COMMENTARY

New Treatment Guidelines for Gonorrhea: Antibiotic Change

Robert D. Kirkcaldy, MD, MPH

Disclosures

August 13, 2012

Editorial Collaboration

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Hello. I am Dr. Bob Kirkcaldy, Medical Officer in the Division of STD Prevention at the Centers for Disease Control and Prevention (CDC). I am also the lead author on the recently updated gonorrhea treatment guidelines; that were published in Morbidity and Mortality Weekly Report (MMWR).[1]

Gonorrhea is a very common infectious disease. In 2010, more than 300,000 cases of gonorrhea were reported to CDC. However, CDC estimates that more than 700,000 people in the United States acquire new gonorrhea infections each year.

This sexually transmitted disease (STD) is often asymptomatic, but if left untreated, it can lead to long-term health consequences, including chronic pelvic pain, ectopic pregnancy, and infertility. Gonorrhea can also increase the risk of contracting and transmitting HIV.

Cephalosporins are currently recommended to treat gonorrhea in the United States. For the past few years, providers have used combination therapy with either cefixime, an oral cephalosporin, or ceftriaxone, an injectable cephalosporin, plus a second antibiotic, to treat this common STD.

Recent laboratory data suggest that the effectiveness of cefixime for treating gonorrhea may be declining. For this reason, CDC has updated its gonorrhea treatment guidelines and no longer recommends the routine use of cefixime. Instead, CDC now recommends using ceftriaxone along with a second antibiotic to treat gonorrhea.

I would like to take this opportunity to give you a brief summary of the updated guidelines for treating gonorrhea. However, the complete guidelines can be viewed at www.cdc.gov/std/treatment.

For patients with uncomplicated genital, rectal, and pharyngeal gonorrhea, CDC now recommends combination therapy with ceftriaxone 250 mg as a single intramuscular dose, plus either azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days.

There are times, however, when it may be necessary to use an alternative antibiotic regimen that does not include ceftriaxone. In instances where ceftriaxone is not available, CDC recommends cefixime 400 mg orally, plus either azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days. For patients with a severe allergy to cephalosporins, CDC recommends a single 2-g dose of azithromycin orally.

In both of these circumstances, CDC recommends a test of cure for these patients 1 week after treatment, and this is an important change in CDC's treatment guidelines. In addition to these treatment changes, we encourage physicians to take 2 additional steps to ensure successful treatment outcomes for their patients.

First, monitor your patient for treatment failure. Patients who have persistent symptoms after treatment should be retested by culture. If these cultures are positive for the gonococcus, isolates should be submitted for resistance testing. A test of cure should be conducted 1 week after retreatment. Providers should also ensure that the patient's sex partners from the preceding 60 days are promptly evaluated and treated.

Second, report suspected treatment failures. Any suspected treatment failure should be reported to CDC through local or state public health officials within 24 hours.

It is important to know that a single 250-mg injection of ceftriaxone is effective in treating gonorrhea at all anatomic sites. There are no clinical data to support the use of higher doses of ceftriaxone. Also, the use of azithromycin as the second antibiotic used in combination therapy may be preferable to the use of doxycycline, for 2 reasons. First, azithromycin is taken as a single pill, which is easier and more convenient for a patient. And secondly, there was a substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin among the isolates studied for this MMWR.

The changes in the gonorrhea treatment guidelines were prompted by laboratory data from CDC's Gonococcal Isolate Surveillance Project (GISP). These data demonstrated recent significant increases in the percentage of Neisseria gonorrhoeae isolates with elevated cefixime minimum inhibitory concentrations (MICs). The percentage of isolates with elevated cefixime MICs increased from 0.1% in 2006 to 1.7% in 2011, a 17-fold increase. CDC anticipates that rising cefixime MICs will soon result in declining effectiveness of cefixime for the treatment of urogenital gonorrhea.

Although there haven't been any documented treatment failures in the United States, the trends reported in this MMWR, the growing number of international reports of cefixime treatment failures, and the bacteria's history of evolving and becoming resistant to antibiotics used for treatment point to the increasing likelihood that gonococcal cephalosporin resistance and treatment failures are on the horizon in the United States.

For more detailed information about gonorrhea or the updated guidelines, please visit CDC's STD homepage at www.cdc.gov/std.

Web Resources

CDC Gonorrhea Treatment Guidelines

CDC. Sexually Transmitted Diseases: Gonorrhea

CDC. Sexually Transmitted Diseases: Antibiotic-Resistant Gonorrhea

CDC Public Health Grand Rounds: The Growing Threat of Multidrug Resistant Gonorrhea

CDC. 2012 Sexually Transmitted Disease Surveillance: The Gonococcal Isolate Surveillance Project (GISP)

Dr. Robert D. Kirkcaldy, MD, MPH , is a medical epidemiologist in the Surveillance and Data Management Branch of the Division of STD Prevention (DSTDP) at the Centers for Disease Control and Prevention (CDC) and a Lieutenant Commander in the Commissioned Corps of the US Public Health Service. Dr. Kirkcaldy obtained his medical degree from the Tulane University School of Medicine and his public health degree from the Johns Hopkins University Bloomberg School of Public Health. Dr. Kirkcaldy completed a combined residency in internal medicine and psychiatry at the Tulane University Health Sciences Center. Dr. Kirkcaldy came to CDC in 2008 as an Epidemic Intelligence Service (EIS) Officer assigned to DSTDP. As an EIS Officer, Dr. Kirkcaldy led investigations of syphilis and congenital syphilis and studied Trichomonas vaginalis antimicrobial resistance. Currently, he is focused on surveillance of Neisseria gonorrhoeae antimicrobial resistance and oversees the Gonococcal Isolate Surveillance Project, a CDC-supported sentinel surveillance system that has monitored gonococcal susceptibility in the United States since 1986. Dr. Kirkcaldy is also the principal investigator of an NIH-supported clinical trial evaluating alternative antimicrobial treatment options for gonorrhea. He helped to update CDC treatment guidance for gonorrhea and develop plans at the federal level to respond to the emerging threat of cephalosporin-resistant N gonorrhoeae.

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