Multidrug-Resistant Gonorrhea: New Treatment Guidelines

Troy Brown

February 19, 2013

Multidrug-resistant gonorrhea is increasing in the United States, and the Centers for Disease Control and Prevention (CDC) has updated its treatment recommendations, according to a report published in the February 15 issue of the Morbidity and Mortality Weekly Report.

In 2011, 11.8% of isolates studied were penicillin-resistant, 22.7% were tetracycline-resistant, and 13.3% were fluoroquinolone-resistant.

In the United States, gonorrhea is the second most frequently reported notifiable infection, with more than 300,000 reported cases in 2011. Gonorrhea is a sexually transmitted infection caused by the Neisseria gonorrhoeae bacterium. Most cases are asymptomatic, and if not completely treated, the illness can facilitate transmission of HIV and cause pelvic inflammatory disease, ectopic pregnancy, and infertility.

Antimicrobial susceptibility testing is not routinely available in the clinical setting. In 1986, the CDC developed the Gonococcal Isolate Surveillance System (GISP) to track antimicrobial susceptibility among N gonorrhoeae isolates obtained from men cared for in participating sexually transmitted disease (STD) clinics. The program aims to provide evidence for treatment recommendations and prevent widespread treatment failures.

Resistance to sulfonamides was widespread in the 1940s, and their use was discontinued. During the 1980s, strains that were resistant to penicillin and tetracycline became widespread.

During the 1990s and 2000s, fluoroquinolones were widely used. In 2007, the CDC stopped recommending fluoroquinolones for gonorrhea treatment after GISP found that the prevalence of fluoroquinolone-resistant N gonorrhoeae was higher than 5% among isolates collected throughout the country.

Cephalosporins such as cefixime and ceftriaxone then became the only antimicrobials recommended for gonococcal infection treatment. Now GISP evidence indicates that cephalosporin resistance may be developing in the United States.

The CDC encourages local and state STD control programs to identify high-prevalence areas and populations to improve primary prevention, screening, and partner services.

The CDC's updated treatment recommendations are:

  • Treat gonorrhea at any anatomic site with a single intramuscular injection of 250 mg ceftriaxone plus either 1 g azithromycin as a single oral dose or 100 mg doxycycline orally twice per day for 7 days.

  • If ceftriaxone is not available, patients can be given a single oral dose of cefixime 400 mg and either a single dose of azithromycin or doxycycline 100 mg orally twice per day for 7 days.

  • If the patient is allergic to cephalosporins, he or she can be given a single dose of azithromycin 2 g.

  • Patients who receive either of the alternatives to ceftriaxone should return for a test of cure in 1 week.

Clinicians should do susceptibility testing in patients who fail to respond to treatment and notify the local public health STD program. Local public health laboratories should maintain or rebuild their capacity to perform cultures for N gonorrhoeae or establish partnerships with laboratories that can.

Laboratories are asked to notify the ordering clinician and local STD control program when they identify isolates with elevated cephalosporin minimum inhibitory concentrations (MICs) (cefixime MIC ≥ 0.25 μg/mL or ceftriaxone MIC ≥ 0.125 μg/mL).

Local and state health departments should notify CDC promptly regarding isolates with elevated cephalosporin MICs or treatment failures.

Patients and their partners need to be evaluated and treated appropriately for cephalosporin-resistant infection. Additional information can be found in the CDC's cephalosporin-resistant N gonorrhoeae public health response plan.

Morb Mortal Wkly Rep. 2013;62:93-98. Full text