What should you be concerned about?
Sure, we all know STDs aren’t something you want and, hopefully, you take all possible precautions to prevent contracting one. This is especially important because it has recently come to light that there are certain STDs that are resistant to treatment. This basically means that there is no treatment option for these particular strains. Why is this the case? What can we do about it?
Sexually transmitted diseases (STD) are now referred to as sexually transmitted infections (STI) because for the most part, they can be treated and gotten rid of just like other infections. Until the past few years, there had been a decline in STIs. They are classified into those that aren’t required to be reported, or non-reportable, and those that are, or reportable. Non-reportable are those that don’t usually cause significant health effects without treatment. Reportable are those that can cause significant health problems if not treated. The most common STI is the human papilloma virus (HPV) and it’s a non-reportable infection. However, it can increase a woman’s risk of developing cervical cancer, which is why doctors screen for it. HPV affects about 79 million Americans with an estimated 14 million new infections every year. Another non-reportable, but common STI, is genital herpes. Infections used to be from predominantly the HSV2 strain but is increasingly due to the HSV1 strain. It’s estimated that 1 in 8 individuals in the US between the ages 14 to 49 years has genital herpes. The main issue is that it can be present in your body but you don’t have any symptoms, which means that you can transmit it to someone else without knowing it. Similar to HPV, there are usually no long-lasting, serious health effects. Both of these infections are treated with anti-viral medications and currently show no signs of resistance to them.
The 3 most common reportable STIs are chlamydia, syphilis and gonorrhea. Of the three, chlamydia is the one that is most frequently reported. There were about 1.6 million new cases in 2016 alone. It isn’t yet associated with antibiotic resistance. Syphilis is an STI that is caused by the bacterium Treponema pallidum. It can lead to significant complications, especially if left untreated, even affecting your neurological function. It does sometimes have resistance to the antibiotic class called macrolides, but the first line treatment is penicillin and it doesn’t show any resistance to this yet. Gonorrhea is also called “the clap” and is the second most commonly reported STI in the US and the is one of the most common sexually transmitted diseases worldwide. According to the World Health Organization (WHO), it infects an estimated 78 million people globally each year. Here in the US, the Center for Disease Control (CDC) estimate that there are almost 400,000 reported cases of gonorrhea per year. However, they estimate there are 820,000 new infections each year. This is because people don’t realize that they have it since sometimes they don’t have any symptoms. If you do have symptoms, they might be a burning sensation during urination (men and women), yellow or green penile discharge, swollen testicles, increased vaginal discharge and spotting between periods. The number of cases reported in 2016 increased nearly 19% over 2015, according to the CDC. The infection mostly affects people between the ages of 15 to 24. Most cases of gonorrhea are still easily treatable with antibiotics. However, at least 30%t of new gonorrhea infections each year are resistant to at least one antibiotic. The WHO estimates that two-thirds of the world’s countries have gonorrhea that is resistant to all known antibiotics. While gonorrhea is rarely fatal, it can cause sterility, miscarriage, pelvic inflammatory disease (PID) and long-term pelvic pain. Gonorrhea can also increase the risk of contracting or spreading HIV.
Antibiotic resistance is a dangerous phenomenon and it’s becoming much more common place across the world. There are a couple of reasons for this. The first is because bacteria and other microbes can evolve much quicker since they have such short life cycles. So, when exposed to antibiotics, most strains of the targeted bacteria will die, but a few have genetic mutations that allow them to survive and pass these genes to their offspring. Over time, this mutation becomes dominant. The other issue is overprescribing and misuse of antibiotics. In our society today, we are used to the idea of being able to take a pill when we’re sick and it makes us feel better. As more research has been done, we’ve come to realize that this isn’t the best thing to do. Most of the time, our bodies can fight infections without any help. This is especially the case for viruses. Antibiotics do not work on viruses. So, when we go to the doctor and demand a prescription for an antibiotic even if the doctor doesn’t think that it’ll help, this can fuel antibiotic resistance. The other issue is when we take antibiotics, we often stop taking them once we start feeling better. This is typically before the prescription is gone. Many people figure that they’ll save it just in case they get sick in the future. The problem with this is that it kills off enough of the bacteria that your body is able to get rid of the rest of the infection, but the remaining bacteria develops resistant to the antibiotic. Also, doctors might be prescribing antibiotics that no longer work against a particular bacterium. This is because as new information is discovered about antibiotic resistance, agencies, like the CDC and WHO, change their standards as to what the best way to treat an infection might be. If a doctor is unaware of these changes, it can result in them following the previous standards. All of these things combined is what is feeding the rise in antibiotic resistance.
The development of antibiotic resistant gonorrhea began soon after the first antibiotics were used to treat it and it has only continued since. In 1941, penicillin was used for the first time to treat gonorrhea, but by 1946, the first instances of gonorrhea strains being resistant to penicillin were recorded. Thirty years after this discovery, researchers studied how the bacteria avoided being killed by penicillin. There were two methods. Some bacteria produced a protein, beta-lactamase, that inactivates penicillin. Others contained damaged DNA that allowed the mutated bacteria to survive in the presence of penicillin. In order to combat this resistance, penicillin treatments were replaced by 1966 with tetracycline, which initially killed 94% of the gonorrhea strains. Unfortunately, the bacteria quickly found ways to survive it and became resistant to tetracycline. This cycle of introducing new drugs, having them work initially and then fail continued for the next four decades.
By the time 1993 came around, the recommended treatment for gonorrhea was a combination of two classes of antibiotics, a fluoroquinolone (ciprofloxacin), and two cephalosporins (ceftriaxone and cefixime). Dual therapy is important because it ensures a clinical cure and can help to prevent further development of resistance. However, in the late 1990s and early 2000s, ciprofloxacin resistance was detected among gonorrhea strains. So, by April 2007, the CDC stopped recommending fluoroquinolones as a treatment option. Since the cephalosporins were the only remaining recommended treatment option, the CDC made changes to its STD Treatment Guidelines for gonorrhea. In 2010, CDC changed its treatment recommendations again to use the cephalosporins and other classes of antibiotics. As part of these recommendations, they increase the dose of ceftriaxone. By 2012, there was evidence of resistance to cefixime. The CDC updated the guidelines once again to use ceftriaxone plus either azithromycin or doxycycline as the first-line treatment. In 2015, they streamlined the recommendation of one regimen of dual therapy as treatment for gonorrhea. This includes receiving an injection of ceftriaxone and taking azithromycin pills. Unfortunately, gonorrhea is starting to show resistance to azithromycin, but it still remains a recommended part of dual therapy and is also the backbone of every alternative treatment option. According to the WHO Global Gonococcal Antimicrobial Surveillance Program, from 2009 to 2014, 97% of countries conveyed that they have gonorrhea that is resistant to ciprofloxacin, 81% have strains of it that are resistant to azithromycin and 66% have strains that are resistant to cefixime and ceftriaxone.
Recognizing the significance of this threat, in 2014, the President released an Executive Order to develop a national strategy to Combat Antibiotic-Resistant Bacteria (CARB). This calls for the prevention, detection, and control of antibiotic resistance. By March of the following year, there was a five-year National Action Plan for CARB. Thanks to this initiative, the CDC’s Division of STD Prevention (DSTDP) is championing a number of new and continuing activities that are focused on slowing the development of antibiotic-resistant gonorrhea and preventing its spread. Since we know that control of gonorrhea relies on our ability to detect and treat each case of quickly and effectively with the right antibiotic, CARB is funding the Antimicrobial Regional Laboratory Network (ARLN). This is a network of regional public health laboratories that have cutting-edge antimicrobial resistance machinery and are able to respond to emerging threats. A part of CARB is the Gonorrhea Rapid Detection and Response program, which is designed to develop and strengthen epidemiological, laboratory and informatics capacity at local and state health department in order to more rapidly detect, and quickly and effectively respond to, antibiotic resistance. All of these are very important steps in dealing with gonorrhea.
The level of gonorrhea’s antibiotic resistance became even more concerning in March 2018 when the Public Health of England published a case report about a man whose gonorrhea was incredibly difficult to treat. What’s unique about this case is that researchers tested his strain of gonorrhea in a lab and found that it was resistant to both of the first-line treatments that are available. Even after finding an antibiotic that this strain showed susceptibility to, his gonorrhea wasn’t cured the first time around. So, the doctors had to try a drug that hasn’t yet been fully studied in clinical trials, but shows great promise in treating gonorrhea. Luckily, it worked and the man’s infection went away. These new cases are being labeled “super drug-resistant” or “multi-drug-resistant” because of their resistance to all or most antibiotics usually used for treating the infection. As of right now, this doesn’t mean that the infection is incurable, but that treatment may take longer and is more complicated.
This development means that the ongoing progression of antibiotic resistance is now combined with a lack of alternative treatments. Unless new antibiotics are developed, or a vaccine created, these types of cases will begin to be more prevalent. In order to help with this process, the WHO has founded the Global Antibiotic Research and Development Partnership (GARDP) and their Sexually Transmitted Infections Program has the goal of releasing of an antibiotic that treats antibiotic-resistant gonorrhea by 2021. Thankfully, there are several promising drugs that are currently being researched with hopes of doing this. One treatment being researched uses low doses of carbon monoxide within the body to stop the gonorrhea bacteria from being able to process oxygen. Another research team has found how gonorrhea is able to evade the body’s immune system in the first place. The researchers found that the bacterium produces two proteins, which are lysozyme inhibitors. Lysozyme is an enzyme in human bodily secretions that kills bacteria. A new, single-dose drug, zoliflodacin, specifically targets antibiotic-resistant gonorrhea and in November 2018, it went through the last phase of clinical trials. These trials have shown that the drug is 96% effective at killing antibiotic-resistant gonorrhea. Researchers are hoping that it’ll be available to the public by 2023, which would make it the first new drug to treat drug-resistant gonorrhea in over two decades. Another option that researchers in New Zealand are working on is creating a vaccine. So far, they’ve found that MeNZB (a meningitis vaccine) has prevented about one-third of potential gonorrhea transmissions in people who have received it.
In the meantime, we need to do everything we can to prevent the spread of any form of gonorrhea, but especially super drug-resistant gonorrhea. From the individual standpoint, abstinence is the only way to stay 100% protected from gonorrhea and any other STI. If you are engaging in sexual activity, limit the number of sexual partners you have, practice other kinds of sex (not just intercourse) and use condoms every time you have intercourse. Also, it’s key to make sure you and your partners are regularly tested for STIs to reduce your chances of getting an infection or spreading one. Using antibiotics appropriately is essential to help stop the development of antibiotic resistance. So, if you aren’t feeling well and go to the doctor, don’t demand a prescription for antibiotics if the doctor doesn’t feel that you need one. If you are prescribed an antibiotic, make sure you follow the instructions exactly and finish all of the pills. Another important element is to take preventative steps to reduce the need for antibiotics, like washing your hands, staying up to date on vaccinations and practicing safe sex. From a societal standpoint, we need to have a coordinated effort among providers, state and local health departments and patients in order to be able to rapidly detect and treat all STIs, but especially those like super drug-resistant gonorrhea. The CDC wants doctors to report any gonorrhea specimen with decreased cephalosporin susceptibility and any gonorrhea cephalosporin treatment failure to their state or local public health authority.
While it might not at the same level as gonorrhea, resistance to antibiotics is a problem with other STIs. In certain areas, HIV is starting to show resistance to some of the drugs used to treat it, but there are still alternative treatments for now. A relatively new STI is Mycoplasma genitalium and it is also developing resistance to antibiotics. It was first identified in the 1980s and thought to be rare, but some recent studies have shown to be as prevalent as chlamydia. Since it wasn’t thought to be common, it’s rarely tested for and diagnosed. It can cause several problems, including lead to infertility and PID in women. Since not much is known about it, the long-term effects for men isn’t well know. Due to the lack of awareness around it, many scientists feel that it has the potential to become the next superbug within a decade.
There’s no question that we need to get a handle on sexually transmitted infections, especially those that are resistant or becoming resistant to their treatments. We need to do everything that we can in order to manage and prevent the spread of these infections. Each person needs to do their part to protect themselves and those that they are intimate with. As a society, we need encourage the use of protective devices, the importance of frequent STI testing and support measures put forth by the CDC and WHO. If we do all this, we might be able to gain the upper hand.