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No evidence of reduced cephalosporin susceptibility of circulating strains of Neisseria gonorrhoeae in the Netherlands despite nearly a decade of recommending ceftriaxone monotherapy
  1. Christophe Van Dijck1,2,
  2. Chris Kenyon1,3
  1. 1Department of Clinical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium
  2. 2Laboratory of Medical Microbiology, University of Antwerp, Antwerpen, Belgium
  3. 3Department of Medicine, University of Cape Town, Cape Town, South Africa
  1. Correspondence to Dr Christophe Van Dijck, Institute of Tropical Medicine, Antwerpen 2000, Belgium; cvandijck{at}

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Due to increasing antimicrobial resistance (AMR), ceftriaxone is the only remaining single-dose antibiotic effective against Neisseria gonorrhoeae.1 To preserve this treatment option, guidelines have recommended combination therapy with azithromycin since 2012.1 The rationale was that azithromycin would eradicate isolates with reduced ceftriaxone susceptibility and thereby prevent the emergence of ceftriaxone resistance.1 However, no randomised controlled trials (RCTs) have assessed if combination therapy is superior to monotherapy for the treatment of gonorrhoea in terms of efficacy or emergence of AMR. Meta-analyses have found no difference in efficacy between monotherapy and dual therapy.2 In fact, increasing macrolide exposure may promote AMR acquisition.3 These considerations have led some guidelines to change back to recommending ceftriaxone monotherapy for uncomplicated gonorrhoea, and the 2020 European guidelines now include monotherapy as an alternative.4–6

Dutch guidelines are unusual in that, unlike the rest of Europe, they never recommended dual therapy; a single 500 mg intramuscular dose of ceftriaxone has been the preferred treatment for gonorrhoea since 2011.7 This policy allowed us to test whether between 2012 and 2019, the use of ceftriaxone monotherapy in the Netherlands …

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  • Handling editor Federico Garcia

  • Contributors CK conceptualised the study. CK and CVD analysed the data and revised and finalised the manuscript. CVD drafted the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.