In late March, the BBC reported a story that was widely repeated in headlines across the world: “Man has ‘world’s worst’ super-gonorrhoea.”
The article told the story of a British man whose symptoms started in early 2018, about a month after he had picked up the bug during a visit to Southeast Asia. Once back home, his doctors were unable to cure it with the standard combination of azithromycin and ceftriaxone — “the first time the infection cannot be cured with first choice antibiotics,” the author wrote.
In most of the world, we don’t have a good picture of antibiotic resistance in gonorrhea.
Actually, a similar case of multidrug-resistant gonorrhea had been documented in the United Kingdom in late 2014, as noted in the New England Journal of Medicine. It was the first verified case to fail to be cured by the azithromycin/ceftriaxone combo — the infection didn’t go away until after the patient was given a double dose of both antibiotics, but by then it had been 112 days and the infection could have cleared on its own. By July 2017, the World Health Organization (WHO) had noted that there had been multiple documented cases of gonorrhea that were “untreatable by all known antibiotics.”
What was different about the man in the BBC story was that his case of ceftriaxone-resistant gonorrhea had a higher level of azithromycin resistance than those that came before. While it may not have truly been the first case of multidrug-resistant gonorrhea that couldn’t be treated with the standard dual therapy of azithromycin and ceftriaxone, it was the “most serious.”
Luckily, the man’s sexual partner in the UK tested negative for the infection, leading British health officials to believe this highly multidrug-resistant strain of gonorrhea wasn’t loose in their country. Unfortunately, as of the update issued on April 20, the search for the man’s sexual partner in Southeast Asia was still “ongoing.” Furthermore, his infection had been cured with an antibiotic called ertapenem — which Newsweek called “the last possible antibiotic available.” Recently, Australia has reported two similar cases — including one diagnosed in a man who also recently had sex in Southeast Asia.
Worldwide, most strains of gonorrhea are resistant to antibiotics. Since the 1930s, the bacteria that cause gonorrhea have consistently evolved resistance to the drugs we’ve used to kill them, starting with sulfa drugs, moving on to penicillin, and then to tetracyclines and fluoroquinolones. Since 2007, we’ve been using third-generation cephalosporins, such as ceftriaxone, considered to be our “last line of defense.” In 2015, we started adding azithromycin into the mix to attack gonorrhea on two different fronts. Today, dual azithromycin and ceftriaxone therapy is the standard treatment, but as we’ve seen in recent years, the wily bacteria that cause gonorrhea are chipping away at them, too.
Experts fear that soon, gonorrhea’s remarkable evolutionary abilities will throw us back into the “pre-antibiotic era,” when gonorrhea was incurable and wreaked untold sexual and reproductive havoc. Dr. Teodora Wi of WHO worries that, while cases like the one reported by the BBC are being caught in developed countries, developing nations are bearing the brunt of the problem — and it’s flying under our collective radars. “These cases may just be the tip of the iceberg,” she said. “Systems to diagnose and report untreatable infections are lacking in lower-income countries where gonorrhoea is actually more common.”
Antibiotic-resistant gonorrhea is a worldwide problem, and the fact that surveillance is weak or nonexistent in most parts of the world means that people in developing countries are in more danger of catching and transmitting difficult- or impossible-to-cure strains. Poor infrastructure for tracking down sexual partners could be one reason why health officials haven’t been able to locate the UK man’s Southeast Asian sexual partner to get her the testing and treatment she very well could need — and to investigate the local spread of the antibiotic-resistant strain.
Gathering more data will help scientists understand where and how fast drug resistance is evolving, and how it’s traveling. It will also help them figure out which treatments work the best from country to country. WHO’s current surveillance program receives inconsistent and spotty data that don’t cohere into a representative picture of what’s happening worldwide. For example, they receive most of their data from Europe — and from only two countries in Africa and one country in the Middle East. WHO and the Centers for Disease Control and Prevention are partnering to lead an improved surveillance effort, called the Enhanced Gonococcal Antimicrobial Surveillance Program, to keep track of gonorrhea worldwide. Although still in its infancy, the program’s goals are to collect robust and standardized data from a more representative sample of countries.
If gonorrhea can’t be cured, your infection could clear up on its own, after a lengthy battle with your immune system. Unfortunately, despite your immune system’s best efforts, gonorrhea doesn’t go out without a fight — it can cause pelvic inflammatory disease (which itself can lead to infertility), ectopic pregnancy, and chronic pain. It can also cause scarring that blocks sperm’s movement out of the testes, resulting in epididymitis, which is associated with infertility, chronic scrotal pain, and testicular shrinkage. Furthermore, gonorrhea increases risk for HIV transmission and can be passed to a baby during childbirth. Worldwide, where gonorrhea and HIV disproportionately affect developing countries, these problems could get even more out of control.
Sexually active people should use barriers, such as condoms and dental dams, during vaginal, anal, and oral sex. They should also keep up-to-date on their STD status by receiving testing and treatment. You can pick up condoms or be tested for gonorrhea at any Planned Parenthood health center.
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