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. Continue reading

STD Awareness: Fully Antibiotic-Resistant Gonorrhea Is on the Horizon

shot-in-armWe’ve been anticipating its arrival for years now, but earlier this fall, the Centers for Disease Control and Prevention (CDC) finally made an announcement: Cases of gonorrhea resistant to the last drugs we use to cure it are emerging.

Over the years, gonorrhea has evolved resistance to every drug we’ve thrown at it — sulfonamides, penicillins, tetracyclines, macrolides, fluoroquinolones, and narrow-spectrum cephalosporins. The last line of defense we have is a one-two punch of a pair of antibiotics: azithromycin and ceftriaxone. By using two drugs, we can delay the inevitable evolution of antibiotic resistance by attacking the bacteria in two vulnerable locations, rather than just one, making it more difficult for the bug to mount a defense and pass on its superior survival skills to subsequent generations.


Prevention is paramount: Stop the spread of antibiotic resistance by practicing safer sex!


Unfortunately, we could only stave off the inevitable for so long. At their conference in September, the CDC announced a cluster of gonorrhea infections that are highly resistant to azithromycin, and that fall prey only to high doses of ceftriaxone. As gonorrhea’s tolerance to ceftriaxone increases, the infection will get more and more difficult to cure.

This cluster of drug-resistant cases was identified in Honolulu in April and May of this year, with five infections showing “dramatic” resistance to azithromycin, as well as reduced vulnerability to ceftriaxone. The good news is that these cases were cured with higher-than-usual doses of antibiotics, but the bad news is that dosages can only climb so high before a drug is no longer considered to be an effective treatment. Continue reading

STD Awareness: Gonorrhea’s Ever-Growing Resistance to Antibiotics

Gonococci, the bacteria that cause gonorrhea.

Ever since the advent of effective antibacterial therapies less than a century ago, humans with access to these drugs can easily cure gonorrhea. Most of us in the developed world have forgotten that this disease was once a leading cause of infertility in women and blindness in babies — sulfa drugs and antibiotics not only erased these infections from our bodies, they also erased memories of gonorrhea’s dangers from our collective consciousness.


There are two drugs remaining to treat gonorrhea, and resistance to them is climbing higher as the years march on.


Unfortunately, thanks to their talent for genetic gymnastics, gonococci, the bacteria that cause gonorrhea, have been evolving resistance to every drug we’ve thrown at them — to tetracycline, to penicillin, and more recently to fluoroquinolones. One class of antibiotics remains to treat gonorrhea: cephalosporins. In 2013, Centers for Disease Control and Prevention (CDC) Director Tom Frieden warned that we could find ourselves in a “post-antibiotic era” – unless we take precautions. And, just two weeks ago, the latest study from the CDC’s Gonococcal Isolate Surveillance Project sounded the alarm that the post-antibiotic era is drawing ever closer, especially when it comes to gonorrhea.

Azithromycin and ceftriaxone, the two drugs that are used in combination to deliver a one-two punch to invading gonococci, are the best antibiotics remaining in our arsenal. Azithromycin is taken by mouth, while ceftriaxone is administered by a shot, and when taken together they team up to target different weak points in gonococci’s armor. Azithromycin interferes with the bacteria’s ability to make proteins, shutting the cells down, while ceftriaxone causes the cell wall to fall apart. However, the gonococci can acquire resistance. For example, in the case of azithromycin, a resistant bacterium can spit out the drug before it has a chance to kill it, or it can change the shape of its protein-making apparatus such that the drug can’t attach to it.  Continue reading

STD Awareness: Ceftriaxone-Resistant Gonorrhea

Nestled in the throat of a Japanese woman was a collection of clones that scientists abducted from their temporary habitat and christened H041 — a humdrum moniker for a strain of bacteria that would burn headlines in medical journals. Though the bacteria never caused symptoms in their host, they lingered in her throat from at least January until April of 2009, when a swab finally tested negative. Rather than succumbing to repeated bombardment by an antibiotic called ceftriaxone, the infection probably just went away on its own — as oral gonorrhea infections tend to do.


Resistance to ceftriaxone, our last good gonorrhea drug, has been reported in Japan, Australia, Sweden, France, and Spain.


The emergence of antibiotic-resistant gonorrhea is considered one of the most pressing problems in infectious disease — just two years ago, the Centers for Disease Control and Prevention named it an “urgent threat.” We have one remaining first-line gonorrhea treatment left: extended-spectrum cephalosporins, which include cefixime, which is taken orally, and ceftriaxone, which is administered as a shot. Resistance to cefixime was first documented in 1999, leaving ceftriaxone as our best remaining option, and the CDC’s first choice for treating gonorrhea. There are no good alternatives to ceftriaxone remaining, which is why reports of ceftriaxone-resistant gonorrhea are so deeply troubling.

What made H041 special was that it was the first extensively drug-resistant strain of Neisseria gonorrhoeae, the bacteria that cause gonorrhea. With an unusually high level of resistance to ceftriaxone — four to eight times higher than the previous record holder — the strain was also resistant to a slew of other antibiotics: penicillin and its relatives, fluoroquinolones, macrolides, tetracycline, trimethoprim-sulfamethoxazole, chloramphenicol, nitrofurantoin, cefpodoxime, cefixime, ciprofloxacin, and levofloxacin — and had reduced susceptibility to azithromycin to boot.

Another thing that made H041 special — as special as clones can be, anyway — is that it never reappeared. After its discovery, researchers in Kyoto and Osaka intensified their surveillance, trying to uncover it again and track its spread through the population. However, their search for H041 turned up empty handed. But other ceftriaxone-resistant strains have been documented around the world. Continue reading

STD Awareness: Why Should You Care About Oral Gonorrhea?

Image: CDC

An illustration of Neisseria gonorrhoeae, the bacteria that cause gonorrhea. Image: CDC

When I say “gonorrhea,” you might think of genitals that feel as though they have been set ablaze, or perhaps a viscous fluid oozing from the urethra. But gonococci, the bacteria that cause gonorrhea, can also set up camp in the pharynx after being transmitted into a mouth and down a throat when its new host gave oral sex to its old host. Indeed, performing oral sex on multiple partners has been found to increase risk for an oral gonorrhea infection (more properly called pharyngeal gonorrhea).

If you read our September 2012 article on gonorrhea of the throat, you might remember these fun facts: Oral gonorrhea goes away within three months, even without treatment! Plus, these infections rarely have symptoms. Why, then, should you care about a gonorrhea infection in your throat? You’re not likely to notice it’s there, and it’ll go away on its own anyway.


Many researchers believe that the throat is an incubator for antibiotic-resistant gonorrhea.


Well, aside from the possibility of transmitting a gonorrhea infection from your throat to someone’s genitals, there’s one other thing to care about: the development of antibiotic resistance.

The emergence of antibiotic-resistant gonorrhea is considered one of the most pressing problems in infectious disease — just two years ago, the Centers for Disease Control and Prevention named it an “urgent threat,” and indeed, gonorrhea seems to be evolving resistance to drugs at quite a rapid clip. If gonorrhea evolves complete resistance to the drugs we use to cure it, we could find ourselves sent back in time, to the days when gonorrhea was untreatable — and responsible for infertility, blindness, and chronic pain. While scientists figure out how to address this emerging threat, you can do your part by avoiding gonorrhea in the first place — and that includes using condoms and dental dams to prevent oral gonorrhea infections.

So, while it sounds like a blessing that gonorrhea of the throat rarely has symptoms, there’s actually a drawback: An oral gonorrhea infection probably won’t be effectively treated — or even identified in the first place. And these hidden throat infections are likely to be helping to drive the development of antibiotic resistance. Continue reading

STD Awareness: Genetics and the Gonococcus

Image: CDC

Ever since the discovery of effective antibacterial therapies less than a century ago, humans have been able to easily cure gonorrhea, the sexually transmitted scourge that laid waste to fallopian tubes and robbed newborns of vision. Most of us in the developed world have forgotten that this disease was once a leading cause of infertility in women and blindness in babies — and still is in much of the developing world.

Unfortunately, gonococci — the species of bacteria that cause gonorrhea — have been evolving resistance to every antibiotic we’ve thrown at them, including sulfonamides, penicillins, tetracyclines, macrolides, fluoroquinolones, and narrow-spectrum cephalosporins. We have one remaining first-line gonorrhea treatment left: extended-spectrum cephalosporins, which include cefixime, which is taken orally, and ceftriaxone, which is administered as a shot — and resistance is emerging to those drugs, as well.


Gonococci don’t swap potato salad recipes at family reunions — they swap genetic material!


The emergence of antibiotic-resistant gonorrhea is considered one of the most pressing problems in infectious disease — just two years ago, the Centers for Disease Control and Prevention named it an “urgent threat,” and indeed, gonorrhea seems to be evolving resistance to drugs at quite a rapid clip. Gonococci can acquire resistance to antibiotics in three ways.

First, a genetic mutation can endow bacteria with special antibiotic-fighting powers, making it harder for a drug like penicillin to attach to their cells and destroy them. Such a mutant is more likely to gain evolutionary traction if it finds itself in an antibiotic-drenched environment in which resistance to that drug allows it to “outcompete” other bacteria. Indeed, antibiotic resistance was first documented in the 1940s, just years after sulfonamides and penicillin were introduced as the first effective cures for gonorrhea. Continue reading

STD Awareness: The Latest on Gonorrhea

Neisseria gonorrhoeae, the bacterium that gangs up on your body to give it gonorrhea. Image: CDC

Neisseria gonorrhoeae, the bacterium that gangs up on your body to give it gonorrhea. Image: CDC

Gonorrhea is that guy with the funny name who’s always up to something new and mischievous. Last year, the New England Journal of Medicine declared that it’s “time to sound the alarm” in response to emerging strains of gonorrhea that are increasingly resistant to antibiotics. Then, earlier this year, the medical journal JAMA reported the first North American sightings of gonorrhea that failed treatment with cefixime, one of the last drugs we have in our anti-gonorrhea arsenal. It’s a great time to be a gonococcus — the type of bacteria that causes gonorrhea — but the humans they infect probably don’t see it that way.

Last month, this bad boy rose to the top of the Most Wanted list when the Centers for Disease Control and Prevention proclaimed antibiotic-resistant gonorrhea an “urgent threat” — the highest threat level, which gonococci share with only two other bacteria types. To give you some context, the much more famous superbug MRSA was categorized as a “serious” threat, one notch below “urgent.”


Antibiotic-resistant gonorrhea is an “urgent” threat; meanwhile, researchers develop a gonorrhea vaccine that works — on mice.


Antibiotic-resistant gonorrhea is especially insidious for two reasons. One, gonorrhea often doesn’t have symptoms, which allows it to jump from one sexual partner to another, the hosts often none the wiser. Two, unless health care providers actually test the bug’s DNA, they have no way of knowing whether or not they’re dealing with a drug-resistant strain. This opens up the possibility for treatment failure — and for the antibiotic-resistant bacteria to be further propagated into the community.

The CDC estimates that the United States sees 246,000 cases of antibiotic-resistant gonorrhea infections annually — that’s about 30 percent of all gonorrhea infections in the country. For now, we seem to be able to cure them with higher doses or different combinations of drugs. So why does antibiotic-resistant gonorrhea deserve the “urgent” designation? While gonorrhea isn’t associated with a body count — unlike other drug-resistant pathogens, which collectively kill at least 23,000 Americans a year — it can have terrible consequences. Gonorrhea can cause pelvic inflammatory disease (PID) when it advances up the female reproductive tract, and epididymitis when it invades the male reproductive tract; both conditions can cause infertility. Also, gonorrhea infections make us more vulnerable to HIV. The CDC estimates that if the most resistant gonorrhea strain gains ground over the next decade, the country could see an additional 75,000 cases of PID, 15,000 cases of epididymitis, and 222 HIV infections, costing us $235 million. Continue reading