Neisseria gonorrhoeae bacteria, as seen in this illustration, consist of a pair of cells, called … [+]
This man’s trip turned out to be super, in a super gonorrhea type of way. A case report just published in the journal Eurosurveillance described what happened to an Austrian man during and after his trip to Cambodia. And the punch-to-the-groin-line of the story is that this man in his 50’s ended up catching a new extensively drug-resistant (XDR) strain of Neisseria gonorrhoeae.
This strain has a high-level of resistance to azithromycin and resistance to ceftriaxone, cefixime, cefotaxime, ciprofloxacin and tetracycline. It’s the second such XDR strain of N. gonorrhoeae that’s been found, according to the case report authors from the Austrian Agency for Health and Food Safety (Sonja Pleininger, Alexander Indra, Florian Heger, and Stefanie Schindler), Örebro University (Daniel Golparian, Susanne Jacobsson, and Magnus Unemo), and LKH Hochsteiermark (Stefan Heidler). This is one situation where new is not good. It’s also not a super thing to hear because azithromycin and ceftriaxone are the standard treatments for gonorrhea.
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Back in March 2018, I covered for Forbes what was called the first reported case of N. gonorrhoeae having both high-level resistance to azithromycin and resistance to ceftriaxone. At the time, James Gallagher of the BBC News had dubbed this case, which was diagnosed in the U.K., as the “world’s worst case of gonorrhea.” Others have used the nickname super-gonorrhea to describe these bacteria not because they are faster than a speeding bullet but because such drug resistance makes them particularly hard to kill. A lot has changed in about four years. Since then, that XDR strain has continued to spread throughout different parts of the world because that’s kind of what happens when you don’t do enough to address a problem. And now the world apparently has a second XDR strain on its hands, as well as other naughtier parts of the body.
Speaking of naughty, you don’t catch super gonorrhea just by going to your local hardware store. Remember gonorrhea is a sexually transmitted infection (STI). Therefore, catching super gonorrhea is usually a tip off that you’ve had sex at some point, no matter what excuses you may tell your spouse or regular partner. The man described in the Eurosurevillance case report not only had sex in Cambodia, he had it with a female sex worker while not wearing a condom. Yeah, that certainly doesn’t qualify as safe sex. Doing that can be like spinning the STI wheel of misfortune.
Indeed, around five days after he had baked the potato, swept the chimney, lit the hot dog on fire, or whatever euphemism you want to use for sex, he developed a burning sensation on urination as well as discharge from his penis. Such symptoms are clearly not things that you can simply walk off or resolve with large amounts of ice cream. Therefore, the man eventually ended up in a urology department in Austria in April 2022. There, the doctor conducted various tests, including a urethral swab, which revealed the presence of N. gonorrhoeae. The doctor then prescribed the man a typical antibiotic treatment for gonorrhea (one gram of ceftriaxone intramuscularly plus 1.5 mg of azithromycin) because he perhaps thought that he was dealing with just a run-of-the-mill case of gonorrhea.
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During his follow-up visit to clinic around two weeks later, the man indicated that his symptoms had resolved. Ah, but no symptoms does not necessarily mean no infection. A N. gonorrhoeae infection isn’t like a mullet. It isn’t always obvious when someone has one. Therefore, the doctor performed a repeat urethral swab. A PCR test of what the cotton swab dug up revealed something super not good. The N. gonorrhoeae seemed to be still hanging around, suggesting that the first round of antibiotics had failed to clear the infection.
Testing of this N. gonorrhoeae strain revealed high-level resistance to azithromycin and resistance to ceftriaxone, cefixime, cefotaxime, ciprofloxacin and tetracycline, leaving much fewer treatment options. Placing the man on one gram of amoxicillin-clavulanic acid twice a day for seven days did seem to clear the infection. However, molecular analysis revealed that the man had a new XDR strain of N. gonorrhoeae. According to the case report, this strain, named AT159, “belongs to the same sublineage as WHO Q,” but differs by 313 DNA sequences. And that kids is how this new strain met the Eurosurveillance journal as a case report.
Of course, case reports are reserved for very unusual situations. And although super gonorrhea has been spreading, it’s as if you routinely hear people say, “yeah, got super gonorrhea again,” when you ask them how they are doing. This situation may change in the future though, perhaps sooner than later. Currently, there’s no gonococcal vaccine, not nearly enough new antibiotics being developed, and a general lack of urgency among politicians, policy makers, and businesses in addressing the increasing problem of antibiotic-resistant bacteria. Ever since antibiotics became available in the 1930’s, bacteria like N. gonorrhoeae have readily adapted to practically every new class of antimicrobials that’s been introduced. If this new strain of N. gonorrhoeae that’s got high-level resistance to azithromycin and resistance to ceftriaxone ends up spreading widely, the world may have a real super problem super soon.
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