Not Your Garden-Variety Gonorrhea
Throughout my years in pharmacy school and now starting my career, I’ve had many friends — gay, bi, and straight — ask random questions about sexually transmitted diseases. Invariably, I get asked whether such-and-such infection can just be treated with antibiotics. I usually give a brief (and sometimes sassy) reply: “For now.”
Gay and bisexual men — or “men who have sex with men” (MSM) — are at increased risk of STDs compared to our straight friends. Scientists think this is due to a complicated jumble of psychological and sociological factors ranging from decreased healthcare access and stigma to increased drug abuse and anonymous sex. As a result, the rates of syphilis, chlamydia, and other infections are skyrocketing in our community, which isn’t the best PR. We are now facing issues with these old-timers of the STD world despite our revolutionary advances in HIV care with PrEP. Specifically, these once-antiquated bugs are becoming resistant to many important antibiotics I carry in the pharmacy, and the worst offender is gonorrhea.
Gonorrhea has been around for ages (probably even before loincloths were in vogue), causing symptoms like unsightly penile or vaginal discharge and pain with urination. It’s primarily spread from semen, vaginal fluids, and other bodily secretions. It’s pretty gross, but it’s also pretty common with about 300K new infections reported in 2013. From 1990 to 2012, the number of MSM testing positive for gonorrhea at STD clinics increased from 4.6 percent to 33.1 percent Realistically, this is an underestimate since gonorrheal infections in the throat and rectum are usually asymptomatic and go unnoticed. Even worse, untreated gonorrhea can spread and infect your joints, causing debilitating arthritis.
I must give a round of applause to “the clap” because it’s a bacterium with a Napoleon complex. It’s less than a billionth our size, it plays rough, and it’s outsmarting us. Being a sly devil, gonorrhea can actually develop ways to evade our drugs as we use more and more antibiotics out in the world. We have encountered these same issues with other bacteria, such as MRSA, where typical antibiotics can’t do the job anymore. The Centers for Disease Control and Prevention has gone so far as to classify resistant gonorrhea as one of the top three bacterial dangers to the nation in a 2013 threat report. The problem is so important that they even have a special task force to solely track gonorrhea resistance — talk about a unique career.
Our community is at higher risk for resistant gonorrhea, and the stats aren’t pretty. In our region, MSM with gonorrhea are more than twice as likely to have a multidrug-resistant version compared to straight men with gonorrhea. We clinicians have needed to completely rethink how we treat gonorrhea as a result. “The CDC stopped recommending fluoroquinolones as a viable treatment option in 2007 when fluoroquinolone resistance was on the rise,” says Kati Shihadeh, PharmD, who is an infectious disease pharmacist in Denver.
However, the problem doesn’t stop there. “Resistance to cephalosporins,” Dr. Shihadeh says, “was on the rise to the point where in 2010, the CDC increased the recommended dose of ceftriaxone. The treatment guidelines were revised again in 2012 to no longer recommend cefixime as a first line option.” To make it even more complicated, we now must treat patients with ceftriaxone and azithromycin, in case one of the drugs isn’t strong enough. If this resistance increases, we are going to have fewer ways to combat gonorrhea, giving it the chance to spread even faster. We may even need to resort to stronger antibiotics with more side effects. For example, gentamicin is a potent drug that can cause kidney and hearing problems, and it is now recommended for treating gonorrhea if you’re allergic to ceftriaxone.
Our community is at higher risk for resistant gonorrhea, and the stats aren’t pretty. In our region, MSM with gonorrhea are more than twice as likely to have a multidrug-resistant version compared to straight men with gonorrhea.
All this information begs an important question: Why are we at higher risk for resistance? Studies have suggested that MSM have more antibiotic exposure than straight folks, possibly due to having more rounds of antibiotic treatment for repeated STDs. This exposure gives gonorrhea the chance to interact with antibiotics and figure out ways to thwart them. Another reason may be our collective interests in travel — after all, we have our own cruises. With our wanderlust, we tend to travel more than straight men, making it easier to pick up resistant strains that are becoming more common abroad.
What can we do to stop this resistance from spreading? As a young gay man and a pharmacist, I always advocate the use of condoms as one of the best ways to prevent the spread of infections. It is also good to get to know your partner and discuss the topic of safe sex before getting serious in the bedroom. I’ve been hearing from more and more friends that they find this message to be repetitive and therefore less meaningful. They feel the “penny of prevention is worth a dollar of cure” motto is becoming stale. However, after seeing these infections in clinical practice and witnessing their toll on people’s health, self-esteem, and pocketbooks, I still stand by the awesome power of this relatively inexpensive (and sometimes flavored) piece of latex.
I also make a point to practice what I preach. I get tested regularly, and Denver has a bounty of clinics that offer free or low-cost testing services. I also make a point to bring up the topic of safe sex early on when I meet a potential suitor. Yes, it can be an awkward conversation, but the fellas who understood ended up being particularly special guys to me. We have the tools, and I believe we can slow the spread of resistant gonorrhea and its sexually-transmitted relatives, but it will mean all of us making a conscious effort to protect ourselves and those around us.
