This article originally appeared on Tonic.
Update 10/1/19: Health officials have warned about the first case of super-gonorrhoea contracted within the UK. In 2018, a British man picked up the "world's worst ever" case of super-gonorrhoea after having sex with a woman in south-east Asia; this time around, the woman is said to have contracted the STI in the UK.
A case of gonorrhoea that’s immune to both of the standard antibiotic treatments has been identified in the United Kingdom, according to the government agency Public Health England. You may have heard of similar-sounding cases of “super gonorrhoea” infection, but thus far they were highly resistant to one drug, and weaker against the second antibiotic. (Such cases have already been found in Canada, Japan, and Hawaii in recent years.)
The unlucky man caught the world’s worst case of the clap on a recent sexual encounter with a woman while travelling somewhere in “southeast Asia,” according to the report. What happened next helps illustrate how serious this is: The strain of gonorrhoea was found to be resistant to both antibiotics in the standard two-drug cocktail—azithromycin and ceftriaxone. After further treatment with a third drug, spectinomycin, the man’s urine test finally came back negative for gonorrhoea but his throat swab was still positive because spectinomycin isn’t great at clearing gonorrhoea from the neck. He is currently being treated with an intravenous drip of ertapenem, part of a class of if-all-else-fails medication called carbapenems. It seems to be working, and Public Health England will release updated test results in mid-April.
But don’t take much comfort from the fact that the last line of defense against truly incurable gonorrhoea seems to be holding firm. Last year the World Health Organization reported that several types of bacterial infection—although not gonorrhoea—were already immune to carbapenems and another antibiotic class called cephalosporins.
“One problem is that the gonococcal bacteria has been able to develop resistance to each new class of antibiotics we have put in its path,” says Alan Katz, an epidemiologist at the University of Hawaii who reported the antibiotic-resistant cases of gonorrhoea found in Hawaii last year.
Generally speaking, antibiotic resistance develops from an overuse of antibiotics to treat and prevent infections in both humans and livestock. As a few tough bacteria in a colony develop certain proteins or mechanisms that make them immune to the drugs, incomplete treatments allow those super bacteria to grow and spread to other hosts.
In the case of gonorrhoea, the antibiotic resistance seems to be developing not from inadequate treatments, but from other bacteria that have already developed immunity to those drugs. “Gonorrhoea is particularly prone to picking up pieces of DNA and incorporating it,” says Peter Leone, a professor of medicine at the University of North Carolina who specializes in sexually transmitted infections. “Gonorrhoea isn’t pushing the development of resistance, it’s the other way around.”
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The Centers for Disease Control and Prevention have a longstanding program to identify and monitor strains of Neisseria gonorrhoeae, the bacteria that causes gonorrhoea. As doctors noticed increasing levels of resistance to the single-drug treatment of ceftriaxone, in 2010 the CDC recommended that all treatment regimens include a second antibiotic, azithromycin, to help wipe out resistant infections. “By attacking gonorrhoea from different angles it would give us a better efficacy and reduce the likelihood of giving us a resistance to any one group of antibiotics,” says Kees Rietmeijer, medical director of the STD control program at Denver Public Health.
For a while, the two-pronged approach seemed to be working, but over the past year, gonorrhoea strains have seemed to grow increasingly resistant to both types of antibiotics.
As gonorrhoea continues to evolve new ways to evade our best antibiotics, then more people might suffer some of the serious complications of a gonorrhoeal infection. In men, the telltale urethral discharge and painful urination eventually leads to inflammation of the epididymis tubes that carry sperm out of the testicles. In women, gonorrhoea leads to pelvic inflammatory disease, which increases the risks of ectopic pregnancy and infertility. It gets worse: Untreated gonorrhoea increases the risks of both picking up and passing on an HIV infection, and gonorrhoea that eventually spreads to the blood and joints can be fatal. For now, however, those worst case scenarios are still rare.
Scientists are working on a gonorrhoea vaccine, but progress has been slow. Last September, researchers in New Zealand reported that a large campaign to prevent meningitis had revealed a hidden benefit: People who received the meningitis vaccine were also 31 percent less likely to acquire gonorrhoea. As it turns out, the bacteria that cause meningitis and gonorrhoea are closely related, sharing much of the same genetic material. It was the first time any vaccine had shown it could protect against the clap, and further study of why exactly it worked might eventually yield an effective gonorrhoea vaccine.
But with a vaccine a long way off, and potentially incurable gonorrhoea on the horizon, some experts are calling for a renewed focus on screening and prevention for a disease that the broader public doesn’t seem to take seriously. “Nationally, STD programs are on the front lines of the STD epidemics, and these programs are poorly resourced,” says David Harvey, executive director of the National Coalition of STD Directors.
As AIDS treatments and pre-exposure prophylaxis pills have whittled down HIV’s death toll, rates of sexually transmitted diseases that aren’t HIV steadily climbed upward. In 2016, the most recent year of data, the CDC reported that new cases of chlamydia increased by 4.7 percent over the previous year, syphilis increased by 17.6 percent, and gonorrhoea increased by 18.5 percent. All told, 468,514 cases of gonorrhoea were reported to the CDC in 2016. “I think we need to realize that these other STIs, including syphilis and gonorrhoea, it’s not a walk in the park and it’s not something that you want to have,” Rietmeijer says.
But not all cases of gonorrhoea cause enough symptoms right away to get people to head to the doctor or an STD clinic, as in the case of the British man. In fact, many cases of gonorrhoea in women don’t cause any symptoms at all. What’s more, gonorrhoea can also infect the rectum, where it may cause itching or a discharge, and the throat, where it might only give you a mild sore throat.
Those barely noticeable throat infections are likely driving the rapidly increasing antibiotic resistance in gonorrhoea, Leone says. “By carrying it in the throat for long periods of time, you now have close proximity to other bacteria with resistant genes that can be passed on to gonorrhoea,” he says. Throat infections also spread during oral sex, when people are less likely to use condoms.
In this age of super gonorrhoea, condoms are a must, and that goes for oral sex, too, unless you're in a mutually monogamous relationship where neither partner has an STD. (The CDC says mutual monogamy is one of the most reliable ways to avoid STDs.)
If you’re not in a monogamous relationship, the CDC says to get screened for STDs at least once a year to catch infections early. Leone suggests making sure they swab the urethra (or vagina for women), rectum, and throat (don’t worry—they use separate swabs for those places). Gonorrhoea rates are higher among the gay community and men who have sex with men, and the CDC recommends that men who have sex with men and have multiple partners increase the frequency of screens to every three to six months.
People who live Maryland, Washington DC, or Alaska can order a free take-home STD kit from Johns Hopkins University at iwantthekit.org. And if you reside anywhere else, you can pay for an at-home kit at mylabbox.com or visit your doctor or a sexual health clinic.
If you think all that testing sounds excessive, consider this: While there’s currently only one reported case of multidrug resistant gonorrhoea, that man is not alone. “It’s the tip of the iceberg,” Leone says. “Are there a lot? Probably not, but certainly if you see this, you know you have someone in southeast Asia walking around with this and they’re probably passing it on to other people.”