Gonorrhea, one of the most common sexually transmitting diseases (STDs) in the U.S, is building an impending resistance to cephalosporins, the class of drugs most recently used to eradicate the condition.
Government agencies, such as Centers for Disease Control and Prevention, are urging healthcare practitioners to pay close attention to documented and possible cases of gonorrhea, an infection thought to affect more than 700,000 each year in this country alone.
In response to recent surveillance data suggesting that the oral antibiotic cefixime is becoming less effective in treating gonorrhea, CDC has revised its gonorrhea treatment guidelines to preserve the last available effective treatment option for as long as possible. The new guidelines were published in the Aug. 10, 2012 issue of the Morbidity and Mortality Weekly Report.
According to the revised guidelines, a combination treatment is the most effective: the injectable antibiotic ceftriaxone along with one of two other oral antibiotics, either azithromycin or doxycycline.
In the past, gonorrhea has developed resistance to every antibiotic recommended for treatment, leaving the cephalosporins, which include cefixime and ceftriaxone, as the final recommended class of drugs.
CDC researchers are concerned that continued use of cefixime may prompt gonorrhea to develop resistance to all cephalosporins. Limiting the use of cefixime now may help preserve ceftriaxone as a treatment option for a little longer.
“While CDC’s revised treatment guidelines may help delay the emergence of cephalosporin-resistant gonorrhea, they do not solve the problem of impending gonorrhea drug resistance,” said Robert D. Kirkcaldy, MD, MPH, medical epidemiologist, division of STD prevention at CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. As the project officer for the Gonococcal Isolate Surveillance Project (GISP), he leads CDC’s efforts to track and respond to the threat of antibiotic-resistant gonorrhea.
“This information, coupled with past experience and the latest U.S. surveillance data, suggest that it is only a matter of time before gonorrhea becomes resistant to the only remaining treatments currently available,” Kirkcaldy explained.
Kirkcaldy noted that, to date, no patients have failed treatment with either cefixime or ceftriaxone in the U.S.; however, a small but growing number of cefixime treatment failures have been observed in other countries.
In order to properly educate about sexually transmitted diseases, a community plan needs to be created and implemented. “The STD problem is so large and so underfunded, that individual and group behavior will not change without community involvement,” said Candy Hadsall, MA, RN, an STD clinical consultant and infertility prevention project coordinator at the Minnesota Department of Health.
Education Needs to Come First
“The potential for some strains of gonorrhea to develop a resistance to cephalosporins stresses the need for prevention and reminds us that our message as practitioners starts with education,” explained Amy Lee, ARNP, MS, WHNP-BC, a nurse practitioner with a focus on inpatient gynecology at Johns Hopkins Hospital in Baltimore. “This news is truly frightening because we’re potentially building a super bug with bad sequelae.”
Gonorrhea can be transmitted through vaginal, anal and oral sex. “The bacteria is passed through sexual contact and infects the urethra in men, the cervix in women and the anus and throat in both sexes,” Lee said.
Some people may show symptoms such as burning when urinating or discharge, but the fact is, most cases go undetected and untreated. Although some men tend to be symptomatic right away, there are often are no immediate symptoms for women. “Men typically receive treatment earlier because they are more immediately symptomatic,” Lee shared. “As a result, men tend to have fewer complications from gonorrhea.
Left untreated, gonorrhea can cause serious health problems, particularly for women, including chronic pelvic pain, life-threatening ectopic pregnancy, tubal and ovarian abscesses, miscarriages and even infertility. Infection also increases the risk of contracting and transmitting HIV.
“With treatment options dwindling, and the very real threat of untreatable gonorrhea on the horizon, it’s critical for sexually active individuals to take important steps to protect themselves from infection,” cautioned Kirkcaldy.
“Protecting yourself against gonorrhea infection has never been more important.”
The surest way to avoid transmission of gonorrhea is to abstain from sex, or to be in a long-term, mutually monogamous relationship with a partner who has been tested and is known to be uninfected.
“Consistent condom use and limiting sexual partners can help reduce risk,” said Lee. “With fewer partners, there is less opportunity to encounter the bacteria.”
Surveillance disease investigators are needed to track down untreated cases before it’s too late.
“We’re trying to reach the sexual partners of those who have been treated to educate them,” Hadsall said. “It’s more difficult to get the message to that population.”
When used consistently and correctly, condoms can reduce the risk of transmission of gonorrhea. “There are messages that need to be repeated for the rest of lives,” Lee shared. “We forget to say that condoms still need to be used even if a patient is on other birth control.”
There is very little research about the transfer rates of STDs through oral sex. “This is a concern for us right now and all we can do is stress the use of condoms for oral sex just as we stress the practice for intercourse,” Hadsall said. “We need to operate under the assumption that STDs may be more easily transmitted through oral sex.”
Role of Healthcare Providers
As a nurse, Hadsall regularly trains providers about how to improve screening and the drug resistance issue is part of her presentation.
“We want providers to step up the screening because it’s going to get worse,” she said. “We need to identify and treat as many people as possible while we still can. And that means that we need all nurses to act as vehicles of information, not just those who work in the sexual health sector.”
CDC encourages all providers to take a sexual history of all patients; promptly treat all patients diagnosed with gonorrhea; make every effort to evaluate and treat all patients’ sex partners from the previous 60 days; and obtain cultures to test for bacterial antibiotic resistance from any patients with suspected or documented gonorrhea treatment failures.
According to Kirkcaldy, regular screening for those individuals identified to be at the greatest risk is critical. CDC recommends that sexually active gay and bisexual men and high-risk sexually active women be tested for gonorrhea at least once a year.
“Anyone who becomes infected should get treated with a ceftriaxone injection and either azithromycin or doxycycline right away to cure the infection and prevent transmission to others,” explained Kirkcaldy. “Patients receiving a treatment other than dual therapy that includes ceftriaxone should be re-tested one week after completing treatment to confirm that the infection has been cured.”
Additionally, clinicians are asked to report any suspected treatment failure to local or state public health officials within 24 hours, helping to ensure that any potential resistance is recognized early. “Physicians and other healthcare providers are on the front lines in the fight against gonorrhea and play a critical role in our response,” said Kirkcaldy.
According to Lee, the community needs to be educated about gonorrhea and it needs to start at a young age. “Knowing what it is is more important than ever,” she said. “Comprehensive sexual education is recommended to be in schools yet it’s not always being put to practice. Providers and clinicians need to continue to educate patients throughout their entire care.”
Another concern is that there has been a rise in the incidence of gonorrhea among older populations, according to Lee. “This trend represents the need for education to be continuous,” Lee observed. “Gonorrhea does not just go away at an older age.”
Practitioners are not expected to educate in silos. To be effective, the efforts need to be widespread. “Education needs to come from a cross section of community members, not just healthcare providers,” Hadsall said.
The Chlamydia Model
“In Minnesota, our epidemic is chlamydia,” Hadsall said. “Our gonorrhea numbers have actually gone down [in Minnesota] in the last 2 years. But that’s not to say it isn’t still a serious problem.” Now that drug resistance is increasing, Hadsall’s attention is turning back to gonorrhea.
Hadsall points to the chlamydia model now in place in the state of Minnesota as a framework for what she believes other areas of the country ought to be doing to battle gonorrhea. “We had the highest rates of chlamydia ever in Minnesota three years ago and we needed to figure out how to make a difference,” she said. “We had to change our approach to effect a change in the number of people infected.”
After receiving a grant from the National Chlamydia Coalition, the Minnesota Department of Health launched a statewide initiative called the Minnesota Chlamydia Partnership. “We had to be better about going out in the community and asking ‘what can we do?’ Before implementing that approach, we would go to community and tell them what to do. Obviously that approach was not working.”
With this approach, volunteers in the community are asked to participate in groups over the course of several months to establish ideas that could be used to help gain general funding, improve screenings and educate parent groups and members of youth organizations.
The Minnesota Chlamydia Strategy is a 75-page resource document available to the public on the Minnesota Department of Health website. The document outlines how best present to sexual health messages to various communities and what parents, children, businesses and healthcare providers can do to get the right information to the public.
“We hope that the document becomes a talking piece and starts conversations,” Hadsall said. “Perhaps someone is looking to form a coalition locally. Our document can serve as a guide.”
The Minnesota Department of Health has launched a plan to target education in the community and hopes to see change. “Obesity is a similar issue in this country,” explained Hadsall. “The problem with obesity is how to get fresh foods into a poor community. For sexually transmitted diseases, the problem is how to get individuals screened and treated.”
According to Hadsall, government agencies focus funding on programs for diabetes, obesity and other health crises but need to look at programs for sexually transmitted diseases. “In order to reach more people, STD awareness programs need state funding and increased federal funding,” she told ADVANCE. “Funding is an issue in many states, not just Minnesota.”
Urgent action now can help preserve ceftriaxone as an effective treatment option for as long as possible and hopefully buy the time needed for new options to be developed, Kirkcaldy told ADVANCE.
CDC is urging researchers in the public and private sectors to step up efforts to develop new treatments for this common but potentially serious STD.
According to Kirkcaldy, a new drug called solithromycin is being studied by scientists for its effectiveness in treating gonorrhea. Additionally, CDC is working with NIH to conduct a randomized controlled trial to see how effective different combinations of existing drugs are at treating gonorrhea.
“The trial is ongoing and we hope to have findings of the trial sometime this year,” Kirkcaldy said. “But more needs to be done. It is likely that many different approaches will need to be studied before suitable treatment options can be found.”
“We want to strongly encourage health care providers to treat as many people who are positive for gonorrhea as possible before there is no longer an effective treatment,” Hadsall relayed. “And we want the public to understand the importance of completing treatment if they are diagnosed with gonorrhea and the importance of being sure their partners get treated while we still have medications that are effective.”
Rebecca Mayer Knutsen
is on staff at ADVANCE. Contact her at email@example.com.