China sees dramatic rise in ceftriaxone-resistant gonorrhea

Gonorrhea bacteria

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China is seeing an alarming increase in ceftriaxone-resistant gonorrhea, researchers report today in Morbidity and Mortality Weekly Reports.

Analysis of 2,084 gonococcal isolates collected from 13 provinces by the China Gonococcal Resistance Surveillance Program from 2017 through 2022 revealed that the prevalence of ceftriaxone-resistant Neisseria gonorrhoeae was 8.1% in 2022, nearly three times the 2.9% prevalence reported in 2017. Five provinces reported that more than 10% of isolates were resistant to ceftriaxone.

Ceftriaxone is the recommended first-line treatment option for gonorrhea in China and many other countries and is essentially the one reliable antibiotic left for treating one of the world's most common sexually transmitted infections. But a ceftriaxone-resistant N gonorrhoeae clone (FC428) that was first identified in Beijing in 2016 is now widely disseminated across China and has been identified in other countries.

The researchers note that China's rate of ceftriaxone-resistant gonorrhea is relatively high compared with other countries. For comparison, the percentage of gonorrhea strains in the United Kingdom with reduced susceptibility to ceftriaxone was 0.21% in 2022. In the United States, the prevalence of isolates exhibiting elevated ceftriaxone minimum inhibitory concentrations—the amount needed to stop the growth of N gonorrhoeae bacteria—was around 0.2% from 2016 through 2020.

Identifying contributing factors

The study authors suggest that spread of the FC428 strain may be the underlying reasons for the high rate of ceftriaxone resistance in China, although whole-genome sequencing of isolates is still ongoing. But they add that gaps in gonorrhea screening, treatment, and partner management, along with non-recommended prescribing or use of antibiotics, could also be contributing.

And the findings may be an underestimate, as the analyzed isolates represent only 2.9% of all gonorrhea cases reported in China and 4.1% of cases reported in the 13 participating provinces.

"These findings underscore the urgent need for a comprehensive approach to address antibiotic-resistant N. gonorrhoeae in China, including identifying factors contributing to this high resistance rate, especially in provinces where the percentage of gonococcal isolates resistant to ceftriaxone is >10%," the authors wrote.

Further underscoring the problem, the analysis also found that resistance levels to other antibiotics that have been used to treat gonorrhea—cefixime, azithromycin, tetracycline, penicillin, and ciprofloxacin—were 16.0%, 16.9%, 77.1%, 77.8%, and 97.6%, respectively. Isolates from 18 patients were resistant to all antibiotics tested except spectinomycin.

"The observed resistance rates for other antibiotics emphasize the complex landscape of gonococcal antimicrobial resistance, further highlighting the urgent need to develop alternative treatment strategies, including vaccines, to counter this growing threat," the authors concluded.

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