Molecular detection ofNeisseria gonorrhoeae causes the second most prevalent bacterial sexually transmitted infection (STI) in men and women globally (42). As clinical signs of gonococcal infection may overlap with those of other STIs, laboratory testing is crucial for appropriate diagnosis and subsequent adequate treatment. The accurate diagnosis of gonorrhea relies on laboratory tests that are sensitive, specific, reproducible, and robust because of nonspecific clinical manifestations or lack of symptoms in women as well as men (43). Nucleic acid amplification tests (NAATs) have a number of recognized advantages over other diagnostic assays, which include increased sensitivity of detection and ease of sample collection (including use of self-collected samples) and transport, compared to culture-based methods (13,26,27,31,32). A number of commercial NAAT systems and assays developed "in-house" are currently in use for the detection of urogenital gonococcal infection, and their use has seen many of the anticipated benefits of NAATs. However, with increasing use of commercial and "in-house" NAAT systems over time and in different geographical settings, the need for both a considered approach to the application of NAATs and for an awareness of their limitations has arisen. These considerations include the sensitivity and specificity of the primary NAAT screening test, and where used, supplementary "confirmatory" tests as well as the prevalence of infection in various population groups (18). A number of assays have been shown to cross-react with other Neisseria species (10,20,23,29,36). The Centers for Disease Control and Prevention (CDC) (Atlanta, Georgia) and the Australian Public Health Laboratory Network have proposed a number of testing algorithms for confirmation of STIs by NAATs, which require the use of additional or supplementary assays (12,28,43). There is increasing evidence for the rise in infection in extragenital sites, which include the rectum and oropharynx, particularly in population groups of men who have sex with men (38). Commercial NAAT systems currently on the market have not been cleared by the FDA for diagnosis of specimens from the rectum, pharynx, or conjunctiva; however, as detection of N. gonorrhoeae by NAAT is more sensitive than culture (43), laboratories continue to offer these tests to diagnose extragenital gonorrhea (4). Extragenital sites carry a number of commensal Neisseria species and commonly Neisseria meningitidis, which due to having a high nucleic acid homology to N. gonorrhoeae may cross-react in the NAAT assay utilized (9). As crossreactions occur in screening assays, steps to include at least one

These data indicate outbreaks of azithromycin-resistant gonococci amongst networks of MSM and heterosexuals in New South Wales. The results also provide further evidence that azithromycin may soon be an ineffective treatment option for gonococcal infection and highlight the urgent need to explore alternative therapies.

Neisseria gonorrhoeae antimicrobial resistance (AMR) is a globally recognized health threat; new strategies are needed to enhance AMR surveillance. The Northern Territory of Australia is unique in that 2 different first-line therapies, based primarily on geographic location, are used for gonorrhea treatment. We tested 1,629 N. gonorrhoeae nucleic acid amplification test–positive clinical samples, collected from regions where ceftriaxone plus azithromycin or amoxicillin plus azithromycin are recommended first-line treatments, by using 8 N. gonorrhoeae AMR PCR assays. We compared results with those from routine culture-based surveillance data. PCR data confirmed an absence of ceftriaxone resistance and a low level of azithromycin resistance (0.2%), and that penicillin resistance was <5% in amoxicillin plus azithromycin regions. Rates of ciprofloxacin resistance and penicillinase-producing N. gonorrhoeae were lower when molecular methods were used. Molecular methods to detect N. gonorrhoeae AMR can increase the evidence base for treatment guidelines, particularly in settings where culture-based surveillance is limited.

The Australian Gonococcal Surveillance Programme (AGSP), established in 1981, has continuously monitored antimicrobial resistance in clinical isolates of <i>Neisseria gonorrhoeae</i> for more than 40 years. In 2020, a total of 7,219 clinical isolates of gonococci from patients in the public and private sectors, in all jurisdictions, were tested for in vitro antimicrobial susceptibility by standardised methods. Current treatment recommendations for gonorrhoea, for the majority of Australia, continues to be dual therapy with ceftriaxone and azithromycin. In 2020, decreased susceptibility (DS) to ceftriaxone (minimum inhibitory concentration [MIC] value ≥ 0.06 mg/L) was found nationally in 0.9% of isolates. There was one isolate, reported from Victoria in 2020, that was resistant to ceftriaxone (MIC value ≥ 0.25 mg/L). Resistance to azithromycin (MIC value ≥ 1.0 mg/L) was found nationally in 3.9% of <i>N. gonorrhoeae</i> isolates, continuing a downward trend observed and reported since 2017. Isolates with high-level resistance to azithromycin (MIC value ≥ 256 mg/L) are identified sporadically in Australia; in 2020, there was one such isolate reported in Queensland. In 2020, penicillin resistance was found in 27% of gonococcal isolates nationally, and ciprofloxacin resistance in 36%; however, there is considerable variation by jurisdiction. In some remote settings, penicillin resistance remains low, and this drug continues to be recommended as part of an empiric therapy strategy. In 2020, in remote Northern Territory, no penicillin resistance was reported, and in remote Western Australia 5/116 of gonococcal isolates (4.3%) were penicillin resistant. There was one ciprofloxacin-resistant isolate reported from remote Northern Territory, and ciprofloxacin resistance rates remain comparatively low in remote Western Australia (4/116; 3.4%).

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