Gonorrhoea remains a serious public health problem and is one of the most common sexually transmitted infections (STIs) in European countries [1]. Successful treatment of Neisseria gonorrhoeae infections reduces the risk of complications - such as pelvic inflammatory disease, first-trimester miscarriage, ectopic pregnancy and infertility [2] - and reduces the risk of HIV acquisition and transmission [3]. Over time, N. gonorrhoeae has developed antimicrobial resistance (AMR) to sulphonamides, penicillins, tetracyclines, macrolides, fluoroquinolones and, more recently, third-generation cephalosporins [4]. Third-generation cephalosporin treatment failures were first reported in Japan in 2000 [5], followed by further cases reported from Asia [6]. The first cases of treatment failure in the European Union/European Economic Area (EU/EEA) were reported from Norway in 2010 [7]. Subsequently, such treatment failures have been reported in the United Kingdom (UK) [8,9], Austria [10], France [11], Canada [12,13] and South Africa [14]. Initial treatment failures were to less potent third-generation cephalosporins, such as cefixime, but in 2009 the first extensively drug-resistant (as defined in [15], see Annex 1), highly ceftriaxone-resistant N. gonorrhoeae strain (H041) was identified in Japan [16]. Further ceftriaxone treatment failures of pharyngeal gonorrhoea were reported in Japan [16] before the first cases were identified in EU/EAA countries, including Sweden [16,17] and Slovenia [18], as well as in Australia [19,20]. The first case of genital infection with highly ceftriaxone-resistant N. gonorrhoeae in Europe was reported in France in 2011 [11] and two high-level ceftriaxone-resistant isolates of the same strain were also reported from Spain in 2012 [21], all of which belonged to sequence type (ST) 1407. As ceftriaxone is the last remaining option for empirical first-line monotherapy, these treatment failures triggered worldwide concern and led to the development of the 'Response plan to control and manage the threat of multidrug-resistant gonorrhoea in Europe' in 2012 [22] by ECDC together with an international expert group. Also in 2012, the 'European guideline on the diagnosis and treatment of gonorrhoea' was revised to recommend a firstline dual antimicrobial therapy consisting of a single 500 mg intramuscular dose of ceftriaxone, plus a single 2 g oral dose of azithromycin [23]. Other international gonorrhoea management guidelines were also updated to recommend similar dual antimicrobial therapies with slightly different dosages [24-26]. In 2016, the first treatment failure globally to dual antimicrobial therapy (500 mg of ceftriaxone plus 1 g of azithromycin) was reported in the UK [27]. This was followed, in 2018, by the first extensively drug-resistant N. gonorrhoeae (XDR NG) strain with ceftriaxone resistance combined with high-level resistance to azithromycin being reported from the UK [28]. This XDR NG strain caused a treatment failure of pharyngeal gonorrhoea with a single 1 g intramuscular dose of ceftriaxone plus 100 mg of doxycycline orally, twice daily for seven days, followed by a single 2 g intramuscular dose of spectinomycin. The pharyngeal infection was finally cured with 1 g ertapenem intravenously, daily for three days. Two gonococcal isolates belonging to the same XDR NG strain were identified in Australia several months later [29], with both the Australian and the UK infections linked to infections in Southeast Asia. In response, a rapid risk assessment on XDR NG in the UK and Australia was published by ECDC on 7 May 2018 [30]. The rapid risk assessment identified the following needs: to strengthen gonococcal AMR surveillance in the Western Pacific region of Asia, to enhance collaboration between the gonococcal AMR surveillance programmes in different regions globally and to collect travel history data of gonorrhoea patients in the EU/EAA. The ECDC response plan [22] published in 2012 complemented the World Health Organization(WHO) Global Action Plan [31], as well as national action plans subsequently published by the US Centers for Disease Control and Prevention [32] and Public Health England [33]. In 2019, the first update to the ECDC response plan was published [34]. It reviewed the effectiveness of the 2012 response plan, updated the indicators with data from 2017 and evaluated the achievements and progress made during the intervening years. In September 2020, EU/EEA countries were invited to provide information on the indicators for 2019, using 2017 as a baseline. Twenty-six of 31 EU/EEA countries provided data in response to this request. The present report seeks to once again review the progress made over the preceding two years, using the data collected for 2019.
