1 Introduction
Neisseria gonorrhoeae is a sexually transmitted infection (STI) that affects both men and women
. It is a Gram-negative diplococci that can infect the urogenital, rectal, and pharyngeal sites [
1]. While males and females can both experience dysuria and purulent urethral discharge, the majority of cases of gonorrhea are asymptomatic [
2]. Untreated infections can cause severe complications, ranging from epididymitis and salpingitis to pelvic inflammatory disease, ectopic pregnancy, and infertility. Gonorrhea can also complicate pregnancy and be transmitted to children, causing blindness if untreated.
N. gonorrhoeae, like other STIs, can facilitate the transmission and acquisition of the human immunodeficiency virus [
3].
Overall,
N. gonorrhoeae is a major public health threat worldwide. It is the second most common bacterial STI in the world after
Chlamydia trachomatis [
4]. The World Health Organization (WHO) estimated there were 87 million new
N. gonorrhoeae cases worldwide in 2016, an increase from 78 million in 2012 [
5,
6].
Complicating the increase of
N. gonorrhoeae infections observed globally has been the emergence of antimicrobial-resistant
N. gonorrhoeae.
N. gonorrhoeae has developed resistance to every class of currently available antibiotic [
7]. The WHO lists
N. gonorrhoeae as a “priority pathogen” for which new therapies are urgently needed [
8]. The current recommended treatment by the WHO is dual therapy with ceftriaxone and azithromycin, although in many countries single-dose ceftriaxone or cefixime is used [
9,
10].
N. gonorrhoeae strains exhibiting resistance to both ceftriaxone and azithromycin have already been identifiied [
11,
12]. In light of this, it is essential to tailor currently available antimicrobial therapies, discover novel alternative treatments, and develop vaccines to curb both the high prevalence and growing resistance of
N. gonorrhoeae. In this review, we will discuss the epidemiology of
N. gonorrhoeae resistance globally, the current progress in new treatments, and vaccine development. All information has been gathered from relevant articles in PubMed under the search terms “
Neisseria gonorrhoeae” and “antimicrobial resistance” or “epidemiology” or “treatment” or “vaccines” published from 2010 through November 27th, 2020.
2 Timeline, Surveillance, and Epidemiology of Antimicrobial Resistance in N. gonorrhoeae
N. gonorrhoeae has an extraordinary ability to develop resistance mechanisms to antibiotics. Data on the evolution of antimicrobial resistance (AMR) show that prior to the modern use of antibiotics,
N. gonorrhoeae did not harbor AMR elements and that resistance has been driven by the widespread use and misuse of antibiotics [
13,
14]. With the introduction of each new antibiotic, resistance soon followed: sulfonamides (1930s, 90% resistance by 1940s), penicillins (1943, no longer recommended 1989), spectinomycin (1961, reported resistance rapidly emerge in 1987), tetracyclines (1962, high-level resistance reported in 1985), fluoroquinolones (1980s, no longer recommended in 2007), azithromycin (1983, no longer recommended in 2007), ceftriaxone (1980, first high-level resistance strain reported in 2009), cefixime (1983, clinical failures in Japan in 2010) [
15‐
18]. Ceftriaxone is currently the final remaining empiric treatment option, highlighting the urgent need for research and development of new antibiotics.
There are several major efforts to monitor antimicrobial susceptibilities in countries worldwide. Country-specific surveillance programs for
N. gonorrhoeae include the Gonococcal Isolate Surveillance Program (GISP) in the USA; the Gonococcal Resistance to Antimicrobial Surveillance (GRASP) in the UK; the Australian Gonococcal Surveillance Program (AGSP) in Australia; and recently, the Enhanced Surveillance of Antimicrobial-Resistant Gonorrhea (ESAG) in Canada [
19,
20]. In Europe, members of the European Union have a joint surveillance program called the European Gonococcal Antimicrobial Surveillance Program (Euro-GASP) [
19]. Although each of those programs differ slightly from each other in terms of methodology, each provide data and analysis on the trends of antimicrobial susceptibilities for treatment guidelines [
19]. The WHO established the Gonococcal Antimicrobial Surveillance Program (GASP) in 1992, with designated regional focal points collecting susceptibility data from participating countries, leading to informed regional and global treatment guidelines. However, only 77 countries reported data in 2014, and the number of countries reporting AMR data for at least one antibiotic each year has been declining [
19]. Finally, there are several other countries still in development of their gonococcal AMR surveillance programs, while other countries lack any effort due to various limitations (e.g. laboratory capacity, funding, etc.). Implementing optimal surveillance programs globally is of utmost importance [
5].
While there is an absence of data from many countries for
N. gonorrhoeae, the proportion of countries reporting resistance to ciprofloxacin from 2014–2016 was 97–100% and to azithromycin 81–83% [
21]. A recent analysis of global AMR surveillance data found the prevalence of
N. gonorrhoeae with decreased susceptibility or resistance to extended-spectrum cephalosporins (e.g. ceftriaxone, cefixime) to be ≥ 5% in China, Greenland, Norway, India, Japan, South Korea, Indonesia, Denmark, Romania, Belgium, and Malaysia [
22].
Although the data are limited, the trend by region for ceftriaxone resistance is generally as follows: (1) Europe: increasing prevalence of ceftriaxone decreased susceptibility (ceftriaxone-DS) about 15% [
23], (2) North America: low prevalence of ceftriaxone-DS, below 2% in both USA and Canada [
24,
25], (3) Oceania: low rates of ceftriaxone-DS below 2% in Australia [
26,
27], (4) Asia: high rates of ceftriaxone-DS with 35.3% (18/51) locations of the Western Pacific Region and South-East Asian Region reporting over 5% prevalence of ceftriaxone-DS [
28] notably with China around 10% ceftriaxone-DS [
29], (5) South America: although surveillance data are limited, the proportion of ceftriaxone-DS strains appears to be low based on the available country-specific data: all strains in published reports from Brazil and Peru were ceftriaxone susceptible [
30,
31], (6) Africa: similarly, surveillance data on ceftriaxone-DS strains from Africa are limited. A recent review of published articles observed no ceftriaxone resistance (ceftriaxone-R), although AMR data were absent for 42.6% of countries in the African continent [
32]. Case reports of specific nations suggest low rates of ceftriaxone-R; for example, 0.5–1.1% ceftriaxone-R in Uganda [
33], 0.1% ceftriaxone-R in South Africa [
34], 0% ceftriaxone-DS in Ethiopia [
35,
36].
Overall, it appears there are overall low rates for ceftriaxone-R < 5% in most countries. The prevalence of decreased susceptibility to ceftriaxone is also low in these countries, with the exception in certain Asian and European countries. Therefore, the dual therapy with ceftriaxone and azithromycin, as recommended by the WHO, remains sufficient for most settings [
9].
There are strains identified to have high levels of resistance to ceftriaxone. Fortunately, those strains have mostly been sporadic [e.g. H041 in Japan (2009) [
7], F89 in France (2010) [
37], A8806 in Australia (2013) [
38], and GU140106 in Japan (2014) [
39]]. However, one ceftriaxone-R strain, FC428, has been identified in several countries including Australia [
40], Canada [
41], China [
42‐
45], Denmark [
40], Ireland [
46], and Japan [
40]. Moreover, strains of this clone have been identified with intermediate resistance to azithromycin (2018) [
12,
46] and multidrug resistance (MDR) status (2019) [
47]. Aside from FC428, a ceftriaxone-R clone deemed A2543 demonstrating high resistance to azithromycin has been found in both the UK and Australia [
11].
While resistance to ceftriaxone and azithromycin is low, there are three goals that should be pursued in order to curb the spread of antimicrobial-resistant N. gonorrhoeae: (1) tailoring treatments to patient-specific N. gonorrhoeae strains, (2) developing novel treatments for gonorrhea, and (3) developing a vaccine for N. gonorrhoeae.
4 Vaccine Development for N. gonorrhoeae
As
N. gonorrhoeae continues to develop resistance to antimicrobial treatments, development of a vaccine is critical. Mathematical modeling suggests that even with a vaccine with 7.5 years of protection and 100% efficacy or a vaccine with durable protection and 50% efficacy, gonococcal infections can be reduced up to 90% after 20 years if vaccination is administered in early adolescence [
131]. However, vaccine efforts in the past have been largely unsuccessful. In the 1970s, a crude, killed whole-cell vaccine was successful in developing an antibody response but failed to induce an adaptive immune response in clinical trials [
132,
133]. Another vaccine utilized the gonococcal pilin, but failed in a large field trial and heterologous challenge study, attributed to the antigenic variation of the pili [
134‐
136]. A third unsuccessful attempt focused on the porin protein, also attributed due to genetic variation [
134]. In general, vaccine development is impeded by the lack of natural acquired immunity that can be developed to
N. gonorrhoeae due to its diverse antigenic variation and multiple mechanisms of immune evasion and its host restriction to humans [
137,
138]. However, further elucidation of the mechanisms of
N. gonorrhoea for evading the immune system, [
139‐
143] humanized mouse models [
144‐
147], and the discovery of promising targets have reignited efforts for vaccine discovery.
4.1 Current Efforts and Targets for N. gonorrhoeae Vaccine Discovery
The first report of potential protective immunity against gonorrhea was from a case-control study by Petousis-Harris et al, involving the MeNZB vaccine against
N. meningitidis in New Zealand. That study used reported gonorrhea cases in New Zealand from 2004 to 2016 and found that those who received the MenNZB vaccine had lower infection rates with an estimated vaccine effectiveness of 31% [
148]. A subsequent retrospective cohort study by Paynter et al. found MeNZB to have a 24% effectiveness against hospitalizations due to gonococcal infections, providing support of the vaccine’s cross-protectivity [
149]. While the efficacy was low and dropped to 9% in 5 years [
150], the durability is less of a concern because the risks of gonorrhea infections substantially decrease after age 30, making lifetime protection less important [
151]. Other studies have also supported the potential protection of the meningococcal serogroup B vaccines against gonorrhea. Analyses of gonorrhea rates in Cuba and Norway both showed decreases in the incidence after their respective MenB vaccination campaigns [
152,
153].
The MeNZB vaccine is no longer available, but a newer serogroup B vaccine, 4CMenB called Bexsero, has the same outer membrane vesicle (OMV) components as in MeNZB, in addition to three recombinant proteins, of which Neisserial heparin binding antigen (NHBA), a target found to be important for gonococcal colonization and survival [
127], is conserved and expressed on the surface of
N. gonorrhoeae [
154]. Not only has the vaccine successfully demonstrated anti-gonococcal antibodies induced by the OMVs, but it has also generated anti-gonococcal NHBA antibodies, putting forth another source of protection from
N. gonorrhoeae [
154]. These results have been further validated by mouse studies examining the cross-protection offered by the vaccine, in which accelerated clearance rates and reduced burden of
N. gonorrhoeae have been found with antibodies recognizing several
N. gonorrhoeae surface proteins including NHBA [
155]. Bexsero is currently undergoing Phase II clinical trials (NCT04350138) with an estimated completion date in August 2023 [
156].
There are also revived efforts to develop a whole-cell–based vaccine for
N. gonorrhoeae. Recently, Gala et al. developed a transdermal whole-cell–based inactivated gonococcal microparticle vaccine formulation [
157]. The proposed advantages over prior vaccines and other whole-cell preparations are (1) the use of formalin-fixed whole gonococci, protecting all immunogenic epitopes from degradation, and (2) the use of microparticles, which mimic the shape of the
N. gonorrhoeae cocci shape, thereby activating the immune system without suppressing it, and (3) transdermal administration using microneedles enabling slow, sustained release of antigens to enhance their uptake [
157]. Thus far, the vaccine has only been evaluated in vitro and in vivo mouse models, in which a significant increase in antigen-specific IgG titers was observed [
157]. Further optimization and evaluation of whether this vaccine can provide immunity to challenge with the isogenic vaccine strain, along with cross-protection against various
N. gonorrhoeae strains are required.
Moreover, there are efforts in the development of alternative methods of antigen presentation for vaccination. Gala et al, as described above, utilized microparticles to mimic cocci shape [
157]. Jiao et al. designed a
N. gonorrhoeae DNA vaccine delivered by
Salmonella enteritidis bacterial ghosts, which are empty bacterial cell envelopes [
158]. Bacterial ghosts enabled excellent DNA loading capacity with delivery to both professional and non-professional APCs, resulting in higher levels of
N. gonorrhoeae PorB-specific serum antibodies than without ghosts in mice [
158]. Wang et al. are working to employ
Helicobacter pylori ferritin nanoparticles to present
N. gonorrhoeae antigens for vaccine development [
159]. This presenting system has been successfully demonstrated by Kanekiyo et al. with the Influenza and Epstein-Barr virus, resulting in more robust immune responses and protection against the viruses [
160,
161].
In addition to the OMVs and NHBA described above, there are many other potential vaccine targets. In general, an ideal target would be one that is highly conserved among
N. gonorrhoeae strains. First, many of the above targets in
N. gonorrhoeae for novel antimicrobial therapy have also been suggested as potential candidates as vaccine targets (Table
1), such as the proteins
N. gonorrhoeae use for complement evasion, nutrient uptake, protein synthesis machinery, lysozyme inactivation, and host-glycan binding. For example, one protein of the aforementioned β-barrel outer membrane complex, BamA, has been shown to be ubiquitously expressed under different growth conditions and elicit antibodies that cross-reacted with several diverse
N. gonorrhoeae strains [
162]. Zielke et al. also demonstrated that depletion of BamA resulted in loss of strain viability. Further research on these targets should be prioritized to facilitate development with respect to both treatment and vaccine.
Regardless, there are several other promising targets for vaccination as well (Table
2). For example, another target of interest is the lipooligosaccharide (LOS)-derived epitope 2C7. Although in general LOS widely varies by phase variation, 2C7 is a broadly expressed virulence determinant that has been found to be critical for gonococcal colonization in the experimental setting [
163]. Gulati et al., who immunized mice with a peptide mimic of 2C7, found cross-reactive IgG antibodies with complement-dependent bactericidal activity that resulted in faster clearance of vaginal colonization and lower gonococcal burdens [
163]. Based on this prototype peptide mimic vaccine, Gulati et al. have developed a tetrapeptide derivative in order to generate a homogeneous and stable vaccine candidate TMCP2 [
164]. When evaluated with two different
N. gonorrhoeae strains in mice, TMCP2 resulted in bactericidal IgG with reduced colonization levels and accelerated clearance, making TMCP2 a promising step forward towards an effective
N. gonorrhoeae vaccine [
164]. Other vaccine targets are listed in Table
2. As more efforts for a
N. gonorrhoeae vaccine are revived, the recent elucidation of these novel targets and
N. gonorrhoeae’s biological mechanisms of survival provide hope for a successful vaccine.
Table 2
Targets of interest for Neisseria gonorrhoeae vaccine development
Six gonococcal proteins expressed during human mucosal infection | Antibody-generation with bactericidal activity against N. gonorrhoeae in mice | |
L-methionine binding lipoprotein MetQ | Displayed on surface of ~ 97% N. gonorrhoeae worldwide, with promising results in mice | |
Lipooligosaccharide-derived epitope 2C7 | 2C7 is broadly expressed amongst N. gonorrhoeae and is critical for gonococcal infection. Tetrapeptide derivative of derivative vaccine TMCP2 developed | |
MtrE protein and its Surface-expressed loop “Loop 2” | MtrE is part of the MtrCDE multidrug transporter system. Generated MtrE-dependent bactericidal activity when used to immunize mice | |
Neisseria gonorrhoeae adhesin complex protein (Ng-ACP) | Rabbit antiserum to recombinant Ng-ACP prevented inhibition of human lysozyme w/100% efficacy | Almonacid-Mendoza et al. [ 176] |
Recombinant truncated N. meningitidis macrophage infectivity potentiator protein (rT-Nm-MIIP) | rT-Nm-MIIP induced cross-reactive antibodies with bactericidal activity against certain N. gonorrhoeae strains in mice | |
Transferrin binding proteins A and B (tbpA and tbpB) | Both are ubiquitously expressed and induced systemic vaginal antibodies in mice, though weak immune response and negligible role in survival | |
Nitrite reductase AniA | Outer membrane glycoprotein essential for growth and survival under O2-limited conditions | |
Outer membrane porin protein B (PorB) | Highly conserved and of interest but has failed to show promising results in vaccine development. Correlates with protection with Th1 response but not antibody response | |
5 Conclusion
In this review, we covered the current status of antimicrobial-resistance in N. gonorrhoeae globally, discussed the importance of tailoring currently used antimicrobial treatments, and reviewed the progress of the development of novel treatments and vaccines. Antimicrobial resistance in N. gonorrhoeae is rising globally. Although prevalence of resistance and decreased susceptibility to ceftriaxone, the most-widely used first-line treatment, is low, the identification of strains with high resistance to ceftriaxone highlight the need for urgent action. Expanded global surveillance of AMR in N. gonorrhoeae is surely needed. In addition, the development of molecular assays to predict ceftriaxone resistance could improve detection and treatment of these infections. Approaches including the re-purposing of antibiotics could reduce our reliance on ceftriaxone. The number of antibiotic treatments for N. gonorrhoeae is extremely limited and there are few potential candidates in development, including zoliflodacin and gepotidacin, both of which are in Phase III clinical trials. There are novel agents in the early stages of investigation, but it will likely be several years before they reach clinical trials, if at all. In addition, efforts to develop vaccines have recently been revived with different modalities of delivery and utilization of highly-conserved surface components of N. gonorrhoeae strains. We have highlighted a few of these targets and summarized their pre-clinical success as in eliciting robust immune responses and effective clearance of N. gonorrhoeae. Overall, significant progress has been made towards combatting the spread of N. gonorrhoeae, but there is still significant work to be done towards effectively countering N. gonorrhoeae as a global health threat.