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DANMAP 2015 3D
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128 8.7 neisseria gonorrhoea
e background: neisseria gonorrhoeae is the causative agent of the sexually transmitted infection gonorrhoea, which is usually located in the urethra in males and cervix in females. n. gonorrhoeae (gonococci) may sometimes be demonstrated in specimens from the pharynx or rectum in either gender. in females, the finding of gonococci in rectal specimens is usually due to colonization after contamination with vaginal secre- tion, while in men who have sex with men (msm) it is due to unprotected anal sex leading to infection. in both genders the condition is generally asymptomatic. pharyngeal gonorrhoea is virtually always asymptomatic. complications of gonorrhoea include e.g. salpingitis, epididymi- tis, orchitis, and prostatitis. further, conjunctivitis may occur in newborns after transmission from an infected mother during labour and rarely in adults following direct inoculation. methods: through decades, all departments of clinical micro- biology in denmark have submitted their isolates of gonococci to the neisseria and streptococcus reference (nsr) laboratory at statens serum institut for national surveillance of antimicro- bial resistance
. at the nsr laboratory ceftriaxone, ciprofloxacin and azithromy- cin mics were determined using the etestŪ on chocolate agar incubated at 35°c in 5% co 2 . the breakpoints used were those defined by the eucast. both fully and intermediary resistant isolates are categorized as resistant in this report. penicillinase production was tested for using the nitrocephin assay. as part of nsr?s participation in ecdc?s surveillance of sexu- ally transmitted infections since 2009, approximately 110 gonococcus isolates are investigated per year for susceptibility to an expanded panel of antimicrobial agents. in addition to ceftriaxone, ciprofloxacin and azithromycin, this panel includes cefixime and in selected years also spectinomycin, and gen- tamicin. the latter two drugs were not included in the surveys in 2014 and 2015. results and discussion: most of the received isolates were from urethra or cervix, while clinicians only rarely obtain speci- mens from rectum and pharynx. occasionally, the nsr labora- tory receives strains isolated from other anatomical sites, such as conjunctivae, joint fluid, blood, bartholin?s abscess, etc. in 2015, isolates from 1127 unique cases of gonorrhoea were received. the annual number has increased considerably from 2011 through 2015, presumably because the widespread use of combined pcr-testing for chlamydia trachomatis and n. gonorrhoeae has identified unexpected cases of gonorrhoea (followed by culture), but possibly also due to an increasing incidence of gonorrhoeae. the ciprofloxacin resistance rate was 46% in 2014 and 29% in 2015, thus showing a steady decline since the peak of 75% in 2009 (figure 8.15). the percentage of strains producing penicillinase was 8% in 2015. it has fluctuated between 22% in 2005 and 11% in 2014 and 2013. ceftriaxone resistant gonococci (mic > 0.125 mg/l) as well as ceftriaxone treatment failure in patients with gonorrhoea have occurred in several countries during recent years. no cases from denmark have ever been reported. during 2003 through 2009 the proportion of isolates with mic ? 0.008 mg/l gradually increased from 40% to nearly 75% (figure 8.16), but during recent years this shift has nearly reversed (44% in 2014 and 17% in 2015). thus, there is no evidence of emerg- ing ceftriaxone resistance in denmark. in 2014, azithromycin resistance including intermediary resist- ance (mic > 0.5 mg/l) in gonococci was 36% while in 2015 it was 11% (table 8.8). the national board of health issued guidelines in 2015 for the diagnosis and treatment of sexually transmitted infections. a combination of high dose ceftriaxone (500 mg i.m.) and azithromycin (2 g) is recommended for the treatment of gonorrhoea. ciprofloxacin 500 mg p.o. may be used for treatment if the strain is fully susceptible. resistance against cefixime (mic > 0.125 mg/l) was 6% in 2014, i.e. a decrease compared to 2013, and further decreased to 0% in 2015. cefixime is an oral cephalosporin that has never been used in denmark. conclusions: the incidence of gonorrhoea is increasing sub- stantially. although resistance problems are so far not present in denmark, the emerging ceftriaxone treatment failures in other countries underlines the importance of maintaining the central- ised national surveillance of antimicrobial resistance in gonococci. steen hoffmann for further information: steen hoffmann (hof@ssi.dk) antimicrobial agent 2009 2010 2011 2012 2013 2014 2015 azithromycin 46 23 12 12 45 36 11 cefixime 15 18 21 11 9 6 0 spectinomycin 0 0 0 0 0 nt nt number of isolates 119 111 126 114 111 108 1127 table 8.8. resistance rates (%) against azithromycin, cefixime and spectinomycin in gonococci, denmark 2009?2015 nt = not tested danmap 2015
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