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Plain Old Gonorrhea Increasingly Difficult to Treat
By Carol Kemper, MD, FACP, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center. Dr. Kemper reports no financial relationship relevant to this field of study.
Source: MMWR. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. 2007; 56:332-336.
Quinolone-resistant neisseria gonorrhea (QRNG) continues to spread with alarming frequency across the United States. Quinolones were first recommended for the treatment of GC by the CDC in 1986. The first quinolone-resistant isolates were reported in Asia and Hawaii in 1991, and sporadic cases occurred in the United States between 1991-1999. However, since 2000, there has been a steady increase in QRNG cases, first in Hawaii, then in California and other Western states, then in men who have sex with men (MSM) throughout major cities in the United States, and now it is appearing with increasing frequency in heterosexual men. In 2003, the CDC revised the treatment recommendations, such that areas experiencing > 5% QRNG no longer use quinolones for first-line treatment of GC.
Surveillance for GC resistance in the United States began in 1986 through a CDC-sponsored program called GISP. Data is presently collected from urethral swabs from 6,000 males annually presenting to 26 to 30 STD clinics throughout the United States. The GISP program provides increasingly important resistance data on STDs in an era with declining use of cultures. Quinolone resistance is defined as an MIC > 1 microgram/mL to ciprofloxacin; intermediate resistance is defined as an MIC 0.125-0.500 microgram/mL.
Since 2001, the prevalence of QRNG in MSM has increased from 1.6% to 29% in 2005; preliminary data for 2006 suggests the current rate is much higher (38%). Resistance in heterosexual men has occurred more slowly, beginning with 0.6% in 2001 and increasing to 3.8% in 2005; preliminary 2006 data suggest the current rate is closer to 6.7%. Certain cities, like Philadelphia and Miami are experiencing even greater rates of resistance, especially in gay men.
The CDC now recommends a single dose of intramuscular ceftriaxone 125 mg for uncomplicated urogenital and anorectal GC. Alternate regimens would include a single dose of cefoxitin 2 grams with probenecid, ceftizoxime 500 mg, cefotaxime 500 mg, or cefiximine oral suspension 400 mg. For persons with severe penicillin or cephalosporin allergies, intramuscular spectinomycin 2 grams can be given (but would presently require being ordered through the public health department, resulting in a delay in treatment). A single oral dose of azithromycin 2 grams is another good option for patients with uncomplicated GC with severe PCN allergy. However, the routine use of azithromycin is not recommended because of concerns regarding the rapid emergence of resistance.
A single dose of intramuscular ceftriaxone 125 mg is also recommended for pharyngeal GC; the alternate regimens above may not be adequate for pharyngeal infection. In addition, quinolones are no longer recommended for treatment of conditions such as PID that may be caused by GC.
A test of cure 2-weeks post-treatment was previously required for persons receiving quinolone therapy. Since quinolones are no longer recommended, a test of cure is not necessary for treatment of uncomplicated GC. However, a culture and susceptibility studies should be obtained in any person with persistent symptoms. Keep in mind that the SF PHD identified 3 cases of combined quinolone and cephalosporin resistance in 2003. As of 2004, the IDSA has listed GC as one of the target organisms in their "Bad Bugs, No Drugs" campaign.