Gonorrhoea is one of the most common sexually transmitted infections globally — caused by Neisseria gonorrhoeae, a bacterium that infects warm, moist body surfaces: urethra (men); endocervix (women); rectum; pharynx; and conjunctiva. It caused 82.4 million new infections in 2020. In men, gonorrhoea causes urethral discharge and dysuria; in women it is often asymptomatic — making silent spread and complications (PID, infertility) common.

Why is drug-resistant gonorrhoea so concerning?

N. gonorrhoeae has developed resistance to every antibiotic class introduced as first-line treatment over 80 years — sulfonamides, penicillin, tetracyclines, fluoroquinolones and now azithromycin. The current last reliable option — ceftriaxone — is under threat from rising MICs (minimum inhibitory concentrations) and documented ceftriaxone treatment failures. XDR gonorrhoea (extensively drug-resistant — resistant to ceftriaxone + all other options) is now documented globally. Without effective treatment, gonorrhoea would cause an epidemic of pelvic inflammatory disease, infertility, ectopic pregnancy and blinding neonatal eye infections.

How is gonorrhoea diagnosed?

Nucleic acid amplification tests (NAATs): the most sensitive and specific tests — from genital, rectal or pharyngeal swabs, or first-void urine. Point-of-care NAATs increasingly available. Culture: essential for antimicrobial susceptibility testing — a WHO priority to track resistance. Gram stain: from urethral discharge in symptomatic men — shows intracellular Gram-negative diplococci; insensitive in women and asymptomatic men. Importantly, gonorrhoea is often mixed with chlamydia — test for both simultaneously.

How is gonorrhoea treated?

Current WHO recommended treatment (2016/2022 guidance): ceftriaxone 500mg IM single dose (previously dual therapy with azithromycin, but de-escalated to monotherapy as azithromycin resistance emerged). If the isolate is susceptible to azithromycin, dual therapy may be used in specific settings. For pharyngeal gonorrhoea (harder to cure): higher ceftriaxone doses (1g IM). If allergy to cephalosporins: gentamicin 240mg IM + azithromycin 2g oral. Test of cure recommended for pharyngeal gonorrhoea and in areas with high ceftriaxone resistance.

What is the link between MenB vaccine and gonorrhoea?

A groundbreaking finding from New Zealand (2017), confirmed in multiple subsequent studies: 4CMenB meningococcal B vaccine (Bexsero, GSK) — developed against Neisseria meningitidis — provides approximately 40% protection against gonorrhoea due to cross-reactivity between meningococcal and gonococcal outer membrane vesicle proteins. This has led several countries (New Zealand, UK) to consider or recommend MenB vaccination for high-risk groups (MSM) as partial gonorrhoea prevention. A dedicated gonorrhoea vaccine programme based on this observation is being developed.

How does GMJ News cover gonorrhoea?

GMJ News covers WHO gonorrhoea burden data, drug-resistant gonorrhoea (DRG) evolution, WHO GASP surveillance, PID complications, ophthalmia neonatorum prevention, ceftriaxone treatment, and the MenB vaccine cross-protection finding. Gonorrhoea represents AMR in a sexually transmitted context — directly relevant to PHIG's STI and AMR programmes.

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Gonorrhoea

GMJ News knowledge hub · last reviewed September 2026 · Georgian Medical Journal

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Gonorrhoea — caused by Neisseria gonorrhoeae — caused an estimated 82.4 million new infections in 2020 and is on the WHO list of critical priority drug-resistant organisms: the emergence of extensively drug-resistant gonorrhoea (XDR-GC) — resistant to penicillins, fluoroquinolones, azithromycin and now reduced susceptibility to ceftriaxone — threatens to render gonorrhoea untreatable (WHO). Untreated gonorrhoea causes pelvic inflammatory disease (PID), ectopic pregnancy, tubal infertility and — in the neonate — ophthalmia neonatorum with risk of permanent blindness. Current WHO recommended treatment: ceftriaxone 500mg IM single dose.

Key messages

82 million cases — drug resistance the defining threat

82.4 million new gonorrhoea infections occurred in 2020. Drug-resistant gonorrhoea (DRG) — now resistant to penicillins, tetracyclines, fluoroquinolones and increasingly to ceftriaxone — is on WHO's critical priority drug-resistant pathogen list (WHO 2020).

Ceftriaxone 500mg — last reliable treatment

The current WHO-recommended treatment is ceftriaxone 500mg IM single dose. Dual therapy (previously ceftriaxone + azithromycin) was de-escalated to monotherapy after XDR strains showed azithromycin resistance. Ceftriaxone resistance would create an effectively untreatable STI.

Often asymptomatic — especially in women

Approximately 50-80% of women with gonorrhoea are asymptomatic — enabling silent transmission and progression to pelvic inflammatory disease (PID), ectopic pregnancy and tubal infertility. Routine STI screening is critical for high-risk women.

PID — the dangerous complication

Ascending gonorrhoeal infection causes pelvic inflammatory disease (PID) — affecting the uterus, fallopian tubes and ovaries. Even one episode of PID increases ectopic pregnancy risk 6-10 fold and causes tubal factor infertility in approximately 20% of cases.

Ophthalmia neonatorum

Gonorrhoeal infection of the newborn's eyes during vaginal delivery causes ophthalmia neonatorum — purulent conjunctivitis that can cause corneal ulceration and permanent blindness within days without treatment. WHO recommends universal neonatal eye prophylaxis.

New vaccines in development

No gonorrhoea vaccine exists, but meningococcal B vaccines (MenB — 4CMenB/Bexsero) have shown approximately 40% effectiveness against gonorrhoea (cross-reactivity between N. meningitidis and N. gonorrhoeae outer membrane vesicles). A dedicated gonorrhoea vaccine is a WHO research priority.

Key statistics

82.4M

new gonorrhoea cases in 2020 (WHO)

WHO 2020

Critical

WHO priority drug-resistant pathogen (2017 priority pathogen list)

WHO

50-80%

of women are asymptomatic

WHO

~20%

tubal infertility after 1 PID episode

WHO

~40%

gonorrhoea protection from MenB vaccine (Bexsero)

WHO/Lancet

500mg IM

ceftriaxone single dose — current WHO first-line

WHO 2016/2022

Gonorrhoea antimicrobial resistance evolution — % of isolates resistant by decade (WHO GASP)

Source: WHO GASP (Global Antimicrobial Surveillance Programme). Sequential resistance development threatens treatment options.

Glossary of key terms

Neisseria gonorrhoeae
WHOA Gram-negative diplococcus — an obligate human pathogen with no animal reservoir. Infects columnar epithelium of the urethra, endocervix, rectum, pharynx, conjunctiva and fallopian tubes. Multiple immune evasion mechanisms (phase variation, antigenic variation of surface proteins, serum resistance) prevent lasting immunity.

Drug-resistant gonorrhoea (DRG)
WHO/GASPN. gonorrhoeae has developed resistance to every antibiotic introduced as a first-line treatment: sulfonamides (1940s); penicillin (1960s-80s); tetracyclines; fluoroquinolones (ciprofloxacin — widespread resistance by 2007); azithromycin (rising). Now reduced susceptibility to ceftriaxone (the last reliable option) is appearing.

Pelvic inflammatory disease (PID)
WHO/RCOGAscending infection from the lower genital tract (cervix/vagina) to upper reproductive organs (uterus, fallopian tubes, ovaries, pelvic peritoneum). Polymicrobial — gonorrhoea, Chlamydia trachomatis, anaerobes. Presentation: lower abdominal pain, cervical motion tenderness, fever. Complications: tubo-ovarian abscess, ectopic pregnancy, tubal factor infertility, chronic pelvic pain.

Ophthalmia neonatorum (gonococcal)
WHOPurulent conjunctivitis in the neonate — acquired during passage through an infected birth canal. Onset 2-5 days after birth (vs chlamydial: 5-14 days). Profuse mucopurulent discharge, eyelid oedema. Untreated: corneal ulceration → perforation → blindness within days. Treatment: IV/IM ceftriaxone. WHO recommends universal neonatal eye prophylaxis (1% silver nitrate, erythromycin or povidone-iodine) in all deliveries.

Disseminated gonococcal infection (DGI)
WHO/ClinicalBacteraemic spread of N. gonorrhoeae — occurring in approximately 0.5-3% of infections. Two syndromes: bacteraemic (triad of fever, tenosynovitis — especially wrist/hand tendons — and petechial/pustular skin lesions); and septic arthritis (monoarticular, usually knee, without rash). Diagnosed by culture of blood, joint fluid or urogenital swabs. Treated with IV ceftriaxone.

WHO GASP (Global Antimicrobial Surveillance Programme)
WHOThe global network monitoring gonorrhoea antimicrobial resistance trends — the primary early warning system for new resistance patterns. GASP data from approximately 70 countries informs WHO treatment guidelines updates. Declining susceptibility to ceftriaxone in multiple countries is triggering intensive surveillance and treatment research.