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As Gonorrhea Cases Mount, Treatment Options Dwindle

This illustration depicts a three-dimensional (3D) computer-generated image of a number of drug-resistant, Neisseria gonorrhoeae diplococcal bacteria. (CDC; Alissa Eckert - Medical Illustrator)

By Donna Campisano, specialist, Communications, APHL

Nearly 650,000 cases of gonorrhea were reported in the U.S. in 2022, making it the second-most commonly notifiable sexually transmitted disease (STD) in this country. Chlamydia takes the number-one spot.

But it’s not just the number of gonorrhea cases that has public health officials alarmed—it’s the propensity of the organism to become resistant to the drugs that can effectively treat it.

What Is Antibiotic Resistance?

Contrary to common belief, it’s pathogens—and not the people who harbor them—that become drug resistant. Antibiotic resistance is a natural process that occurs when germs mutate and outwit the drugs used to fight them. This can make the drugs progressively less effective until they are powerless altogether, leaving germs to grow unabated. Fueling the crisis are the misuse and overuse of antibiotics.

According to the Centers for Disease Control and Prevention (CDC), antibiotic resistance is one of the world’s most urgent public health problems, killing 1.27 million people worldwide in 2019—35,000 of them in the U.S. alone. Antibiotic resistance makes disease more difficult to treat and can lead to more serious outcomes.

One Drug Left

Gonorrhea is an often-silent disease that affects the mucosal membranes of both men and women and can cause everything from infertility to a higher susceptibility to HIV. And roughly half of gonorrhea infections are resistant to at least one antibiotic.

 For years, health care providers turned to antibiotics like penicillin, and then tetracycline, to fight Neisseria gonorrhoeae (N. gonorrhoeae), the pathogen that causes gonorrhea. Eventually the bacterium learned to outsmart these drugs, causing health professionals to turn to other antibiotics, such as ciprofloxacin, ceftriaxone and cefixime. By the early 2000s, however, ciprofloxacin resistance had become so widespread that experts stopped recommending it for gonorrhea treatment. Roughly 10 years later, guidelines changed again after signs began emerging that cefixime was losing effectiveness.

Today, the one antibiotic treatment regimen left standing in the fight against gonorrhea is a singular intra-muscular injection of ceftriaxone. With a dwindling disease-fighting arsenal, detecting and monitoring drug resistance for gonorrhea is more important now than ever.

How Public Health Labs Are Detecting Drug Resistance

Currently, detecting antibiotic resistance in N. gonorrhoeae depends on the ability to culture the organism. Once N. gonorrhoeae is grown, it’s exposed to relevant antibiotics to see how responsive it is to them. Results can be used to guide patient therapy or become part of surveillance programs that inform national treatment recommendations.

But N. gonorrhoeae is a notoriously difficult pathogen to culture. Successful isolation of N. gonorrhoeae from primary specimens is dependent on many factors, including the specimen collection method, transport and storage environment, and dilution of the organism in the collection medium.

APHL offers guidance on collecting and shipping specimens to maintain their viability.

What is CDC’s Role?

To monitor emerging gonococcal drug resistance, one of the programs CDC initiated was the Gonococcal Isolate Surveillance Program (GISP), and, later, the Enhanced Gonococcal Isolate Surveillance Program (eGISP).

Each month, as part of these programs, N. gonorrhoeae isolates cultured from the genitals and extragenital areas (such as the rectum and pharynx) of people who have tested positive for gonorrhea at select STD clinics around the country are collected. These specimens are then sent to one of four regional labs in CDC’s Antimicrobial Resistance Laboratory Network (AR Lab Network), a nationwide network of labs that have the expertise to culture the finicky N. gonorrhoeae and then test it for drug resistance. According to CDC, gonorrhea has a decreased susceptibility to a particular antibiotic when higher-than-anticipated levels of the drug are needed to stop the bacterium’s growth.

APHL supports the AR Lab Network, which has labs in all 50 states and Puerto Rico in addition to regional labs (although not all labs participate in GISPS or eGISPS), with communications, fellowships, training and liaising with public health and laboratory partners. APHL also participates in collaborative, multi-organizational efforts to release and revise guidance, develop educational material for laboratories and sponsor forums and workshops for public health and clinical laboratories. This is all done to help create a seamless exchange of specimens and information with the ultimate aim of combatting drug resistance.

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