Research Article: Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action

Date Published: July 7, 2017

Publisher: Public Library of Science

Author(s): Teodora Wi, Monica M. Lahra, Francis Ndowa, Manju Bala, Jo-Anne R. Dillon, Pilar Ramon-Pardo, Sergey R. Eremin, Gail Bolan, Magnus Unemo

Abstract: In a Policy Forum, Teodora Wi and colleagues discuss the challenges of antimicrobial resistance in gonococci.

Partial Text: Gonorrhea is a sexually transmitted infection (STI) caused by Neisseria gonorrhoeae (gonococcus), and it is a major public health priority globally. In 2012, the World Health Organization (WHO) estimated that there were 78 million cases among adults worldwide, including 35.2 million in the WHO Western Pacific Region, 11.4 million in the Southeast Asian Region, 11.4 million in the African Region, 11 million in the Region of the Americas, 4.7 million in the European Region, and 4.5 million in the Eastern Mediterranean Region [1]. According to the 2013 Global Burden of Disease Study, gonorrhea is responsible for 225,400 years lived with disability (YLD) per year and 313,900 disability-adjusted life years (DALYs) [2,3]. The complications of gonorrhea disproportionally affect women and include pelvic inflammatory disease, ectopic pregnancy, and infertility, as well as increased transmission and acquisition of HIV [4–6].

The WHO Global Gonococcal Antimicrobial Surveillance Programme (WHO GASP), a collaborative global network of regional and subregional reference laboratories, was initiated in 1990 to monitor gonococcal AMR worldwide [17]. WHO GASP data have since then informed revisions of global, regional, and national gonorrhea treatment guidelines, as well as public health strategies and policies developed by WHO and other organizations. WHO recommends that treatment guidelines are refined based on data from recent and quality-assured gonococcal AMR surveillance and that the use of an antimicrobial in empiric treatment is discontinued when the rates of therapeutic failures and/or AMR reach a level of 5% [5,18]. Since 2009, WHO has substantially strengthened the WHO GASP, which is coordinated by regional coordinating centers (“focal points”) (see S1 Table). To ensure quality-assured, valid, and comparable data among countries, regional focal points provide technical support and training in countries to strengthen laboratory capacities (e.g., for sample collection and transport, gonococcal culturing, preservations of strains, AMR testing), to conduct a GASP external quality assurance (EQA) program, and to curate, update, and distribute the WHO gonococcal reference strains for EQA and internal quality control (QC) [19,20]. The 2016 WHO reference strains can also be used for QC in phenotypic and molecular diagnostics, molecular AMR prediction, molecular epidemiology, and as fully characterized reference genomes in whole-genome sequencing analysis [20]. The WHO GASP works in close collaboration with other international and national quality-assured GASPs, including Euro-GASP [21,22], United States Gonococcal Isolate Surveillance Project (GISP; [23,24], Canadian GASP [25], Australian Gonococcal Surveillance Programme (AGSP) [26], and United Kingdom Gonococcal Resistance to Antimicrobials Surveillance Programme (UK GRASP) [27].

Gonococcal AMR is a major concern that threatens our ability to treat and control gonorrhea, and its complications and sequelae, globally. WHO GASP, in collaboration with other GASPs, monitors gonococcal AMR worldwide. However, GASPs need to be substantially strengthened, especially in many less-resourced settings in Eastern Europe, Central Asia, parts of Latin America (including the Caribbean), the WHO Eastern Mediterranean Region and the WHO African Region. Building national leadership and commitment—both political and financial—to address gonococcal AMR is essential. In general, there is a need for greater involvement and increasing country-level ownership through advocacy, capacity-building, strengthened communications, and linkages with broader interventions to control AMR. Efforts are underway to ensure that gonococcal AMR is addressed in the global AMR action plan [16] and in the global AMR research and development agenda. Approaches are also under development to monitor gonococcal AMR within the Global AMR Surveillance System (GLASS;, to conduct regular systematic reviews, and to update treatment guidelines more rapidly. Furthermore, work is ongoing internationally to improve the regulation of drugs and prescription policies and to increase awareness about the correct use of antimicrobials. At the national level, countries need to strengthen and support their gonococcal AMR surveillance programs in the context of national AMR programs. Countries in less-resourced settings should be supported technically and funded appropriately to develop and/or enhance their national GASP and ensure timely dissemination of data as a basis for the revision of treatment guidelines and public health action. Consistent national and international financial and political commitment is urgently needed.



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