Background Gonorrhoea and antimicrobial resistance (AMR) in Neisseria gonorrhoeae are major health concerns globally. Increased global surveillance of gonococcal AMR is essential. We aimed to describe the 2017-18 data from WHO's global gonococcal AMR surveillance, and to discuss priorities essential for the effective management and control of gonorrhoea. MethodsWe did a retrospective observational study of the AMR data of gonococcal isolates reported to WHO by 73 countries in 2017-18. WHO recommends that each country collects at least 100 gonococcal isolates per year, and that quantitative methods to determine the minimum inhibitory concentration of antimicrobials, interpreted by internationally standardised resistance breakpoints, are used. FindingsIn 2017-18, 73 countries provided AMR data for one or more drug. Decreased susceptibility or resistance to ceftriaxone was reported by 21 (31%) of 68 reporting countries and to cefixime by 24 (47%) of 51 reporting countries. Resistance to azithromycin was reported by 51 (84%) of 61 reporting countries and to ciprofloxacin by all 70 (100%) reporting countries. The annual proportion of decreased susceptibility or resistance across countries was 0-21% to ceftriaxone and 0-22% to cefixime, and that of resistance was 0-60% to azithromycin and 0-100% to ciprofloxacin. The number of countries reporting gonococcal AMR and resistant isolates, and the number of examined isolates, have increased since 2015-16. Surveillance remains scarce in central America and the Caribbean and eastern Europe, and in the WHO African, Eastern Mediterranean, and South-East Asian regions.Interpretation In many countries, ciprofloxacin resistance was exceedingly high, azithromycin resistance was increasing, and decreased susceptibility or resistance to ceftriaxone and cefixime continued to emerge. WHO's global surveillance of gonococcal AMR needs to expand internationally to provide imperative data for national and international management guidelines and public health policies. Improved prevention, early diagnosis, treatment of index patients and partners, enhanced surveillance (eg, infection, AMR, treatment failures, and antimicrobial use or misuse), and increased knowledge on antimicrobial selection, stewardship, and pharmacokinetics or pharmacodynamics are essential. The development of rapid, accurate, and affordable point-of-care gonococcal diagnostic tests, new antimicrobials, and gonococcal vaccines is imperative.
Our results highlight the need to improve the procedures of antimicrobial prescription in the study setting. This can be achieved by supporting the guidance for antimicrobial use at the local level, with the adoption of specific guidelines, and at the national level with a further implementation of the policies of prudent prescriptions.
We describe a foodborne outbreak in Italy caused by enteroinvasive Escherichia coli (EIEC), an enteric pathogen uncommon in industrialized countries. On 14 April 2012 a number of employees of the city of Milan Fire Brigade (FB) were admitted to hospital with severe diarrhoea after attending their canteen. Thirty-two patients were hospitalized and a total of 109 cases were identified. A case-control study conducted on 83 cases and 32 controls attending the canteen without having symptoms identified cooked vegetables to be significantly associated with the disease. Stool samples collected from 62 subjects were screened for enteric pathogens using PCR-based commercial kits: 17 cases and two asymptomatic kitchen-workers were positive for the Shigella marker gene ipaH; an ipaH-positive EIEC strain O96:H19 was isolated from six cases. EIEC may cause serious dysentery-like outbreaks even in Western European countries. Microbiologists should be aware of microbiological procedures to detect EIEC, to be applied especially when no common enteric pathogens are identified.
This study investigated two foodborne outbreaks of gastroenteritis that occurred 10 days apart among individuals who had meals at the restaurant of a farm holiday resort. Mild gastrointestinal symptoms were reported and none of the patients needed hospitalization. Mean incubation times were 45 and 33 h, and the overall attack rates were 43.5 and 58.3 %, respectively. Stool sample examination was negative for common enteric pathogens in both outbreaks. Specimens from 13 people involved in the second outbreak and 3 restaurant staff were examined for diarrhoeagenic Escherichia coli. An enteroaggregative E. coli (EAEC) strain of serotype O92 : H33 was isolated from six participants and one member of staff. In particular, the EAEC strain was isolated from five of the six cases of diarrhoea examined. The strain showed an aggregative pattern of adherence to HEp-2 cells, did not produce a biofilm and possessed the virulence-related genes aat, aggR, aap and set1A, but not the astA gene. A retrospective cohort study indicated a pecorino cheese made with unpasteurized sheep milk as the possible source (P,0.001). Samples of the cheese had E. coli counts higher than 10 6 c.f.u. g "1 , but the outbreak EAEC strain was not isolated. This report confirms that EAEC infections are probably underdiagnosed because of the limited availability of laboratories capable of identifying this group of pathogenic E. coli. INTRODUCTIONEnteroaggregative Escherichia coli (EAEC) are diarrhoeagenic E. coli characterized by the ability to adhere to HEp-2 cells in a characteristic 'stacked-brick' pattern (Nataro & Kaper, 1998). This property is usually due to the presence of aggregative adherence fimbriae, whose expression is positively controlled by the aggR gene, located on a large plasmid termed pAA (Nataro, 2005). EAEC infections are usually associated with watery diarrhoea, which is often persistent (Nataro & Kaper, 1998). Illness results from a complex interaction between pathogen and host, which implicates the initial adherence of the bacteria to the epithelium of terminal ileum and colon, in the characteristic aggregative pattern, followed by damage and a subsequent inflammatory response of the intestinal mucosa (Nataro, 2005;Huang et al., 2006).EAEC are a major cause of protracted diarrhoea in children in developing countries (Nataro & Kaper, 1998;Huang et al., 2006), where they are also linked to diarrhoeal illness of travellers and human immunodeficiency virus-positive patients (Huang et al., 2006). However, they have also been found to be associated with diarrhoea in industrialized countries (Tompkins et al., 1999;Weintraub, 2007). EAEC belong to a wide range of serotypes (Wilson et al., 2001) and are considered as emerging pathogens, characterized by a varied and complex epidemiology (Huang et al., 2006). Cases of EAEC infection are reported to be sporadic, but some outbreaks, involving both children and adults, have been described. The sources of infection have rarely been identified in these episodes. In France, an outbreak due to a...
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