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Is Kissing Spreading Gonorrhea? - Psychology Today

I got one of the more unusual and interesting messages earlier this year: Can you help a friend out with a gonorrhea outbreak in her home? There was no way I was going to say no to that.

After learning more, I became concerned that gonorrhea may be spreading more widely in people's throats than we realize, that kissing may be one culprit, and that sexually active adults should be getting tested in their throats more often.

An Outbreak of Gonorrhea at a Party

When I contacted this person, I learned that she and her husband live in a major metropolitan area in the Midwest, where they frequently host sex parties. At one party, 10 men and 10 women attended. Women had sex with both men and women, and men only with women. Condoms were used for toys and vaginal and anal sex, but not oral sex.

Here's where things got even more interesting. The hosts asked everyone to get tested for sexually transmitted infections (STI) within five days after the party, and, more importantly, to make sure people got more than just their genitals tested. They wanted to also see if people had STIs in their throat and anus as well.

After the party, five of the men tested positive for gonorrhea in both their throat and urine, as did five of the women. None of them had symptoms.

How is Gonorrhea Testing Performed?

It helps to have some background about STI testing before we go further. When getting tested for gonorrhea and chlamydia, the standard approach is to test a patient's urine. It's less invasive and equally as reliable for as swabbing the genitals.

But these two bacteria can also infect the anus and the throat, the other locations where people interact sexually. To test these locations, doctors ask you to run a swab around the back of your throat or just inside your anus. Studies and real-world experience, including in my clinic, show it is safe and accurate for people to collect these specimens themselves.

As of now, CDC and most experts only recommend this more extensive testing—referred to as "three-site testing" for genitals, anus, and throat—in people who have symptoms or in asymptomatic men who have sex with men (MSM) and transwomen who have sex with men. This is because rates of gonorrhea and chlamydia infections in the throat and anus are high among MSM and transwomen, and it's assumed that women and straight men do not practice oral and anal sex as frequently as other groups.

How Does Gonorrhea Spread to the Throat?

So let's get back to the party. How did 50% of men get infected if they only had sex with women and used condoms when they had penis-in-vagina sex with a woman? And how did women get infected if they used condoms for vaginal sex?

The most likely explanation is that they got infected with their mouths. This matters because I suspect oral transmission is more common than we realize, and there is a lot about these infections we do not understand.

Gonorrhea can infect the throat, but people do not always have sore throat, fever, or other symptoms. Almost all studies done on gonorrhea in the throat have focused on MSM, not on straight men and women. The estimate is that up to 17% of MSM have throat gonorrhea infections at any given time.

One study done in straight men and women with gonorrhea infection in their genitals found that 39% of them also had it in their throats.

Why Worry About Gonorrhea Infections in the Throat?

One of the challenges about gonorrhea is that you can be infected but not have any obvious symptoms of infection.

If you never get tested and just have gonorrhea hanging out in your throat, is it a danger to you? We know these infections remain in people's throats, even without symptoms, for four months or longer. And we know that asymptomatic infections in the genitals can lead to infertility and more severe infections. But we do not know if gonorrhea infection in the throat always harms the person carrying it.

If you never get tested and just have the infection hanging out there, is it a danger to others? Almost certainly, because there is a risk of transmitting it to other people, as we saw in this party. Unfortunately, we do not know exactly which sex acts led to infections at the party. Was it throat-to-throat, throat-to-penis, penis-to-throat, throat-to-vulva, or vulva-to-throat?

Does Kissing Spread Gonorrhea?

We assume most gonorrhea spread is from throat-to-penis, throat-to-anus, and vice versa. But it could also be throat-to-throat – that is, through kissing. Studies among MSM in Australia have found that kissing is one of the strongest risk factors for gonorrhea infection of the throat.

I suspect kissing may have transmitted gonorrhea at this party and is happening more frequently among all sexually active adults. There are likely far more undiagnosed and untreated gonorrhea throat infections than we realize, because most straight men and women aren't being tested in their throats. Kissing may be one way in which it spreads from throat-to-throat in a community, eventually causing genital infections through oral sex.

Why Not Recommend That Everyone Test Throats for Gonorrhea?

For an individual, three site testing may be the right decision, especially if you engage in oral sex with new or multiple partners, participate in group sex, have sex with partners who also have other partners, or are part of a community where STI rates are known to be high.

For the entire population, public health officials must weigh: how commonly does this occur, how beneficial is early detection and treatment, how much does it cost compared to not doing this and just treating people when they have symptoms, and is limited funding better used for something else?

Doctors are already advised to screen asymptomatic patients for gonorrhea and chlamydia in the genitals using urine testing. Adding two more sites costs more both in dollars and time. Providers often don't offer it, and patients, especially outside LGBTQ+ communities, don't know to ask for it.

Should You Get Tested in Your Throat?

We need to start looking for gonorrhea in all the places it persists, regardless of sexual identity or behaviors. If you are sexually active, I recommend getting tested in your throat, genitals, and anus regularly. If your provider hesitates, advocate for yourself by showing them this article and the studies on this topic.

New Antibiotic Is Effective Against Gonorrhea, Could Be First New ...

By Jacqueline Howard, CNN

(CNN) — A new type of antibiotic for treatment of urinary tract infections in women could also work against gonorrhea infections, a new study finds. This could put the medication, called gepotidacin, on track to become the first new antibiotic for gonorrhea since the 1990s.

"Gepotidacin is a novel oral antibacterial treatment with the potential to become an alternative option for the treatment of gonococcal infections, supported by an acceptable safety and tolerability profile," the researchers wrote in the study published Monday in The Lancet, adding that the drug "could mark a meaningful advancement in patient care."

As an antibiotic, gepotidacin works by inhibiting bacteria from replicating in the body. In March, it was approved by the US Food and Drug Administration to treat uncomplicated urinary tract infections in women and girls ages 12 and older. Recurrent UTIs have become a bigger problem as the bacteria that cause them have become more resistant to the antibiotics available to treat them.

Now, there is new hope that gepotidacin may help fight drug-resistant gonorrhea.

"The big takeaway is that having additional treatment options for gonorrhea is fantastic," said Dr. Jason Zucker, an infectious disease and sexually transmitted infections expert and assistant professor of medicine at Columbia University Vagelos College of Physicians and Surgeons, who was not involved in the new study.

Effective treatments for gonorrhea have become increasingly limited in recent years due to the global rise of antimicrobial resistance in Neisseria gonorrhoeae, the bacteria that cause gonorrhea, rendering many previously used first-line antibiotics ineffective.

The current standard of care involves an intramuscular injection of the antibiotic ceftriaxone, which requires a visit to a care facility.

A key benefit of gepotidacin is that it would not involve an injection at the doctor's office, which could make treating gonorrhea more convenient for patients, Zucker said.

"Right now, patients come in, especially if they are not having symptoms, if they test positive, we have to ask them to come back. For some people, that's not so easy," he said. "So obviously, the ability to have the pharmacy send treatment to their house, or have them be able to pick it up, would really make things a lot easier for people and reduce the number of doctor visits they have, especially if they have jobs where they don't have a lot of time off."

Gonorrhea can lead to serious health problems if left untreated, and though rare, can even spread to the blood or joints. Among women, untreated gonorrhea can cause an infection of the reproductive organs called pelvic inflammatory disease, which can lead to a greater risk of pregnancy complications and infertility. In men, gonorrhea also can lead to infertility in rare cases.

In the United States, gonorrhea and other sexually transmitted infections or STIs have become more common. Reported cases of three nationally notifiable STIs – chlamydia, gonorrhea and syphilis – were up 90% in the US in 2023 compared with about two decades prior in 2004, according to data released last year by the US Centers for Disease Control and Prevention. More than 2.4 million cases of STIs were reported in 2023 nationally.

A race to treat gonorrhea

The Phase 3 trial, conducted between October 2019 and October 2023, included more than 600 people ages 12 and older who were diagnosed with gonorrhea in the urogenital area across six countries: Australia, Germany, Mexico, Spain, the United Kingdom and the United States.

The study was funded by the pharmaceutical company GSK, which developed the antibiotic, and the development of gepotidacin was funded in part with federal funds from the US Department of Health and Human Services, Administration for Strategic Preparedness and Response, Biomedical Advanced Research and Development Authority, and the Defense Threat Reduction Agency, according to GSK.

About half of the study participants were treated with a gepotidacin regimen of two oral doses administered about 10 to 12 hours apart, at 3,000-milligrams per dose. The other participants were provided with the current standard treatment of administering a single dose of the antibiotic ceftriaxone as an injection paired with orally taking the antibiotic azithromycin.

The trial data, which is being presented at the European Society of Clinical Microbiology and Infectious Diseases conference, showed that gepotidacin was as effective as the current leading combination treatment, and was also effective against treatment-resistant infections, which occur when strains of gonorrhea are resistant to currently used antibiotics.

The gonorrhea infections were cured among 92.6% of the study participants who were administered gepotidacin compared with 91.2% of the study participants who were treated with ceftriaxone plus azithromycin.

Among the 7.4% of participants in the gepotidacin group who were not successfully treated, they all were due to missing data, according to GSK, which added that "in participants with complete data, there was no bacterial persistence at the urogenital body site."

While the study primarily assessed gepotidacin as a treatment for urogenital gonorrhea, some participants with rectal and throat infections were evaluated. Of those with complete data, the study showed that it was more difficult to treat gonorrhea in the throat compared with other body sites, as 14 out of 16 people with throat gonorrhea and complete data – 88% – were successfully treated.

The researchers wrote that the prevalence of throat infections "warrants further investigation" in a larger group of participants, as does studying the efficacy of geptodiacin in the treatment of gonorrhea in the throat.

"Pharyngeal gonorrhea is notoriously harder to treat and plays a key role in silent transmission and resistance development, so having reliable oral options at all anatomical sites is critical," Zucker, said.

The international team of researchers found no life-threatening nor fatal side effects associated with either treatment approach used in the study, but the gepotidacin group had higher rates of side effects compared with the ceftriaxone-plus-azithromycin group, which were mostly gastrointestinal, such as diarrhea and nausea, and almost all were mild or moderate, according to the study.

"One of the challenges is that a lot of oral antibiotics have GI side effects," Zucker said.

The researchers noted that it will be important to investigate the efficacy of gepotidacin for treating gonorrhea in groups not primarily represented in the study especially women and Black and Brown communities, as 92% of participants in the study were men, 74% were White and 71% were men who have sex with men.

If gepotidacin is approved for the treatment of gonorrhea in the United States, "the price will be disclosed when the product will be supplied in a market. Our approach would be for it to reflect the value and outcomes they bring to patients, providers and payers while being sensitive to market and societal expectations," according to a GSK spokesperson.

Bluejepa, the brand name for the version of gepotidacin approved in the United States to treat UTIs, is expected to be available in the second half of 2025.

'A true advance'

The new study was "very well-done" with "rigorous data," and having more options to treat gonorrhea is critical for slowing down the bacteria's drug resistance, said Dr. Jeffrey Klausner, a clinical professor of public health at the University of Southern California's Keck School of Medicine in Los Angeles, who was not involved in the trial.

"The more options doctors have to treat gonorrhea means that they do not have to use the same drug over and over again, which is a recipe for disaster and more resistance. We know that using the same drug over and over again leads to drug resistance," Klausner said in the email. "If gepotidacin is approved and recommended for gonorrhea treatment, that is a true advance and will greatly help our efforts to slow down drug resistance in gonorrhea."

In the study, researchers noted that using gepotidacin to treat gonorrhea as an oral treatment option, not an injection, may be more efficient and reduces the risk of persistent, drug-resistant infections.

Yet there is some concern that strains of gonorrhea may eventually develop resistance to gepotidacin, according to a comment paper accompanying the new study in The Lancet.

"In our opinion, N gonorrhoeae will also develop gepotidacin resistance when the selective pressure increases and where compliance to the dual-dose regimen is suboptimal," Magnus Unemo of Örebro University in Sweden and Teodora Wi of the World Health Organization in Switzerland wrote in the paper.

"Due to the inherent ability of gonococci to develop resistance, difficulties in increasing the gepotidacin dose due to adverse events, and the lack of other treatment options, preclinical and clinical development of additional gonorrhoea treatments remains important," they wrote. "In conclusion, gepotidacin is promising for the treatment of gonorrhoea, but the challenges to retain gonorrhoea as a treatable infection will continue."

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Sex Hormones Help Gonorrhea Fight Off Antimicrobials And Antibiotics

Published February 8, 2024

Notorious infection monitors the environment and waits for its opportunity

You know that package warning that oral birth control won't prevent STIs? Well in the case of gonorrhea, the sexually transmitted bacterium that causes the disease can use those hormones to help it resist antibiotic attacks.

Like many bacteria, this bug, Neisseria gonorrhoeae, is equipped with pumps to push the killing chemicals out of its cells. But what's unique, according to a Duke and Emory study online this week in Nature Communications, is that the hormones of the human urogenital tract actually allow gonorrhea to make and use more of these pumps to fight intrinsic antimicrobials and prescribed antibiotics.

The researchers uncovered the trick while examining a transcription factor – a protein that binds to specific sites on the bacterium's DNA and slows production of the efflux pumps that protect it.

Led by Duke graduate student Grace Hooks and her mentor, Biochemistry chair Richard Brennan, Ph.D., the study used a variety of approaches to characterize the shape and function of the transcription factor.

What they found is that, unfortunately, this transcription factor, called MtrR, has an affinity for binding to the hormonal steroids progesterone, estrogen and testosterone and the synthetic hormone ethinyl estradiol. When it binds to a hormone, the transcription factor becomes less effective at suppressing the production of bacterial pumps.

Hooks said the bacterium appears to be able to sense its hormonal environment and wait for the opportune time in the female's menstrual cycle to ramp up its colonization.

Estrogen rises dramatically in the week before ovulation, and progesterone peaks in the two weeks between ovulation and menstruation. These fluctuations are thought to suppress the immune system, giving sperm and eggs a window of opportunity to survive in the urogenital tract, but that same window also creates a vulnerability to this infection.

"It's kind of utilizing this sensory system to gauge where it is in this cycle and when it can best colonize," Hooks said. "It can only survive in the human host, it can't survive outside. So, it has to really be good at sensing where it is and when's the best time for colonizing."

The transcription factor MtrR also helps signal the bacterium to protect itself against reactive oxygen species. "What this one protein does is a dual system to protect Neisseria gonorrhea," Brennan said.

Gonorrhea has been with humans far longer than there have been antibiotics, appearing in texts as ancient as 2600 BC and making famous appearances in Julius Caesar's Roman legions and the Crimean war.

Ancient or not, the Centers for Disease Control considers gonorrhea an urgent public health threat, because it is now resistant to every antibiotic except for one, ceftriaxone. But strains resistant to this antibiotic have been identified recently in Europe and Asia.

Known historically and colloquially as 'the clap,' untreated gonorrhea in women can lead to pelvic inflammatory disease and infertility. It may also be passed from mother to infant during childbirth.

While the infection is more obvious in men, it is less dramatic, as men don't experience the wider hormonal shifts, nor is their urogenital tract as complicated or deep as a woman's, Hooks said. But men still carry all the same hormones that the transcription factor latches onto, she added.

And, of course, the bacteria must thrive in both men and women to be a successful STI. "Neisseria gonorrhoeae is an obligate human pathogen," Brennan said. "We don't know where it is the rest of the time."

When Hooks presented some of her data in a laboratory meeting, fellow graduate student Emily Cannistraci from the next-door Schumacher laboratory asked if the synthetic hormone ethinyl estradiol, which is found in many oral contraceptives for women, would have a similar effect. Hooks checked, and it certainly did.

The takeaway is not only the package warning that oral birth control won't prevent STIs, but in this case, it might even make them worse.

This research was supported by the National Institutes of Health (R35GM130290, R05 AI048593, R01 AI021150), the US Department of Veterans Affairs and the U.S. Department of Energy.

CITATION: "Hormonal Steroids Induce Multidrug Resistance and Stress Response Genes in Neisseria gonorrhoeae by Binding to MtrR," Grace M. Hooks, Julio C. Ayala, Concerta L. Holley, Vijaya Dhulipala, Grace A. Beggs, John R. Perfect, Maria A. Schumacher, William M. Shafer, Richard G. Brennan. Nature Communications, Online Feb. 7, 2024. DOI: 10.1038/s41467-024-45195-1

Online: https://www.Nature.Com/articles/s41467-024-45195-1

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