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. 2021 Mar 18;21(1):273.
doi: 10.1186/s12879-021-05931-0.

Associations between antimicrobial susceptibility/resistance of Neisseria gonorrhoeae isolates in European Union/European Economic Area and patients' gender, sexual orientation and anatomical site of infection, 2009-2016

Susanne Jacobsson #  1 , Michelle J Cole #  2 , Gianfranco Spiteri  3 , Michaela Day  2 , Magnus Unemo  4 ; Euro-GASP Network
Collaborators, Affiliations

Associations between antimicrobial susceptibility/resistance of Neisseria gonorrhoeae isolates in European Union/European Economic Area and patients' gender, sexual orientation and anatomical site of infection, 2009-2016

Susanne Jacobsson et al. BMC Infect Dis. .

Abstract

Background: The emergence and spread of antimicrobial resistance (AMR) in Neisseria gonorrhoeae, nationally and internationally, is a serious threat to the management and control of gonorrhoea. Limited and conflicting data regarding the epidemiological drivers of gonococcal AMR internationally have been published. We examined the antimicrobial susceptibility/resistance of gonococcal isolates (n = 15,803) collected across 27 European Union/European Economic Area (EU/EEA) countries in 2009-2016, in conjunction to epidemiological and clinical data of the corresponding patients, to elucidate associations between antimicrobial susceptibility/resistance and patients' gender, sexual orientation and anatomical site of infection.

Methods: In total, 15,803 N. gonorrhoeae isolates from the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP), 2009-2016, were examined. Associations between gonococcal susceptibility/resistance and patients' gender, sexual orientation and anatomical site of infection were investigated using univariate and multivariate logistic regression analysis. Statistical significance was determined by Pearson χ2-test or Fisher's exact test with two-tailed p-values of < 0.05 indicating significance.

Results: The overall gonococcal resistance from 2009 to 2016 was 51.7% (range during the years: 46.5-63.5%), 7.1% (4.5-13.2%), 4.3% (1.8-8.7%), and 0.2% (0.0-0.5%) to ciprofloxacin, azithromycin, cefixime, and ceftriaxone, respectively. The level of resistance combined with decreased susceptibility to ceftriaxone was 10.2% (5.7-15.5%). Resistance to cefixime and ciprofloxacin, and resistance combined with decreased susceptibility to ceftriaxone were positively associated with urogenital infections and heterosexual males, males with sexual orientation not reported and females (except for ciprofloxacin), i.e. when compared to men-who-have-sex-with-men (MSM). Azithromycin resistance was positively associated with heterosexual males, but no association was significant regarding anatomical site of infection.

Conclusions: Overall, sexual orientation was the main variable associated with gonococcal AMR. Strongest positive associations were identified with heterosexual patients, particularly males, and not MSM. To provide evidence-based understanding and mitigate gonococcal AMR emergence and spread, associations between antimicrobial susceptibility/resistance and patients' gender, sexual orientation and anatomical site of infection need to be further investigated in different geographic settings. In general, these insights will support identification of groups at increased risk and targeted public health actions such as intensified screening, 3-site testing using molecular diagnostics, sexual contact tracing, and surveillance of treatment failures.

Keywords: Antimicrobial resistance; Azithromycin; Ceftriaxone; Europe; European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP); Gonorrhoea; Surveillance.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Proportion of Neisseria gonorrhoeae isolates with a resistance combined with decreased susceptibility to ceftriaxone, b resistance to cefixime, c resistance to azithromycin, and d resistance to ciprofloxacin, over time by gender and sexual orientation, 2009 to 2016
Fig. 2
Fig. 2
Proportion of cefixime-resistant gonococcal isolates divided into gender, sexual orientation, and anatomical site of infection displayed over time. a Females b Heterosexual males c Men who have sex with men (MSM), and d Males with other sexual orientation or not reported
Fig. 3
Fig. 3
Proportion of azithromycin-resistant gonococcal isolates divided into gender, sexual orientation and anatomical site of infection displayed over time. a Females b Heterosexual males c Men who have sex with men (MSM), and d Males with other sexual orientation or not reported
Fig. 4
Fig. 4
Proportion of ciprofloxacin-resistant gonococcal isolates divided into gender, sexual orientation and anatomical site of infection displayed over time. a Females b Heterosexual males c Men who have sex with men (MSM), and d Males with other sexual orientation or not reported
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