Ciprofloxacin-resistant gonorrhoea in South Africa

Abstract

Surveillance to monitor susceptibility patterns of Neisseria gonorrhoeae is not a regular feature of the national sexually transmitted infection (STI) control programme in South Africa, and occurs mainly in the context of research settings. Ciprofloxacin is included in the syndromic management package for treatment of potential infection with N gonorrhoeae. The Prince Cyril Zulu Centre for Communicable Diseases in Durban houses one of the largest STI clinics in the province. We have been testing the susceptibility of N gonorrhoeae isolates from this centre to ciprofloxacin since 1995. Up until 2002, all isolates were susceptible to ciprofloxacin (table). However, reports of treatment failures among patients with genital discharge who were following syndromic management appeared in November, 2003, and coincided with the appearance of ciprofloxacin-resistant N gonorrhoeae isolates (minimum inhibitory concentration [MIC] ⩾1 mg/L) at a prevalence of 22%.1Moodley P Moodley D Sturm AW Ciprofloxacin resistant Neisseria gonorrhoeae in South Africa.Int J Antimicrob Agents. 2004; 24: 192-193Summary Full Text Full Text PDF PubMed Scopus (16) Google ScholarTableActivity of ciprofloxacin on Neisseria gonorrhoeae isolates in Durban, South AfricaNumber of isolatesNumber with each minimum inhibitory concentration⩽0·03 mg/L0·06–0·50 mg/L⩾1·00 mg/L19956161 (100%)001997198198 (100%)0019999894 (96%)6 (4%)020005858 (100%)002002443443 (100%)00Nov, 2003139107 (77%)1 (1%)31 (22%)Jan/Feb, 2004259194 (75%)3 (1%)62 (24%)Jan/Feb, 2005248139 (56%)5 (2%)104 (42%) Open table in a new tab The National Department of Health (DoH) in South Africa was informed and a meeting of the STI Treatment Advisory Group to the DoH was convened in January, 2004. The decision was to do susceptibility surveillance at a few selected clinics, including the Prince Cyril Zulu Centre. 259 isolates were obtained from this clinic and tested between January and March, 2003. The prevalence of ciprofloxacin-resistant isolates was 24% (table). This was again reported to the DoH and we expected that the recommendation of ciprofloxacin as first-line treatment for gonorrhoea would be changed. However, ciprofloxacin remained a first-line agent in the syndromic management package for genital discharge. The only adjustment to the guidelines was a change from retreatment with ciprofloxacin to ceftriaxone in patients whose disease failed to respond. A further susceptibility survey at the same clinic was done in January, 2005. This study revealed that the prevalence of ciprofloxacin-resistant isolates among men presenting with male urethritis syndrome had risen to 42% (table). Postponing effective treatment in an area with a high prevalence of HIV and N gonorrhoeae has obvious implications in terms of the transmission of both organisms. The initial inappropriate treatment resulted in preferential transmission of the resistant organisms. Non-responding gonococcal disease increases the duration of mucosal inflammation, which in turn increases the likelihood of transmission of HIV.2Fleming DT Wasserheit JN From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection.Sex Transm Infect. 1999; 75: 3-17Crossref PubMed Scopus (1782) Google Scholar The recommendation from WHO is to use drugs that are 95% effective as empirical treatment for the management of STIs.3World Health Organisation Programme for Sexually Transmitted Diseases, Global Programme on AIDS. Recommendations for the management of sexually transmitted diseases: WHO/GPA/TEM/94. WHO, Geneva1994Google Scholar However, in KwaZulu Natal, the prevalence of ciprofloxacin-resistant N gonorrhoeae increased from 24% to 42% over a 12-month period, and continues to go unchecked. We hope that this report expedites action from the DoH to do rapid nationwide surveillance to assess the extent of the problem in South Africa. In addition, an urgent review of the syndromic management guidelines, with a view to replacing ciprofloxacin as first-line treatment in Durban, KwaZulu Natal, is long overdue. We declare that we have no conflict of interest.