Alarming Rise in Drug-Resistant Gonorrhea

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Earlier this year, the CDC announced that an entire class of antibiotics called fluoroquinolones should no longer be used to treat gonorrhea in the U.S.  Fluoroquinolones include ciprofloxacin, levofloxacin, and ofloxacin.  A similar recommendation has been in effect in California since 2002, however, this announcement marks yet another national shift in the drugs we have available to effectively treat gonorrhea infection.  Cephalosporins are now the only drugs recommended as first-line treatment for gonorrhea.
PHOTO CREDIT: Scanning electron micrograph image of gonococcal-lymphocyte interactions. Source: Dr. Ian Boulton, Nat Immunol. 2002 3:229-236.  www.Neisseria.org

NEW Gonorrhea Treatment Recommendations

For uncomplicated gonococcal infections of the cervix, urethra, and rectum, the recommended regimens include:

Alternative regimens include:

For uncomplicated gonococcal infections of the pharynx, the recommended regimens include:

For all gonorrheal infections, regimens effective against chlamydia should be included, unless chlamydia has been ruled out using a nucleic acid amplification test.

The California Gonorrhea Treatment Guidelines vary somewhat from national guidelines, particularly for oral cephalosporin alternatives.

Gonorrhea treatment recommendations for other sites of infection and among patients with drug allergies are available on the CDC STD website  and the California STD website,

Fluoroquinolone Resistant Gonorrhea

The Gonococcal Isolate Surveillance Project (GISP) was established in 1986 to monitor trends in antimicrobial susceptibilities of strains of Neisseria gonorrhoeae in the United States in order to establish a rational basis for the selection of gonococcal therapies. GISP is a collaborative project between selected sexually transmitted diseases (STD) clinics, five regional laboratories, and the Centers for Disease Control and Prevention (CDC).
Gonococcal isolates resistant to fluoroquinolones were detected only sporadically in the United States before 1998. Fluoroquinolone-resistant Neisseria gonorrhoeae (QRNG) was first isolated in Hawaii in 1991, but it was not until after 1998 that a dramatic rise in resistant isolates were detected in that state. Beginning in 2000, fluoroquinolones were no longer recommended for gonorrhea treatment in persons who acquired their infections in Asia or the Pacific Islands, including Hawaii.

In California, the frequency of QRNG isolates increased from less than 1% in 2000 to 2.8% in 2001. The rapid spread of resistant infections prompted the California Department of Health Services STD Control Program to release new treatment guidelines in 2002. According to the most recent California STD Surveillance Report, the rate of QRNG in California exceeded 25% in 2005.

In 2004, the CDC announced high rates of QRNG among men who have sex with men (MSM), which prompted the recommendation that fluoroquinolones not be used anywhere in the United States to treat gonorrhea in MSM. Several urban areas across the country began to see increasing rates of QRNG which lead to a patchwork of treatment recommendations.

In the April 13 2007 issue of MMWR, the CDC announced that QRNG rates nationally have exceeded the threshold that warrants a change in the treatment recommendations. Based on an analysis of GISP isolates tested from January through June 2006, 13.3% were resistant; outside Hawaii and California, 8.6% of isolates were QRNG. QRNG prevalence was 38.3% among MSM and 6.7% among heterosexual males. Outside Hawaii and California, QRNG prevalence was 30.7% in MSM and 5.1% in heterosexual males.

Related Resources:

• Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2006: Fluoroquinolones No Longer Recommended for Treatment of Gonococcal Infections MMWR April 13, 2007
• CDC Dear Colleague Letter, April 12, 2007
• California Gonorrhea Treatment Guidelines
• CDC Sexually Transmitted Diseases Treatment Guidelines, 2006 MMWR August 4, 2006
• CAPTC STD Treatment Guidelines Summary Table