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3. Rise of Antimicrobial Resistance in Gonorrhea: A Threat to Women’s Reproductive Health
Authors & Affiliations
1. Veronika Tursunova
2. Mohammad Nadeem
3. Ali Haider
4. Priom Kumar Bharti
5. Dharamraj
6. Rahul Raj Gupta
7. Akash Kanshana
8. Bhoomika Pal
(1. Teacher “International Medical Faculty” Osh State University, Osh, Kyrgyzstan.)
(2-8 Students “International Medical Faculty” Osh State University, Osh, Kyrgyzstan.)
Abstract
Neisseria gonorrhoeae( NG) has consecutively developed resistance to every antimicrobial introduced for its treatment. Ceftriaxone a third- generation cephalosporin is presently the foundation of empiric remedy for uncomplicated gonorrhea worldwide. still, the recent global emergence and spread of ceftriaxone- resistant and considerably medicine- resistant NG duplicates( specially the FC428 lineage and affiliated penA mosaic- carrying strains) threatens to render infections untreatable with standard rules. This review synthesizes contemporary surveillance data, molecular mechanisms of resistance, clinical counteraccusations for women( particularly threat of pelvic seditious complaint( PID), tubal factor gravidity, and habitual pelvic pain), and current/ possible mitigation strategies. We performed a structured narrative review of peer- reviewed literature, transnational surveillance reports, and guideline updates( 2015 – 2025). substantiation indicates that ceftriaxone- resistant isolates have circulated internationally, frequently via sexual networks and trip, and employ mosaic penA alleles( e.g., penA- 60.001), efflux pump and porin changes to increase MICs. Clinically, delayed effective remedy or treatment failure increases the threat of thrusting infection, intermittent PID, tubal damage and consequent gravidity and habitual pelvic pain. critical precedences include enhanced surveillance( molecular phenotypic), forestallment( webbing, mate treatment), stewardship, accelerated development of new antimicrobials(e.g., gepotidacin) and contingency treatment algorithms. The gynecologic community must prepare for an period when standard first- line remedy is unreliable, with counteraccusations for prenatal care, PID operation, fertility preservation and health policy.
(Keywords : emerging ceftriaxone-resistant strains; impact on PID, infertility, chronic pelvic pain)
Introduction
Neisseria gonorrhoeae remains one of the most common bacterial sexually transmitted infections( STIs) encyclopedically, with major counteraccusations for women’s reproductive health. Historically, gonococcus has evolved resistance to sulfonamides, penicillins, tetracyclines, macrolides and fluoroquinolones; third- generation cephalosporins( ceftriaxone/ cefixime) have been the last extensively effective class for empiric remedy. still, recent times have seen the emergence and transnational spread of strains with reduced vulnerability and foursquare resistance to ceftriaxone most specially those belonging to the FC428 lineage carrying mosaic penA alleles( e.g., penA- 60.001) raising the specter of untreatable gonorrhea. The consequences are especially grave for women because undressed or deficiently treated cervical infection constantly ascends to beget pelvic seditious complaint( PID), which in turn is a major cause of tubal factor gravidity, ectopic gestation and habitual pelvic pain. This composition reviews the epidemiology of ceftriaxone- resistant NG, molecular mechanisms bolstering resistance, clinical impact on PID and reproductive sequelae in women, and strategies for clinicians and public health.
Methods
This composition is a focused narrative review using structured quests of PubMed/ PMC, major public- health agency websites (WHO, CDC, ECDC), and leading contagious complaint journals (Lancet Infect Dis, Clin Infect Dis, Eurosurveillance) for primary data, surveillance reports and reviews published between 2015 and 2025. Search terms included “ceftriaxone- resistant Neisseria gonorrhoea, FC428, penA mosaic, gonorrhoea antimicrobial resistance, pelvic seditious complaint gravidity , and gonorrhea treatment failure ”. Reports of novel resistant isolates, molecular medium reviews, guideline changes( CDC 2020/2021, WHO EGASP) and papers quantifying PID sequelae were prioritized. Where possible,multi-country surveillance and genomic epidemiology studies were used to establish global dispersion patterns.
Summaries below synthesize phenotypic, genotypic, and clinical outgrowth data applicable to gynecology practice.
Results
1. Emergence & transnational spread of ceftriaxone- resistant strains
Since the discovery of the FC428 clone in Japan (first described around 2015) and posterior discovery of affiliated isolates worldwide, sporadic but decreasingly frequent reports of ceftriaxone - resistant NG have been proved in Asia, Europe, Australia and North America. These isolates generally carry mosaic penA alleles (specially penA- 60.001) associated with elevated ceftriaxone minimum inhibitory attention (MICs); some isolates also show elevated azithromycin MICs or high- position azithromycin resistance, creating XDR phenotypes. Surveillance reports (EGASP, ECDC) and case series emphasize transnational dispersion via trip and sexual networks.
2. Molecular mechanisms of ceftriaxone resistance
Crucial mechanisms include (a) mosaic penA alleles garbling altered penicillin- binding protein 2 (PBP2) that reduce affinity for cephalosporins, (b) increased efflux via mtrR and affiliated controllers, and (c) porin (PorB) mutations that reduce medicine affluence. The penA mosaic armature seems to arise from recombination events with commensal Neisseria species; particular alleles (e.g., penA- 60.001) are constantly intertwined in resistant outbreaks. The combination of multiple small- effect mutations yields clinically significant MIC increases.
3. Clinical reports of treatment failure & remedial counteraccusations
Proved ceftriaxone treatment failures and isolates with ceftriaxone MICs above breakpoints have led to original treatment acclimations, including use of advanced ceftriaxone boluses, carbapenems( e.g., ertapenem) in select cases, or newer agents in clinical trials. The CDC streamlined recommendations to 500mg IM ceftriaxone (2020) as a response to evolving vulnerability data; still, where resistance renders ceftriaxone ineffective, empiric rules may fail, dragging infectiousness and allowing thrusting infection. New agents (e.g. gepotidacin) have shown pledge in phase III trials but are n't yet widely available.
4. Impact on PID, gravidity & habitual pelvic pain in women
Epidemiologic and cohort studies attribute a substantial proportion of PID occurrences and their sequelae to sexually transmitted pathogens, generally Chlamydia trachomatis and N. gonorrhoeae. Compared with chlamydia, gonorrhea is associated with a advanced short- term threat of clinically overt PID taking hospitalization, and both pathogens contribute to tubal scarring, gravidity and habitual pelvic pain when treatment is delayed or ineffective. The threat of gravidity increases with thrusting infection and intermittent PID occurrences; thus antimicrobial resistance that causes treatment failure directly increases the threat of reproductive morbidity in women.
5. Surveillance gaps & geographic diversity
Global surveillance is uneven high- income countries frequently have better capacity for culture, MIC testing and genomic analysis, while low and middle income regions where burdens are frequently loftiest have meager AMR data. This creates eyeless spots for early discovery of spread and undermines global response. WHO’s EGASP and public programs aim to expand quality- assured surveillance to close these gaps.
Discussion
Trouble pathway How AMR in gonorrhea amplifies reproductive detriment
The unproductive pathway linking ceftriaxone resistance to adverse reproductive issues in women proceeds through several linked marvels.
Treatment failures and delayed cure. When first- line remedy fails, cervical infection persists longer, adding the chance of thrusting infection to endometrium and fallopian tubes. proved ceftriaxone treatment failures however still comparatively rare - demonstrate this threat.
Increased probability of PID and severe PID. NG is a potent pathogen for upper genital tract sowing. Studies show that gonorrhea confers a advanced short- term threat of hospitalization for PID compared with chlamydia; intermittent or severe PID is more likely to leave endless tubal damage.
Gravidity, ectopic gestation and habitual pelvic pain. Tubal scarring from PID is a leading cause of tubal factor gravidity and increases ectopic gestation threat; habitual pelvic pain is a common long- term morbidity. Gravidity threat rises with the number and inflexibility of PID occurrences. Accordingly, antimicrobial resistance that increases the liability of failed or delayed eradication will increase these downstream reproductive damages.
Clinical operation counteraccusations for gynecology practice
Jacked individual alert. In areas with proved ceftriaxone resistance, clinicians should maintain dubitation
for patient NG infection after remedy and consider test of cure (TOC) for characteristic women or those at high threat. Culture with MIC determination or molecular resistance labels (where available) is important to descry resistance.
Partner announcement and expedited mate remedy. Rapid mate treatment reduces reinfection threat, a crucial motorist of repeated PID occurrences and accretive tubal damage. Mathematical models indicate undressed mates mainly increase reinfection chances.
Indispensable rules and salvage remedy. Case reports and small series describe use of ertapenem or other rules for verified ceftriaxone- resistant infections; newer oral agents (e.g. gepotidacin and zoliflodacin) are in late- stage trials and may expand options if approved and accessible. Stewardship is critical to save new agents.
PID operation algorithms. In settings with high AMR threat, empiric PID rules may need adaption; still, robust substantiation to change standard PID rules is limited and must balance diapason, toxin and stewardship. Beforehand surgical discussion for tubo- ovarian abscess and outpatient parenteral remedy remain essential where indicated.
Public health & system responses needed
Scale up surveillance (Phenotypic genomic). Rapid identification of resistant strains (Culture MIC testing, whole- genome sequencing) supports outbreak discovery and targeted public- health action. WHO’s EGASP expansion is a crucial step.
Investment in diagnostics and point of care resistance testing. Molecular assays that descry resistance- associated mutations could permit acclimatized remedy at point of care, reducing ineffective empiric treatments. Research into affordable, robust resistance diagnostics is critical.
Prevention webbing, condoms, and education. Routine webbing of sexually active women, especially adolescents and pregnant persons per original guidelines, plus corroborated condom creation can reduce prevalence and hence the picky pressure for resistance. For pregnant women, prenatal webbing for syphilis and gonorrhea is critical to help obstetric/ neonatal sequelae.
Antimicrobial development & indifferent access. Pipeline agents need accelerated study, nonsupervisory blessing, and indifferent global access. Guarding new medicines from rapid-fire resistance requires stewardship fabrics at rollout.
Limitations of current substantiation
Important of the literature on ceftriaxone resistance comprises case reports, surveillance shots and genomic surveillance; experimental substantiation links patient/ undressed infection to PID sequelae but direct occasion between AMR emergence and population- position increases in gravidity remains to be strictly quantified. Global surveillance gaps, especially in low- resource settings, limit precise burden estimates.
Conclusion And Recommendations
Ceftriaxone resistant Neisseria gonorrhoea poses a substantial and growing trouble to women’s reproductive health by adding the threat that cervical infection will persist and lift to beget PID, tubal damage, gravidity and habitual pelvic pain. The gynecology community must engage clinically and at the public- health interface by
Enhancing clinical alert use test of cure where indicated, insure mate treatment, and consider culture/ MIC or resistance testing for patient infections.
Championing for surveillance And diagnostics support participation in public/ indigenous AMR surveillance and relinquishment of molecular resistance tests as they come validated.
Prioritizing forestallment - webbing, condom creation, and sexual health education to reduce prevalence.
Preparing for new rectifiers cover arising data on new antimicrobials (e.g., gepotidacin, zoliflodacin), plan stewardship programs, and advocate for indifferent access.
Without coordinated clinical mindfulness, strengthened surveillance, and investment in new rectifiers and diagnostics, the projected spread of ceftriaxone resistant NG could mainly increase the burden of PID related gravidity and habitual pelvic pain in women worldwide. Gynecologists are on the frontal line of discovery, operation and forestallment and must be mates in the response.
References
l Adamson, P. C., et al. (2024). Ceftriaxone resistance in Neisseria gonorrhoeae: clinical reports and implications. The Lancet Infectious Diseases.
l Bayoumi, R. R., et al. (2024). A critical systematic review and meta-analyses of risk factors associated with fertility problems. [Journal].
l CDC. (2020). Update to CDC’s Treatment Guidelines for Gonococcal Infection. MMWR.
l Chen, Y., et al. (2025). Emerging epidemic of predominant clusters of FC428 subclones. [Journal].
l Day, M. J., et al. (2022). Significant increase in azithromycin resistance and surveillance within EU/EEA. BMC Infectious Diseases.
l Eyre, D. W., et al. (2018). Detection in the United Kingdom of the Neisseria gonorrhoeae FC428 clone. Eurosurveillance.
l Golparian, D., Rose, L., Lynam, A., et al. (2019). Multidrug-resistant N. gonorrhoeae isolate belonging to FC428 clone. Euro surveillance.
l Haggerty, C. L., et al. (2010). Risk of sequelae after Chlamydia trachomatis genital infection in women. The Journal of Infectious Diseases.
l Liao, Y., et al. (2024). penA profile of N. gonorrhoeae in Guangdong, China. [Journal of Microbial Resistance].
l Lancet/WP Commission (Lan, P. T.). (2025). The WHO EGASP analysis and AMR trends. Lancet World Public Health.
l Mlynarczyk-Bonikowska, B., et al. (2022). Molecular mechanisms of drug resistance in N. gonorrhoeae. Frontiers/PMC review.
l Merrick, R., et al. (2022). National public health response to ceftriaxone resistance, England 2013–2020. [Public Health Journal].
l Nguyen, (author placeholder). (2023). Identification of ceftriaxone-resistant Neisseria gonorrhoeae in China. J Antimicrobial Chemotherapy.
l Peng, J. (2023). Identification of ceftriaxone-resistant N. gonorrhoeae: penA mutations. [Preprint/Journal].
l Peyvandi / Pavletic, A. J. (1999). Infertility following pelvic inflammatory disease. [Journal: PubMed].
l Price, C. (various). (2013–2018). Studies of gonorrhea and PID risk in population cohorts. Clinical Infectious Diseases / CID.
l St Cyr, S. S., et al. (2020). CDC STI Treatment Guideline Update Summary. CDC MMWR.
l Sweet, R. L. (2011). Treatment of acute pelvic inflammatory disease. Clinical Therapeutics / Review.
l The WHO. (2024–2025). WHO Gonorrhoea treatment optimization and EGASP reports. World Health Organization.
l UK/England public health reports (Eyre, DW; Eyre et al.). (2018–2019). UK detection of combined ceftriaxone/azithromycin resistant strains. Eurosurveillance.
l Van der Veen, S., et al. (2023). Global transmission of penA-60.001 containing FC428 subclones. Review/technical brief.
l Wang, D., et al. (2023). Molecular epidemiology analysis of resistant N. gonorrhoeae in Shenzhen. International Microbiology & Drug Resistance.
l WHO news releases and analyses (2025). Rising levels of drug-resistant gonorrhoea. WHO News.
l World Bank / Global Burden analyses and reviews on AMR (FT / Lancet coverage). (2024–2025). Financial Times / Lancet.
l Zoliflodacin / Gepotidacin trial reports (Lancet, 2025). (2025). New agents for gonorrhea — trial outcomes. Lancet.
l European Centre for Disease Prevention and Control (ECDC). (2019). Extensively drug-resistant gonorrhoea dissemination risk briefing.
l Day, M. J., et al. (2022). EU/EEA surveillance of NG resistance trends and azithromycin resistance rise. BMC Infectious Diseases.
l Jennison, A. V., et al. (2019). Genetic relatedness of ceftriaxone-resistant and azithromycin high-level resistant cases, UK & Australia. Eurosurveillance.
l ResearchGate / case reports (Ko K.K.K. et al.). (2019). First case of ceftriaxone-resistant NG in Singapore: clinical and molecular details. Antimicrobial Agents & Chemotherapy.
l Clinical Infectious Diseases / Reviews on sequelae of STIs and infertility (Tsevat et al., 2017). Clinical Microbiology Reviews.
l Reekie, J., et al. (2018). Risk of PID in relation to chlamydia and gonorrhea testing & positivity — cohort data. Clinical Infectious Diseases.
l MedRxiv / recent preprints and country investigations (McHugh et al., 2024). (2024). Investigations of ceftriaxone-resistant NG in Scotland and UK surveillance updates.
