Antibiotic – Resistant N. gonorrhoeae; do we need a new drug?

Gonorrhoea is caused by Neisseria gonorrhoeae, a gram-negative diplococcal bacterium. It is the second most reported communicable disease according to Centre for Disease Control, CDC. Urethral infections caused by N. gonorrhoeae among men can produce symptoms that cause them to seek curative treatment soon enough to prevent sequelae but often not too soon enough to prevent transmission to others. Among women, gonococcal infections might not produce recognizable symptoms until certain complications have occurred.

In 2008, the World Health Organization (WHO) estimated that there were 106 million new cases of gonorrhea among adults globally. The disease affects both men and women, especially sexually active adolescents and younger adults. Prevalence is highest in communities of lower socioeconomic status.

A random group of 45 people were administered questionnaires to access their knowledge of the infection. Out of the 45 responses, majority attested to the fact that the infection is a sexually transmitted disease hence one can get it from sexual intercourse with an infected person and that both male and females can be infected. Few of the participants think only males can be infected with the disease. However, a few also indicated that the disease can be transmitted through oral sex. All the participants agreed that the infection is acquired through unprotected sex.
Majority indicated to seek orthodox treatment as their first line of resort when diagnosed of gonorrhoea. However, a few of them also preferred homeopathy treatment approach and majority of the participants did not know the duration of the treatment.

Stigmatization was ruled out by the participants. Most indicated that gonorrhoea is not a disease of bad people thus about 92% indicated and accepted to socialize with infected person since they know it’s not contagious.
Although, majority (about 91.3%) thought gonorrhoea is the disease of the prostitute, majority also indicated that, infected person can still associate with uninfected persons.
The WHO news release “Antibiotic-resistant gonorrhoea on the rise; need for new drugs” stated a global resistance to antibiotic treatment against the bacterium. However, the research
which triggered the news release was specific and explained that the surveillance data was largely from the European region and only very few from Africa region. This could actually mean that there is no or little resistance in most Africa countries.

Is the antibiotic resistance really global or it just concerned a particular geographical location? Are African countries involved and for that matter have reported the resistance?
“I was first given amoxiclav but my condition did not go because I failed to complete my dose after I felt some sense of recovery, so I had to go for a second drug (Doxycycline)” says one of the patients interviewed.
Inappropriate use of antibiotics has led society to antibiotic resistance. Certain factors have been found to contribute immensely to antibiotic resistance. These include not adhering to antibiotic regime as well as purchasing antibiotics from pharmacies without prescription, or using leftover antibiotics from previous course of treatment. It is estimated that more than 50% of antibiotics worldwide are purchased without a prescription from pharmacies. Over the counter purchase of antibiotics is becoming a common picture seen across our country where antibiotics are dispensed as a single dose therapy but thankfully some pharmacies insist on prescription forms before dispensing antibiotics. In Ghana, antibiotics often with high resistance potential include: Ampicillin, Carbenicillin, Gentamicin, Tetracycline, Ciprofloxacin, Imipenem, and Ceftazidime. However antigonoccocal drugs such as the extended-spectrum cephalosporins (ESCs) oral cefixime or injectable ceftriaxone have not yet been listed.
In Ghana, experts’ opinion states that, they have had no issue with antibiotic resistance in the treatment of gonorrhoea infection and hence occasionally uses a combine dose.

“Although there may be resistance to antibiotics in general, I have not noticed that in my entire practice of 10 years and so far, the antibiotics given to patients have proven effective” explained an expert from the department of Gynaecology at the Korle-Bu Teaching Hospital.
“There are some few cases of resistance but in all, it’s not really a problem “added Dr.Nguni Ukeria from Cameroon.

Gonorrhea treatment is usually complicated by the ability of N. gonorrhoea to develop resistance to antimicrobials. The epidemiology of antimicrobial resistance guides decisions about gonococcal treatment recommendations and has evolved because of shifts in antimicrobial resistance patterns.
In cases of increasing gonococcal resistance, CDC’s 2010 STD treatment guidelines recommends the dual therapy for gonorrhea with a cephalosporin plus either Azithromycin or Doxycycline.
In America where there is increased resistance to Cefixime, the CDC recommends Ceftriaxone to be used in combination with one or two oral antibiotics either Azithromycin or doxycycline. Ceftriaxone has been proven to be more potent against gonorrhoea than Cefixime and when paired with the additional oral antibiotic, might slow the emergence of drug resistance by ensuring that the gonococcal infections are quickly cured and not allowed to spread. However, combined doses are hardly used in Ghana due to very little resistance
The PLOS medicine research paper which guided the WHO news release indicated that ‘’future treatment recommendations for N. gonorrhoeae should carefully balance prevention of N. gonorrhoeae infection and avoidance of the spread of resistance’’. To do this, we should focus on prevention mechanism such as education on sexual behaviour among sexually active individuals.

Abstinence is the surest way to avoid transmission of gonorrhea i.e. to abstain from sexual intercourse, or to be in long term, mutual monogamous relationship with a partner who has been tested and is known to be uninfected.
Use of Condoms is another way of curbing the gonorrhea menace. Condoms when used consistently and correctly can reduce the risk of transmission of gonorrhoea. Free condoms can be distributed on regular basis among sexually active individuals.

Regular screening of those at greatest risk is critical and hence sexually active gay, bisexual men and high risk sexually active women should be tested for gonorrhea at least once a year.