“We are approaching an era where [patients] may stop responding to the drug, said Dr. Katherine Hsu, medical director of the Division of STD Prevention and HIV/AIDS at the Massachusetts Department of Public Health.
The discovery comes as sexually transmitted diseases, particularly gonorrhea, are on the rise across the country, and the ability of many microbes to outsmart the drugs used to kill them is a growing concern.
“We have very few – very few – options. The concern is that we’re getting to a point where there are no options left,” said Dr. Helen Boucher, chief academic officer of the Tufts Medicine health system and member of the presidential advisory board on combating antibiotic-resistant bacteria. “This is a common infection in young, healthy people. … There is only one thing, and that one thing may no longer work.”
Dr. Ruanne Barnabas, chief of Massachusetts General Hospital’s infectious disease division, called the discovery of the species “significant”.
“But given how mobile we are as a global community, that’s not surprising,” she said.
Massachusetts news should alert doctors and patients to take gonorrhea seriously and watch for signs of resistance, said Dr. Laura Bachmann, chief medical officer of the CDC’s division of STD prevention.
The Centers for Disease Control and Prevention and state health officials both sent alerts to providers Thursday afternoon. The Massachusetts alert said the finding is a warning that gonorrhea is “less responsive to a limited arsenal of antibiotics.”
“The message to providers is, ‘Hey, we need to keep an eye on this,'” Bachmann said. “Antimicrobial resistance is an important and urgent threat to public health.”
Still, the CDC has not changed its recommendations for gonorrhea testing and treatment. Bachmann called it “reassuring” that both Massachusetts patients were cured with a standard treatment, a single injection of ceftriaxone.
The strain circulates in the Asia-Pacific region and 10 cases were recently identified in the UK. The British patients were also cured with ceftriaxone.
Should ceftriaxone stop working, there are alternative medications, but they have greater risks or are less effective, doctors say.
“We want to keep the options we have,” Barnabas said.
She added that a potential vaccine is in development.
A few new antibiotics that could work are also in the pipeline, but “economic realities” have slowed progress, with companies working on them going out of business, Boucher said.
Gonorrhea is a common and rapidly spreading sexually transmitted disease. The incidence increased by 45 percent between 2016 and 2020, and more than half of those infected are between the ages of 15 and 24. In Massachusetts, lab-confirmed cases of gonorrhea have quadrupled from a low of 1,976 cases in 2009 to 8,133 in 2021. The bacteria that cause it infect the mucous membranes of the reproductive tract and urethra in women and men, as well as the mouth, throat, eyes and rectum.
In many cases, infected people have no symptoms, which is why the CDC recommends screening tests for sexually active people. When symptoms do occur, they may include painful urination and urethral or vaginal discharge.
If left untreated, gonorrhea can lead to pelvic inflammatory disease and infertility in women, and inflammation in the scrotum in men. Over time, it can spread to the blood and cause inflammation of tendons, joints, the brain, or the heart.
The Massachusetts cases were discovered as part of a routine testing process. A family doctor performed a standard test to identify gonorrhea and also cultured the sample. After the culture identified the infection as gonorrhea, an isolate of the organism was sent to the state lab, which conducted further testing for drug resistance.
The sample showed signs of resistance, so the state sent it to the CDC for more advanced testing, which identified the troubling genetic pattern: The bacteria were resistant to ciprofloxacin, penicillin and tetracycline and had reduced susceptibility to ceftriaxone, cefixime and azithromycin.
That prompted the health department to ask clinical laboratories in the same region to send additional samples from around the same time period. Further testing at the CDC yielded the second case.
Health officials found no link between the two cases, and Barnabas said there are certainly more than two people infected with the new strain. But there is no information to indicate how widespread the new bug is. A similar strain that was not as resistant was identified in Nevada in 2019, but never seen again.
“We can’t be sure without scaling up our surveillance efforts,” Hsu said, and this is now “a critical public health proactive moment.”
It’s possible the species is circulating elsewhere, Bachmann said. “That’s why it’s so important for health care providers to be on their radar and to keep an eye on public health departments for treatment failures.”
“To prevent resistance,” said Bachmann, “it is very important to identify gonorrhea quickly and treat it appropriately with the right drug at the right time and in the right amount. That requires healthcare providers to be aware of screening guidelines and appropriate treatment.
The Massachusetts Department of Health is asking health care providers to treat gonorrhea with high doses of ceftriaxone, perform cultures of symptomatic cases of gonorrhea and follow protocols for submitting samples to the state laboratory, and testing to make sure patients healed after treatment. In addition, regular screening is recommended for sexually active women aged 24 and under, women at risk, and sexually active men who have sex with men.
As for what individuals can do, Health Commissioner Margret Cooke gave this advice in a statement: “We urge all sexually active people to get tested regularly for sexually transmitted infections and to consider reducing the number of sexual partners and use more condoms when you have sex.”
Felice J. Freyer can be reached at firstname.lastname@example.org. Follow her on Twitter @felicejfreyer.