Combating the Threat of Antibiotic-Resistant Gonorrhea
Antibiotic-Resistant Gonorrhea: A Public Health Threat
- Gonorrhea is the second most commonly reported notifiable disease in the United States.
- There are nearly 400,000 reported cases of gonorrhea per year, yet CDC estimates 820,000 new infections may actually occur each year.
- Thirty percent of new gonorrhea infections each year are resistant to at least one drug.
- In 2006, CDC had five recommended treatment options for gonorrhea—now the U.S. has only one option remaining.
The National Strategy: A Roadmap for Combating Antibiotic Resistance
In 2013 CDC released Antibiotic Resistance Threats in the United States, the first report to look at the burden and threats posed by antibiotic resistance on human health. This report named antibiotic-resistant gonorrhea among the three most urgent threats of its kind in the country. One year later the President released an Executive OrderExternal and the White House developed the National Strategy to “Combat Antibiotic-Resistant Bacteria” (CARB), both of which call for the prevention, detection, and control of antibiotic resistance.
In March 2015, the White House released the five-year National Action PlanCdc-pdfExternal for CARB, which outlines steps for implementing the National Strategy. Through federal funding for CARB in fiscal year 2016, CDC’s Division of STD Prevention (DSTDP) is supporting a number of new and continuing activitiesCdc-pdf that aim to slow the development of antibiotic-resistant gonorrhea and prevent its spread. Gonorrhea control in the U.S. relies on our ability to detect and treat each case of gonorrhea quickly and effectively with the right antibiotic; because of this, DSTDP is taking a multipronged, capacity-building approach to tackle the problem.
Determining the Best Way to Treat Gonorrhea
In large part, DSTDP makes decisions about national treatment recommendations using data from the Gonococcal Isolate Surveillance Project (GISP). Gonorrhea specimens from men with symptoms of urethritis in 26 STD clinics in selected U.S. cities are collected each month for culture and sent to their local laboratory for isolation of the bacteria. Participating regional laboratories then test these isolates for resistance to the different antibiotics that are, or were, used to treat gonorrhea. All clinical, epidemiologic, and laboratory results are then sent to CDC and used to determine the most effective treatment to recommend for gonorrhea, based on nationwide susceptibility and resistance patterns and trends.
Ensuring Individuals Receive Recommended Treatment
To make sure individuals with gonorrhea are receiving CDC’s recommended treatment, DSTDP monitors a representative sample of reported gonorrhea cases from the STD Surveillance Network (SSuN). SSuN is a sentinel network of 10 geographically diverse state and local health department STD prevention programs. Directly-funded STD programs also receive support to monitor gonorrhea treatment practices in their jurisdiction.
Improving Laboratory Work Central to the Threat Response
CARB is funding the Antimicrobial Regional Laboratory Network (ARLN)—a network of regional public health laboratories that provide cutting-edge antimicrobial resistance laboratory support and are able to respond to a number of emerging threats. Since gonorrhea is an important part of CARB activities, four labs in the ARLN will be funded to build robust capacity for culture-based antimicrobial susceptibility testing and genomic sequencing. These labs will process more than 20,000 isolates per year from GISP and Rapid Detection and Response activities. The public health data generated by the ARLN will help DSTDP better monitor antibiotic resistance in gonorrhea and inform treatment recommendations and prevention interventions. A select number of isolates tested by the ARLN will be archived in CDC’s ARLN Isolate Bank for gonorrhea diagnostic, drug, and vaccine development, as well as other future antibiotic-resistant gonorrhea studies.
Preparing to Rapidly Detect and Respond to Resistant Gonorrhea Strains
CARB is also supporting the multisite activity, Gonorrhea Rapid Detection and Response, which will develop and strengthen local and state health department epidemiological, laboratory, and informatics capacity to more rapidly detect, and quickly and effectively respond to, antibiotic resistance through network analysis of transmission dynamics and novel interventions. The AR Investment Map shows CDC’s key investments to combat antibiotic resistance (AR), including resistant gonorrhea, across the nation.
This will be done in many ways, as illustrated by the following key examples:
(1) Hiring and training state and local public health personnel so they have better tools and systems to respond to emerging threats;
(2) Increasing epidemiological investigations of gonorrhea cases and their sexual and social networks to help local jurisdictions better understand gonorrhea-related transmission dynamics in their area;
(3) Expanding the use of culture beyond male urethritis in STD clinics, so that extragenital specimens and specimens from women with gonorrhea are routinely collected, as well as test-of-cure specimens as needed;
(4) Exploring different ways to expand gonorrhea culture to sexual and social networks, populations, and funded jurisdictions where nucleic acid amplification tests (NAATs) without antimicrobial susceptibility testing markers are the current gonorrhea diagnostic testing method;
(5) Establishing Etest capacity as a rapid way to detect susceptibility and resistance until novel rapid molecular tests are in place; and
(6) Rapidly providing lab results on resistance to providers and public health personnel to quickly identify, treat, and stop the spread of resistant gonorrhea strains.
For 30 years CDC has monitored antibiotic-resistant gonorrhea trends to help ensure that the recommended drug treatment for gonorrhea is working. With White House support, we arm state and local health departments with the tools they need to stay a step ahead of resistant gonorrhea – one of the nation’s most urgent public health threats. We also work together with health departments to enhance their capacity to monitor and test for resistant gonorrhea and develop rapid response strategies if resistance is detected. See below for a brief overview of current activities.
Established in 1986, the Gonococcal Isolate Surveillance Project (GISP) monitors U.S. antibiotic resistance trends in gonorrhea. Through the collaborative effort of selected STD clinics and their local laboratories, regional laboratories, and CDC, GISP’s collected data helps ensure patients with gonorrhea receive the right antibiotic treatment. GISP monitors antimicrobial susceptibility of approximately 5,000 male gonococcal urethritis cases seen in 27 STD clinics.
The enhanced Gonococcal Isolate Surveillance Project (eGISP) strengthens surveillance of resistant gonorrhea and increases state and local capacity to detect and monitor it. In select STD clinics, eGISP not only collects samples from men with gonococcal urethritis but also from women and from extragenital sites. These specimens are sent to regional laboratories for susceptibility testing.
The STD Surveillance Network (SSuN) is a collaborative network of state, county and/or city health departments funded by CDC to conduct sentinel and enhanced STD surveillance activities. The purpose of SSuN is to improve the capacity of national, state and local STD programs to detect, monitor, and respond to trends in STDs through enhanced collection, reporting, analysis, visualization, and interpretation of disease information.
Strengthening the United States Response to Resistant Gonorrhea (SURRG) began in 2016 with three goals: 1) enhance domestic gonorrhea surveillance and infrastructure; 2) build capacity for rapid detection and response to resistant gonorrhea through increased culturing and local antibiotic susceptibility testing; and 3) rapid field investigation to stop the spread of resistant infections. The project also aims to gain a better understanding of the epidemiological factors contributing to resistant gonorrhea. Nine jurisdictions collect and analyze data, helping guide national recommendations for the public health response to resistant gonorrhea.
The Antimicrobial Regional Laboratory Network is a network of regional public health laboratories equipped to respond to emerging health threats and provide cutting-edge antimicrobial resistance laboratory support. Since gonorrhea is an important part of these activities, four labs in the ARLN will receive funding to build capacity for culture-based antimicrobial susceptibility testing and genomic sequencing.