Background: Gonorrhoea resistance surveillance relies on the N. gonorrhoeae reaching a laboratory. However, in many low-and-middle-income settings, STI management is mostly syndromic, and often without clinical assessments, specimen collection or diagnostic test. Consequently, the pathogens driving antimicrobial resistance rarely undergo laboratory testing. This study presents preliminary data from Tamale, Northern Ghana, quantifying syndromic management and assessing its implications for N. gonorrhoeae resistance.
Methods: A cross-sectional, multi-component survey was conducted in February-April 2026 among community adults (n=150), medicine outlet operators (37), comprising pharmacy (n=21/37) and licensed over-the-counter medicine shop (OTCMS) operators (n=16/37), and medical doctors at hospitals/clinics (n=16). Survey instruments assessed STI symptom management, antibiotic acquisition routes, testing intentions and barriers, treatment failure, and provider assessments of antibiotic resistance burden.
Results: Among community respondents reporting STI-compatible symptoms, 63.4% (26/41) purchased antibiotics without clinical assessment. Of these, 43.9% (18/41) purchased antibiotics from a pharmacy and 19.5% (8/41) from OTMCS operators, while 19.5% (8/41) had clinical assessment at a hospital/clinic. Of those who answered the paid-testing question, testing willingness was 63.5% (94/148), except for one non-respondent; it increased to 81.6% (120/147) if testing were free. Definitive refusal decreased from 15.5% (23/148) to 2.7% (4/148), confirming a structural rather than attitudinal barrier to testing. Among antibiotic users answering course-completion question (n=107), 42.1% (45/107) did not complete. Respondents to escalation due to treatment failure (n=70), 17.1% (12/70), increased the dose independently. Notably, OTCMS in communities without health facilities or pharmacies admitted to dispensing antibiotics non-compliantly. Operators highlight that stigma deters STI patients from appropriate facilities, making the OTMC the only accessible treatment point. No specimens from these encounters enter any gonorrhoea surveillance systems. Gonorrhoea was the most suspected STI by 75.0% (12/16) of clinicians, who also rated the need for new effective antibiotics as urgent.
Conclusions: The STI care chain in Tamale generates sustained yet unmeasured selection pressure on N. gonorrhoeae through treatment mismatching, incomplete courses, and dose escalation, all outside any surveillance framework. This resistance is not locally contained but mobile and transmissible globally. Gonorrhoea AMR control strategies that exclude LMIC informal and syndromic care pathways will monitor only the resistance they can detect.