Antimicrobial resistance in Neisseria gonorrhoeae is a global problem, but valid data are lacking in many areas. Gonorrhea surveillance is crucial for public health to help prevent untreatable infections and inform treatment guidelines. However, resistance to traditional antibiotics is very high in most countries, and multi-drug resistant strains have emerged. Improved diagnostic testing and surveillance of antibiotic resistance according to WHO standards is needed worldwide, especially in low-resource areas.

1. Antimicrobial resistance (AMR) in N. gonorrhoeae (GC) - global problem but valid data are lacking in many geographic areas Magnus Unemo, PhD, Assoc. Professor Reference Laboratory for Pathogenic Neisseria Department of Clinical Microbiology Örebro University Hospital Sweden

3.     (  ) GISP EURO- GASP RU- GASP    !  (  ) !  WHO SEARO WHO WPRO   Global surveillance of GC AMR possible? An attempt is in progress!

5. Overall incidence of resistant GC 2004, 2006 and 2007 Recommended threshold for exclusion: 5% R in general population

6. Ciprofloxacin resistance in 2004 (n=12 countries) and 2007 (n=14) 2004: Martin I, et al. 2006. J Antimicrob Chemother: 587-93; 2007: ESSTI Annual Report No. 2, 2007 Ciprofloxacin resistance: 2004: 30.9% (7.6-53.1%)! 2007: 52.2 (20.3-90.3%)! Recommended threshold for exclusion: 5% R in general population

8. Problems - many different antimicrobials used for treatment - poor quality of many of the antimicrobials - valid resistance data exceedingly rare (due to use mainly of microscopy for diagnosis and overall rare use of AMR testing) - methodological problems and differences - high potentials for emergence of new resistance - treatment failures? - Large need of evalution, optimisation, and quality assurance of the AMR testing (as well as overall introduction of improved culture diagnostics and AMR testing in some countries)! AMR of GC and gonorrhoea treatment in Eastern Europe

9. Russian Gonococcal antimicrobial susceptibility program (RU-GASP): initiated in 2004 at CNIKVI, Health Ministry, Moscow Sex Transm Infect. 2008; 84:285-9

10. Resistance in Russia in 2005-2007 2005-2006: Kubanova A, et al. 2008. Sex Transm Infect. 84:285-9; 2007: Kubanova A, et. 2008. Submitted. Multiresistance common: 2007: 1.1% to all antimicrobials except ceftriaxone (PcG, tetracycline, ciprofloxacin, azithromycin, spectinomycin)!

11. “ In Russia, penicillins, ciprofloxacin, or tetracycline should definitively not be used in empirical treatment of gonorrhoea, i.e. if results from antibiotic susceptibility testing are not available. The recommended first-line antimicrobial should be ceftriaxone. If not access to ceftriaxone, spectinomycin ought to be used.” Kubanova A, et al. 2008. Sex Transm Infect. 84;285-9 New antimicrobial treatment recommendations for gonorrhoea in Russia:

13. RU- GASP             GC AMR surveillance in Eastern European Sexual and Reproductive Health (EE-SRH) Network countries?

17. J Antimicrobial Chemother 2009, in press

19. Results

21. Similar problems as in Eastern Europe: - updated quality assured and quality controlled data needed! - many different antimicrobials used for treatment! - poor quality of many of the antimicrobials! - valid recent resistance data rare! - methodological problems and differences! - high potentials for emergence of new resistance! - Coordinated approaches needed and in progress! AMR of GC in Africa; Eastern-Mediterranean region (EMRO); Caribbean, Central and South America

22. GC AMR in USA (GISP), South-East Asia (WHO SEARO), Western Pacific (WHO WPRO) - the oldest, most ambitious and best working GC AMR surveillance systems! - however, all systems have limitations such as representativeness, limited no. of specimens, identification of local AMR prevalence, etc. - GISP: mainly similar resistance problems as in Europe! - WHO SEARO: highest level of resistance and probably the most important region because most of the resistances emerge there (low control of infection and the no. as well as quality of antimicrobials used)!