Establishment of a Gonococcal Antimicrobial Surveillance Programme, in Accordance With World Health Organization Standards, in Côte d'Ivoire, Western Africa, 2014–2017

Abstract

Background Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is compromising the treatment of gonorrhea globally. Recent AMR data are extremely limited in Africa, and mainly totally lacking in Western Africa, including Côte d'Ivoire. This study (i) established a quality-assured gonococcal antimicrobial surveillance program, according to World Health Organization quality criteria, (ii) investigated the AMR to 8 therapeutic antimicrobials in gonococcal isolates from 2014 to 2017, and (iii) provided evidence for updating the National Sexually Transmitted Disease Syndromic Management Guidelines in Côte d'Ivoire. Methods During 2014 to 2017, gonococcal isolates were obtained from sexually active symptomatic or asymptomatic males and females in 14 sites in Côte d'Ivoire. It was a special focus on symptomatic males, and their sexual partners, due to the higher culture positivity rates in symptomatic males. Patient metadata were collected, including age, gender, sexual orientation, and symptoms. Minimum inhibitory concentrations of 8 antimicrobials were determined by Etest and interpreted using European Committee on Antimicrobial Susceptibility Testing breakpoints. β-lactamase production was detected using cefinase disks. Results The level of resistance, examining 212 gonococcal isolates, was as follows: 84.9% to tetracycline, 68.9% to benzylpenicillin, 62.7% to ciprofloxacin, 6.1% to azithromycin, and 1.4% to gentamicin. All isolates were susceptible to ceftriaxone, cefixime and spectinomycin. Conclusions We provide the first gonococcal AMR data, quality assured according to World Health Organization standards, from Côte d'Ivoire since more than 20 years. The high ciprofloxacin resistance, which informed a revision of the national syndromic management guideline during study, and relatively high resistance to azithromycin demand an improved gonococcal antimicrobial surveillance program and increased awareness when prescribing treatment in Côte d'Ivoire.

World Health Organization Global Gonococcal Antimicrobial Surveillance Program (WHO GASP): review of new data and evidence to inform international collaborative actions and research efforts

“…4,67 To develop evidence-based treatment guidelines based on validated surveillance information, it is crucial to strengthen the WHO GASP and other GASPs (both more countries and more representative isolates), including the use of only MIC determination (agar dilution or MIC gradient strip tests) instead of different disc diffusion methods, and to monitor treatment failures. Strengthened AMR surveillance is especially urgent in the WHO AFR, where some progress has been made recently, 63,64,89 and in the EMR. In the SEAR and WPR, there has been a substantial increase in the number of countries providing surveillance data for both ceftriaxone and azithromycin, and in ceftriaxone MIC testing across the Asia-Pacific; 59 however, much more needs to be done in these regions because many ceftriaxone-resistant strains have originated from this region.…”

“…Notably, DS/R to ceftriaxone has been reported from South Africa and Uganda. 6 In 2016, no DS/R to cefixime was detected in Cote d'Ivoire, 63 Malawi, South Africa or Zimbabwe (Fig. 2).…”

“…In 2013-14, DS/R to cefixime was reported also in Chile and Uruguay. 6 In 2016, only four of 47 WHO AFR countries (8.5%) provided ceftriaxone susceptibility data for 496 isolates and no DS/R was reported from Cote d'Ivoire, 63 South Africa or Zimbabwe. 64 However, one of 35 isolates (3.0%) from Madagascar showed DS/R to ceftriaxone, but this single isolate was not confirmed using MIC determination (Fig.…”

“…In the WHO AFR, Cote d'Ivoire 63 and Malawi reported azithromycin-resistant isolates (2.0% and 12.6% respectively) in 2016, whereas no azithromycin resistance was detected in Madagascar or South Africa. Notably, !5% azithromycin resistance was reported in Uganda in 2014, South Africa in 2013 and Kenya in 2014 6 and 2015 ( Fig.…”

“…Also in the WHO AFR (69.1%), EMR (Pakistan: 96.9%) and EUR (45.4%), three countries reported >90% resistance, namely Madagascar, Pakistan and Kyrgyzstan respectively. Countries belonging to all the remaining WHO regions reported !70% ciprofloxacin resistance (Argentina, Cuba, Peru, Cote D'Ivoire, 63 Malawi, South Africa, Iceland, Luxembourg; 7,8 Fig. 4).…”