Antimicrobial resistance prediction in <i>Neisseria gonorrhoeae</i>: current status and future prospects

Several nucleic acid amplification tests (NAATs), mostly PCRs, to detect antimicrobial resistance (AMR) determinants and predict AMR in Neisseria gonorrhoeae are promising, and some may be ready to apply at the point-of-care (POC), but important limitations remain with NAATs. Next-generation sequencing (NGS) can overcome many of these limitations.Recent advances, with main focus on publications since 2017, in the development and use of NAATs and NGS to predict gonococcal AMR for surveillance and clinical use, and the pros and cons of these tests as well as future perspectives for appropriate use of molecular AMR prediction for gonococci.NAATs and/or NGS for AMR prediction should supplement culture-based AMR surveillance, which will remain because it also detects AMR due to unknown AMR determinants, and translation into POC tests is imperative for the end-goal of individualized treatment, sparing ceftriaxone ± azithromycin. Several challenges for direct testing of clinical, especially pharyngeal, specimens and for accurate prediction of cephalosporins and azithromycin resistance, especially using NAATs, remain. The choice of AMR prediction assay needs to carefully consider the intended use of the assay; limitations intrinsic to the AMR prediction technology, algorithms specific to the chosen methodology; specimen types analyzed; and cost-effectiveness.