STD Awareness: Is Gonorrhea Becoming “Impossible” to Treat?

Image: National Institute of Allergy and Infectious Disease

Health authorities have been worried about it for a long time now, and we’ve been following it on our blog since 2012. The boogeyman? Antibiotic-resistant gonorrhea, a strain of the sexually transmitted bacteria that is becoming more and more difficult to treat. Higher doses of the drug will be needed to cure stubborn cases of gonorrhea — until the doses can no longer be increased. Then, untreatable gonorrhea could be a reality.

“Little now stands between us and untreatable gonorrhea.”

The World Health Organization (WHO), in a press release last month, finally used the word “impossible” when describing treatment of antibiotic-resistant gonorrhea, referring to documented cases of gonorrhea that were “untreatable by all known antibiotics.” Worse, these cases are thought to be the proverbial “tip of the iceberg,” as there aren’t good data on antibiotic-resistant gonorrhea in many developing countries, where gonorrhea is more prevalent and epidemics could be spreading under the radar. Adding to this problem is the fact that gonorrhea rates are climbing worldwide, which is thought to be due to a number of factors, including the decline in condom use, the frequent absence of symptoms, inadequate treatment, and increasing urbanization and travel.

What will happen if gonorrhea can’t be cured? Your infection could clear up on its own, after a lengthy battle with your immune system, but we don’t know a lot about how long this could take (weeks? months? never?). Unfortunately, despite your immune system’s best efforts, gonorrhea doesn’t go out without a fight. Gonorrhea can lead to pelvic inflammatory disease, which can cause tissue damage to the reproductive organs resulting in 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. The CDC estimates that, in the United States alone, untreatable gonorrhea could cause 75,000 cases of pelvic inflammatory disease, 15,000 cases of epididymitis, and 222 extra HIV infections over a 10-year period. Worldwide, where gonorrhea and HIV disproportionately affect developing countries, these problems could get even more out of control.

We have treated gonorrhea with many antibiotics since the 1930s, moving from drug to drug as the bacteria evolved resistance to each antibiotic we used. Since 2007, we’ve been using third-generation cephalosporins, such as ceftriaxone and cefixime, considered to be our “last line of defense.” But now, according to WHO, two-thirds of countries surveyed have documented gonorrhea cases that are resistant to these “last-resort” drugs. What’s more, 81 percent of countries found strains of gonorrhea that were resistant to azithromycin, another type of antibiotic that WHO recommends doctors pair with ceftriaxone in the hopes that the combination guards against antibiotic resistance.

More depressingly, WHO described the pipeline for new antibiotics against gonorrhea as “relatively empty.” There are three drugs currently undergoing trials in humans: solithromycin, zoliflodacin, and gepotidacin. Solithromycin is the furthest along in the clinical-trial process, and shows promise in treating not just genital gonorrhea, but rectal and oral gonorrhea as well. It could also be used to treat chlamydia and genital mycoplasmas. Unfortunately, even at this stage there is no guarantee that it will be safe and effective — the FDA rejected solithromycin’s application, requesting more studies on safety. Beyond traditional antibiotics, there is also early research into a molecule that releases carbon monoxide, which might be able to kill the bacteria that cause gonorrhea without harming human cells; this research will have to advance beyond the Petri dish and into human volunteers before we can figure out whether it could be an effective cure.

Even better than continuing the antibiotic arms race with gonorrhea would simply be to vaccinate the bacteria out of existence — a strategy that WHO says is the only “sustainable” way to control gonorrhea. Generations of scientists have dreamed of a gonorrhea vaccine, and in July, researchers in New Zealand reported that a vaccine for a type of meningitis caused by a species of bacteria closely related to those that cause gonorrhea might offer some degree of protection against gonorrhea. In a nutshell, New Zealand ordered a custom-made vaccine for a meningitis outbreak that was spreading across the country; it was discontinued after the outbreak was brought under control. A review of medical records, however, has shown that the vaccine inadvertently provided 31 percent protection against gonorrhea — not great (the measles vaccine is 97 percent effective, after all), but better than nothing. And pretty good for a vaccine that wasn’t even designed to prevent gonorrhea in the first place, and is the only one to show evidence of doing so. This lead will inspire renewed attempts to develop a gonorrhea vaccine.

Prevention is more important than ever. As the CDC says in one of their recent educational videos: “Little now stands between us and untreatable gonorrhea.” But, as individuals and as a society, we can take actions to put some distance between ourselves and that inevitable future.

  • By using condoms and dental dams, getting tested and treated for STDs, and limiting sex partners, people can protect their own sexual health.
  • By not prescribing unnecessary antibiotics, doctors can help preserve these drugs for when they’re really needed.
  • By taking antibiotics correctly, patients won’t help bacteria develop resistance.
  • By notifying partners, patients and health officials can help ensure that people who have been exposed to gonorrhea can be tested and treated.
  • By investing taxpayer dollars into research, we all benefit from access to effective drugs. Additionally, research into vaccines can help us circumvent the problem of drug resistance, and the development of better testing can help health-care providers offer better treatment.

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.

Click here to check out other installments of our monthly STD Awareness series!