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For the first time in 13 years, the World Health Organization on Tuesday is outlining new recommendations on how to treat three common sexually transmitted diseases, one of which — gonorrhea — has been rapidly developing resistance to nearly every weapon in the medical arsenal.

The voluminous guidelines are used by member countries to develop their own guidance to doctors for the treatment of gonorrhea, syphilis, and chlamydia.


The guidelines for each spell out the best approach in a variety of scenarios. But the most pressing need, the WHO acknowledged, was to update advice on how to treat gonorrhea. The wily bacteria that cause the disease is increasingly developing resistance to the antibiotics left that can cure it.

There are currently only two that, given in combination, reliably cure gonorrhea. But experts know it’s only a matter of time before the bacteria vanquish ceftriaxone and azithromycin, as well.

US data published this summer raised the alarming specter of a time when gonorrhea infections may be untreatable.


Globally, surveillance of antibiotic resistance to these drugs is spotty, with only 56 countries conducting the type of testing needed to get a full picture of the scale of the problem. Ten countries have already reported some treatment failures with the current drug regime — although increases in the amount of drugs used has helped patients overcome the disease. Nearly 30 countries have reported seeing increasing resistance to one or the other of the drugs in the recommended treatment cocktail.

“At least with these few countries that we have, we know that soon we will have developed high-level resistance to ceftriaxone,” said Dr. Teodora Wi, a medical officer with the WHO’s department of reproductive health and research.

The updated recommendations urge countries not to use a class of antibiotics called quinolones for gonorrhea. They no longer work. And the recommendations now favor the use of dual therapy — two drugs — over monotherapy when possible. Using only one drug speeds the development of resistance.

The WHO suggests countries that have antibiotic resistance data tailor the recommendations they make to doctors based on the patterns they are seeing. Countries that don’t have resistance data should use ceftriaxone or a related drug, cefixime, plus azithromycin in combination.

The Centers for Disease Control and Prevention told doctors to stop using cefixime in 2012 because gonorrhea strains in the United States were developing resistance to it.

The last time the WHO published new guidance for all three sexually transmitted diseases was in 2003. Wi attributed the delay to a change in the way the agency compiles treatment recommendations — requiring a thorough review of available scientific literature and expert consultations.

Dr. Vanessa Allen, chief medical microbiologist for Public Health Ontario, who has been tracking gonorrhea resistance for years, said the new guidelines are “well overdue.”

“I don’t think they’re highly revolutionary,” she said, “but it is very helpful that they have updated them.”

There was not much change in the updated guidance for the treatment of chlamydia. But the guidance for syphilis treatment highlighted a vexing problem.

The best treatment for that disease is benzathine penicillin. Unlike gonorrhea, Treponema pallidum, the bacteria that cause syphilis, have not developed resistance to this drug.

But the drug is in short supply globally; at times it is not available. One of the alternatives, doxycycline, can’t be given to pregnant women. And two other antibiotics would treat the mother, but don’t cross the placenta to reach the fetus, leaving it untreated.

Untreated syphilis infection in pregnancy can lead to pregnancy losses. And infants born with with congenital syphilis can have severe health problems, including skeletal abnormalities, deafness, vision loss, developmental delays, and seizures.

Benzathine penicillin is “not being manufactured because it’s too cheap,” Wi said “Drug companies don’t want to manufacture it.”

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