Gonorrhoea bacteria Maurizio De Angelis/SPL

England’s public health agency has launched an “incident response” after discovering more cases of gonorrhoea that are resistant to nearly all antibiotics.

Doctors across England have been asked to double-check that people they treat for gonorrhoea have been cured, to report any treatment failures, and to treat their sexual contacts in hope of containing the bacteria. But fewer than half of such contacts are being traced.

Gonorrhoea, also known as “the clap”, was largely controlled by antibiotics after the second world war. But the bacteria readily acquire genes for resisting drugs, and by 2012, the World Health Organization warned that strains of the infection were appearing that resisted nearly all classes of antibiotics.


In 2012, the UK mandated treatment with two antibiotics at once – azithromycin pills plus an injection of ceftriaxone – so if bacteria acquired resistance to one, they would be killed by the other. Gonorrhoea that resists azithromycin was detected in Japan in 2013, and in 2015 clinics in northern England reported 16 people with similarly resistant infections.

That means the infections are only killed by ceftriaxone – and if any of the bacteria acquire resistance to it, there is no backup antibiotic to kill them off – so resistance to this last treatment could develop quickly, says Mark Lawton, a doctor in Liverpool and a spokesman for the British Association for Sexual Health and HIV.

Secret treatment

Resistance to azithromycin is emerging, Lawton says, partly because people who test positive for gonorrhoea have been buying treatments confidentially from internet pharmacies. You cannot buy a drug that must be injected, like ceftriaxone, on the internet, so people have bought the related oral drug cefixime instead. But that doesn’t penetrate rectal and other tissues that harbour the bacteria as readily as the injected drug, leaving azithromycin on its own. Any bacteria that resisted it could therefore thrive.

The drugs don’t work any more Sam Shere/The LIFE Picture Collection/Getty

Now Public Health England reports that 34 more cases have been found across England since November 2014, including in London. The initial cases were in heterosexuals, but some of the new ones are in men who have sex with men, who spread the infection faster.

In 2012, David Fisman at the University of Toronto in Canada used epidemiological models to show that the only way to stop transmission of gonorrhoea in a population was to target treatment at people who change sex partners frequently, especially sex workers and men who have sex with men. The model also showed resistance to antibiotics also spreads fastest in these groups.

Shifting responsibility

And the spread can be hard to track. Public Health England says that of the 50 sex partners that the people with the newly discovered cases report having, only 22 could be contacted, and just 18 were tested – but 17 of those tested positive for gonorrhoea. The bacteria’s genomes showed they were related to the previously discovered cases, and recently transmitted.

“We stress that people should get tested if they think they might be at risk,” says Lawton, because two-thirds or more of infections can be symptom-free. But responsibility for sexual health in the UK has been shifted from the National Health Service to local governments over the past few years, and some sexual health clinics have had their budgets slashed, says Lawton.

Otherwise new drugs are needed – but there has been little interest in developing them for gonorrhoea, an apparently defeated disease, and little is in the pipeline, says Fisman.

One option may be to increase the doses of the existing drugs, or perhaps to go back to old drugs that might work against gonorrhoea. Research has started that is aimed at finding out if a vaccine against meningitis B, caused by related bacteria, might cause some cross-immunity to gonorrhoea.