Sexual and reproductive health

Scientists warn that antibiotic-resistant gonorrhoea is on the rise

New drugs and better preventative methods urgently needed

07 July 2017: . Every day, more than 1 million sexually transmitted infections are acquired worldwide, and each year an estimated 78 million people are infected with gonorrhoea (1). New data from 77 countries show that antibiotic resistance is making gonorrhoea much harder – and sometimes impossible – to treat.

The data has been published in PLOS, in two new scientific articles led respectively by authors from WHO Department of Reproductive Health and Research including HRP, and the Global Antibiotic Research and Development Partnership (GARDP).

Photo of young people lying in park
WHO/Sergey Volkov

Negative health impact

Gonorrhoea can infect the genitals, rectum, and throat. Complications of gonorrhoea disproportionally affect women, including pelvic inflammatory disease, ectopic pregnancy and infertility, as well as an increased risk of HIV. The infection can have a significant negative impact upon the health and well-being of infected individuals, who can be faced – in addition to the immediate physical impact of infection – with emotional distress, as well as stigma and discrimination.

‘Intelligent’ bacteria

“The bacteria that cause gonorrhoea are particularly smart. Every time we use a new class of antibiotics to treat the infection, the bacteria evolve to resist them,” said Dr Teodora Wi, Medical Officer at WHO Department of Reproductive Health and Research including HRP.

WHO reports widespread resistance to older and cheaper antibiotics. Some countries—particularly high-income ones, where surveillance is best—are finding cases of the infection that are untreatable by all known antibiotics.

“These cases may just be the tip of the iceberg, since systems to diagnose and report untreatable infections are lacking in lower-income countries where gonorrhoea is actually more common,” adds Dr Wi.

Decreasing condom use, increased urbanization and travel, poor infection detection rates, and inadequate or failed treatment are likely all contributing to increasing infections.

Call for prevention

Gonorrhoea can be prevented through safer sex practices, in particular consistent and correct condom use. Information, education and communication can help to promote safer sex practices, improve people’s ability to recognize the symptoms of gonorrhoea, and increase the likelihood they will seek care. Today, lack of public awareness, lack of training of health workers, and stigma around sexually transmitted infections remain barriers to greater and more effective use of these interventions.

There are no affordable, rapid, point-of-care diagnostic tests for gonorrhoea, which makes the infection difficult to accurately detect, diagnose and treat. Many people who are infected with gonorrhoea do not have any symptoms, so they go undiagnosed and untreated. When patients do have symptoms however, such as discharge from the urethra or the vagina, doctors sometimes assume it is gonorrhoea and prescribe antibiotics – even though people may be suffering from another kind of infection. The overall inappropriate use of antibiotics increases the development of antibiotic resistance in gonorrhoea as well as other bacterial diseases.

New tools and systems for better prevention, as well as vaccines, earlier diagnosis and better tracking and reporting of new infections, antibiotic use, resistance and treatment failures, are needed.

Dr Marc Sprenger, Director of Antimicrobial resistance at WHO comments, “Specifically, we need new antibiotics, as well as rapid, accurate, point-of-care diagnostic tests—ideally, ones that can predict which antibiotics will work on that particular infection—and longer term, a vaccine to prevent gonorrhoea.”

Monitoring drug resistance

The WHO Global Gonococcal Antimicrobial Surveillance Programme (WHO GASP), monitors trends in drug-resistant gonorrhoea. WHO GASP data from 2009 to 2014 finds widespread resistance to different antibiotics used to treat the infection including: ciprofloxacin [97% of countries that reported data in that period found drug-resistant strains]; increasing resistance to azithromycin [81%]; and the emergence of resistance to the current last-resort treatment: the extended-spectrum cephalosporins (ESCs) oral cefixime or injectable ceftriaxone [66%].

Currently, in most countries, ESCs are the only antibiotics that remain effective for treating gonorrhoea. But resistance to cefixime—and more rarely to ceftriaxone—has now been reported in more than 50 countries. As a result, WHO has issued updated global treatment recommendations in 2016 advising doctors to give 2 antibiotics: ceftriaxone and azithromycin.

Development of new drugs

The development of new antibiotics is not very attractive to commercial pharmaceutical companies, as treatments are taken only for short periods of time (unlike medicines for chronic diseases) and, they also become less effective as resistance develops, meaning that the supply of new drugs constantly needs to be replenished.

There are only 3 new candidate drugs in various stages of clinical development: Solithromycin, for which a phase III trial has recently been completed; Zoliflodacin, which has completed a phase II trial; and Gepotidacin, which has also completed a phase II trial.

The Drugs for Neglected Diseases initiative (DNDi) and WHO have launched the Global Antibiotic Research and Development Partnership (GARDP), a not-for-profit research and development organization, hosted by DNDi, to address this issue. GARDP’s mission is to develop new antibiotic treatments and promote appropriate use, so that they remain effective for as long as possible, while ensuring access for all in need. One of GARDP’s key priorities is the development of new antibiotic treatments for gonorrhoea.

“To address the pressing need for new treatments for gonorrhoea, we urgently need to seize the opportunities we have with existing drugs and candidates in the pipeline. In the short term, we aim to accelerate the development and introduction of at least one of these pipeline drugs, and will evaluate the possible development of combination treatments for public health use,” said Dr Manica Balasegaram, GARDP Director. “Any new treatment developed should be accessible to everyone who needs it, while ensuring it’s used appropriately, so that drug resistance is slowed as much as possible.”

(1) 35.2 million in the WHO Western Pacific Region, 11.4 million in the South-East Asian Region, 11.4 million in the African Region, 11.0 million in the Region of the Americas, 4.7 million in the European Region and 4.5 million in the Eastern Mediterranean Region.