"Super Gonorrhea" Found to Be Resistant to First-Line Therapy in the UK

Over the years, gonorrhea has progressively become more of a public health threat, increasingly gaining resistance to the drugs available to treat it.

Now, one of the worst fears of many public health officials and providers around the world has been realized—a man in the United Kingdom has been infected with an isolate of Neisseria gonorrhoeae resistant to all first-line treatment.

Although medication to treat gonorrhea has been around for decades now, the bacteria has managed to become resistant to several drugs over the years—from penicillin and tetracycline in the 1980s to fluoroquinolones in the 1990s to some cephalosporins, such as cefixime, in the 2000s.

The current recommendation from the Centers for Disease Control and Prevention (CDC) calls for the use of dual therapy to treat gonorrhea infection: a single dose of 250 mg of intramuscular ceftriaxone and 1 g of oral azithromycin.

The “first global report” is of an isolate that has a ceftriaxone MIC of 0.5 mg/L and an azithromycin MIC of >256 mg/L, which the Public Health England (PHE) Laboratory referred to as high-level azithromycin resistant, or HLAziR.

The strain was isolated from a heterosexual male who attended sexual health services in England in early 2018, according to the report. The male reported having a regular sexual partner in the United Kingdom, but potentially picked up the “world’s worst super gonorrhea” via a sexual encounter with a woman living in south-east Asia, as 1 month later, he started presenting with symptoms.

Initially, health care officials treated the man with ceftriaxone 1 g, and then with spectinomycin, an aminocyclitol antibiotic. Although the urine nucleic acid amplification test (NAAT) came back as negative at test-of-cure, a throat swab was culture-positive.

“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,” Dr. Gwenda Hughes, a consultant scientist and head of the Sexually Transmitted Infection section at PHE is quoted as saying in a recent statement.

Currently, the man is being treated intravenously with ertapenem. “The ertapenem MIC was low (0.032 mg/L),” the report reads, which suggests that this therapy may be effective; however, breakpoints have not been defined.

The PHE has formed an incident management team to coordinate the investigation of the super-gonorrhea case and is working actively with clinical and microbiology teams to prevent the disease from spreading.

“We are following up on this case to ensure that the infection was effectively treated with other options and the risk of any onward risk transmission is minimized,” Dr. Hughes said.

Results of the next test-of-cure will be made available mid-April, according to the report.

“Clinical laboratories should continue to refer N. gonorrhoeae isolates with resistance to ceftriaxone (MIC >0.125 mg/L) or azithromycin (MIC >0.5 mg/L) to the PHE Reference Bacteriology at PHE Colindale for confirmation,” the authors write. Meanwhile, practitioners should remember to refer all suspected gonorrhea cases to genitourinary medicine services for appropriate management.