From CDC Expert Commentary

New Treatment Guidelines for Gonorrhea: Antibiotic Change

Robert D. Kirkcaldy, MD, MPH

Hello. I am Dr. Bob Kirkcaldy, Medical Officer in the Division of STD Prevention at the
Centers for Disease Control and Prevention (CDC). I am also the lead author on the recently
updated gonorrhea treatment guidelines; that were published in Morbidity and Mortality
Weekly Report (MMWR).[1]
Gonorrhea is a very common infectious disease. In 2010, more than 300,000 cases of
gonorrhea were reported to CDC. However, CDC estimates that more than 700,000 people
in the United States acquire new gonorrhea infections each year.
This sexually transmitted disease (STD) is often asymptomatic, but if left untreated, it can
lead to long-term health consequences, including chronic pelvic pain, ectopic pregnancy,
and infertility. Gonorrhea can also increase the risk of contracting and transmitting HIV.
Cephalosporins are currently recommended to treat gonorrhea in the United States. For the
past few years, providers have used combination therapy with either cefixime, an oral
cephalosporin, or ceftriaxone, an injectable cephalosporin, plus a second antibiotic, to treat
this common STD.
Recent laboratory data suggest that the effectiveness of cefixime for treating gonorrhea
may be declining. For this reason, CDC has updated its gonorrhea treatment guidelines and
no longer recommends the routine use of cefixime. Instead, CDC now recommends using
ceftriaxone along with a second antibiotic to treat gonorrhea.
I would like to take this opportunity to give you a brief summary of the updated guidelines
for treating gonorrhea. However, the complete guidelines can be viewed at
www.cdc.gov/std/treatment.
For patients with uncomplicated genital, rectal, and pharyngeal gonorrhea, CDC now
recommends combination therapy with ceftriaxone 250 mg as a single intramuscular dose,
plus either azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily
for 7 days.
There are times, however, when it may be necessary to use an alternative antibiotic
regimen that does not include ceftriaxone. In instances where ceftriaxone is not available,
CDC recommends cefixime 400 mg orally, plus either azithromycin 1 g orally or doxycycline
100 mg orally twice daily for 7 days. For patients with a severe allergy to cephalosporins,
CDC recommends a single 2-g dose of azithromycin orally.

In both of these circumstances, CDC recommends a test of cure for these patients 1 week
after treatment, and this is an important change in CDC's treatment guidelines. In addition
to these treatment changes, we encourage physicians to take 2 additional steps to ensure
successful treatment outcomes for their patients.
First, monitor your patient for treatment failure. Patients who have persistent symptoms
after treatment should be retested by culture. If these cultures are positive for the
gonococcus, isolates should be submitted for resistance testing. A test of cure should be
conducted 1 week after retreatment. Providers should also ensure that the patient's sex
partners from the preceding 60 days are promptly evaluated and treated.
Second, report suspected treatment failures. Any suspected treatment failure should be
reported to CDC through local or state public health officials within 24 hours.
It is important to know that a single 250-mg injection of ceftriaxone is effective in treating
gonorrhea at all anatomic sites. There are no clinical data to support the use of higher doses
of ceftriaxone. Also, the use of azithromycin as the second antibiotic used in combination
therapy may be preferable to the use of doxycycline, for 2 reasons. First, azithromycin is
taken as a single pill, which is easier and more convenient for a patient. And secondly, there
was a substantially higher prevalence of gonococcal resistance to tetracycline than to
azithromycin among the isolates studied for this MMWR.
The changes in the gonorrhea treatment guidelines were prompted by laboratory data from
CDC's Gonococcal Isolate Surveillance Project (GISP). These data demonstrated recent
significant increases in the percentage of Neisseria gonorrhoeae isolates with elevated
cefixime minimum inhibitory concentrations (MICs). The percentage of isolates with
elevated cefixime MICs increased from 0.1% in 2006 to 1.7% in 2011, a 17-fold increase. CDC
anticipates that rising cefixime MICs will soon result in declining effectiveness of cefixime for
the treatment of urogenital gonorrhea.
Although there haven't been any documented treatment failures in the United States, the
trends reported in this MMWR, the growing number of international reports of cefixime
treatment failures, and the bacteria's history of evolving and becoming resistant to
antibiotics used for treatment point to the increasing likelihood that gonococcal
cephalosporin resistance and treatment failures are on the horizon in the United States.
For more detailed information about gonorrhea or the updated guidelines, please visit CDC's
STD homepage at www.cdc.gov/std.