. gonorrhea (PRNG) isolates has level was 23 mm zone diameter (Figure 6, Table 2). been reported as extremely high level in Indonesia, This result indicates that erythromycin is still active 60.0% isolates from Bandung and 70.9% isolates from against N. gonorrhea but soon it may lose as a choice of Jakarta were resistant to penicillin [23]. Another recent drug for the treatment of gonorrhea. Three different survey has shown 25.8% PRNG in South Africa [21] mechanisms are involved in macrolide resistant whereas a study done in Canada revealed 89.2% PRNG N. gonorrhea: efflux systems, modification of ribosomal [24]. In this study three isolates, SW2, SW4 and SW7, target by methylases and ribosomal modification by point were penicillin resistant (Figure 4A, 5A, 6 and Table 2) mutations in macrolide targets [24]. To determine the and one isolate SW9 was intermediately resistant molecular mechanism of high-level resistance in SW9 (Figure 7A, Table 2) against penicillin. Gonococci with isolate is beyond of our study. 10 IU penicillin disc, diameter of zones of 19 mm are likely to be -lactamase producers [22]. Isolate SW7 in Ciprofloxacin: Fluoroquinolones, ciprofloxacin or this study was inhibited by same penicillin disk with ofloxacin, were excellent antimicrobials against diameter of 10 mm indicating that SW7 is -lactamase N. gonorrhea in last decade. Wide use of producer. Two isolates, SW2 and SW4, had a drift fluoroquinolones resulted in an emergence of resistant towards -lactamase producer. Three isolates were N. gonorrhea strains against ciprofloxacin in many resistant and one isolate was intermediately resistant countries including Japan, the United States, Canada, against penicillin. Denmark, Korea, Bangladesh [19, 26-30]. In Japan, about 3.7% of gonorrhea strains were ciprofloxacin resistant in Cefixim-Ceftriaxone: Third generation cephalosporins, 1981 that reached to 46.8% from [31]. cefixime and ceftriaxone, has been used in this study that Prevalence of quinolone-resistant N. gonorrhoea has is more reliable therapeutic option with increasing increased rapidly in Ontario - Canada's most populous prevalence of fluoroquinolone-resistant N. gonorrhea. province - from 2 to 28% in , found a study All four isolates were susceptible to cefixime (Figure 4B, published in CMA, Science Daily, Feb 2, In this 5B, 6 and 7B) although three of them, SW2, SW4 and study two isolates, SW4 and SW7, were ciprofloxacin SW9, had decreased susceptibility with a slight drift resistant (Figure 5B, 6, Table 2) and one of them SW4 towards intermediate level of resistance (Table 2). showed no zone of inhibition (Figure 5B) indicating a Ceftriaxone is also a first-line drug for the treatment of high-level of resistant against ciprofloxacin. Other two gonorrhea. For past few years the widespread clinical use isolates, SW2 and SW9, were in intermediate level of of ceftriaxone N. gonorrhea strains of decreased resistant (Figure 4B, 7B, Table 2). No isolates were susceptibility to ceftriaxone has been reported [24]. susceptible against ciprofloxacin. Therefore, our result No isolates in this study were susceptible to ceftriaxone. confirmed that ciprofloxacin can no longer be used The zones of inhibition of all isolates by ceftriaxone were against N. gonorrhea strain. Liao et al found 6 mm below the susceptible level (Table 2). Since intermediate zone inhibition by ciprofloxacin for N. gonorrhea in category of resistance for N. gonorrhea indicates a lower chocolate agar media in Taiwan [32]. In this study isolate cure rate (85-95%) compared to the cure rates for SW4 which showed no zone inhibition can be susceptible patients [22], ceftriaxone can no longer be characterized as high-level ciprofloxacin resistant used for gonorrhea treatment. Very recently high level N. gonorrhea strain. 172

7 DISCUSSION uncomplicated gonorrhoea in this region [42]. In this study we showed that N. gonorrhea started to become Antimicrobial resistance has been recognized as a resistant against ceftriaxone. In contrast all isolates were growing public health threat in all over the world. In many fully susceptible against cefixime but it seems that the areas of the world N. gonorrhea resistance to multiple resistance against cefixime is not a far way and soon this agents is common. In some developed countries low drug may not be a good choice. spectrum antibiotics are still used effectively but imported In Bangladesh, there is no established antimicrobial infections are creating problems. Many researchers have susceptibility surveillance for N. gonorrhea. Lack of documented the high frequency and increasing compilation of laboratory data and established monitoring prevalence of antimicrobial resistance of N. gonorrhea in system, selection of appropriate antibiotics for the Africa, especially to penicillin and tetracycline [33-37]. treatment of gonorrhea is getting difficult. Moreover, There are reports that documented 11 to 45% increase of inappropriate dosage as well as antimicrobial usage as TRNG in female sex workers in Kinshasa within 30 months prophylaxis by sex workers is allowing N. gonorrhea [38]. Some other reports documented 59 to 90% strain to be resistant. Therefore, there should be a antibiotic resistant of this strain in Asia [39]. In 2000, restraint for the inappropriate use of antibiotics to WPRO (WHO Western Pacific Region Office) reported a minimize the spread of resistant strains. Therefore, it very high portion of ciprofloxacin resistance in China needs periodic local monitoring of the the antimicrobial (85.2%), Hong Kong (79.5%), Japan (40%) and Korea sensitivity pattern so as to plan the line of treatment. (63.3%) [39]. In Korea, both PRNG and TRNG was about 94% and ciprofloxacin resistance increased from 1 to 5% CONCLUSION in and also resistance to ceftriaxone were shown to be increased [30]. In 1999, 11.7% gonorrhea Health care providers in Bangladesh are following isolates reported as resistant to ciprofloxacin in Dhaka, currently available national guidelines for the treatment of Bangladesh [11] that reached 37.8% in 2001 [18,19]. In this gonorrhea which still recommended ciprofloxacin, study, all gonorrhea isolates were resistant to penicillin, ceftriaxone as the first line therapy. But in this study tetracycline, ciprofloxacin and ceftriaxone among ciprofloxacin, ceftriaxone resistance against gonorrhea hotel-based sex workers in Rajshahi, Bangladesh. isolates, therefore, suggests that national guidelines need Therefore, the trend becoming multi-drug resistance in to be re-evaluated and modified based on updated data. N. gonorrhea is rapidly increasing in this region. Medical practitioners should be aware of the treatment In Hawaii 2001, four urogenital N. gonorrhea isolates regimen considering the rapidly changing pattern of showed resistance to penicillin, tetracycline and antimicrobial susceptibility in N. gonorrhea. Moreover, ciprofloxacin and reduced susceptibility to cefixime [40]. the choice of antibiotic for the treatment of gonorrhea is In this study, four endocervical N. gonorrhea isolates becoming increasingly restricted. An early and effective were susceptible to cefixime but three of them diagnosis with proper treatment can only have a major showed reduced susceptibility. In Fukuoka, Japan 2006, impact on decreasing incidence and limiting spread of N. gonorrhea strain with a reduced susceptibility to gonorrhea. Therefore, continued monitoring of resistance ceftriaxone is reported that showed multi-drug resistance patterns is required to keep the treatment regimen against penicillin, tetracycline, azithromycin and updated. ciprofloxacin [31]. All isolates in this study were intermediately resistant to ceftriaxone. Recently, a novel Limitations and Future Directions: The study was ceftriaxone-resistant gonorrhea isolate was found in planned as a pilot to hotel-based sex workers, so the throat sample of a 31-year-old commercial sex worker in number of isolates was relatively small that might not Kyoto, Japan but her vaginal sample was gonorrhea reflect even local status of antimicrobial resistance pattern negative [41]. That report is a warning message on of gonorrhea. Therefore, we could not make our result of gonorrhea treatment although ceftriaxone is one of the drug-resistance profile as percentage. We faced trouble to best choices of gonococcal infection to date. convince target people and to collect the endocervical Current treatment for gonorrhea in most countries is swab sample from them. However, the study still reflects either cefixime or ceftriaxone. With increased prevalence the updated scenario of multi-drug resistance profile of of ciprofloxacin resistance in Bangladesh and other parts N. gonorrhea in Rajshahi, Bangladesh. Further follow-up of Asia, fluoroquinolones (including ciprofloxacin) are no study covering street-based sex workers will be longer recommended for use in Asia by CDC and WHO continue to document overall multi-drug resistance [42]. Instead cefixime or ceftriaxone are recommended for status of N. gonorrhea in this region. 173

8 ACKNOWLEDGEMENTS 9. Ray, K., M. Bala, J. Kumar and R.S. Misra, Trend of antimicrobial resistance in N. gonorrhea at Authors thank the Public Health Section, Rajshahi New Delhi, India. Internation Journal of STD and City Corporation, Rajshahi for information and AIDS, 11: arrangement to contact with sex workers. Authors also 10. Abeyewickereme, I., L. Seneratne and V.B. Prithiviraj, thank a regional non-governmental organization, HELP, Rapid emergence of 4 fluoroquinolone for the cooperation in specimen collection and handling resistance with associated decline in penicillinase the target people. producing Neisseria gonorrhea in Colombo, Sri. Lanka. Genitourinary Medicine, 72: 302. REFERENCES 11. Bhuiyan, B.U., M. Rahman, R.A. Miah, S. Nahar, N. Islam and M. Ahmed, Antimicrobial 1. DeSchryver, A. and A. Meheus, Epidemiology susceptibilities and plasmid contents of Neisseria of sexually transmitted diseases: the global picture. gonorrhea isolates from commercial sex workers in Bulletin of World Health Organization, 68: Dhaka, Bangladesh: Emergence of high-level 2. Cohen, M.S. and P.F. Sparling, Mucosal resistance to ciprofloxacin. Journal of Clinical infection with Neisseria gonorrhea: bacterial Microbiology, 37: adaptation and mucosal defences. The Journal of 12. Covino, J.M., M. Cummings, B. Smith, S. Benes, Clinical Investigation, 89: K. Draft and W.M. McCormack, Comparison of 3. Wasserheit, J.N., Epidemiological synergy: ofloxacin and ceftriaxone in the treatment of Interrelation ships between human uncomplicated gonorrhea caused by penicillin immunodeficiency virus infection and other producing and non-penicillin-producing strains. sexually transmitted diseases. Sexually Transmitted Antimicrobial Agents and Chemotherapy, Diseases, 19: : Laga, M., A. Manoka, M. Kivuvu, B. Malele, 13. Bryan, J.P., S.K. Hira, W. Brady, N. Luo, C. Mwale, M. Tuliza, N. Nzila, J. Goeman, F. Behets, V. Batter G. Mpoko, R. Krieg, E. Siwiwaliondo, C. Reichart and and M. Alary, Non-ulcerative sexually C. Waters, Oral ciprofloxacin versus ceftriaxone transmitted diseases as risk factors for for the treatment of urethritis from resistant Neisseria HIV-1transmission in women: results from a cohort gonorrhea in Zambia. Antimicrobial Agents and study. AIDS, 7(1): Chemotherapy, 34: Cohen, M.S., I.F. Hoffman, R.A. Royce, P. Kazembe, 14. Dan, M., F. Poch and B. Sheinberg, High J.R. Dyer, C.C. Daly, D. Zimba, P.L. Vernazza, M. prevalence of high-level ciprofloxacin resistance Maida, S.A. Fiscus and J.J. Eron, Reduction of in Neisseria gonorrhea in Tel Aviv, Israel: Correlation concentration of HIV-1 in semen after treatment of with response to therapy. Antimicrobial Agents and urethitis: implications for prevention of sexual Chemotherapy, 46: transmission of HIV-1. AIDSCAP Malawi Research 15. Krishna, R., B. Manju, K. Sudarshan and P.N. Jai, Group. Lancet, 349(9069): Antimicrobial resistance of Neisseria gonorrhea 6. Clendennen, T.E., P. Echeverria, S. Saengeur, in selected World Health Organization Southeast E.S. Kees, J.W. Boslego and F.S. Wignall, Asia region countries: An overview. Sexually Antibiotics susceptibility survey of Neisseria Transmitted Diseases, 32: gonorrhea in Thailand. Antimicrobial Agents and 16. Wang, S.A., A.B. Harvey, S.M. Conner, A.A. Zaidi, Chemotherapy, 36: J.S. Knapp, W.L. Whittington, C. Del Rio, 7. Ison, C.A., J. Pepin, N.S. Roope, E. Demba, O. Secka F.N. Judson and K.K. Holmes, Antimicrobial and C.S.F. Easmon, The dominance of a resistance for Neisseria gonorrhea in the United multiresistant strain of Neisseria gonorrhea among States, 1988 to 2003: The spread of fluoroquinolone prostitutes and STD patients in Gambia. resistance. Annals of Internal Medicine, 147(2): Genitourinary Medicine, 68: Bala, M., K. Ray, S.M. Gupta, S. Muralidhar and 8. Ray, K., M. Bala, S. Kumari and J.P. Narain, R.K. Jain, Changing trends of antimicrobial Antimicrobial resistance of Neisseria gonorrhea in susceptibility patterns of Neisseria gonorrheain India selected World Health Organization Southeast Asia and the emergence of ceftriaxone less region countries: An overview. Sexually Transmitted susceptible N. gonorrhea strains. Journal of Diseases, 32(3): Antimicrobial Chemotherapy, 60:

9 18. Rahman, M., A. Alam, K. Nessa, S. Nahar, D.K. Dutta, 27. Trees, D.L., A.L. Sandul, S.W. Neal, H. Higa and L. Yasmin, S. Monira, Z. Sultan, S.A. Khan and J.S. Knapp, Molecular epidemiology of M.J. Albert, Treatment failure with the use of Neisseria gonorrhea exhibiting decreased ciprofloxacin for gonorrhoea correlates with the susceptibility and resistance to ciprofloxacin in prevalence of fluoroquinolone resistant Neisseria Hawaii, Sexually Transmitted Diseases, gonorrhea strains in Bangladesh. Clinical Infectious 28: Diseases, 32(6): Ng, L.K., P. Sawatzky, I.E. Martin and S. Booth, Rahman, M., Z. Sultan, S. Monira, A. Alam, K. Nessa, Characterization of ciprofloxacin resistance in S. Islam, S. Nahar, A.W. Shama, A. Khan, J. Bogaerts, Neisseria gonorrhea isolates in Canada. Sexually N. Islam and J. Albert, Antimicrobial Transmitted Diseases, 29: susceptibility of Neisseria gonorrhea isolated in 29. Su, X. and I. Lind, Molecular basis of high-level Bangladesh (1997 to 1999): Rapid shift to ciprofloxacin resistance in Neisseria gonorrhea fluoroquinolone resistance. Journal of Clinical strains isolated in Denmark from Microbiology, 40(6): Antimicrobial Agents and Chemotherapy, 20. Bauer, A.W., W.M.M. Kirby, J.C. Sherris and 45: M. Turck, Antibiotic susceptibility testing by a 30. Sewong, W.K., K.T. Chung, J.Y. Kill, S.H. Kim and standardized single disk method. American Journal of H.B. Oh, Antimicrobial resistance of Neisseria Clinical Pathology, 45: gonorrhea isolated in Korea. Korean Journal of 21. Fayemiwo, S.A., E.E. Muller, L. Gumede and Infectious Diseases, 33(5): D.A. Lewis, Plasmid-mediated penicillin and 31. Tanaka, M., H. Nakayama, K. Huruya, I. Konomi, tetracycline resistance among Neisseria gonorrhea S. Irie, A. Kanayama, T. Saika and I. Kobayashi, isolates in South Africa: Prevalence, detection and Analysis of mutations within multiple genes typing using a novel molecular assay. Sexually associated with resistance in a clinical isolate of Transmitted Diseases, 38(4): Neisseria gonorrhea with reduced ceftriaxone 22. Monica, C., District Laboratory practice in susceptibility that shows a multidrug-resistant Tropical Countries, Ed 2, Part 2, pp: 141. phenotype. International Journal of Antimicrobial 23. Margareta, I., V. Looveren, S. Sunarjati, R. Yeva, Agents, 27(1): G. Wendy, L. Christine, M. Andre and G. Herman, 32. Liao, C.H., C.C. Lai, M.S. Hsu, F.Y. Chu, M.Y. Wu, Antimicrobial susceptibilities of Neisseria Y.T. Huang and P.R. Hsueh, gonorrhea strains isolated in Java, Indonesia. Antimicrobial susceptibility of Neisseria Sexually Transmitted Diseases, 30(1): gonorrhea isolates determined by the agar dilution, 24. Allen, V.G., D.J. Farrell, A. Rebbapragada, J. Tan, disk diffusion and E-test methods: comparison N. Tijet, S.J. Perusini, L. Towns, S. Lo, D.E. Low and of results using GC agar and chocolate agar. R.G. Melano, Molecular analysis of International Journal of Antimicrobial Agents, antimicrobial resistance mechanisms in Neisseria 35: gonorrhea isolates from Ontario, Canada. 33. Mason, P.R., L. Gwanzura, A.S. Latif and E. Marowa, Antimicrobial Agents and Chemotherapy, Antimicrobial susceptibility of Neisseria 55(2): gonorrhea in Harare, Zimbabwe. Sexually Transmitted 25. Unemo, M., D. Golparian, R. Nicholas, M. Ohnishi, Diseases, 17: A. Gallay and P. Sednaoui, High-level 34. Lind, I., M. Arborio, M.W. Bentzon, Y. Buisson, cefixime- and ceftriaxone-resistant Neisseria M. Guibourdenche, K. Reimann and J.Y. Riou, gonorrhea in France: Novel pena mosaic allele in a The epidemiology of Neisseria gonorrhea isolates in successful international clone causes treatment Dakar, Senegal, : antimicrobial resistance, failure. Antimicrobial Agents and Chemotherapy, auxotypes and plasmid profiles. Genitourinary 56(3): Medicine, 67: Tanaka, M., H. Nakayama, M. Haraoka, T. Saika, 35. Bogaerts, J., W.M. Tello, J. Akingeneye, I. Kobayashi and S. Naito, Antimicrobial V. Mukantabana, E. VanDyck and P. Piot, resistance of Neisseria gonorrhea and high Effectiveness of norfloxacin and ofloxacin for prevalence of ciprofloxacin-resistant isolates in treatment of gonorrhea and decrease of in vitro Japan, 1993 to Journal of Clinical Microbiology, susceptibility over time in Rwanda. Genitourinary 38: Medicine, 69:

10 36. West, B., J. Changalucha, H. Grosskurth, P. Mayaud, 39. The WHO Western Pacific Gonococcal Antimicrobial R.M. Gabone, G. Ka-Gina and D. Mabey, Surveillance Programme. Available at: Antimicrobial susceptibility, auxotype and plasmid content of Neisseria gonorrhea in northern Tanzania: 40. Wang, S.A., M.V.C. Lee, N. O Connor, C.J. Iverson, emergence of high level plasmid mediated R.G. Ohye, P.M. Whiticar, J.A. Hale, D.L. Trees, tetracycline resistance. Genitourinary Medicine, J.S. Knapp, P.V. Effler and H.S. Weinstock, (1): Multidrug-resistant Neisseria gonorrhea with 37. Alli, J.A.O., I.O. Okonko, N.N. Odu and A.F. Kolade, decreased susceptibility to cefixime- Hawaii, Detection and prevalence of genital pathogens Clinical Infectious Diseases, 37: among attendees of Sti clinic of a tertiary care 41. Ohnishi, M., T. Saika, S. Hoshina, K. Iwasaku, hospital in Ibadan, Southwestern Nigeria. World S.I. Nakayama, H. Watanabe and J. Kitawaki, Journal of Medical Sciences, 6(3): Ceftriaxone-resistant Neisseria gonorrhea, Japan. 38. VanDyck, E., M. Laga, A.T. Manoka, F. Behets and Emergence of Infectious Diseases, 17(1): P. Piot, Epidemic spread of plasmid-mediated 42. Centers for Disease Control and Prevention. Sexually tetracycline resistant Neisseria gonorrhea in Zaire. transmitted diseases treatment guidelines International Journal of STD and AIDS, 6: MMWR Recomm Rep 2010, 59(RR-12):