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Pictured above: An illustration of Neisseria gonorrhoeae, the bacteria that cause gonorrhea. From http://www.cdc.gov/std/gonorrhea/

When I say “gonorrhea,” you might think of genitals that feel as though they have been set ablaze, or perhaps a viscous fluid oozing from the urethra. But gonococci, the bacteria that cause gonorrhea, can also set up camp in the pharynx after being transmitted into a mouth and down a throat when its new host gave oral sex to its old host. Indeed, performing oral sex on multiple partners has been found to increase risk for an oral gonorrhea infection (more properly called pharyngeal gonorrhea).

If you read our September 2012 article on gonorrhea of the throat, you might remember these fun facts: Oral gonorrhea goes away within three months, even without treatment! Plus, these infections rarely have symptoms. Why, then, should you care about a gonorrhea infection in your throat? You’re not likely to notice it’s there, and it’ll go away on its own anyway.

Many researchers believe that the throat is an incubator for antibiotic-resistant gonorrhea.

Well, aside from the possibility of transmitting a gonorrhea infection from your throat to someone’s genitals, there’s one other thing to care about: the development of antibiotic resistance.

The emergence of antibiotic-resistant gonorrhea is considered one of the most pressing problems in infectious disease — just two years ago, the Centers for Disease Control and Prevention named it an “urgent threat,” and indeed, gonorrhea seems to be evolving resistance to drugs at quite a rapid clip. If gonorrhea evolves complete resistance to the drugs we use to cure it, we could find ourselves sent back in time, to the days when gonorrhea was untreatable — and responsible for infertility, blindness, and chronic pain. While scientists figure out how to address this emerging threat, you can do your part by avoiding gonorrhea in the first place — and that includes using condoms and dental dams to prevent oral gonorrhea infections.

So, while it sounds like a blessing that gonorrhea of the throat rarely has symptoms, there’s actually a drawback: An oral gonorrhea infection probably won’t be effectively treated — or even identified in the first place. And these hidden throat infections are likely to be helping to drive the development of antibiotic resistance.

Let’s say that someone with gonorrhea infections in both the throat and the genital region visits a clinic, where he is promptly diagnosed with a genital gonorrhea infection, but is not tested for an oral infection. The antibiotics he takes will be effective in the genital region, but are not as likely to eradicate the gonococci colonizing his throat. Oral gonorrhea is more difficult to cure than genital gonorrhea, because cephalosporins, the antibiotics we currently use to treat it, aren’t able to concentrate in the throat tissues at dosages high enough to reliably kill gonococci. While these insufficient doses might not be strong enough to clear a throat infection, exposure to them will help the bacteria adapt to drug-drenched environments, allowing them to evolve right under our noses — literally!

If the gonorrhea-afflicted individual doesn’t visit a clinic at all — either due to fear, lack of access, or lack of symptoms — he or she won’t receive any treatment whatsoever. In this case, the gonococci have up to three months to chill out in the throat, where they can meet closely related bacteria species — which are able to share antibiotic-resistance genes with gonococci! Then, if they are transferred to a new host, their genetic resistance to drugs might give them a leg up on their competitors.

The idea that throats around the world are becoming unwitting incubators for new antibiotic-resistant strains of gonorrhea is supported by an expanding pool of scientific evidence. For example, several teams of researchers in Japan have collected antibiotic-resistant strains of gonococci in Fukuoka CityTokyo, and Gifu, and all came to the same conclusion: These gonococci contained antibiotic-resistance genes that were very close to those found in closely related but harmless bacteria species that naturally occur in human throats. The findings all point to one conclusion: Gonococci are getting their antibiotic-resistance genes from their throat-dwelling cousins.

Other scientists have found similar evidence. Way back in 1991, one team found striking genetic similarities between an antibiotic-resistant strain of gonococci and an antibiotic-resistance gene from a related bacteria species called Neisseria flavescensOther scientists have tested archived N. flavescens samples taken from before antibiotics were developed, and have found them to be naturally resistant to penicillin — a genetic talent they could have shared with gonococci in human throats, where bacteria are able to pass genes to one another in a process called “horizontal gene transfer.”

Unfortunately, it’s pretty difficult to untangle all the cause-and-effect relationships between unprotected oral sex, gonorrhea infections of the throat, and the emergence of antibiotic-resistant gonorrhea. The circumstantial evidence we have is pretty solid, but so far, there is only one published study that examined the relationship between anatomical site of infection and antibiotic resistance. The investigators did find that gonococci isolated from the throat were much more resistant to ceftriaxone, the antibiotic that is currently our last line of defense against gonorrhea — and to which the disease is starting to show resistance. This finding lends more credence to the hypothesis that the throat is an important breeding ground for antibiotic-resistant gonorrhea.

Oral gonorrhea is diagnosed by taking a swab of the throat. You can receive testing and treatment at a Planned Parenthood health center, as well as other clinics, health departments, and private health care providers. Infected individuals should also make sure their sexual partners receive treatment to ensure they won’t be reinfected.

Tags: genetics, genes, ARG, antibiotics, gonorrhea, unprotected sex, STI, sexually transmitted infections, bacteria, oral sex, STD Awareness

About Anna C.

Anna first volunteered for Planned Parenthood as a high school student in the 1990s. Since then, she has received a bachelor’s degree from UC Berkeley and a master's degree in epidemiology from the University of Arizona. As an ode to her fascination with microbes, she writes the monthly STD Awareness series, as well as other pieces focusing on health and medicine.

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