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GRASP (Gonococcal Resistance to Antimicrobials Surveillance Programme)

GRASP (Gonococcal Resistance to Antimicrobials Surveillance Programme). Catherine Ison Sexually Transmitted Bacteria Reference Laboratory. Diagnoses of gonorrhoea seen in GUM clinics, England and Wales*: 1996 to 2002. % Change 2002 2001-2002 1996-2002

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GRASP (Gonococcal Resistance to Antimicrobials Surveillance Programme)

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  1. GRASP(Gonococcal Resistance to AntimicrobialsSurveillance Programme) Catherine Ison Sexually Transmitted Bacteria Reference Laboratory

  2. Diagnoses of gonorrhoea seen in GUM clinics, England and Wales*: 1996 to 2002 % Change 2002 2001-2002 1996-2002 Chlamydia 81,680 14% 139% Genital warts 69,417 2% 17% Gonorrhoea 24,953 9% 106% Genital herpes 18,392 3% 16% Syphilis 1,193 63% 870% Source: Health Protection Agency 2003

  3. Cases of uncomplicated gonorrhoea seen in GUM clinics by sex and male sexual orientation, E, W & NI : 1995 to 2002 Source: Health Protection Agency 2003

  4. Regional distribution of diagnoses of uncomplicated gonorrhoea by sex: 2002* Source: Health Protection Agency 2003 *1999 data used for Scotland

  5. GRASP - Gonococcal Resistance to Antimicrobials Surveillance Programme • Established in 2000. National extension of London Gonococcal Collection • CDSC, GUIRL, Bristol and Imperial College, London • In 2002 ARMRL, Colindale replaced GUIRL • Network of participating GUM clinics and microbiology laboratories in England and Wales • Funded by the Department of Health for 2000-2004

  6. GRASP Centres in England and Wales • 26 participating GUM clinics and laboratories • Regional representation • 3 month collection each year • One isolate from consecutive patients Newcastle Leeds Liverpool Sheffield Manchester Nottingham Wolverhampton Cambridge Birmingham Newport Northampton Luton Gloucester Cardiff London (9) Bristol Reading Brighton

  7. Referring laboratory GUM Clinic Clinical data 1. Gonococcal isolates 2. All isolates received during June, July & August 4. Data collection forms CDSC Data linking and analysis GRASP Reference laboratory 3. Data on GRASP patients GRASP Data Collection Process

  8. Clinical Information • Demographic information • Age, gender, post code (prefix), ethnicity • Sexual behaviour • Sexual orientation, previous gonorrhoea diagnosis, number of sexual partners (UK and abroad) • Current infection • Concurrent STIs, antibiotic treatment, test of cure, symptoms

  9. Laboratory Testing • One isolate from consecutive patients diagnosed during collection period referred • Minimum inhibitory concentrations (MICs) are determined for:Penicillin Ciprofloxacin Tetracycline Azithromycin Spectinomycin Ceftriaxone • 2 annual quality control exercises are run between the 2 reference laboratories and SNGRL

  10. Sample Description

  11. Demographic Characteristics Age group, sex and male sexual orientation of GRASP GUM clinic attenders diagnosed with gonorrhoea between June and August 2002.

  12. Ethnicity Ethnicity , sex and male sexual orientation of GRASP GUM clinic attenders diagnosed with gonorrhoea 2002.

  13. Concurrent STI Diagnosis Percentage of patients diagnosed with gonorrhoea with concurrent STIs* at participating GRASP clinics by sexual orientation, 2001-2002. * A Patient may present with more than one concurrent STI

  14. Sexual Behaviour Number of UK partners within the past three months of patients diagnosed with gonorrhoea at participating GRASP clinics by sexual orientation, 2001- 2002.

  15. Sexual Contact Abroad Distribution of geographic location of sexual contact abroad in the past 3 months for patients diagnosed with gonorrhoea at participating GRASP clinics 2001 and 2002

  16. Antimicrobial treatment received, 2002 • 68% fluoroquinolone • 13.2% North West • 93.8% South • 11.5% penicillin • 15% cephalosporin • 3% South West • 76.9% East Midlands

  17. CATEGORIES OF RESISTANT ISOLATES • PPNG - Penicillinase producing, tetracycline sensitive • PP/TRNG- PPNG, tetracycline resistant • CMRNG- low level resistance to penicillin and tetracycline. • QRNG - PPNG, nonPPNG, TRNG, PP/TRNG, or CMRNG which are resistant to ciprofloxacin.

  18. Antimicrobial Resistance 2000-2002 Overall prevalence of gonococcal antimicrobial resistance in GUM patients from participating GRASP clinics: June to August 2000 to 2002. 5%

  19. Antimicrobial Susceptibility 2002

  20. Overall prevalence of ciprofloxacin resistance (>=1mg/l) in GUM patients from participating GRASP clinics: June to August 2000 to 2002. 20.5 4.66.5 10.1 8.64.4 12.4 2.63.8 12.1 3.03.4 11.8 4.03.0 7.1 3.10.0 13.3 5.2 1.0 6.6 3.04.2 7.2 1.80.9 Trends in ciprofloxacin resistance, 2000-2002 England and Wales Key 2002 2001 2000

  21. Ciprofloxacin Resistance Age group, sex and male sexual orientation of GRASP GUM clinic attenders with ciprofloxacin resistant gonorrhoea: Jun-Aug 2002.

  22. Percentage of resistance attributable to Sex Abroad Percentage of resistant isolates attributable to acquisition abroad in GRASP GUM patients: 2001 to 2002 (number acquired abroad/total resistant strains).

  23. Antimicrobial Resistance Trends 2000-2002 • Significant trend of increasing resistant or decreased susceptibility to ciprofloxacin (p<0.0005) • No significant change observed amongst penicillin resistant isolates • Significant trend of increasing chromosomally mediated tetracycline resistance (TetR) p<0.05

  24. London GUM patients: Overall prevalence of gonococcal antimicrobial resistance 2000 to 2003.

  25. Non-London GUM patients: Overall prevalence of gonococcal antimicrobial resistance 2000 to 2003. 14 2000 2001 2002 2003 12 10 8 % Resistance 6 4 2 0 PPNG & TRNG & CMRNG Ciprofloxacin Ciprofloxacin Ceftriaxone Spectinomycin Azithromycin PP/TRNG PP/TRNG Resistant Intermediate Resistant Type of Resistance

  26. Question:Has the epidemiology of ciprofloxacin resistant gonorrhoea in London changed? • Gonococci collected through GRASP. • Consecutive isolates for a three month period. • Typed using bi-locus sequence typing. • Variation in two genes, por and tbpB. • Assigned a sequence type (ST). • Size of clusters compared.

  27. 2000 – 0.9% resistance rate QRNG (19) 1 x 2 1 x 2 12 unique STs 1 x 3

  28. 2001- 2.3% resistance rate QRNG (30) 1 x 2 1 x 3 1 x 4 1 x 4 13 unique STs 1 x 4

  29. 2002 - 7.2% resistance rate QRNG (81) 24 13 unique STs 20 2 x 2 13 3 4 Having a unique ST was significantly associated with having acquired the infection abroad, compared to clusters >4 isolates.

  30.  Incidence  Importation  ST cluster size %

  31. Conclusions • Significant increase in prevalence of ciprofloxacin resistance, 9.8% in 2002 compared to 3.1% in 2001 (p<0.0005). • Ciprofloxacin resistance was stable in 2003. • Stable prevalence of penicillin resistance, 9.8% in 2002 compared to 8.1% in 2001. • Resistance to other antimicrobials at very low levels • Ongoing surveillance is necessary

  32. Acknowledgements • GRASP Steering Group: Dr K Fenton, Prof C Ison, Dr A Johnson, Dr G Kinghorn, Mr T Nichols, Dr A Robinson, Dr J Ross, Dr H Young, Dr I Martin, E Rudd. • All staff from participating laboratories for sending isolates to ARMRL and Imperial College • All GUM clinic staff involved in the collection of clinical data.

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