Researchers from the WHO Collaborating Centre for Gonorrhoea and other STIs at Örebro University- Sweden along with medical scientists from the Austrian Agency for Health and Food Safety-Austria, LKH Hochsteiermark, Leoben-Austria and the University College London-UK are warning of the spread of a new super drug resistant strain of Neisseria Gonorrhoeae that is thought to be originating from countries in South East Asia including Cambodia and also another country infamous for its sex industry after a few documented case reports in various parts of Europe including Austria have emerged.
We describe the second global XDR gonococcal strain [4,5], with high-level resistance to azithromycin and resistance to ceftriaxone, cefixime, cefotaxime, ciprofloxacin, and tetracycline, which caused a possible gonorrhoea treatment failure with recommended ceftriaxone plus azithromycin therapy.
The case from Austria reported about condomless sexual contact with a female sex worker in Cambodia 5 days before onset of symptoms. A limitation of our study is that the female sex worker could not be traced and, thus, no gonococcal isolate or other samples from this female were available to link to AT159.
Notably, in 2019, another ceftriaxone-resistant gonococcal strain was reported in France, also after stating sexual contact with a female in Cambodia . However, this strain belonged to the internationally spreading FC428 clone [13-18,21].
In the absence of a gonococcal vaccine, early and effective diagnosis and antimicrobial treatment of gonorrhoea are essential [1,3,10]. However, N. gonorrhoeae has developed resistance to all classes of antimicrobials since introduction of antimicrobial treatment in the 1930s [1,7,8,10,13-18,21,22]. XDR N. gonorrhoeae strains, including those with resistance to all available treatment options, are a major global public health concern.
They pose a risk of treatment failure and serious complications/sequelae on the individual level but also compromise the management and control of gonorrhoea on the public health level. Resistance or decreased susceptibility to ceftriaxone and azithromycin resistance in N. gonorrhoeae has been reported worldwide .
In recent years in Europe, the susceptibility to ceftriaxone has increased but, worryingly, the resistance to azithromycin rapidly increased [19,23]. Furthermore, sporadic ceftriaxone-resistant strains have been identified in several European countries [1,5,7,15,18,19,22,23].
However, the XDR strain described in the present paper is the second global gonococcal strain with ceftriaxone resistance combined with high-level azithromycin resistance, with relatively close relationship with WHO Q [7,8], although not the same subvariant (Figure). It is of concern that high-level azithromycin-resistant strains in an Asian N. gonorrhoeae genomic sublineage are able to develop ceftriaxone resistance by acquisition of mosaic penA-60.001.
If such strains manage to establish a sustained transmission, many gonorrhoea cases might become untreatable. Promisingly, the XDR AT159 strain had wild-type MICs of the novel gonorrhoea antimicrobials lefamulin and zoliflodacin, which is in a phase 3 randomised clinical trial [10,12,19,22].
The “WHO Q” strain has been associated with three cases of gonorrhea notified in the United Kingdom and Australia in 2018 with reported links to South East Asia. https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2018.23.27.1800323
Since the identification of the new “WHO Q” strain, more case reports have appeared all over Europe.
In February 2022, a few cases were identified in UK. https://www.telegraph.co.uk/global-health/climate-and-people/new-super-gonorrhoea-cases-uk-spark-track-and-trace-investigation/
At present there are another 27 cases being investigated including cases reported in UK, Germany, France, Sweden, Denmark and Netherlands