According to WHO, in 2017, at least 78 million people are infected with gonorrhea each year. A total of 77 countries have reported antibiotic resistance gonorrhea. Decreased condom use, increased urbanization and travel, low gonorrhea infection detection, and inadequate treatment contributed to increased drug-resistant gonorrhea.

This is similar to the European Center for Disease and Prevention Control (ECDC) regarding the cause of the increase in drug-resistant gonorrhea. These things are the various sexual activities that increase in tourists due to the phenomenon of being separated from daily routines (travel-associated gonorrhea), anonymous conditions, and norms that are not accepted by society. The prevalence of travel-related sex activities is 20% to 34%.

The discovery of the FC428 strain in antibiotic-resistant gonorrhea in Canada shows a variety of antibiotic resistance that can lead to the development of multidrug-resistant (MDR) and extended drug-resistant (XDR) strains.



Current State of Gonorrhea Resistance
There are currently two major antibiotic resistance divisions against gonorrhea, namely multidrug-resistant gonorrhea (MDR-GC) and extensively drug-resistant gonorrhea (EDR-GC).

The definitions of MDR-GC and EDR-GC are as follows:
MDR-GC is a gonorrhea infection that is resistant to any of the category 1 antibiotics (including broad-spectrum injectable/oral cephalosporins and spectinomycin) and at least 2 category two antibiotics (including penicillin, fluoroquinolones, azithromycin, aminoglycoside, and carbapenem)
EDR-GC is an infection that is resistant to two or more of the category 1 class of antibiotics and three or more category 2.
In 2016, the Canadian Ministry of Public Health reported 23,708 gonorrhea cases increased by 87%, from 34.9 cases / 100,000 population in 2012 to 65.4 cases / 100,000 in 2016.
In 2012, 7 EDR-GC isolates (0.2%) showed a decrease in cephalosporins' susceptibility and resistance to azithromycin, which then increased to 8 (0.3%) in 2013. From 2014 to 2016, the XDR-GC numbers decreased significantly. , only 1 case in 2014, 2 cases in 2015, and 1 case in 2016. Meanwhile, the MDR-GC cases increased from 6.2% (n = 189 / 3.036) in 2012 to 8.9% (n = 406 / 4,538) in 2016 in Canada.

These percentages indicate the proportion of isolates with decreased susceptibility to cephalosporins or resistance to azithromycin, followed by resistance to 2 other antimicrobials.

Furthermore, according to the European Gonococcal Antimicrobial Surveillance Program (EURO-GASP), there is an increasing trend of resistance to cefixime and ciprofloxacin antibiotics in:
heterosexuals (only men with ciprofloxacin resistance), 
older patients (> 25 years), 
and without prior chlamydia infection.
Factors Affecting Antibiotic Resistance in Gonorrhea
A review by Abraha et al. in 2018 assessed the factors associated with antibiotic-resistant gonorrhea. Some of the influencing factors are epidemiological, habitual, and clinical factors.

Epidemiological Factors
Age, sex, same-sex sexual relations, and race epidemiologically affect gonorrhea infection. Ages 20–24 years are the peak group of gonorrhea infections in the United States and Great Britain.

Men have a risk of 2 times higher than women. Same-sex sex, especially in men, has a higher rate of gonorrhea infection than heterosexual behavior.

Low socioeconomic conditions have a higher rate of gonorrhea infection. This is due to low education, difficulty in health facilities, and low knowledge of sexually transmitted infections (STIs).

Habitual factors of life
Several behavioral patterns are considered to increase gonorrhea infection. Behaviors such as multiple sexual partners, travelers, tourists who engage in sexual activity (sex tourism), commercial sex work (CSW), and abuse alcohol and drugs.

Clinical Factors
The following are some clinical factors that aggravate antibiotic-resistant gonorrhea infection:
Anatomical region of infection: in Europe, the pharynx is the most common anatomical site for antibiotic-resistant gonorrhea infection in the same sex group. Whereas in the heterosexual group, there is in the genital area.

Co-infection with HIV and other STIs: antibiotic-resistant gonorrhea infection in HIV-positive patients has a higher risk rate. The last study was only conducted on HIV-negative infections, which had an OR rate of 0.72 with a 95% CI 0.54 - 0.96.

Previous use of antibiotics: Previous use of antibiotics, such as ciprofloxacin in CSWs in the Philippines, had a higher rate of gonorrhea infection than those who did not use previous antibiotics.

Efforts to Reduce the Number of Drug-Resistant Gonorrhea
Given the increase in antibiotic-resistant gonorrhea infections and the potential dangers in the future, some efforts are needed to reduce the incidence of gonorrhea. Some ways are increasing screening and health promotion, counseling before traveling, and providing optimal treatment.

Increased screening and promotion of safe sexual activity:
Education to remove the negative stigma of gonorrhea infection
Routine checks for sexually transmitted infections
taking samples from areas of the body exposed to suspicious sexual activity

Pre-travel screening:
Pre-travel counseling for education on safe sexual activity
Check for sexually transmitted infections before traveling
Recording of suspicious sexual activity in the transmission of gonorrhea

Enhancement of specimen culture for diagnosis and laboratory tests:
Increased frequency of Nucleic Acid Amplification Tests (NAAT) in the diagnosis of gonorrhea to reduce the occurrence of antibiotic resistance to gonorrhea

Combined antibiotic therapy according to the latest consensus:
The use of combination antibiotics is adjusted to the area of ​​each patient's gonorrhea infection.
Update each combination therapy treatment
Empiric therapy was carried out within 60 days after the occurrence of suspicious sexual activity.