Detection of Azithromycin Resistance in Neisseria Gonorrhoeae, Chlamydia Trachomatis and Mycoplasma Genitalium Among Symptomatic Women Attending Two Hospitals in Busia County, Kenya

Abstract

Background Neisseria gonorrhoeae and Chlamydia trachomatis are among the most prevalent organisms responsible for reproductive tract infections in both men and women, according to the World Health Organization (WHO). Mycoplasma genitalium is also being implicated as a cause more frequently. Several high-risk populations exist in Busia County and there have been increased reports of persistent sexually transmitted infections (STIs) in recent years. Women appear to be affected by these STIs more than men and are mostly asymptomatic which delays treatment. Health complications could arise if therapy is postponed. Treatment may become more challenging if the STIs become coinfected with one another. Sexually transmitted infections can raise the possibility of contracting and spreading the human immunodeficiency virus (HIV). The treatment of infections is increasingly threatened by the rising instances of antimicrobial resistance (AMR) to azithromycin. Objectives The study was carried out to determine the prevalence of three sexually transmitted infections: N. gonorrhoeae, C. trachomatis and M. genitalium, the prevalence of coinfections among the STIs, and to detect resistance markers involved in azithromycin resistance among symptomatic women attending Busia County referral hospital and Khunyangu sub county hospital in Busia County, Kenya. Methods Sexually active women of reproductive age attending STI, family planning and outpatient clinics in the two hospitals in Busia County were enrolled conveniently in this cross-sectional study. Endocervical swabs were collected from 424 women who presented with symptoms of sexually transmitted infections. Detection of the STIs was done using multiplex polymerase chain reaction. Amplification was then performed to detect resistant markers on the mtrR and 23S rRNA genes. The amplicons were then purified followed by Sanger sequencing and analyzed to detect point mutations. Results Among the symptomatic women, 23.6% had at least one sexually transmitted infection with prevalence as follows: N. gonorrhoeae (NG) at 17.7%, C. trachomatis (CT) at 6.8%, and xv M. genitalium (MG) infection at 4%. The rates for coinfection were as follows: CT/NG at 2.1%, NG/MG at 1.9%, CT/MG at 1.7% and CT/NG/MG at 0.7%. None of the most commonly reported mutations were found for the 23S rRNA gene (A2058G and A2059G) or the mtrR gene (H105Y, A39T and G45D). Novel mutations that have not been previously reported or associated with resistance were found in this study. The most prevalent mutations were: P101A, H102Yand S110N for N. gonorrhoeae, G1987T (Escherichia. coli numbering) for C. trachomatis and G2010T (E. coli numbering) for M. genitalium. Conclusion There was a high prevalence of sexually transmitted infections among symptomatic women attending the two hospitals (23.6%). Markers for resistance that have not being previously reported were present and most of them were responsible for amino acid changes. There is a need for screening, surveillance, and treatment programs owing to the high prevalence of STIs in the study population. Antimicrobial susceptibility testing is needed to establish whether the reported mutations are associated with reduced azithromycin efficacy. Further surveillance and studies to investigate other mechanisms of azithromycin resistance should also be considered.