The Rise of Super Gonorrhoea

The Rise of Super Gonorrhoea
Illustration: Libby McGuire

In February, public health officials in the UK reported that three people there had recently contracted gonorrhoea, the well-known sexually transmitted infection. What made the cases noteworthy is that they were caused by a highly resistant strain of the bacteria. This “super gonorrhoea” threatens to be one of the first omnipresent dangers of a post-antibiotic era that’s already well on its way here.

Gonorrhoea, caused by the bacteria Neisseria gonorrhoeae, is just the latest of previously tamed illnesses that have evolved to become more dangerous. Drug-resistant infections, commonly known as superbugs, directly killed 1.27 million people worldwide in 2019 — a sum higher than deaths individually caused by tuberculosis, HIV, and malaria, the big three infectious killers that year — and they may have contributed to 5 million deaths in total, according to a recent report published in the Lancet. A 2018 study estimated that superbugs killed up to 160,000 Americans in 2010.

These resistant infections usually find us in our most vulnerable moments. Hospitals tend to be a breeding ground for superbugs, both because patients are in poorer health and because antimicrobials are so widely used in these places, fostering further resistance. It’s why current efforts to stop superbugs generally focus on hospitals and other health care settings (that’s not to say antibiotics aren’t widely present elsewhere, particularly in livestock).

Gonorrhoea is a bit different, though. It’s widespread, and it’s become resistant to almost every drug we’ve thrown against it over the years. For many otherwise healthy people, gonorrhoea could become one of the first superbugs that they have to be on guard for.

That said, the story of super gonorrhoea mirrors the story of antibiotic resistance in general, according to David Hyun, director of The Pew Charitable Trusts’ antibiotic resistance project.

“As soon as we start using antibiotics, that raises the risk of bacterial evolution and the bacteria learning how to evade the effects of antibiotics,” Hyun told Gizmodo in a video call. “If you look at the history of gonorrhoea and resistance, it did really start in the 1930s. The first drugs they used were sulfa drugs, and almost immediately doctors started seeing treatment failures, and it’s just gotten progressively worse over time.”

In recent years, our arms race with gonorrhoea had gotten to the point where there were only two widely recommended antibiotics for its standard treatment: azithromycin, taken as a pill, and ceftriaxone, given as a shot. By the mid-2010s, though, some regions were already seeing a large percentage of strains with some resistance to azithromycin, which led to a recommendation in many countries, including the U.S., to adopt a combination strategy of using both drugs at once. Then, in 2018, something that many experts had feared came to pass: A man in the UK was found to be infected with a strain highly resistant to the combo. Soon after, two similar cases were reported in Australia.

Those cases were traced back to Southeast Asia, which has led to some speculation that the infections were linked to the area’s sex tourism industry. There isn’t any clear evidence of that, though, according to an investigation of the cases by EU officials (only one of the three patients said they caught it from a sex worker). But many developing nations are less capable of tracking antibiotic-resistant germs in general, Hyun notes. And that leaves open the possibility that we won’t see a rise in these pan-resistant infections, as they’re called, until it’s well underway.

The hard data we do have on gonorrhoea resistance isn’t looking good. A 2021 Lancet report by scientists at the World Health Organisation found growing rates of azithromycin and ceftriaxone resistance in 73 countries from 2017 to 2018. The CDC estimates that half of all gonorrhoea infections in 2020 were resistant to at least one antibiotic, usually azithromycin. As a result, the CDC and other organisations have stopped recommending that patients with uncomplicated gonorrhoea take azithromycin; now, the sole remaining option is ceftriaxone, and at a higher dose than before. At least in the U.S., ceftriaxone resistance remains low for now, but that’s no guarantee that it will stay low, with the drug having become the only frontline choice left. In December 2020, the same month that the CDC changed its guidelines, doctors reported the country’s first known case of a gonorrhoea strain carrying a well-known and emerging mutation to the drug.

Gonorrhoea often goes unnoticed; data suggests that about half of cases never experience symptoms at all. But it can occasionally be a gruesome experience, complete with puke-coloured discharge from your genitals, painful or burning urination, and added bleeding between periods for women. It can also reach the throat or anus via oral and anal sex. The most dangerous aspect of gonorrhoea, however, is what happens when it goes untreated.

In men and especially women, it can cause inflammation and permanent damage to the reproductive system, which can then lead to infertility. More rarely, it can reach the bloodstream and spread to other places in the body, causing serious or fatal complications like arthritis, endocarditis, and meningitis. If it’s passed from mother to child during delivery, the infection can reach a newborn’s eyes and cause blindness, or it can outright kill them. It also increases the risk of contracting other STIs, particularly HIV.

All of those risks will be compounded as gonorrhoea becomes less treatable, and life will become more frustrating for anyone who catches it. Two decades ago, a simple pill would have cleared up an infection. Today, people have to get a shot. A decade from now, it could take antibiotics with harsher side-effects that may still not work, especially for infections found in the throat or rectum (a worry with the few possible alternatives we have). And some day beyond that, we may simply stop being able to treat it reliably at all.

Every one of these treatment failures would allow infections to persist and spread further to others. In a 2018 interview, Teodora Wi, a WHO expert specialising in sexually transmitted infections, stated that up to 300,000 more people worldwide could die annually if resistant gonorrhoea became widespread. Even if these numbers are a high estimate, a world without reliable antibiotics for gonorrhoea means that more people will lose the chance to have biological children, and more babies born every year will lose their eyesight.

There is some hope that this worst-case scenario won’t come to pass. According to Pew’s most recent report this February, there are four potential antibiotics close to being approved that could be used as new treatments for gonorrhoea. Notably, though, only two of the four potential new antibiotics in the pipeline come from a novel drug class. That’s a crucial distinction, because bacteria will more easily develop resistance to new drugs that resemble those already in use.

An effective vaccine for gonorrhoea would provide longer-lasting protection against the disease, while giving bacteria less opportunity to outsmart the latest drug. Since people don’t develop durable immunity to gonorrhoea naturally, however, a vaccine has been a challenge to create. But there is at least one candidate being tested in Phase II trials that’s thought to have overcome this hurdle, and last year, the same Oxford University team that developed a covid-19 vaccine announced work on their own candidate. We might even be able to get some help from an existing vaccine in the meantime: A study published earlier this month was the latest to find that teens and young adults vaccinated against meningococcal serogroup B bacteria — a cousin of gonorrhoea — also had some protection against gonorrhoea infection.

That said, the potential protection afforded by the meningococcal B vaccine is modest (estimated to be 33% effective in the recent study) and it’s not clear how long it might last. Right now, the vaccine isn’t even routinely recommended for everyone in the U.S., only for teens and young people who might be at higher risk of serious meningitis. So whether its added protection for gonorrhoea might change that recommendation is an open question. And none of the experimental options on the table are sure-fire bets to pan out, either.

Outside of new drugs and vaccines, the most effective long-term strategy we have against super gonorrhoea would be to cut down on sexually transmitted infections altogether. Unfortunately, those trends are going in the wrong direction. In April, the CDC announced that gonorrhoea (and syphilis) cases once again reached a new record high in the U.S. in 2020, with over 670,000 cases, making it the seventh straight year of rising numbers in the country. Worldwide, the annual rate of sexually transmitted infections has declined since the 1990s, according to a study this April, but the absolute number of cases has continued to climb through 2019.

There’s a stigma attached to catching any STI, gonorrhoea included. But the germ has managed to exist alongside humanity for at least thousands of years, going under colourful names like “the clap” or “the drip.” Like other infectious diseases, it takes advantage of our human nature to spread, and it’s learned time and again how to beat us. But while evolution and antibiotic resistance are inevitable, our current predicament wasn’t.

A little more than a decade ago, rates of gonorrhoea in the U.S. had reached an all-time low. The fact that we’ve been losing ground ever since represents a public health failure across the board: in providing easier access to condoms, teaching and persuading people to have safe sex, and in helping people get regularly tested. Our health care system has been eroding under our feet for a long time. Like so many things, this crisis has only worsened during the covid-19 pandemic.

“Antibiotic resistance — having effective antibiotics — touches pretty much every corner of medicine, including the covid pandemic. And what we have seen during the pandemic is that because the response has stretched the resources and the bandwidth capacity of all healthcare facilities, there’s been an increase of not only healthcare associated infections, but resistant ones as well,” Hyun said.

We’ve known almost from the very start that antibiotics were not the invincible miracles they first appeared to be. For decades, scientists had warned about resistance and called for changes in how we use and develop these precious resources. But antibiotics have continued to be used when not needed, both in the medical and agricultural world, and the pipeline of new drugs has slowed to a crawl.

There are still many people and organisations devoted to turning the tide against superbugs, like Hyun and others at Pew. One hope is that new funding or incentive models can convince pharmaceutical companies to buy back into antibiotic development. Others have called for more radical options, like having governments collectively develop antibiotics by themselves. But whatever ends up happening, it has to happen soon.

“If we don’t stem the tide here with the multiple types of actions that that we’re trying to push, we may very well be looking at a near future where common infections that we used to treat easily are not as easily treatable anymore,” Hyun said.

Super gonorrhoea may become the first superbug that infects you or someone you know, but unless things change, it certainly won’t be the last.