close
close

Multidrug-resistant gonorrhea

Posted on by angelo

Highlights

  • Antimicrobial resistance in gonorrhea has increased rapidly in recent years and has reduced treatment options.
  • Eighty-two million new cases of gonorrhea occurred in 2020.
  • In 2020, most gonorrhoea cases were reported in the WHO African Region and the Western Pacific Region.
  • Most of those affected are between the ages of 15 and 49.

Preview

Gonorrhoea is a sexually transmitted infection (STI) that remains a major public health problem. WHO estimates that in 2020, 82.4 million (47.7 million–130.4 million) new cases of infection were reported among adolescents and adults aged 15–49 years worldwide, with a global incidence rate of 19 (11–29) per 1000 females and 23 (10–43) per 1000 males. Most cases were reported in the WHO African Region and the Western Pacific Region.

Antimicrobial resistance (AMR) in Neisseria gonorrhoeae (N. gonorrhoeae) emerged shortly after the start of antimicrobial drug use. This trend has continued over the last 80 years, affecting drugs such as tetracyclines, macrolides (including azithromycin), sulfonamides and trimethoprim combinations, and, more recently, quinolones. In many countries, resistance to ciprofloxacin is extremely high, resistance to azithromycin is increasing, and resistance or reduced susceptibility to cefixime and ceftriaxone continues to emerge.

Extensively drug-resistant gonorrhoeae, with high resistance to the currently recommended treatment for gonorrhoea (ceftriaxone), but also resistance to penicillin, sulfonamides, tetracycline, fluoroquinolones and macrolides (including azithromycin), are called gonorrhoea superbugs or supergonorrhoeae.

History

The first reported treatment failure with cefixime occurred in Japan. Over the past decade, confirmed failures of cure of gonorrhoea with ceftriaxone alone or in combination with azithromycin or doxycycline have been reported in Australia, France, Japan, Slovenia, Sweden, and the United Kingdom of Great Britain and Northern Ireland. In 2016, the first global failure of cure of pharyngeal gonorrhoea with dual therapy (ceftriaxone 500 mg plus azithromycin 1 gram) was confirmed in the United Kingdom. A ceftriaxone-resistant gonococcal strain spreading internationally has been reported in Denmark, France, Japan, and the United Kingdom. In 2018, the first global gonococcal strain resistant to ceftriaxone and with high resistance to azithromycin causing pharyngeal gonorrhoea was reported in the United Kingdom. An increasing number of cases of treatment failure are reported in Austria, the United Kingdom and other countries.

All confirmed treatment failures, except for one recent case in the UK, have been pharyngeal infections affecting the throat. The majority of pharyngeal infections are asymptomatic. Antimicrobial drugs do not penetrate the tissues in this area well, and the pharynx also harbours related bacteria naturally present in the area. Neisseria species that may contribute to drug resistance. Most data on this issue come from high-income countries; however, the majority of gonorrhea cases occur in less wealthy countries and regions.

This suggests that reports of treatment failures and drug resistance in wealthier regions represent only the tip of the global health burden. Surveillance data on antibiotic resistance and treatment failure in poorer countries are extremely scarce and need to be improved. Gonococcal resistance to ceftriaxone, the last remaining option for first-line empirical treatment of gonorrhoea, is a major public health problem. Strains across the phylogeny of gonococcal species have been shown to develop resistance to ceftriaxone. The WHO Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) has noted high levels of resistance to ceftriaxone, mainly due to the spread of particularly resistant strains. This underlines the importance of gonococcal surveillance.

Causes

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

This resistance is caused by a number of factors, including unrestricted access to antimicrobials, inappropriate selection and overuse of antibiotics, and poor quality of antibiotics. In addition, genetic mutations within the body have contributed to increased drug resistance in N. gonorrhoeaeInfections outside the genital area, particularly in the throat and rectum, particularly affect key populations such as men who have sex with men. This may also play an important role in the development of resistant strains, such as N. gonorrhoeae interact and exchange genetic material with other organisms in these parts of the body.

Consequences

Gonococcal infections have critical consequences for reproductive, maternal and neonatal health, including:

  • a fivefold increase in HIV transmission
  • infertility, with its cultural and social implications
  • inflammation, leading to acute and chronic lower abdominal pain in women
  • ectopic pregnancy and maternal death
  • first trimester abortion
  • serious neonatal eye infections that can lead to blindness.

The financial costs of these complications are very high, both for individuals and for health systems. Antimicrobial resistance compounds this burden by prolonging the infection in more people and increasing the number of people suffering from long-term complications related to gonococcal infections.

The emergence of different forms of resistance N. gonorrhoeae The disease is spreading rapidly. This is not just a problem in low- and middle-income countries. Recent treatment failures have also been observed in high-income countries. Because comprehensive information can be difficult to find in areas with limited surveillance resources, antimicrobial resistance is expected to be much higher than currently observed due to silent spread.

WHO response

Fight against multidrug resistance N. gonorrhoeae Combating antimicrobial resistance requires two approaches: combating antimicrobial resistance and combating gonorrhoea. Both approaches must be addressed in the broader context of combating antimicrobial resistance globally.

WHO is implementing the Global Action Plan to control the spread and impact of antimicrobial resistance in N. gonorrhoeae to facilitate effective actions against the spread of multi-resistant drugs N. gonorrhoeaeThis plan is part of the broader STI surveillance plan aimed at promoting early detection of emerging resistant strains, combined with a public health response aimed at preventing and treating gonococcal infections and reducing the impact of gonorrhoea on sexual and reproductive health.

The Global Health Sector Strategy for HIV, Hepatitis and STIs (2022–2030) set targets to reduce the number of new cases of gonorrhoea among people aged 15–49 years from 82.3 million per year in 2020 to 8.23 ​​million per year in 2030, thereby reducing annual incidence by 90% by 2030. Recognizing that this reduction may be difficult to achieve with available interventions, and given increasing antimicrobial resistance, the strategy emphasized the need to develop effective gonococcal vaccines. There are currently no licensed gonococcal vaccines. However, interest in developing gonococcal vaccines has been rekindled not only by the marked increase in gonococcal antimicrobial resistance, but also by accumulating scientific evidence suggesting that gonococcal vaccines are biologically feasible.

The main actions of WHO are as follows:

  • effective prevention and control of gonococcal infections, through appropriate prevention messages and interventions and treatment regimens;
  • establish effective drug regulation;
  • Strengthen antimicrobial resistance surveillance systems, particularly in countries with a high burden of gonococcal infections, and increase the number of countries (>70% by 2030 from 36% in 2020) reporting antimicrobial resistance N. gonorrhoeae to the WHO Gonococcal Antimicrobial Monitoring Programme;
  • strengthen the Gonococcal Antimicrobial Surveillance Programme by establishing a network of laboratories to coordinate surveillance of gonococcal antimicrobial resistance, linked to the Global Antimicrobial Resistance and Use Surveillance System;
  • establish regional networks of laboratories capable of performing gonococcal cultures, with good quality control mechanisms;
  • ensure appropriate and quality management of STI cases and, where possible, same-day testing and treatment;
  • monitor treatment failures by developing a standard set of monitoring protocols;
  • support research to find low-cost tests to identify N. gonorrhoeaewhich would allow effective screening in priority populations defined by each country, including men who have sex with men, sex workers and people living with HIV;
  • support research aimed at developing methods for detecting antimicrobial resistance; and
  • research into alternative treatments for gonococcal infections.

WHO will continue to work with Member States and partners to understand and reduce antimicrobial resistance through improved antibiotic control and measures to prevent the spread of gonorrhoea.