Neisseria gonorrhoeae, the bacterium responsible for the sexually transmitted infection Gonorrhea.

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The most recent findings in the European Union/European Economic Area (EU/EEA) for 2022 uncover patterns in antibiotic resistance among gonorrhoea isolates. This surge in resistance coincides with an uptick in confirmed gonorrhoea cases across 28 EU/EEA countries, reaching 70,881 cases in 2022. This marks a 48% surge from the previous year, indicating the highest notification rate recorded since the initiation of European STI surveillance in 2009.

Identified were 2 isolates displaying resistance to ceftriaxone, the primary antibiotic prescribed for gonorrhoea treatment. These strains demonstrated extensive drug resistance (XDR) and multidrug resistance (MDR), posing significant challenges in treatment selection.

In 2022, 23 European countries submitted a total of 4,396 isolates from patients diagnosed with gonorrhoea to the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP). The proportion of isolates resistant to azithromycin increased to 25.6%, up from 14.2% in 2021, a concerning trend considering azithromycin’s common use alongside ceftriaxone for treatment. Additionally, resistance to ciprofloxacin rose to 65.9% of isolates in 2022, compared to 62.8% in 2021. Despite resistance to cefixime remaining low at 0.3%, continuous monitoring is essential, particularly with the emergence of gonococcal strains resistant to cefixime and ceftriaxone.¹

Occurrence in the US

While most gonorrhoea infections in the EU/EEA are still treatable with current antibiotics, the upward trajectory in resistance underscores the urgent need for heightened vigilance. According to the United States CDC,

“The bacteria that cause gonorrhea has grown resistant to nearly every drug ever used to treat it. It’s only a matter of time until it becomes resistant to the last available cure. Gonorrhea is skilled at outsmarting the antibiotics that are used to kill it. For this reason, we must continuously monitor for resistance and encourage the research and development of new drugs for gonorrhea treatment.”³

A recent commentary in JAMA discussed the growing concerns around a Neisseria gonorrhoeae strain and the 18 bacteria and fungi on the CDC 2019 antibiotic resistance threats report, N gonorrhoea ranked among the highest tier “urgent threats.” And just last month, the WHO released its drug-resistant pathogens list, and included N gonorrhoea, third-generation cephalosporin- and/or fluoroquinolone-resistant as a high priority.

The JAMA commentator wrote, “The rise of multidrug-resistant gonorrhea strains with high-level resistance to ceftriaxone and azithromycin in addition to previously used first-line antibiotics has earned the name ‘super gonorrhea.’”

In terms of antibiotic development, the commentary mentions 2 investigational antimicrobials, gepotidacin and zoliflodacin, and their possible utility in a future armamentarium, if they are FDA approved.⁴

To address these concerns, the ECDC recommends intensified surveillance, expanded antimicrobial susceptibility surveillance to detect and monitor resistance patterns, and regular updates to treatment guidelines based on the latest surveillance data on antimicrobial resistance. They advocate for public health initiatives to prevent the spread of gonorrhoea, including enhanced access to diagnostic services and international cooperation to monitor and control the dissemination of resistant strains.²

References

1. European Centre for Disease Prevention and Control. Antimicrobial resistance in gonorrhoea: Rising threat to treatment efficacy. Stockholm: ECDC. Published June 10, 2024. Accessed June 12, 2024. https://www.ecdc.europa.eu/en/news-events/antimicrobial-resistance-gonorrhoea-rising-threat-treatment-efficacy

2. European Centre for Disease Prevention and Control. Gonococcal antimicrobial susceptibility surveillance in the European Union/European Economic Area, 2022. Stockholm: ECDC; Published June 10, 2024. Accessed June 12, 2024. https://www.ecdc.europa.eu/en/publications-data/gonococcal-antimicrobial-susceptibility-surveillance-eu-eea

3. CDC. Drug-Resistant Gonorrhea. Published April 2024. Accessed June 12, 2024. https://www.cdc.gov/gonorrhea/hcp/drug-resistant/

4. Parkinson J. ‘Super Gonorrhea’ is Evolving as a Greater Treatment Challenge. ContagionLive. Published June 4, 2024. Accessed June 12, 2024. https://www.contagionlive.com/view/-super-gonorrhea-is-evolving-as-a-greater-treatment-challenge