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New recommendations out for gonorrhea treatment
Update your practice when it comes to treatment of gonorrhea: The Centers for Disease Control and Prevention (CDC) no longer recommends the fluoroquinolone antibiotics ciprofloxacin, ofloxacin, and levofloxacin as a treatment for gonorrhea in the United States.1
The change comes on the heels of the release of the agency's updated Sexually Transmitted Diseases Treatment Guidelines.2
What led to the revision? Publication of just-released data indicates that fluoroquinolone- resistant gonorrhea is now widespread in the United States among heterosexuals and men who have sex with men (MSM).1 According to the new report, the proportion of drug-resistant cases among heterosexuals has risen above the recognized threshold of 5% for changing treatment recommendations. The CDC took similar measures in 2004, when officials stated that fluoroquinolones should no longer be used to treat gonorrhea in MSM.
In the new report, derived from the CDC's Gonococcal Isolate Surveillance Project (GISP) in 26 U.S. cities, data showed that among heterosexual men, the proportion of gonorrhea cases classified as fluoroquinolone-resistant Neisseria gonorrhoeae (QRNG) reached 6.7% in the first half of 2006, which represented an 11-fold increase from 0.6% in 2001.
Providers now are down to a single class of antibiotics known as cephalosporins when it comes to recommended options for treating gonorrhea. The lack of treatment options calls for accelerated research into new drugs, as well as increased monitoring for emerging drug resistance, especially to cephalosporins, say CDC officials. The agency is working with the World Health Organization to strengthen international efforts to monitor emergence of cephalosporin resistance and is communicating with government and industry partners to identify and evaluate promising new drug regimens.
"We are running out of options to treat this serious disease," said Kevin Fenton, MD, PhD, director of the agency's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, in a press statement on the revised recommendations. "Increased vigilance in monitoring for resistance to all available drugs is essential."
The Infectious Diseases Society of America (IDSA) also is raising the flag for new antibiotics. In a prepared statement issued following the CDC recommendations, the professional society called on the U.S. Congress to address the issue.2 The Food and Drug Administration Revitalization Act now under consideration by the Senate provides an opportunity to expand existing incentives for so-called orphan drugs and specifically targets antibiotics, states the IDSA.
Henry Masur, MD, IDSA president, in the issued statement said, "Gonorrhea has now joined the list of other superbugs for which treatment options have become dangerously few. To make a bad problem even worse, we're also seeing a decline in the development of new antibiotics to treat these infections."
Gonorrhea is the second most commonly reported infectious disease in the United States after chlamydia, according to the CDC. In 2005, there were 339,593 cases reported nationwide, although experts believe the actual number of cases may be twice that amount. While national gonorrhea rates recorded a substantial decline from 1975 to 1997, overall rates appear to have leveled off in recent years, the agency states.
Oral fluoroquinolones were recommended as first-line treatments for gonorrhea in 1993. When drug-resistant cases increased in recent years, the CDC began to modify its approach. In 2002, the agency recommended that fluoroquinolones no longer be used for gonorrhea infections acquired in California and Hawaii, followed by the change in treatment for MSM in 2004.
25 of 26 cities have resistance
According to the new CDC analysis, fluoroquinolone resistance now is widespread. Resistant cases were seen in 25 of the 26 cities included in the analysis. Sharp increases occurred from 2004 to 2006 in several cities including Philadelphia —spiking from 1.2% to 26.6 % of gonorrhea cases — and Miami, rising from 2.1% to 15.3% of cases. Resistant cases continued to increase in the MSM population; 38% of MSM gonorrhea cases were fluoroquinolone-resistant in the first half of 2006, compared to 1.6% in 2001.1
What is your first-line defense against the STD? Within the class of cephalosporins, CDC now recommends ceftriaxone, available as an injection, as the preferred treatment for genital, anal, and throat gonorrheal infection. While there are some alternative oral cephalosporin treatments for genital and anal gonorrhea, there currently are no recommended alternatives for pharyngeal infection. Clinicians can review additional information on available gonorrhea treatments at: www.cdc.gov/std/gonorrhea/arg.