Failure of 500 mg of ceftriaxone to eradicate pharyngeal gonorrhoea, Australia

Abstract

The patient continued to have episodes of fever, which had been occurring since admission. On day 14, the patient developed leucocytosis and blood cultures were drawn, which grew MRSA. The MIC of vancomycin increased to 2 mg/L, with that of daptomycin remaining at 0.38 mg/L. Since the patient continued to be symptomatic, irrigation and debridement was scheduled, but due to surgeon availability issues this was not performed until hospital day 19. A sample was obtained during the procedure and cultured, and on day 22, after .2 weeks of treatment with daptomycin, MRSA grew with a daptomycin MIC of 3 mg/L [daptomycin-non-susceptible S. aureus (DNSSA)]. The primary cause of the daptomycin failure was most likely a delay in incision and drainage of the abscesses. Experimental osteomyelitis models have shown selective resistance with daptomycin monotherapy, 2 which possibly contributed to the resistance in this case. Daptomycin was discontinued and, unfortunately, vancomycin was restarted over the weekend. After the patient became bacteraemic on day 14, we recommended a TEE, which was ordered but not performed until day 23. Lesions were found on the left coronary cusp (LCC) and the tricuspid valve, consistent with endocarditis. Vancomycin was discontinued, since current expert opinion states alternative antimicrobials should be considered when the vancomycin MIC is ≥2 mg/L, due to treatment failures. 3,4 Considering this and the severity of infection in this patient, we turned to salvage therapy options and ceftaroline (600 mg intravenously every 12 h), which had an Etest MIC of 0.5 mg/L, was chosen. Ceftaroline is a fifth-generation cephalosporin with activity against MRSA. Ceftaroline was chosen for a number of reasons. First, it is rapidly bactericidal. Ho et al. 5 reported sterilization in 13 days in a case of endocarditis. Also, the incidence of thrombocytopenia with long-term use is low, which was particularly important since our patient had a history of thrombocytopenia secondary to hepatitis. Finally, a literature search revealed a series of case reports showing successful use of ceftaroline in the treatment of MRSA endocarditis 5 and an experimental model demonstrating potential use in osteomyelitis. 6 Subsequent blood cultures drawn on days 29 and 32 were negative. On day 32, a repeat irrigation and debridement was performed. After 37 consecutive days of ceftaroline treatment, a TEE showed resolution of echodensities at the base of the tricuspid valve and a stable, fibronodular lesion on the LCC. Ceftaroline was continued for a total of 44 days, with no further episodes of bacteraemia, leucocytosis or fever, which completed his treatment. The patient was discharged home but was lost to follow-up. This case report demonstrates the importance of surgery for the primary treatment of abscesses and osteomyelitis. A delay in surgical intervention was likely the cause of endocarditis and the development of daptomycin resistance in this patient. Elevated vancomycin MICs have been associated with increased daptomycin M...

Antimicrobial Resistance in Neisseria gonorrhoeae in the 21st Century: Past, Evolution, and Future

“…Worryingly, gonococcal AMR surveillance remains highly limited in many regions worldwide (104,106,152), and accordingly, the global burden of decreased susceptibility and resistance to ESCs is largely unknown. Currently, cefixime treatment failures have been verified in Japan, several European countries, Canada, and South America (4,142,145,(153)(154)(155)(156)(157), and a few ceftriaxone treatment failures for pharyngeal gonorrhea have been identified in Japan, some European countries, and Australia (3,(158)(159)(160)(161).…”

Importance of Multidrug Efflux Pumps in the Antimicrobial Resistance Property of Clinical Multidrug-Resistant Isolates of Neisseria gonorrhoeae

“…Neisseria gonorrhoeae has developed resistance to all antimicrobials introduced for treatment (2)(3)(4)(5). Recently, treatment failures with the extended-spectrum cephalosporins (ESCs) cefixime and ceftriaxone were verified in several countries and some extensively drug-resistant (XDR) gonococcal strains displaying high-level ceftriaxone resistance have been described (3,(6)(7)(8)(9)(10)(11)(12)(13). ESCs are the last options for antimicrobial monotherapy of gonorrhea.…”

001.6 Exploring the benefits of molecular testing for gonorrhoea antibiotic resistance surveillance in remote settings

“…For example, cases of ceftriaxone treatment failure for pharyngeal infections have been reported in Australia [27][28][29] but not for rectal or urethral infection. We have only considered genital infection in the current study as most infections in remote communities are through heterosexual contact [1].…”