UK Investigates 'Very Resistant' Gonorrhea Case

Tim Locke

April 04, 2018

UK public health experts are investigating a case of gonorrhea that's believed to be the first to display such high-level resistance to first-line treatments.

In July 2017 the World Health Organization reported on data from 77 countries showing that antibiotic resistance is making gonorrhea "much harder, and sometimes impossible, to treat."

Public Health England (PHE) believes the male patient acquired the Neisseria gonorrhoeae infection from a woman he met while traveling in south Asia.

The man sought treatment from sexual health services after returning to the United Kingdom earlier this year.

In a statement, Gwenda Hughes, MD, consultant scientist and head of the Sexually Transmitted Infection Section at PHE, said in a news release: "First line treatment for gonorrhea is a combination of two antibiotics (azithromycin and ceftriaxone). This is the first time a case has displayed such high-level resistance to both of these drugs and to most other commonly used antibiotics."

The patient is now being treated with intravenous ertapenem. The minimum inhibitory concentration for ertapenem was low, which suggests that this last-resort antibiotic could be effective. However, it won't be known for some time if the treatment is working.

In a Health Protection Report, officials say an existing partner of the patient's in the United Kingdom has so far tested negative for the infection. An incident management team has been set up to coordinate the investigation, follow up on other sexual contacts, and help contain the spread of this strain of gonorrhea.

Hughes continues: "We are following up this case to ensure that the infection was effectively treated with other options and the risk of any onward transmission is minimized. PHE actively monitors, and acts on, the spread of antibiotic resistance in gonorrhea and potential treatment failures, and has introduced enhanced surveillance to identify and manage resistant strains of infection promptly to help reduce further spread."

Commenting on the emergence of this multidrug resistant gonorrhea, Dr Olwen Williams, president of the British Association for Sexual Health and HIV (BASHH), says in a statement: "The emergence of this new strain of highly resistant gonorrhoea is of huge concern and is a significant development.

"Clinicians are working closely with Public Health England and key partners to help contain its spread, the success of which is dependent on judicious use of antimicrobials, effective partner notification and robust laboratory testing services, all of which are in line with BASHH guidance."

Not Unexpected

Although the case has attracted widespread attention, "it's not that unexpected," Richard Stabler, PhD, associate professor in molecular bacteriology, the London School of Hygiene & Tropical Medicine, told Medscape Medical News. "There has been reported throughout the world a few cases of azithromycin and ceftriaxone resistance, so we knew it was going to come somewhere. It's not that surprising.

"The fact that it's to do with travel is fairly expected, because these things move around the globe very quickly and very easily, as we've seen with lots of other drug-resistant infections."

On a positive note, "the fact that it was picked up is quite reassuring because if these things are coming in and being undetected, that's when they can start to be spread before any infection control can be put into place."

Experts have been warning for some time about the growing threat of antibiotic resistance. England's chief medical officer, Professor Dame Sally Davies, has referred to it as an "antibiotic apocalypse." Official estimates say at least 5000 deaths are caused every year in England because some infections have become resistant to current antibiotics. A 2016 review on antimicrobial resistance predicted that in just over 30 years antibiotic resistance will kill more people in England than the current toll for cancer and diabetes combined.

Last winter the agency began an advertising campaign using singing pills to warn the public that "antibiotics don't work for everything" and that taking them unnecessarily puts people at risk for a more severe or longer infection.

Antibiotic resistance is nothing new, Stabler said: "Ever since penicillin was started, Fleming noted then that if you misuse antibiotics, you'll get drug resistance. When every new antibiotic has come in, antibiotic resistance has evolved. Some very quickly. Things like methicillin I think was the same year it was released. Some like vancomycin have taken a long time. Bacteria have a very strong selective pressure. It's evolve or die."

Public Health England is reminding general practitioners to refer suspected cases of gonorrhea to genitourinary medicine services for treatment.

Dr Stabler said that asking patients with suspected gonorrhea about recent travel, especially to southeast Asia, could be important to allow for additional checks.

PHE also used the case to stress its safer sex public health message encouraging condom use with new and casual partners.

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