The prospect of seeing drug-resistant gonorrhea emerge in the U.S. has alarmed health officials and brought heightened scrutiny to new testing and treatment strategies being used to quell the sexually transmitted disease.

While there has yet to be a case of the gonorrhea "superbug" found in the U.S., health officials fear it could be only a matter of time until that day comes.

"We are concerned about it. There is good evidence it is probably going to happen," said Dr. Heidi Bauer, chief of the STD Control Branch at the California Department of Public Health. "The good news is folks are doing research on alternative drugs currently and those may prove to be promising."

Caused by a bacterial organism known as Neisseria gonorrhoeae, the STD has long been resistant to most antibiotics. Last year Japanese researchers discovered a strain, named H041, impervious to all known forms of available treatments.

The discovery alarmed health officials, and last month, the Centers for Disease Control and Prevention updated its guidelines on how doctors should treat patients with a gonorrhea infection. The federal agency now says the recommended treatment is to use a ceftriaxone-based dual regimen, where patients receive a 250 mg ceftriaxone injection and an oral dosage of 1g azithromycin or are prescribed to take 100mg of doxycycline orally twice daily for seven days.

Nonetheless, the CDC predicts it is "very likely" that cases of gonorrhea resistant to the cephalosporin treatment "will emerge in the United States." The federal agency also warns that gay and bisexual men are at particular risk.

In their monthly STD report released August 31, San Francisco health officials warned that "based on earlier resistance patterns to other classes of antibiotics, California will likely be among the first U.S. states to see cases" of the gonorrhea superbug.

"People are wanting to know what it means and what do we need to be doing to prepare for this," Dr. Susan Philip, director of STD Prevention and Control at the San Francisco Department of Public Health, told the Bay Area Reporter during a phone interview last month. "We are working with our lab partners to look for this in San Francisco."

Philip stressed that, so far, if someone is diagnosed with having gonorrhea, "it is curable. There is no untreatable gonorrhea in the U.S. that we have seen."

Treatment has become harder

But treating for the STD has become harder over the years.

In 2010, 27 percent of all gonorrhea cases were resistant to penicillin, tetracycline, ciprofloxacin, or some combination of those antimicrobials, according to the CDC. Roughly 7 percent were resistant to all three antimicrobials, reported the CDC, which no longer recommends penicillin, tetracycline, or fluoroquinolone antimicrobials as appropriate treatment for gonorrhea.

In California "we do lots of testing" of STD strains, said Bauer. "We are seeing over time a large proportion able to survive larger concentrations of antibiotics. They are not drug resistant but it is concerning because it is a pre-curser to resistance."

Between 2000 and 2010 the national gonorrhea rate decreased nearly 22 percent, with 309,341 cases reported at the end of the decade.

In California the state has seen gonorrhea rates decrease since 2007, when a total of 31,191 cases were reported. Last year the number had fallen to 27,455 cases, though that marked a slight increase over the 26,842 cases in 2010.

Rates of gonorrhea have been rising, however, in San Francisco for several years now. Percentagewise, the number of gonorrhea cases in 2011 rose by double digits, from 1,943 in 2010 to 2,243 in 2011. In 2010 the STD section reported an increase of 8.6 percent in cases.

This year is expected to see more increases. The reported cases of gonorrhea during the first seven months of 2012 are already higher than what was seen in San Francisco during the same period last year.

According to the August STD report, there have been 1,475 cases of gonorrhea through July of this year compared to 1,221 reported in the first seven months of 2011. Cases of male rectal gonorrhea are also higher, with 456 reported through July this year compared to the 321 counted during the first seven months of 2011.

San Francisco health officials for some time now have recommended doctors locally treat gonorrhea with the injection and pill protocol. More recently they have begun to advise sexually active gay and bisexual men to be tested for gonorrhea infections in the throat and rectum every three to six months.

Screening in the throat and rectum "is essential as these sites are where the majority of infections are found and most are asymptomatic and therefore would not be detected without screening," advised Philip and City Clinic medical director Dr. Stephanie Cohen in the latest STD report. "Providers and [patients] should also be alert for possible treatment failures. Patients treated for gonorrhea should be advised to return if their symptoms do not resolve."

At Magnet, the gay men's health center in the Castro that is part of the San Francisco AIDS Foundation, the standard protocol is to use pharyngeal and rectal swabs to screen for the STD. Urine tests for gonorrhea are no longer conducted unless a patient has visible signs of an infection or knows a sex partner has exposed him to it.

Otherwise, "if he has an infection in his butt or throat he doesn't know about it so he can't get it treated," explained Steve Gibson, the clinic's director. "He might pass it on to his partners and vice versa and it can keep going back and forth."

Awareness vs. alarm

Renewed media attention on the issue, such as a recent headline on the LGBT blog Queerty that asked if gonorrhea is the new AIDS, has raised concern that men who have sex with men may tune out the warnings from health officials.

"There is a fine balance between raising awareness without creating a lot of alarm," acknowledged Bauer. "It is alarmist to say this is a new AIDS-like syndrome."

Writing on the National Lesbian and Gay Journalists Association's blog, Poz magazine deputy editor Oriol R. Gutierrez countered that gonorrhea "is not the new AIDS." The new treatment guidelines, however, make it clear that "the CDC is worried," wrote Gutierrez.

"Which then prompts the question: How worried should we be? I can't put an exact measure on it, but I feel safe in saying that this should provide motivation for those who have become weary of safer sex, particularly condom use," he added. "If untreated, gonorrhea can spread to the blood or joints, which can be life threatening. And gonorrhea can make it easier to both give and get HIV."

Local health advocate and blogger Race Bannon, a gay man who lives in the Castro, cautioned that over-hyping the advent of a gonorrhea "superbug" could lessen health officials' warnings about the need to get properly screened and treated for the STD.

"They have heard before public health officials, the CDC etc., sometimes raise an alarm bell prematurely or incorrectly," said Bannon. "So what happens is when that does happen the natural instinct is to say, 'Well this just may be another instance of them overblowing the case.' With that said, I do think the messaging is getting out that sexually active gay and bi men should get tested, at a minimum, every six months."

The community should embrace efforts to normalize the need to ask your primary care physician for pharyngeal and rectal STD tests, added Bannon.

"The community as a whole must normalize this. When guys are lined up outside City Clinic or Magnet, they should be applauded, not be demonized," he said. "A lot of tests are falling through the cracks, so to speak. I think it is incredibly vital to have oral and anal swabs in every single instance of STD testing. Unless you absolutely never engage in receptive anal or have never sucked a dick or rimmed."

While health officials hope to stem the rising rates of gonorrhea, they do not expect to see the number fall to zero.

"I would say the goal is not total eradication. I don't see how that is possible in a sexually active city like San Francisco with so many new people coming in," said Gibson. "The rates are really high and should be reduced, but total eradication doesn't seem like a realistic goal."