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Seventeen 369 August 2004

In October 2016, the Brigade Headquarters and Special Troops Battalion Headquarters deployed to Kuwait under the 1st Theater Sustainment Command in support of Operation Inherent Resolve and Operation Spartan Shield. The 369th assumed the mission from the 17th Sustainment Brigade. During its deployment the 369th provided mission command to Logistics, Human Resources, Military Police and Financial Management units in seventeen countries. The 369th was commanded by Colonel Stephen Bousquet and the Special Troops Battalion by Colonel Seth Morgulas.

Seventeen 369 August 2004

In late 2016, the 369th Sustainment Brigade was deployed to Camp Arifjan, Kuwait, and assumed command and control of sustainment operations in seventeen west Asian countries under the United States Central Command.[6]

Medical record reviews were performed at six of the STD clinics. During January--July 2003, a total of 394 gonococcal isolates from 369 patients at these six clinics were tested for antimicrobial susceptibility; QRNG was identified in 5% (18 of 369) of the patients. Seventeen (94%) of the 18 patients with QRNG were male, and 13 (77%) reported being MSM. QRNG prevalence among patients for whom sexual behavior was documented was 12.5% (14 of 112) among MSM, 1.6% (three of 183) among heterosexual men, and 2.4% (one of 42) among women. Fourteen of the 17 patients with QRNG for whom gonorrhea treatment history was available had been treated with ceftriaxone. New York City STD clinic treatment protocols specify that gonorrhea be treated with ceftriaxone and that fluoroquinolones only be used if culture is performed so the patient can be recalled if QRNG is identified. Reported by: S Ratelle, T Bertrand, W Dumas, Massachusetts Dept of Public Health. K Macomber, D Ganoczy, Michigan Dept of Community Health. J Schillinger, S Manning, J Reddy, S Blank, New York City Dept of Health and Mental Hygiene. S Wang, H Weinstock, J Newhall, K Workowski, S Berman, Div of STD Prevention, National Center for HIV, STD, and TB Prevention, CDC. Editorial Note: Fluoroquinolones are used frequently to treat gonorrhea in the United States because they are inexpensive and easy to administer and their continued use might decrease the use of cephalosporins and delay the development of cephalosporin resistance. However, local and national data suggest that the prevalence of QRNG among MSM infected with gonorrhea is close to or exceeds 5%. This level of resistance often is used as the level at which a therapeutic regimen should be changed (7); other factors, including prevalence of gonorrhea, availability of antimicrobial susceptibility data, and cost of various diagnostic and treatment options, might result in higher or lower thresholds for change. In the absence of antimicrobial susceptibility testing or tests of cure, fluoroquinolones should no longer be used to treat proven or suspected gonococcal infections in MSM in the United States. Health departments should notify clinicians about this new recommendation. Some local health departments have issued similar recommendations recently.Fluoroquinolones also should not be used to treat patients whose gonorrhea was acquired in Asia, the Pacific Islands (including Hawaii), California, and other areas, such as England and Wales, with increased QRNG prevalence (4,8). For those infections acquired where QRNG is not endemic, before determining treatment, clinicians should obtain travel histories from patients and information on the sex of sex partners from male patients with proven or suspected gonorrhea. A list of places that should be included in a relevant travel history is available at patients with gonorrhea who are MSM or who provide a history suggesting acquisition of infection in an area with high QRNG prevalence, CDC recommends ceftriaxone 125 mg intramuscularly or cefixime 400 mg orally (not currently available in the United States [9]); spectinomycin 2 g intramuscularly is an alternative. Spectinomycin may be used for urogenital and anorectal gonorrhea but is not sufficiently effective to treat pharyngeal gonorrhea (4,10). If Chlamydia trachomatis is not ruled out, each regimen should be followed with either azithromycin 1.0 g orally (single dose) or doxycycline 100 mg orally twice daily for 7 days to treat possible co-infection with chlamydia. The limited availability of a recommended oral treatment regimen for gonorrhea poses practical problems for treating QRNG. Besides the fluoroquinolones, cefixime, whose manufacture was discontinued in 2002, is the only CDC-recommended oral agent for treating gonorrhea. Although Lupin, Ltd. (Baltimore, Maryland) received Food and Drug Administration approval to manufacture and market cefixime in February 2004, the 400-mg tablets to treat gonorrhea are not yet available; the suspension (100 mg/5 mL) is available. The health departments of California and Washington state have suggested alternative oral treatments (e.g., cefpodoxime 400 mg) that have not yet been evaluated adequately. CDC will provide additional information about the availability of cefixime and efficacy of other oral agents for treating gonorrhea as it becomes available ( ).Clinicians must be vigilant in identifying treatment failures when fluoroquinolones are used, advise their patients about the importance of follow-up if symptoms persist, and be prepared to evaluate such cases by culture. In cases of persistent gonococcal infection after treatment with fluoroquinolones, antimicrobial susceptibility testing should be performed. Only culture of N. gonorrhoeae can be used to determine antimicrobial susceptibility. Health departments without the capacity to perform culture and antimicrobial susceptibility testing should develop those capabilities locally or partner with laboratories outside their jurisdictions. The antimicrobial susceptibility testing panel should, at a minimum, include a fluoroquinolone, ceftriaxone, spectinomycin, azithromycin, and any other drugs in local use for gonorrhea treatment. Arrangements forantimicrobial susceptibility testing can be made by contacting state and local health departments. Through their state and local health departments, clinicians and laboratorians should report treatment failures or resistant gonococcal isolates to CDC, telephone 404-639-2059.

  • Given the apparent low prevalence of QRNG among heterosexuals, a national change in treatment in that group is not recommended at this time. However, QRNG prevalence among heterosexuals is likely to increase over time and already might be high enough in some areas to warrant new local treatment recommendations. For example, increased prevalence of QRNG among heterosexuals has been identified in several counties in Michigan, where recommendations have been made to avoid using fluoroquinolones among all persons infected with gonorrhea. Because gonococcal infections, especially in women, frequently are asymptomatic, monitoring for symptomatic treatment failures alone does not provide a reliable indication of emerging antimicrobial resistance. Therefore, as part of effective gonorrhea-control programs, health departments should evaluate their current QRNG surveillance activities and consider plans to monitor for the presence of QRNG among heterosexual populations with gonorrhea. If prevalence increases nationally among heterosexuals, guidance from CDC will be forthcoming. Local and state treatment recommendations, technical information, surveillance data, references, and other links related to gonococcal resistance are available at Institute of Medicine, Division of Health Promotion and Disease Prevention. The hidden epidemic: confronting sexually transmitted diseases. Eng TR, Butler WT, eds. Washington, DC: National Academy Press, 1997.

  • Weinstock H, Berman S, Cates W. Sexually transmitted infections in American youth: incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health 2004;36:6--10.

  • CDC. Fluoroquinolone-resistance in Neisseria gonorrhoeae in Hawaii, 1999 and decreased susceptibility to azithromycin in N. gonorrhoeae, Missouri, 1999. MMWR 2000;49:833--6.

  • CDC. Sexually transmitted diseases treatment guidelines 2002. MMWR 2002;51(No. RR-6).

  • CDC. Increases in fluoroquinolone-resistant Neisseria gonorrhoeae---Hawaii and California, 2001. MMWR 2002;51:1041--4.

  • CDC. Sexually Transmitted Disease Surveillance 2002 Supplement: Gonococcal Isolate Surveillance Project (GISP) Annual Report 2002. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, 2003.

  • Tapsall J. Antimicrobial resistance in Neisseria gonorrhoeae. Geneva, Switzerland: World Health Organization, 2001; WHO/CDS/DRS/2001.3:16.

  • Fenton KA, Ison C, Johnson AP, et al. Ciprofloxacin resistance in Neisseria gonorrhoeae in England and Wales in 2002. Lancet 2003;361:1867--9.

  • CDC. Discontinuation of cefixime tablets---United States. MMWR 2002;51:1052.

  • CDC. Oral alternatives to cefixime for the treatment of uncomplicated Neisseria gonorrhoeae urogenital infections. Available at

* Defined by the National Committee on Clinical Laboratory Standards as N. gonorrhoeae resistant to ciprofloxacin (minimum inhibitory concentration [MIC] >1.0 µg/mL by agar dilution or disk diffusion zone size 2.0 µg/mL or disk diffusion zone size

Overview of the treatment protocols. (A) HLH-94 and (B) HLH-2004. (A) Both HLH-94 and HLH-2004 consist of an initial therapy of 8 weeks, with immunosuppressive and cytotoxic agents, and continuation therapy thereafter, for patients with familial, relapsing, or severe and persistent, aiming at a HSCT as soon as an acceptable donor is available. In both HLH-94 and HLH-2004, daily dexamethasone (Dexa) (10 mg/m2 per day weeks 1-2; 5 mg/m2 per day weeks 3-4; 2.5 mg/m2 per day weeks 5-6; 1.25 mg/m2 per day week 7, and tapering during week 8), and etoposide (VP-16) (150 mg/m2, twice weekly weeks 1-2, then once weekly) is administrated during the initial therapy. The continuation therapy for both HLH-2004 and HLH-94 consists of Dexa every second week (10 mg/m2 per day for 3 days), VP-16 (150 mg/m2) every second week, and CSA (aiming at 200 µg/L trough value). For patients with progressive neurological symptoms during the first 2 weeks, or if an abnormal cerebrospinal fluid value at onset has not improved after 2 weeks, intrathecal (I.T.) treatment is recommended (up to 4 doses, weeks 3, 4, 5, 6). In the HLH-94 protocol, I.T. MTX (doses by age: 3 years, 12 mg each dose) is recommended. (B) In HLH-2004, CSA (aiming at 200 µg/L trough value) is administered already upfront during the initial therapy, a modification from HLH-94 where CSA is not administered until the continuation therapy. It is recommended to start CSA with 6 mg/kg daily orally (divide in 2 daily doses), if normal kidney function. Moreover, in the HLH-2004 protocol, in addition to I.T. MTX, I.T. prednisolone (doses by age: 3 years, 10 mg each dose) is recommended. In HLH-2004, the total treatment period is reduced to 40 weeks as compared with 52 weeks in HLH-94. Reprinted from Henter et al12 (A) and Henter et al11 (B) with permission. BMT, bone marrow transplantation. 041b061a72


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