Managing treatment failure in Neisseria gonorrhoeae infection: current guidelines and future directions

Due to the continued emergence of resistance to extended-spectrum cephalosporin antibiotics, clinicians are increasingly more likely to encounter cases of Neisseria gonorrhoeae treatment failure. The current international treatment guidelines offer few regimens for cases of N gonorrhoeae infection that do not respond to first-line therapy, and there are many complexities that should be considered with such regimens; these include regional variations in resistance to alternative agents, access to different antibiotics, and penetration of those antibiotics within different tissues. Further, such regimens do not account for the challenges of treating pharyngeal infections; many patients who have not responded to treatment with extended-spectrum cephalosporin antibiotics to date have had pharyngeal involvement. In addition, pharyngeal infections play a pivotal role in the emergence and spread of antimicrobial resistance in N gonorrhoeae and are more difficult to treat than urogenital infections because of the unfavourable pharmacokinetics of cephalosporins in pharyngeal tissues. Here, we summarise the current guidelines, provide additional approaches and considerations for clinicians, and highlight knowledge gaps that should be addressed to ensure appropriate therapy in cases of treatment failure.