title: Is the tide turning again for cephalosporin resistance in Neisseria gonorrhoeae in Europe? Results from the 2013 European surveillance.
abstract: BACKGROUND
  The emerging resistance to the extended-spectrum cephalosporins (ESCs) in Neisseria gonorrhoeae together with increasing incidence of gonorrhoea cases in many countries have been global public health concerns. However, in recent years the levels of ESC resistance have decreased in several regions worldwide. We describe the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP) data from 2013, and compare them to corresponding data from 2009-2012.
  
  
  METHODS
  During 2013, N. gonorrhoeae isolates from 21 participating countries were examined. Antimicrobial susceptibility testing (Etest or agar dilution) was performed for cefixime, ceftriaxone, ciprofloxacin, azithromycin, spectinomycin and gentamicin. Statistical analyses were performed to identify significant changes in resistance between years and to investigate associations between patients with resistant gonococcal isolates and collected epidemiological variables.
  
  
  RESULTS
  In total, 93 (4.7 %) of 1994 isolates displayed resistance to cefixime, representing an increase compared to the 3.9 % detected in 2012 (p = 0.23). Cefixime resistance was detected in 13 (61.9 %) of the 21 countries. Cefixime resistance among men who have sex with men was only 1.2 %, compared to 5.6 % and 6.1 % in females and male heterosexuals, respectively. The univariate analysis confirmed that isolates resistant to cefixime were more likely to be from females (OR 4.87, p < 0.01) or male heterosexuals (OR 5.32, p < 0.01). Seven (0.4 %) isolates displayed ceftriaxone resistance (in addition to cefixime resistance) compared to three and 10 isolates in 2012 and 2011, respectively. All 93 isolates with cefixime resistance were additionally resistant to ciprofloxacin and 16 (17.2 %) were also resistant to azithromycin. Among all tested isolates (n = 1994), the ciprofloxacin resistance level (52.9 %) was higher than in 2012 (50.1 %; p = 0.08), and azithromycin resistance (5.4 %) increased since 2012 (4.5 %; p = 0.16).
  
  
  CONCLUSIONS
  In 2013, the ESC resistance was again slightly increasing in Europe. This emphasises the importance of implementing the actions outlined in the European and additional response plans, particularly activities strengthening the surveillance of antimicrobial resistance. Ceftriaxone combined with azithromycin remains a satisfactory option for the first-line treatment of gonorrhoea. However novel antimicrobials (new derivatives of previously developed antimicrobials or newly developed antimicrobials) for effective monotherapy or at least inclusion in new dual antimicrobial therapy regimens (combined with previously developed antimicrobials or novel antimicrobials) will likely be required.
authors.affiliation: Sexually Transmitted Bacteria Reference Unit, Microbiological Services, Public Health England, London, England, United Kingdom. michelle.cole@phe.gov.uk.
authors.forename: Michelle J
authors.initials: MJ
authors.lastname: Cole
authors.affiliation: European Centre for Disease Prevention and Control, Stockholm, Sweden. Gianfranco.Spiteri@ecdc.europa.eu.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Spiteri
authors.affiliation: WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden. susanne.jacobsson@regionorebrolan.se.
authors.forename: Susanne
authors.initials: S
authors.lastname: Jacobsson
authors.affiliation: Sexually Transmitted Bacteria Reference Unit, Microbiological Services, Public Health England, London, England, United Kingdom. rachel.pitt@phe.gov.uk.
authors.forename: Rachel
authors.initials: R
authors.lastname: Pitt
authors.affiliation: Sexually Transmitted Bacteria Reference Unit, Microbiological Services, Public Health England, London, England, United Kingdom. gvladja@gmail.com.
authors.forename: Vlad
authors.initials: V
authors.lastname: Grigorjev
authors.affiliation: WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden. magnus.unemo@regionorebrolan.se.
authors.forename: Magnus
authors.initials: M
authors.lastname: Unemo
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use; D020682:Cefixime / Q000494:pharmacology / Q000627:therapeutic use; D018550:Cephalosporin Resistance; D005060:Europe / Q000453:epidemiology; D005260:Female; D006069:Gonorrhea / Q000188:drug therapy / Q000453:epidemiology*; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D009344:Neisseria gonorrhoeae / Q000187:drug effects / Q000302:isolation & purification*; D018571:Sentinel Surveillance; D012725:Sexual Behavior / Q000706:statistics & numerical data
chemical_list: D000900:Anti-Bacterial Agents; D020682:Cefixime