ProMED – Updates

Outbreak of high level azithromycin resistant gonorrhoea in England: an update

The outbreak of HL-AziR gonorrhoea in England, described in HPR in April [2016], persists. There have been 17 cases of HL-AziR gonorrhoea reported to date in 2016 compared to 15 cases for the same time period in 2015. Between November 2014 and August 2016 there have been a total of 48 confirmed and 2 probable cases (figure 1).

The initial outbreak cases reported in Leeds were all heterosexual with the majority under 20 years of age. Between November 2015 and February 2016, cases were predominantly men who have sex with men (MSM), from a slightly older age range (18-31), with the majority resident in London or the South East. Since March 2016, cases have been mixed in terms of sexual orientation and geographically dispersed.

The potential for rapid spread of HL-AziR N. gonorrhoeae among high-risk sexual networks including MSM is of particular concern. Whole genome sequencing (WGS) analysis suggests transmission between heterosexual and MSM sexual networks has occurred at least twice.

Few antimicrobials remain effective in the treatment of gonorrhoea. If azithromycin becomes ineffective against gonorrhoea, there is no “2nd lock” to prevent or delay the emergence of ceftriaxone resistance, and gonorrhoea may become untreatable. The 1st documented case in the world of gonorrhoea treatment failure to both ceftriaxone and azithromycin was reported in the UK in July this year [2016].

PHE has convened a Level 2 Incident Control Team to monitor and respond to the HL-AziR gonorrhoea outbreak. PHE has alerted clinicians in order to raise awareness of HL-AziR gonorrhoea via the British Association for Sexual Health and HIV network. A National Resistance Alert was issued to all microbiologists in October 2015 to ensure that all gonococcal isolates are tested for azithromycin and ceftriaxone susceptibility, and that all resistant isolates (MIC greater than 0.5 mg/L for azithromycin, and greater than 0.125 mg/L for ceftriaxone) are referred to PHE Colindale for confirmation and follow-up.

[REF] Fifer H, Natarajan U, Jones L, Alexander S, Hughes G, Golparian D, Unemo M (2016). Failure of Dual Antimicrobial Therapy in Treatment of Gonorrhea. N Engl J Med (23 June); 374(25): 2504-6.


A worryingly resilient strain of gonorrhea has infected 7 people in Hawaii, the CDC has confirmed. The 6 men and 1 woman were all ultimately treated by the CDC’s recommended combination treatment of ceftriaxone and azithromycin. But the Hawaii State Department of Health said lab tests showed the infections were not destroyed as quickly or as easily as they have done in all previous cases.

Health officials fear this means the incredibly common sexually-transmitted disease could become untreatable sooner than we think. Gonorrhea, chlamydia and syphilis are normally treated with a short dose of antibiotics. But at this rate, it could be just years before this method becomes ineffective

Since 2005, we have seen 4 isolated cases that showed resistance to both ceftriaxone and azithromycin. This is the 1st cluster of cases we have seen with reduced susceptibility to both drugs. The report, released on Wed [21 Sep 2016] [<>], came just hours after the United Nations held the 1st ever top-level summit on antibiotic resistance.