CDC changes treatment recommendations for gonorrhea infections

Issue: September 2012

The CDC no longer recommends cefixime as a first-line treatment for gonorrhea infections because of the increased resistance to the drug, according to findings published in Morbidity and Mortality Weekly Report.

Perspective from Edward W. Hook, MD

Combination therapy with ceftriaxone 250 mg given intramuscularly with either a single dose of azithromycin 1 g orally or doxycycline 100 mg orally, twice daily for 7 days is recommended for the treatment of uncomplicated gonorrhea. This is an update to 2010 CDC guidelines that recommend a cephalosporin be used in conjunction with azithromycin or doxycycline.

“As with other bacterial pathogens, Neisseria gonorrhoeae continues to relentlessly develop resistance, even as fewer and fewer new antibiotics are being developed,” Robert Kirkcaldy, MD, MPH, medical epidemiologist at CDC’s Division of STD prevention, told Infectious Disease News. “CDC is collaborating with the National Institute of Allergy and Infectious Diseases to evaluate combinations of existing antibiotics for gonorrhea treatment, but more needs to be done. Researchers and pharmaceutical companies are urged to prioritize research to identify or develop new and effective drugs or drug combinations.”

Robert Kirkcaldy

CDC researchers evaluated data from the Gonococcal Isolate Surveillance Project (GISP) to reach their recommendation. GISP has monitored N. gonorrhoeae antimicrobial susceptibility since 1986. GISP data came from men attending STD clinics and includes approximately 6,000 new gonococcal urethral isolates each year.

In the event that ceftriaxone cannot be given, CDC recommends that a single oral dose of cefixime (Suprax, Lupin Pharmaceuticals) 400 mg be given instead, with azithromycin or doxycycline. The patient should undergo a test of cure in 1 week.

“These revised guidelines are just one aspect of CDC’s response to the public health threat of multidrug-resistant gonorrhea,” Kirkcaldy said. “CDC has published a public health response plan, offering guidance on steps that state and local health departments can take to prepare for the emergence of multidrug-resistant gonorrhea. CDC will continue to closely monitor gonorrhea resistance through GISP. Also, CDC is working with WHO to monitor for emerging resistance on the global level.”

Kirkcaldy urged physicians to screen patients at risk for gonorrhea and remain knowledgeable about how to collect specimens for culture and what local laboratories can process culture specimens. In additions, physicians are urged to closely monitor for ceftriaxone treatment failure and report suspected gonorrhea cephalosporin treatment failures to local STD programs and to the CDC.

References:

CDC. MMWR. 2012;61:590-594.

Disclosures:

Dr. Kirkcaldy reports no relevant financial disclosures.

Perspective

Edward W. Hook, MD

The changes to treatment guidelines for gonorrhea are warranted because of the clear demonstration of progressively-increasing resistance to cefixime, the oral medication that has been used widely. This decision was not made lightly as it does have several important ramifications. In particular, it represents a challenge for health care providers who practice in settings where they don’t typically give injections. It also represents a challenge to the practice of expedited partner therapy. We’re going to have to work through how to best implement these changes because itt is quite clear that if those changes weren’t made, we could see increased treatment failures with the oral medications. It is a far better approach to change recommendations on the basis of good data for a problem that is on the horizon, than to wait for that problem to occur. Whenever possible, the injectable antibiotic ceftriaxone should be used, despite the fact that it may be an inconvenience. In certain settings, oral therapy can be used, but that creates extra work for clinicians, because it means they should monitor for the potential of treatment failure using test-of-cure tests to make sure that the therapy has been effective.

Edward W. Hook, MD

Director, division of Infectious Diseases, University of Alabama at Birmingham

Disclosures: