Antimicrobial resistance in Neisseria gonorrhoeae and its risk groups in 23 European countries in 2022 within the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP): a retrospective observational study

Abstract

Background: Since 2009, the European Centre for Disease Prevention and Control (ECDC) has coordinated the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP) to monitor antimicrobial resistance (AMR) in Neisseria gonorrhoeae across the European Union and European Economic Area (EU/EEA). The aims of this study were to report Euro-GASP 2022 data and to compare with the most recently published Euro-GASP data (from 2016 to 2019), to identify changes in AMR and in risk groups for AMR.

Methods: In this observational study, 23 EU/EEA countries submitted AMR data for gonococcal isolates from 2022, linked to patient epidemiological data, to The European Surveillance System (TESSy). Statistical analyses (Z-test) were used to determine the significance of the differences between the epidemiological data and proportion of AMR isolates in 2022 versus 2019 and 2016. The risk factors associated with AMR isolates were assessed using univariate and multivariable logistic regression analyses of odds ratios.

Findings: Ceftriaxone resistance in 2022 (0.03%, 1/3008) remained low (0.06% (2/3239) in 2019), and cefixime resistance (0.3%, 10/3008) had decreased (0.8% (26/3239) in 2019). Azithromycin resistance (24.9%, 749/3008) and ciprofloxacin resistance (65.8%, 1980/3008) had increased (9.0% (284/3159) and 57.4% (1665/2884), respectively, in 2019). A marked increase in the number (575; 502 in 2019) and proportion (19.2%; 15.8% in 2019) of female gonorrhoea cases was also identified in 2022. In the univariate analysis, azithromycin resistance was associated with oropharyngeal (OR 1.67, CI 1.28-2.18; p < 0.0001) and anorectal infections (OR 1.38, CI 1.08-1.76; p = 0.0094), men-who-have-sex-with-men (MSM) (OR 3.88, CI 2.80-5.37; p < 0.0001), and females (1.71, CI 1.21-2.41; p = 0.0022). In the multivariable logistic regression model, only azithromycin resistance and MSM remained associated (OR 2.85, CI 1.33-4.73; p = 0.0040).

Interpretation: While ceftriaxone resistance remains sporadically detected in Euro-GASP, the increase in reports of occasional ceftriaxone resistance in EU/EEA countries and substantial increase in azithromycin resistance underscore the urgent need for enhanced AMR surveillance. The Euro-GASP data is crucial for refining treatment guidelines and mitigating the spread of AMR gonococcal strains. Novel effective antimicrobials for gonorrhoea treatment remain imperative.

Funding: ECDC.

Keywords: Antimicrobial resistance; ECDC; Europe; Gonorrhoea; Neisseria gonorrhoeae; Surveillance; Treatment.

Fig. 1

Proportion (%) of resistant Neisseria gonorrhoeae isolates by antimicrobial and year within European Union (including UK until 2019) and European Economic Area, from 2016 to 2022. All collected Euro-GASP isolates from each year are included in this graph.

Fig. 2

Minimum inhibitory concentration (MIC; mg/L) distributions for Neisseria gonorrhoeae isolates collected within European Union (including UK until 2019) and European Economic Area, from 2016 to 2022. a) ceftriaxone, b) cefixime, c) azithromycin, and d) ciprofloxacin. All collected Euro-GASP isolates from each year are included in this graph.