Antimicrobial resistance in gonorrhoea is no longer a looming concern. It is a present-day crisis. The World Health Organization (WHO) has confirmed that multidrug-resistant strains of Neisseria gonorrhoeae are spreading across regions at a speed and scale that leaves treatment options dwindling. Eighty-two million new cases were reported globally in 2020, with most concentrated in Africa and the Western Pacific. The majority of infections are in people aged 15 to 49—the most sexually active age group. The implications stretch beyond sexual health, touching maternal care, HIV prevention, and newborn health outcomes.
Rising Resistance Across Antibiotics
Gonorrhoea’s ability to outsmart drugs is not new. Resistance was observed as early as the 1940s, but the current trend is different. The bacterium has now developed resilience against nearly all available classes of antibiotics. These include penicillins, tetracyclines, quinolones, macrolides like azithromycin, and even cephalosporins such as cefixime and ceftriaxone—the last reliable line of defense. WHO surveillance shows ciprofloxacin resistance rates exceeding 90% in some countries, while azithromycin resistance is climbing. Even ceftriaxone, long considered the gold standard, is showing cracks.
This is not a localized problem. Confirmed treatment failures have been documented in Japan, Australia, France, Slovenia, Sweden, and the United Kingdom. In 2016, the UK reported the world’s first failure of dual therapy—ceftriaxone plus azithromycin. By 2018, strains resistant to both drugs were reported, again in the UK. Similar strains have since appeared in Denmark, France, and Japan. These developments confirm that resistant strains are not isolated; they are spreading internationally.
The Silent Spread in Throat Infections
An alarming pattern has emerged: most treatment failures involve pharyngeal infections. Unlike genital gonorrhoea, throat infections often show no symptoms. The pharynx also provides a unique environment for resistance to develop. Antibiotics do not penetrate the tissue effectively, and the area is home to other Neisseria species that can exchange resistance genes. This silent spread means resistant strains may circulate undetected for years before being identified.
In wealthier nations, surveillance detects these strains early. In low- and middle-income countries, where most infections occur, monitoring is weak or absent. WHO officials caution that current data may represent only the “tip of the iceberg.” Without better surveillance in resource-limited regions, the true scale of resistance remains unknown.
Why Resistance Is Rising
Multiple factors fuel this rise. Overuse and misuse of antibiotics remain central. In many countries, drugs can be bought without prescriptions, making self-medication common. Poor-quality or counterfeit antibiotics worsen the problem by exposing bacteria to sub-lethal doses. Genetic adaptability also plays a role. N. gonorrhoeae mutates quickly and can exchange DNA with other bacteria in the throat or rectum, speeding up resistance. Key populations—such as men who have sex with men—are particularly affected by these extragenital infections.
Health Consequences Beyond Infection
Gonorrhoea is not just another sexually transmitted infection. Untreated cases can have severe health consequences. Women face increased risks of infertility, pelvic inflammatory disease, and ectopic pregnancies. Pregnant women can transmit the infection to newborns, causing severe eye infections that may result in blindness. The infection also multiplies the risk of HIV transmission fivefold.
From a public health perspective, the economic burden is enormous. Resistant gonorrhoea prolongs infections, requiring repeated treatments, more costly drugs, and extended hospital stays. The result is higher costs for both individuals and healthcare systems, particularly in countries already stretched thin.
A Race Against Time
WHO’s Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) has documented resistant strains in multiple regions. But less than 40% of countries currently report data. WHO has set a goal to expand this to over 70% by 2030. Without improved surveillance, resistant strains will continue to spread unchecked.
Treatment guidelines are also under pressure. Ceftriaxone remains the standard recommendation, but reports of resistance suggest it may not hold much longer. No new drug classes are ready for widespread use. Research into alternatives, including new antibiotics and combination therapies, is underway but progress is slow.
Vaccine Research Gains Urgency
For decades, the idea of a gonorrhoea vaccine seemed remote. Now, the urgency has reignited global interest. Evidence suggests that vaccines designed for meningitis B may offer partial protection against gonorrhoea, raising hope that a targeted vaccine is biologically possible. WHO’s Global Health Sector Strategy on HIV, Hepatitis and STIs (2022–2030) sets an ambitious target: a 90% reduction in new gonorrhoea cases by 2030. Meeting that goal will almost certainly require an effective vaccine.
WHO’s Multi-Pronged Response
WHO is coordinating a global action plan that addresses both gonorrhoea and the broader threat of antimicrobial resistance. Key actions include:
- Expanding laboratory networks to strengthen surveillance, particularly in Africa and Asia.
- Supporting countries in enforcing stricter antibiotic regulations.
- Promoting prevention campaigns focused on condom use, regular testing, and safe sexual practices.
- Developing affordable diagnostic tools for same-day testing and treatment.
- Encouraging research into low-cost methods to detect resistance.
- Funding innovation in vaccines and new treatment options.
The focus is not only on controlling resistant strains but also on reducing overall infection rates. If fewer people are infected, fewer bacteria are exposed to antibiotics, reducing the opportunities for resistance to develop.
Action Steps for Healthcare Providers
Doctors and clinics face immediate challenges. Standard treatment is becoming unreliable, and culture-based testing is not always available. Experts recommend the following measures:
- Strengthen Diagnostic Testing – Where possible, providers should use culture and sensitivity testing rather than treating empirically.
- Report Treatment Failures Promptly – National health authorities rely on clinicians to flag suspected cases.
- Promote Safer Sexual Practices – Counseling patients on consistent condom use and regular STI screening remains essential.
- Avoid Unnecessary Antibiotic Use – Overprescription, particularly of broad-spectrum antibiotics, increases resistance pressure.
- Partner Notification – Ensuring that sexual partners are tested and treated reduces reinfection and wider spread.
What Governments Must Do
The responsibility extends beyond clinics. Governments must strengthen pharmaceutical regulations to prevent the sale of poor-quality or unregulated antibiotics. They must also invest in laboratory capacity to expand resistance surveillance. WHO calls for national plans that integrate STI prevention into broader antimicrobial resistance strategies.
High-income countries, where most resistance is first detected, must support low- and middle-income countries financially and technically. Without global solidarity, resistant strains will continue to circulate across borders.
Looking Ahead
The threat of “super gonorrhoea” is not hypothetical. It is already here. Infections resistant to nearly all available drugs have been confirmed in multiple countries. WHO’s projections suggest that without urgent action, cases could rise sharply, undermining sexual health programs and placing reproductive health at risk.
But solutions are within reach. Expanding surveillance, enforcing antibiotic stewardship, accelerating vaccine research, and scaling prevention programs could slow the tide. Time, however, is short. Each treatment failure signals that the last line of defense is weakening.
If the world is to avoid a future where gonorrhoea becomes untreatable, governments, researchers, and healthcare providers must act decisively now. The lessons of antimicrobial resistance are clear: once drugs fail, regaining control is far harder than preventing the loss in the first place.
The race is no longer about finding the next drug. It is about buying time until vaccines or new therapies arrive. In that race, every day matters.
