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. Author manuscript; available in PMC: 2020 Jul 10.
Published in final edited form as: Lancet Infect Dis. 2018 Jul;18(7):716–717. doi: 10.1016/S1473-3099(18)30341-4

Testing for gonorrhoea should routinely include the pharynx, regardless of sexual behaviour or orientation

Lilith K Whittles 1, Xavier Didelot 1, Yonatan H Grad 2,3, Peter J White 1,4
PMCID: PMC7349805  NIHMSID: NIHMS1598646  PMID: 29976520

The recent profile of Kit Fairley highlighted his work on the potentially important role of kissing among men who have sex with men (MSM) in gonorrhoea transmission.1 The role of pharyngeal infection in gonorrhoea transmission, and in the emergence and spread of antimicrobial resistance, is poorly-characterised, which represents an important knowledge gap.2 Intimate kissing is a risk factor for meningococcal carriage, indicating other Neisseria can transmit via this route.3 Pharyngeal gonococcal infection is predominantly asymptomatic, frequently undetected, and often exposed to suboptimal antibiotic concentrations in therapy,2,4 hence infection may be persistent. With a large proportion of gonorrhoea transmission likely to occur from asymptomatic infections5 the pharynx may an important reservoir of infection. Furthermore, the threat of antibiotic-resistant gonorrhoea globally is of grave concern, and the pharynx may be an important site for resistance emergence, due to low antibiotic penetration, and colonisation by commensal Neisseria species allowing horizontal gene transfer conferring resistance.4

We suggest that concern about pharyngeal gonorrhoea should not be limited to MSM. The first reported case worldwide of azithromycin-ceftriaxone dual-therapy failure occurred in the UK in 2014,6 followed in March 2018 by a similar case that also failed to respond to a last-resort therapy, spectinomycin.7 The patients in both cases were men with pharyngeal gonorrhoea infections, reporting only heterosexual contact. With both recent UK case reports of multi-drug resistant gonorrhoea involving the heterosexual male pharynx – which is typically not tested – we are concerned that many, potentially antibiotic-resistant, infections are systematically overlooked. Indeed, a 2013 study found that 9/97 gonorrhoea-infected heterosexual men in England had pharyngeal infection.8 These findings are broadly consistent with other data (e.g. see2). We lack estimates of gonorrhoea transmissibility to and from the pharnyx,2 and whilst it is likely to be most efficient during fellatio, it is also likely that transmission can occur via kissing and cunnilingus.1,4 This means that pharyngeal infection is likely to be important in the epidemiology of gonorrhoea in heterosexuals as well as MSM.

We recommend routine pharyngeal testing of all individuals tested for gonorrhoea, regardless of gender or sexual orientation, or at least pharyngeal testing at treatment follow-up of all individuals diagnosed with gonorrhoea. Routine testing, linked to research based on whole-genome sequence and epidemiological data9 would allow assessment of the importance of pharyngeal infection in gonorrhoea transmission and antimicrobial resistance,2 and improved parameterisation of models to assess fitness costs and benefits of antimicrobial resistance to inform control strategies.5

Yours faithfully

Lilith K Whittles MRes, Dr Xavier Didelot DPhil, Dr Yonatan H Grad PhD, Dr Peter J White PhD

Acknowledgments

LKW, XD, and PJW thank the Medical Research Council (grants MR/K010174/1 and MR/K010174/1), PJW thanks the UK National Institute for Health Research (NIHR) Health Protection Research Unit in Modelling Methodology at Imperial College London, in partnership with Public Health England (HPRU-2012-10080), and YHG thanks the National Institutes of Health (R01AI132606), for funding.

Role of the funding sources

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Footnotes

Declaration of interests

LKW, XD, and PJW declare no competing interests. YHG has received consulting fees from GSK for work on gonorrhoea.

Ethics committee approval

Not required.

Disclaimer

The views expressed are those of the authors and not necessarily those of the Department of Health, Medical Research Council, NHS, NIHR, Public Health England or the official views of the National Institutes of Health.

References

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