Human vs. Microbe: Looming Resistance in Gonorrhea

According to The Bay Area Reporter and to preliminary data from the Department of Public Health’s STD Prevention and Control Section, cases of gonorrhea in San Francisco jumped from 1,943 in 2010 to 2,243 in 2011. This is the increase in reported gonorrhea cases, only.

Gonorrhea, a sexually transmitted disease caused by the bacteria Neisseria gonorrhoeae, is the second most commonly reported STD in the United States, with an estimated incidence of 700,000 cases a year. Anyone who is sexually active can be infected with gonorrhea.

Many of those infected with gonorrhea show no symptoms and are able to, unknowingly, transmit the disease through sexual contact. Those who do experience symptoms may feel burning sensations, similar to those that signal bladder or vaginal infections. If left untreated, gonorrhea may cause serious complications in men and women. The bacteria can spread to the other parts of the body through the blood stream, causing fever, rash, skin sores, stiffness and swelling. Both men and women with untreated gonorrhea are at risk for infertility. Gonorrhea in women is one of the common causes of pelvic inflammatory disease, a condition that can damage fallopian tubes and lead to ectopic pregnancies, infertility, and chronic pelvic pain. Further, pregnant women can transmit gonorrhea to their babies, which may result in blindness or skin sores.

So, gonorrhea is serious and extremely common. We’ve known that for a while. What is new is the bacteria’s increasing resistance to the last available effective antibiotics, third generation cephalosporins, as reported in today’s New England Journal of Medicine by Gail A. Bolan MD.

Though the bacteria’s increasing resistance to a variety of drugs has been known for a few decades now, the news that we may be on our last line of defense caused, as expected, a flurry of posts from science and medicine journalists. Maryn McKenna, author of Wired’s science blog, Superbug, was one of them. McKenna begins with a brief history of sexually transmitted disease treatment, using 20 patients hospitalized at Walter Reed Medical Center in 1911 as examples. As she points out, hospitalization for STDs, other than HIV, seems over zealous today. However, she states, “in the years before antibiotics, syphilis and gonorrhea were fantastically destructive of productivity.” These men suffered from “arthritis, ulcerated skin, heart-valve failure, [and] necrosis of the skull.” Some of the men were hospitalized for over five months.

The “magic bullet,” as it was commonly known, came in 1911. Paul Ehrlich developed Salvarsan 606, which “set the stage for penicillin” and chemotherapy (treatment with chemicals). Salvarsan 606 was the treatment for syphilis until penicillin was discovered in 1929. More important, as McKenna states, “[i]t made it possible to believe that patients could be flat-out cured of diseases that were disabling, deadly and incredibly common.” Years later, penicillin offered this hope for gonorrhea patients.

However, gonorrhea has shown its ability to develop resistance to antibiotics since the 1940s. In the 1970s, the bacteria demonstrated resistance to penicillin and tetracycline. The CDC recommended cephalosporin and either doxycycline or azithromycin for gonorrhea treatment. Last year, Japanese scientists discovered a strain of gonorrhea, called H041, which is resistant to all known antibiotics.

McKenna contrasts what living with an STD was like in the pre-antibiotic era, with what it is like today: “the most-reported infectious diseases in the United States…[are] temporary embarrassment[s] that could be cured in a single anonymous clinic visit with a quick prescription of pills or a single shot,” but then delivers the harsh news that these pills and shots are losing their effectiveness. She quotes Bolan: “It is time to sound the alarm. During the past 3 years, the wily gonococcus has become less susceptible to our last line of antimicrobial defense, threatening our ability to cure gonorrhea and prevent severe sequelae.”

McKenna’s contrast between the pre and post antibiotic eras brings Laurie Garrett’s warnings from The Coming Plague to mind:

“Humanity’s ancient enemies are, after all, microbes. They didn’t go away just because science invented drugs, antibiotics, and vaccines (with the exception of smallpox). They didn’t disappear form the planet when Americans and Europeans cleaned up their towns and cities in the postindustrial era. And they certainly won’t become extinct simply because human beings choose to ignore their existence.”

Garrett, one could argue, would call that feeling of invincibility that came with the developments of Salvarsan and penicillin foolish and arrogant. Garrett doesn’t entirely leave the reader in despair and offers a way towards progress: “What is required, overall, is a new paradigm in the way people think about disease.” We need to understand that our relationships to microbes are nonlinear and ever-changing. Just as human beings are fighting for survival against pathogens, microbes are fighting for survival against our arsenal of antibiotics. The solution to this growing problem is not simple; it is probably far more complex than this writer realizes. However it is a problem that demands reporting, discussion, awareness, hard work and imagination.

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