Antimicrobial resistance in Neisseria gonorrhoeae in England and Wales; findings from the gonococcal resistance to antimicrobials surveillance programme (GRASP 2024)

Background: Gonococcal resistance in England and Wales has been monitored since 2000 by the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP). Here we present the findings from the 2024 sentinel data and describe the recent trends in gonococcal susceptibility. Methods: Consecutive N. gonorrhoeae isolates from 22 clinics, collected during August-September 2024, were sent by participating laboratories to the UK Health Security Agency (UKHSA) STI Reference Laboratory (STIRL) for antimicrobial susceptibility testing. Data are linked to the national STI surveillance system and further supplemented by participating sexual health clinics. Results: N. gonorrhoeae remains highly susceptible to the first-line treatment, ceftriaxone, with just 1.7% of isolates (25/1,512) having reduced susceptibility (MIC >0.03 mg/L); 3.1% of isolates were resistant to the oral alternative treatment, cefixime (MIC >0.125 mg/L). Reduced susceptibility to azithromycin (ECOFF >1 mg/L) was 13.6%; however, most isolates (87.9%) had an azithromycin MIC of 2 mg/L, immediately above the ECOFF. Most isolates (90.6%) were resistant to tetracycline (MIC >0.5 mg/L). A quarter of isolates (25.9%) were resistant to penicillin (MIC >1 mg/L), nearly double that the proportion in the previous year. Ciprofloxacin susceptibility was predicted from genomic data; resistance decreased from 58.7 in 2023 to 46.4%. Prescribing data demonstrated excellent adherence to the UK guideline for managing infection with N. gonorrhoeae, with 97.0% of individuals receiving the recommended first-line of ceftriaxone 1g intramuscular monotherapy in 2024. Conclusions: Cefixime resistance and azithromycin reduced susceptibility levels are concerning and may have implications for their use as second-line treatments in the future. Most isolates were resistant to tetracycline, supporting limited expectations for doxyPEP in reducing N. gonorrhoeae incidence.