From 'special' treatment to no treatment

MEDICAL MATTERS:Gonorrhoea is becoming resistant to antibiotics

AS A medical student I spent some time in residence at Dr Steevens’s Hospital in Dublin. While in res you lived in the hospital and were expected to contribute to the work of a particular surgical or medical team.

While in the emergency department one evening I noticed that a previously quiet corridor was now rather busy. A porter was directing male patients to a consulting room staffed by a registrar. There was a slightly furtive air about the set-up which puzzled me.

Over a cup of tea with the registrar later that night it emerged that I had stumbled upon a “special” clinic.

As David Fitzpatrick notes in his history of the federated Dublin voluntary hospitals, until the early 1980s venereal disease clinics were held regularly in Dr Steevens and Sir Patrick Dun’s hospitals.

“Patients for these clinics attended in the evening, in contrast to all other outpatient services, which were held at normal hours. It was therefore obvious to hospital staff and the public that these clinics were somewhat different or ‘special’ as they became known.”

Thankfully the stigma of “special” clinics has gone; many hospitals have fully developed genitourinary medicine departments which enjoy an equal status with other units.

Despite the discovery of HIV/Aids, many sexually transmitted diseases such as gonorrhoea and syphilis persist.

With more than 32,000 cases, gonorrhoea was the second-most commonly reported sexually transmitted infection (STI) in Europe in 2010. The number of newly diagnosed cases of gonorrhoea in England soared by 25 per cent in 2011. And the bacterium is becoming progressively resistant to antibiotics, including the newer agents.

It has reached a point where, according to the director of the European Centre for Disease Prevention and Control, Marc Sprenger, “gonorrhoea may become an untreatable disease in the near future”.

According to the World Health Organisation, several countries, including Australia, France, Japan, Norway, Britain and Sweden, are already reporting cases of resistance to cephalosporin antibiotics – the last treatment option against gonorrhoea.

Neisseria gonorrhoea, to give it its full name, is transmitted through sexual activity. Symptoms include a penile or vaginal discharge, rectal discharge and pain on urination. It is diagnosed by sending a swab or urine sample to the hospital lab for analysis.

At any time, about 3 per cent of the sexually active population has an STI. Females are five times more likely than males to have gonorrhoea, with the infection most common in 20-29 year olds. Untreated gonococcal infection can cause complications in men, women and newborn babies including:

infection of the urethra, cervix and rectum;

infertility;

a significantly increased risk of HIV infection;

ectopic pregnancy, spontaneous abortion, stillbirths and premature deliveries;

severe eye infections occur in 30-50 per cent of babies born to women with untreated gonorrhoea, which can lead to blindness.

Why is gonorrhoea becoming antibiotic-resistant so quickly? It’s the same old story of overprescribing for humans and an unrestricted access to antimicrobials in farming. Gonorrhoea strains also tend to retain genetic resistance to previous antibiotics even after their use has been discontinued. The extent of this resistance worldwide is not known due to lack of reliable data.

Just like other areas of medicine, prevention is the best approach to STIs. Abstinence is the only sure way of avoidance, while condoms diminish the risk significantly. But there is now a welcome trend towards secondary prevention, in which young people with a number of sexual partners realise the importance of regular check-ups. Early detection and prompt treatment is essential to control STIs such as gonorrhoea.

The two “special” clinics in Dr Steevens and Paddy Dun’s hospitals were amalgamated and moved to St James’s Hospital following the appointment of Dr Fiona Mulcahy as the State’s first genitourinary medicine consultant. The “clap” and its STI bedfellows would not be considered “special” again.