The last line of defense for treating gonorrhea is crumbling, according to an article published in the July 8 issue of the Centers for Disease Control and Prevention’s (CDC’s) Morbidity and Mortality Weekly Report.
Cephalosporins, the last class of antibiotics that treat gonorrhea, seem to be losing their effectiveness as the pathogen quickly evolves to bypass the antibiotic.
After 10 years of study, the CDC researchers studying gonorrhea cultures show that higher doses of antibiotics are needed to inhibit growth in the lab The gonorrhea samples collected through the CDC’s Gonococcal Isolate Surveillance Project from male patients in 30 US cities. Close to 6000 isolates were collected each year.
A pattern of emerging resistance is developing says Gail Bolan, MD, director of CDC’s Division of Sexually Transmitted Disease Prevention.
Although no treatment failures have been reported yet in the United States, there have been reports from Asia and other parts of the world suggesting gonorrhea’s declining susceptibility to cephalosporin, said Hillard Weinstock, MD, MPH, from the same division.
At an Impasse
Historically, since the 1930s and 1940s, antibiotics have treated gonorrhea. However, during the past 40 years, the bacteria Neisseria gonorrhoeae has developed resistance to several drugs, including sulfonamides, penicillin, and tetracycline. As recently as 2007, the CDC stopped recommending any fluoroquinolone regimens to treat gonorrhea, leaving cephalosporins the last class of antibiotics standing.
The CDC is down to recommending a cephalosporin (cefixime or ceftriaxone), along with a macrolide antibiotic, preferably azithromycin. Ceftriaxone is the most effective cephalosporin for treating gonorrhea, and azithromycin is better than doxycycline for dual therapy with ceftriaxone, the CDC notes. (Dosing recommendations are available in the article.)
Gonorrhea is one of the most common sexually transmitted diseases. Among serious health consequences, it can lead to infertility in women and increase a person’s risk of acquiring HIV.
Given the possibility of rising resistance, clinicians should be on the lookout for treatment failures, Dr. Bolan said, which will show up as persistent symptoms or a positive follow-up test despite treatment with CDC-recommended antibiotics. Clinicians should also obtain specimens for gonococcal culture from patients whose treatments may have failed. “You need to find labs that are still doing the [gonococcal] culture,” she said.
The CDC recommends that individual providers:
- promptly treat all patients diagnosed with gonorrhea according to CDC Treatment Guidelines,
- obtain cultures to test for decreased susceptibility from any patients with suspected or documented gonorrhea treatment failures, and
- report any suspected treatment failure to local or state public health officials within 24 hours, helping to ensure that any future resistance is recognized early.
Clinicians who care for patients with gonorrhea, especially men who have sex with men in the western United States, should consider having patients return 1 week after treatment for test-of-cure with culture, preferably, or with nucleic acid amplification tests. The CDC report notes that the pattern of cephalosporin susceptibility in the West and among men who have sex with men during 2009 to 2010 resembles the drop in effectiveness observed earlier when a fluoroquinolone-resistant N gonorrhoeae emerged in the United States.
Although Dr. Bolan said she was not aware of any new drug development in the pipeline, the CDC and the National Institutes of Health are running a treatment trial on existing drugs: gentamicin, azithromycin, and gemifloxacin. The trial is expected to yield results by late 2012, said Bob Kirkcaldy, MD, MPH, from the CDC’s Office of Workforce Development and Division of STD Prevention.
“We really do want to have more treatment trials so that we have more treatment options down the pike,” Dr. Bolan said.
However, the development of new antibiotics is unlikely, according to Brad Spellberg, MD, author of Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them. A fellow of the Infectious Diseases Society of America who sits on its antimicrobial availability taskforce, Dr. Spellberg characterized the next several decades as “a very barren period of time” in terms of antibiotics development.
Dr. Spellberg offered 3 reasons to explain his outlook: First, there is a significant scientific challenge. After 60 years of antibiotic discovery, all the low-hanging fruit has been plucked, and developing new antibiotics would be difficult. Second, pharmaceutical companies have found that they make much more money off drugs that target chronic illnesses, not ones consumers will take for only 14 days. Third, “nobody even knows how to do drug trials for antibiotics anymore,” Dr. Spellberg said, and the US Food and Drug Administration’s requirements, he explained, are unclear, infeasible, and/or unreasonable.
“There’s never going to be an endgame to this,” he said. Industry, he predicted, will exit antibiotic development. “It doesn’t make enough money for them, and the regulatory morass exacerbates the problem.” Morb Mortal Wkly Rep. 2011:60;873-877. Full text
What are the signs and symptoms of gonorrhea?
Some men with gonorrhea may have no symptoms at all. However, some men have signs or symptoms that appear one to fourteen days after infection. Symptoms and signs include a burning sensation when urinating, or a white, yellow, or green discharge from the penis. Sometimes men with gonorrhea get painful or swollen testicles.
In women, the symptoms of gonorrhea are often mild, but most women who are infected have no symptoms. Even when a woman has symptoms, they can be so non-specific as to be mistaken for a bladder or vaginal infection. The initial symptoms and signs in women include a painful or burning sensation when urinating, increased vaginal discharge, or vaginal bleeding between periods. Women with gonorrhea are at risk of developing serious complications from the infection, regardless of the presence or severity of symptoms.
Symptoms of rectal infection in both men and women may include discharge, anal itching, soreness, bleeding, or painful bowel movements. Rectal infection also may cause no symptoms. Infections in the throat may cause a sore throat, but usually causes no symptoms.
What are the complications of gonorrhea?
Untreated gonorrhea can cause serious and permanent health problems in both women and men.
In women, gonorrhea is a common cause of pelvic inflammatory disease (PID). About 750,000 women each year in the United States develop PID. The symptoms may be quite mild or can be very severe and can include abdominal pain and fever. PID can lead to internal abscesses (pus-filled “pockets” that are hard to cure) and long-lasting, chronic pelvic pain. PID can damage the fallopian tubes enough to cause infertility or increase the risk of ectopic pregnancy. Ectopic pregnancy is a life-threatening condition in which a fertilized egg grows outside the uterus, usually in a fallopian tube.
In men, gonorrhea can cause epididymitis, a painful condition of the ducts attached to the testicles that may lead to infertility if left untreated.
Gonorrhea can spread to the blood or joints. This condition can be life threatening. In addition, people with gonorrhea can more easily contract HIV, the virus that causes AIDS. HIV-infected people with gonorrhea can transmit HIV more easily to someone else than if they did not have gonorrhea.
How does gonorrhea affect a pregnant woman and her baby?
If a pregnant woman has gonorrhea, she may give the infection to her baby as the baby passes through the birth canal during delivery. This can cause blindness, joint infection, or a life-threatening blood infection in the baby. Treatment of gonorrhea as soon as it is detected in pregnant women will reduce the risk of these complications. Pregnant women should consult a health care provider for appropriate examination, testing, and treatment, as necessary.
Alternative Health Care
Natural medicine’s approach to treating all diseases is to look at the whole person and provide treatment that is specific to that person. Through individualized care in classical homeopathy, nutrition, herbal,oriental and Ayurvedic medicines and stress management care, possibly coupled with tradition drugs a person has the best opportunity to heal, because the body is not simply overwhelmed with a chemical antibiotic in hopes of repeatedly and blindly trying to drive the invader out of the body. Overwhelming the delicate systems of the body with chemicals only surpresses the symptoms of the disease and creates deeper pathology. (For more information-Mary Wolken-editor CMA)