Volume 24, Number 2—February 2018
Ceftriaxone-Resistant Neisseria gonorrhoeae, Canada, 2017
Ceftriaxone is one of the last remaining treatments available for gonorrhea and a component of the recommended dual therapy with azithromycin in Canada (1). As of October 15, 2017, only 5 ceftriaxone-resistant Neisseria gonorrhoeae isolates had been reported worldwide (MIC range 0.5–2 mg/L) (2–6). The highest ceftriaxone MIC reported in Canada was 0.25 mg/L, representing only 0.45% (49/10,805) of all N. gonorrhoeae isolates tested during 2010‒2016 (7). We describe ceftriaxone-resistant N. gonorrhoeae isolated in Canada.
An asymptomatic 23-year-old woman had a positive N. gonorrhoeae nucleic acid amplification test (NAAT) result (Cobas 4800 CTNG; Roche Diagnostics Canada, Laval, Canada) on January 17, 2017, obtained as part of a screening for sexually transmitted infections (STIs). Upon receiving the result, a physician instructed the patient to follow-up with the STI clinic to have proper counselling. She visited on January 24 and obtained a prescription of single-dose cefixime 800 mg and azithromycin 1 g (recommended therapy according to Québec STI Treatment Guidelines) (8). Because the patient was from a low-prevalence population, the healthcare provider decided to perform a genital gonorrhea culture. The culture was positive for N. gonorrhoeae (no. GC063564/47707), thus confirming the positive NAAT result.
Because antimicrobial susceptibility testing (Etest, bioMérieux, Marcy l’Etoile, France) demonstrated nonsusceptibility of the isolate to ceftriaxone and cefixime but susceptibility to azithromycin, a second follow-up visit was requested by the practitioner. The second visit occurred February 7, 2017, and the patient was then prescribed empirically a single 2-g dose of azithromycin. Tests of cure by NAAT and cervical culture were performed during this visit and were negative for N. gonorrhoeae, indicating a successful initial treatment with cefixime and azithromycin administered 14 days earlier.
The patient reported a month-long sexual relationship 60 days before the STI screening. The partner was assessed by clinical examination and screening tests and treated with cefixime 800 mg and azithromycin 1 g on January 27, 2017. He was asymptomatic and his urinary NAAT screening result was negative for N. gonorrhoeae. He did not have sex with men or a sex worker but did report unprotected sexual activity during a trip to China and Thailand in November 2016, before his relationship with the patient in this case study. Information about antimicrobial drug use during his trip to Asia was not available. He was followed up February 2017, and NAAT test results of his urine and pharyngeal specimens were again both negative for gonorrhea. Public health professionals also contacted the case study patient’s next-to-last partner (5 months earlier), and his screening result was also negative for N. gonorrhoeae.
The bacterial isolate from our patient was confirmed to be N. gonorrhoeae by API NH (bioMérieux), VITEK (bioMérieux), matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (bioMérieux), and whole-genome sequencing. Antimicrobial susceptibilities for isolate GC063564 were confirmed by using the agar dilution method according to the Clinical and Laboratory Standards Institute protocol (9). The strain was resistant to ceftriaxone (MIC 1 mg/L), cefixime (MIC 2 mg/L), ciprofloxacin (MIC 32 mg/L), and tetracycline (MIC 4 mg/L) and susceptible to azithromycin (MIC 0.5 mg/L). The Clinical and Laboratory Standards Institute does not have a resistance breakpoint for cefixime or ceftriaxone but defines susceptibility at an MIC <0.25 mg/L. The European Committee on Antimicrobial Susceptibility Testing defines cefixime and ceftriaxone resistance at an MIC >0.125 mg/L (10), and the World Health Organization defines decreased susceptibility to cefixime as an MIC ≥0.25 mg/L and to ceftriaxone an MIC ≥0.125 mg/L (11). Although the defined resistance breakpoint is not consistent among these organizations, a ceftriaxone MIC 1 mg/L has been previously reported as resistance (2,6).
We performed molecular typing in silico using whole-genome sequence data (BioProject PRJNA415047). We sequenced the isolate with the Illumina MiSeq platform (Illumina, San Diego, CA, USA) and used genomic quality, assembly, and annotation pipelines as previously described (12). The multilocus sequence type (ST) of GC063564 was ST1903, and N. gonorrhoeae multiantigen sequence type (MAST) was ST1614. Using a novel antimicrobial genomic sequence analytic tool called NG-STAR (N. gonorrhoeae Sequence Typing for Antimicrobial Resistance) (13), we identified the isolate GC063564 as NG-STAR ST233, which contains a mosaic penA allele, mtrR-35A deletion, porB G120K/A121D, ponA L421P, gyrA S91F/D94A, parC S87R, and no 23S rRNA A2059/C2611 mutations. The GC063564 isolate also had an rpsJ V57M mutation, and tetM was not detected.
The molecular antimicrobial resistance profile corresponds to the MICs determined phenotypically (13). The multilocus sequence type (ST1903) and mosaic penA allele (penA-60) of this isolate from Canada were identical to those of the ceftriaxone- and multidrug-resistant N. gonorrhoeae FC428 isolated in 2015 in Japan (14). PenA-60 has a mosaic penicillin-binding protein 2 structure with 2 key mutations (A311V and T483S) that confer ceftriaxone resistance. PenA-60 differs substantially from previously described penA types (5), resembling only 80% of the closest-related mosaic allele penA-XXVII. Bacterial isolates GC063564 and FC428 had identical porB1b NG-MAST alleles but different tbpB alleles (GC063564 had tbpB-33; FC428 had tpbB-21), resulting in different N. gonorrhoeae MAST profiles (ST-1614 for GC063564 and ST-3435 for FC428). The variation in the N. gonorrhoeaeMAST types between the 2 isolates collected 2 years apart is not unexpected, considering the highly recombinant nature of the N. gonorrhoeae genome (15).
We identified a ceftriaxone-resistant N. gonorrhoeae isolate in Canada that contained the penA-60 allele formerly reported in Japan in 2015. Epidemiologic information suggests international spread of a penA allele associated with high-level ceftriaxone resistance. Antimicrobial susceptibility surveillance successfully identified this novel isolate introduced into Canada and prompted public health officials to rapidly conduct an investigation to prevent further spread in the community. In an era of multidrug-resistant gonorrhea, ongoing antimicrobial susceptibility surveillance of N. gonorrhoeae is critical to support treatment guidelines, public health intervention, and protection.
Dr. Lefebvre is the head of the Antibiotics Resistance Department at the Laboratoire de Santé Publique du Québec, Québec, Canada, and in charge of the provincial surveillance programs, which investigates invasive Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae infections and monitors for resistance of Neisseria gonorrhoeae and carbapenemase-producing enterobacteria. Her research interests includes antimicrobial drug resistance of pathogenic agents of public health interest.
- Public Health Agency of Canada. Canadian guidelines on sexually transmitted infections ‒ management and treatment of specific infections ‒ gonococcal infections. 2013 [cited 2017 Oct 23]. http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-6-eng.php
- Cámara J, Serra J, Ayats J, Bastida T, Carnicer-Pont D, Andreu A, et al. Molecular characterization of two high-level ceftriaxone-resistant Neisseria gonorrhoeae isolates detected in Catalonia, Spain. J Antimicrob Chemother. 2012;67:1858–60.
- Deguchi T, Yasuda M, Hatazaki K, Kameyama K, Horie K, Kato T, et al. New clinical strain of Neisseria gonorrhoeae with decreased susceptibility to ceftriaxone, Japan. Emerg Infect Dis. 2016;22:142–4.
- Lahra MM, Ryder N, Whiley DM. A new multidrug-resistant strain of Neisseria gonorrhoeae in Australia. N Engl J Med. 2014;371:1850–1.
- Ohnishi M, Golparian D, Shimuta K, Saika T, Hoshina S, Iwasaku K, et al. Is Neisseria gonorrhoeae initiating a future era of untreatable gonorrhea?: detailed characterization of the first strain with high-level resistance to ceftriaxone. Antimicrob Agents Chemother. 2011;55:3538–45.
- Unemo M, Golparian D, Nicholas R, Ohnishi M, Gallay A, Sednaoui P. High-level cefixime- and ceftriaxone-resistant Neisseria gonorrhoeae in France: novel penA mosaic allele in a successful international clone causes treatment failure. Antimicrob Agents Chemother. 2012;56:1273–80.
- Public Health Agency of Canada, National Microbiology Laboratory. National surveillance of antimicrobial susceptibilities of Neisseria gonorrhoeae‒ annual summary 2014. 2016 Mar 10 [cited 2017 Oct 23]. https://www.canada.ca/en/public-health/services/publications/drugs-health-products/national-surveillance-antimicrobial-susceptibilities-neisseria-gonorrhoeae-annual-summary-2014.html
- Institut National d'excellence en Santé et en Services Sociaux. Guide de traitement pharmacologique sur les ITSS. Infection à Chlamydia trachomatiset infection à Neisseria gonorrhoeae. 2015 [cited 2017 Oct 23]. http://www.inesss.qc.ca/fileadmin/doc/INESSS/Outils/Guides_ITSS/Guide_ITSS-Chlamydia_gonorrhoeae_majdec2015_.pdf
- Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing; twenty-seven informational supplement (M100–S27). Wayne (PA): The Institute; 2017.
- European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters. Version 7.1. 2017Mar 13 [cited 2017 Oct 23]. http://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/Breakpoint_tables/v_7.1_Breakpoint_Tables.pdf
- World Health Organization. Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae. 2012 [cited 2017 Oct 23]. http://www.who.int/reproductivehealth/publications/rtis/9789241503501/en/
- Demczuk W, Lynch T, Martin I, Van Domselaar G, Graham M, Bharat A, et al. Whole-genome phylogenomic heterogeneity of Neisseria gonorrhoeaeisolates with decreased cephalosporin susceptibility collected in Canada between 1989 and 2013. J Clin Microbiol. 2015;53:191–200.
- Demczuk W, Sidhu S, Unemo M, Whiley DM, Allen VG, Dillon JR, et al. Neisseria gonorrhoeae sequence typing for antimicrobial resistance, a novel antimicrobial resistance multilocus typing scheme for tracking global dissemination of N. gonorrhoeae strains. J Clin Microbiol. 2017;55:1454–68.
- Nakayama S, Shimuta K, Furubayashi K, Kawahata T, Unemo M, Ohnishi M. New ceftriaxone- and multidrug-resistant Neisseria gonorrhoeae strain with a novel mosaic penA gene isolated in Japan. Antimicrob Agents Chemother. 2016;60:4339–41.
- De Silva D, Peters J, Cole K, Cole MJ, Cresswell F, Dean G, et al. Whole-genome sequencing to determine transmission of Neisseria gonorrhoeae: an observational study. Lancet Infect Dis. 2016;16:1295–303.
Suggested citation for this article: Lefebvre B, Martin I, Demczuk W, Deshaies L, Michaud S, Labbé A-C, et al. Ceftriaxone-resistant Neisseria gonorrhoeae, Canada, 2017. Emerg Infect Dis. 2018 Feb [date cited]. http://doi.org/10.3201/eid2402.171756