A bacterial infection and one of the most common STDs, gonorrhea is known to be treatable by the consumption of antibiotics. According to the World Health Organization (WHO), in 2020, a total of 82.4 million new cases were found and adolescents and adults aged 15-49 years are the ones who were infected. The African Region and the Western Pacific Region are where most of the cases were detected. Ever since antimicrobial medicines began to be utilized to treat the disease, antimicrobial resistance (AMR) in the bacteria (N. gonorrhoeae) that causes the STD also emerged. This resistance has progressively developed in the past 80 years. The resistance occurs to medicines such as tetracyclines, macrolides (including azithromycin), sulphonamides, trimethoprim combinations as well as quinolones. In this article, we will discuss how this phenomenon started to take place, what causes it, its implications as well as WHO’s response.

How it first happened

Japan was reportedly the first country that detected treatment failure. The antibiotics at play at that time were cefixime. In the last 10 years, the failure to cure gonorrhea with antibiotics (ceftriaxone alone or in combination with azithromycin or doxycycline) also came from Australia, France, Japan, Slovenia, Sweden, the United Kingdom of Great Britain and Northern Ireland. The United Kingdom reported the first global failure to cure pharyngeal gonorrhea with 500mg of ceftriaxone and 1g of azithromycin or what is also known as ‘dual therapy’. Afterwards, the international gonococcal strain resistance to ceftriaxone was reported in Denmark, France, Japan and the United Kingdom.

These confirmed failures with the exception of one recent case in the United Kingdom are all pharyngeal infections attacking the throat. Most of the pharyngeal infections are without symptoms and the tissue is not penetrated thoroughly by antimicrobial drugs in that area. The pharynx is also known to be home to the related bacteria of the Neisseria species which naturally occurs there. Most data related to this issue come from high-income countries while data on antibiotic resistance and treatment failure are still insufficient.

What causes it

It can be concluded that N.gonorrheae’s resistance to several treatment options renders it a multidrug resistant organism. This resistance can develop overtime due to a number of factors such as access to antimicrobials which are not limited, incorrect selection and overuse of antibiotics and the existence of poor quality antibiotics. What is more, the organism might experience genetic mutations, therefore contributing to increased drug resistance in the bacteria. It is known that infections which occur outside the genital area (in the rectum and throat) distinctly affect men who have sex with men (MSM). This can also contribute to the development of resistant strains since N.gonorrhoeae connect with and exchange genetic material with other organisms in these body parts.

Implications of gonococcal infections

When treated early and successfully, gonorrhea does not bring lifelong complications. However, if left untreated, it can lead to major complications including:

• Infertility in women: Gonorrhea is often asymptomatic in women, making it very possible to go unnoticed and untreated. Untreated gonorrhea in women can end up in pelvic inflammatory disease (PID). As a result, women with this complication may suffer from scarring of the tubes, ectopic pregnancy, higher risks in pregnancy complications and infertility. In several cases, maternal death is also an implication of untreated gonorrhea.
• Infertility in men: Similar to women, untreated gonorrhea can trigger epididymitis in men. Epididymitis is an inflammation of the coiled tube of the testicles where sperm ducts are at. Left untreated, epididymitis can cause infertility.
• Heightened risks for HIV/AIDS: According to WHO, having gonorrhea makes people 5 times more prone to contracting HIV. On the other hand, people with both HIV and gonorrhea can transmit both diseases more easily to their partners.
• Neonatal complications: These complications occur to newborn babies who contract gonorrhea from their mothers. The extent of the complications revolves around infections, sores on the scalp, and even blindness.
• Extended infections which spread to the joints and other body areas: The gonorrhea-causing bacterium can make way to the bloodstream and infect the joints. Possible complications include rash, fever, joint pain, and swelling.

Both individuals and health care systems will be burdened by hefty financial costs because of these complications. AMR which prolongs the length of infection and increases the amount of people with long term complications of gonococcal infections also adds to the burden. It is important to note that this problem is not only spotted in developing countries as high-income and developed countries also experience treatment failure with antibiotics. It can be safely said that the actual number is much higher than what we are seeing due to the limitation on surveillance data for developing countries.

WHO’s response

To mitigate this situation and reduce the number of gonorrhea cases, WHO has taken key actions and some of them include:

• Spreading prevention messages, interventions and the correct treatment regimens to effectively prevent gonorrhea
• Issuing effective regulations regarding drugs
• Improving surveillance systems for antimicrobial resistance, particularly in countries with a high burden of gonococcal infections
• Supporting research that are focused on finding out methods to detect antimicrobial resistance
• Looking into alternative treatments for gonococcal infections
• Being watchful of treatment failures by establishing a standard set of monitoring protocols
• Supporting research that are focused on finding low-cost tests to detect the bacterium in priority populations such as sex workers and HIV-positive people
• Looking at the increase in antimicrobial resistance, WHO has emphasized the importance of finding effective gonococcal vaccines. To date, there are still no licensed gonococcal vaccines.

Gonorrhea is curable, but above all, preventable. One of the simplest ways is to regularly use condoms during sexual intercourse, which is known to be 98% effective at warding off the STD. Besides gonorrhea, HIV and HPV are two STDs which are preventable. Getting vaccinated for HPV is imperative for young people while taking HIV PrEP is highly encouraged for those who are at higher risk for HIV exposure. If you feel like you have been exposed to HIV, HIV PEP can help reduce the chance of becoming HIV positive by over 90%.