Global Sexually Transmitted Infections Programme

The Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes leads the development and implementation of the global health sector strategy on the elimination of sexually transmitted infections as a public health threats.

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Addressing antimicrobial resistance in STIs

Antimicrobial resistance in Neisseria gonorrhoeae

Widespread antimicrobial resistance (AMR) in highly variable strains of Neisseria gonorrhoeae has continuously compromised the management and control of gonorrhoea. Because of widespread AMR – as well as the persistence of AMR determinants in gonococci and the unavailability of diagnostic tests that provide AMR results at the time of treatment – clinicians resort to empiric treatment for gonorrhoea.

Since the introduction of antimicrobial treatment, resistance has rapidly emerged to sulphonamides, penicillins, tetracyclines, macrolides, fluoroquinolones and early-generation cephalosporins. In most countries, the injectable extended-spectrum cephalosporin ceftriaxone is currently the only remaining empiric monotherapy for gonorrhoea. However, gonococcal in vitro resistance and/or treatment failures to the last-line oral extended-spectrum cephalosporin cefixime and ceftriaxone, and also azithromycin, have been verified in many countries.

The Global Health Sector Strategies on, respectively, HIV, viral hepatitis and sexually transmitted infections for the period 2022-2030 (GHSS) set ambitious targets to reduce new gonorrhoea cases by 90% by 2030 among people 15–49 years old. This goal cannot be achieved without addressing gonococcal AMR. The strategy also set the goal of increasing the number of countries reporting AMR in Neisseria gonorrhoeae to the WHO Gonococcal Antimicrobial Surveillance Programme (GASP) by more than 70%.

In 2012, WHO launched a global action plan to control the spread and impact of gonococcal AMR (key priorities are summarized below). This plan is linked to WHO’s “Global action plan on antimicrobial resistance”, which was adopted by the World Health Assembly in 2015, and reaffirmed during the United Nations General Assembly High-level Meeting on AMR in September 2016.

Key priorities of the WHO global action plan

Advocacy for increased awareness on correct use of antibiotics among health-care providers and the consumer, particularly in key populations including men who have sex with men and sex workers
Effective prevention, diagnosis and control of gonococcal infections, using prevention messages and interventions, recommended adequate diagnosis, and appropriate treatment regimens
Systematic monitoring of treatment failures, by developing a standard case definition of treatment failure, as well as protocols for verification, reporting and management
Effective drug regulations and prescription policies
Strengthened AMR surveillance, especially in countries with a high burden of gonococcal infections, other STIs and HIV
Capacity-building to establish regional networks of laboratories to perform gonococcal culture, with high-quality control mechanisms
Research into newer molecular methods for monitoring and detecting AMR, and development of new treatment options
Research into, and identification of, alternate effective treatment regimen(s) and vaccine(s) for gonococcal infections

Global action plan

Gonorrhoea is a major public health challenge today, due to the high incidence of infections accompanied by a dwindling number of treatment options. The...

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Resistance in other STIs

Azithromycin is recommended for Mycoplasma genitalium internationally, as well as for the treatment of Chlamydia trachomatis and Neisseria gonorrhoeae. In addition to increasing resistance to azithromycin in Neisseria gonorrhoeae, high levels of azithromycin resistance in Mycoplasma genitalium reported in Europe, Australia, Japan and the United States of America question its sustained activity against this STI. Furthermore, Mycoplasma genitalium resistance to alternative regimens (i.e. moxifloxacin) has been reported in many countries. Finally, resistance to the recommended regimens for trichomoniasis has been verified in the USA.