Trends and regional variations of gonococcal antimicrobial resistance in the Netherlands, 2013 to 2019

Background: Gonococcal antimicrobial resistance is emerging worldwide and is monitored in the Netherlands in 18 of 24 Sexual Health Centres (SHC). Aim: To report trends, predictors and regional variation of gonococcal azithromycin resistance (AZI-R, minimum inhibitory concentration (MIC) ) 1 mg/L) and ceftriaxone decreased susceptibility (CEF-DS, MIC ) 0.032 mg/L) in 2013-2019. Methods: SHC reported data on indi-vidual characteristics, sexually transmitted infection diagnoses, and susceptibility testing (MIC, measured by Etest). We used multilevel logistic regression analy-sis to identify AZI-R/CEF-DS predictors, correcting for SHC region. Population differences' effect on regional variance of AZI-R and CEF-DS was assessed with a separate multilevel model. Results: The study included 13,172 isolates, predominantly (n = 9,751; 74%) from men who have sex with men (MSM). Between 2013 and 2019, annual proportions of AZI-R isolates appeared to increase from 2.8% (37/1,304) to 9.3% (210/2,264), while those of CEF-DS seemed to decrease from 7.0% (91/1,306) to 2.9% (65/2,276). Among SHC regions, 0.0-16.9% isolates were AZI-R and 0.0-7.0% CEF-DS; population characteristics could not explain regional variance. Pharyngeal strain origin and consultation year were significantly associated with AZI-R and CEF-DS for MSM, women, and heterosexual men. Among women and heterosexual men ??? 4 partners was associated with CEF-DS, and ??? 10 with AZI-R. Conclusions: No resist-ance or decreasing susceptibility was found for CEF, the first line gonorrhoea treatment in the Netherlands. Similar to trends worldwide, AZI-R appeared to increase. Regional differences between SHC support nationwide surveillance with regional-level reporting. The increased risk of resistance/decreased susceptibil-ity in pharyngeal strains underlines the importance of including extragenital infections in gonococcal resist-ance surveillance.