Last year, we shared the fascinating and frightening story of the emergence of increasingly antibiotic-resistant gonorrhea, an STD caused by the gonococci bacteria. The sexually transmitted scourge, which we only so recently reined in with the development of antibiotics, has been performing some genetic gymnastics to defeat almost every drug we’ve thrown at it. We douse it with certain drugs, and the bacterium literally spits them back out at us, and it inactivates other drugs by snapping the active molecules in half. Sulfa drugs, penicillins, tetracyclines, fluoroquinolones — they all make a gonococcus heave a bored sigh. Luckily, cephalosporins were still an effective treatment, but recently there have been reports of stubborn gonorrhea infections caused by the latest and greatest (and some might say most hated) strain of gonococci.

The bacteria that cause gonorrhea continue to evolve, right under our noses!

Well, the story isn’t over — just like the bacteria that cause gonorrhea, the tale is rapidly evolving. The latest class of antibiotics that the gonococci are chipping away at is the cephalosporin family, which includes several chemically related drugs that work in similar ways — and that can likewise be defeated by microbes in similar ways. Cephalosporin-resistant gonorrhea was first reported in Japan and documented in a few European countries. The Japanese case that inspired the New England Journal of Medicine to declare last year that it was “time to sound the alarm” was an oral gonorrhea infection that was resistant to one member of the cephalosporin family: ceftriaxone.

Earlier this month, the prestigious medical journal JAMA reported the first North American sightings of gonorrhea that failed treatment with another cephalosporin: cefixime. Yeah, I know, you’d rather hear about Big Foot or UFO sightings, not evidence that something as real and unmythical as Gonorrhea 5.0 has landed in your back yard. Luckily, there’s plenty you can do to protect yourself from it, and we’ll tell you all about it toward the end of this article. (Spoiler alert: It involves using condoms!)

These recent North American sightings occurred in Toronto, where gonorrhea patients at a clinic were dosed with cefixime and told to come back for a followup to verify that their infection had indeed been eradicated. About 1 out of 15 patients (out of a total of 133) was found still to be infected with the same strain of gonorrhea with which they had initially presented. These resistant gonorrhea infections were caused by bacteria that were, upon analysis, found to be genetically similar, with genes for antibiotic resistance. The Canadian patients were eventually cured, either with ceftriaxone or double doses of cefixime, but ceftriaxone resistance has been documented in other parts of the world and gonorrhea has a history of becoming resistant to bigger and bigger dosages.

Want more bad news? Promising new gonorrhea drugs aren’t on the horizon, although one new antibiotic is being studied in a small trial. Mostly, researchers are trying new combinations of preexisting antibiotics in attempts to foil the gonococci’s wily ways. The Centers for Disease Control and Prevention now advises that gonorrhea be treated with a shot of ceftriaxone along with either azithromycin or a week-long course of doxycycline. Other drug combos are under study.

The CDC doesn’t recommend cefixime as a treatment for gonorrhea — at the time of the study in Canada, 400 mg. of cefixime was recommended by the Public Health Agency of Canada, but after the study was over those recommendations changed. Canadian public health authorities now recommend either a shot of ceftriaxone or an 800 mg. dose of cefixime. They furthermore recommend that only ceftriaxone be used for oral gonorrhea or when treating men who have sex with men.

Since gonorrhea is transmitted through sexual activity, the best protection available to sexually active people is the humble latex condom: inexpensive, accessible, and protective in so many other ways. Are you and your partner(s) unaware of each other’s STD status? If at least one of you has a penis, put a condom on it — yes, even for oral sex. Gonorrhea can easily pass back and forth between a penis and a throat, as well as between a penis and a vagina, and a penis and a rectum. Gonorrhea transmission via cunnilingus (oral contact with female genitalia) has been documented as well, although not as extensively, so dental dams are also advised for partners who haven’t been tested for STDs before initiating sexual activity. (Especially thorough STD testing would include an oral swab to detect oral gonorrhea infections.)

It is thought that the human throat offers a convenient hideout for gonorrhea, since oral gonorrhea rarely has symptoms and can lurk in there for months, sneakily infecting others in the event of oral sexual contact. It’s even possible that the throat doubles as a very special breeding ground for antibiotic resistance, as gonococci have a knack for swapping genes with living microbes, as well as scavenging DNA from dead microbes, and incorporating the genes into their own genomes. When these genes are useful, the new and improved gonococcus has a survival advantage and might flourish in the wild. The throat is a hub for all kinds of pathogenic bacteria, including many with resistance to antibiotics — such as those taken for sore throats, for example. Antibiotic-resistance genes might be readily available to throat-dwelling gonococci.

More information about antibiotic-resistant gonorrhea is available from the Centers for Disease Control and Prevention and the National Institute of Allergy and Infectious Diseases. Sexually active people should use latex barriers, such as condoms, during vaginal, anal, and oral sex. You can be screened and treated for gonorrhea (you’ll just need to provide a urine sample), or drop by to pick up condoms, at any Planned Parenthood health center. Researchers now believe that anyone being treated for gonorrhea should be retested three months later as a precautionary measure.

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