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Researchers in Austria are reporting the identification of a second strain of extensively drug-resistant (XDR) gonorrhea.

In a case report published yesterday in Eurosurveillance, researchers described the strain, which was detected in a heterosexual man from Austria who had unprotected sex with a female commercial sex worker in Cambodia. The patient was treated with the standard gonorrhea treatment regimen (an intramuscular dose of ceftriaxone plus an oral dose of azithromycin), and symptoms had resolved at the 2-week follow-up visit, but a polymerase chain reaction (PCR) test found the patient was still positive for Neisseria gonorrhoeae.

The case was considered a treatment failure, and additional antibiotic treatment was prescribed.

Subsequent antimicrobial susceptibility testing of N gonorrhoeae isolates from the patient found high-level resistance to azithromycin and resistance to ceftriaxone, cefixime, cefotaxime, ciprofloxacin, and tetracycline. Molecular investigation found genetic mutations that are similar to those detected in a strain of XDR N gonorrhoeae identified in three patients in the United Kingdom and Australia in 2018. The researchers say the strains belong to the same sublineage, which they warn could make gonorrhea untreatable if it establishes sustained transmission.

"XDR N. gonorrhoeae strains, including those with resistance to all available treatment options, are a major global public health concern," the researchers wrote. "They pose a risk of treatment failure and serious complications/sequelae on the individual level but also compromise the management and control of gonorrhoea on the public health level."

They add that antimicrobial susceptibility surveillance, both nationally and internationally but particularly in Asia, where many strains of ceftriaxone-resistant gonorrhea have emerged, is necessary, and that new antibiotics for effective gonorrhea treatment are needed. Jun 16 Eurosurveill rapid communication

A study conducted in a large healthcare system in the Upper Midwest found that unnecessary antibiotic prescribing for upper respiratory infections (URIs) was common among all primary care providers, but worse among older, rural clinicians and those in high-volume specialties, researchers reported today in Open Forum Infectious Diseases.

In the analysis of electronic medical records from Sanford Health, which serves patients in South Dakota, North Dakota, and Minnesota, researchers looked at all patients 18 and older who were seen by a primary care provider for a URI (acute bronchitis, pharyngitis, nonspecific acute respiratory tract infection, and uncomplicated acute rhinosinusitis) from June 2017 through May 2018. They then compared individual provider rates of unnecessary antibiotic prescribing for primary care providers practicing in the departments of internal medicine, family medicine, and urgent care, and identified patient and provider characteristics associated with unnecessary prescribing.

Of the 49,463 patient encounters included in the study, antibiotics were prescribed unnecessarily for 42.2%. Acute bronchitis had the highest rate of unnecessary prescribing, with antibiotics prescribed in 74.2% of encounters. Men and older patients were more likely to be prescribed unnecessary antibiotics.

Provider characteristics associated with higher rates of unnecessary prescribing included being in a rural practice (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.20 to 1.84), having more years in practice (OR, 1.09; 95% CI, 1.01 to 1.06 for every 5 years), and being in a high-volume specialty such as urgent care (OR, 1.43; 95% CI, 1.08 to 1.89).

"Despite multiple public health initiatives and professional society guidelines aimed at producing more judicious use of antibiotics for URIs in the outpatient setting, overuse remains quite common," the study authors conclude. "Targeting higher volume clinicians may be particularly impactful."

They add, "Health systems should be encouraged to engage these, as well as novel strategies, to promote necessary and appropriate antibiotic usage as an urgent priority for their quality improvement initiatives." Jun 17 Open Forum Infect Dis abstract

Global humanitarian organization Doctors Without Borders/Medecins Sans Frontieres (MSF) announced this week that a mobile application it helped develop to aid the diagnosis of antibiotic-resistant infections in low- and middle-income countries (LMICs) has been certified in Europe and is one step closer to being widely available.

Antibiogo, which is available as a free, open source and offline application for Android devices, allows non-expert laboratory technicians in LMICS to measure and interpret antibiograms—the lab tests that determine whether bacteria cultured from patients is susceptible to antibiotics—with a smart phone. Using image processing and artificial intelligence technology, the app processes an uploaded photo of the cultured bacteria and selected antibiotics in a petri dish, summarizes and interprets the results based on rules from European and American microbiology societies, and recommends an antibiotic.

MSF says the test was specifically developed for low-resource settings, which often lack the equipment necessary to carry out antibiograms, don't have enough microbiologists to interpret them, or are not well-suited for automated diagnostic tests that require reliable electricity sources. Field tests have shown a high level of concordance with the interpretation made by qualified microbiologists.

"Thanks to Antibiogo, any microbiology laboratory technician anywhere will be able to read and interpret an antibiogram directly on their telephone—online or offline—and know the resistance profile of the bacteria responsible for a patient's infection," Nada Malou, PhD, head of the Antibiogo program, said in an MSF press release.

"Properly used, it is a fantastic new diagnostic tool which will help to ensure wider access to high-quality bacteriological tests even in the absence of microbiologists. This will make it possible not only to treat patients with the most appropriate antibiotics but also to reduce antibiotic resistance."

The app will be used first in MSF laboratories in Mali, Central African Republic, Yemen, and Jordan this summer, which will allow MSF to collect user feedback and performance data under real-world conditions. Jun 15 MSF press release

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