The global epidemiology of antibiotic-resistant Neisseria gonorrhoeae

Abstract

Antimicrobial-resistant Neisseria gonorrhoeae is an evolving global public health threat that increasingly limits treatment options for one of the world’s most common sexually transmitted infections. This review synthesizes the global epidemiology of antimicrobial resistance in N. gonorrhoeae across phenotypic, genomic, clinical and population-level dimensions. Resistance to agents no longer recommended for empiric treatment is widespread, while azithromycin resistance and reduced susceptibility to extended-spectrum cephalosporins continue to emerge. Resistant lineages, including internationally disseminated ceftriaxone-resistant and extensively drug-resistant strains, highlight the capacity of N. gonorrhoeae to acquire and spread resistance across geographic and genetic backgrounds. However, the global burden remains difficult to quantify because surveillance is uneven, extragenital and asymptomatic infections are underrepresented and susceptibility testing methods and interpretive thresholds vary across settings. Resistance is shaped by antimicrobial exposure, sexual network dynamics, international travel, delayed diagnosis and treatment and structural barriers to sexual healthcare. Opportunities to mitigate resistance include more representative and standardized phenotypic and genomic surveillance; diversified treatment strategies including aetiologic point-of-care diagnostics, rapid resistance-guided therapy and newly available oral agents and strengthened prevention efforts through partner notification and treatment and vaccine development. Coordinated, locally informed implementation of those approaches may help preserve effective treatment and reduce the impact of antimicrobial resistance.