Gonorrhea showing increasing resistance to drugs

Gonorrhea has been growing increasingly resistant to antibiotics for many decades, but there’s always been at least one backup drug patients could rely on to fight the disease. Now, even those backups are starting to lose effectiveness.

There hasn’t yet been a case of gonorrhea in the United States that didn’t respond to treatment. But doctors and other health care providers have seen a growing proportion of gonorrhea bacteria that have decreased susceptibility to cephalosporin antibiotics, the standard treatment for the infection.

And in the United States, California will probably be among the first states to see a strain that doesn’t respond to any drugs.

“We’re concerned that it’s just amatter of time,” said Dr. Susan Philip, the director of sexually transmitted disease prevention and control at the San Francisco

Department of Public Health.

Strains of gonorrhea that are resistant to multiple types of antibiotics are appearing more often in the western part of the country and in men who have sex with men, Philip said. California and Hawaii have in the past been the first states to have new, resistant types of gonorrhea, probably because of their ties to Asia, where stronger strains often are seen earliest.

“We are aware that historically when you start to see resistance emerge in gonorrhea to certain antibiotics in the United States, it often starts in the western part of the country,” said Dr. Nicholas Moss of the Alameda County Public Health Department.

Bay Area counties

Bay Area counties typically have higher rates of gonorrhea than most other counties in the state, in part because the disease disproportionately affects African Americans and men who have sex with men.

Gonorrhea is the second most common reportable infectious disease in the country and state, with more than 300,000 cases nationwide in 2011; the most common is chlamydia. Gonorrhea can be hard to track because most cases are asymptomatic, particularly if the disease takes hold in the rectum or throat. Cases in the urethra are more likely to display symptoms, including burning and discharge.

The disease can lead to pelvic inflammatory disease and infertility in women, but the big concern is that it can make one more vulnerable to HIV.

The Centers for Disease Control and Prevention recommends cases be treated with both an injection of a cephalosporin called ceftriaxone and an oral therapy, either azithromycin or doxycycline.

In San Francisco in 2011, there were more than 2,200 reported cases of gonorrhea, for a rate of 278.7 cases per 100,000 people — the highest of any county in the state. The rate that year increased by 15.5 percent over 2010, but it was entirely driven by men. Rates among women in the county dropped 22 percent in 2011, but rates among men rose 21.5 percent.

Early data from 2013 shows some improvements over 2012 in San Francisco. In January and February of this year, there were 378 cases compared with 418 at that point in 2012. This year, 120 of the cases were male rectal gonorrhea compared with 146 in 2012.

Statewide, there were 27,455 cases of gonorrhea in 2011, or roughly 73 cases per 100,000 people. But the disease did not affect all demographics in the same way. Black women were 15 times more likely to get gonorrhea as white women, and black men had rates seven times higher than white men, according to state data.

In one survey, 60 percent of the cases in men were in men who have sex with men.

Officials encourage people who test positive for gonorrhea to contact their public health department. Experts hope that studying more cases will point them to a better understanding of the development of resistance. For example, there may be molecular markers that are unique to drug-resistant strains.

Public health officials also urge infected people’s partners to get tested. Sometimes one person will seek treatment but his or her partner will not, which leads to re-infection.

‘Pingpong effect’

“It’s a pingpong effect,” said Gay Calhoun of the Alameda County Public Health Department.

Last month, the National Coalition of STD Directors held congressional briefings for lawmakers calling for $53.48 million in emergency funding for health departments to address gonorrhea.

The group warned that public health departments are so financially strained that they are having trouble keeping up with CDC recommendations for treatment. If Congress does not approve the emergency funding, the cost down the road could be in the hundreds of millions of dollars, advocates cautioned.

“Anyone asking for additional money in Washington right now has their work cut out for them,” said William Smith, the executive director of the organization.

But “it’s not like we didn’t know this is coming,” he added. “We know what we have to do.”