Data from 10 sentinel sites in Cambodia show a high prevalence of ceftriaxone-resistant and multidrug- and extensively drug-resistant (XDR) gonorrhea, researchers reported yesterday in JAC-Antimicrobial Resistance.

To investigate Neisseria gonorrhoeae levels in Cambodia, which has been linked to cases of ceftriaxone-resistant gonorrhea in France and Australia, researchers with the World Health Organization (WHO) Enhanced Gonococcal Antimicrobial Surveillance Program (EGASP) analyzed urethral swabs of 437 male patients who presented at the 10 sites with urethral discharge from January 2022 to June 2023. Of those men, 306 had positive N gonorrhoeae cultures, antimicrobial resistance (AMR) test results, and complete epidemiologic data.

Findings of 'grave concern'

Resistance ceftriaxone, cefixime, azithromycin, and ciprofloxacin was 15.4%, 43.1%, 14.4%, 97.1%, respectively. Nineteen (6.2%) of isolates collected from 7 of the 10 sentinel sites were resistant to all four antibiotics and categorized as XDR. Furthermore, 18 of the 19 XDR isolates displayed high-level resistance to azithromycin.

The most frequently reported treatment was the nationally recommended dual therapy of cefixime plus azithromycin, which was used in 65.4% of cases. The rest were treated with ceftriaxone plus azithromycin. Of the 30 patients who received a test of cure, 11 (36.6%) were still N gonorrhoeae–positive.

The authors of the study note that the prevalence of resistance to ceftriaxone, cefixime, and azithromycin all exceeded the 5% AMR level used by the WHO and other public health agencies to indicate when the recommended first-line treatment should be changed. They say the findings are of "grave concern" both for Cambodia and from an international perspective.

"This necessitates expanded N. gonorrhoeae AMR surveillance, revision of the nationally recommended gonorrhoea treatment, mandatory test of cure, enhanced sexual contact notification, and ultimately novel antimicrobials for the treatment of gonorrhoea," they wrote.

Hospitalized COVID-19 patients with neurologic manifestations at the time of admission had worse long-term outcomes at various time points up to 3 years compared to matched controls in a study published yesterday in PLOS Medicine. 

The study is based on outcomes seen in patients at the Montefiore Health System in the Bronx, New York, in March and April 2020. Follow-up data were captured through January 2023. The health system was one of the first epicenters of the COVID-19 pandemic in the United States

The researchers compared 414 patients with COVID-19 who had significant neurological manifestations with 1,199 patients matched for age and COVID-19 severity score but without neurologic manifestations. Significant neurologic manifestations included stroke, seizure, and vertigo.

Higher death rates 

A higher percentage of patients in the neurologic cohort were discharged to acute rehabilitation (10.39% versus 3.34%), the authors said. The incidence of readmission for any reason was also higher for the neurologic group (65.70% versus 60.72%). 

Overall, patients in the neurologic cohort were more likely to die post-discharge compared to controls (hazard ratio, 2.35; 95% confidence interval, 1.59 to 3.47), with higher death rates at 6 months, 1 year, and 3 years post-hospitalization. 

Patients with significant neurological findings during COVID-19 hospitalization were more likely to have worse outcomes.

"Patients with significant neurological findings during COVID-19 hospitalization were more likely to have worse outcomes at 3-year follow-up compared to propensity matched controls," the authors concluded. "Improved understanding of the long-term outcomes of patients with COVID-19 with neurological involvement could help to develop effective screening methods and innovative interventions to address the potentially high burden of care among these COVID-19 survivors."

A new US Department of Health and Human Services (HHS) white paper outlines progress it has made toward preventing and lessening the impact of drug shortages—particularly the vulnerable generic injectable drugs used in hospitals—while acknowledging its efforts are only part of the solution. 

"All across our Department, we are working to ensure that millions of Americans will have access to medication, treatment, and services that save lives and improve health outcomes," HHS Secretary Xavier Becerra said in a department press release.

"That's why advancing and implementing solutions to the nation’s drug shortages are so important, and why we want members of Congress and all actors in the supply chain to consider and act on the policy options presented in today’s white paper."

Authorities, resources needed to incentivize market

HHS and its agencies have been working to better track the drug supply chain and respond to disruptions, including:

• The establishment of a new supply chain resilience and shortage coordinator role to implement strategies to shore up supply chains for drugs and other medical products
• The publication of guidance to boost supply chain transparency and consider other long- and short-term solutions.
• A joint HHS and Federal Trade Commission request for information on how group purchasing organizations (GPOs) and drug wholesalers contribute to generic drug shortages.
• A $500 million Administration for Strategic Preparedness and Response (ASPR) investment to support domestic manufacturing of active pharmaceutical ingredients, as well as an exploration of how to return overseas manufacturing of essential medicines, medical countermeasures, and their ingredients to the United States.
• Proposals for policies to foster a diverse drug supply chain through Medicare payments.

Additional authorities and resources are needed to reward investment in supply chains through the development of a manufacturer resiliency assessment program and hospital resilient supply program, HHS adds.

Drug shortages have been a problem around the world for decades for reasons such as the interference of supply chain "middlemen" and a generic-drug price "race to the bottom" that provides little incentive for redundancy and resilient manufacturing, distribution, and purchasing.

• Zoonotic (ie, from animals), human-to-human close contact, and human-to-human sexual transmission are occurring in the Democratic Republic of the Congo (DRC) mpox outbreak, which involves a different clade than the one that continues to circulate globally, the European Centre for Disease Prevention and Control (ECDC) said today in an epidemiologic update. Children make up 70% of cases and 88% of deaths, and their infections are mainly due to household contact with infected adults and spillover from small animals. The ECDC added that the DRC's sexual transmission cases seem to be concentrated among sex workers—both women and men—and their contacts in the mining areas, which don't have direct travel connections to Europe and pose a limited risk of spread. So far, no recent clade 1 cases have been confirmed outside of the DRC, but local spread to Rwanda and Burundi is possible.
• As part of the response to cholera outbreaks in multiple countries, the World Health Organization (WHO) today announced the first shipments of rapid tests for the illness, starting with Malawi. The WHO said more than 1.2 million tests will be deployed to 14 countries and funded through Gavi, the Vaccine Alliance. The goals are to help speed detection, monitor outbreaks, gauge vaccine campaign effectiveness, and target future vaccination efforts.
• Afghanistan has reported its first wild poliovirus type 1 (WPV1) case of the year, according to the latest weekly update from the Global Polio Eradication Initiative (GPEI). The patient is from Kunar province in the northeast. Afghanistan and Pakistan are among the countries in which WPV1 is still endemic. Pakistan had earlier reported two WPV1 cases this year. Elsewhere, Nigeria reported three more cases involving circulating vaccine-derived poliovirus type 2 (cVDPV2), bringing its total for the year to seven. The cases are in Kano, Kaduna, and Katsina states.