Spotlight 23/04/18 | Successful treatment of “world’s worst” antibiotic resistant “super-gonorrhoea”

Late last week, Public Health England (PHE) reported that a UK man infected with the “world’s worst” antibiotic resistant “super-gonorrhoea” has been successfully treated. The case was initially announced by PHE in March, and widely publicized in the mainstream news media. The infection, contracted in southeast Asia, is resistant to both elements of the recommended dual first-line treatment, azithromycin and ceftriaxone. Based on susceptibility testing, the patient received a course of ertapenem (a broad-spectrum carbapenem antibiotic administered intravenously), which successfully cleared the infection. Two subsequent cases with similar resistance profiles have been reported in Australia.

The progressive development and spread of antibiotic resistant Neisseria gonorrhoeae, a sexually transmitted bacterial infection, has been an evolving public health concern for years. Seemingly inexorably, since the introduction of antibiotics, strains of N. gonorrhoeae have been found with resistance to sulfonamides, penicillins, fluoroquinolones, tetracyclines, and azithromycin. Since around 2010, most evidence-based guidelines recommend dual therapy with a 3rd or 4th generation cephalosporin plus azithromycin or doxycycline, although subsequent spread of resistance means that even these relatively well-tolerated regimens are failing. The US CDC’s Gonococcal Isolate Surveillance Project (GISP), now in its fourth decade, is an example of a long-running AMR surveillance effort. The WHO runs GASP (the Gonococcal Antimicrobial Surveillance Programme), and N. gonorrhoeae is a “high priority” pathogen in the WHO’s call for R&D for new antibiotics, and in the WHO GLASS surveillance platform. UK health agencies track gonorrhoeae resistance, with a recent Lancet ID publication detailing sustained transmission of high-level azithromycin resistance in England, and another recent publication focusing on factors associated with multi-drug resistance gonorrhoeae in England and Wales.

Gonorrhoeae would seem to be an ideal candidate for multidisciplinary research on AMR. Understanding and addressing transmission networks and treatment seeking across different contexts requires expertise in social science and human sexual behaviour. Targeted testing strategies in London and South Africa, and a safer sex messaging intervention, are being evaluated by LSHTM researchers. Better diagnostics should improve detection and timely treatment. New drugs are under investigation, including work by LSHTM researchers. A recent Nature Review shows how elucidation of bacterial factors can inform novel interventions. How can these different strands of inquiry be pulled together for public health benefit?

Heidi Hopkins, lead for Clinical and Veterinary Sciences.

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