Gonorrhea resistance to antibiotics is increasing

Abstain from sex. That's "the only way to completely avoid STIs," is what we hear from public health bodies. Do not have any vaginal, anal or oral sex.

It makes for sobering advice. But it also makes perfect sense when you read the latest data from the European Centre for Disease Prevention and Control (ECDC) on the spread of gonorrhea, a bacterial sexually transmitted infection (STI), and antimicrobial resistance (AMR).

Antibiotics, such as azithromycin, ceftriaxone and cefixime, are common medical treatments to cure gonorrhea, but they are growing increasingly ineffective. And that may be contributing to a European, if not global, increase in gonorrhea cases and STIs more generally.

The ECDC said in a report published June 10, 2024 that the total number of confirmed cases of gonorrhea in 28 EU/EEA (European Union/European Economic Area) countries in 2022 rose to 70,881 — a jump of 48% compared to the year before.

AMR is one reason why antibiotics across the board — whether it's for STIs or an earache — are failing public health efforts. Either we use them too much, or we don't bother to take all the pills, with the result that bacteria are able to build up a resistance to many of our "go-to" drugs of the past 100 years.

What is gonorrhea?

Gonorrhea is caused by the Neisseria gonorrhea bacterium. It can affect the genitals, rectum and/or throat. Infections are prevalent among young people aged 15-24 years.

Women often don't have symptoms, and if they do, the symptoms tend to be mild and can be mistaken for another vaginal or bladder infection — women are higher at risk than men simply because diagnosis is tougher. And especially pregnant women because they can pass STI infections to an unborn child. Women can experience prenatal complications due to undiagnosed STIs or become infertile.

Men, on the other hand, do have symptoms, including a burning sensation when urinating, a white, yellow or green discharge, and/or painful or swollen testicles.

"But this is rarer than what you see in women. We must prioritize women because they are asymptomatic," said Teodora Elvira Wi, who leads the global HIV, hepatitis and STIs programs at the World Health Organization in Geneva.

"We need opportunities for women to be screened for STIs, and especially people at higher risk, people who have multiple partners and sexually active adolescents," said Wi.

Antimicrobial resistance to common antibiotics for gonorrhea 'concerning'

The ECDC report featured an analysis of 4,396 samples (or "isolates") of gonorrhea collected in 2022 from 23 countries. 

They found "isolates resistant to azithromycin increased significantly to 25.6%, compared to 14.2% in 2021."

As azithromycin is often combined with ceftriaxone, the ECDC labeled this finding "particularly concerning."

Resistance to ciprofloxacin also increased, but not as significantly — 65.9% of isolates exhibited resistance in 2022, up from 62.8% in 2021.

Resistance to cefixime remained "low at 0.3%."

Overall, the ECDC figures are reflected in data that the World Health Organization is seeing in other regions, including Africa and Asia.

"Antimicrobial resistance is not the only cause [there], but in countries where antimicrobial resistance is even higher than in Europe, it is contributing to the increase in bacterial STIs," said Wi, adding that, globally, 73 countries have reported antimicrobial resistance data in gonorrhea.

The ECDC data indicated a rise in pharyngeal (throat) gonorrhea, while cases of genital and anorectal gonorrhea remained stable in 2022.

How to slow the spread of STIs

Global WHO data from 2020 showed 374 million new cases per year of syphilis, gonorrhea, chlamydia and trichomoniasis among people aged 15-49 years. The WHO cited the following reasons for the growing number of STI cases:

• Increase in unsafe sexual behavior, including low condom use, increase in number of partners and casual partners
• Asymptomatic infections and socioeconomic influences; biological factors
• Poor access to STI services, lack of STI services and lack of tools for diagnostic tests due to underfunding of services
• Stigma: STI patients do not seek care, and stigma results in underfunding of STI services and research

Addressing and/or reversing these factors would be good a start in public health efforts to get STIs under control.

But don't stop having sex completely, said Wi — instead, get educated about sex. "Have sex, have pleasure in sex, make it a voluntary thing, do it for your sexual well-being and protect yourself the way you protect yourself from other infections," she said.

Edited by: Davis VanOpdorp

Primary source:

Gonococcal antimicrobial susceptibility surveillance in the EU/ EEA, European Centre for Disease Prevention and Control, June 2024 https://www.ecdc.europa.eu/en/publications-data/gonococcal-antimicrobial-susceptibility-surveillance-eu-eea