Gonorrhoea treatment combined with population-level general cephalosporin and quinolone consumption may select for Neisseria gonorrhoeae antimicrobial resistance at the levels of NG-MAST genogroup: An ecological study in Europe.

OBJECTIVES: The prevalence of Neisseria gonorrhoeae NG-MAST genogroup G1407, associated with decreased susceptibility to extended-spectrum cephalosporins and fluoroquinolone resistance, has declined in Europe and it switched from circulating predominantly in men who have sex with men (MSM) in 2009-2010 to heterosexuals in 2013. We hypothesise that changes to gonorrhoea treatment guidelines combined with differences in country-level consumption of cephalosporins and quinolones contributed to this shift. METHODS: Linear regression was used to evaluate the association between changes in prevalence of G1407 between 2009-2010 and 2013 and country-level consumption of quinolones and cephalosporins in 2011/12 in 20 European countries. RESULTS: Whilst the prevalence of G1407 declined between 2009-2010 and 2013 in the EU/EEA, its absolute prevalence increased by 10% or more in three countries. The national prevalence of G1407 in 2013 was positively associated with population-level general cephalosporin and quinolone consumption in the preceding 2 years. The association between the prevalence of G1407 and proportion of the national sample derived from MSM was non-significant in 2009-2010 and was negative in 2013. CONCLUSIONS: Our results are broadly compatible with the hypothesis that changes in gonorrhoea therapy to the more efficacious ceftriaxone (plus azithromycin) from 2010 to 2011 onwards resulted in a reduced prevalence of the resistance-associated G1407 overall but in MSM in particular. High population-level consumption of quinolones and cephalosporins in certain countries then contributed to the selection of G1407 predominantly in heterosexuals in these countries.

Could Intensive Screening for Gonorrhea/Chlamydia in Preexposure Prophylaxis Cohorts Select for Resistance? Historical Lessons From a Mass Treatment Campaign in Greenland.

INTRODUCTION: Neisseria gonorrhoeae has developed resistance to all classes of antimicrobials used against it. Current strategies to prevent the emergence of pan-resistance include increased gonorrhea screening in high-prevalence populations such as men who have sex with men taking HIV preexposure prophylaxis. By increasing antimicrobial exposure, others have argued that intensive screening may inadvertently promote the emergence of antimicrobial resistance. AIM/METHODOLOGY: To contribute to this discussion, we conducted a historical review of the effect of a mass gonorrhea treatment campaign in Greenland from 1965 to 1968 on the incidence of gonorrhea and antimicrobial resistance. We conducted a literature review using PubMed and Google Scholar to find relevant studies. Data on the incidence of gonorrhea, antimicrobial susceptibility, and antimicrobials dispensed were extracted and analyzed. RESULTS: Eight articles were found with relevant information. The cornerstone of the campaign involved the repeated treatment for all persons with a diagnosis of gonorrhea in the past 6 months as well as all remaining unmarried persons between 15 and 30 years of age. There was a small and temporary decline in the incidence of gonorrhea during the campaign. The campaign was, however, associated with an increase in the proportion of gonococci that were not susceptible to penicillin. Gonococcal incidence continued to climb after the campaign ended but did decline dramatically after reductions in risk behavior after the global AIDS epidemic. DISCUSSIONS: The mass gonorrhea treatment campaign in Greenland was associated with only a temporary decline in the incidence of gonorrhea. It was, however, followed by an increase in penicillin nonsusceptibility. Intense gonorrhea screening and treatment strategies should be aware of the risk of inducing antimicrobial resistance.

Where have all the susceptible gonococci gone? A historical review of changes in MIC distribution over the past 75 years.

BACKGROUND: Does the emergence of antimicrobial resistance in Neisseria gonorrhoeae include the erasure of highly susceptible strains or does it merely involve a stretching of the MIC distribution? If it was the former this would be important to know as it would increase the probability that the loss of susceptibility is irreversible. METHODS: We conducted a historical analysis based on a literature review of changes of N. gonorrhoeae MIC distribution over the past 75 years for 3 antimicrobials (benzylpenicillin, ceftriaxone and azithromycin) in five countries (Denmark, Japan, South Africa, the United Kingdom and the United States). RESULTS: Changes in MIC distribution were most marked for benzylpenicillin and showed evidence of a right shifting of MIC distribution that was associated with a reduction/elimination of susceptible strains in all countries. In the case of ceftriaxone and azithromycin, where only more recent data was available, right shifting was also found in all countries but the extent of right shifting varied and the evidence for the elimination of susceptible strains was more mixed. CONCLUSIONS: The finding of right shifting of MIC distribution combined with reduction/elimination of susceptible strains is of concern since it suggests that this shifting may not be reversible. Since excess antimicrobial consumption is likely to be responsible for this right shifting, this insight provides additional impetus to promote antimicrobial stewardship.