Sex and the Superbug: Meet Antibiotic-Resistant Gonorrhea

Here’s a tidbit you probably didn’t know: Gonorrhea is the second-most frequently reported “notifiable” disease, according to the Centers for Disease Control (CDC). (That means that if you have it, your doctor or local health official needs to report it to the federal government so they can track it; gonorrhea is beaten out only by chlamydia.)

Though gonorrhea—being a sexually transmitted disease (STD) and all—doesn’t come up in conversation too often, it's way more prevalent than you probably think. It’s also a superbug, meaning it’s grown resistant to the usual treatments because the gonorrhea bacteria has mutated to become stronger than ever.  In fact, earlier this month you may have seen alarmist headlines (“Sex Superbug Could be ‘Worse Than AIDS,’” said CNBC.com) about drug-resistant gonorrhea. The CDC was quick to respond, quelling fears about the bug’s presence in the U.S. Many reports were referring to gonorrhea strain H041, which is very resistant to ceftriaxone—the drug widely recommended for treating gonorrhea. That strain, though, hasn’t ever been reported in the U.S., said the CDC.

Gonorrhea is caused by Neisseria gonorrhoeae, a gram-negative bacterium (which means the cells have a double cell lining). The World Health Organization (WHO) estimates that about 62 million people get gonorrhea every year. To get it, you have to have contact with the mouth, penis, vagina, or anus of an infected sexual partner. Once N. gonorrhoeae bacteria have been transmitted, they infect mucosal surfaces in the genitals and throat.

Symptoms of gonorrhea manifest differently in men and women, and also vary in severity (many people, in fact, are asymptomatic). When symptoms do appear, men may see a urethral discharge, or feel pain in their testicles or scrotum. Complications for guys can result in epididymitis, which is pain and inflammation of the epididymis (for those not into genital anatomy and physiology, that’s part of the testicle that stores sperm; we’re getting up close and personal now). In women, gonorrhea may also cause vaginal discharge or bleeding between periods.

Symptoms of untreated gonorrhea aren’t just uncomfortable and embarrassing, though. There are complications of gonorrhea infections that nobody likes to think about: In women, the STD can spread to the uterus and fallopian tubes, increasing the risk of pelvic inflammatory disease, infertility, and ectopic pregnancy (a dangerous situation in which the embryo implants outside of the uterus). Gonorrhea can be passed from mother to child, and it also increases your risk for HIV. So, in the end, it’s a pretty serious infection.





For a while, gonorrhea could be treated easily with penicillin and sulfa drugs. In the late 1960s, though, studies began showing that gonorrhea was rapidly increasing its resistance to penicillin. It beat the antibiotics by making an enzyme—penicillinase—that made penicillin totally ineffective. Then, in the 1980s, strains of gonorrhea that did not produce penicillinase began showing resistance; they showed up in the U.S. in 1980 during an outbreak in North Carolina. This meant that certain strains of gonorrhea had undergone a genetic mutation: They had picked up a chromosome that allowed them to be resistant in a different way. (As a reminder, antibiotics target certain structural components in bacteria to defeat them. If these structural components change, even just a little bit, this change affects the susceptibility of the bacteria to an antibiotic.) What we learned in the ‘80s was that not only did some strains of gonorrhea produce an enzyme that destroyed penicillin, other strains were shifting so that penicillin couldn’t affect them.

Since 1986, the United States Gonococcal Isolate Surveillance Project (GISP) has been monitoring antibiotic resistance to gonorrhea. According to GISP, by 2010, 27 percent of all of the gonorrhea samples were resistant to penicillin, tetracycline, and ciprofloxacin, or some combination of these drugs.

By 2010, 27 percent of all gonorrhea tested was resistant to three major antibiotics or some combination of these drugs.

Cefixime, an oral cephalosporin antibiotic (cephalosporins are a sub-group of beta-lactam antibiotics, like carbapenems) was the recommended antibiotic for gonorrhea treatment, until gonorrhea began to develop resistance that drug too. In 2012, the CDC  updated its treatment guidelines and now recommends an injectable cephalosporin, called ceftriaxone, along with azithromycin or doxycycline, instead of oral cephalosporins. Combination therapies (meaning more than one antibiotic) provide almost a one-two punch against these bacteria—so the hope is that this remains effective. But cephalosporins are our last line of antibiotic defense against gonorrhea. As authors wrote in 2012 in a piece in the New England Journal of Medicine, it is now “time to sound the alarm.”

Simply put, the outlook is not good. In 2011, doctors from Japan published a case study revealing that gonorrhea was acquiring even more resistance—this time, to injectable ceftriaxone. Since then, samples of ceftriaxone-resistant gonorrhea have been detected in France and Spain, too, reports the CDC.

So what to do? We clearly need new options for treatment, but those don’t seem to be coming any time soon. The best method of protection against gonorrhea is abstinence. But that’s not always the most realistic prevention method. The CDC also strongly recommends the use of latex condoms—and not just for vaginal intercourse, but also for oral sex as well. In his New Yorker piece on antibiotic-resistant gonorrhea, Dr. Jerome Groopman briefly explores condom use in fellatio; through interviews with medical professionals, Groopman explains that the most conventional (and effective) way to transmit gonorrhea is through fellatio, because the urethra can come into contact with the human pharynx (throat). The pharynx is a breeding ground for resistance in gonorrhea.

So while we wait for new antibiotics, the best advice we have when it comes to gonorrhea superbugs is: Don’t forget to use a condom.