The prospect of untreatable gonorrhoeaBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3973 (Published 25 August 2017) Cite this as: BMJ 2017;358:j3973
All rapid responses
Non-antibiotic solutions to manage invasive bacterial infections like untreatable gonorrhoea, Tuberculosis etc
According to Steven M. Opal (1):
We must consider non-antibiotic solutions to manage invasive bacterial infections. Transition from antibiotics to non-traditional treatments poses real clinical challenges that will not be easy to solve. Antibiotics will continue to reliably treat some infections (e.g., group A streptococci and Treponema pallidum) but will likely need adjuvant therapies or will need to be replaced for many bacterial infections in the future. These adjuvant therapies narrated by him are:
1. Hemofiltration devices: filters are in development which can bind and remove an array of blood stream pathogens. Reduction in the bacterial load by hemofilters could theoretically allow the host innate and adaptive immune systems to remove residual pathogens despite pan-resistance to antimicrobial agents.
2. Quorum sensing inhibitors
Many bacteria employ some form of intercellular communication to alert pathogens about their collective bacterial concentration. If high concentrations are detected, pathogens can switch their transcription profiles to an invasive phenotype. An impressive array of natural and synthetic molecules can block quorum sensing and improve outcomes in experimental models of systemic infection.
3. Lytic bacteriophages
The use of bacteriophages (viruses that lyse specific bacteria) as a replacement for antimicrobial agents against MDR pathogens remains an attractive option despite numerous challenges. Phage invade bacteria via attachment to surface receptors on bacteria where they replicate intracellularly and kill the bacterial host by digesting the peptidoglycan cell wall. The major problem is their exquisite specificity. Phage infect only one strain of bacteria, thereby precluding their use as empiric therapy for acute infections.
Immunotherapy to treat infectious diseases is not a new idea, but innovations in the generation of high affinity, human polyclonal or monoclonal antibodies against an array of molecular targets makes this an attractive approach. Active immunizations with adjuvanted, multi-eptitope bacterial vaccines are in development, as are monoclonal and polyclonal antibodies, as passive therapies against bacterial pathogens.
5. Alternative efforts to limit virulence
Liposome-based cyto-toxin inhibitors have been engineered to capture a variety of cell membrane lytic toxins produced by bacteria. These liposomes serve as cell membrane decoys to absorb cyto-toxins and thereby protect human cells from injury.
6. Non-immune tolerance to pathogens: Varuiable genetic expression against a pathogen.
1: Opal SM. Non-antibiotic treatments for bacterial diseases in an era of progressive antibiotic resistance. Crit Care. 2016 Dec 16;20(1):397. doi: 10.1186/s13054-016-1549-1.
Competing interests: No competing interests
Topical treatment (urethral instillations, etc.) were the main therapeutic modality for gonorrhea (Gn) prior to the discovery of antibiotics . It seems to be too early to discard topical therapy of Gn. Antimicrobial resistance (AMR) of N. gonorrhoeae is developing . There are concerns that Gn might become untreatable  by antibiotics, which would bring topical therapy back on the agenda. One of the factors contributing to AMR is probably the addition of antibiotics to milk and other perishable foodstuffs, e.g., water where frozen fish is stored, which is known to occur in Russia [5,6]. It has been noticed in this country since the 1990s that non-sterilized (short-life) milk is going rancid rather than sour. Antibiotics in food might cause gastrointestinal dysbiosis and have other adverse effects , which is outside the scope of this response. Irresponsible use of antibiotics beyond their evidence-based medical applications might generally accelerate the acquisition of AMR in diverse microbial populations. More details .
1. Walker TO. Management of acute gonorrhea in the Male. J Natl Med Assoc 1938; 30(2): 66-7.
2. Lewis DA. Global resistance of Neisseria gonorrhoeae: when theory becomes reality. Curr Opin Infect Dis 2014; 27(1): 62-7.
3. Johnson AP. The prospect of untreatable gonorrhea. BMJ 2017;358:j3973
4 . News Release. Again antibiotics in milk. Federal Service for Veterinary and Phytosanitary Surveillance (Rosselkhoznadzor), Kaluga Branch, 22.01.2016 http://www.rsn.kaluga.ru/news/2763/ (accessed August 25, 2017).
5. Malakhova LP. Products without secrets. Moscow: Eksmo 2012. (in Russian)
6. Onishchenko GG, Sheveleva SA, Khotimchenko SA. Hygienic substantiation of the permissible levels for tetracycline-group antibiotics in food. Gig Sanit 2012; (6): 4-14.
7. Jargin SV. Treatment of gonorrhea in Russia: Recent history. Global Journal of Dermatology & Venereology 2016;4(1):5 https://www.researchgate.net/publication/309856016_Treatment_of_gonorrhe...
Competing interests: No competing interests