New strains of Gonorrhea difficult to treat

Dear Dr. Eva,

I have read that there is a new kind of gonorrhea which is untreatable. Is this true?

Worried

Dear Worried,

Before I begin, my thanks to Dr. Khalil Ghanem of Johns Hopkins for assisting with this column.

It’s important to understand that every type of infection comes in multiple strains or varieties. This makes it difficult to make statements about gonorrhea as a whole because strains vary. For this reason, I will refer to “certain strains” of gonorrhea, because most of what I’m saying does not apply to all strains.

An article was published on July 8 by the U.S. Centers for Disease Control (CDC) describing two separate issues involving new strains of gonorrhea. Gonorrhea is the bacteria that causes gonorrheal urethritis, also called “drip” or “clap.” Gonorrhea is a fairly common infection. It does not always cause symptoms – while many people who have gonorrhea infection will experience a discharge from the vagina, penis, or anus, others will have no signs of infection at all. In addition to discharge (drip), some strains of gonorrhea can spread throughout the body to cause skin pustules, joint infections, heart infection (endocarditis) and even meningitis.

The first issue the CDC discussed was that some gonorrhea strains in the U.S. are losing their sensitivity to ceftriaxone, the injectable antibiotic which is currently the gold standard for treatment. These strains had already lost susceptibility to all antibiotics which can be taken by mouth. For example, Cipro (ciprofloxacin) and Suprax (cefixime), two oral antibiotics which until recently were the main treatments used for gonorrhea, will not kill these strains of gonorrhea. Now some strains are losing susceptibility to injected ceftriaxone. Therefore, the CDC is now recommending that all cases of gonorrhea be treated with 250 mg of injectable ceftriaxone (which is double the dose used in the past) plus 1 gram of azithromycin, a second antibiotic, by mouth. Many (but by no means all) strains of gonorrhea are still susceptible to azithromycin. The idea is that, by using two antibiotics instead of one, we may be able to slow the evolution of new resistant strains. This is very similar to the idea of using two or three effective anti-HIV drugs together to prevent HIV from becoming resistant. Gonorrhea bacteria, like HIV virus, happens to mutate very frequently.

Like many other new sexually transmitted diseases have been, these resistant strains of gonorrhea are being found mostly in men who have sex with men.

In a second, separate issue, one case has been identified in Japan in which the patient’s gonorrhea was not susceptible to any oral drugs or to high dose injectable ceftriaxone. Resistance this extreme has never been seen before. It is very worrisome, even though it has not been seen outside Japan and has, so far, only been seen in one individual. All epidemics start with one individual, and the infected individual in this case was a sex worker so a large number of people may have been exposed.

What these two situations have in common is that they highlight the fact that we are running out of medicines to treat gonorrhea. If resistance to ceftriaxone becomes widespread, it will be very difficult to avoid an epidemic of gonorrhea.

The good news is that you can avoid this infection! Gonorrhea is 100 percent preventable with condom use. This means condom use for oral sex as well as for anal and vaginal intercourse. The myth persists that it’s not necessary to use condoms for oral sex, and in part for this reason we are seeing more and more cases of gonorrhea infection in the mouth and throat. If you have had unprotected oral sex, it’s very important for you to get tested.

Gonorrhea in the throat usually does not cause any symptoms, so the infected person continues to carry gonorrhea in their throat without suspecting that they are infected. The test for throat gonorrhea is simple and just involves swabbing the throat with a cotton swab, like getting a test for strep throat. A routine throat culture will not test for gonorrhea, so you must tell your medical provider that you want to be tested for gonorrhea specifically. And If you did not have enough good reasons to use a condom before, maybe this will tip the balance for you.

Dr. Eva

Ask Dr. Eva is distributed by Healthy Living News. Dr. Eva Hersh is chief medical officer at Chase Brexton Health Services. Email comments and questions to [email protected] or write to Eva Hersh MD, Chase Brexton Health Services, 1001 Cathedral St., Baltimore, MD 21201

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