By Carol A. Kemper, MD, FACP

Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center

Dr. Kemper reports no financial relationships relevant to this field of study.

SOURCE: Blank S, Daskalakis DC. Neisseria gonorrhoeae – Rising infection rates, dwindling treatment options. N Engl J Med 2018;379:1795-1797.

The United States spends an estimated $182 million annually on the treatment of acute gonococcal infection (in 2017 dollars). Imagine what would happen to that dollar figure if we lost ceftriaxone as an effective therapy for gonococcal infection.

Investigators started the Gonococcal Isolate Surveillance Program (GISP) in 1986 to monitor antibiotic resistance in Neisseria gonorrhoeae isolates at selected sites throughout the United States. The first evidence of a serious shift in susceptibility patterns occurred in 2007, with evidence of increasing resistance to fluoroquinolones, along with reports of clinical treatment failure. As a result, fluoroquinolones were removed from recommended treatment guidelines for gonococcal infection. Subsequently, increasing minimum inhibitory concentrations to cefixime and other oral cephalosporins were observed. Clinical failures to these agents began to appear. Over the past few years, increasing minimum inhibitory concentrations to azithromycin have been observed.

Currently, resistance to ceftriaxone in the United States remains limited to a handful of cases. Fortunately, all isolates with reduced susceptibility to azithromycin have retained sensitivity to ceftriaxone. Although ceftriaxone retains its efficacy (for now), the threat of evolving resistance to what is virtually the only remaining reliable therapy looms. Should this occur, it is not clear what the best treatment regimen might be and it may just require days of parenteral treatment.

The editorial by Blank and Daskalakis underscores the threat by laying out the possible consequences of a further shift in gonorrhea susceptibility patterns: 1) younger, sexually active people will be affected disproportionately, potentially resulting in lost wages and even days of hospitalization; 2) increasing risk of refractory pelvic inflammatory disease in young women, with resulting infertility; 3) higher risk to pregnant women and neonates, with serious health consequences and adverse pregnancy outcomes (e.g., blindness in neonates); 4) the use of potentially more toxic agents; 5) more HIV infections; and 6) a stunning increase in the annual cost of STD treatment. Safe and reliable agents are needed urgently for the treatment of acute gonococcal infection.