The inevitable arrival of extensively-drug resistant (XDR) gonorrhoea in Australian cities is the focus of a session on day two of the Australasian Society for Infectious Diseases (ASID) Gram Negative ‘Superbugs’ Meeting on the Gold Coast.
Associate Professor David Whiley of the Queensland Children’s Medical Research Institute (QCMRI), the University of Queensland, will tell delegates that, while no XDR strains have been detected in Australia so far, the general consensus among sexual health experts is that it will only be a matter of time.
“The XDR strains that have been reported so far in places like France and Japan are simply a slight variant of a multi-drug resistant clone that appears to have spread very quickly throughout the world over the last 10 years,” says Dr Whiley. “And we know we have considerable numbers of these multi-drug resistant varieties already in Australia. So it very likely that a super-resistant or XDR strain will arrive sooner or later.”
Rates of gonorrhoea are particularly high among gay men (officially termed men who have sex with men), as with other developed nations. Travellers (of any sexuality) that visit Asia are also at a much higher risk of contracting drug resistant strains and then transmitting these on returning to Australia before they are diagnosed and treated.
“Another unique issue we face in Australia is that rates are disproportionally higher in our Aboriginal and Torres Strait Islander communities: approximately 30 times greater than non-indigenous people.”
Dr Whiley will also raise his concerns about how clinical laboratories have largely moved away from using culture-based methods to diagnose gonorrhoea, since this undermines doctors’ ability to detect gonococcal antimicrobial resistance through existing technology. The reasons for this are that the new technology, while not great for detecting resistance, is very sensitive for detecting the actual presence of gonorrhoea, does not require invasive samples (thus patients prefer it) and is cheaper and easier for labs to use. “This limits our ability to look for resistance at the laboratory level, and means we must rely on clinicians to identify patients that fail treatment. The problem with this is that it is really too late to contain further spread of a resistant strain by the time treatment failures begin to be identified,” says Dr Whiley.
Since 2011 treatment changes have been implemented overseas and Australia, initially in Melbourne and Sydney but now being rolled out elsewhere, whereby dual therapy (combined oral azithromycin/ ceftriaxone injection) is being used.
Without concerted action, it is likely Australia will soon face a scenario of a high proportion of more difficult-to-treat cases, with the expense and social implications that brings. “We have some antibiotics that are looking promising but only limited data to support their use,” says Dr Whiley. “The biggest problem is that these are almost all injectable antibiotics, which is not ideal in remote resource-poor settings (oral treatments are best). And of course most patients in any setting would prefer oral drugs to injections.”
He concludes: “The best way to deal with resistance is to do our best to eliminate the disease before resistance becomes a problem. Currently we are not doing a very good job at this, with gonorrhoea rates increasing about 10 to 20% each year over the last three years in Australia and elsewhere. We need to get serious about reducing infection rates now, particularly in our remote aboriginal communities. For example, we need to look more seriously at improving STI services in vulnerable communities in Australia, and ensure that people at risk of gonorrhoea have the same level of access to medical care irrespective of where they are. Because gonorrhoea disease rates will further skyrocket if resistant strains get into those populations.”
In terms of surveillance, Dr Whiley says the Commonwealth Government is continuing to fund the Australian Gonococcal Surveillance Programme, which is highly regarded globally. In addition, his own lab has been funded by the National Health and Medical Research Council to look at molecular surveillance methods.
But along with ASID leaders and other experts in this field*, Dr Whiley supports the call for Australia to have its own equivalent of USA’s Centers for Disease Control and Prevention (CDC)*. At the moment, it remains up to the Communicable Disease Network of Australia (CDNA)** to cobble together responses to emerging issues with their limited time and resources.
“With the CDNA members also being pushed by increasing demands from their own State/Territory jurisdictions, they just can’t keep up with all that is required for timely responses and coordination for all the ongoing and emerging communicable diseases issues,” says Professor David Looke, President of ASID.
“ASID is giving its full support to calls being made for an Australian CDC, since this would have centrally based professional staff to drive essential surveillance efforts in collaboration with the current jurisdictional expertise that runs CDNA,” concludes Dr Looke.
The Communicable Diseases Network Australia