Discussion

This is the first study describing the antimicrobials recommended for gonorrhoea treatment in 11 East European countries. In all countries, ceftriaxone (250–1000 mg, IM×1) was recommended as first-line, which is appropriate also in a global perspective.3 However, certainly not all, especially not private physicians, strictly adhere to these public sector recommendations. Accordingly, the present survey cannot inform on the antimicrobials actually administered to all gonorrhoea patients in clinical practice. Further studies are in progress to determine what is actually being used in both public and private clinics. In general, it would be valuable to monitor and regulate the type of antimicrobials used, the amount of the different antimicrobials, the manufacturers of the antimicrobials and the quality of the antimicrobials in all these countries. As second-line, spectinomycin was predominantly recommended. Spectinomycin is effective, and resistance is rare worldwide.3 However, resistance may emerge rapidly and has recently been reported in Russia.3 9 Five countries reported using Trobicin; however, in 2005, Pfizer discontinued this production. In many countries, the recommendations of second-line and alternative treatments were suboptimal. Based on AMR data from Russia,9 and worldwide,3 many of these antimicrobials should not be used in empirical gonorrhoea treatment.

In most countries, antimicrobials manufactured nationally, regionally or in India, for example, were predominantly used, because of the higher costs of antimicrobials from internationally recognised companies. Some countries even mentioned treatment failures using regionally manufactured ceftriaxone, which presumably reflects suboptimal quality of the antimicrobial; however, this is crucial to confirm. In settings, such as most East European countries, where antimicrobials are easily available, and the quality of antimicrobials may be suboptimal, there is a substantially increased risk for emergence and rapid spread of gonococcal AMR and gonorrhoea.3

As the WHO has stated, to avoid making gonorrhoea untreatable under certain circumstances, global initiatives integrating disease control and AMR containment are urgently needed.3 The overuse and misuse of antimicrobials, including using antimicrobials of suboptimal quality, especially in settings where the disease control is insufficient, rapidly increase the AMR.3 The WHO initiatives include enhanced global, quality-assured and quality-controlled, AMR surveillance, which is crucial for public health.3 8 Valid AMR data are exceedingly scarce in many regions, including Eastern Europe beyond Russia.9 Accordingly, implementation of local, national and international gonococcal AMR surveillance in the other East European countries is crucial; to provide evidence-based data, regarding antimicrobials used for treatment, for regular and timely updating of STI management and treatment guidelines, to identify emerging resistance and to assist in the prevention, control and containment of gonococcal AMR and gonorrhoea.3 4

In conclusion, this study ascertained the recommendations for antimicrobial treatment of gonorrhoea in 11 East European countries. Ceftriaxone (250–1000 mg) was a first-line antimicrobial in all the countries, which is an appropriate choice also in a global perspective. However, the adherence, especially among private physicians, to these public sector recommendations is questionable. This is valuable information for implementing an international gonococcal AMR surveillance programme in this region, based on WHO protocols,3 8 10 which is crucial for informing STI management and treatment guidelines for gonorrhoea and, accordingly, for public health.