As gonorrhea rates continue to climb in Canada, health officials are warning the infection is also becoming more resistant to antibiotics, which could lead to the possibility of the sexually transmitted infection (STI) becoming untreatable.
The World Health Organization (WHO) said in a media release on Monday that several countries, including Canada, are witnessing a growing number of treatment failures for gonorrhea.
Gonorrhea, a common STI, is easily treated with modern drugs, such as ceftriaxone. However, a particular strain of Neisseria gonorrhoeae, the bacteria responsible for causing gonorrhea, has developed a significant level of resistance to ceftriaxone and other antibiotics, like penicillin.
“Gonorrhea rates in Canada and globally have been increasing for many years,” said Dr. Ameeta Singh, an infectious disease specialist at the University of Alberta. “And every antibiotic that has been used to treat gonorrhea, it has developed resistance to rendering the antibiotic ineffective within a few years of starting to use it.”
Antimicrobial resistance in gonorrhea remains an important public health concern in Canada, according to the Public Health Agency of Canada (PHAC).
“Overall rates of gonococcal infection are increasing in Canada and it is more prevalent among adolescents and young adults,” a PHAC spokesperson told Global News in an email Tuesday. “Its’ causative agent, Neisseria gonorrhoeae, has acquired resistance or displayed decreased susceptibility to many antibiotics, leading to the possible emergence of untreatable gonorrhea in Canada.”
Percentage of antimicrobial resistance of Neisseria gonorrhoeae tested in Canada, 2008-20.
PHAC
The symptoms of gonorrhea vary, but many with the infection, especially females, may have no symptoms at all, according to PHAC.
Symptoms in men may include a burning sensation when urinating, yellowish and/or white discharge from the penis, burning or itching at the opening of the penis and painful or swollen testicles.
For women, the early symptoms of gonorrhea are often mild and non-specific and are often mistaken for a bladder or vaginal infection. Other symptoms include a burning sensation when urinating, vaginal discharge, pain in the lower abdomen, pain during sex and vaginal bleeding between periods or after sex.
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Untreated cases of gonorrhea can have severe consequences and even cause death for both women and men, according to Singh.
In women, the bacterium can spread to other reproductive organs, such as the uterus and fallopian tubes, leading to infertility. Infection can also spread to other body parts, causing issues like swollen joints, liver inflammation and brain damage. Infants born to untreated birthing parents may suffer from eye problems that can result in blindness.
In men, untreated gonorrhea can also lead to infertility and cause inflammations in the testicles, liver, and brain.
Gonorrhea rates in Canada
Gonorrhea is the second most commonly reported STI in Canada, according to PHAC, and rates have almost tripled from 2010 to 2019.
During this period, gonorrhea rates were consistently higher among males compared with females. And in 2019, more than half (51.9 per cent) of reported cases were among people less than 30 years of age.
There are many theories as to why rates are increasing; one is the recent introduction of a more sensitive diagnostic tool for the infection (called the Nucleic Acid Amplification Test), which has significantly increased the number of cases detected.
But the rise of antibiotic-resistant gonorrhea is probably the main reason, Singh warned.
Since 2011, she said two different antibiotics have been mainly used to treat gonorrhea: ceftriaxone and azithromycin.
“The idea was that if we use two antibiotics, which work against gonorrhea, we would in essence reduce the antibiotic pressure caused by using just one of those antibiotics, and hopefully delay the development of resistance.”
As it turns out, she said, that strategy actually worked for a number of years in some parts of the world, including Canada. For instance, in Alberta, using the two antibiotics as a treatment for the STI proved highly effective, and currently, the gonorrhea strain in the province remains vulnerable to this treatment, she said.
However, other regions in Canada, such as Manitoba and Saskatchewan, have not seen the same level of success with this treatment strategy, as some gonorrhea isolates in these areas have developed resistance to these antibiotics.
“There is a geographic difference. So some parts of the country are seeing higher resistance than others,” Singh said.
How gonorrhea builds resistance
Neisseria gonorrhoeae is a multi-drug-resistant organism, the WHO said, as it has proven resistant to many main and last-resort treatment options.
The bacterium responsible for gonorrhea is Neisseria gonorrhoeae, and like all living organisms, it can undergo genetic mutations.
When antibiotics are used to treat an infection, they work by targeting and killing the bacteria. However, some bacteria may have genetic mutations that make them less susceptible to the effects of the antibiotic, such as in the case of gonorrhea.
When a person with gonorrhea is treated with antibiotics, the drug may kill off most of the bacteria causing the infection, but some of the resistant bacteria may survive. These surviving resistant bacteria then have a chance to multiply and pass on their resistance genes and over time become more prevalent in the population, Singh explained.
“The bacteria is quite clever. It’ll just adapt and change and it will continue to grow despite that antibiotic that was once effective to treat it,” Singh said.
She said the resistance organisms for gonorrhea globally are arising mainly in Asia.
“That is why the cases of multi-drug-resistant gonorrhea that we’ve seen have been acquired by individuals who either had sexual contact with individuals in Asia or persons who’ve travelled from Asia to Canada,” Singh said.
“Of course, once it enters the population, it can then continue to spread.”
Possible solutions
In 2022, the WHO created a Global Health Sector Strategy on HIV, Hepatitis and STIs (2022–2030), which set targets to reduce the number of new cases of gonorrhea.
The goal is to reduce global rates of the infection among people aged 15 to 49 to 8.23 million per year in 2030 from 82.3 million per year in 2020. This would reduce the number of infections per year by 90 per cent by 2030.
However, Singh believes that may be too ambitious given the challenges of combating the growing threat of drug-resistant strains and the need for comprehensive efforts in education and prevention.
“Unless things change dramatically in terms of our options to offer testing and treatment,” she said. “For example, currently there is no widely available rapid test for gonorrhea. We desperately need that. And a test that will not only identify the presence of the organism but ideally tell us which antibiotics would work and which wouldn’t.”
There also hasn’t been much of an impact on prevention, as cases continue to rise, she said.
But one of the best prevention methods is testing, as many gonorrhea infections are asymptomatic.
“In the case of gonorrhea, most often, it’s a simple urine test for both males and females. And it is also possible in some places to get swabs done from the throat and from the rectum as well, because we are noticing a lot of infections in so-called extra-genital sites. So bottom line, get tested and treated if you may potentially have been exposed.”
The use of vaccines may also be a helpful prevention tool.
“There is some data now suggesting that the vaccines that we use to prevent meningitis, which is also caused by a similar bacteria, may prevent cases of gonorrhea. That’s something that I think we need to look at quite seriously.”
There are currently no licensed vaccines available for gonorrhea, the WHO stated.
However, the organization added there is interest in vaccine development due to “mounting scientific evidence suggesting gonococcal vaccines are biologically feasible.”
— with files from Patrick Cain