title: Antimicrobial susceptibility testing of Neisseria gonorrhoeae isolates in Pakistan by Etest compared to Calibrated Dichotomous Sensitivity and Clinical Laboratory Standards Institute disc diffusion techniques.
abstract: BACKGROUND
  Accurate detection of Neisseria gonorrhoeae antimicrobial resistance is essential for appropriate management and prevention of spread of infection in the community. In this study Calibrated Dichotomous Sensitivity (CDS) and Clinical Laboratory Standards Institute (CLSI) disc diffusion methods were compared with minimum inhibitory concentration (MIC) by Etest in Neisseria gonorrhoeae isolates from Karachi, Pakistan. CDS and CLSI disc diffusion techniques, and Etest for ceftriaxone, penicillin G, spectinomycin and ciprofloxacin against 100 isolates from years 2012-2014 were performed. Due to lack of CLSI breakpoints for azithromycin, it was interpreted using cut-offs from British Society of Antimicrobial Chemotherapy (BSAC). Due to lack of low concentration tetracycline discs, tetracycline was tested with CLSI disc diffusion and Etest only. Comparisons were based on the identified susceptibility, intermediate susceptibility and resistance (SIR) categories using the different methods. Complete percent agreement was percentage agreement achieved when test and reference method had identical SIR-category. Essential percent agreement was percentage agreement when minor discrepancies were disregarded.
  
  
  RESULTS
  There was 100 % and 99 % overall essential agreement and 50 % versus 23 % overall complete agreement by CDS and CLSI methods, respectively, with MICs for all tested antibiotics. Using either method, there was 100 % complete agreement for ceftriaxone and spectinomycin. There was 90 % versus 86 % complete agreement for ciprofloxacin, and 60 % and 75 % for penicillin using CDS and CLSI method, respectively. Essential agreement of 99 % and complete agreement of 62 % was found for tetracycline with CLSI method. There was 100 % essential and complete agreement by CDS, BSAC and Etest for azithromycin.
  
  
  CONCLUSIONS
  No major errors with regard to identified SIR-categories were found for penicillin, ciprofloxacin, ceftriaxone and spectinomycin using CLSI and CDS methods. All isolates were susceptible to ceftriaxone and spectinomycin, and 99 % to azithromycin. In low-resource settings, both the CLSI and CDS disc diffusion techniques might be used for susceptibility testing of gonococcal isolates. However, these methods require considerable standardization and quality controls for adequate levels of reproducibility and correct interpretation to reflect appropriately the MIC values of the different antimicrobials. New, emerging, or rare resistance should be confirmed by MIC determination.
authors.affiliation: Section of Pathology and Laboratory Medicine, Clinical Microbiology Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan.
authors.forename: Pushpa Bhawan
authors.initials: PB
authors.lastname: Mal
authors.affiliation: Section of Pathology and Laboratory Medicine, Clinical Microbiology Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan. kauser.jabeen@aku.edu.
authors.forename: Kauser
authors.initials: K
authors.lastname: Jabeen
authors.affiliation: Section of Pathology and Laboratory Medicine, Clinical Microbiology Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan.
authors.forename: Joveria
authors.initials: J
authors.lastname: Farooqi
authors.affiliation: WHO Collaborating Centre for Gonorrhoea and other STIs, Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
authors.forename: Magnus
authors.initials: M
authors.lastname: Unemo
authors.affiliation: Section of Pathology and Laboratory Medicine, Clinical Microbiology Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan.
authors.forename: Erum
authors.initials: E
authors.lastname: Khan
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D003430:Cross-Sectional Studies; D052978:Disk Diffusion Antimicrobial Tests / Q000379:methods*; D024881:Drug Resistance, Bacterial; D005260:Female; D006069:Gonorrhea / Q000382:microbiology; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests / Q000379:methods*; D009344:Neisseria gonorrhoeae / Q000187:drug effects* / Q000302:isolation & purification*; D010154:Pakistan; D015203:Reproducibility of Results; D013752:Tetracycline / Q000494:pharmacology
chemical_list: D000900:Anti-Bacterial Agents; D013752:Tetracycline
keywords: Antimicrobial surveillance; CDS; CLSI; Disc diffusion; Etest; Neisseria gonorrhoeae