Background
The global emergence of multidrug-resistant Neisseria gonorrhoeae represents a major public health threat, particularly in regions with limited genomic and epidemiological surveillance. Contemporary multicentric data describing transmission dynamics, resistance trends, and extragenital disease burden from India remain scarce. We aimed to investigate the evolving epidemiology, antimicrobial resistance patterns, and circulating transmission clusters of gonococcal infection across tertiary sexually transmitted infection (STI) clinics in India.
Methods
A prospective multicentric surveillance study was conducted across five tertiary STI referral centers in India between January 2025 and March 2026. Consecutive patients with laboratory-confirmed gonorrhoea underwent standardized clinical evaluation, antimicrobial susceptibility testing, and molecular characterization of isolates. Demographic, behavioral, and microbiological data were analyzed to identify predictors of multidrug resistance and transmission clustering. Whole genome sequencing (WGS) and multilocus sequence typing were performed in a representative subset of isolates to evaluate phylogenetic relatedness and circulating resistant lineages.
Results
A total of 326 gonococcal isolates were analyzed, including 74 extragenital isolates. Multidrug resistance was identified in 31.6% of isolates, with reduced ceftriaxone susceptibility observed in 11.3%. Extragenital isolates demonstrated significantly higher multidrug resistance compared with urogenital isolates (59.4% vs 23.8%, p<0.001). WGS identified phylogenetic clustering of resistant isolates within closely related transmission networks distributed across multiple geographic regions, suggesting ongoing dissemination of high-risk gonococcal lineages. Mosaic penA alleles and concurrent mtrR and porB mutations were strongly associated with reduced ceftriaxone susceptibility. Patients reporting recent digital dating application use and multiple sexual partners demonstrated significantly higher odds of infection with multidrug-resistant strains. HIV coinfection was present in 18.7% of patients and was associated with multisite gonococcal disease.
Conclusions
This multicentric study demonstrates the emergence and interstate dissemination of multidrug-resistant gonococcal lineages in India, particularly among extragenital infections. Integration of molecular epidemiological surveillance with antimicrobial resistance monitoring is urgently required to strengthen gonococcal control strategies and guide future therapeutic policies in high-burden settings.