Global Resistance of Neisseria gonorrhoeae

When Theory Becomes Reality

David A. Lewis


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

In This Article

Extended Spectrum Cephalosporin Strategies to Slow Down the Spread of Multidrug Resistant/Extensively Drug Resistant Neisseria gonorrhoeae

Two ESC-based strategies are currently receiving attention as a means to slow down the spread of MDR and the further emergence of XDR N. gonorrhoeae strains. Firstly, there is growing evidence from Japan as well as England and Wales that a national change in recommended first-line therapy for gonorrhoea from oral cefixime to injectable high-dose ceftriaxone is slowing down the transmission of N. gonorrhoeae with reduced susceptibility/resistance to oral ESCs.[19,23] Given this observation, there is a growing consensus that the use of oral ESCs should be abandoned in favour of injectable ceftriaxone.

Secondly, the use of dual antimicrobial therapy to treat gonorrhoea has already been instituted in some countries in order to curtail the rise in prevalence of gonococci with reduced susceptibility/resistance to ESCs.[19,39] It has been argued that a more proactive approach to antimicrobial therapy for gonorrhoea is required, with preemptive changes in national first-line therapy occurring before the prevalence of treatment failure exceeds the 5% threshold.[19] The United Kingdom currently favours a single dose of intramuscular ceftriaxone (500 mg) given in combination with a single dose of oral azithromycin (1 g).[19,40] In contrast, the US Centers for Disease Control and Prevention (CDC) currently recommends a lower dose of intramuscular ceftriaxone (250 mg) that should be given as dual therapy with either single-dose oral azithromycin (1 g) or with a 7 days' course of oral doxycycline (100 mg, 12 hourly).[39]

The National Institute for Allergy and Infectious Diseases, in collaboration with the CDC, have conducted a randomized multicentre clinical trial to evaluate the efficacy and safety of single-dose oral azithromycin (2 g) given as dual therapy with either single-dose intramuscular gentamicin (240 mg) or single-dose oral gemifloxacin (320 mg).[41] Preliminary results indicate that the azithromycin/gentamicin combination was 100% effective, whereas the azithromycin/gemifloxacin combination was 99.5% effective, in curing urogenital gonorrhoea.[41]