In 2022, the UK Health Security Agency recorded over 82,000 cases of gonorrhea, the highest number in decades. The infection, caused by Neisseria gonorrhoeae, was once easily cured with a single shot of penicillin. Today, the standard treatment is a dual therapy: an injection of ceftriaxone plus oral azithromycin. But that regimen is under strain as the bacterium develops resistance to each drug class it encounters. At the same time, rapid diagnostic tests that could help tailor antibiotics remain largely confined to urban sexual health clinics, while patients in rural and suburban areas wait days for lab results. A 2023 study in the British Medical Journal found that patients in rural areas waited on average 5.7 days for test results, compared to 1.8 days in urban clinics, a gap that has consequences for both individual patients and public health.

A Familiar Infection Now Harder to Treat

Gonorrhea has been circulating in human populations for centuries, but its current trajectory in the UK is troubling. After decades of decline, incidence began rising around 2009, and the trend accelerated after 2020. The 82,000 cases reported in 2022 represent a rate of roughly 140 per 100,000 population, with the highest burden among young adults aged 15 to 24. The World Health Organization lists resistant gonorrhea as a high-priority pathogen, and the UK is not immune to the global pattern.

The infection often causes no symptoms, especially in women, where up to half of cases are asymptomatic. When symptoms do appear, they include discharge, pain on urination, and — in women — pelvic pain that can progress to pelvic inflammatory disease, ectopic pregnancy, or infertility. In men, untreated infection can lead to epididymitis and, rarely, disseminated infection affecting joints and skin. The public health stakes are high: each untreated case fuels onward transmission and, critically, gives the bacterium more opportunities to develop resistance.

What makes the current situation different from past decades is the narrowing of treatment options. Every antibiotic class deployed against gonorrhea has eventually failed. Penicillin was first-line until the 1970s, when resistant strains emerged. Tetracyclines and fluoroquinolones followed the same path; by the early 2000s, ciprofloxacin was no longer reliable. The current dual therapy — ceftriaxone 1 gram intramuscularly plus azithromycin 2 grams orally — has been the standard since 2011, but its effectiveness is eroding.

Surveillance data from the UK show that azithromycin resistance now hovers around 10 percent of isolates. Ceftriaxone remains effective for now, but so-called MIC creep — a gradual upward drift in the minimum inhibitory concentration — has been detected in Europe and Asia. No new single-dose oral drug is in late-stage clinical trials, so clinicians must work with the tools they have while hoping for a new class of antibiotics that may be years away.

The Steady March of Antimicrobial Resistance

Antimicrobial resistance in gonorrhea is not a sudden crisis but a predictable process. The bacterium is adept at acquiring resistance genes from other microbes and mutating its own targets. Each time a new antibiotic is introduced, resistant strains emerge within a few years. Penicillin resistance spread globally within a decade of widespread use. Fluoroquinolone resistance appeared in the 1990s and rendered the class useless by the early 2000s. The pattern is so consistent that the WHO has called gonorrhea a "canary in the coal mine" for antibiotic resistance.

The current dual therapy was designed to delay resistance by hitting the bacterium with two mechanisms simultaneously. But the strategy has limits. Azithromycin resistance has been rising steadily, and some isolates in the UK and elsewhere are resistant to both azithromycin and ceftriaxone — so-called extensively drug-resistant strains. As of late 2024, these remain rare in the UK, but they have been documented in several countries, including Japan, Australia, and parts of Europe.

The pipeline for new antibiotics is thin. Few pharmaceutical companies invest in drugs for gonorrhea because the market is relatively small and the return on investment uncertain. Most candidates in development are modifications of existing classes rather than entirely new mechanisms. The most advanced candidate, zoliflodacin, completed a phase 3 trial in 2023 and showed non-inferiority to ceftriaxone, but it is not yet approved in any major market. Even if approved, it would likely be reserved for resistant cases, not used as a first-line agent, to preserve its effectiveness.

This slow pipeline means that the current treatment approach — empiric dual therapy while waiting for lab results — will remain the standard for the foreseeable future. And that approach is only as good as the diagnostic system that supports it.

Current Treatment: Longer Courses, More Follow-Up

When a patient tests positive for gonorrhea at a UK sexual health clinic, the standard is to treat them immediately with ceftriaxone and azithromycin. But treatment does not end there. Guidelines from the British Association for Sexual Health and HIV (BASHH) recommend a test of cure — a repeat swab or urine sample — taken at least 14 days after treatment, to confirm the infection has cleared. For patients whose symptoms persist or who had a known contact with a resistant strain, the test of cure is essential.

Retesting for reinfection is advised at three months, particularly for young people and those with multiple partners. Sexual partners need to be notified and treated, either through patient referral or provider-based contact tracing. This follow-up cascade is time-consuming and resource-intensive, and it relies on patients returning to the clinic — something that does not always happen. In a 2023 audit of London clinics, around 40 percent of patients did not complete the test of cure within the recommended window.

For cases where treatment fails — meaning symptoms persist or the test of cure is positive — clinicians must switch to alternative regimens, such as high-dose ceftriaxone over several days or gentamicin plus azithromycin. These salvage therapies require susceptibility testing to guide choice, which adds another layer of delay. The culture and sensitivity process takes 48 to 72 hours in a lab, and not all clinics have easy access to a reference laboratory.

This extended treatment pathway places a heavy burden on both patients and the health system. For the patient, it means multiple visits, potential side effects from second-line drugs, and anxiety about whether the infection will clear. For the system, it means more clinic appointments, more lab work, and more opportunities for loss to follow-up. The whole process would be simpler if clinicians knew, at the point of care, which antibiotics would work.

Rapid Diagnostics Remain Concentrated in Urban Centres

Point-of-care tests for gonorrhea exist and are approved for use in the UK. The most widely deployed platform is the GeneXpert CT/NG assay, which can detect both Chlamydia trachomatis and Neisseria gonorrhoeae from a single swab or urine sample in about 90 minutes. Another platform, the binx io, is a fully automated system that gives results in roughly 30 minutes. These tests are accurate, with sensitivity and specificity above 95 percent for symptomatic patients.

But their availability is patchy. Most GeneXpert machines are located in genitourinary medicine (GUM) clinics in major cities such as London, Manchester, and Birmingham. Community pharmacies and general practice surgeries — where many patients first seek help — rarely have the equipment or trained staff to run these tests. Instead, they rely on postal self-sampling kits, which the patient takes home, mails to a lab, and waits for a result. The turnaround time for lab-based tests is typically 3 to 7 days, depending on the region and the lab's backlog.

Data from BASHH suggest that return rates for postal kits are lower in deprived areas, where patients may have less reliable mailing addresses or less access to a phone to receive results. This means the people who are most at risk of gonorrhea — young adults in lower-income neighbourhoods — are also the ones most likely to experience diagnostic delay. And delay matters: each day that an infection goes untreated, the patient can transmit the bacterium to others, and the infection has more time to ascend the reproductive tract.

Asymptomatic infections, which are common in women, are especially vulnerable to this gap. A woman who uses a postal kit and gets a positive result a week later may already have developed pelvic inflammatory disease by the time she is treated. Her sexual partners may have been infected in the interim. Contact tracing becomes far harder when the index case is diagnosed late, because partners may have moved on or forgotten the encounter.

Why Rapid Testing Matters for Resistance Control

Rapid tests are not just about convenience; they have a direct impact on antibiotic resistance. When a clinician knows the result within an hour, they can prescribe a targeted antibiotic — or, if the test includes a resistance marker, they can choose a drug that the strain is likely to respond to. At the moment, most patients are treated empirically, meaning they get the standard dual therapy even if their strain would be cured by a single agent. That unnecessary use of two broad-spectrum antibiotics drives resistance in both the gonococcus and the patient's commensal bacteria.

A 2020 modelling study by Dr. Hannah Christensen and colleagues at the University of Bristol, published in The Lancet Infectious Diseases, estimated that widespread deployment of point-of-care tests could reduce the emergence of resistant gonorrhea by roughly 30 percent over a decade. The National Institute for Health and Care Excellence (NICE) approved the NG-MAST test — a molecular assay that detects resistance markers — for use in the NHS in 2023. But approval is not the same as rollout. Uptake depends on local commissioning decisions, and many areas have not yet purchased the equipment or trained staff to use it.

The technology exists, but the system has not caught up. Part of the reason is cost: a GeneXpert cartridge costs roughly £15 to £20, compared with £2 for a standard lab test. Sexual health clinics, already under budget pressure, may be reluctant to invest in a more expensive test even if it reduces downstream costs from treatment failures and hospital admissions. Another barrier is training: running a point-of-care test requires someone who can operate the machine, interpret the result, and enter data into the surveillance system. In rural clinics with a single nurse covering multiple roles, that is a hard ask.

There is also the question of what to do with the result. A rapid positive test still does not tell the clinician whether the strain is resistant to ceftriaxone, because the current point-of-care tests do not cover all resistance markers. Culture and susceptibility remain the gold standard for resistance surveillance, and that takes days. So even with a same-day diagnosis, the clinician may still prescribe dual therapy empirically, waiting for the culture result to confirm or adjust. The benefit of rapid testing is therefore greatest when it is paired with a rapid resistance test — something that is not yet widely available.

Closing the Gap: What Would Narrow the Divide?

Bridging the urban–rural diagnostic divide would require a combination of funding, training, and system redesign. One step is to commission near-patient NAAT platforms in areas with high gonorrhea burden, as identified by local surveillance data. Some regions, such as the North West of England, have piloted mobile testing units that bring GeneXpert machines to community centres and pharmacies. Early results from these pilots show that same-day testing increases the proportion of patients who receive treatment within 48 hours from around 60 percent to over 90 percent.

Training non-specialist clinicians — GPs, practice nurses, and pharmacists — in STI management is another piece of the puzzle. Many primary care clinicians are uncomfortable diagnosing and treating gonorrhea, partly because they see it infrequently and partly because guidelines change as resistance patterns shift. A 2022 survey of GPs in the South West found that only a third felt confident managing a case of uncomplicated gonorrhea without referring to a GUM clinic. Integrating gonorrhea testing into routine primary care workflows, such as during contraceptive consultations or cervical screening, could normalise the process and reduce stigma.

Subsidised rapid tests for pharmacy-based services could also help. Scotland has already expanded its pharmacy-based STI testing programme to include gonorrhea, with results available within an hour at participating pharmacies. Early data show high patient satisfaction and a shorter time to treatment compared with postal kits. But the model relies on pharmacy staff being trained to take swabs and interpret results, which is not yet standard across the UK.

Finally, a national surveillance feedback loop could help local clinicians adjust their prescribing in real time. If a clinic in a certain area knows that 15 percent of local gonorrhea isolates are azithromycin-resistant, it might choose to treat with ceftriaxone alone or use a different combination. That kind of local guidance requires up-to-date surveillance data, which in turn depends on consistent culture and susceptibility testing — something that is less common in areas without a nearby reference lab. The UK Health Security Agency publishes quarterly surveillance reports, but they are national averages and may not reflect local patterns.

None of these interventions is a silver bullet. Rapid tests are expensive, training takes time, and surveillance systems require sustained investment. But the alternative — continuing with the current patchwork — means that the gap between urban and rural care will persist, and antibiotic resistance will continue to edge upward. The tools to do better exist; the question is whether the system will choose to deploy them equitably.