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In this article of the Financial Times about a "sexual health crisis" in the US, the following claim is made:
The study showed doxycycline was less effective for preventing gonorrhoea, which is on the brink of becoming untreatable and can increase a patient’s risk of contracting HIV.
Is this statement true, partially true or false?
"Untreatable" in this context is used to mean "resistant to all available antibiotics".
Quotes from some recent reviews, editorials, and research papers:
Unemo, M., & Nicholas, R. A. (2012). Emergence of multidrug-resistant, extensively drug-resistant and untreatable gonorrhea. Future microbiology, 7(12), 1401-1422.
The new superbug Neisseria gonorrhoeae has retained resistance to antimicrobials previously recommended for first-line treatment and has now demonstrated its capacity to develop resistance to the extended-spectrum cephalosporin, ceftriaxone, the last remaining option for first-line empiric treatment of gonorrhea. An era of untreatable gonorrhea may be approaching, which represents an exceedingly serious public health problem.
This is saying that gonorrhea strains now exist that are resistant to every one of the proven first-line treatments for gonorrhea. That doesn't mean that it's already untreatable, but when first-line treatment fails it's necessary to go to other backup drugs, including those that typically come with worse side effects or require injections. Once there is resistance to the backups, there's nothing left. Just a couple years before was a paper recommending the switch to drugs like ceftriaxone:
Deguchi, T., Nakane, K., Yasuda, M., & Maeda, S. I. (2010). Emergence and spread of drug resistant Neisseria gonorrhoeae. The Journal of urology, 184(3), 851-858.
Due to the spread of fluoroquinolone resistant N. gonorrhoeae fluoroquinolones are no longer recommended for the treatment of gonorrhea. The emergence of N. gonorrhoeae with a mosaic penicillin-binding protein 2 associated with oral cephalosporin resistance has threatened cefixime treatment for gonorrhea. Emergence of N. gonorrhoeae with high level resistance to azithromycin has also been documented. However, injectable antibiotics (sepctinomycin and ceftriaxone) retain their activity against N. gonorrhoeae
Low, N., Unemo, M., Skov Jensen, J., Breuer, J., & Stephenson, J. M. (2014). Molecular diagnostics for gonorrhoea: implications for antimicrobial resistance and the threat of untreatable gonorrhoea. PLoS medicine, 11(2), e1001598.
Neisseria gonorrhoeae susceptibility to extended spectrum cephalosporins is decreasing and treatment failures are spreading, but no new drug class is licensed to replace them for immediate treatment.
No new drugs are available to treat gonorrhea and the existing drugs are becoming less effective.
Barbee, L. A. (2014). Preparing for an era of untreatable gonorrhea. Current opinion in infectious diseases, 27(3), 282.
The proportion of Neisseria gonorrhoeae isolates with reduced susceptibility to extended-spectrum cephalosporins (ESC) has increased rapidly since 2006. Clinicians, researchers and public health officials need to be prepared for the possibility of an era of untreatable gonorrhea.
Ndowa, F., Lusti-Narasimhan, M., & Unemo, M. (2012). The serious threat of multidrug-resistant and untreatable gonorrhoea: the pressing need for global action to control the spread of antimicrobial resistance, and mitigate the impact on sexual and reproductive health. Sexually transmitted infections, 88(5), 317-318.
Worryingly, resistance and treatment failures to cefixime have been verified in Japan6 and recently in Europe.7–9 The recent report of a strain of N gonorrhoeae in Japan that was highly resistant to the parenteral ceftriaxone, and associated with a probable treatment failure with ceftriaxone,10 the last remaining option for empiric treatment, sounded alarm bells of significant future challenges to the treatment and control of gonococcal infections and their complications. This was also followed by the identification of a highly ceftriaxone-resistant strain in France11 and in Spain.12 Furthermore, many regions, worldwide, describe a decreasing susceptibility to ceftriaxone, and reports of ceftriaxone treatment failure of gonococcal pharyngeal infections have been published.3 ,13 w2 w3 Given the ability of N gonorrhoeae to develop AMR within a relatively short time span compounded with its ability to retain the resistance to previous antibiotics, even after their use has been discontinued, the threat of a widespread ceftriaxone resistance and untreatable gonorrhoea in certain circumstances is real.3 ,10 ,11 w2 w3
The statement itself is not really measurable; "on the brink of becoming untreatable" doesn't have any clear definition (how far away do you have to be to be "on the brink"? how many cases need to be untreatable - one? 5%? 50%?). However, it's certainly a sentiment expressed seriously in scientific and public health venues. Multidrug-resistant strains exist already, there are no replacements in the pipeline, and even if replacements arrive, these particular bacteria have shown high potential for resistance, so it's unlikely that new drugs will remain effective indefinitely.
Without any doubt the answer is a very clear: YES!
And it has been for some time, in quite the same manner —if not exactly— as expressed in the quote presented in the question.
The WHO chose these words in 2012:
Gonorrhoea has the potential to become untreatable
— WHO: "Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae", 4 May 2012.
Likewise:
Because many strains of microorganisms have been shown to be resistant to doxycycline, culture and susceptibility testing are recommended. […] Prolonged use may result in super-infection…
— RxList: DOXYCYCLINE 3/15/2022
The abuse of antibiotic treatments by doctors, sex program advisors, agriculture, etc. will only accelerate this trend, and not just for this one specific Neisseria bug. Many medical researchers agree:
Importantly, it remains the case that doxycycline taken as PEP or pre-exposure prophylaxis (PrEP) for STIs is not endorsed by BASHH or UKHSA. This remains in line with international counterparts. […] However, high rates of tetracycline resistance in Neisseria gonorrhoeae already preclude treatment of gonorrhoea with doxycycline, and its use as prophylaxis is not likely to be effective in preventing gonorrhoea infection. Also of major concern is the potential for selection of resistance among potentially pathogenic bacterial flora […]
— Manik Kohli: "BASHH updated position statement on doxycycline as prophylaxis for sexually transmitted infections", Sex Transm Infect. 2022 May; 98(3): 235–236.
The population-level risks of bacterial STI prophylaxis are […] Long-term use of doxycycline is likely to promote resistance in patients' endogenous microbial flora and could lead to more widespread doxycycline resistance in MSM.
— Matthew R. Golden et al.: "Preexposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infections in Men Who Have Sex With Men", Sex Transm Dis. 2015 Feb;42(2):104-6.
Gonorrhea is the second most commonly reported STI in Canada, and the threat of untreatable infection is becoming a real possibility due to antimicrobial resistance.
— Laura Fusca: "High Interest in Syphilis Pre-exposure and Post-exposure Prophylaxis Among Gay, Bisexual and Other Men Who Have Sex With Men in Vancouver and Toronto", Sex Transm Dis. 2020 Apr; 47(4): 224–231.
This is of course grossly increased by the abuse of self-administered and self-sourced antibiotics, leading to increased risk-seeking behaviour — and perversely to even more sexually transmitted disease cases:
PrEP users from this community sample reported self-prescribed STI prophylaxis. STI prophylaxis was associated with sexual behaviour known to facilitate STI transmission and with a history of recent STIs acquisition. Given the potential risk of antimicrobial resistance, sexual health clinicians should consider asking attendees, especially HIV PrEP users, about the use of antibiotics as STI prophylaxis, […]
— Charlotte O'Halloran: "Factors associated with reporting antibiotic use as STI prophylaxis among HIV PrEP users: findings from a cross-sectional online community survey, May-July 2019, UK", Sex Transm Infect. 2021 Sep;97(6):429-433
STI prophylaxis use has been found to be associated with higher risk behaviours, for example greater numbers of condomless sex partners and chemsex, and is also associated with STI diagnosis in the past 12 months.
— BASHH 2022, see above
I wouldn't worry about it too much. Gonorrhea is bacterial. This article gives pretty clear hope for bacterial infections reaching super-bug status.
https://www.cnn.com/2022/07/08/health/phage-superbug-killer-life-itself-wellness/index.html
Short answer: There is likely a phage that can treat it when it becomes an issue.
This article discusses some research into that area though it's in early stages: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6022920/
