Upsurge in ceftriaxone-resistant Neisseria gonorrhoeae with evidence of domestic transmission in the EU/EEA and the UK

Introduction

Since 2022, an increasing number of European countries have reported cases of gonorrhoea caused by ceftriaxone-resistant Neisseria gonorrhoeae, including multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains. While early detections were mainly sporadic and often travel-associated, the situation has evolved in 2025–2026, with rising case numbers in several countries and growing evidence of domestic transmission in the EU/EEA and the United Kingdom (UK). France, Germany, Sweden and the UK have reported notable increases, while several other countries continue to detect sporadic cases. Importation from areas with higher circulation of resistant strains, particularly in South-East Asia, remains an important route of introduction, but clusters and locally acquired infections indicate that onward transmission is now occurring within Europe.

Risk assessment

For the general sexually active population in the EU/EEA who do not engage in behaviours associated with an increased probability of acquiring sexually transmitted infections (STIs), the overall risk is assessed as low. For people with multiple or frequently changing sexual partners, and those having condomless sex with casual or new partners, the risk is assessed as low-to-moderate. For people living or residing in the EU/EEA who travel to areas with increased circulation of ceftriaxone-resistant MDR/XDR N. gonorrhoeae and engage in behaviours associated with an increased probability of acquiring STIs, the overall risk is assessed as moderate. If sustained transmission of ceftriaxone-resistant MDR/XDR N. gonorrhoeae becomes established in the EU/EEA, the effectiveness of currently recommended first-line treatment regimens (ceftriaxone monotherapy or in combination with azithromycin) could be substantially reduced, potentially limiting treatment options and complicating case management. Although reported cases remain limited and to date all reported infections have been successfully treated, the increasing detections, evidence of domestic transmission, and narrowing treatment options indicate a risk of further escalation if control measures are not implemented and maintained.

Recommendations

• EU/EEA countries should strengthen gonococcal antimicrobial resistance surveillance, including culture-based testing, antimicrobial susceptibility testing and genomic surveillance, to support timely detection and reporting of ceftriaxone-resistant, MDR and XDR strains.
• Healthcare providers should ensure appropriate testing of exposed anatomical sites, prescribe treatment in line with current European and national guidelines, perform test-of-cure for ceftriaxone-resistant infections where feasible, and promptly investigate suspected treatment failures.
• Public health authorities and clinical services should reinforce partner notification and case management to prevent reinfection and onward transmission, particularly in sexual networks with multiple or frequently changing partners.
• Risk communication should provide clear, non-stigmatising messages on safer sex, regular STI testing, timely treatment and the importance of seeking testing after symptoms, potential exposure or sexual contact during travel to areas with higher circulation of resistant strains.