The Last Drug That Can Fight Gonorrhea Is Starting to Falter

In 2020, the CDC declared that physicians should only administer ceftriaxone against gonorrhea because all the other antibiotics historically used against the infection had lost effectiveness. Fortunately, the substantial dose recommended by the CDC still worked for this patient. It also cured the second person, whom the health department says has no connection to the first and was carrying the same strain with the same resistance pattern. But to experts, that reduced susceptibility indicated ceftriaxone could also be on its way out.

“This situation is both a warning and an opportunity,” says Kathleen Roosevelt, director of Massachusetts’ Division of STD Prevention and HIV Surveillance, emphasizing that rates of gonorrhea are at historic highs across the US. To try to curb that trend, her agency pushed out instructions to every frontline health care professional in the state, asking them to extensively interview patients who test positive, encourage those who’ve received treatment to come back to be sure they’re cured—and, crucially, change the way clinics test patients for infection to begin with.

That last request hints at why the emergence of gonorrhea has been so hard to control. The bacterium is very good at amassing mutations that protect it against antibiotics. It churned through sulfa drugs, the first antibacterials, in the 1940s; penicillin and tetracycline, some of the earliest antibiotics, by the 1980s; and fluoroquinolones such as Cipro by the mid-2000s. Until two years ago, successful treatment relied on administering azithromycin, a macrolide introduced in the mid-1980s, alongside ceftriaxone—but in revised CDC guidelines in 2020 the agency removed azithromycin from the regimen because resistance to it had spiked. As early as 2012, academic and CDC researchers warned in the New England Journal of Medicine that “untreatable gonococcal infection” was on the way.

Aside from being good at protecting itself, gonorrhea poses a challenge that other bacterial infections—pneumonia, for instance—do not. Because it can be a stigmatized disease, people may be reluctant to go to their regular physicians, and so public health departments set up freestanding clinics. That imposed the need to deliver a cure in one dose—first pills, then the ceftriaxone shot—in case people didn’t come back. 

Public clinic use isn’t universal, of course. Gay and bisexual men who take PrEP, pre-exposure prophylaxis against HIV, must be tested for STDs periodically to keep their prescriptions, and that is equally likely to happen in private offices or group practices. And the Massachusetts department says it learned of its first case via primary care. But public funding for sexual health has been repeatedly cut—by 40 percent since 2003, according to the National Academies of Sciences, Engineering, and Medicine. And primary care practitioners aren’t equally thorough in interrogating their patients’ sex lives. 

“We know that clinicians often aren’t super comfortable talking about sexual health, and patients aren’t either,” says Elizabeth Finley, director of communications at the National Coalition of STD Directors, the professional association for STD chiefs such as Roosevelt. “So recommendations to be tested can get skipped over, or requests aren’t heard.”