Kristian Kofoed and Helle Kiellberg Larsen – Controversies and challenges in Venerology in Denmark
the Nordic countries. In 1995, only 15 cases of syphilis were reported in Denmark. However, in the past 20 years, a 50-fold increase, to 777 cases in 2015, has been observed( 4). The majority of those infected are men who have sex with men( 5). However, in recent years there has been a considerable increase among heterosexual men and women, and it seems that syphilis is being reintroduced in both sexes. Approximately one-third of infected men are HIV-positive. HIV and syphilis are a bad combination, as each can facilitate infection by the other( 5).
Penicillin remains the drug of choice to treat syphilis, and even though it has been used to treat the disease for many decades, we still have no issues with resistance to penicillin.
Gonorrhea
In contrast to syphilis, gonorrhoea has progressively developed resistance to the antibiotics prescribed to treat it. Following the spread of gonococcal fluoroquinolone resistance, the cephalosporin antibiotics have been the foundation of recommended treatment for gonorrhoea. The emergence of cephalosporin-resistant gonorrhoea would significantly complicate the ability of providers to treat gonorrhoea successfully, since we have few antibiotic options left that are simple, well-studied, well-tolerated and highly effective. Thus, it is disturbing that treatment failure to third-generation cephalosporin has been confirmed in Norway and Sweden( 6, 7). To our knowledge, so far, no cases have been reported in the other Nordic countries.
Since 2011 there has been an increase in Denmark in the number of cases of gonorrhoea, especially among heterosexuals. In 2015, 2,735 cases were reported, compared with only 492 in 2011( 8)( Fig. 1). Even though some of the increase may be due to change in the reporting system, the number is alarming. In 2015 the recommended treatment in Denmark was changed to intramuscular ceftriaxone, 500 mg, in combination with oral azithromycin, 2 g. Denmark never introduced cefixime as a treatment option. It is worth mentioning that, among the cases of gonorrhoea from 2015, 26 % of cases had a negative culture and were only detected by the nucleic acid amplification test( NAAT)( 8).
To conclude, we need to focus on the venereology part of our specialty, as the demand for our expertise is growing rapidly!
References
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2. Sandø N, Kofoed K, Zachariae C, Fouchard J. A reduced national incidence of anogenital warts in young Danish men and women after introduction of a national quadrivalent human papillomavirus vaccination programme for young women— an ecological study. Acta Derm Venereol 2014; 94: 288 – 292.
3. Knell RJ. Syphilis in renaissance Europe: rapid evolution of an introduced sexually transmitted disease? Proc Biol Sci 2004; 271 Suppl 4: S174 – S176. 4. Cowen S, Hofmann S. Syphilis 2015. Epi-Nyt 2016; Uge 36. 5. Kofoed K, Gerstoft J, Mathiesen LR, Benfield T. Syphilis and human immunodeficiency virus( HIV)-1 coinfection: influence on CD4 T-cell count, HIV-1 viral load, and treatment response. Sex Transm Dis 2006; 33: 143 – 148.
6. Unemo M, Golparian D, Syversen G, Vestrheim DF, Moi H. Two cases of verified clinical failures using internationally recommended first-line cefixime for gonorrhoea treatment, Norway, 2010. Euro Surveill 2010; 15( 47).
7. Golparian D, Ohlsson A, Janson H, Lidbrink P, Richtner T, Ekelund O, et al. Four treatment failures of pharyngeal gonorrhoea with ceftriaxone( 500 mg) or cefotaxime( 500 mg), Sweden, 2013 and 2014. Euro Surveill. 2014; 19( 30).
8. Cowan S, Espenhain L, Hoffmann S. Gonorré 2015. Epi-Nyt 2016; Uge 38.
9. Cowan S, Christiansen AH, Hoffmann S. Gonoré 2014. Epi-Nyt
2015; Uge 40. 10. Cowan S, Hoffmann S. Gonoré 2013. Epi-Nyt 2014; Uge 35. 11. Søborg B, Cowan S, Jensen JS. Gonoré 2012. Epi-Nyt 2013; Uge 35. 12. Søborg B, Cowan S, Hoffmann S. Gonoré 2011. Epi-Nyt 2012;
Uge 36.
3000
2011 2012 2013 2014 2015
2500
2000
1500
1000
500
0 Total DK Men DK Women DK Total BBH Men BBH Women BBH
Fig. 1. Number of cases of gonorrhoea in Denmark( DK) and the Venereal Clinic Bispebjerg Hospital( BBH) 2011 – 2015( missing data from 2011 and 2014 BBH)( 8 – 12). Since 2014, data has been extracted from the Danish Microbiology Database( MiBa)( 8).
88 Dermato-Venereology in the Nordic Countries
Forum for Nord Derm Ven 2016, Vol. 21, No. 4