ORIGINAL STUDY Changing Figures of Antimicrobial Susceptibility and Serovar Distribution in Neisseria gonorrhoeae Isolated in Greece Eva Tzelepi, PHD,* Helen Avgerinou, MD,† Alexandros Flemetakis, MD,† Eirini Siatravani, BSc,*† Maria Stathi, PHD,* Maria Daniilidou, MD,‡ and Vivi Miriagou, PHD* Objectives: To update surveillance data on antimicrobial suscepti- bility of Neisseria gonorrhoeae isolated in Greece with information for the years 2005 to 2008, and analyze changes occurred from the previ- ous 4-year period. Methods: Annual antimicrobial susceptibility rates, susceptibility patterns, and serovars of 635 gonococci isolated in 2005 to 2008 were determined and compared to respective data concerning the gonococcal sample of 2001 to 2004. Genetic similarity of the isolates in phenotypic clusters was investigated by pulsed field gel electrophoresis. Epidemi- ologic information was also considered. Results: Despite a reduction in the isolation frequency of penicilli- nase-producing strains (3.9% vs. 11.6% in the previous period), the rates of resistance and intermediate susceptibility increased for peni- cillin, as well as for tetracycline, erythromycin, and chloramphenicol, leaving very small proportions of isolates sensitive to these agents (4.3%, 12.8%, 10.2%, and 3.6%, respectively). Resistance to fluoro- quinolones increased from 11.3% in 2004 up to 63% in 2008, and strongly correlated with multidrug-resistant isolates of Bropyst serovar, accounting for 72.6% of the quinolone-resistant strains isolated during the last 4 years. All isolates were susceptible to spectinomycin and only 2 exceeded susceptibility breakpoints set for cefotaxime, exhibiting MICs 0.75 to 1g/mL. These latter isolates, however, belonged to a cluster of strains with decreased susceptibility to cephalosporins (CDS, cefotaxime MICs 0.25 g/mL) that emerged in late 2006 and in- creased in frequency up to 20.7% through 2008. Notably, CDS isolates were also quinolone-resistant and multiresistant, further contributing to the increasing rates of quinolone and multidrug resistance in the Greek gonococcal sample. Conclusions: Antimicrobial susceptibility figures of Neisseria gon- orrhoeae in Greece are worsening due to changes in the synthesis of gonococcal population, resulting from high endemicity rates of multi- drug-resistant strains. N eisseria gonorrhoeae, due to its genetic properties, readily acquires and develops resistance to antibiotics and rapidly changes phenotypic and genotypic determinants used as mark- ers for the recognition and follow-up of particular resistant strains. Accordingly, antimicrobial susceptibility rates, essen- tially driven by strain types prevailing in a given gonococcal population, vary widely depending on time and geographical location. 1,2 As a consequence, continuous surveillance of N. gon- orrhoeae susceptibility to antimicrobials in national and interna- tional level is of great importance for prompt and successful choice of gonorrhea treatment regimens. 2,3 Typing of gonococcal isolates and epidemiologic data for the patients enhances this surveillance by providing information for resistant strains and the routes of their dissemination in the community. 4 Gonorrhea therapy policies followed in Greece are not uniform, depending on different hospital’s directives and pri- vate practitioners’ awareness. In this respect, the attainment of national and local data on gonococcal susceptibility trends of N. gonorrhoeae is crucial in guiding gonorrhea management. In a previous study of the National Reference Center for N. gonorrhoeae (NRCNG), antimicrobial susceptibility rates were reported for gonococci isolated in Greece up to 2004, while in a more recent publication we have reported on the emergence, in North Greece, of a cluster of quinolone-resistant (QRNG) strains that exhibited also decreased susceptibility to the newer cephalosporins. 5,6 In the current study, aiming to update surveillance data on antimicrobial susceptibility of our gonococcal population with information for the years 2005 to 2008, we confronted considerable changes that we tried to explore by a comparative consideration of antibiotic susceptibility patterns and serovars of gonococci circulating in the Greek community during this and the previous 4-year period. MATERIALS AND METHODS Neisseria gonorrhoeae Isolates A total of 635 gonococci submitted to the NRCNG from January 2005 through December 2008 were characterized by antibiotic susceptibility and serovar and the results were com- From the *National Reference Center for Neisseria gonorrhoeae, Lab- oratory of Bacteriology, Hellenic Pasteur Institute, Athens, Greece; †Microbiology Laboratory of the “Andreas Sygros” Hospital for Skin and Venereal Diseases, Athens, Greece; and ‡Laboratory of Microbiology, Venereal and Skin Diseases Hospital of Thessal- oniki, Thessaloniki, Greece The authors thank the following for their contribution to gonorrhea surveillance: Olga Paniara and Athena Argyropoulou (“Evangelis- mos” General Hospital, Athens), Evangelos Papafrangas and Maria Martsoukou (“Sismanogleion” General Hospital, Athens), Alkivia- dis Vatopoulos (National School of Public Health), Lucia Zerva (“Attikon” Hospital, Athens), Dimitra Gianneli (Microbiology Lab- oratory, “Tzanion” General Hospital, Piraeus), Efthimia Pavlidou (Venereal and Skin Diseases Hospital of Thesaloniki, North Greece), and Martha Dionyssopoulou (General Hospital of Sparta, South Greece). Supported by Greek Ministry of Health and the Hellenic Pasteur Institute. Correspondence: Eva Tzelepi, PHD, National Reference Center for N. gonorrhoeae, Laboratory of Bacteriology, Hellenic Pasteur Institute, Vas. Sofias 127, 11521-Athens, Greece. E-mail: tzelepi@pasteur.gr. Received for publication 1 June, 2009, and accepted 17 August, 2009. DOI: 10.1097/OLQ.0b013e3181bcd0b8 Copyright © 2010 American Sexually Transmitted Diseases Association All rights reserved. Sexually Transmitted Diseases ● Volume 37, Number 2, February 2010 115