Background: N. gonorrhoeae and M. genitalium infections remain public health concern due to emerging antimicrobial resistance which compromise effective treatment and infection prevention and control. Objective: To estimate the prevalence for N. gonorrhoeae and M. genitalium infections and identify demographic and sexual behavioral risk factors in Bulgarian population of reproductive age from Sofia municipality. Material and methods: Participants were sexually active 443 men and 198 women aged 18-49 years. They answered questionnaires on sexual behavior and provided samples for N. gonorrhoeae and M. genitalium testing. Results: The prevalence of N. gonorrhoeae infection was 3.28% (21/641) and with M. genitalium infection it was 2.49% (16/641). For both infections the presence of urogenital symptoms was associated with greater risk of being infected. Among gonococcal infections an increased number of lifetime partners and partners during the last 6 months, previously diagnosed STIs and use of contraception other than condoms were associated risk factors. Conclusions: The prevalence of N. gonorrhoeae and M. genitalium infections in Bulgarian population of reproductive age from Sofia municipality was relatively low but due to significant disease burden data on prevalence and identified risk factors should help the development of future control strategies.

Introduction: Mycoplasma genitalium is an established cause of sexually transmitted infections in men and women. Current guidelines recommend azithromycin and moxifloxacin as first- and second-line treatment, respectively. However, azithromycin treatment failure has been increasingly reported. The aim of this study was to determine the efficacy of azithromycin and alternative antibiotic regimens in a prospective cohort of M. genitalium-positive patients, and macrolide resistance mutations associated with azithromycin failure. Materials and methods: Consecutive eligible M. genitalium-positive patients attending the National Center of Infectious and Parasitic Diseases in Sofia, Bulgaria between 1 January 2018 and 31 December 2020 were treated with azithromycin and retested by polymerase chain reaction 21-28 days after completion of the treatment. Cure was defined as M. genitalium-negative result on the test of cure. Cases failing azithromycin were treated with moxifloxacin and retested another 21-28 days after treatment. Pre- and post-treatment samples were assessed for macrolide resistance mutations by conventional DNA sequencing. Results: Of 21 patients treated with azithromycin, 11 (52.4%) were cured. Pre- and post-treatment macrolide resistance mutations were detected in 10 (47.6%) patients, and all of them failed azithromycin. Moxifloxacin was effective in all cases failing azithromycin; and all were M. genitalium-negative at the test of cure after moxifloxacin treatment. Conclusions: In this study a high azithromycin failure rate (47.6%) in an M. genitalium-positive cohort in association with high levels of pretreatment macrolide resistance was reported. Moxifloxacin was highly effective in treating macrolide-resistant infections. These findings necessitate implementation of new diagnostic and therapeutic strategies such as sequential antimicrobial therapy for M. genitalium guided by a macrolide-resistance assay.

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Neisseria gonorrhoeae is evolving into a superbug with resistance to previously and currently recommended antimicrobials for treatment of gonorrhoea, which creates a significant public health concern globally. Antimicrobial resistance (AMR) poses a great threat; it causes longer duration of illness and treatment, and increases health care costs and the social, psychological and financial burden to families and societies. In response to this worrying situation laboratory research should be strengthened with implementation of newer molecular methods for monitoring and detecting AMR, and evaluation of the correlation of obtained genetic data with corresponding phenotypes. This study aimed to implement whole genome sequencing analysis for the first time of N. gonorrhoeae isolates from Bulgaria and to acquire molecular epidemiological and AMR information linked with phenotypic resistance data. Although the tested strains were susceptible to current recommended dual therapy, genetic analysis showed the presence of several mutations responsible for reducing susceptibility to third generation cephalosporins, namely the presence of genotype G1407 strains in the Bulgarian population. Regarding previously recommended antimicrobials, penicillin resistance and intermediate sensitivity to tetracyclines was demonstrated in all strains, and fluoroquinolone resistance in two strains. The obtained results showed that the use of whole genome sequencing was feasible, could describe current circulating gonococcal strains and predict and infer transmission of antimicrobial resistance. Therefore, gonococcal infections prevention and control programmes will be aided to target interventions where needed and to revise treatment guidelines that will help improve patient care.