Resistance Patterns of Neisseria gonorrhoeae in PLHIV: A Cross-Sectional Study from the Republic of Cyprus, 2015-2023

Abstract

Background: The rise in antimicrobial-resistant (AMR) strains of Neisseria gonorrhoeae is internationally recognised as a critical public health concern, with limited treatment options available. The urgency of this issue prompted the European Centre for Disease Prevention and Control to establish 'EURO-GASP' to monitor trends in resistance and address developments. Comprehensive data on AMR strains in people living with HIV (PLHIV) is limited, especially in Cyprus. Objectives: To analyse trends in rates of resistant N. gonorrhoeae infections and identify any correlations between patient factors that may contribute to such in PLHIV in The Republic of Cyprus. Methods: We conducted a retrospective chart review study on N. gonorrhoea resistance among PLHIV from the Gregorios HIV reference clinic in Larnaca, Cyprus, between 2015 and 2023. Antimicrobial susceptibility was assessed via disc diffusion or gradient strip method on GC II agar against a non-homogenous panel of antibiotic preparations, based on standard laboratory practice variation. Demographic and clinical data, including antibiograms, treatments and test of cure, were recorded. Statistical analysis was performed using Stata v16, with significance set at p < 0.05. The study received approval from the Cyprus National Bioethics Committee. Results: A total of 45 isolates from 39 patients were analysed, with 62% of these demonstrating resistance to at least one antibiotic. Resistance rates were not shown to change over time. We identified a statistically significant linear association between a person having a history of an STI and the number of antibiotics which the isolate is resistant to (β = 1.2; p: 0.004). Notably, a single isolate demonstrated resistance to ceftriaxone, the first-line treatment currently recommended in both Europe and the United States. This finding is particularly alarming given the critical role of ceftriaxone in the management of gonorrhoea. Conclusions: Whilst there has been no increase in resistance rates over time, the detection of ceftriaxone-resistant N. gonorrhoeae is a significant public health concern. Given that having a history of an STI makes a person more likely to develop a resistant infection, PLHIV or those who engage in risky sexual behaviours are particularly vulnerable. There is a pressing need to enhance surveillance and implement routine susceptibility testing in Cyprus, given the country's role as a major international hub for travel and migration. Molecular analysis can further improve our understanding. Additionally, the global public health community must urgently prioritise the development of novel therapeutic agents for the treatment of gonorrhoea.

Keywords: HIV; N. gonorrhoeae; PLHIV; antibiotics; antimicrobial resistance; gonorrhoea.