Q&A: Pan-resistant gonorrhea ‘may be inevitable’ without changes
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Massachusetts health officials detected a novel strain of gonorrhea with reduced susceptibility or resistance to five antibiotic classes — the first of its kind in the United States.
Two patients infected with the strain were successfully cured with a 500 mg intramuscular dose of ceftriaxone, the CDC-recommended treatment, the state health department said in a press release.
However, the strain exhibited reduced susceptibility to the cephalosporins ceftriaxone and cefixime, and also azithromycin, as well as resistance to ciprofloxacin, penicillin and tetracycline.
We asked Jeffrey Klausner, MD, MPH, clinical professor of population and public health science at the University of Southern California Keck School of Medicine, about the discovery and what clinicians need to know.
Healio: Is there anything about this report that makes you less confident in the current recommendation of 500 mg intramuscular ceftriaxone for uncomplicated gonorrhea?
Klausner: Ceftriaxone 500 mg intramuscular once is the new CDC 2020 STI Guidelines-recommended treatment for uncomplicated gonorrhea. Based on the Massachusetts report, there was no evidence of treatment failure.
There is a paucity of clinical data in the management of Neisseria gonorrhoeae infections with elevated minimum inhibitory concentrations.
Healio: Other countries, including the United Kingdom, have reported cases of gonorrhea that are resistant to ceftriaxone. The Massachusetts strain showed reduced susceptibility to ceftriaxone, but the patient was ultimately successfully treated with the recommended 500 mg injection. How concerned are you about pan-resistant gonorrhea? Does it keep you up at night?
Klausner: Lots of things keep me up a night. We just had a 4.2-magnitude earthquake last night that violently shook our house. N. gonorrhoeae that is resistant to all available antibiotics is a serious concern. It makes me think about those urine culture results where one sees Klebsiella resistant to every antibiotic tested. Totally antibiotic-resistant gonorrhea may be inevitable unless we change the way we treat gonorrhea.
Healio: Gonorrhea cases have increased by 131% nationally, according to the CDC, and 312% in Massachusetts, health officials said. Why have they increased so much? Is it because of the increased resistance to treatment?
Klausner: There is no evidence that antibiotic resistance has contributed to the large increases in gonorrhea nationally. Those increases are directly due to a closure of public health clinics and reduction in public health staff that are involved in gonorrhea prevention and control.
The CDC recommends expedited partner treatment for gonorrhea — through extra medication or extra prescriptions for patients — but few clinics or providers routinely provide adequate partner treatment. Physicians may be liable for failure to comply with standard-of-care and CDC recommendations by not offering expedited partner therapy.
Healio: Gonorrhea has been described as a “smart bug.” What gives it the ability to so easily adapt and develop resistance to new drugs introduced to treat it?
Klausner: One of the main reasons N. gonorrhoeae adapts to antibiotics so quickly and develops resistance is that it incorporates DNA in its environment readily through what is called transformation. N. gonorrhoeae in the throat are swimming in a bath of other Neisseria species that may have picked up resistance elements. Those resistance elements are readily transferred to N. gonorrhoeae.
Healio: Are new drugs being developed with gonorrhea in mind?
Klausner: Yes, there are new drugs in the pipeline and some new classes that N. gonorrhoeae have not seen. Over time, however, we might expect resistant to those, too.
What we need to do is practice what I call resistance-guided therapy, where we treat gonorrhea based on its antibiotic susceptibility profile. We do that routinely for other serious infections like tuberculosis, HIV and infections in the hospital. NIH funded a clinical trial of resistance-guided therapy that I led. We found that the strategy was 100% effective at curing infections at any anatomic site.
Currently, NIH is intending to fund a new trial for FDA approval of diagnostic devices that can predict gonorrhea resistance — something urgently needed.
References:
- Commonwealth of Massachusetts. Clinical alert. https://www.mass.gov/doc/clinical-alert-on-non-susceptible-gonorrhea-january-19-2023/download. Published Jan. 19, 2023. Accessed Jan. 26, 2023.
- Department of public health announces first cases of concerning gonorrhea strain. https://www.mass.gov/news/department-of-public-health-announces-first-cases-of-concerning-gonorrhea-strain. Published Jan. 19, 2023. Accessed Jan. 26, 2023.
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