“We are approaching an era where [patients] “You may no longer respond” to the drug, said Dr. Kathryn Hsu, medical director of the Division of STD and HIV/AIDS Prevention at the Massachusetts Department of Public Health.
The discovery comes as sexually transmitted diseases, particularly gonorrhea, are circulating across the country, and the ability of many microbes to overcome the drugs used to kill them is a growing concern.
“We depend on very few — very few — options. The concern is that we’ll get to a place where there are no options,” said Dr. Helen Boucher, chief academic officer for the health system at Tufts Medicine and a member of the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria. “This is a common infection among healthy young people. … There is only one thing, and that one thing may not work anymore. “
Dr. Rowan Barnabas, chief of infectious diseases at Massachusetts General Hospital, called the strain discovery “significant.”
“But given how mobile we are as a global community, it’s not surprising,” she said.
The Massachusetts news should serve as a wake-up call to doctors and patients to take gonorrhea seriously and watch for signs of resistance, said Dr. Laura Bachmann, medical director of the CDC’s division of STD prevention.
Both the Centers for Disease Control and Prevention and state health officials sent alerts to providers Thursday afternoon. The result is a warning that gonorrhea is “becoming less responsive to a limited arsenal of antibiotics,” the Massachusetts warning said.
“The message to providers is, ‘Hey, we have to watch this,’” Bachmann said. “Antimicrobial resistance is an important and urgent threat to public health.”
However, the Centers for Disease Control and Prevention has not changed its recommendations regarding testing and treatment for gonorrhea. Bachmann called it “reassuring” that both Massachusetts patients were cured with the standard treatment, a one-time injection of ceftriaxone.
The strain is common in the Asia-Pacific region, and 10 cases were recently identified in the UK. UK patients were also treated with ceftriaxone.
Doctors say that if ceftriaxone stops working, there are alternative medications but they carry greater risks or are less effective.
“We want to preserve the options we have,” Barnabas said.
She added that a potential vaccine was being developed.
A few new antibiotics that might work also are in the pipeline, Boucher said, but “economic realities” have slowed progress, as companies working on them have stalled.
Gonorrhea is a common and rapidly spreading disease that is transmitted through sexual contact. The incidence of gonorrhea increased by 45 percent from 2016 to 2020, and more than half of those infected are between the ages of 15 and 24. And in Massachusetts, laboratory-confirmed cases of gonorrhea have quadrupled from a low of 1,976 in 2009 to 8,133 in 2021. The bacteria it causes infects the mucous membranes of the genital tract and urethra in women and men, as well as the mouth, throat, and eyes. and rectum.
In many cases, those infected show no symptoms, which is why the CDC recommends screening tests for people who are sexually active. When symptoms do occur, they can include painful urination and urethral or vaginal discharge.
If not treated, gonorrhea can lead to pelvic inflammatory disease and infertility in women, and inflammation of the scrotum in men. Over time it can spread to the blood and cause inflammation of tendons, joints, brain or heart.
The Massachusetts cases were discovered as part of a routine testing process. A standard test to identify gonorrhea was performed by a primary care physician, and the sample was cultured. After the culture identified infection with gonorrhea, an isolate of the organism was sent to a state laboratory, which performed further testing for drug resistance.
The sample showed signs of resistance, so the state sent it to the Centers for Disease Control and Prevention for more advanced testing, which identified a troubling genotype: The bacteria was resistant to ciprofloxacin, penicillin, and tetracycline and had reduced sensitivity to ceftriaxone, cefixime, and azithromycin.
This prompted the health department to ask clinical laboratories in the same area to send additional samples from around the same time period. Further testing at the CDC resulted in the second case.
Health officials found no connection between the two cases, and Barnabas said there were definitely more than two people infected with the new strain. But there is no information indicating how widespread the new error is. A similar strain that wasn’t completely resistant was identified in Nevada in 2019 but has never been seen again.
“We can’t be sure without increasing our surveillance efforts,” Hsu said, and now represents a “pivotal proactive moment for public health.”
It’s possible, Bachmann said, that the strain is circulating elsewhere. “This is why it is so important for providers to be on the radar and for their public health departments to monitor treatment failure.”
Bachmann said, “To prevent resistance, it’s really important that gonorrhea is recognized quickly and treated appropriately with the right drug at the right time and in the right amount. And that requires providers to be in tune with appropriate screening and treatment guidelines.”
The Massachusetts Department of Health requires providers to treat gonorrhea with high doses of ceftriaxone, perform cultures of symptomatic gonorrhea cases and follow protocols for submitting samples to a state laboratory, and testing to ensure patients are cured after treatment. In addition, regular screening is recommended for sexually active women age 24 or younger, women at increased risk, and sexually active men who have sex with men.
In terms of what individuals can do, Public Health Commissioner Margaret Cook offered this advice in a statement: “We urge all sexually active people to get regular tests for sexually transmitted diseases and to consider reducing the number of their sexual partners and increasing their use of condoms ‘when having sex’.”
Felice J. Freyer can be reached at email@example.com. Follow her on Twitter @tweet.