Neisseria gonorrhoeae, the bacterium that gangs up on your body to give it gonorrhea. Image: CDC
Gonorrhea is that guy with the funny name who’s always up to something new and mischievous. Last year, the New England Journal of Medicine declared that it’s “time to sound the alarm” in response to emerging strains of gonorrhea that are increasingly resistant to antibiotics. Then, earlier this year, the medical journal JAMA reported the first North American sightings of gonorrhea that failed treatment with cefixime, one of the last drugs we have in our anti-gonorrhea arsenal. It’s a great time to be a gonococcus — the type of bacteria that causes gonorrhea — but the humans they infect probably don’t see it that way.
Last month, this bad boy rose to the top of the Most Wanted list when the Centers for Disease Control and Prevention proclaimed antibiotic-resistant gonorrhea an “urgent threat” — the highest threat level, which gonococci share with only two other bacteria types. To give you some context, the much more famous superbug MRSA was categorized as a “serious” threat, one notch below “urgent.”
Antibiotic-resistant gonorrhea is an “urgent” threat; meanwhile, researchers develop a gonorrhea vaccine that works — on mice.
Antibiotic-resistant gonorrhea is especially insidious for two reasons. One, gonorrhea often doesn’t have symptoms, which allows it to jump from one sexual partner to another, the hosts often none the wiser. Two, unless health care providers actually test the bug’s DNA, they have no way of knowing whether or not they’re dealing with a drug-resistant strain. This opens up the possibility for treatment failure — and for the antibiotic-resistant bacteria to be further propagated into the community.
The CDC estimates that the United States sees 246,000 cases of antibiotic-resistant gonorrhea infections annually — that’s about 30 percent of all gonorrhea infections in the country. For now, we seem to be able to cure them with higher doses or different combinations of drugs. So why does antibiotic-resistant gonorrhea deserve the “urgent” designation? While gonorrhea isn’t associated with a body count — unlike other drug-resistant pathogens, which collectively kill at least 23,000 Americans a year — it can have terrible consequences. Gonorrhea can cause pelvic inflammatory disease (PID) when it advances up the female reproductive tract, and epididymitis when it invades the male reproductive tract; both conditions can cause infertility. Also, gonorrhea infections make us more vulnerable to HIV. The CDC estimates that if the most resistant gonorrhea strain gains ground over the next decade, the country could see an additional 75,000 cases of PID, 15,000 cases of epididymitis, and 222 HIV infections, costing us $235 million.
Bacteria are microscopic organisms that reproduce asexually, meaning that one bacterium clones itself by dividing into two. The advantage that bacteria have over their human conquests is that they can multiply quickly. Sometimes, a bacterium has a gene (or two, or three …) that helps it stay alive even in the presence of antibiotics — for example, by producing an enzyme that neutralizes the drug’s effects. Thanks to evolution by natural selection, these bacteria can outlast their non-resistant counterparts.
In addition to disease-causing bacteria, our bodies are also habitat to beneficial bacteria that “hold territory,” making it more difficult for pathogens to get a foothold. However, if you were to take penicillin for a gonorrhea infection (penicillin hasn’t been effective against gonorrhea in around 40 years), the drug would just kill off a bunch of the “good guys,” leaving vast tracts of cellular real estate open to invading gonococci. Their resistance to drugs gives them two advantages: They don’t die (always a plus), and their competitors are killed off (bonus!).
There is mounting evidence that many drug-resistant bugs originate in factory-farmed livestock, to whom preventive antibiotics are administered at staggeringly high rates (an estimated 70 percent of antibiotics in the United States are given to livestock, not humans). There are also many antibiotic-resistant infections that can plague hospitals, where antibiotic usage is routine. These bugs are then able to attack patients, whose immunity might already be in a state of vulnerability. Antibiotic-resistant gonorrhea, however, only arises from sexual contact. Gonococci don’t live in cows or chickens — only in humans — and you can’t get gonorrhea from a hospital setting, either, unless you’re having sex in a supply closet or something.
The CDC now advises that gonorrhea be treated with a shot of ceftriaxone along with either azithromycin or a week-long course of doxycycline — and many researchers believe that retesting should occur three months later. Unfortunately, research on new antibiotics isn’t flourishing at nearly the same rate as antibiotic-resistance genes among the world’s gonococci. There is one drug in development, but more research is needed before it can seek FDA approval. Mostly, researchers are trying new combinations of preexisting antibiotics in attempts to foil the gonococci’s wily ways.
An effective gonorrhea vaccine could circumvent drug resistance by training our immune systems to do the antibiotics’ work for them. And September may have given us some good news from the University of Buffalo, which developed a vaccine that cures and prevents reinfection with gonorrhea — in mice. Of course, mice can’t mimic the human body, and researchers are often disappointed when successful animal studies can’t be replicated in people. Because gonococci are experts at evading our immune systems, a successful gonorrhea vaccine has thus far lived only in the realm of imagination. However, the Buffalo team was able to create a drug that could stimulate an effective immune response to gonorrhea, allowing mouse immune systems to kill the bacteria while simultaneously developing an immunological memory to protect against future infections. It was a cool experiment, but success in human subjects is not guaranteed.
So, if you’re having vaginal, anal, or oral sex — whether you’re in a hospital supply closet, at home, or anywhere in between — protect yourself with a barrier, such as a condom or a dental dam. You can be tested and treated for gonorrhea, or drop by to pick up condoms, at any Planned Parenthood health center.
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