Gonorrhea and the Discovery of Super Gonorrhea

Gonorrhea is a sexually transmitted infection (STI) that can affect both males and females. It often results in infections of the genitals, rectum, and throat, and most commonly afflicts within sexually active people between the ages of 15 to 24. Gonorrhea is transmitted through vaginal, anal, and oral sex, and can also be spread from mother to child during labor. Symptoms include painful urination, soreness, bleeding, and unusual discharge.¹ Usually, gonorrhea can be easily treated with a course of antibiotics, but in the last few decades, mutations in the genetic material of the bacteria have given way to an ever growing list of antibiotics that are rendered ineffective. This antibiotic-resistant strain of Neisseria gonnorrhoeae, the bacteria that is responsible for gonorrhea, has been given a name: Super Gonorrhea.

When sulfa drugs (a mild antibiotic) were discovered as an effective treatment for super gonorrhea, gonorrhea was considered a very mild ailment with few consequences. However, because bacteria constantly adapt to outcompete their surroundings, sulfa drugs stopped working around the 1940s, and doctors began to prescribe penicillin.2 By the late 1960s, gonorrhea had mutated into a strain that could break down penicillin, which was the first indication that the bacteria would continue evolving into different, more resistant strains. In 1983, scientists isolated strains of the bacterium resistant not only to penicillin but also to other heavy duty antibiotics (e.g., tetracycline, spectinomycin, and fluoroquinolones). By 2002, only one class of antibiotics, cephalosporins, was able to treat the infection via oral medication or an injection.³ In 2007, oral medication began to fail, and in 2010, the Centers for Disease Control (CDC) recommended ceftriaxone, a potent cephalosporin to be administered via injection along with an orally administered treatment azithromycin as the only possible treatment to address resistant strains of  gonorrhea.² Currently, the CDC’s STD Treatment Guidelines now suggests only one regiment of injectable ceftriaxone along with oral azithromycin. The use of two antibiotics is encouraged to address the emergence of N. gonnorhoeae developing resistant to any cephalosporin.³

Diagnosis

Clinicians have two tests to diagnose for gonorrhea: a simple DNA test, or a more complex antibiotic susceptibility test. This second method uses a culture that determines which antibiotics the specific strain of infection is susceptible to.² Doctors use the DNA test for both the sake of convenience and the fact that that many laboratories simply lack the technology necessary for antibiotic susceptibility testing. Unfortunately, this has become a major challenge in monitoring the ever-changing antimicrobial resistance of the gonorrhea bacteria.³ Culture testing, while slow, is incredibly effective at figuring out which antibiotics a given strain of super gonorrhea is resistant to. It involves growing the bacteria directly in the lab and then exposing it to controlled amounts of the antibiotics, which allows for precision and accuracy when determining its resistance. However, DNA testing, or more specifically Nucleic Acid Amplification Test (NAAT), is much cheaper and less work intensive.³ Because of this, CDC physicians recommend that doctors re-evaluate patients for treatment failure by repeating the NAAT, making sure to obtain a culture and performing antibiotic susceptibility testing.²

Risk Factors

One major issue with treating and reevaluating gonorrhea is that it becomes the patients responsibility to notice lingering symptoms and go back to the doctor. Often, gonorrhea is asymptomatic (doesn’t show symptoms), so there are many cases of individuals who receive a positive gonorrhea test, receive treatment, and present as symptom free while still actively transmitting the infection to new sexual partners. While this type of transmission is highly unlikely in the United States, resistant strains have popped up in England, Japan, and Canada, and there have been scares in US territories like Hawaii and Puerto Rico.²  Recently, the World Health Organization declared gonorrhea a “global concern” and doctors are labelling super gonorrhea a “superbug.”⁴ In 2008, 0.1 % of the 820,000 new infections showed some resistance to ceftriaxone, the last effective drug against gonorrhea. Within 3 years, 0.4 % of infections showed resistance, and the number did not drop until doctors increased the dosage of antibiotics.⁴ The greatest risk of transmission and highest prevalence of resistant strains is with men who have sex with men, and in December federal officials reported that for the first time in 10+ years, gonorrhea infection rates in men were higher than those of women.⁴ However, new findings show that the bacterium is spreading to heterosexual populations as well. In July of 2016, Swedish doctors published a journal where they describe the great difficult of eradicating a particularly resistant strain of gonorrhea from the throats of four heterosexual men and women.⁴ Contracting gonorrhea puts the human body at risk for many health problems. If left untreated, the infection may cause infertility or even death. The “super gonorrhea” infection is faster acting and more resilient than typical gonorrhea, making it more difficult to detect and treat before significant damage has been done. One strain of antimicrobial resistant gonorrhea is known as HO41. Researchers have put this strain in the same drug resistant category as Methicillin-resistant Staphylococcus aureus (MRSA) and other highly dangerous drug-resistant superbugs. Although there have only been a few cases of HO41 around the world, the CDC and drug researchers are preparing for a time when the superbug becomes more common, and are taking the potential epidemic as seriously as HIV and AIDS.³

Treatment and Prevention: What’s Next

The current regimen to combat super gonorrhea is an injection of 250mg of ceftriaxone, along with a second antibiotic for seven days as backup. Some very persistent infections have needed up to 1000mg, due to cephalosporin resistance.⁴ Researchers are continually working on a plan to combat super strains of gonorrhea, but they are facing some major setbacks. It is difficult to find the funding, awareness and manpower necessary to seek out a cure for the infection. The National Coalition of STD Directors (NCSD) has declared this a state of emergency, and has lobbied on Capitol Hill asking law makers for an extra $53 million that will fund more labs to perform culture tests, increase surveillance on the spread of resistant bacteria, and teach private doctors to make proper diagnoses and increase public awareness. Additionally, according to the NCSD, this money would strengthen local health departments which are currently reeling from a lack of funding (e.g., in 2012, more than 50% of the country’s STI programs lost budget money, and 21 health departments closed their STI clinics altogether).⁴ Because of this, public health departments are fighting for more funding and awareness of the spread of antibiotic-resistant STIs, as the race against resistance becomes more and more urgent. Several new drugs have been proposed as possible treatments for super gonorrhea and are currently awaiting approval from the Food and Drug Administration (FDA). However, it may take years for these treatments to reach consumers.³

The best way to prevent the spread of such infections is to practice safe sex through the use of barrier contraceptives, like male condoms, dental dams, and female condoms. Additionally, it is very important to communicate with any new sexual partner about their STI status and getting tested, as gonorrhea is only one among many infections that can be asymptomatic.

References

1. “Antibiotic-Resistant Gonorrhea Basic Information.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 13 June 2016. Web. 26 Feb. 2017.
2. “Gonorrhea – CDC Fact Sheet.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 19 May 2016. Web. 26 Feb. 2017.
3. “Gonorrhea ‘Super Bug’ Presents Looming Public Health Crisis.” RH Reality Check. RH Reality Check, n.d. Web. 29 Oct. 2014.
4. “Concerns Over ‘Super Gonorrhea’ Spreading to the United States.” Healthline. N.p., 04 May 2016. Web. 4 May 2016.
5. “The Terrifying Truth about Super-Gonorrhea.” Men’s Health. N.p., 07 May 2015. Web. 28 Feb. 2017.

Last Updated: 20 March 2017.