Drug-resistant gonorrhoea cases are spiking globally, with the World Health Organization warning that the sexually transmitted infection is in danger of becoming one of the first diseases for which no antibiotic treatment remains effective. The unprecedented surge — there were 82 million new gonorrhoea infections worldwide in 2020, the majority in low- and middle-income countries — is being driven by the ease with which antimicrobial resistance now travels not only through hospitals but through everyday community life.
The speed and scale of modern travel, migration and dense urban living are allowing drug-resistant pathogens to move rapidly across populations and continents. What begins as a local outbreak can quickly become a global threat. Extensively drug-resistant strains of gonorrhoea first detected in Cambodia have since been identified as far afield as France and Australia. In Europe, surveillance data for 2022 recorded two isolates resistant to the last-resort antibiotic ceftriaxone, displaying both extensive drug resistance (XDR) and multidrug resistance (MDR). Germany reported autochthonous transmission of XDR gonorrhoea in 2025.
Drug resistance moves far beyond hospital walls
Too often, antimicrobial resistance is framed as a problem confined to intensive care units or cancer wards. But the bacteria that cause these infections do not stay neatly within clinical settings, and nor do they necessarily originate there. They move with and among us — across cities, borders and continents — carried not only by those who are infected but also by those who are unwittingly colonised.
While sexually transmitted infections require sexual contact to spread, drug-resistant bacteria can pass through far more routine interactions or persist on surfaces and objects long enough to travel with you. In a world where billions of journeys are made each year, and where increasing numbers of people live in dense urban settings — particularly in the fast-growing cities of low- and middle-income countries — that is a concern. It means antimicrobial resistance can circulate globally and spread among us with remarkable ease.
Evidence now shows that drug-resistant infections acquired in everyday environments are also becoming more common. Methicillin-resistant Staphylococcus aureus (MRSA) — once considered a hospital-associated bug — is increasingly being contracted in the community, and it is proving particularly dangerous for vulnerable groups such as cancer patients. Large studies report high rates of drug-resistant infections among cancer patients receiving outpatient care, with infections such as pneumonia occurring far more frequently and carrying a significant risk of death. In low- and middle-income countries, where outpatient care plays a larger role and infection prevention resources are limited, the risks are amplified.
A gene that renders bacteria resistant to last-resort antibiotics was first identified in the 1990s and quickly moved between countries until it became established all over the world within little more than a decade. This is a pattern now repeating with gonorrhoea through sexual contact, and it serves as an early warning sign for how other drug-resistant infections are spreading all around us.
The European STI surge: a warning for the world
The spike in drug-resistant gonorrhoea is part of a broader, record-breaking rise in sexually transmitted infections across Europe. In 2024, gonorrhoea cases in Europe exceeded 106,000 — a 303% increase since 2015. Syphilis cases more than doubled over the same period to nearly 45,600, while chlamydia remains the most common STI with over 213,000 cases in 2024.
A particularly concerning trend is the rise in congenital syphilis — transmitted from mother to child — which nearly doubled between 2023 and 2024, reaching its highest level since 2009. While men who have sex with men remain disproportionately affected, there are significant increases in heterosexual transmission, particularly among women of childbearing age.
Following the lifting of COVID-19 restrictions, STI cases climbed rapidly. In Spain, 2021 saw sharp surges in gonorrhoea (49%), HIV (45%), chlamydia (39%), and syphilis (32%). In England, gonorrhoea diagnoses among young people aged 15-24 nearly doubled between 2021 and 2023. By 2024, the UK Health Security Agency reported 71,802 gonorrhoea diagnoses in England — a 16% drop from the previous year — but syphilis diagnoses continued to rise by 2% to 9,535. Overall, there were nearly 169,000 chlamydia cases, 72,000 gonorrhoea cases, and 9,500 syphilis cases in England in 2024.
The limits of treatment
Neisseria gonorrhoeae has developed resistance to nearly every antibiotic used against it. Ceftriaxone is now the last remaining recommended antibiotic, but cases resistant even to this drug are increasing. This threatens to make gonorrhoea untreatable — a prospect with severe consequences, particularly in low- and middle-income countries where health systems are already under strain. A modelling study indicated that less than 7% of carbapenem-resistant Gram-negative bacterial infections in eight low- and middle-income countries received appropriate antibiotic treatment in 2019.
Globally, one in six bacterial infections is now resistant to first-line antibiotics. The World Health Organization classifies antimicrobial resistance as one of the top 10 global public health threats. It is estimated that nearly 5 million deaths globally are indirectly linked to AMR each year, with over 1 million deaths directly attributed to it. In the WHO European Region, AMR is directly responsible for approximately 133,000 deaths annually and indirectly linked to 541,000. In the UK, AMR contributes to an estimated 35,200 deaths each year, with 7,600 directly attributed.
The economic toll is substantial too: the European Centre for Disease Prevention and Control estimates that AMR costs the EU/EEA €11.7 billion annually in increased healthcare expenditure and productivity losses.
A new model for developing the right antibiotics
Drug resistance is now outpacing antibiotic development. The traditional commercial model has repeatedly failed to deliver the antibiotics most needed — particularly for populations in low- and middle-income countries, where expected returns are lowest. A new approach is required, and the development of zoliflodacin shows how this can be achieved.
Zoliflodacin (brand name Nuzolvence) is the first new treatment developed solely for gonorrhoea in decades. It was created through a public-private partnership led by the Global Antibiotic Research & Development Partnership and Entasis Therapeutics, using a not-for-profit model that prioritises access, stewardship and sustainable use across all countries over profit margins. A second new antibiotic, gepotidacin, has also been approved in the US for treating gonorrhoea. Both drugs inhibit bacterial DNA replication, offering a novel mechanism of action against resistant strains.
Such innovations are urgently needed because the threat is accelerating. By 2050, AMR-related deaths are expected to rise by 70% from the current nearly 5 million per year. The UK government has a 20-year vision to contain and control AMR, supported by five-year national action plans. The current plan (2024-2029) aims to reduce antibiotic use by 5% by 2029 and increase public knowledge of AMR. The UK has invested over £560 million in its AMR programme from 2020-21 to 2023-24.
The disappearing boundary between everyday life and high-risk settings
What makes this moment especially dangerous is not just the scale of the problem, but where the threat now lies. As drug-resistant infections take hold in the community, the boundary between everyday life and high-risk settings is disappearing. Ordinary interactions — at home, at work, in public — are becoming pathways for infections that are increasingly hard to treat. Untreated infections can lead to severe complications including infertility, and increase the risk of HIV infection. Routine medical procedures like surgery and cancer chemotherapy rely on effective antimicrobials, meaning AMR threatens the very foundation of modern medicine.
Better antibiotic stewardship can curb the overuse and inappropriate use that drive resistance, but stewardship and infection control alone cannot solve the problem. For a growing number of infections, particularly the most difficult to treat and deadly, resistance is now outpacing antibiotic development. Drugs are being lost faster than they are being replaced. The development of zoliflodacin and gepotidacin offers a glimpse of a different path — one where antibiotics are created as global public health goods, not commercial products. In the coming years, we are going to need many more such breakthroughs, because the threat is already spreading among us and it is not going to wait.
