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Volume 2 No 37; 12 September 2008

Recent trends and emerging resistance in gonorrhoea – annual GRASP report for 2007

The newly published annual report of the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP 2007) [1] has identified for the first time decreased susceptibility to cefixime and the emergence of high-level resistance to azithromycin in gonococcal isolates from England and Wales. Ciprofloxacin resistance remained high but the increase compared to GRASP 2006 [2] was small.

The greatest burden of antimicrobial resistant gonorrhoea continued to be among men who have sex with men (MSM) highlighting the need to raise awareness and target interventions in this group.

Two isolates were categorised as exhibiting decreased susceptibility (minimum inhibitory concentration (MIC) ≥0.25mg/L) to cefixime, the oral third generation cephalosporin recommended as first line therapy. Confirmatory testing using Etests showed these isolates to have a marginally lower MIC of 0.19mg/L than the 0.25 mg/L determined by the agar dilution method used in GRASP. However, these isolates have the highest MICs to cefixime detected within GRASP and, together with the drift towards decreased susceptibility also shown for ceftriaxone, the more active but injectable third generation cephalosporin, gives a warning that vigilance is needed to maintain the useful life of these agents. Neither of these patients is known to have failed therapy, and the isolates were susceptible to ceftriaxone (MIC 0.015 mg/l). The correlation between MIC, dosage and treatment failure is as yet unclear in the absence of known therapeutic failure to either cefixime or ceftriaxone.

High-level resistance to azithromycin (>256mg/L) was detected for the first time in six isolates and an alert was issued to all microbiology laboratories earlier this year [3, 4]. Azithromycin is not a recommended therapy for gonorrhoea and high-level resistance should not present a therapeutic problem if all cases are treated with specific gonorrhoea therapy. Overall, azithromycin resistance (MIC ≥1mg/L) more than doubled between 2006 and 2007 from 1.8% to 4.1%, respectively (p=0.09).

Ciprofloxacin resistance remains high at 27%, a slight increase from 26% in 2006, and is highest among MSM, where the prevalence increased to 47% compared with 44% in 2006.

Following the change in treatment guidelines in 2004, GRASP 2007 reports that >90% of patients treated in the GRASP sentinel clinics received a third generation cephalosporin, consistent with national guidance.

References
1. Details of other categories of resistance and the full report can be found at:
http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1221117908959?
p=1221117908959
2. The gonococcal resistance to antimicrobials surveillance programme annual report 2006. London: HPA, 2007. http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947393147
3. Department of Health. Resistance alert: High-level azithromycin resistance in Neisseria gonorrhoeae. London: Departement of Health, 2008. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_083963
 4. HPA. High-level azithromycin resistance in Neisseria gonorrhoeae. Health Protection Report [serial online] 2008, 2(14): news. Available at http://www.hpa.org.uk/hpr/archives/2008/news1408.htm#azith.

Rabies reminder for travellers returning from France

Following the rabies incident in France earlier this year involving an illegally imported dog, with transmission to two indigenous dogs [1, 2], health professionals are reminded that France is no longer rabies free.

There is a low but increased risk of rabies in three previously identified areas of France (Gers, Grandpuits and Calvados). Elsewhere the risk of rabies is considered to be extremely small, but cannot be completely ruled out.

Health professionals are reminded that travellers returning from France who have been bitten, scratched or licked by dogs or other animals whilst in France should undergo risk assessment to determine whether they require rabies post-exposure prophylaxis (PEP). Further advice is available from local Health Protection Units [3] or the HPA Centre for Infections on 020 8200 6868.

References
1. http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1209196817832.
2. Canine rabies in France, Health Protection Report [serial online] 2008, 2(10): news. Available at:http://www.hpa.org.uk/hpr/archives/2008/news1008.htm.
3. See HPA website: http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1158945066055.

HPA toxicology handbook for public health specialists

The HPA has published an introduction to toxicology for health protection professionals who may be involved in responding to acute and chronic chemical release incidents. Essentials of toxicology for health protection - a handbook for field professionals [1] is intended primarily for public or environmental health scientists, the emergency services and those working in industries, such as water supply and waste processing, where there is potential for public health risk from chemical contamination.

Sections are devoted to: fundamentals of toxicology; applications of toxicology (including exposure assessment and susceptible populations); environmental toxicology (incorporating air, land and water contamination); a review of selected toxic agents (including the deliberate release of toxic agents); and relevant case studies and UK legislation. A section, including a glossary, on basic medical concepts is intended for those without a background in medicine, biology or the health sciences.

Further information
1. Essentials of toxicology for health protection - a handbook for field professionals, £19.99 (plus £1.90 postage and packing for UK & Ireland). Further details email kalpna.kotecha@hpa.org.uk.