The prevalence of gonococcus in this study was relatively higher than other studies conducted in Ethiopia (12,13,14). The difference might be due to the nature of participants in the current study that all of them were males. The general notion is that naturally, males tend to be more symptomatic for gonococcal infection and hence can have increased level of health care seeking behavior which in turn make them more represented in the statistics (15).
In sub-Saharan Africa, gonococcal treatment practice is based on syndromic approach using single dose fluoroquinolone treatment. It is hypothesized that resistance to fluoroquinolones is low in Africa, but there has been limited systematic data collection and analysis to verify this notion. A multicounty antimicrobial resistance study on gonococcal strains isolated in 2004-2006, indicated low rates of fluoroquinolone resistance with 0% ,1.3and 4.0% in Central African Republic, Cameroon, and Madagascar, respectively (16). Similarly, study conducted in a Maputo and Mozambique, in 2005, suggested that there was no resistance to fluoroquinolone by gonococcal isolates (17).
In contrast, the findings from several other countries in sub-Saharan Africa suggested increasing levels of fluoroquinolone resistance in gonococcal isolates. According to a study done in South Africa, in 2004, 7% of the gonococcal isolates from Pretoria region, 8% from Western Cape and 17% from Johannesburg were found to be resistant to antibiotics from the class of fluoroquinolone. In addition, another study conducted in same country and the same study populations, in 2007, indicated that; 27% of the gonococcal isolates from Cape Town and 32% from Johannesburg isolates were found to be resistant to ciprofloxacin (18). This represents 2.9 fold and 1.9 fold increases, respectively within a 3-year time period. Similarly, a 2-year prospective study carried out among STI patients, from 2004 to 2006, in Johannesburg indicated an increase in ciprofloxacin resistance from 13% in the first year to 26.3% in the second year (19). Study conducted in Kenya and Uganda also showed that gonococcal resistance level to fluoroquinolone has reached up to 53% and 83%, respectively (20,21).
The present study has revealed that N. gonorrhoeae isolates recovered from this study have shown high level of resistance to commonly prescribed fluoroquinolone class of antibiotics in Ethiopia. This finding is in agreement with other studies which reported a resistance level of 53% and 83% in the East African region Kenya and Uganda. Reports from South Africa also indicate that the resistance level reached up to 32% (19,20,21,22). High proportion of quinolone resistance in this study might be due to prior treatment using ciprofloxacin as indicated in table 4. Gonococcal syndromic treatment using oral fluoroquinolone has become very problematic due to the emergence of high proportion of resistant isolates as witnessed from the current study. Non-susceptibility to ceftriaxone was not detected in all of the isolates tested during the study period. This finding is not in agreement with other studies conducted in different part of Ethiopia (12, 13, 14 ). However, our finding was in agreement with other studies conducted elsewhere (23,24,25,26,27). This might be due to exposure of participants for specific group of antimicrobial agents during the study period. As indicated in figure-1, the existence of certain segment of isolate population with MIC value close to the cutoff point may mean that there are concerns over the possibility of minority non-susceptible bacterial population to potentially replacing the susceptible majority ones. Therefore, investigating the molecular mechanism of resistance in these group of isolates may be imperative to fully understand the epidemiology (26).
Penicillinase test was done by chromogenic test and almost more than half of the isolates were positive for beta lactamase. Table 2, Table 3.. Most of the isolates in the current study were resistant to Benzyl penicillin even though the antibiotic is not used for the national gonococcal treatment algorithm. This finding from our study was in line with other studies (24, 25,27, 28,29).
Formerly, the STI treatment practice in Ethiopia was based on the syndromic approach (treating individuals immediately for possible causes of STI syndromes based on symptom). However, because of the finding from this study, the national guideline for treatment has been changed. Besides this, the etiologic approach of diagnosis of gonorrhea is important at least for revisiting clients in order to identify non susceptible isolates for the current candidate of antimicrobial agents in practice.