Perspective

Review finds high rates of drug-resistant gonorrhea in China

A review of national surveillance data found high rates of drug-resistant gonorrhea in China, including an increased prevalence of Neisseria gonorrhoeae isolates with decreased susceptibility to the widely recommended first-line treatment.

The CDC and WHO recommend treating gonorrhea with 1 g of oral azithromycin and a 250-mg intramuscular injection of ceftriaxone, but many countries have reported resistance or decreased susceptibility of N. gonorrhoeae to those antibiotics, raising fears that the once easily curable STD is becoming untreatable.

According to WHO, most countries have reported seeing isolates with decreased resistance to extended-spectrum cephalosporins — including injectable ceftriaxone — and even more have seen isolates resistant to azithromycin.

Recently, researchers in Canada reported what they said was just the sixth ceftriaxone-resistant N. gonorrhoeae isolate in the world. In China, where ceftriaxone is still the recommended therapy for gonorrhea, there have been no documented treatment failures of the drug, researchers reported in PLoS Medicine.

“To halt the development and spread of resistance, dual therapy consisting of ceftriaxone and azithromycin has been recommended as the first-line therapy in international and national guidelines. However, the first treatment failure with dual therapy was reported in 2016 in the United Kingdom,” they wrote. “To provide evidence for updating China's national treatment recommendations for gonorrhea, we analyzed data on the susceptibility to azithromycin and ceftriaxone of N. gonorrhoeae isolates collected in the China Gonococcal Resistance Surveillance Program (China-GRSP).”

A three-dimensional computer-generated image of drug-resistant Neisseria gonorrhoeae diplococcal bacteria.
A computer-generated image of drug-resistant gonorrhea.
Source: CDC

According to the researchers, China reports around 115,000 new cases of gonorrhea each year, making it one of the most commonly notifiable diseases in the country. For their retrospective study, they performed antibiotic susceptibility testing on 3,849 N. gonorrhoeae isolates — mostly from male patients — from 2013 through 2016 at clinics in seven provinces.

The prevalence of isolates resistant to azithromycin — defined as having a minimum inhibitory concentration (MIC) of 1 mg/L or greater — was 18.6% (95% CI, 17.4% to 19.8%) and was associated with younger age and being female. The percentage of patients with decreased susceptibility to ceftriaxone — a MIC of .125 mg/L or greater — fluctuated between 9.7% and 12.2% during the study period and was significantly associated with living near the coast.

The overall prevalence of isolates showing both resistance to azithromycin and decreased susceptibility to ceftriaxone was 2.3% (95% CI 1.9% to 2.8%) and increased from 1.9% in 2013 to 3.3% in 2016, according to the study.

“It is important that clinicians be on high alert to recognize gonorrhea treatment failures so that they can be reported promptly to public health officials,” the researchers concluded. “The high and increasing prevalence of [isolates showing both resistance to azithromycin and decreased susceptibility to ceftriaxone] found in the current study suggests the need for further consideration and validation of an appropriate regimen for treatment of gonorrhea in China. – by Gerard Gallagher

Disclosures: The authors report no relevant financial disclosures.

A review of national surveillance data found high rates of drug-resistant gonorrhea in China, including an increased prevalence of Neisseria gonorrhoeae isolates with decreased susceptibility to the widely recommended first-line treatment.

The CDC and WHO recommend treating gonorrhea with 1 g of oral azithromycin and a 250-mg intramuscular injection of ceftriaxone, but many countries have reported resistance or decreased susceptibility of N. gonorrhoeae to those antibiotics, raising fears that the once easily curable STD is becoming untreatable.

According to WHO, most countries have reported seeing isolates with decreased resistance to extended-spectrum cephalosporins — including injectable ceftriaxone — and even more have seen isolates resistant to azithromycin.

Recently, researchers in Canada reported what they said was just the sixth ceftriaxone-resistant N. gonorrhoeae isolate in the world. In China, where ceftriaxone is still the recommended therapy for gonorrhea, there have been no documented treatment failures of the drug, researchers reported in PLoS Medicine.

“To halt the development and spread of resistance, dual therapy consisting of ceftriaxone and azithromycin has been recommended as the first-line therapy in international and national guidelines. However, the first treatment failure with dual therapy was reported in 2016 in the United Kingdom,” they wrote. “To provide evidence for updating China's national treatment recommendations for gonorrhea, we analyzed data on the susceptibility to azithromycin and ceftriaxone of N. gonorrhoeae isolates collected in the China Gonococcal Resistance Surveillance Program (China-GRSP).”

A three-dimensional computer-generated image of drug-resistant Neisseria gonorrhoeae diplococcal bacteria.
A computer-generated image of drug-resistant gonorrhea.
Source: CDC

According to the researchers, China reports around 115,000 new cases of gonorrhea each year, making it one of the most commonly notifiable diseases in the country. For their retrospective study, they performed antibiotic susceptibility testing on 3,849 N. gonorrhoeae isolates — mostly from male patients — from 2013 through 2016 at clinics in seven provinces.

The prevalence of isolates resistant to azithromycin — defined as having a minimum inhibitory concentration (MIC) of 1 mg/L or greater — was 18.6% (95% CI, 17.4% to 19.8%) and was associated with younger age and being female. The percentage of patients with decreased susceptibility to ceftriaxone — a MIC of .125 mg/L or greater — fluctuated between 9.7% and 12.2% during the study period and was significantly associated with living near the coast.

The overall prevalence of isolates showing both resistance to azithromycin and decreased susceptibility to ceftriaxone was 2.3% (95% CI 1.9% to 2.8%) and increased from 1.9% in 2013 to 3.3% in 2016, according to the study.

“It is important that clinicians be on high alert to recognize gonorrhea treatment failures so that they can be reported promptly to public health officials,” the researchers concluded. “The high and increasing prevalence of [isolates showing both resistance to azithromycin and decreased susceptibility to ceftriaxone] found in the current study suggests the need for further consideration and validation of an appropriate regimen for treatment of gonorrhea in China. – by Gerard Gallagher

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Amesh Adalja

    Amesh A. Adalja

    The march of antimicrobial-resistant bacteria has continued virtually unabated since the dawn of the antibiotic age. The rise of multidrug-resistant gonorrhea is one of the most urgent antimicrobial threats the human race faces. The fact that rates of dual resistance to ceftriaxone and azithromycin have increased in China is very alarming. Such a finding underscores the absolute need to develop new antimicrobial agents, including those that move beyond traditional antibiotics, including bacteriophages and monoclonal antibodies. 

    • Amesh A. Adalja, MD
    • Senior scholar
      Johns Hopkins Center for Health Security

    Disclosures: Adalja reports no relevant financial disclosures.