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UK investigates cases of drug-resistant gonorrhea linked to Ibiza

Two women who traveled to the Balearic Island, or had unprotected sex with men who had been there, failed to respond to the standard treatment

Microscopic image of 'Neisseria gonorrhhoea,' the bacteria that causes gonorrhea.
Microscopic image of 'Neisseria gonorrhhoea,' the bacteria that causes gonorrhea.

Health authorities in the United Kingdom are investigating several reported cases of gonorrhea that were highly resistant to antibiotics. At least four people, all UK residents, were involved in the transmission of the infection following travel to the Balearic Island of Ibiza, or after having sexual contact with people who spent time in the popular Spanish tourist destination.

The cases, which are believed to be linked through a common sexual network, were described in the European public health journal Eurosurveillance, which said two women tested positive for Neisseria gonorrheae after having had unprotected sex with male partners. In both cases, the infection proved resistant to the standard antibiotics.

The first woman had been to Ibiza on vacation, where she had intercourse with more than one male partner, none of whom have been located for testing

The first woman had been to Ibiza on vacation, where she had intercourse with more than one male partner, none of whom have been located for testing. The second woman had unprotected sex with a UK man who “had been in Ibiza and had links with the same sexual network as Case 1.” This man tested negative, but doctors believe he was probably the source of the second woman’s infection, and that “his own infection spontaneously cleared up.”

The sexually transmitted infection (STI), which is caused by bacteria called Neisseria gonorrhoeae or gonococcus, can cause pain and discharge in the genital area, throat and rectum. The World Health Organization estimates that more than 106 million people contract it worldwide each year. In Spain, there were more than 5,000 recorded cases last year.

The strain involved in these cases is the FC428 clone, which first emerged in South East Asia and had sporadically turned up in other parts of the world. But this is the first known instance of “sustained local transmission,” according to Eurosurveillance. Health authorities in the Balearic Islands said they have no reports of FC428.

Ibiza is a major party destination.
Ibiza is a major party destination.

When British authorities concluded that all the cases were linked, they triggered European alert mechanisms. “The British warned the European Center for Disease Prevention and Control (ECDC), which contacted us in January as a country that could potentially be affected,” said Julio Núñez, head of Spain’s National Microbiology Center.

The next step was alerting the regional government of the Balearic Islands, where none of the strains isolated in recent months at Ibiza’s Can Misses hospital or in the public health surveillance network have shown resistance to drugs, or any ties to the UK cases, said Núñez.

“This clearly illustrates how the problem we face is global,” said Adrià Curran, of the infectious disease unit at Vall d’Hebron hospital in Barcelona. “The strain emerged in Asia, arrived at a tourist destination, Ibiza, and was carried to the UK, where heterosexual women have been diagnosed with it. For years we have been warning about the rise in STI cases. This proves that it is not reduced to a few countries, social groups or specific practices.”

Reversible resistance

José Miguel Cisneros, president of the Spanish Society of Infectious Diseases and Clinical Microbiology, said these cases evidence “the need to systematically implement tools of molecular diagnosis.”

“Resistance is reversible. If we stop exposing bacteria to many antibiotics, they’ll go back to being sensitive to them again. That’s the good news at the end of the road,” he said. “But in order to get there, it is necessary to have better knowledge of what we are dealing with, to fight it with the antibiotic that fits the bill the best. Genomic sequencing is the way forward.”

The ECDC is concerned that several of the last known cases have required intravenous treatment with ertapenem, an antibiotic that José Miguel Cisneros said is “strategic and should be used as sparingly as possible.”

The cases

The first case was detected in October 2018 at a sexual health clinic in the UK, the public health journal reported. The patient had had unprotected vaginal intercourse with more than one male partner while on holiday two months earlier in Ibiza. These partners were normally resident in the UK.

This woman initially received a single dose of intramuscular ceftriaxone (500 mg) and oral azithromycin (1g) in line with standard national guidelines, but tests conducted two weeks later showed that the bacteria were immune to the first antibiotic and showed intermediate resistance to the second one.

A month later, another woman went in for a health screen at a different clinic in the UK. Although she had no symptoms, she said she had had unprotected sex with a man who had been to Ibiza that summer “and had links with the same sexual network as Case 1,” according to the journal. Tests showed that this woman carried the bacteria, and subsequent analyses proved that both women were infected with the same pathogen.

In the second case, treating the infection proved much harder. She was treated with a single dose of intramuscular ceftriaxone (1 g) but relapsed, and then received intramuscular gentamicin plus oral azithromycin. This treatment failed as well, and doctors then administered three doses of intravenous ertapenem.

The fourth person involved is another man who had sexual contact with the second woman while she was free from symptoms. He was also treated with three doses of intravenous ertapenem.

English version by Susana Urra.

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