FROM THE BENCH
Milwaukee Strengthens Surveillance and Response
to Drug-Resistant Neisseria gonorrhoeae
By Manjeet Khubbar, MSc, lead microbiologist; City of Milwaukee Health Department; Josh Weiner, MS, laboratory data specialist, City of Milwaukee
Health Department; Raquel Gomez, M(ASCP)CM, Microbiologist,City of Milwaukee Health Department; Helen Hermus, MS, BSN, RN, public health nurse
supervisor,City of Milwaukee Health Department; Trivikram Dasu, PhD, D(ABMLI), deputy laboratory director, City of Milwaukee Health Department;
Dhana Shrestha, MPH, epidemiology analyst, STD Control Section, Wisconsin Division of Public Health, Bureau of Communicable Diseases; Lori
Amsterdam, MPH, epidemiology coordinator, STD Control Section, Wisconsin Division of Public Health, Bureau of Communicable Diseases; John Pfister,
MS, epidemiology consultant, Health Care Education and Training (HCET); and Sanjib Bhattacharyya, PhD, laboratory director and special deputy health
commissioner, City of Milwaukee Health Department
For over 25 years the Milwaukee Health
Department Laboratory (MHDL) has
surveilled for drug resistant Neisseria
gonorrhoeae (GC) in clinical cultures
received from Milwaukee’s STD clinics
and sentinel laboratories. Funded in
August 2016 as one of the US Centers for
Disease Control and Prevention (CDC)’s
SURRG (Strengthening the United States
Response to Resistant Gonorrhea) 1 sites,
MHDL has improved GC antimicrobial
susceptibility testing (AST) capacity to:
• Enhance domestic gonorrhea
surveillance and infrastructure
• Build capacity for rapid detection
and response to resistant gonorrhea
through increased culturing and AST
• Conduct rapid field investigation to
stop the spread of resistant infections.
MHDL has addressed many challenges
related to specimen collection, transport,
analysis, and results communications
to grant and local PHL system partners,
resulting in significantly improved
GC-AST workflow and culture criteria
(Figure 1).
Building testing capacity
As an initial step toward implementing
SURRG project goals, MHDL validated
the bioMérieux, Inc. Etest ® as a reliable
alternative quantitative method for
AST determination. Etest ® strips have
a predefined gradient of antibiotic
concentrations which allows minimum
inhibitory concentrations (MICs) of
antibiotics to be read directly from the
plate. Increased MICs provide an indirect
measure of reduced susceptibility (RS)
and/or treatment failure. This triggers
disease intervention specialists (DIS) and
clinicians to initiate a “test of cure” (TOC)
in patients with increased MICs to the
prescribed antibiotic.
In 2016, MHDL collaborated with CDC
to evaluate recovery of GC from four
commercially available transport
systems. 2 As a result, MHDL validated two
highly efficient collection and transport
systems to expand and maintain culture
collection capacity in varied clinical
settings. The Copan ESwab ™ system
allows transport and recovery of GC for up
to 24 hours at ambient and refrigeration
temperatures for use in satellite clinics,
while the InTray ™ GC system is used for
direct specimen collection/inoculation in
more proximal clinics. This strategy has
improved the viability and isolation of GC
during transport and storage, increased
testing capacity while maintaining
high recovery standards, and improved
turnaround time (TAT) critical to rapid
field investigations to mitigate the spread
of resistant GC infections.
Figure 1: Outcome of change in culture selection criteria at non-STD (blue) and MSM (orange) clinics. Numbers following are average (range). In non-STD clinics, number of specimens decreased
from 100.6 (16-187) to 34.7 (19-53). Number of positives improved from 4.1 (0-13) to 12.6 (7-21). In MSM clinics, number of specimens decreased from 83.5 (60-105) to 21 (8-31), with positives
decreasing slightly from 5 (2-10) to 4.3 (2-8).
12 LAB MATTERS Summer 2020
PublicHealthLabs
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