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Fluoroquinolones No Longer Recommended for Gonorrhea
Abstract & Commentary
By Mary-Louise Scully, MD
Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, CA.
Dr. Scully reports no financial relationship relevant to this field of study.
Synopsis: On the basis of surveillance data showing a significant rise in fluoroquinolone resistance, the CDC has issued a new update removing fluoroquinolones from the recommended options for the treatment of gonococcal infections.
Source: CDC. Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2006: Fluoroquinolones No Longer Recommended for Treatment of Gonococcal Infections. MMWR Morb Mortal Wkly Rep 2007:56:332-336.
Since 1993, oral quinolones (ciprofloxacin, ofloxacin, and levofloxacin) have been recommended by the CDC as first-line treatments for gonorrhea. The Gonococcal Isolate Surveillance Project (GISP) monitors trends in the development of antimicrobial resistance of Neisseria gonorrhoeae in the United States. Throughout most of the 1990s the prevalence of fluoroquinolone-resistant N. gonorrhoeae (QRNG) remained at less than 1%, but in 2000, based on rising resistance rates, fluoroquinolones were no longer recommended for gonorrhea treatment in persons who acquired their infections in Asia or the Pacific Islands (including Hawaii). In 2002, this recommendation was extended to California and more recently (2004) to men who have sex with men (MSM). Recommendation changes are made when QRNG prevalence exceeds 5% in defined groups or locations. Both the CDC and the WHO have used this 5% threshold so that all recommended treatment regimens for gonorrhea can be expected to cure >95% of infections.
By June of 2006, the QRNG prevalence had increased to 38.3% among MSM and 6.7% among heterosexual men. Therefore, on April 12, 2007, the CDC announced that fluoroquinolones were no longer recommended for the treatment of gonorrhea in the United States.
Options for treating gonorrhea are now limited to a single class of antibiotics, cephalosporins. Ceftriaxone, given as a 125 mg intramuscular (IM) dose, remains the preferred treatment for many types of gonorrhea infection (genital, anal, and pharyngeal). A single oral dose of cefixime 400 mg can also be used for uncomplicated urogenital and anorectal gonorrhea, but cefixime does not appear to be adequate for treating the more difficult to eradicate pharyngeal infections. However, in the United States the 400 mg cefixime tablets are not available, although there is a suspension formulation. Other parenteral single dose regimens for uncomplicated urogenital and anorectal gonorrhea (ceftizoxime 500 mg IM; cefoxitin, 2 g IM with 1 g probenecid orally; or cefotaxime 500 mg IM) remain options though they do not appear to offer any advantage over ceftriaxone.
A single oral dose of azithromycin 2 g is effective against uncomplicated gonococcal infections from any site, but due to concerns that widespread use will result in more rapid emergence of resistance, this option should be reserved for persons with documented severe-allergic reactions to penicillins or cephalosporins.1
Patients diagnosed with gonococcal infections should be treated for possible coinfection with Chlamydia trachomatis if chlamydial infection has not been ruled out. Either doxycycline, 100 mg twice a day for 7 days, or azithromycin 1 g by mouth are acceptable regimens.
Gonorrhea is the second most commonly reported infectious disease in the United States with over 330,000 cases reported in 2004.2 N. gonorrhoeae infections are important causes of urethritis, cervicitis, pelvic inflammatory disease, and less frequently may cause of pharyngitis, proctitis, and disseminated disease. Reported cases likely underestimate the number of people truly infected and long-term sequelae such as infertility, ectopic pregnancy, and chronic pelvic pain can result from previous gonorrhea infection. Rarely, untreated gonorrhea may be associated with serious sequelae such as infectious arthritis, meningitis, or endocarditis.
Treatment is challenging because of the ability of N. gonorrhoeae to develop resistance to antimicrobial therapies. Recent reviews of published literature on the global prevalence of QRNG shows high prevalence of QRNG in Europe, Central and southeast Asia, and the South Pacific.3 In many areas of South America and Africa there are insufficient surveillance data available to assure that quinolones are still effective. The United Kingdom preceded the United States by 3 to 4 years in recommending the switch from fluoroquinolones to cephalosporins for gonorrhea treatment.
Quinolones for gonorrhea treatment were single-dose oral regimens that improved compliance and were relatively affordable in a variety of health care settings. Treatment of sexual partners, when appropriate, was also readily accomplished using these single-dose oral options. The development of fluoroquinolone resistance has now eliminated these as recommended drugs regimens. With cephalosporins now being the only class of drugs for gonorrhea treatment, we will need vigilance about monitoring for the possible emergence of cephalosporin resistance. The new updated guidelines including recommended treatments regimens for disseminated gonococcal disease, pelvic inflammatory disease, and disease during pregnancy can be accessed at www.cdc.gov/std/treatment. Clinicians and laboratories should report treatment failures or resistant gonococcal isolates to CDC at (404) 639-8373 through state and local public health authorities.