Global Resistance of Neisseria gonorrhoeae

When Theory Becomes Reality

David A. Lewis

Disclosures

Curr Opin Infect Dis. 2014;27(1):62-67. 

In This Article

Alternative Single-Dose Options for Treating Gonorrhoea

Spectinomycin, gentamicin and azithromycin have been considered as alternative monotherapeutic options to treat or prevent further spread of ESC-resistant gonorrhoea. However, there are limitations to the use of each of these three antimicrobial agents.

Spectinomycin is not available in several countries and is a costly drug. In addition, spectinomycin has a low cure rate for oro-pharyngeal gonorrhoea, which means it is of limited use in treating MSM and CSWs. Furthermore, resistance to spectinomycin rapidly emerged, as a result of a single nucleotide polymorphism in the 16S rRNA gene, when it was introduced as a first-line treatment for gonorrhoea in the Republic of Korea in 1981.[30] A novel mechanism of high-level spectinomycin resistance has been recently reported in a Norwegian strain due to mutations in the gonococcal gene encoding ribsosomal protein S5.[31]

Single-dose intramuscular gentamicin (240 mg) has been used in Malawi for approximately 20 years as national first-line therapy to treat presumptive gonorrhoea as part of the syndromic management of genital discharges. There are limited in-vitro data to suggest that it has remained effective, at least up to 2007.[32] However, carefully designed clinical studies are still required to assess the safety and efficacy of gentamicin monotherapy for gonorrhoea.[33] A recent study of over 1300 European gonococcal isolates reported high susceptibility to gentamicin.[34] In contrast, a recent meta-analysis reported that single-dose gentamicin resulted in an unacceptable pooled cure rate of 91.5% (95% CIs, 88.1–94.0%).[35] Importantly, few data exist for the effectiveness of gentamicin in treating oropharyngeal gonorrhoea, and more studies are required in this regard.[33]

Single-dose oral azithromycin has been shown to be effective in treating gonorrhoea in clinical trials undertaken in an era of full susceptibility to ESCs.[36] Gonococci that are nonsusceptible to ESCs also tend to exhibit reduced susceptibility or resistance to azithromycin, which will limit the usefulness of this drug as a single first-line agent.[12,37] Importantly, strains with high-level resistance to azithromycin have already been described, and there also have been a number of reports of the development of azithromycin resistance during therapy.[2,3,37,38]

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