Heterogeneity of azithromycin resistance markers in Neisseria gonorrhoeae and challenges in implementing molecular assays for routine surveillance.
Neisseria gonorrhoeae is the second most prevalent bacterial sexually transmitted infection and a major contributor to the global antimicrobial resistance crisis. The World Health Organization (WHO) has designated N. gonorrhoeae as a high-priority pathogen due to its resistance to nearly all empirically recommended therapies. While dual therapy with ceftriaxone and azithromycin initially demonstrated efficacy, the rapid global rise in azithromycin resistance over the past five years threatens the efficacy of this regimen. Resistance mechanisms, including mutations in the 23S rRNA gene and overexpression of the MtrCDE efflux pump, are highly heterogeneous, complicating molecular diagnostic efforts. This review examines the evolving landscape of azithromycin resistance, highlighting key mechanisms of resistance, and recent epidemiological and genomic surveillance data. We discuss challenges in implementing molecular assays for routine resistance monitoring due to molecular heterogeneity in azithromycin resistance markers and emphasize the critical need for tailored approaches based on local genetic epidemiology. Enhanced surveillance and molecular diagnostics are essential to sustaining effective treatment strategies and combating gonococcal resistance.