Oral drug no longer first-line for gonorrhea

Update your practice: The Centers for Disease Control and Prevention (CDC) no longer recommends the oral antibiotic cefixime as a first-line treatment option for gonorrhea due to possible drug resistance.1

The most effective treatment for gonorrhea is now a combination therapy: the injectable antibiotic ceftriaxone along with one of two other oral antibiotics, either azithromycin or doxycycline. The revised guidance was published in the Aug. 10, 2012, edition of the CDC's Morbidity and Mortality Weekly Report (http://1.usa.gov/NlL4W5).

The change in first-line treatment was prompted after recent trends in laboratory data showed that cefixime is becoming less effective in treating the sexually transmitted infection (STI). [Did you receive the CTU bulletin on this latest CDC guidance? To receive breaking news as it occurs, provide your e-mail address to AHC Media customer service at (800) 688-2421 or customerservice@ahcmedia.com.]

"As cefixime is losing its effectiveness as a treatment for gonorrhea infections, this change is a critical pre-emptive strike to preserve ceftriaxone, our last proven treatment option," said Kevin Fenton, MD, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, in a statement accompany the new guidance. "Changing how we treat infections now may buy the time needed to develop new treatment options."

The new CDC guidance calls for additional follow-up steps to monitor for ceftriaxone treatment failure. Patients who have persistent symptoms should be retested with a culture-based gonorrhea test, which can identify antibiotic-resistant infections, the CDC advises. These patients should return one week after re-treatment for a test-of-cure to ensure treatment success, according to the new recommendations.

Cefixime sometimes needed as alternative

Cefixime might be needed as an alternative treatment option in some instances, the CDC notes. If ceftriaxone is not readily available, providers may prescribe a dual therapy of cefixime plus either azithromycin or doxycycline, the CDC states. Azithromycin may be given alone if a patient has a severe allergy to cephalosporins, the new guidance states. If either of these alternative regimens is used, clinicians should perform a test-of-cure one week after treatment to closely monitor for resistance, the CDC states.

The new changes may make treatment more challenging for some providers and patients, CDC officials note. Clinics that might not have been keeping injectable medications in stock will now need to begin carrying ceftriaxone, and all patients will need to undergo an injection to ensure effective treatment for gonorrhea.

Partner treatment might be complicated by the change. The CDC calls for every effort to be made to ensure that the sex partners of all patients with gonorrhea from the past 60 days are evaluated and treated for gonorrhea with ceftriaxone and either azithromycin or doxycycline, if possible, or an alternative treatment, if ceftriaxone cannot be prescribed. If a partner cannot be brought in for treatment, clinicians may consider expedited partner therapy, or having the patient deliver an oral combination regimen of cefixime with azithromycin to their partner.

New drugs needed

The revised guidelines are just one aspect of CDC's response to the threat of untreatable gonorrhea. The agency has issued a public health response plan to offer guidance to state and local health departments in monitoring the emergence of drug resistance. (To review the plan, visit the "Antibiotic-Resistant Gonorrhea" page at the CDC web site, http://1.usa.gov/GFutpE.) In addition to its monitoring of U.S. resistance, CDC is working with the World Health Organization to track emerging resistance on the global level.

There are few new promising gonorrhea drugs in the pipeline, and only one clinical trial is under way to examine treating gonorrhea using new combinations of existing drugs, CDC officials state. The agency is partnering with the National Institutes of Health to test new combinations of existing drugs.

Gail Bolan, MD, director of CDC's Division of STD Prevention, says, "It is imperative that researchers and pharmaceutical companies prioritize research to identify or develop new, effective drugs or drug combinations. Health departments and labs can help CDC monitor for emerging resistance by enhancing or re-building their ability to do culture testing."

Be sure that you are providing appropriate screening for gonorrhea. The CDC recommends that sexually active gay and bisexual men and high-risk sexually active women be tested for gonorrhea at least once a year. Women who are considered high risk include those with previous gonorrhea infection, other STIs, new or multiple sex partners, and inconsistent condom use; those who engage in commercial sex work and drug use; women in certain demographic groups; and those living in communities with a high prevalence of disease.2

Also remember to counsel on condom use. When used consistently and correctly, condoms can reduce the risk of transmission of gonorrhea.


  1. Centers for Disease Control and Prevention. Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR 2012; 61:590-594.
  2. U.S. Preventive Services Task Force. Screening for gonorrhea: recommendation statement. Ann Fam Med 2005; 3:263-267.