Global Resistance of Neisseria gonorrhoeae

When Theory Becomes Reality

David A. Lewis


Curr Opin Infect Dis. 2014;27(1):62-67. 

In This Article

Emergence of Multidrug Resistant and Extensively Drug Resistant Gonorrhoea

Nonsusceptible gonococci with elevated ESC MICs are now being identified at increasing prevalence in many other countries and regions of the world.[2,11,12–14,15–18,19,20] As noted above, these gonococci are typically multidrug-resistant (MDR) strains exhibiting additional resistance to fluoroquinolones as well as older drugs.[4,12,21]

More worrying has been the recent emergence of XDR N. gonorrhoeae strains among CSW and MSM populations, which are characterized by high ceftriaxone MICs.[11,14,22] The first such gonococcal strain (H041) possessed a ceftriaxone MIC of 2–4 mg/l and was isolated from the oropharynx of a Japanese female CSW in Kyoto in 2009.[22] Following the identification of this XDR strain, an intensified surveillance activity was undertaken in both Kyoto and Osaka (2010–2012) in order to determine the extent of spread of this strain.[23] It has been reassuring to note that all 193 N. gonorrhoeae isolates tested were classified as susceptible in vitro to both cefixime and ceftriaxone (MIC ≤ 0.25 mg/l). These data suggest that the H041 strain has not spread further within the local community and raise the intriguing possibility that the H041 strain may be less fit than ceftriaxone-susceptible strains. Subsequent to identification of the H041 strain, gonococci with substantially elevated ceftriaxone MICs were isolated from the urethra of an MSM patient in France (strain F89, ceftriaxone MIC 2 mg/l) and from the urethral and rectal samples of two sexually related male partners in Spain (ceftriaxone MIC 1.5 mg/l).[11,14] These three European isolates appear to be related as they share the same N. gonorrhoeae multiantigen sequence typing (NG-MAST) sequence type (ST 1407) but are unrelated to the Japanese H041 strain (NG-MAST ST 4220).[11,14,22] These three NG-MAST ST 1407 isolates also belong to the same multilocus sequence typing-based ST 1901 superclone that is presently circulating internationally.[2,12,13,24–27]

A number of verified ceftriaxone-associated oro-pharyngeal gonorrhoea treatment failures have also been recently reported.[15,22,28,29] The ceftriaxone MICs for these strains varied from 0.016 mg/l to 2–4 mg/l and, for those isolates with lower MICs, it is likely that pharmacodynamic factors were important in the failure of ceftriaxone to eradicate N. gonorrhoeae from the oropharynx.[2]