How to protect yourself against drug-resistant infections—and why condom use during intercourse may not be enough. 

Amanda MacMillan
March 29, 2018

A man in the United Kingdom has been diagnosed with the “worst-ever” case of drug-resistant gonorrhea—also known as super-gonorrhea—BBC News reported yesterday. Doctors at Public Health England say the man’s disease has not responded to the two antibiotics commonly used to treat this type of sexually transmitted infection (STI), and that such “high-level resistance” is unprecedented anywhere in the world.

The patient apparently picked up the infection after a sexual encounter with a woman in Southeast Asia. Officials are now attempting to trace other sexual partners the man has had, in order to hopefully contain the spread of this extremely hard-to-treat strain.

While this may be the worst case of super-gonorrhea on record, it’s not the first: Experts have been warning about the disease’s increasing drug resistance for years. To learn more about how this happens—and what we can do to protect ourselves—Health spoke with Jeanne Marrazzo, MD, MPH, director of the division of infectious diseases at the University of Alabama at Birmingham. Here’s what she wants everyone to know.

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Drug-resistant gonorrhea isn’t new—but this case is still extra scary

Dr. Marrazzo says the case in the U.K. is a “natural expected evolution” of Neisseria gonorrhoeae, the bacterium that causes gonorrhea. Doctors have been treating gonorrhea with antibiotics since the 1940s, she says, but “every couple of decades, if not more frequently, it figures out how to become resistant to whatever drugs we’re using at the time.”

The problem now, she says, is that we’ve run out of antibiotics that still work against the disease. In recent years, most strains of gonorrhea have been treated with two antibiotics—ceftriaxone, which tends to work in almost all cases, and azithromycin, “to hedge our bets and give the ceftriaxone more punch,” says Dr. Marrazzo.

Cases of ceftriaxone-resistant gonorrhea have been reported previously, in Canada, Japan, France, and Scandinavia, to name a few. But this is the first time the bacterium showed high levels of resistance to both of these drugs, “and to most other commonly used antibiotics,” said Gwenda Hughes, head of Public Health England’s sexually transmitted infection section, in a statement.

Preliminary tests have suggested that one remaining drug—a broad-spectrum antibiotic called ertapenem—may still work in the U.K. case in question, although doctors will have to evaluate the patient again next month to know for sure.

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The one remaining drug treatment can have serious side effects

It's not just worrisome that there’s only one drug left to treat this strain of gonorrhea; there are also several problems with that drug itself. For one, says Dr. Marrazzo, ertapenem’s a “big gun” as far as antibiotics go: It would need to be administered via IV (there's no pill version), and it’s extremely broad-spectrum, meaning it will kill a wide variety of bacteria in the body.

“To give you a sense of how serious this drug is, it’s something we use in patients in the intensive care unit who have complicated intra-abdominal infections,” says Dr. Marrazzo. “You almost never use it in anybody who’s not really, significantly ill.”

Ertapenem would be difficult to administer in an outpatient setting, she continues, and it can have serious side effects. “We know that broad-spectrum antibiotics completely mess with your gastrointestinal microbiome,” she says. In other words, it can wipe out lots of good bacteria along with the bad—which can be bad news for a person’s immune system, digestion, and overall health.

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We haven’t seen it in the United States—yet

Drug-resistant gonorrhea isn’t yet a serious problem in America, but the Centers for Disease Control and Prevention warned in 2016 that the disease could soon become untreatable. Samples taken from seven patients in Hawaii earlier that year showed increased resistance to azithromycin, and five of them showed increased resistance to ceftriaxone as well.

Many cases of superbugs reported around the world have originated in Southeast Asia—probably because there’s so much over-the-counter use of antibiotics there, says Dr. Marrazzo. “These types of things often follow an interesting progression,” she says. “They’ll start in Southeast Asia, come across the Pacific to Hawaii, then to California, up the West Coast, and outward to the rest of the country.”

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Using condoms for intercourse isn’t enough

Wearing a condom for sexual intercourse can protect against gonorrhea and other STIs, but vaginal and anal sex aren’t the only ways these infections can be transmitted.

“Gonorrhea is very good at infecting the throat, and that’s where it’s really hard to get rid of, no matter what antibiotics you use,” says Dr. Marrazzo. In fact, this new and unidentified super-gonorrhea victim tested positive in his throat, suggesting that he may have gotten the disease through oral sex.

"We know that people are significantly less likely to use condoms for oral sex, and that’s a big problem,” says Dr. Marrazzo. Doctors are also concerned that men who have sex with men may be less likely to use condoms if they take PrEP, a medication that protects against HIV.

“Yes, condoms are great and they can protect you if you use them properly,” says Dr. Marrazzo. But they're not the whole solution. "We have to find ways to address these other behaviors that put people at risk as well.”