JMIR Publications

ABSTRACT

Background:

Neisseria gonorrhea has developed resistance to all first-line therapy in Southeast Asia. East Africa has historically had absent or rudimentary gonorrhea surveillance programs and, while documented, the extent of antimicrobial resistant - gonorrhea is largely unknown. In 2016, the World Health Organization (WHO) Enhanced Gonococcal Antimicrobial Surveillance Program (EGASP) was initiated in Uganda to monitor resistance trends.

Objective:

This study describes patterns of gonorrhea, associations, and resistance patterns in a large surveillance program of men with urethral discharge syndrome from Kampala, Uganda.

Methods:

Men attending sentinel clinics with urethritis provided demographic and behavioral data and a urethral swab in line with WHO-EGASP for culture, identification and antibiotic sensitivity testing (disk diffusion; Etest). A subset underwent more detailed antimicrobial resistance testing.

Results:

Of 639 samples collected (09/2016-02/2018), 414 had microscopic evidence of gonorrhea, 400 (76.4%) were culture-positive. Mean age was 26.9 years and 7.2% of the total reported having HIV. There was high-level (>90%) resistance to ciprofloxacin, tetracycline and penicillin by Kirby-Bauer disk diffusion and 2.1% had reduced azithromycin sensitivity by Etest. Of the 116 early isolates that underwent detailed characterization, 70 (60.3%) were culture-positive, 66 (94%) isolates were ciprofloxacin-resistant or -intermediate by E-test, 96% (65/68) were azithromycin-, and 96% (66/69) gentamicin-sensitive. Resistance profiles were comparable between methods except Ceftriaxone (97% and 99% sensitive) and Gentamicin (25% and 96% sensitive) by disk diffusion and Etest respectively.

Conclusions:

This is the first report from a systematic gonorrhea surveillance program in Uganda. It demonstrates resistance/increased minimum inhibitory concentration to all key anti-gonococcal antibiotics. There was evidence of poor antibiotic stewardship, near-universal resistance to several antibiotics and emerging resistance to others. The population sampled were at exceptionally high risk of STI and HIV infection requiring intervention. Ongoing surveillance efforts to develop interventions to curtail antimicrobial resistant-gonorrhea are needed.