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Antimicrobial susceptibility of Neisseria gonorrheae strains in three regions of ArmeniaOBJECTIVE: There are no data available on gonococcal susceptibility in the Caucasus region. We aimed to determine in vitro antimicrobial susceptibility of Neisseria gonorrheae in Armenia in order to update the national treatment protocol. METHODS: Isolates from men with urethral discharge presenting at 3 STI clinics in 3 different sites of Armenia were used to determine susceptibility of N. gonorrheae strains for 11 antimicrobials using the disc diffusion technique. RESULTS: Among the 101 isolates tested the susceptibility rate for penicillin, doxycycline, and kanamycin were 37.6, 25.7, and 80.2%, respectively. Sensitivity to quinolones was 95% for both ofloxacin and ciprofloxacin. All strains were susceptible to third-generation cephalosporins and to spectinomycin. Only 11% of strains were susceptible to all antibiotics tested. CONCLUSION: Third-generation cephalosporines and spectinomycin are suitable first-line regimens. Quinolones are not advisable as first-line treatment given current borderline susceptibility, known tendency for rapid resistance development in this class, and frequent over-the-counter use of this antibiotic in Armenia.
Optimising the management of vaginal discharge syndrome in Bulgaria: cost effectiveness of four clinical algorithms with risk assessmentOBJECTIVES: To evaluate the performance and cost effectiveness of the WHO recommendations of incorporating risk-assessment scores and population prevalence of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) into vaginal discharge syndrome (VDS) algorithms. METHODS: Non-pregnant women presenting with VDS were recruited at a non-governmental sexual health clinic in Sofia, Bulgaria. NG and CT were diagnosed by PCR and vaginal infections by microscopy. Risk factors for NG/CT were identified in multivariable analysis. Four algorithms based on different combinations of behavioural factors, clinical findings and vaginal microscopy were developed. Performance of each algorithm was evaluated for detecting vaginal and cervical infections separately. Cost effectiveness was based on cost per patient treated and cost per case correctly treated. Sensitivity analysis explored the influence of NG/CT prevalence on cost effectiveness. RESULTS: 60% (252/420) of women had genital infections, with 9.5% (40/423) having NG/CT. Factors associated with NG/CT included new and multiple sexual partners in the past 3 months, symptomatic partner, childlessness and >or=10 polymorphonuclear cells per field on vaginal microscopy. For NG/CT detection, the algorithm that relied solely on behavioural risk factors was less sensitive but more specific than those that included speculum examination or microscopy but had higher correct-treatment rate and lower over-treatment rates. The cost per true case treated using a combination of risk factors, speculum examination and microscopy was euro 24.08. A halving and tripling of NG/CT prevalence would have approximately the inverse impact on the cost-effectiveness estimates. CONCLUSIONS: Management of NG/CT in Bulgaria was improved by the use of a syndromic approach that included risk scores. Approaches that did not rely on microscopy lost sensitivity but were more cost effective.