Friday, June 19, 2020

CDC MMWR / HAN Advisory: Ciprofloxacin-resistant, β-lactamase-producing Neisseria meningitidis Serogroup Y Isolates, United States, 2019–2020










#15,331


While we remain focused on COVID-19 there are other public health threats out there that have not receded in deference to our current pandemic.  Old scourges - like Ebola, Lassa Fever, influenza and West Nile virus (to name but a few) still circulate - and evolutionary processes continue to propel other pathogens towards greater human impact.
Although novel viral respiratory pathogens pose the greatest risk of producing a sudden pandemic, growing antibiotic resistance is no less of a threat to human health, albeit on a longer time scale.
Each year we draw a little closer to a long-predicted, but highly plausible `post-antibiotic era', where even common infections become resistant to most antibiotics, and something as simple as a scraped knee, or elective surgery, could be deadly.


Yesterday the CDC released an MMWR report and a HAN (Health Alert Network) Advisory on the detection of a small number of Ciprofloxacin-Resistant Neisseria meningitidis Serogroup Y Isolates in the United States over the the past 18 months. 

Fortunately, rates of meningococcal disease are at historic lows in the United States (see chart below), and there are other antibiotics available to treat this disease. 

Credit CDC
But this uptick in resistant infections is another reminder that our armamentarium against bacterial diseases is limited, and continues to erode with time. 

I've posted excerpts from both reports, click the links to read them in their entirety.

Detection of Ciprofloxacin-Resistant, β-Lactamase–Producing Neisseria meningitidis Serogroup Y Isolates — United States, 2019–2020

Weekly / June 19, 2020 / 69(24);735–739
Lucy A. McNamara, PhD1; Caelin Potts, PhD1; Amy E. Blain, MPH1; Adam C. Retchless, PhD1; Natashia Reese, MS2; Stephanie Swint, MS2; David Lonsway, MMSc2; Maria Karlsson, PhD2; Kristy Lunquest, ScM3; John J. Sweitzer, ScM3; Xin Wang, PhD1; Susan Hariri, PhD1; LeAnne M. Fox, MD1; Antimicrobial-Resistant Neisseria meningitidis Team (View author affiliations)View suggested citation
Summary
What is already known about this topic?
Most Neisseria meningitidis isolates in the United States have been susceptible to antibiotics recommended for treatment and prophylaxis.
What is added by this report?
During 2019–2020, 11 meningococcal isolates from U.S. patients had isolates containing a blaROB-1 β-lactamase gene associated with penicillin resistance and mutations associated with ciprofloxacin resistance. An additional 22 cases reported during 2013–2020 contained blaROB-1 but did not have mutations associated with ciprofloxacin resistance.
What are the implications for public health practice?
Ceftriaxone and cefotaxime can continue to be used for empiric bacterial meningitis treatment; meningococcal isolate susceptibility to penicillin should be determined before switching to penicillin or ampicillin. Prophylaxis failures and antimicrobial resistance among meningococcal isolates should be monitored to inform meningococcal prophylaxis recommendations.
          (Continue . . . )



Detection of Ciprofloxacin-resistant, β-lactamase-producing Neisseria meningitidis Serogroup Y Isolates, United States, 2019–2020
Distributed via the CDC Health Alert Network
June 18, 2020, 1:00 PM ET
CDCHAN-00433
Summary
Meningococcal disease, which typically presents as meningitis or meningococcemia, is a life-threatening illness requiring prompt antibiotic treatment for patients and antibiotic prophylaxis for their close contacts. Neisseria meningitidis isolates in the United States have been largely susceptible to the antibiotics recommended for treatment and prophylaxis.
However, 11 meningococcal disease cases reported in the United States during 2019–2020 had isolates containing a blaROB-1 β-lactamase gene associated with penicillin resistance, as well as mutations associated with ciprofloxacin resistance. An additional 22 cases reported during 2013–2020 contained a blaROB-1 β-lactamasegene but did not have mutations associated with ciprofloxacin resistance.
Background
Meningococcal disease is a sudden-onset, life-threatening illness caused by the bacterium Neisseria meningitidis. Prompt antibiotic treatment can reduce morbidity and mortality among patients and antibiotic prophylaxis can prevent secondary disease in close contacts (https://redbook.solutions.aap.org/chapter.aspx?sectionid=189640131&bookid=2205external icon). 
Resistance to the antibiotics used for meningococcal treatment and prophylaxis, including penicillin and ciprofloxacin, has been rare in the United States. Recently, however, penicillin- and ciprofloxacin-resistant N. meningitidis serogroup Y (NmY) isolates have been detected in the United States.
The U.S. Centers for Disease Control and Prevention (CDC) made a request for isolate submissions from state health departments and reviewed the existing whole genome sequencing data for those isolates. CDC identified 33 meningococcal disease cases occurring between 2013 and 2020 that were caused by NmY isolates containing a blaROB-1 β-lactamase enzyme gene conferring resistance to penicillins. The 33 cases were reported from 12 geographically disparate states. A majority of the cases (22/33, 67%) occurred in Hispanic individuals. Isolates from 11 of these cases, reported during 2019–2020 from nine states, were also resistant to ciprofloxacin.
These cases represent a significant increase in penicillin- and ciprofloxacin-resistant meningococci in the United States. 
Recommendations
  • Healthcare providers should perform antimicrobial susceptibility testing (AST) to determine susceptibility of all meningococcal isolates to penicillin before changing from empirical treatment with cefotaxime or ceftriaxone to penicillin or ampicillin.
  • In states that have experienced meningococcal disease cases caused by ciprofloxacin-resistant strains within the past 1–2 years, clinicians and public health staff should consider AST on meningococcal isolates to inform prophylaxis decisions. AST should not delay the initiation of prophylaxis with ciprofloxacin, rifampin, or ceftriaxone.
  • State and territorial health departments should continue submitting all meningococcal isolates to CDC for AST and whole genome sequencing. Health departments also should report any suspected meningococcal treatment or prophylaxis failures.
For More Information
MMWR on Detection of Ciprofloxacin-resistant, β-lactamase-producing Neisseria meningitidis Serogroup Y Isolates: https://www.cdc.gov/mmwr/volumes/69/wr/mm6924a2.htm?s_cid=mm6924a2_w
CDC Meningococcal Disease Website: https://www.cdc.gov/meningococcal/index.html
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