My first blog is unfortunately not a celebration of medical research but a worrying tale of bacteria doing what they do best; being better than us. This story follows the news that doctors this week have been advised that the main antibiotic used to treat the STD gonorrhoea may not be effective any more as bacteria are now resistant to it. With the inevitability that alternative antibiotics may only be effective for another decade, what is the future of treating gonorrhoea?
Gonorrhoea, also known as the clap, is a sexually acquired infection caused by transmission of the bacterium Neisseria gonorrhoeae. Gonorrhoea is the 2nd most common bacterial STI in the UK after chlamydia (1). Whilst gonorrhoea cases in England and Wales were declining at the beginning of the decade, unfortunately despite the improved accessibility of STI clinics, since 2008 cases are now rising. According to the Health Protection Agency, in 2010 there were 16,145 new diagnoses of gonorrhoea, a 3% increase on 2009 when there were 15,606, as shown in the graph below.
Gonorrhoea is transmitted during unprotected sexual intercourse. Diagnosis of the infection is often delayed as symptoms are often mild or there are none. In both young men and women, the first sign of infection are a burning sensation when passing urine which can occur as late as 10 days after infection. If left untreated, gonorrhoea can have serious long term effects especially for women. Pelvic inflammatory disease (PID) is caused when the bacteria spread up the vagina and cervix into the reproductive tubes towards the ovaries. Here the bacteria can cause chronic abdominal pain and pain during intercourse. PID can cause ectopic pregnancies, infertility and even death. A further complication of gonorrhoea occurs when an infected woman passes the bacteria to her baby during delivery causing neonatal conjunctivitis. This can be an easily treatable infection if the mothers’ infection is detected. In few cases however, the infection can cause the babies blindness.
Since the first discovery of penicillin, gonorrhoea was considered an easy infection to treat. But like any bacteria, with rapid reproduction leading to evolution, gonorrhoea soon became resistant to penicillin. Since then the bacteria has gained resistance against other antibiotics such as the tetracyclines and ciprofloxacin.
The World Health Organisation recommends that the first line antibiotic used to treat the STI is changed to an alternative when resistance among gonococcal isolates reaches 5%. To determine this level, a national surveillance programme called GRASP was set up in 2000 (2). The programme collects bacteria samples from patients attending 26 different STI clinics over England and Wales. As a result of findings in 2002, GRASP ordered a change in the choice of antibiotic for gonorrhoea treatment from ciprofloxacin, to the 3rd generation cephalospotins, cefixime and ceftriaxone. These two antibiotics were used without worry until 2009 when GRASP acknowledged a decreased susceptibility to these antibiotic, but especially cefixime the most widely used agent. In the GRASP report this year, laboratory rests on samples taken in clinics showed 17.4% of bacteria had a reduced susceptibility to cefixime compared to 10.6% the year before. It has now been released that the first cases of treatment failures have been discovered.
Doctors are now being advised to treat the infection with a combination of two drugs; azithromycin which is given orally, and ceftriazone, a more powerful antibiotic than cefixime which is given by injection. This is almost certainly a worry as treatment via injection requires more assistance and is likely to put a lot of patients off. Professor Cathy Ison from the Health Protection Agency has said on the subject;
“many patients may feel anxious about having an injection, but this is now the best way of avoiding treatment failure.” (1)
The search for new antibiotics is a lengthy and ongoing process that requires copious amounts of time and effort. We must hope that scientists can continue their research and efforts into finding new antibiotics so we may treat gonorrhoea. Until then, the importance of wearing a condom during sexual intercourse must be stressed.