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Worrisome rise in drug-resistant gonorrhea described in New Yorker

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National Institutes of Health via WikiMedia Commons
Treatments that were once effective against gonorrhea, like penicillin, are no longer reliable as the disease adapts.

Given that gonorrhea is the second most commonly reported infectious disease in the United States (chlamydia is ranked No. 1), the recent emergence of a drug-resistant strain is extremely worrisome.

Adding to that worry is the fact that some men and many women who are infected with the sexually transmitted disease have no symptoms — or the symptoms are so mild they are mistaken for a bladder or vaginal infection or a sore throat (if the disease is in the throat).

Many individuals, therefore, are unaware that they are carrying and transmitting the disease.

When symptoms do occur, they can be quite unpleasant and painful: a discharge from the penis, vagina, rectum or eyes; pain when urinating; and pain in the testicles, throat and joints.

Untreated, gonorrhea can cause infertility (in both men and women) and infections that spread to other areas of the body, including the joints, heart and brain. Babies born to mothers with gonorrhea can become blind. Having gonorrhea also increases an individual's susceptibility to HIV infection.

An adaptive disease

The Oct. 1  issue of the New Yorker contains a troubling report about drug-resistant gonorrhea, including a description of current public health efforts — so far, ineffective — to contain it. Written by staff writer Dr. Jerome Groopman, a cancer and AIDS researcher and professor of medicine at the Harvard Medical School, the article discusses how a disease that scientists as recently as a decade ago believed might be eradicated in some Western countries may now become a global epidemic.

An untreatable epidemic.

Writes Groopman:

[A]s modern medicine has adapted so has the microbe. Natural selection has given rise to strains of the bacterium that are resistant, in varying degrees, to some or all of the treatments applied to them — sulfa drugs, penicillin, tetracyclines, fluoroquinolones, and macrolides. Now only one class of drugs, called cephalosporins — cefixime, a tablet, and ceftriaxone, administered by injection — is known to reliably treat it, and for several years resistance to cefixime has been rising. …

Between 2000 and 2010, the number of cases of decreased cefixime susceptibility in California and Hawaii rose from zero per cent to more than four per cent and seven per cent, respectively, probably as a result of traffic from Asia, where cefixime resistance is more widespread.

Five per cent is cause for concern; in August, the C.D.C. recommended phasing out cefixime nationwide and, instead, treating gonorrhea with a combination of ceftriaxone and either azithromycin or doxycycline. According to a recent British report, last year eleven per cent of isolates of the microbe showed reduced susceptibility to cefixime; among gay men, the figure is seventeen per cent.

“We are seeing decreased sensitivity to cefixime in all twenty-one countries in Europe,” Dr. Catherine Ison, a researcher in the U.K.’s surveillance program for sexually transmitted infections, told me. “It’s worrying.” …

No cases have yet been reported in the U.S., but resistant gonorrhea is likely to arrive and spread long before physicians and the C.D.C. recognize it; some public-health officials predict that in five to eight years the superbug will be widespread.

Few financial incentives to develop new antibiotics

As Groopman points out, “[t]he surest defense against cephalosporin-resistant gonorrhea would be a new antibiotic, but there are no commercially available treatments to take the place of cefriaxone. The economics of drug development favor daily medications that are taken for long periods — such as Lipitor, for high cholesterol, and Prozac for depression — over antibiotics that are typically prescribed for only days or weeks. As a result, efforts to develop new antibiotics against superbugs have been all but abandoned by most major pharmaceutical companies.”

Scientists have also made little progress in developing a vaccine. The body’s immune response to the gonorrhea microbe is very short-lived, a factor that makes developing a long-lasting vaccine extremely difficult, Gropman explains. (That short immune response is also why people become easily reinfected, sometimes within three weeks of being treated.)

A need to change behavior

“The primary hope for stemming the expected epidemic of resistant gonorrhea lies in persuading people to alter their behavior,” writes Groopman. That means using condoms not only for vaginal and anal intercourse, but also for oral sex.

“The challenge now facing the public-health community is how to persuade people to rethink an insidious disease — and, to a great extent, a sexual practice — that has come to be viewed as trivial,” Groopman concludes. “As the distinction between safe sex and safer sex becomes ever less meaningful, the responsibility to be vigilant grows more personal, and more urgent.”

You'll have to pick up an Oct. 1 1 issue of the New Yorker to read the article, as it's behind a paywall on the magazine's website. NPR ran a story on this topic in August, when the CDC issued its new treatment recommendations regarding gonorrhea. You can listen to that report on NPR's health blog.

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