Antibiotic Resistance in Neisseria gonorrhoeae: Will Infections be Untreatable in the Future?
Culture Volume 35 Number 1
Jo-Anne R. Dillon1,2*, Rajinder P. Parti2, Sidharath Dev Thakur3
A Re-emerging Public Health Threat
Neisseria gonorrhoeae (the gonococcus) causes gonorrhea, a sexually transmitted infection (STI) described in the ancient texts of several cultures. Once again, however, N. gonorrhoeae is re-emerging as a potent threat to public health both because of its high morbidity (the World Health Organization estimated 106 million new N. gonorrhoeae infections in 2008) and because the pathogen can be resistant to all classes of antibiotic making it a ‘superbug’. The failure to produce new, effective strategies to cure antibiotic resistant gonorrhea infections may lead to a situation reminiscent of the pre-antibiotic era where there were no effective treatments.
1. Department of Microbiology and Immunology, College of Medicine 2. Vaccine and Infectious Disease Organization - International Vaccine Centre, University of Saskatchewan, Saskatoon, Canada 3. Department of Veterinary Public Health and Epidemiology, DGCN College of Veterinary and Animal Sciences, Palampur, Himachal Pradesh, India
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About the author
Jo-Anne R Dillon is a Professor in the Department of Microbiology and Immunology (College of Medicine) and Research Scientist (Vaccine and Infectious Disease Organization – International Vaccine Centre) at the University of Saskatchewan. She completed undergraduate and postgraduate degrees at the University of Toronto and Queen’s University (Kingston, Ontario), respectively, and postdoctoral studies at the University of Pittsburgh.
Former positions include: founding Chief, National Laboratory for Sexually Transmitted Infections (Health Canada); founding co-ordinator of the Gonococcal Antimicrobial Surveillance Program (GASP) in Latin America and the Caribbean; Chair, Department of Microbiology and Immunology (University of Ottawa); founding Director, Centre for Research in Biopharmaceuticals and Biotechnology (University of Ottawa); Dean, College of Arts and Science (University of Saskatchewan). Dr Dillon was the first female President of the Canadian Society of Microbiologists and is a past President of the International Society for STD Research. Her research interests include the biology and molecular epidemiology of Neisseria gonorrhoeae and the molecular biology of antimicrobial resistance.
An interview with the author
I have had an abiding interest in the question of antimicrobial resistance and public health microbiology since entering graduate school. As an undergraduate at the University of Toronto, I had absolutely stupendous teachers in microbiology. They ignited a passion that shifted my interest from chemistry and physics to bacterial genetics and public health microbiology. I began to read voraciously about pioneers in microbiology. During my postdoctoral studies, my supervisor, Dr Charles C Brinton Jr, began working on Neisseria gonorrhoeae, investigating pili as possible candidates for a gonococcal vaccine. Time in his laboratory exposed me to newly emerging recombinant DNA methods and the emerging genetic knowledge of N. gonorrhoeae. After my postdoctoral work, I made “pilgrimages” to Louis Pasteur’s birthplace and the World Health Organization (WHO) to “see what they did”. Ever since, I have tried to link research in public health microbiology and molecular biological methods. My service in the Government of Canada allowed me to work on both national and international issues regarding sexually transmissible infections, especially the molecular epidemiology and antibiotic resistance of N. gonorrhoeae. I have been privileged to be the founding co-ordinator for WHO’s Gonococcal Antimicrobial Surveillance Program (GASP) in Latin America and the Caribbean. Throughout my career, I have balanced the role of administrator with my passion for research and public health. I have also been an advocate of the positive benefits of volunteering to work with various scientific organizations in my field. I have had the pleasure of leading several such organizations and this has facilitated my meeting scientists, clinicians, other researchers and health care workers from around the world.
Gonorrhea is the most common sexually transmitted disease (STD) in the world and it’s making a comeback due to emerging antimicrobial resistance (AMR). Physicians can no longer use a single magic bullet (i.e. an antibiotic) to cure the disease; they now must use a combination of antibiotics. New strategies are needed to ensure that we can control and cure this widespread infection; for example, a fast, effective detection kit for the pathogen and its antibiotic resistance and a safe, effective vaccine. Almost all of my research, whether it’s public health-oriented and dealing with the frequency of and molecular epidemiology of gonococcal antimicrobial resistance in various regions around the world, or more basic research on mechanisms of antimicrobial resistance, connects to an overall theme of antimicrobial resistance. I developed a passion for studying bacteria at a time when DNA technology was rapidly evolving and have sought to integrate new technologies with public health microbiology. I also study bacterial cell division mechanisms in N. gonorrhoeae and other microorganisms.
There is a resurgence of interest in the area of antimicrobial resistance, mechanisms of resistance and the identification of new effective agents or approaches for treating gonococcal infections. There is recognition that this is a global problem and the WHO has led an initiative to control the spread of antibiotic resistant N. gonorrhoeae that will lead to profound impacts in public health capacity building, public health policy, and innovative diagnostic and prevention approaches for sexually transmissible infections.
My job is multi-focal. It involves teaching, training, mentoring, research, as well as the provision of technical and policy advice. I love the complexity of what I do and I especially enjoy my interaction with people from all areas of the health care spectrum. I am so proud of my students and trainees who have gone on to significant roles in research and public health leadership in Canada and around the world.
First I feed my cats and appreciate the beauty of Saskatchewan countryside. Then, my typical day would comprise teaching undergraduate or graduate students in formal university courses; consulting and advising people in my own laboratory regarding on-going projects; perhaps a seminar in which I speak about my research; responding to a myriad of emails regarding on-going projects, future meetings and collaborations; writing grants, papers, and articles; consultation with public health authorities; and, planning for travel (e.g. to visit various GASP laboratories in Latin America and the Caribbean).
For the next few years, I will be concentrating on my various research projects in the area of gonococcal antimicrobial resistance and its detection. I will be working with health care researchers from a variety of different regions from around the world and within the province of Saskatchewan to gain a better perspective of the burden of gonococcal resistance both locally and internationally. I hope to be able to work with colleagues to improve infrastructure to diagnose N. gonorrhoeae and its antibiotic resistance.
There has been significant international publicity about the problem of potentially untreatable gonococcal infections. The issue has been highlighted by initiatives and national strategies to combat this resistance in various countries. Many countries have called together their medical officers of health from various regions to discuss the problem. Nevertheless, I am sometimes amazed at how difficult it is to communicate the extent of the problem to health care givers working in the trenches. Also, in some cases, despite evidence that isolates may be resistant to various antibiotics in a region, it has proven to be quite a challenge for local authorities to modify and communicate new effective treatment guidelines. Further, the need for capacity building, which entails rebuilding laboratory infrastructures and extensive training, has presented significant challenges as well.
There is a clear need to increase laboratory capacity for the culture, diagnosis and susceptibility testing of N. gonorrhoeae in many countries. Alarmingly, this capacity has actually declined as syndromic management of gonococcal infections became policy in many regions. Thus the treatment of gonorrhea has been based on empirical guidelines. Without an adequate laboratory and surveillance infrastructure, there may be a real lack of knowledge of the extent of gonococcal antimicrobial resistance present. Treatment guidelines may recommend antibiotics to which the organism is resistant and it has been extraordinarily difficult for some regions to implement changes to treatment guidelines in a timely fashion. As well, clinical research regarding effective new antimicrobials and new antibiotic combinations for treatment are urgently needed. One could also ask whether the time is ripe to take a renewed interest in plant extracts as a source of novel antimicrobial agents.
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