Gonorrhoeae bacteria in urethral exudate. Dr. Norman Jacobs/USCDC/public domain.

The United Kingdom's chief medical officer has sent a warning to all doctors that the sexually transmitted disease gonorrhea could evolve to the point where it cannot be treated, returning humanity to the pre-penicillin era. Such an outcome can be delayed, and possibly prevented entirely, if doctors prescribe drugs correctly, Dame Sally Davies claimed. Sadly, this is not currently happening, at least not all the time.

It seems that just as medicine starts to make sex safe from one threat, another rises in its place. This is not entirely coincidental. The arrival of better treatments for HIV, at least in the developed world, may have led to an increased number of people becoming blasé about safer sex practices. This could explain the spiraling rates of diseases such as syphilis and chlamydia, particularly among a generation too young to remember when deaths from AIDS were common in the West.

For gonorrhea, increased opportunities for transmission are combining with the antibiotic resistance seen emerging across many bacterial diseases. In March this year, an outbreak of drug-resistant gonorrhea was reported in Leeds, with cases spreading to other north-England towns.

This is not the first time the bacterium Neisseria gonorrhoeae has developed resistance to antibiotics. However, at one time, a variety of spare drugs existed that could be pressed into service when an old one no longer worked. Those days may soon be over, warn infectious disease specialists.

The recommended treatment for gonorrhea is to combine a ceftriaxone injection and an oral dose of azithromycin or doxycycline. This double hit of very different types of antibiotics almost always kills the bacterium, at least currently. Taking only one of the antibiotics opens up the danger of resistance appearing to first one drug and then the other.

Consequently, the British Association for Sexual Health and HIV were concerned to discover that online pharmacies were offering azithromycin on its own, while some doctors are prescribing obsolete antibiotics.

Most women, and some men, infected with gonorrhea show no symptoms, although they can still transmit it. For those who experience symptoms, the most common are yellow or green genital discharge, bleeding between periods and pain during sex or urination. Rarer outcomes include a 20 percent increased risk of prostate cancer, and blindness in children born with the disease.

In 2009, a strain of gonorrhea, called H041, was identified that was untreatable with all cephalosporin-class antibiotics, which includes ceftriaxone. However, only one case of H041 has been reported. Although cases of two other ceftriaxone-resistant strains have been published, it is clear that not every multidrug-resistant strain will spread wildly. Nevertheless, with 16 cases now known from the Leeds outbreak, warning signs are obvious.

The announcement that Truvada can prevent infection with HIV when used as a “morning after drug” has sparked concerns that people will become even more lax about condom use, opening the door to other diseases. These fears are debated, but haven't been helped by poster campaigns apparently advocating condomless sex, as if HIV was the only threat.

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