A subject that Maryn McKenna and I have both covered several times over the past year has been the worrisome rise in antibiotic-resistant gonorrhea around the globe.
Last year in The Path Of Increased Resistance I wrote about the history and recent rise of resistant gonorrhea around the globe and an MMWR report (Cephalosporin Susceptibility Among Neisseria gonorrhoeae Isolates --- United States, 2000—2010) chronicling its spread over the past decade.
Briefly, I wrote:
Despite 70 years of effective antibiotic treatment for this sexually transmitted disease, it remains the second most common STD in the United States. The CDC estimates that more than 700,000 persons in the U.S. contract gonorrhea each year, although less than half of those infections are reported to CDC.
In 2009, the CDC recorded 301,174 cases of gonorrhea.
The introduction of penicillin in the 1940s represented the first truly effective treatment for this scourge. And for roughly 30 years, penicillin and tetracycline both proved effective weapons against this disease.
But by the 1970s penicillin/tetracycline resistant forms of Neisseria gonorrhoeae began to appear in the United States, and by the 1980s had become common. In response, the CDC began recommending cephalosporins as the first-line treatment for gonorrhea.
In 1993, the CDC also recommended the use of fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) to treat gonorrhea, as they were relatively cheap, effective, and allowed for a 1 dose treatment.
But in less than a decade, fluoroquinolone-resistant N. gonorrhoeae (QRNG) emerged out of Asia and began showing up in Hawaii and then California (see MMWR Increases in Fluoroquinolone-Resistant Neisseria gonorrhoeae --- Hawaii and California, 2001)
In 2007, the CDC announced Fluoroquinolones No Longer Recommended for Treatment of Gonococcal Infections, leaving just one class of antibiotics - the cephalosporins -still recommended and available for the treatment of gonorrhea.
Last month the CDC Grand Rounds: Multidrug-Resistant Gonorrhea webcast provided expert presentations from:
Edward Hook III, MD
William Shafer, PhD
Carolyn Deal, PhD
Robert D. Kirkcaldy, MD, MPH
All of which serves as prelude to a news release today from the World Health Organization on the growing global threat of resistant gonorrhea.
Note for the media
6 June 2012 | Geneva - Millions of people with gonorrhoea may be at risk of running out of treatment options unless urgent action is taken, according WHO. Already several countries, including Australia, France, Japan, Norway, Sweden and the United Kingdom are reporting cases of resistance to cephalosporin antibiotics – the last treatment option against gonorrhoea. Every year an estimated 106 million people are infected with gonorrhea, which is transmitted sexually.
Dwindling treatment options
“Gonorrhoea is becoming a major public health challenge, due to the high incidence of infections accompanied by dwindling treatment options,” says Dr Manjula Lusti-Narasimhan, from the Department of Reproductive Health and Research at WHO. “The available data only shows the tip of the iceberg. Without adequate surveillance we won’t know the extent of resistance to gonorrhoea and without research into new antimicrobial agents, there could soon be no effective treatment for patients.”
Correct use of antibiotics needed
In new guidance issued today, WHO is calling for greater vigilance on the correct use of antibiotics and more research into alternative treatment regimens for gonococcal infections. WHO’s Global Action Plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoea also calls for increased monitoring and reporting of resistant strains as well as better prevention, diagnosis and control of gonococcal infections.
Health implications are important
Gonorrhoea makes up one quarter of the four major curable sexually-transmitted infections1. Since the development of antibiotics, the pathogen has developed resistance to many of the common antibiotics used as treatment, including penicillin, tetracyclines and quinolones.
“We are very concerned about recent reports of treatment failure from the last effective treatment option – the class of cephalosporin antibiotics – as there are no new therapeutic drugs in development,” says Dr Lusti-Narasimhan. “If gonococcal infections become untreatable, the health implications are significant.”
Antimicrobial resistance is caused by the unrestricted access to antimicrobials, overuse and poor quality of antibiotics, as well as natural genetic mutations within disease organisms. In addition, gonorrhoea strains tend to retain genetic resistance to previous antibiotics even after their use has been discontinued. The extent of this resistance worldwide is not known due to lack of reliable data for gonorrhoea in many countries and insufficient research.
Untreated gonococcal infection can cause health problems in men, women and newborn babies including:
- infection of the urethra, cervix and rectum;
- infertility in both men and women;
- a significantly increased risk of HIV infection and transmission;
- ectopic pregnancy, spontaneous abortion, stillbirths and premature deliveries; and
- severe eye infections occur in 30-50% of babies born to women with untreated gonorrhoea, which can lead to blindness.
Gonorrhoea can be prevented through safer sexual intercourse. Early detection and prompt treatment, including of sexual partners, is essential to control sexually transmitted infections.
1 The four major curable sexually-transmitted infections are syphilis, gonorrhoea, chlamydial infection and trichomoniasis.
Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae
World Health Organization, Department of Reproductive Health and Research
Number of pages: 36
Publication date: 2012
ISBN: 978 92 4 150350 1 - Web only
In a related story, Director-General Margaret Chan of the WHO warned this year during a keynote address to the Conference on Combating Antimicrobial Resistance in Copenhagen, Denmark that our World Faces A `Post-Antibiotic Era’.
The D-G’s entire remarks may be viewed on the WHO’s website at Antimicrobial resistance in the European Union and the world, but I’ve excerpted a few choice statements below, after which you’ll find a link to the World Health Organization’s latest publication on antibiotic resistance.
Excerpts from D-G Chan’s March 14th, 2012 speech.
Antimicrobial resistance is on the rise in Europe, and elsewhere in the world. We are losing our first-line antimicrobials. Replacement treatments are more costly, more toxic, need much longer durations of treatment, and may require treatment in intensive care units.
For patients infected with some drug-resistant pathogens, mortality has been shown to increase by around 50%. Let me give an example of what this means for a disease of global significance.
If current trends continue unabated, the future is easy to predict. Some experts say we are moving back to the pre-antibiotic era. No. This will be a post-antibiotic era. In terms of new replacement antibiotics, the pipeline is virtually dry, especially for gram-negative bacteria. The cupboard is nearly bare.
A post-antibiotic era means, in effect, an end to modern medicine as we know it. Things as common as strep throat or a child’s scratched knee could once again kill.
The World Health Organization recently released a 120 page book that provides options and strategies for combating this global threat.
World Health Organization
Number of pages: 120
Publication date: 2012
ISBN: 978 92 4 1503181