Unlike killer bees in the 1970s, Y2K at the turn of the century, and numerous fear fads spread via social media over the past several years, the potential appearance of so-called “super gonorrhea” has been a legitimate concern for doctors in the United States since the 1990s. Sadly, it appears that time is close at hand. At least it sure looks that way according to a number of recent news reports.
But what is super gonorrhea, and is it something that we should all be worried about? Are there any effective treatments left? Is it time to make a run for our emergency apocalypse bunkers hidden deep in the Black Hills of South Dakota? The answer to all of these questions is an unqualified yes. Fly, you fools!
What is super gonorrhea?
Back on January 19th, Massachusetts health authorities announced the identification of a “concerning gonorrhea strain” found in two unrelated individuals diagnosed with the infection. The bacteria in each case showed signs of resistance or reduced response to 6 of the 7 antibiotics tracked for resistance by state and federal surveillance programs, the first time this has been observed in the United States. Both patients were still able to be successfully cured using an antibiotic named ceftriaxone, which has been the standard first line treatment for gonorrhea for several years, but don’t let that reassure you too much.
Ceftriaxone is an injectable (IM/IV) broad spectrum antibiotic in the cephalosporin class, and It is one of the most important drugs currently in our armamentarium when treating a wide variety of serious bacterial infections, including meningitis, pneumonia, soft tissue infections, and urinary tract infections. Since 2012, it has been recommended as the first line treatment for gonorrhea because of rising resistance to other choices that could be taken orally. Unfortunately, the strain of bacteria in the recent Massachusetts cases was found to have the penA60 allele, a mutation in the penA gene associated with resistance to ceftriaxone.
The two Massachusetts isolates mark only the 2nd and 3rd time that the penA60 allele has been seen in the United States, though it has been identified in several other countries around the world. In the first case, seen in Nevada, the strain of gonorrhea was sensitive to several other antibiotics. These recent cases were not.
Ceftriaxone worked this time, but there was a reduced response that could quickly evolve in to full resistance. In susceptibility testing, the only antibiotic without any reduced gonorrhea murderability, at least in a Petri dish, was gentamicin. This particular drug has a worse safety profile, though I would still consider it pretty safe in most cases, but isn’t as effective in treating all types of gonorrhea infections as ceftriaxone.
How worried do we need to be?
Well, it depends. If you don’t plan on ever contracting gonorrhea, and take well established precautions, you are probably going to be fine. I’m not sure how many people actually plan to get gonorrhea, though. Certainly some people take a riskier approach to life than I would recommend.
Gonorrhea is an incredibly common infection, second only to chlamydia among reported sexually transmitted infections, and it effects people from all walks of life. Even children aren’t spared from it. Newborns acquire the infection when passing through infected fluids during a vaginal delivery and can develop vision-threatening eye infections, arthritis, meningitis, and even sepsis. Some younger children become infected during acts of sexual abuse. And sexually active older kids also encounter gonorrhea the old fashioned way.
Most gonorrhea infections are mild or even asymptomatic. When symptomatic, most men and women have inflammation in the genitourinary tract, but the throat and rectum are other common locations. Infection in women can spread to the uterus and ovaries leading to infertility. In some cases the bacteria can disseminate throughout the body, causing inflammation of the joints and skin in particular. Systemic disease can even be fatal.
Like all sexually transmitted infections, gonorrhea is on the rise. In Massachusetts, confirmed cases have gone up by more than 300% since 2009. In total across the country, there has been a 131% increase, with nearly 700,000 cases reported in 2021. According to Massachusetts authorities, the two patients with the highly resistant strain were not linked in any way. And because one of them had no history of travel to regions where this strain is known to exist, it is likely that others are infected with it and spreading it right now.
Losing ceftriaxone as an effective treatment for gonorrhea would be really bad. Some patients would still be curable using older treatment strategies, but there would be many treatment failures. If this new (to us) strain takes hold, our options would become even more limited, and with a few strokes of genetic bad luck there may be no options left at all. Numbers of gonorrhea cases would skyrocket since treatment prevents spread, and a lot of people would suffer.
Through the efforts of CDC and FDA fast track programs, there are two new antibiotics currently in phase 3 trials that look promising. There is also some hope that a vaccine could be developed considering that the bacteria that causes gonorrhea shares 80-90% of its DNA with Neisseria meningitidis, a common and vaccine-preventable cause of meningitis. But we can’t count on these to be available anytime soon. So, in the meantime, be careful out there.