Abstract
BackgroundSurveillance of Neisseria gonorrhoeae antimicrobial susceptibility in Europe is performed through the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP), which additionally provides data to inform the European gonorrhoea treatment guideline; currently recommending ceftriaxone 500 mg plus azithromycin 2 g as first-line therapy. We present antimicrobial susceptibility data from 24 European countries in 2015, linked to epidemiological data of patients, and compare the results to Euro-GASP data from previous years.MethodsAntimicrobial susceptibility testing by MIC gradient strips or agar dilution methodology was performed on 2134 N. gonorrhoeae isolates and interpreted using EUCAST breakpoints. Patient variables associated with resistance were established using logistic regression to estimate odds ratios (ORs).ResultsIn 2015, 1.7% of isolates were cefixime resistant compared to 2.0% in 2014. Ceftriaxone resistance was detected in only one (0.05%) isolate in 2015, compared with five (0.2%) in 2014. Azithromycin resistance was detected in 7.1% of isolates in 2015 (7.9% in 2014), and five (0.2%) isolates displayed high-level azithromycin resistance (MIC ≥ 256 mg/L) compared with one (0.05%) in 2014. Ciprofloxacin resistance remained high (49.4%, vs. 50.7% in 2014). Cefixime resistance significantly increased among heterosexual males (4.1% vs. 1.7% in 2014), which was mainly attributable to data from two countries with high cefixime resistance (~11%), however rates among men-who-have-sex-with-men (MSM) and females continued to decline to 0.5% and 1%, respectively. Azithromycin resistance in MSM and heterosexual males was higher (both 8.1%) than in females (4.9% vs. 2.2% in 2014). The association between azithromycin resistance and previous gonorrhoea infection, observed in 2014, continued in 2015 (OR 2.1, CI 1.2–3.5, p < 0.01).ConclusionsThe 2015 Euro-GASP sentinel system revealed high, but stable azithromycin resistance and low overall resistance to ceftriaxone and cefixime. The low cephalosporin resistance may be attributable to the effectiveness of the currently recommended first-line dual antimicrobial therapy; however the high azithromycin resistance threatens the effectiveness of this therapeutic regimen. Whether the global use of azithromycin in mono- or dual antimicrobial therapy of gonorrhoea is contributing to the global increases in azithromycin resistance remains to be elucidated. The increasing cefixime resistance in heterosexual males also needs close monitoring.
Highlights
Surveillance of Neisseria gonorrhoeae antimicrobial susceptibility in Europe is performed through the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP), which provides data to inform the European gonorrhoea treatment guideline; currently recommending ceftriaxone 500 mg plus azithromycin 2 g as first-line therapy
The first failure to treat gonorrhoea with empirical dual antimicrobial therapy (250 mg ceftriaxone by single intramuscular dose plus 1 g of azithromycin by single oral dose) was recently reported in a male in the United Kingdom (UK) with pharyngeal gonorrhoea caused by a ceftriaxone- and azithromycin-resistant strain [6]
The present study describes the Euro-GASP antimicrobial susceptibility and resistance data from 24 European countries in 2015, linked to clinical and epidemiological data of the patients, and compares these results to Euro-GASP data from previous years, with particular focus on 2014
Summary
Surveillance of Neisseria gonorrhoeae antimicrobial susceptibility in Europe is performed through the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP), which provides data to inform the European gonorrhoea treatment guideline; currently recommending ceftriaxone 500 mg plus azithromycin 2 g as first-line therapy. Due to the extraordinary ability of N. gonorrhoeae to rapidly and effectively develop AMR, combined multidisciplinary efforts are required to retain gonorrhoea as a treatable infection These include: antimicrobial susceptibility surveillance of N. gonorrhoeae, including appropriate analysis of patient risk-group, the early identification of treatment failures, monitoring of antimicrobial usage, appropriate diagnostic testing strategies and evidence-based patient management [2, 3]. The European guidelines on the diagnosis and treatment of gonorrhoea currently recommend a single intramuscular dose of 500 mg of ceftriaxone plus a single oral dose of 2 g of azithromycin as empirical first-line dual antimicrobial therapy for all cases of urogenital and extra-genital gonorrhoea [4]. The first failure (globally) to treat gonorrhoea with empirical dual antimicrobial therapy (250 mg ceftriaxone by single intramuscular dose plus 1 g of azithromycin by single oral dose) was recently reported in a male in the United Kingdom (UK) with pharyngeal gonorrhoea caused by a ceftriaxone- and azithromycin-resistant strain [6]
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