The first three cases of infection with extensively drug-resistant (XDR) Neisseria gonorrhoeae resistant to ceftriaxone and with high-level resistance to azithromycin (HLAziR; minimum inhibitory concentration of ≥256 mg/L.) on a global scale were reported in the United Kingdom (one) and Australia (two). These extensively drug-resistant isolates were not susceptible in vitro to the empiric first-line dual antimicrobial therapy recommended in the EU/EEA (ceftriaxone 500 mg intramuscularly together with azithromycin 2g orally as a single dose), or in Australia (ceftriaxone 500mg IM plus azithromycin 1g orally) and showed resistance to most commonly used antibiotics. Ceftriaxone and azithromycin in varying doses is widely recommended as the first-line treatment for N. gonorrhoeae and these strains are also resistant to most alternative available treatments. There are currently very limited treatment options for such cases and the spread of ceftriaxone-resistant and HLAziR N. gonorrhoeae would have a significant public health impact. In its list of priority antibiotic-resistant bacteria to guide research, discovery and development of new antimicrobials, the World Health Organization has identified N. gonorrhoeae as a high priority.
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