CDC updates treatment, surveillance recommendations for gonorrhea

The Centers for Disease Control and Prevention has updated its recommendations for treatment and surveillance of Neisseria gonorrhoeae infection, according to a recent report.

Cephalosporins are a mainstay of the CDC's recommended treatment for gonorrhea. However, in Asia and Europe, cephalosporin susceptibility has been decreasing and treatment failure has been increasing. The CDC reviewed current trends in the U.S. and found that minimum inhibitory concentrations (MICs) to cephalosporins, specifically cefixime and ceftriaxone, are rising, pointing to decreased cephalosporin susceptibility here as well, although overall prevalence of isolates with elevated MICs is currently low. The findings indicated that resistance to cefixime may emerge before resistance to ceftriaxone in the U.S., the CDC said. The report appeared in the July 8 Morbidity and Mortality Weekly Report and is available online.

The report's findings are limited because its data, from the Gonococcal Isolate Surveillance Project (GISP), include only men who attended publicly funded STD clinics, and because transient decreases in MIC susceptibility have been observed in GISP before, the CDC said. However, in light of the findings and the similar trends observed in other countries, the agency made the following recommendations:

• For uncomplicated gonorrhea, treatment with 250 mg of ceftriaxone intramuscularly in single dose and 1 g of oral azithromycin in a single dose is usually most effective.
• Clinicians treating patients for gonorrhea should remain alert to treatment failure, defined as persistent symptoms or positive results on a follow-up test despite treatment.
• Clinicians should consider performing a test-of-cure with culture (preferred) or nucleic acid amplification tests (NAATs) in patients undergoing gonorrhea treatment, especially men in the western U.S. who have sex with men.
• Patients taking cefixime who have treatment failure should be retreated with 250 mg of ceftriaxone intramuscularly and 2 g of azithromycin orally.
• Clinicians caring for patients who experience treatment failure on ceftriaxone should consult with an infectious diseases expert and the CDC to determine retreatment. Such patients should also undergo tests-of-cure with culture (preferred) or NAAT within one week, and a culture specimen should be taken if the follow-up NAAT is positive.
• Sex partners in the preceding two months of patients with ceftriaxone treatment failure should be tested for gonorrhea (culture preferred) and should receive empirical treatment with ceftriaxone, 250 mg intramuscularly, and azithromycin, 2 g orally.
• Ceftriaxone treatment failures should be reported to local or state health departments within 24 hours.

“The eventual emergence of cephalosporin resistance remains likely,” the CDC wrote. “Actions taken now could delay the spread of cephalosporin-resistant strains and mitigate the public health consequences.”