High prevalence of ceftriaxone-resistant and XDR Neisseria gonorrhoeae in several cities of Cambodia, 2022-23: WHO Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP)

V Ouk; L Say Heng; M Virak; S Deng; M M Lahra; R Frankson; K Kreisel; R McDonald; M Escher; M Unemo; T Wi; I Maatouk; EGASP Cambodia Working Group

doi:10.1093/jacamr/dlae053

High prevalence of ceftriaxone-resistant and XDR Neisseria gonorrhoeae in several cities of Cambodia, 2022-23: WHO Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP)

JAC Antimicrob Resist. 2024 Apr 4;6(2):dlae053. doi: 10.1093/jacamr/dlae053. eCollection 2024 Apr.

Authors

V Ouk¹, L Say Heng¹, M Virak², S Deng³, M M Lahra⁴, R Frankson⁵, K Kreisel⁵, R McDonald⁵, M Escher⁶, M Unemo^{7

8}, T Wi⁹, I Maatouk⁹; EGASP Cambodia Working Group

Collaborators

EGASP Cambodia Working Group:
Phnom Penh, Vivian Fensham, Ellen Kersh, Philippe Cavailler, Yamuna Mundade, Sebastiaan J van Hal, Ratan L Kundu, Tiffany R Hogan, David M Whiley, Kiyohiko Izumi, Takeshi Nishijima

Affiliations

¹ National Center for HIV/AIDS, Dermatology and Sexually Transmitted Diseases, Phnom Penh, Cambodia.
² Laboratory of the National Institute of Public Health, Phnom Penh, Cambodia.
³ WHO, Office of Cambodia, Phnom Penh, Cambodia.
⁴ WHO Collaborating Centre for Sexually Transmitted Infections and Antimicrobial Resistance, New South Wales Health Pathology, Microbiology, The Prince of Wales Hospital, Randwick, NSW, Australia.
⁵ Division of STD Prevention, CDC, Atlanta, GA, USA.
⁶ AMR Division, WHO, Geneva, Switzerland.
⁷ Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and other STIs, Örebro University, Örebro, Sweden.
⁸ Institute for Global Health, University College London, London, UK.
⁹ Department of the Global HIV, Hepatitis and STI Programmes, WHO, Geneva, Switzerland.

Abstract

Objectives: Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a global public health concern. Ceftriaxone is the last effective and recommended option for empirical gonorrhoea therapy worldwide, but several ceftriaxone-resistant cases linked to Asia have been reported internationally. During January 2022-June 2023, the WHO Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) investigated N. gonorrhoeae AMR and epidemiological factors in patients from 10 clinical sentinel sites in Cambodia.

Methods: Urethral swabs from males with urethral discharge were cultured. ETEST determined the MIC of five antimicrobials, and EGASP MIC alert values and EUCAST breakpoints were used. EGASP demographic, behavioural and clinical variables were collected using a standardized questionnaire.

Results: From 437 male patients, 306 had positive N. gonorrhoeae cultures, AMR testing and complete epidemiological data. Resistance to ceftriaxone, cefixime, azithromycin and ciprofloxacin was 15.4%, 43.1%, 14.4% and 97.1%, respectively. Nineteen (6.2%) isolates were resistant to all four antimicrobials and, accordingly, categorized as XDR N. gonorrhoeae. These XDR isolates were collected from 7 of the 10 sentinel sites. No EGASP MIC alert values for gentamicin were reported. The nationally recommended cefixime 400 mg plus azithromycin 1 g (65.4%) or ceftriaxone 1 g plus azithromycin 1 g (34.6%) was used for treatment.

Conclusions: A high prevalence of ceftriaxone-resistant, MDR and XDR N. gonorrhoeae in several cities of Cambodia were found during 2022-23 in WHO EGASP. This necessitates expanded N. gonorrhoeae AMR surveillance, revision of the nationally recommended gonorrhoea treatment, mandatory test of cure, enhanced sexual contact notification, and ultimately novel antimicrobials for the treatment of gonorrhoea.