Ceftriaxone resistance in gonorrhoea rose from 0.8% to 5% in two years, WHO reports

Resistance to the two antibiotics that anchor gonorrhoea treatment rose sharply between 2022 and 2024, according to data from the World Health Organization's Enhanced Gonococcal Antimicrobial Surveillance Programme released on 19 November, during World AMR Awareness Week [s1].

Resistance to ceftriaxone, the primary treatment, rose from 0.8% to 5% [s1]. Resistance to cefixime, the oral cephalosporin used in some settings, rose from 1.7% to 11% [s1]. Resistant strains were detected in more countries than before [s1].

Azithromycin resistance held steady at 4% [s1]. Ciprofloxacin resistance reached 95% — a drug effectively out of use for this infection [s1].

What EGASP is and what it caught

EGASP was launched by WHO in 2015 to collect laboratory and clinical data from sentinel sites around the world, tracking antimicrobial resistance and feeding treatment guidelines [s1].

Its reach has expanded quickly. In 2024, 12 countries across five WHO regions contributed data, up from four countries in 2022 [s1]. The 12 — Brazil, Cambodia, India, Indonesia, Malawi, the Philippines, Qatar, South Africa, Sweden, Thailand, Uganda and Viet Nam — together reported 3,615 cases of gonorrhoea [s1]. Brazil, Côte d'Ivoire and Qatar joined the programme in 2024, and India began implementation with data reporting from 2025 under its National AIDS and Sexually Transmitted Diseases Control Programme [s1].

Cambodia and Viet Nam reported the highest resistance rates [s1].

The geography of reported cases is heavily weighted to the Western Pacific: over half of all symptomatic gonorrhoea cases in men (52%) came from that region, including the Philippines (28%), Viet Nam (12%), Cambodia (9%) and Indonesia (3%) [s1]. The African Region accounted for 28% of cases, followed by South-East Asia (13%, Thailand), the Eastern Mediterranean (4%, Qatar) and the Americas (2%, Brazil) [s1].

Among reported cases, median patient age was 27 (range 12 to 94); 20% were men who have sex with men; 42% reported multiple sexual partners in the previous 30 days; 8% reported recent antibiotic use; and 19% had travelled recently [s1].

Why the expansion complicates the trend

A rise from four reporting countries to 12 in two years is good news for surveillance and a complication for interpreting the numbers. Some of the increase in measured resistance may reflect which countries joined — Cambodia and Viet Nam, which report the highest rates, are among the sentinel sites — rather than a uniform worsening everywhere. WHO presents both facts side by side and describes the country expansion as a positive development reflecting growing commitment [s1].

The programme's own stated limitations sharpen the caution. WHO names limited funding, incomplete reporting, and gaps in data from women and from extragenital sites — pharyngeal and rectal infections, which are frequently asymptomatic and are where resistance is thought to be selected [s1]. A surveillance system built largely on symptomatic men is not sampling the whole epidemic.

What is coming behind the cephalosporins

Two things are moving. WHO advanced genomic surveillance in 2024, with nearly 3,000 samples sequenced from eight countries [s1]. And its Collaborating Centre on AMR in STI in Sweden conducted studies on zoliflodacin and gepotidacin — two new antibiotics — as well as on tetracycline resistance, work WHO says is helping guide future gonorrhoea control and doxycycline-based post-exposure prevention strategies [s1].

That matters because ceftriaxone has been the last reliable first-line option. A resistance rate climbing from under 1% to 5% in two years is not yet treatment failure at scale, but it is the direction that ended the useful life of every previous first-line drug for this organism.

The wider framework

Five days after the EGASP release, on 24 November, WHO launched an integrated drug resistance action framework covering HIV, hepatitis B and C, and sexually transmitted infections for 2026 to 2030 [s2].

The framework sets out five strategic areas: prevention and response; monitoring and surveillance; research and innovation; laboratory capacity; and governance and enabling mechanisms [s2]. It emphasises antimicrobial stewardship, stronger surveillance systems, and equitable access to high-quality prevention, diagnosis and treatment services [s2]. WHO frames it as a response to renewed political commitment following the 2024 UN High-level Meeting on Antimicrobial Resistance, and as a multisectoral implementation roadmap [s2].

The logic of bundling these pathogens together is that drug resistance in each is monitored by different programmes with different funding, and that treatment failure in any of them undermines elimination targets set for all of them [s2].

Dr Tereza Kasaeva, who directs WHO's Department for HIV, Tuberculosis, Hepatitis and Sexually Transmitted Infections, called on all countries to address rising STI levels and to integrate gonorrhoea surveillance into national STI programmes [s1].

That is the practical ask underneath the numbers. Twelve countries reporting 3,615 cases is a sentinel network, not a global picture. Whether the ceftriaxone trend holds, accelerates or turns out to be an artefact of who joined the programme depends on how many more countries start counting.

Sources

• [s1] More countries report rising levels of drug-resistant gonorrhoea, warns WHO, World Health Organization, 19 November 2025. https://www.who.int/news/item/19-11-2025-more-countries-report-rising-levels-of-drug-resistant-gonorrhoea--warns-who
• [s2] WHO launches new framework to tackle drug resistance to HIV, hepatitis B and C, and STIs, World Health Organization, 24 November 2025. https://www.who.int/news/item/24-11-2025-who-launches-new-framework-to-tackle-drug-resistance-to-hiv-hepatitis-b-and-c-and-stis