antibiotic-resistant gonorrhea in the US

 There was a recent report in the Boston Globe highlighting 2 people who had antibiotic-resistant gonorrhea (https://www.bostonglobe.com/2023/01/19/metro/massachusetts-detects-troubling-new-strain-gonorrhea/ ). These 2 people, who had no connection with each other, were effectively treated with antibiotics, but the “new bug’s genetic profile indicates that gonorrhea, which has already developed resistance to nearly all antibiotics used to treat it, is starting to gain the ability to overpower the one antibiotic (ceftriaxone) doctors still use”.  It is notable that this is the first report in the US.  The N gonorrhea was resistant to cipro, penicillin, and tetracycline and had reduced susceptibility to ceftriaxone, cefixime, and azithromycin. No further details or comments by the CDC.

These cases bring up lots of issues about antibiotic resistance, and in particular to N gonorrhea. I have written many blogs on this in the past (see below) and I think this is an opportunity to present some of them again, especially since I do have many new readers over the past couple of years. A few points:

-- given the levels of international travel, any resistant bug in pretty much any part of the world will spread to everywhere. So we should expect an antibiotic-resistant one to come to the US eventually

-- we humans seem to have an evolutionary imperative to react strongly to an immediate threat (the “flight or flight” response to the approaching tiger), and a weaker response to longer-term, perhaps more cerebral threats: eg, climate change, a truly existential threat, seems to take a back row in many people’s minds tothe  current economic issues, inflation, immigration, etc, etc. So, hearing about antibiotic-resistant N gonorrhea in the UK does not bubble up as a serious threat in the minds of many people (and it may not even reach the popular press)

So, here’s the litany of some of the prior blogs, showing that the scare of antimicrobial resistance has been of increasing concern globally for the past decade plus:

-- the dramatic increase in gonorrhea cases in Massachusetts in 2018 over a 20-year period:  http://gmodestmedblogs.blogspot.com/2018/06/increasing-gonorrhea-and-syphilis-in.html 

     -- in 2020 there were 677,769 cases of gonorrhea in the US, an 111% increase from 2009: http://gmodestmedblogs.blogspot.com/2022/08/stds-increasing.html documents that in 2020 there were 677,769 cases of gonorrhea in the US, an 111% increase from 2009

  

-- the 2014 WHO report that worldwide there was >25% resistance to 3rd generation cephalosporins in 3 of 6 regions of the world: http://gmodestmedblogs.blogspot.com/2014/05/who-report-on-antimicrobial-resistance.html 

-- a 2016 MMWR documenting gonorrhea’s increasing antibiotic resistance in the US: http://gmodestmedblogs.blogspot.com/2016/07/gonorrhea-resistance-increasing.html \

-- the 2019 CDC report that drug-resistant N gonorrhea is one of the 5 drug-resistant bacteria in their highest category of an “urgent threat”, with an estimated 550,000 drug-resistant infections per year: http://gmodestmedblogs.blogspot.com/2019/11/cdc-updated-threats-of-antibiotic.html

-- N gonorrhea (resistant to cephalosporins and fluoroquinolones) had become an international high priority pathogen for development of antibiotics: http://gmodestmedblogs.blogspot.com/2017/03/antibiotic-resistant-bacteria-of-concern.html 

     -- BUT, most pharmaceuticals dumped antibiotic research (not profitable, since antibiotics are short-term meds; the money is in chronic disease med). This blog highlights the case of Novartis, one of the few drug companies that made an international commitment at the 2016 World Economic Forum in Davos, Switzerland dealing with the threat of increasing antibiotics to “invest in research and development of innovative treatments and diagnostics to combat antibiotic-resistant bacteria"; this commitment was subsequently retracted: http://gmodestmedblogs.blogspot.com/2018/07/novartis-dumps-antibiotic-research.html 

-- another blog documents antibiotic overuse in humans and animals (80-90% of antibiotics are used in animal agriculture, a likely very large source of antibiotic resistance in humans), along with case reports of people resistant to essentially all antibiotics: http://gmodestmedblogs.blogspot.com/2018/04/antibiotic-overuse-in-animals-and.html 

    -- the latest report on teh extent of antibiotics used in food-producing animals: https://www.fda.gov/industry/animal-drug-user-fee-act-adufa/questions-and-answers-summary-report-antimicrobials-sold-or-distributed-use-food-producing-animals

blogs on antibiotic overprescribing:  

    -- 4 articles noting high prescription rates of antibiotics for URIs, pharyngitis and acute rhinosinusitis: http://gmodestmedblogs.blogspot.com/2016/01/antibiotic-overprescribing-and-acute.html  

    -- another with a CDC report from 2013 finding huge overprescription of antibiotics for respiratory infections: http://gmodestmedblogs.blogspot.com/2015/07/antibiotic-overprescribing.html 

 

blogs on effects of antibiotics on the body:

    -- a study finding similar outcomes and fewer adverse events in kids on narrower-spectrum antibiotics: http://gmodestmedblogs.blogspot.com/2018/01/antibiotic-use-in-kids-narrow-spectrum.html 

    -- a small study showing that there can be long-term effects (12 month) on the gut microbiome even after a single exposure to antibiotics: http://gmodestmedblogs.blogspot.com/2015/11/longterm-microbiome-changes-with.html  

   -- increased colorectal adenomas, including advanced ones, in women exposed to antibiotics: http://gmodestmedblogs.blogspot.com/2017/04/antibiotics-microbiome-changes-and.html 

   -- increased risk of colon cancer in those exposed to antibiotics, perhaps more so with penicillins: http://gmodestmedblogs.blogspot.com/2019/10/antibiotics-increased-colon-cancer-risk.html 

   -- increased obesity and allergy in kids exposed to antibiotics: http://gmodestmedblogs.blogspot.com/2018/12/antibiotics-ppish2ras-increase-obesity.html 

   -- and a blog with 2 articles, one showing an unfortunate shift from prescribing narrow to broad-spectrum antibiotics and another showing that clinicians tend to prescribe more antibiotics late in a clinical session ("clinician fatigue"): http://gmodestmedblogs.blogspot.com/2015/07/antibiotic-overprescribing.html 

 

and somewhat hopeful blogs:

   -- a hospital stewardship program leading to less antibiotic resistance: http://gmodestmedblogs.blogspot.com/2017/06/decreasing-antibiotic-resistance-by.html

    -- an effective antibiotic stewardship program developed by the Agency for Healthcare Research and Quality Safety Program, which was effective and generalizable: http://gmodestmedblogs.blogspot.com/2021/03/antibiotic-stewardship-and.html

    -- a 2017 CDC report that antibiotic use in the US was decreasing: see http://gmodestmedblogs.blogspot.com/2017/08/antibiotic-use-decreasing.html

So, this is overall a pretty dismal picture. We have clear documentation that antibiotic-resistant bugs are spreading, that they are becoming more and more untreatable, that we do not have the mechanism to deal with them pharmacologically and that there are limited attempts at new antibiotic development (of note, the WHO found only 27 new antibiotics in cliinical development against priority pathogens in 2021, down from 31 in 2017: https://www.who.int/news/item/22-06-2022-22-06-2022-lack-of-innovation-set-to-undermine-antibiotic-performance-and-health-gains#:~:text=According%20to%20WHO%20annual%20analyses,from%2031%20products%20in%202017. ). we need a really nimble pharmaceutical industry to deal with the array of urgent candidates. and, very unfortunately, our public health system has limited ability to effect major changes in some of the most important causes of the increasing resistance: overuse of antibiotics in people and animals

geoff

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