Rapid Risk Assessment: Extensively drug-resistant (XDR) Neisseria gonorrhoeae in the United Kingdom and Australia

The first three cases of infection with extensively drug-resistant (XDR) Neisseria gonorrhoeae displaying resistance to ceftriaxone (MIC = 0.5 mg/L) and high-level resistance to azithromycin (MIC >256 mg/L) at a global level were reported by the United Kingdom (one case) and Australia (two cases) in February and March 2018, respectively. The case from the UK and one case from Australia were travel-associated and both acquired gonorrhoea in South-East Asia. These strains are the first global reports of high-level azithromycin resistant N. gonorrhoeae which is also resistant to ceftriaxone as well as most other alternative antimicrobials. Consequently, they are resistant to the first line dual therapy for gonorrhoea (ceftriaxone intramuscularly and azithromycin orally) recommended by European, Australian, World Health Organisation and other guidelines. They highlight the increasing threat of multidrug- (MDR) and extensively drug-resistant (XDR) gonorrhoea in the context of limited therapeutic alternatives, lack of vaccine and limited surveillance capacity in many regions globally.

Effective response to this threat will require strengthened collaboration between clinicians, microbiologists, epidemiologists and public health authorities at national and international level through the adoption of measures to preserve ceftriaxone and azithromycin as viable treatment options for gonorrhoea. The recently reported cases indicate a need to continue to increase awareness of the issue among the public, clinicians, laboratory staff, epidemiologists and other healthcare and public health professionals.

Prevention efforts need to be focused on measures to reduce the overall number of gonorrhoea cases, by emphasising the importance of safer sex practices, in particular the use of condoms, and following any national guidelines on STI testing after unprotected sexual activity with new or casual partners. Considering that two of the three XDR gonorrhoea cases reported here were travel-related, provision of information on safer sex practice should be considered as routine advice for travellers. All patients diagnosed with gonorrhoea, need to be reminded of the importance of partner notification and attending for test of cure.

Clinicians need to ensure that all gonorrhoea cases are managed according to national and/or international guidelines, be aware of the possibility of further cases which are resistant to ceftriaxone and azithromycin, ensure that tests of cure are performed for all diagnosed cases, and submit samples for culture and antimicrobial susceptibility testing from all suspected or proven positive sites of infection. In case of XDR gonorrhoea, clinicians should consider taking pharyngeal samples irrespective of reported sexual practices. Sexual health services also need to ensure that partner notification is undertaken for all cases. Particular attention should be paid to effective detection and treatment of pharyngeal gonorrhoea, which is frequently more difficult to eradicate compared to urogenital infections.  

Antimicrobial resistance surveillance for N. gonorrhoeae in EU/EEA countries and globally, needs to continue to be prioritised and strengthened. Reporting of treatment failures should be implemented and/or strengthened at the national and European level to enable rapid implementation of interventions to prevent the spread of MDR- and XDR N. gonorrhoeae. Timely sharing of data between national authorities on treatment failures will also facilitate a more effective global response.