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Strains of gonorrhea that are hard to treat with antibiotics are beginning to become much more common in the USA, the Centers for Disease Control warns.

One of the Most Common Sexually Transmitted Diseases May Not Be Treatable

And a strain of gonorrhea that is resistant to the last antibiotic that can be used to treat the disease has appeared in among female sex workers in Japan and, not necessarily through any direct connection, heterosexual men in Norway.

Gonorrhea is an oozing infection of mucous membranes caused by a microorganism known as Neisseria gonorrheae. Also known as "clap" or "drip," gonorrhea can cause inflammation in any of the organs involved in sexual activity, and also spread throughout the body. It causes increased risk for ectopic (tubal) pregnancy in women, and increased risk for HIV infection in both sexes.

How Gonorrhea Becomes Resistant to Antibiotics

Although gonorrhea bacteria reproduce by fission, splitting into essentially identical copies, they can exchange genetic material through "replicons" also known as plasmids. A replicon is a strand of DNA that can reproduce itself inside or outside a living host.  It can be absorbed into a bacterium, where it may attach itself to the the main strand of DNA in the cell. Once it gets inside the bacterium, even if it is not attached to other DNA, it can give the bacterium new powers or new problems.

Sometimes plasmids give bacteria the ability to change nitrogen in the air to nitrates that eventually fertilize plants. Sometimes plasmids actually make bacteria sick, by directing the cell to make toxic proteins. And sometimes plasmids give bacteria the ability to resist antibiotics.

The power to antibiotics comes from random mutations. Millions, billions, or trillions of plasmids may appear that do not confer any protection to their hosts. More or less by chance, a plasmid may occur that gives its host ability to function even when it is exposed to medication. If all the surrounding bacteria get wiped out, then the one bacterium that has antibiotic resistance can reproduce itself without any other bacteria competing with it for food. In just hours, dozens of antibiotic-resistant bacteria can be created from the mutant.

The process of creating a bacterium that is resistant to antibiotic treatment only becomes a problem in people who are treated with antibiotics. If the infection is not treated, other bacteria will probably battle with the resistant bacterium and keep it from multiplying (at least keeping it from multiplying to large enough numbers to cause an untreatable infection). If the infection is treated, however, the treatment may fail, and a "superbug" may be waiting to be transmitted through the next sexual encounter.

Who Gets Gonorrhea?

In the USA, different parts of the country have dramatically different rates of gonorrhea infection. The states of Montana, New Hampshire, and Vermont, for example, have only 8 cases per year for every 100,000 residents. Louisiana has over 200 cases per 100,000 residents, and Mississippi, 246 cases per 100,000 residents, 30 times more than Montana. Rates in Europe and Japan are similar to those in the United States, with certain locations reporting many more cases than others.

In the United States, the greatest number of women are infected between the ages of 15 and 19, and the greatest number of men are infected between the ages of 20 and 24. This isn't because 20-year-old men are having sex with 15-year-old girls, but because of the susceptibility of the cervix to infection that is higher in teenaged women and lower as they get older.

Why Is It Important to Treat Gonorrhea?

Some of the long-term consequences of gonorrhea include:

  • Scarring of the upper reproductive tract (cervix, uterus, and fallopian tubes) in women, leading to infertility and pelvic inflammatory disease,
  • Scarring of the urethra in men, leading to infertility,
  • Scarring of the corneas and possible blindness when gonorrhea gets into the eyes,
  • Infection of an infant born to a mother who is infected,
  • Destruction of the joints,
  • Meningitis, and
  • Heart failure.

And treating gonorrhea isn't as easy as it used to be.

Why It's Harder to Treat Gonorrhea in 2011

It used to be that gonorrhea was more of an embarrassment than a life-long curse. One would have an embarrassing trip to the doctor, get a penicillin shot, and then be cured. In the 1960's and 1970's, pencillin stopped working, so doctors started giving tetracycline. In the 1980's tetracycline didn't work any more, so doctors started giving a class of antibiotics called fluoroquinolones, and in 2007 the Centers for Disease Control issued a warning that these drugs would no longer work, either. Still, some people respond to very simple treatment with other medications.

  • A single Suprax (cefixime) pill may cure about 90% of  infections. (Gonorrhea is resistant to Suprax about 10% of the time.) Unfortunately, the drug is sometimes simply not available in the USA due to shortages.
  • Rocephin (ceftriaxone) is given when gonorrhea has already spread outside the organs involved in sex acts, or when Suprax doesn't work. It has to be given by injection.
  • Trobicin (spectinomycin) is given when there are allergies to the first two medications, but it is not very useful for treating gonorrhea of the throat.
  • Erythromycin is given to children or for eye infections caused by gonorrhea, but it doesn't always work and it often causes stomach upset.
  • Vibramycin (doxycycline) stops growth of the bacterium without killing it.
  • And silver nitrate, the same remedy used in the nineteenth century, is used when all the other options fail, but it's typically only used in a very weak solution to treat babies who may have eye infections. It tends to stain membranes purple, and if it is overused in the eyes, babies may go blind.
Bacteria don't become resistant to silver nitrate, because it works by physically clumping them together (with silver particles). Chinese and Japanese herbal medicine also offer treatments including clay that literally sticks to the bacterium in the urinary tract. Neither of these treatments treats infections that have spread throughout the body.

What You Can Do to Stop Antibiotic Resistance

The single most important thing anyone who has gonorrhea can do to prevent the development of antibiotic resistance is to take absolutely all prescribed antibiotic medication, even if feeling well.

If antibiotic resistance only develops when antibiotics are used, how can this help?

Antibiotics aren't the only way your body fights the disease. A full course of antibiotics kills the maximum number of bacteria. Even if some of the trillions of bacteria that infected you develop antibiotic resistance, reducing their numbers gives your immune system a lot less work to do. Even urination flushes a lot of the bacteria away.

If you don't take all of your prescribed antibiotics, you may have too many bacteria left for your body to get rid of the infection. You may have enough resistant bacteria left to cause an infection that is nearly impossible to treat, while you killed enough of the non-resistant bacteria competing with them for food that they grow more rapidly. The person you protect by taking all the medication you are prescribed isn't just your lover. It may also be you.

What Doctors (and You) Can Do When Antibiotics Don't Work

Unfortunately, there is not a lot doctors can do when antibiotics don't work. The old remedies like kaolin clay (used in Japanese and Chinese formulas) and silver nitrate simply can't reach the bacterium in joints, heart, and central nervous system. Even worse, there are no new drugs in the pipeline to replace the antibiotics now being used.

The best treatment for gonorrhea is prevention. Know your partner, or use condoms if you don't. Using condoms stops about 80% of gonorrhea infections. Get treatment at the very first sign of infection, and make sure your partner or partners do, too.
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  • CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections.n MMWR Morb Mortal Wkly Rep. Apr 13 2007, 56(14):332-6.
  • Warner L, Stone KM, Macaluso M, Buehler JW, Austin HD. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis. Jan 2006, 33(1):36-51.
  • Photo courtesy of tonbabydc on Flickr: www.flickr.com/photos/9545289@N05/4589870692