Increasing trend in gonococcal resistance to ciprofloxacin in The Netherlands, 2006-8.

INTRODUCTION: Rapid development of Neisseria gonorrhoeae resistance to several antibiotics in recent years threatens treatment and prevention. Targeted surveillance of new resistance patterns and insight into networks and determinants are essential to control this trend. METHODS: Since the Gonococcal Resistance to Antimicrobials Surveillance (GRAS) project was implemented within the Dutch national sexually transmitted infection (STI) surveillance network in July 2006, participating STI centres have collected a culture from each gonorrhoea patient. Isolates were tested for susceptibility to penicillin, tetracycline, ciprofloxacin and cefotaxime using Etest. Logistic regression was used to determine risk factors for ciprofloxacin resistance. RESULTS: Between July 2006 and July 2008, prevalence of resistance to penicillin was 10%, to tetracycline 22% and to ciprofloxacin 42%. Resistance to cefotaxime was not found, although minimum inhibitory concentrations higher than 0.125 mg/l drifted upward (p<0.05). Ciprofloxacin resistance rose from 35% in 2006 to 46% in 2008 (p<0.05), despite 2003 guidelines naming cefotaxime as first-choice therapy. In men, ciprofloxacin resistance was higher in men having sex with men (MSM) than in heterosexual men (adjusted OR 2.0, 95% CI : 1.5 to 2.6). In women, it was higher in commercial sex workers (adjusted OR 25.0, 95% CI 7.7 to 78.2) and women aged over 35 years (adjusted OR 8.2, 95% CI 3.0 to 22.7) than in other women. CONCLUSION: Ciprofloxacin resistance in The Netherlands is increasing, and is particularly found in MSM, older women, and female sex workers. No resistance to current first-choice therapy was found, but alertness to potential clinical failures is essential. By merging epidemiological and microbiological data in GRAS, specific high-risk transmission groups can be identified and policy adjusted when needed.

Travel to Asia and traveller's diarrhoea with antibiotic treatment are independent risk factors for acquiring ciprofloxacin-resistant and extended spectrum ß-lactamase-producing Enterobacteriaceae-a prospective cohort study.

Travel to (sub)tropical countries is a well-known risk factor for acquiring resistant bacterial strains, which is especially of significance for travellers from countries with low resistance rates. In this study we investigated the rate of and risk factors for travel-related acquisition of extended spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-E), ciprofloxacin-resistant Enterobacteriaceae (CIPR-E) and carbapenem-resistant Enterobacteriaceae. Data before and after travel were collected from 445 participants. Swabs were cultured with an enrichment broth and sub-cultured on selective agar plates for ESBL detection, and on plates with a ciprofloxacin disc. ESBL production was confirmed with the double-disc synergy test. Species identification and susceptibility testing were performed with the Vitek-2 system. All isolates were subjected to ertapenem Etest. ESBL and carbapenemase genes were characterized by PCR and sequencing. Twenty-seven out of 445 travellers (6.1%) already had ESBL-producing strains and 45 of 445 (10.1%) travellers had strains resistant to ciprofloxacin before travel. Ninety-eight out of 418 (23.4%) travellers acquired ESBL-E and 130 of 400 (32.5%) travellers acquired a ciprofloxacin-resistant strain. Of the 98 ESBL-E, predominantly Escherichia coli and predominantly blaCTX-M-15, 56% (55/98) were resistant to gentamicin, ciprofloxacin and co-trimoxazole. Multivariate analysis showed that Asia was a high-risk area for ESBL-E as well as CIPR-E acquisition. Travellers with diarrhoea combined with antimicrobial use were significantly at higher risk for acquisition of resistant strains. Only one carbapenemase-producing isolate was acquired, isolated from a participant after visiting Egypt. In conclusion, travelling to Asia and diarrhoea combined with antimicrobial use are important risk factors for acquiring ESBL-E and CIPR-E.