Fluoroquinolone-Resistant Gonorrhea on the Rise: Exposure History is Critical

Abstract & Commentary

Source: Centers for Disease Control. Increases in Fluoroquinolone-Resistant Neisseria gonorrhoeae Among Men Who Have Sex with Men — United States, 2003, and Revised Recommendations for Gonorrhea Treatment, 2004. Morb Mort Wkly Rep MMWR 2004; 53;335-336.

The Centers for Disease Control and Prevention (CDC) support ongoing surveillance of antibiotic susceptibilities of Neisseria gonorrhea isolates obtained from individuals presenting to sexually transmitted disease clinics in multiple U.S. locations. Preliminary data from the first nine months of 2003 suggest that the prevalence of fluoroquinolone (FQ) resistance among all gonorrhea isolates was 4.2%, compared with 2.2% in 2002 and 0.7% in 2001. Excluding Hawaii and California, the prevalence of FQ-resistant gonorrhea in men was just under 1% in 2003. However, among men who have sex with men (MSM), the prevalence of FQ-resistance gonorrhea was 4.9% in 2003, compared with 1.8% for the prior year.

Because the prevalence of FQ-resistant gonorrhea isolates now approaches 5% among MSM, the CDC no longer recommends FQ therapy for treating gonorrhea in this population. This parallels the CDC’s recommendations for treating gonorrhea in both MSM and heterosexuals when infections were acquired in California, Hawaii, and Asia.

Commentary by David J. Karras, MD, FAAEM, FACEP

Oral agents largely have replaced the use of intramuscular antibiotics in treating gonococcal urethritis and cervicitis. Because cefixime (an oral, third-generation cephalosporin) has been unavailable for the past few years, FQs have been the drugs of choice. In 2002, the CDC reported that the prevalence of FQ-resistant gonorrhea had reached 5% among patients with infections acquired in Asia, the Pacific Islands (including Hawaii), and California. This level of resistance generally is used as the threshold for a change in therapy. The CDC, therefore, recommended that FQs no longer be used to treat infections acquired in these regions.

It was inevitable that FQ-resistant gonorrhea would extend beyond these specific geographic areas. The CDC now recommends ceftriaxone 125 mg intramuscularly (IM) as the preferred therapy for gonococcal urethritis acquired in these endemic regions and in all MSM; spectinomycin 2 g IM is the alternative. Unless co-infection with chlamydia has been ruled out, concomitant therapy with doxycycline or azithromycin also is necessary.

FQ therapy still may be appropriate for heterosexual patients outside the endemic regions. The CDC urges that practitioners obtain a careful travel and exposure history in patients with urethritis, and that they obtain gonorrhea cultures in cases of treatment failure to exclude the possibility of a drug-resistant infection.

Fortunately, cefixime soon may again become available, and will be an acceptable oral therapeutic option for infections in MSM and in areas with high rates of FQ-resistant gonorrhea.

Dr. Karras, Associate Professor of Emergency Medicine, Associate Chair for Academic Affairs, and Research Director, Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA, is on the editorial board of Emergency Medicine Alert.