Burden of Gonorrhea and Trends in Antibiotic Susceptibility Pattern of Neisseria gonorrhoea in Bhutan Over Four Years (2012-15)

Introduction: Gonorrhea is a worldwide public health problem. In Bhutan, the incidence of sexually transmitted infections increased from 12/10,000 in 2011 to 92/10,000 population in 2015. Disease burden and antibiotic resistance of Neisseria gonorrhoea have never been studied.

Aim: To study the burden of gonorrhea and trends in antibiotic susceptibility pattern of N. gonorrhoea in Bhutan.

Study Design: A descriptive, retrospective study.

Place of Study: The study was carried out in four large hospitals, the only hospitals with microbiology culture facilities in Bhutan; the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Eastern Regional Referral Hospital (ERRH), Central Regional Referral Hospital (CRRH), and Phuentsholing General Hospital (PGH).

Methods: Laboratory data of patients investigated for gonococcal urethritis in the four hospitals; over four years (2012-15) were analyzed. Laboratory processes involved microscopy by Gram stain and culture.

Results: A total of 1,858 samples were processed; JDWNRH (60.2%, 1,119), PGH (17.7%, 329), CRRH (11.5%, 214) and ERRH (10.6%, 196). Only 1.2% (22) was females. The commonest age group was 20-30 years. There was an increasing trend in the number of cases in all hospitals. Microscopically, Gram-negative diplococci were seen in 80.7% (1,499) of cases and N. gonorrhoea was isolated in 78.3% (1,173). Only 13.6% (3/22) were culture positive in females. Resistance against nalidixic acid, ciprofloxacin, penicillin, and tetracycline were >70% but against ceftriaxone (currently recommended antibiotic), azithromycin, spectinomycin and cefpodoxime were <5% (critical resistance level for recommended therapy).

Conclusion: The burden of gonorrhea increased over years but there were only a few female patients indicating poor adherence to ‘seek and treat partners’ advocated in treatment guidelines. Compliance with treatment guidelines warrants reinforcement. With ceftriaxone resistance of 0.2%, Bhutan can continue to use it as recommended therapy with ongoing, multi-site, resistance surveillance as resistances continue to emerge and spread worldwide. Such surveillance would provide early warning or evidence to base future changes in therapeutic choices.