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What to do when my STD is drug-resistant?

This is a rather peculiar case of a young man coming to me for semen discharge while urinating. This is not a simple case because it is not a typical case. This patient initially went to a clinic for yellow pus discharge from the tip of the urethra after unprotected sex with a sex worker. He was given oral antibiotics of 5 days and the pus reduced during the entire course of antibiotics. After completion of the antibiotics about 2 to 3 days later the pus recurred again but the pus has changed to become green. He went to the same clinic and the doctor gave him another course of oral antibiotics claiming that it is stronger antibiotics which he took for about 7 days but the pus keeps oozing with some blood.

Since there was no improvement, he decided to google up STD clinics in Johor and found me. By the time he came to see me his underwear was stuffed with tissue to prevent the pus from leaking through his pants. It was rather sad because he has been stuffing his underwear with tissue for the past 1week and totally embarrassed. I took his pus sample and tested him for Gonorrhea and Chlamydia. In a matter of minutes, his test was positive for Gonorrhea and I started treatment with intramuscular Injection of Rocephine and oral Azithromycin.

After the treatment, I advised him to retest him for Gonorrhea to ensure that his Gonorrhea has been totally eradicated. A week later he called me again as his pus discharge did improve but there was still a residue of minimal pus discharge. I decided to give him a double dose of Rocephine and Azithromycin when he came back but the symptoms did not improve significantly. In this situation, I realized that he may have multidrug-resistant gonorrhoea.

As a doctor, I need to prime the patient to help him through this situation as it can be scary if he thinks he has some untreatable STD. Sitting with him I spoke to him about multidrug-resistant Gonorrhea. Multidrug-resistant Gonorrhea mainly means in layman term “SUPERBUG”, when most antibiotics are rendered incapable to kill the bacteria. Gonorrhoea previously had a history as an easy to treat bacteria until the CDC (Control of Disease Center) noted that there were newer cases of Gonorrhea which did not respond to common antibiotics. This chart shows the progression of Gonorrhea becoming drug-resistant.

We started in 1980 where common penicillin and tetracycline were able to treat gonorrhoea. In a matter of 10 years, a new resistant form of gonorrhoea emerged in 1990, therefore requiring fluoroquinolones. Then 10 years later a new resistant form emerges in 2000 which, requires either cefixime or ceftriaxone. Again in 2007 changes to the antibiotic regime to combine two antibiotics together was used to treat Gonorrhea. The combination of Ceftriaxone and Azithromycin were recommended in 2007 and we did not see many forms of drug-resistant gonorrhoea until 2018. In 2018 gonorrhoea became resistance in two cases in the UK and in South East Asia. The bacteria were resistant to so many types of antibiotics that a newer class of antibiotics Ertapenam was used. This antibiotic is not freely available in most countries therefore doctors face a dilemma in treating gonorrhoea. People think gonorrhoea is about just treating with antibiotics but it is more complicated than that.

This is a predicament which is growing. In testing for multidrug-resistant gonorrhoea, it is difficult to find a lab which can culture gonorrhoea and test the bacteria against specific antibiotics. Gonorrhoea can only grow in Charcoal Medium and it is difficult to find a laboratory providing Charcoal Medium. I retested the patient with a Charcoal Swab and in 5 days the results showed resistant to Ceftriaxone, Ciprofloxacin, Penicillin, Tetracycline and Bactrim, except Fosfomycin. I started him on Fosfomycin and in 2 days the pus totally cleared and 1 week later his Gonorrhea swab was negative.

A physician needs to consider drug-resistant STD during treatment and among other things will be to trace the primary source of the person who carries resistant gonorrhoea, this is called CONTACT TRACING. I was looking through his sexual history and looking at his previous partners in the past 1 month. I phoned them and some refused to get tested whereas some were worried and came to get tested. Some of his contact partners turned out to have rather other sexually transmitted bacterias and HPV virus (Human Papillomavirus). Finally, I found the source of drug-resistant gonorrhoea and got him treated also.

Both patients were very happy that it was able to be treated despite the course of treatment was long but a satisfactory outcome was achieved. We still had another hurdle which to test him for HIV and other blood-borne sexually transmitted diseases at the appropriate time. He was confirmed free of HIV and I started him on PrEP (Pre-Exposure Prophylaxis against HIV) due to his high-risk behaviour to prevent HIV if he engages in any high-risk sexual activities again.

Read more about HPV (Human Papillomavirus): HPV information

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