the second most commonly reported sexually transmitted disease in the United States behind
chlamydia.1 Prevention and treatment of N. gonorrheae, through safe sex practices and
antibiotics, can result in a decrease of male patients with epididymitis and female patients with
pelvic inflammatory disease and the possibility of infertility. Historically, several different
antibiotic classes have been used to treat N. gonorrheae including sulfonamides, penicillins,
tetracyclines and fluoroquinolones, but all have been met with resistant strains. By the 1980s,
sulfonamides, penicillin and tetracyclines were no longer seen as first-line options for treatment.
In 2007, fluoroquinolone-resistant N. gonorrheae emerged in the United States which left
cephalosporins as the only recommended antimicrobial class available for treatment.2
Recently, the CDC’s Gonococcal Isolate Surveillance Project (GISP) is showing an alarming
trend of resistance, increased minimum inhibitory concentrations (MICs), and reduced susceptibility
to the only orally available agent, cefixime.3 From January 2006 to August 2011, the
percentages of isolates with elevated cefixime MICs (≥ 0.25 mcg/mL) have increased from 0.1% to
ceftriaxone MIC elevations have also increased but very minimally as compared to cefixime, 0% to
0.4% in the same timeline.4 The highest
reported incidence of elevated MICs for cefixime and ceftriaxone isolates are in the Western United
States and in men who have sex with men. In Europe,
there have been several reports of gonorrhea treatment failure with cefixime.5 This data is indicative of declining effectiveness of
cefixime and therefore, as of August 2012 the CDC no longer recommends the routine use of cefixime
as a first-line regimen for the treatment of N. gonorrheae in the United States. As cefixime is used less for treatment of N.
gonorrheae, the increased usage of ceftriaxone will likely hasten the continued development of
resistance patterns. With intramuscular ceftriaxone
being the remaining critical treatment for N. gonorrheae and resistance beginning to emerge,
there is an increased need for new treatment regimens for N. gonorrheae.
Based on the new
data showing increased resistance for treatment of N. gonorrheae, the CDC has updated their
recommendations from the 2010 Sexually Transmitted Diseases Treatment Guidelines. When looking at the treatment of uncomplicated urogenital,
anorectal and pharyngeal gonorrhea, the CDC recommends combination therapy with a single
intramuscular dose of ceftriaxone 250 mg plus either a single dose of azithromycin 1 g orally or
doxycycline 100 mg orally twice daily for 7 days.4
Patients with persistent infections despite treatment with the recommended combination
therapy regimen should have cultures gathered with susceptibility testing of the N.
Despite changes to
the guidelines, cefixime has not been fully removed from treatment regimens. Cefixime 400 mg orally plus either azithromycin 1 g orally or
doxycycline 100 mg orally twice daily for 7 days can be used if ceftriaxone is not readily
available. Azithromycin 2 g orally in a single dose
should be the agent used if ceftriaxone cannot be given because of severe allergy. If a patient with
gonorrhea is treated with an alternative regimen, the patient should return 1 week after treatment
for a test-of-cure at the infected anatomic site.4
Cases of treatment failure with either the first-line or alternative regimens should be
reported to the CDC through the local or state health department. Sexual partners of patients with gonorrhea should be tested
for N. gonorrheae and if detected should be treated with a recommended
1. "Gonorrhea." Centers for Disease Control
and Prevention. Centers for Disease Control and Prevention, 17 Nov. 2011. Web. 01 Nov. 2012.
2. CDC. Update to CDC's sexually transmitted diseases
treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal
infections. MMWR Morb Mortal Wkly Rep 2007;56:332–6.
3. CDC. Sexually transmitted diseases treatment
guidelines, 2010. MMWR Recomm Rep 2010;59(No. RR-12):1-110.
4. CDC. Update to CDC's sexually transmitted diseases
treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal
infections. MMWR Morb Mortal Wkly Rep 2012; 61(31);590-594
5. Unemo M, Golparian D, Stary A, Eigentler A. First
Neisseria gonorrhoeae strain with resistance to cefixime causing gonorrhea treatment failure in
Austria, 2011. Euro Surveill 2011;16:pi:19998.