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Original article
Antimicrobial resistance in Neisseria gonorrhoeae isolates from foreign-born population in the European Gonococcal Antimicrobial Surveillance Programme
  1. Cristina Hernando Rovirola1,2,
  2. Gianfranco Spiteri3,
  3. Meritxell Sabidó4,5,
  4. Alexandra Montoliu2,6,
  5. Victoria Gonzalez2,7,
  6. Jordi Casabona2,5,6,8,
  7. Michelle Jayne Cole9,
  8. Teymur Noori3,
  9. Magnus Unemo10
  1. 1PhD on Preventive Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
  2. 2Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Agència de Salut Publica de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain
  3. 3European Centre for Disease Prevention and Control, Stockholm, Sweden
  4. 4TransLab, Medical Science Department, Universitat de Girona, Girona, Spain
  5. 5CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
  6. 6Health Sciences Research Institute of the Germans Trias i Pujol Foundation (IGTP), Badalona, Spain
  7. 7Laboratory of Microbiology, Germans Trias i Pujol Hospital (HGTiP), Badalona, Spain
  8. 8Department of Pediatrics, Obstetrics and Gynecology, and Preventive Medicine, Universitat Autònoma de Barcelona, Badalona, Spain
  9. 9National Infection Service, Public Health England, London, UK
  10. 10WHO Collaborating Centre for Gonorrhoea and other STIs, Örebro University, Örebro, Sweden
  1. Correspondence to Dr Magnus Unemo, Department of Laboratory Medicine, Örebro University, Örebro SE-701 85, Sweden; magnus.unemo{at}


Objectives International spread has contributed substantially to the high prevalence of antimicrobial resistant (AMR) Neisseria gonorrhoeae infections worldwide. We compared the prevalence of AMR gonococcal isolates among native persons to foreign-born (reporting country different from country of birth) persons, and describe the epidemiological and clinical characteristics of foreign-born patients and their associations to AMR.

Methods We analysed isolates and patient data reported to the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP) 2010–2014 (n=9529).

Results Forty-three per cent of isolates had known country of birth and 17.2% of these were from persons born abroad. Almost 50% of foreign-born were from the WHO European Region (13.1% from non-European Union [EU] and the European Economic Area [EEA] countries). Compared with isolates from natives, isolates from foreign-born had a similar level (p>0.05) of azithromycin resistance (7.5% vs 7.2%), ciprofloxacin resistance (50.0% vs 46.3%) and of decreased susceptibility to ceftriaxone (1.9% vs 2.8%); a lower rate of cefixime resistance (5.7% vs 3.6%, p=0.02), and a higher proportion of isolates producing penicillinase (8.4% vs 11.7%, p=0.02). Among isolates from persons born outside EU/EEA, the level of decreased susceptibility to ceftriaxone was higher (1.8% vs 3.5%, p=0.02), particularly in those from the WHO Eastern Mediterranean Region and non-EU/EEA WHO European countries (1.9% vs 9.6% and 8.7%, respectively, p<0.01). In multivariable analysis, foreign-born patients with AMR isolates were more likely to be from non-EU/EEA WHO European countries (adjusted OR [aOR]: 3.2, 95% CI 1.8 to 5.8), WHO Eastern Mediterranean countries (aOR: 1.8, 95% CI 1.1 to 3.3) and heterosexual males (aOR: 1.8, 95% CI 1.2 to 2.7).

Conclusions Importation of AMR strains remains an important threat in the EU/EEA. Research to improve understanding of sexual networks within foreign born and sexual tourism populations could help to inform effective tailor-made interventions. The Euro-GASP demonstrates the public health value of quality-assured surveillance of gonococcal AMR and the need for strengthened AMR surveillance, particularly in the non-EU/EEA WHO European Region.

  • gonorrhoea
  • treatment
  • ceftriaxone
  • antimicrobial resistance
  • surveillance
  • Euro-GASP
  • Europe
  • migrants

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  • Handling editor Catherine A Ison

  • Contributors CHR, GS and TN designed, initiated and coordinated the study. Euro-GASP network members coordinated and performed the laboratory analyses. Patient data was supplied by the Euro-GASP network members. CHR, GS, AM, VG, MJC and MU analysed and interpreted all the data, and wrote a first draft of the paper. MS and JC critically read and commented on the manuscript. All authors read, commented and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All relevant data are included in the manuscript or in the supplementary file.

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