Resistance Takes Gonorrhea to Last Line of Defense

ATLANTA, April 13 -- The rate of fluoroquinolone-resistant gonorrhea has become so high in the U.S. that physicians have been urged to switch to the last line of defense, the cephalosporins.

Resistance to fluoroquinolones such as ciprofloxacin (Cipro) has risen to nearly 39% in some subpopulations and more than 13% overall, the CDC reported in the April 13 issue of Morbidity and Mortality Weekly Report.

On the basis of that evidence, the agency said it "no longer recommends the use of fluoroquinolones for the treatment of gonococcal infections and associated conditions such as pelvic inflammatory disease."

What's left are the cephalosporins, such as ceftriaxone (Rocephin), which are less commonly available and for the most part must be given by injection, the agency said.

Gonorrhea, the second most common notifiable disease in the U.S., has become a "superbug," according to Henry Masur, M.D., of Dartmouth, president of the Infectious Diseases Society of America.

"Gonorrhea has now joined the list of other superbugs for which treatment options have become dangerously few," Dr. Masur said in a statement. "To make a bad problem even worse, we're also seeing a decline in the development of new antibiotics to treat these infections."

The CDC's assessment of resistance is based on the Gonococcal Isolate Surveillance Project, which monitors resistance in isolates from men treated in STD clinics in 26 U.S. cities. The agency usually collects about 6,000 isolates a year.

For the first six months of 2006, the agency said:

• Overall, 13.3% of 3,005 isolates were resistant.
• Among men who have sex with men, the rate was 38.3%.
• Among heterosexual males, it was 6.7%

By comparison, rates in 2002 were 7.2% and 0.9% among homosexual and heterosexual men, respectively.

While the rates among heterosexual men remain lower, they have skyrocketed in some places, the agency said:

• In Philadelphia, the prevalence of fluoroquinolone-resistant gonorrhea was 1.2% in 2004, 9.9% in 2005, and 26.6% in 2006.
• In Miami, the rate was 2.1% in 2004, 4.5% in 2005, and 15.3% in 2006.

The agency has recommended single-dose oral fluoroquinolones since 1993, but resistance has been increasing since 1999. In 2000, the CDC said fluoroquinolones shouldn't be used to treat people who acquired their infections in Asia or the Pacific Islands (including Hawaii). In 2002, the recommendation was extended to California, and in 2004, the CDC urged that that fluoroquinolones not be used to treat men who have sex with men.

In the absence of the fluoroquinolones, the agency now recommends:

• For uncomplicated gonococcal infections of the cervix, urethra, and rectum, either 125 milligrams of ceftriaxone in a single intramuscular dose or 400 milligrams of cefixime (Suprax) in a single oral dose.
• Also, treatment for possible coinfection with chlamydia should be undertaken, unless it can be ruled out. Treatment should include a single dose of azithromycin at 1 g by mouth or with doxycycline at 100 mg twice a day, by mouth for seven days.
• Alternative regimens for uncomplicated gonococcal infections include 2 g of spectinomycin (Trobicin) or another cephalosporin single-dose regimen.
• For uncomplicated gonococcal infections of the pharynx, 125 milligrams of ceftriaxone in a single intramuscular dose.

The public health approach to gonorrhea has traditionally been to find and treat patients and their partners, in an attempt to interrupt the chain of transmission, said Gail Bolan, M.D., of the California Department of Health Services and a spokesperson for the infectious diseases society.

"This has meant relying on inexpensive drugs which are easy to administer," Dr. Bolan said. "Now we're down to one class of drugs. That is a very perilous situation to be in."

Dr. Masur called for incentives to encourage drug companies to pursue research into new antibiotics. "Unless we develop more incentives for drug development, we will soon return to the pre-antibiotic era, when acquiring a bacterial infection was often a death sentence," he said.