More Countries Detect Hard-to-Treat Gonorrhoea
Geneva: The world may be entering one of the most precarious phases of the antimicrobial resistance era: a point at which gonorrhoea, a sexually transmitted infection, is becoming difficult—at times nearly impossible—to cure. New data from the World Health Organization (WHO)’s Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) today revealed rising resistance to the antibiotics that have long been used as the last reliable treatments for gonorrhoea.
Countries in every region are reporting upward trends, with particularly sharp increases in Asia, where health systems already face high caseloads and limited diagnostic capacity.
WHO officials say the evidence is unambiguous: without rapid, globally coordinated action, drug-resistant gonorrhoea will spread faster, reach more countries and become harder to manage. The agency’s update aligns with the findings of the EGASP technical report, which shows marked increases in resistance to ceftriaxone—the backbone of current treatment—in multiple countries between 2022 and 2023.
Surveillance from eight countries recorded rising non-susceptibility, with some of the largest increases documented in Thailand and the Philippines. Thailand reported that non-susceptible isolates reached 14% in 2023, while similar upward trends were noted in Viet Nam, the Philippines and China, which have been documenting high levels of resistance for several years. Resistance to cefixime, another key cephalosporin, also rose, with the Western Pacific Region showing particularly sharp increases across multiple settings.
The WHO notes that the patterns now emerging reflect both biological evolution and systemic vulnerabilities. Many countries continue to diagnose gonorrhoea based on symptoms alone, and empirical antibiotic use—especially ciprofloxacin—remains widespread. The consequences are visible in laboratory results: ciprofloxacin resistance now approaches or exceeds 95% in several settings, effectively rendering it unusable for treatment in most of the world. Although resistance to azithromycin remains relatively low in EGASP countries, the Western Pacific Region report shows that China faces an exceptionally high burden of azithromycin-resistant strains, underscoring the geographic unevenness of the threat.
Across the 12 countries that contributed to EGASP’s most recent reporting cycle—Brazil, Cambodia, India, Indonesia, Malawi, the Philippines, Qatar, South Africa, Sweden, Thailand, Uganda and Viet Nam—laboratories recorded 3615 confirmed gonorrhoea cases. More than half of all symptomatic male cases arose in the Western Pacific Region, with the Philippines, Viet Nam, Cambodia and Indonesia alone accounting for 52% of the total. The African Region followed with 28%, and South-East Asia contributed 13% of cases via Thailand. The typical patient was a young adult: the median age was 27, with cases ranging from early adolescence to old age. Behavioural indicators paint a picture of elevated transmission risks. Twenty per cent of reported cases involved men who have sex with men, and 42% of all patients had multiple sexual partners in the previous 30 days. Recent antibiotic use was reported by 8%, and 19% had travelled internationally—factors that facilitate both the selection and cross-border movement of resistant strains.
The WHO’s technical documents help explain why the pathogen has proved so adaptable. Neisseria gonorrhoeae evolves rapidly, acquires resistance genes efficiently and often circulates among networks where asymptomatic infections are common. Laboratory guidelines stress that intramuscular routes of treatment—once standard—no longer maintain adequate drug concentrations, reinforcing the need for careful dosing and updated protocols. The laboratory workflow detailed in the WHO reference manual highlights how surveillance requires coordination between clinics, microbiology labs and genomic sequencing centres, and why gaps in any part of this chain weaken the global response. Molecular typing, a key tool for tracking transmission and identifying emerging high-risk clones, is still limited outside better-resourced health systems, leaving surveillance blind spots in regions with the highest caseloads.
The consequences of under-detection extend beyond clinical uncertainty. Without routine susceptibility testing, clinicians often continue prescribing failing therapies. The WHO report shows that in several countries, ceftriaxone non-susceptibility has now passed thresholds that, in other pathogens, would trigger urgent policy shifts. Rising cefixime resistance adds further complexity. In the Western Pacific Region, cefixime-resistant and non-susceptible isolates have become more common, signalling that the dual-drug era that stabilised treatment a decade ago is coming under strain. Azithromycin—once part of combination therapy—cannot play the same role it did earlier, because resistance patterns are inconsistent and, in places such as China, alarmingly high.
Amid these challenges, the WHO emphasises that one of the most important developments of 2024 was the expansion of genomic surveillance. Nearly 3000 gonococcal samples were sequenced in eight countries, generating detailed insights into how resistant lineages spread, how clusters form and which strains are most likely to acquire new resistance mechanisms. This genomic work, led by WHO collaborating centres, also supported landmark studies on next-generation treatments such as zoliflodacin and gepotidacin. Both drugs have shown promise in clinical trials, with zoliflodacin in particular demonstrating activity against many strains resistant to existing antibiotics. These studies, along with research into tetracycline resistance and doxycycline-based prevention strategies (DoxyPEP), are expected to guide treatment algorithms in the coming years. The shift cannot come soon enough: countries are already reporting cases that push the limits of traditional therapy, and the availability of new oral treatments could be a decisive turning point.
Even as laboratories expand sequencing and clinical trials advance, the WHO warns that surveillance systems remain fragile. The EGASP platform, launched a decade ago to standardise global monitoring, added Brazil, Côte d’Ivoire and Qatar during the latest cycle, and India is preparing to begin data reporting in 2025 under its National AIDS and Sexually Transmitted Diseases Control Programme. Yet despite this progress, the WHO notes persistent gaps: incomplete reporting, under-sampling from women, limited data from extragenital sites, and resource constraints in several national programmes. Without sustained funding, surveillance programmes risk losing momentum at the very moment resistance is accelerating. The WHO urges governments to invest in national and regional surveillance networks, improve diagnostic access and integrate gonorrhoea testing into broader sexual health services.
The human dimension behind these numbers is often obscured by technical language. Gonorrhoea remains one of the most common sexually transmitted infections, and resistant strains do not always present differently from susceptible ones. Many patients seek treatment only after symptoms worsen, by which point they may have infected partners or developed complications. Others are treated with antibiotics that no longer work, prolonging symptoms and raising the risk of transmission. For women, untreated or inadequately treated infections can lead to pelvic inflammatory disease, infertility and chronic pain, outcomes that are seldom captured in surveillance datasets. For men, persistent urethral infection can cause painful inflammation, impaired reproductive health and increased vulnerability to other infections.
The WHO’s warning also raises broader questions about the global fight against antimicrobial resistance. Drug-resistant gonorrhoea spreads more quickly than many other resistant pathogens because of social factors—stigma, lack of routine screening, limited contact tracing—and biological ones, including the bacterium’s capacity for rapid genetic change. As with tuberculosis or malaria, resistance develops first where diagnostic and treatment systems are weakest. Yet unlike those diseases, gonorrhoea often circulates in populations where healthcare-seeking behaviour is inconsistent, making surveillance difficult and treatment unpredictable. The pathogen thrives in these gaps, evolving each time an antibiotic is used without laboratory confirmation of susceptibility.
Global travel accelerates the problem. The WHO report notes that nearly one-fifth of recent cases involved international travel, underscoring how easily resistant strains cross borders. Countries that conduct stronger surveillance often detect resistant isolates earlier, not because they have higher transmission, but because they look more closely. Conversely, settings where surveillance is limited may harbour resistant strains for years before they appear in official records. This uneven detection pattern complicates global mapping and makes it difficult to distinguish where resistance is emerging from where it is merely unnoticed.
Against this backdrop, the WHO’s message for World Antimicrobial Resistance Awareness Week is stark. The rise of resistance to ceftriaxone, cefixime and other key antibiotics demonstrates that the world cannot rely indefinitely on existing treatments. Surveillance must expand, diagnostics must improve and new therapies must be made accessible—not only to wealthier countries but also to those regions bearing the highest burden of disease. The agency stresses that while drug development is essential, it cannot replace prevention. Reducing transmission, ensuring early diagnosis, strengthening contact tracing and integrating STI services into primary healthcare remain the most effective ways to slow the spread.
The rise in drug-resistant gonorrhoea mirrors a broader pattern across infectious diseases: scientific advances are outpacing political and financial commitments to implement them. The EGASP data show that resistance is not an abstract threat but a measurable, escalating reality. If current trends continue, the world may soon face strains for which no reliable treatment exists. The WHO’s call for action is therefore not merely an institutional warning but a reflection of a changing microbial landscape. Whether countries act now or wait until treatment failures become more widespread will determine how deep the crisis becomes.
– global bihari bureau
