Antimicrobial resistance in sexually transmitted infections

Rationale for review International travel facilitates the spread of drug-resistant infections, including sexually transmitted infections (STIs). In 2016, the World Health Organization highlighted the global burden of 'curable' STIs, estimating 376 million new infections of gonorrhoea, chlamydia, syphilis and trichomoniasis annually, with considerable geographic variation in both the burden of disease and prevalence of resistance. Travelers' risk of contracting and transmitting drug-resistant STIs depends in part on their geographic exposure. In this review, we describe the epidemiology of antimicrobial resistance (AMR) and the management of these four common STIs and Mycoplasma genitalium, an increasingly recognized cause of non-gonococcal urethritis. Key findings Multi-drug and extensively drug resistant gonorrhoea strains have been associated with international spread, particularly in travelers returning from Southeast Asia. Chlamydia is the most common bacterial STI worldwide. Although in vitro resistance has been reported, surveillance data suggest that clinically significant resistance to macrolides and tetracyclines is rare. Macrolide resistance in syphilis is now endemic in much of the world but there is no documented penicillin resistance, which remains first-line therapy. Trichomoniasis is the most common non-viral STI worldwide. Although clinical failure after treatment occurs, resistance to metronidazole is thought to be uncommon. Mycoplasma genitalium exhibits intrinsic resistance to many antibiotics, and the prevalence of resistance to both first- and second-line regimens (macrolides and fluoroquinolones) is increasing worldwide, with limited alternative therapeutic options. Recommendations International travelers are at risk for acquiring resistant STIs with limited therapeutic options. Improved diagnostics are urgently needed to improve AMR surveillance and the management of infected patients. As no vaccinations are currently available for these STIs, and pre-exposure prophylaxis is an area of active study with limited data, condom use is critical for prevention. Travel medicine providers should incorporate STI risk reduction counselling, with an emphasis on condom use, into the routine pre-travel consultation.