Introduction:
According to the World Health Organization’s (WHO) 2017-2018 gonococcal antimicrobial surveillance report, increasing resistance in Neisseria gonorrhoeae strains is compromising gonorrhea treatment globally (1, 2).
Methods:
In Uganda, the WHO Enhanced Gonococcal Antimicrobial Surveillance Program (EGASP), was instituted in to monitor resistance trends of Neisseria gonorrhoeae. Surveillance is conducted at four sentinel sites within Central Uganda, which are linked to a national reference laboratory. Males presenting with urethral discharge, who meet inclusion criteria are subjected to a 1-page questionnaire before providing urethral swabs. The swabs undergo culture and Neisseria gonorrhoeae isolates are identified using microscopy and biochemical tests. Antimicrobial susceptibility testing is conducted using the E-test (bioMérieux, France) gradient diffusion method, with results interpreted according to Clinical Laboratory Standards Institute guidelines (3). Isolates are considered resistant to Azithromycin if minimum inhibitory concentrations (MICs) ≥2.0µg/mL as per WHO EGASP protocol (3). Data is collected on sociodemographic characteristics, sexually transmitted infections history, sexual partners, antibiotic use history, HIV status, travel history and condom use.
Results:
Since July 2022, 1247 men have presented with urethral discharge, 69.61% (868/1247) of whom have had culture confirmed Neisseria gonorrhoeae. Amongst these isolates, there was no resistance to Azithromycin before July 2024 Figure 1. Between July 2024 and December 2025, 470 Neisseria gonorrhoeae isolates were obtained, of which 4.04% (19/470) were resistant to Azithromycin. The men from whom these resistant isolates were isolated had a median age of 24 years (IQR: 22.5, 50), had a median of two sexual partners each (IQR 1,4) and the median MIC for Azithromycin on E-test was 256µg/mL, far above the global MIC alert level of ≥2.0µg/mL as per CLSI and WHO EGASP guidelines Table 1.
Conclusions:
The increasing number of azithromycin-resistant Neisseria gonorrhoeae isolates is a cause for concern, particularly given that no prior cases of resistance had been reported in Uganda. The detection of high-level resistance to azithromycin underscores the urgent need for molecular surveillance and evidence-based clinical policies in the management of gonorrhoea. We highlight this emerging trend to encourage stringent monitoring, consideration for genomic surveillance in Uganda, and continued investment in antimicrobial resistance surveillance systems.