Gonorrhea becomes unstoppable; highly resistant cases found in the United States

The most drug-resistant cases of gonorrhea detected in the United States to date have occurred in two unrelated people in Massachusetts, state health officials said Thursday.

These cases mark the first time that US isolates of the bacterium that causes gonorrhea, Neisseria gonorrhoeaehave shown complete resistance or reduced susceptibility to all drugs recommended for treatment.

Fortunately, both cases were successfully cured with powerful injections of the antibiotic ceftriaxone, despite the bacterial isolates showing reduced susceptibility to the drug. Ceftriaxone is currently the recommended first-line treatment for sexually transmitted infections.

But health officials said the cases were a warning. “N. gonorrhoeae becomes less sensitive to a limited arsenal of antibiotics,” they said.

Stirring resistance

For years, global surveillance data collected by the World Health Organization has shown that gonorrhea is becoming increasingly resistant to our entire range of drugs, including first-line drugs like ceftriaxone. Although surveillance is patchy globally, a study of WHO data for 2017-2018 published in 2021 found N. gonorrhoeae isolates with reduced susceptibility or resistance to ceftriaxone occurred in 21 of 68 reporting countries, or 31%.

Resistance to alternative antibiotics was even higher. Of the 61 countries reporting data on another antibiotic, azithromycin, 51 countries (84%) reported resistance. And of 51 countries reporting data on the alternative antibiotic treatment, cefixime, 24 countries (47%) reported resistance. For ciprofloxacin, an antibiotic widely abandoned as a treatment for gonorrhea due to resistance, all 70 reporting countries found resistance.

“In many countries, resistance to ciprofloxacin is extremely high, resistance to azithromycin is increasing rapidly, and resistance or decreased susceptibility to ceftriaxone and cefixime continues to emerge,” the WHO said in 2021. “Without new treatments for gonorrhea, there will be people with gonorrhea infections that will be difficult to treat and cure.”

The agency wasn’t exaggerating. Last year, the WHO added that reports of gonorrhea treatment failures are piling up. “During the past decade, confirmed failure to cure gonorrhea with ceftriaxone alone or in combination with azithromycin or doxycyline has been reported in Australia, France, Japan, Slovenia, Sweden and United Kingdom of Great Britain and Northern Ireland,” the WHO reported.

One of the isolates reported from Massachusetts yesterday demonstrated reduced susceptibility to ceftriaxone, cefixime and azithromycin and resistance to ciprofloxacin, penicillin and tetracycline in laboratory tests. The second isolate appeared to have a similar profile based on genetic data, the Massachusetts Department of Public Health reported. This strain of N. gonorrhoeae has been seen circulating in Asia-Pacific countries and has been detected in recent cases in the UK.

High cases

Along with the worrying trend of increased resistance is the fact that gonorrhea cases are high globally and are increasing in the United States. In 2020, the WHO estimated that there were 82.4 million new cases of gonorrhea worldwide. In the United States, there were nearly 700,000 cases in 2021, up more than 25% from 2017, according to preliminary estimates from the Centers for Disease Control and Prevention.

In many people, gonorrhea has no symptoms. In others, it’s so mild it can be mistaken for a minor bladder infection or yeast infection. Over time, however, this can lead to pelvic inflammatory disease, severe pain, and fertility issues. Health officials stress the need for testing and surveillance to treat infections early before they become serious and have a chance to spread.

For the two Massachusetts cases, health officials are currently working on contact tracing. With no clear link between the two cases, officials say it is likely to be more widespread than currently known.

“The discovery of this strain of gonorrhea is a serious public health concern that DPH, the CDC and other health departments have been working to detect in the United States,” said Massachusetts Public Health Commissioner Margret Cooke, in a statement. “We urge all sexually active people to be tested regularly for sexually transmitted infections and to consider reducing the number of their sexual partners and increasing their use of condoms during sexual intercourse. Clinicians are advised to review the clinical alert and participate in our expanded surveillance efforts.”