Which drugs are not primary treatment options for gonorrhea?

Updated: Sep 07, 2018
  • Author: Brian Wong, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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Answer

Prior to 2007, fluoroquinolones were the preferred class of antimicrobials for the treatment of gonorrhea; however, reports surfaced of N gonorrhoeae infection with decreasing susceptibilities and frank resistance. In addition, United States gonococcal strains with elevated MICs to cefixime also are likely to be resistant to tetracyclines but susceptible to azithromycin. Consequently, only 1 regimen, dual treatment with ceftriaxone and azithromycin, is recommended for treatment of gonorrhea in the United States. [1]

In August 2012, the CDC announced changes to 2010 sexually transmitted disease guidelines for gonorrhea treatment. The Gonococcal Isolate Surveillance Project (GISP) described a decline in cefixime susceptibility among urethral N gonorrhoeae isolates in the United States during 2006-2011. Because of cefixime’s susceptibility, new guidelines were issued that no longer recommend oral cephalosporins for first-line gonococcal infection treatment. [61]

In April 2007, the CDC updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics were no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC's aforementioned GISP. The data showed the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone-resistant (QRNG) reached 6.7%, an 11-fold increase from 0.6% in 2001. [6]

However, if a patient has an absolute contraindication to cephalosporin and other viable antibiotic options are limited, a fluoroquinolone may still have a role in treatment. In these situations, sensitivity testing would be necessary in the event of treatment failure.

Tetracyclines are no longer acceptable first-line therapy for gonorrhea because of the prevalence of tetracycline-resistant strains. Doxycycline 100 mg PO BID for 7 days can be used in place of azithromycin as an alternative second antimicrobial when used in combination with ceftriaxone or cefixime (also second-line therapy). Furthermore, as cefixime becomes less effective, continued used of cefixime might hasten the development of resistance to ceftriaxone, a safe, well-tolerated, injectable cephalosporin and the last antimicrobial known to be highly effective in a single dose for treatment of gonorrhea at all anatomic sites of infection. Other oral cephalosporins (eg, cefpodoxime and cefuroxime) are not recommended because of inferior efficacy and less favorable pharmacodynamics. The frequency of such gonococcal strains is increasing, having climbed to 5-15% in various US cities. [1]


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