Abstract
Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a major public health problem. Traditionally, AMR surveillance programs for N. gonorrhoeae have focused mainly on laboratory data to describe the prevalence and trends of resistance. However, integrating individual-level risk factors (e.g., sexual orientation or international travel) with laboratory data provides important insights into factors promoting the spread of resistant N. gonorrhoeae Here, over a 12-year period, we assessed the trends and risk factors for resistant N. gonorrhoeae in individuals attending a large publicly funded sexual health center in Melbourne, Australia. A total of 7,588 N. gonorrhoeae isolates were cultured from 5,593 individuals between 1 January 2007 and 31 December 2018. The proportion of isolates with penicillin resistance decreased from 49.5% in 2007 to 18.3% in 2018 (ptrend < 0.001) and from 63.5% in 2007 to 21.1% in 2018 for ciprofloxacin resistance (ptrend < 0.001). In contrast, the proportion of isolates displaying decreased susceptibility to ceftriaxone increased from 0.5% in 2007 to 2.9% in 2018 (ptrend < 0.001), with a significant increase in low-level azithromycin resistance, from 2.5% in 2012 to 8.2% in 2018 (ptrend < 0.001). Multivariate analysis identified risk factors for multidrug-resistant (MDR) N. gonorrhoeae, namely, female sex and country of birth, with MDR isolates more common in individuals born in northeast Asia, further highlighting the importance of this region and international travel as factors in the cross-border transmission of MDR N. gonorrhoeae Future surveillance work should incorporate additional epidemiological and genomic data to provide a comprehensive overview of the emergence and spread of resistant N. gonorrhoeae.
Highlights
Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a major public health problem
Our data highlight the potential importance of international travel in the cross-border transmission of N. gonorrhoeae resistance from Asia to other parts of the globe
Of note was the overall increase in low-level azithromycin resistance across the study period, a similar trend that has been observed in other countries, such as the United Kingdom and the United States [12, 13]
Summary
Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a major public health problem. In the context of reports of increasing low-level resistance to azithromycin and transmission of high-level azithromycin-resistant isolates, in January 2019 the British Association for Sexual Health and HIV (BASHH) national guideline for the management of gonorrhea has recommended ceftriaxone be used as monotherapy (increased from 500 mg to 1 g intramuscularly), with ciprofloxacin as an alternative agent if phenotypic or genotypic susceptibility testing data are available and indicate sensitivity to ciprofloxacin [9]. Many countries, including Australia, have national surveillance programs to monitor AMR in N. gonorrhoeae [11], few studies to date have combined AMR data with epidemiological and individual-level behavioral risk factors Such information can provide important evidence-based insights into factors promoting the acquisition of resistant N. gonorrhoeae, such as sexual orientation, international travel, or sexual behaviors. In order to determine specific risk factors for acquiring AMR N. gonorrhoeae in our setting, we undertook a longitudinal observational study between 2007 and 2018 of all individuals with culture-confirmed gonorrhea presenting to a large urban sexual health center in Melbourne, Australia
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