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Fluoroquinolone-Resistant Neisseria gonorrhoeae in Bali, Indonesia: 2004

Donegan, Elizabeth A. MD*; Wirawan, Dewa N. MD; Muliawan, P MD; Schachter, Julius PhD*; Moncada, Jeanne MT*; Parekh, Manhar MS; Knapp, Joan S. PhD

doi: 10.1097/

Objectives: In the mid-1990s, fluoroquinolones were introduced in Indonesia for the management of gonorrhea and are now part of the national recommended treatment guidelines. We recently documented introduction of ciprofloxacin-resistant Neisseria gonorrhoeae strains in female sex workers (FSWs) in Timika, Indonesia, 5 years after treating gonococcal cervicitis with ciprofloxacin and periodically monitoring antimicrobial susceptibility of isolates. To assess the importance of this observation, we determined antimicrobial susceptibilities and strain types of N. gonorrhoeae isolates from FSWs seen in a sexually transmitted infection (STI) clinic in Denpasar, Bali, Indonesia.

Goal: The goal of this study was to determine antimicrobial susceptibilities and strain types among N. gonorrhoeae isolated from FSWs in Denpasar, Bali.

Study Design: FSWs in Denpasar were screened for N. gonorrhoeae by standard culture. Endocervical isolates were frozen in Microbank tubes and sent to the University of California at San Francisco on dry ice. Antimicrobial susceptibility testing using a Clinical Laboratory Standards Institute-recommended agar dilution method was performed at the Centers for Disease Control and Prevention. Isolates were characterized by β-lactamase production, antimicrobial resistance phenotypes, and auxotype/serovar class.

Results: One hundred forty-seven N. gonorrhoeae isolates were characterized. All isolates were highly resistant to tetracycline (minimum inhibitory concentration, ≥16.0 μg/mL): 117 (79.1%) were β-lactamase-positive (PP-TR), 3 (2.0%) exhibited chromosomally mediated resistance to penicillin (PenR-TRNG), and 27 (18.2%) were susceptible to penicillin (TRNG). All isolates were susceptible to ceftriaxone, cefixime, and spectinomycin; lack of interpretive criteria do not allow interpretation of susceptibilities of cefoxitin, cefpodoxime, or azithromycin. Fifty-nine (40.1%) isolates were ciprofloxacin-resistant; 35 (59.3%) of the ciprofloxacin-resistant isolates exhibited high-level resistance to ciprofloxacin (Cip-HLR; minimum inhibitory concentration, ≥4.0 μg/mL of ciprofloxacin). Three (2.0%) isolates were intermediate to ciprofloxacin. Twenty-two strain types were identified among these isolates; small clusters were identified with 3 strain types.

Conclusions: N. gonorrhoeae isolates from FSWs in Denpasar were resistant to penicillin and tetracycline; 40.1% of the isolates were fluoroquinolone-resistant. With gonorrhea prevalence of 35% at this clinic (by nucleic acid amplified tests), ongoing surveillance for antimicrobial resistance will be needed to appropriately choose treatment for infections caused by these resistant organisms.

Neisseria gonorrhoeae isolates collected in 2004 from female sex workers in Denpasar, Bali, were characterized by antimicrobial susceptibility patterns and strain typing. Ciprofloxacin resistance was high (40.1%) and found in many strains.

From the *University of California, San Francisco, California; the †Kerti Praja Foundation, Denpasar, Bali, Indonesia; and the ‡Centers for Disease Control and Prevention, Atlanta, Georgia

Correspondence: Elizabeth A. Donegan, MD, Department of Anesthesia, C-450, Box 0648, University of California San Francisco, San Francisco, CA 94143. E-mail:

Received for publication October 25, 2005, and accepted February 3, 2006.

© Copyright 2006 American Sexually Transmitted Diseases Association