National surveillance of Neisseria gonorrhoeae antimicrobial susceptibility and epidemiological data of gonorrhoea patients across Brazil, 2018–20
Authors: Machado Hanalydia de Melo , Martins Jéssica Motta , Schörner Marcos André , Gaspar Pamela Cristina , Bigolin Alisson , Ramos Mauro Cunha , Ferreira Willian Antunes , Pereira Gerson Fernando Mendes , Miranda Angélica Espinosa , Unemo Magnus , Bazzo Maria Luiza ,   Brazilian-GASP Network, de Carvalho Simone Veloso Faria , Costa Maria Rita Rabelo , Dias Luciane Guimarães , Porto Elly Rodrigo , da Fonseca Andrade Lidiane , de Castro e Caldo Lima Glaura Regina , Lozano Viviane Furlan , Bazzo Maria Luiza , de Rocco Felipe , Barazzetti Fernando Hartmann , Kerber Guilherme , de Melo Machado Hanalydia , Martins Jéssica Motta , Buss Ketlyn , Scheffer Mara Cristina , Schörner Marcos André , Zonta Ronaldo , Ramos Mauro Cunha , Nicola Maria Rita Castilhos , Cecconi Maria Cristina , de Noronha Barbara Suely Souza , Santos Cleiby Andrade dos , Lopes Francinete Motta , de Souza Gomes Jairo , Saif Jamile Izan Lopes Palhesta Júnior; Paulo Tadeu Cavalcante , Ferreira Willian Antunes , Freire Miralba , Ramos André , Carvalho Felipe Nogueira M. , Politano Aida , da Silva Roberto José Carvalho , de Araújo; Claudio Campos do Porto Sandra , Bocalon Roberta Alessandra Lima , de Oliveira Machado de Souza Ursula , Mialski Rafael , da Silva Nogueira Keite , Bay Mônica Baumgardt , do Monte Alves Manoella , Campos Juliana Cintra , Junior Luíz Fernando Aires , de Oliveira Camargo Larissa , de Souza Neves Lis Aparecida , Paes Ana Paula Luchetta , Barufaldi Felipe , Reis Henrique Dib Oliveira , Rocha Luiz Sérgio D’Oliveira , Ribeiro Marta Inês Cazentini , da Silva Paulo , Amaral Fabiana Rezende , de Figueiroa François José , Barbosa Anesia Maria Siqueira , Araujo Ana Albertina , Varejão Maria Goretti , de França Mendes Fernanda Garnier , Cavalcanti Valdelucia Oliveira , Ribeiro Paulo Gabriel Lima , Ishigami Bruno , Caheté Lucas , Zoccoli Cássia Maria 
Published: July 2022

Abstract

Objectives
To (i) describe the nationwide antimicrobial susceptibility of Neisseria gonorrhoeae (NG) isolates cultured across Brazil in 2018–20 and compare it with NG antimicrobial resistance data from 2015–16, and (ii) present epidemiological data of the corresponding gonorrhoea patients in 2018–20.

Methods
Twelve representative sentinel sites cultured NG isolates from men with urethral discharge. Susceptibility to eight antimicrobials was examined using agar dilution method, according to WHO standards. The consenting participants were invited to provide epidemiological data.

Results
In total, 633 NG isolates (one isolate per participant) were analysed, and 449 (70.9%) questionnaires were answered. Heterosexual (68.2%) and homosexual (23.1%) sexual orientations were common, and most prevalent types of unprotected sexual intercourse were vaginal insertive (69.9%), oral giving (56.6%) and anal insertive (47.4%). The levels of in vitro NG resistance to ciprofloxacin, tetracycline, benzylpenicillin, azithromycin, cefixime, gentamicin, spectinomycin and ceftriaxone were 67.3%, 40.0%, 25.7%, 10.6%, 0.3%, 0%, 0% and 0%, respectively. Compliance with the recommended first-line ceftriaxone 500 mg plus azithromycin 1 g therapy was high (90.9%).

Conclusions
Compared with 2015–16, ciprofloxacin resistance has remained high and azithromycin and cefixime resistance rates have increased in Brazil. Resistance remained lacking to ceftriaxone, gentamicin and spectinomycin, which all are gonorrhoea treatment options. The increasing azithromycin resistance in Brazil and internationally may threaten the future use of azithromycin in dual regimens for treatment of gonorrhoea. Consequently, continued and enhanced quality-assured surveillance of gonococcal AMR, and ideally also treatment failures and including WGS, is imperative in Brazil and worldwide.