Imagine this: you go to your sexual health clinic and find out that you have a sexually transmitted infection (STI). You're then told by the doctor that your infection is incurable, untreatable and that you have a high risk of passing it to your future sexual partners.
Terrence Higgins Trust and British Association for Sexual Health and HIV (BASHH) have recently released a report shedding light on STIs in England, including the threat of antimicrobial resistance (AMR). Sexually Transmitted Infections in England: The State of the Nation highlights how AMR is a real ‘here and now’ issue in the field of sexual health. So what can we do to prevent the above scenario becoming an everyday reality?
Firstly, people should have timely access to STI testing, including Mgen and Trichomonas when indicated. The samples that test positive for GC should go on to have further tests to ‘grow’ the bacterium (GC culture) and subsequently check the bacteria’s sensitivity to antibiotics, thus ensuring the individual has had the correct treatment, in line with BASHH guidelines.
Worryingly, we continue to receive reports of services that are unable to get timely access to GC culture. This is a serious problem as the delay ‘kills’ the bacteria, preventing it from growing and leading to an inability to perform antimicrobial sensitivities. This may lead to individuals not getting the correct treatment.
Because of this, there's a possibility that we lose sight of the antimicrobial resistance and patients may harbour inadequately treated GC, leading to a risk of onward transmission of a resistant strain, or remaining symptomatic.
Another strategy is to ensure all individuals with GC have a repeat test after treatment to ensure the bacteria has been cleared – commonly called ‘test of cure’. However, in some areas in England the ‘test of cure’ is not commissioned, so services do not received remuneration for the service and may as a consequence miss a valuable opportunity to detect AMR.
A third area that has a significant impact on ensuring AMR does not become widespread is the timely management of the sexual contacts of individuals diagnosed with an STI.
Partner notification is a subtle skill that trained sexual health advisors use to enable the delicate process of enabling an individual to ensure the ‘chain of infection’ is broken. However, over the past decade there has been a disinvestment in health advisors, compromising this process. This has been short-sighted considering their unique and crucial skill. Re-investment is a must.
So what about the prospect of ‘new’ antibiotics that bacteria haven’t developed resistance to? Well, there is a step before this: correct prescribing in line with guidelines of treatment for both GC and MGen. This needs to be addressed through widespread training, which is also needed to avoid indiscriminate ‘epidemiological’ treatment and non-prudent prescribing in non-sexual health settings.
While there are potential new antimicrobials in the pipeline, at present those which are able to treat ‘super gonorrhoea’ (i.e. the highly resistant strains that you may have seen making headlines) are more expensive to treat and also require a hospital admission, resulting in extra costs and more pressure to the system.
Finally, we need a robust surveillance system in place to help us monitor the changing patterns of AMR and provide timely alerts to inform clinical behaviour and the guidelines that underpin this.
The UK has been fortunate in having the Public Health England Gonococcal Resistance to Antimicrobial Surveillance Programme (GRASP) in place for the past 20 years, and the State of the Nation report makes it clear that we must work to maintain and widen this in the coming years to help us meet the challenges ahead of us.
Anyone concerned about their sexual health and require more information about STIs and how to get tested can visit BASHH online or attend their local sexual health clinic.