Growing Antibiotic Resistance Prompts New WHO STI Guidelines

Megan Brooks

August 31, 2016

In response to the growing threat of antibiotic resistance, the World Health Organization (WHO) has released new guidelines for the treatment of three common sexually transmitted infections (STIs), one of which, gonorrhea, is facing more limited treatment options by the day.

"Chlamydia, gonorrhea, and syphilis are major public health problems worldwide, affecting millions of peoples’ quality of life, causing serious illness and sometimes death," Ian Askew, PhD, WHO director of reproductive health and research, said in a news release.

"The new WHO guidelines reinforce the need to treat these STIs with the right antibiotic, at the right dose, and the right time to reduce their spread and improve sexual and reproductive health. To do that, national health services need to monitor the patterns of antibiotic resistance in these infections within their countries," Dr Askew advises.

According to the WHO, more than 1 million STIs are acquired every day worldwide. Each year, an estimated 131 million people are infected with Chlamydia, 78 million with gonorrhea, and 5.6 million with syphilis. Antibiotic resistance to these STIs has increased rapidly in recent years and has reduced treatment options.

Gonorrhea has developed the strongest resistance to antibiotics, with strains of multidrug-resistant gonorrhea that do not respond to any available antibiotics already reported, the WHO notes. Antibiotic resistance to Chlamydia and syphilis, though less common, also exists.

The new recommendations, contained in three separate modules, are based on the latest available evidence on the most effective treatments for these three STIs, the WHO says.


For gonorrhea, the new WHO guidelines provide six treatment recommendations for specific conditions caused by Neisseria gonorrhoeae.

Notable changes from the 2003 WHO STI guidelines include a recommendation against use of quinolones. "High-level resistance to previously recommended quinolones is widespread and decreased susceptibility to the extended-spectrum (third-generation) cephalosporins, another recommended first-line treatment in the 2003 guidelines, is increasing and several countries have reported treatment failures," the WHO says.

The new guidelines also include specific recommendations for oropharygeal infections and retreatment of gonococcal infections after treatment failure. They also note that dual therapy is a preferred option for treatment of gonococcal infections over single therapy. Single therapy is based on local resistance data, and changes have been made to some dosages. In addition, new topical medications have been suggested for prophylaxis against ophthalmia neonatorum.

Overall, the WHO recommends that health authorities track the prevalence of resistance to different antibiotics in the strains of gonorrhea circulating among their population and advise doctors to prescribe whichever antibiotic would be most effective, as determined on the basis of local resistance patterns.


For syphilis, the new WHO guidelines recommend a single intramuscular injection of benzathine penicillin G 2.4 million units for adults and adolescents with early syphilis. "This is the most effective treatment for syphilis; more effective and cheaper than oral antibiotics," the WHO says.

Benzathine penicillin G 2.4 million units adminstered once intramuscularly is recommended over procaine penicillin G 1.2 million units administered over 10 to 14 days intramuscularly. When benzathine or procaine penicillin cannot be used (eg, because of penicillin allergy) or are not available (eg, because of stockouts), the guideline suggests using doxycycline 100 mg twice daily orally for 14 days or ceftriaxone 1 g intramuscularly once daily for 10 to 14 days or, in special circumstances, azithromycin 2 g once orally.

Unfortunately, benzathine penicillin is in short supply. The WHO has received reports of stock outages from antenatal care representatives and providers in countries with high burdens of syphilis from three WHO regions. "WHO is working with partners to identify countries with shortages and help monitor global availability of benzathine penicillin to close the gap between national needs and supply of the antibiotic," the WHO says.

The guidelines also provide recommendations for treating syphilis in pregnant women and for treating late syphilis infections and congenital syphilis.


For Chlamydia, the WHO provides nine specific treatment recommendations for genital infections and lymphogranuloma venereum caused by C trachomatis. The recommendations apply to adults, persons aged 10 to 19 years, people living with HIV, and key populations, including sex workers, men who have sex with men, and transgender persons. Specific recommendations are also provided for genital chlamydial infection in pregnant women and for prophylaxis and treatment of ophthalmia neonatorum caused by C trachomatis.

For example, for uncomplicated genital Chlamydia, the guidelines suggest one of the following options: azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice a day for 7 days. Other alternatives are tetracycline 500 mg orally four times a day for 7 days; erythromycin 500 mg orally twice a day for 7 days; and ofloxacin 200-400 mg orally twice a day for 7 days.

"While good practice based on evidence of large net benefit dictates that patients should be treated for chlamydial infection, the choice of treatment may depend on the convenience of dosage, the cost and quality of the medicines in different settings, and equity considerations," the WHO says.

The WHO is calling on countries to start using the updated guidelines immediately, "as recommended in the Global Health Sector Strategy for STIs (2016-2021) endorsed by governments at the World Health Assembly in May 2016. The new guidelines are also in line with the Global Action Plan on Antimicrobial Resistance, adopted by governments at the World Health Assembly in May 2015."


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