EXECUTIVE SUMMARY

The CDC recently released an update of its 2013 report, Antibiotic Resistance Threats in the United States. Antibiotic-resistant gonorrhea continues to be one of the most urgent threats, according to the 2019 update.

Gonorrhea has quickly developed resistance to all but one class of antibiotics, and half of all infections are resistant to at least one antibiotic.

There are 550,000 estimated drug-resistant cases of gonorrhea each year, with 1.14 million total new infections each year. Cost for care is estimated at $133.4 million in annual discounted lifetime direct medical costs.


Reproductive health clinicians are all too familiar with Neisseria gonorrhoeae, the bacterium that causes gonorrhea. This infection can result in ectopic pregnancy, infertility, and can increase the risk of contracting and transmitting HIV.

Gonorrhea has quickly developed resistance to all but one class of antibiotics, and half of all infections are resistant to at least one antibiotic. In the 1980s, providers stopped recommending penicillin and tetracycline for treatment, and by 2007, ciprofloxacin was no longer effective. By 2012, cefixime was no longer indicated as a first-line regimen, leaving ceftriaxone as the last recommended treatment.1 The current recommended regimen is a single dose of ceftriaxone 250 mg intramuscularly, and azithromycin 1 g orally as a single dose.2

The CDC recently released an update of its 2013 report, Antibiotic Resistance Threats in the United States, the first report to examine the threats posed by antibiotic resistance on human health. Antibiotic-resistant gonorrhea was listed as one of the three most urgent threats of its kind in the United States in 2013, and it retains its status as one of the five most urgent threats in the 2019 report. The other urgent threats include carbapenem-resistant AcinetobacterCandida aurisClostridioides difficile, and carbapenem-resistant Enterobacteriaceae.

There are 550,000 estimated drug-resistant cases of gonorrhea and 1.14 million total new infections each year, according to the report. Cost for care is estimated at $133.4 million in annual discounted lifetime direct medical costs.1 Gonorrhea diagnoses increased 67% overall, rising from 333,004 to 555,608 cases, according to preliminary 2017 data. Diagnoses in men nearly doubled in 2018 — from 169,130 to 322,169 — with cases in women rising for the third year in a row, from 197,499 to 232,587.3

The CDC report shows that antibiotic resistance is a larger threat in the United States than previously estimated, and the threat is not going away, said CDC Director Robert Redfield, MD, at a press conference.

“A death from antibiotic-resistant infections occurs about every 15 minutes, and a resistant infection occurs every 11 seconds,” Redfield stated.

Pushing on All Public Health Fronts

The CDC developed Strengthening the United States Response to Resistant Gonorrhea (SURRG) in 2016 to help monitor and test for resistant gonorrhea and develop rapid response strategies if resistance is detected. The program is designed to enhance domestic gonorrhea surveillance and infrastructure, boost availability of culturing and local antibiotic susceptibility testing, and increase rapid field investigation to slow the spread of resistant infections. Nine jurisdictions are collecting and analyzing data to develop national recommendations for the public health response to resistant gonorrhea.

The San Francisco AIDS Foundation is participating in SURRG. Its nurse practitioners collect samples from people with confirmed cases of gonorrhea to be analyzed by the San Francisco Department of Public Health. Samples are tested to see how susceptible the gonorrhea bacteria are to three of the antibiotics commonly used for gonorrhea treatment. About a week after samples are taken, foundation healthcare providers receive a report of lab analyses. If testing indicates a reduced susceptibility to one or more of the medications, additional follow-up is provided.

“While a number of new antibiotic agents are in development to treat gonorrhea, drug development has been slow, prompting the need for creative strategies to better use the drugs we already have,” Christopher Hall, MD, San Francisco AIDS Foundation’s vice president of medical affairs, said in a statement.4

Recent research has identified a drug combination that could be an effective back-up for patients not responding to current therapy for gonorrhea. Researchers from University Hospitals Birmingham in England report that the antibiotic gentamicin with azithromycin worked almost as well as ceftriaxone for genital gonorrhea.5

Funded by the United Kingdom’s National Institute for Health Research, the study is the first randomized, controlled trial to compare the two treatments for the sexually transmitted infection. To conduct the study, 720 participants at 14 sexual health clinics in England were randomized to receive either injections of gentamicin or the current treatment of ceftriaxone intravenously. Both groups also were given a single dose of azithromycin orally. Results indicate that 98% of participants given ceftriaxone were successfully treated, compared to 91% given gentamicin.5

Researchers released results of a Phase III trial in which an oral solithromycin monotherapy was tested for noninferiority against intramuscular ceftriaxone plus oral azithromycin in patients with uncomplicated gonorrhea.6 However, scientists report that solithromycin as a single 1,000 mg dose is not a suitable alternative to ceftriaxone plus azithromycin as first-line treatment for gonorrhea.5

REFERENCES

  1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2019. Available at: https://bit.ly/2QEUx3H.
  2. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. Available at: https://bit.ly/2s1LyPE.
  3. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2017. Available at: https://bit.ly/2OALD4r.
  4. San Francisco AIDS Foundation. Coordinated response to antibiotic-resistant gonorrhea. Aug. 14, 2019. Available at: https://bit.ly/374bDgZ.
  5. Ross JDC, Brittain C, Cole M, et al; G-ToG trial team. Gentamicin compared with ceftriaxone for the treatment of gonorrhoea (G-ToG): A randomised non-inferiority trial. Lancet 2019;393:2511-2520.
  6. Chen MY, McNulty A, Avery A, et al; Solitaire-U Team. Solithromycin versus ceftriaxone plus azithromycin for the treatment of uncomplicated genital gonorrhoea (SOLITAIRE-U): A randomised phase 3 non-inferiority trial. Lancet Infect Dis 2019;19:833-842.