Multi-drug resistant gonorrhoea - World Health Organization (WHO)

Overview

Gonorrhoea is a sexually transmitted infection (STI) that remains a major public health concern. WHO estimates that in 2020, there were 82.4 million [47.7 million-130.4 million] new cases infected among adolescents and adults aged 15–49 years worldwide, with a global incident rate of 19 (11–29) per 1000 women and 23 (10–43) per 1000 men. Most cases were in the WHO African Region and the Western Pacific Region.

Antimicrobial resistance (AMR) in Neisseria gonorrhoeae (N. gonorrhoeae) appeared soon after the antimicrobial medicines started to be used. This has continued to expand over the past 80 years, affecting medicines such as tetracyclines, macrolides (including azithromycin), sulphonamides and trimethoprim combinations and, more recently, quinolones. In many countries, ciprofloxacin resistance is exceedingly high, azithromycin resistance is increasing and resistance or decreased susceptibility to cefixime and ceftriaxone continue to emerge.

The extensively drug-resistant gonorrhoea with high-level resistance to the current recommended treatment for gonorrhoea (ceftriaxone and azithromycin) but also including resistance to penicillin, sulphonamides, tetracycline, fluoroquinolones and macrolides are called gonorrhoea superbugs or super gonorrhoea.

History

The first reported treatment failure with cefixime was in Japan. In the past decade, confirmed failure to cure gonorrhoea with ceftriaxone alone or combined with azithromycin or doxycyline was reported in Australia, France, Japan, Slovenia, Sweden and the United Kingdom of Great Britain and Northern Ireland. In 2016, the first global failure to cure pharyngeal gonorrhoea with dual therapy (ceftriaxone 500 mg plus azithromycin 1 gram) was confirmed in the United Kingdom. An international spreading ceftriaxone-resistant gonococcal strain has been reported in Denmark, France, Japan and United Kingdom. In 2018, the first global gonococcal strains with ceftriaxone resistance and high azithromycin resistance causing pharyngeal gonorrhoea was reported in the United Kingdom. There are increasing numbers of treatment failure cases being reported from United Kingdom, Austria and other countries.

All confirmed treatment failures except one recent case in the United Kingdom have been pharyngeal infections affecting the throat. The majority of infections in the pharynx are asymptomatic. Antimicrobial drugs don't penetrate the tissue well in that area, and the pharynx is also home to naturally occurring related bacteria of the Neisseria species that can contribute to drug resistance. Most data on this issue come from higher income countries; however, the majority of cases of gonorrhoea are in less resourced countries and areas. This suggests that reports of treatment failures and drug resistance in wealthier areas are only the tip of the global health burden. Surveillance data on antibiotic resistance and treatment failures from poorer countries are exceedingly scarce and need to be improved. High rates of antimicrobial resistance to penicillins, tetracyclines and quinolones have been known for a longer time, and these medicines are currently not recommended for the treatment of gonorrhoea in most countries around the world.

Causes

Resistance to so many treatment options, including penicillins, sulphonamides, tetracyclines, quinolones and macrolides (including azithromycin), as well as so-called last line options like cephalosporins, make N. gonorrhoeae a multidrug resistant organism.