Sexually Transmitted Diseases (STDs)

Antibiotic-Resistant Gonorrhea
Basic Information

The development of antibiotic resistance in Neisseria gonorrhoeae is a growing public health concern, in particular because the United States gonorrhea control strategy relies on effective antibiotic therapy. Since antibiotics were first used for treatment of gonorrhea, N. gonorrhoeae has progressively developed resistance to the antibiotic drugs prescribed to treat it: sulfonilamides, penicillin, tetracycline, and ciprofloxacin. Currently, CDC STD treatment guidelines recommend dual therapy with the injectable cephalosporin ceftriaxone and either azithromycin or doxycycline to treat all uncomplicated gonococcal infections among adults and adolescents in the United States. Dual therapy is recommended to address the potential emergence of gonococcal cephalosporin resistance. Given the ability of N. gonorrhoeae to develop antibiotic resistance, it is critical to continuously monitor gonococcal antibiotic resistance and encourage research and development of new treatment regimens for gonorrhea.

Surveillance

Surveillance for antimicrobial resistance in N. gonorrhoeae in the United States is conducted through the Gonococcal Isolate Surveillance Project (GISP), which was established in 1986. Approximately 25-30 sites and 4-5 regional laboratories across the United States participate in GISP. Data from this project have been reported and have directly contributed to CDC's STD Treatment Guidelines in 1989, 1993, 1998, 2002, 2006, and 2010.

Clinicians are asked to report any N. gonorrhoeae specimen with decreased cephalosporin susceptibility and any gonorrhea cephalosporin treatment failure to CDC through their state/local public health authorities.

In the United States, reports of apparent failures of infections to respond to treatment with CDC recommended therapies should be reported to Robert D. Kirkcaldy, MD, MPH (rkirkcaldy@cdc.gov; 404-639-8659). Epidemiology and Surveillance Branch, Division of STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Mailstop E02, Atlanta, GA 30333.

In the United States, it is also recommended that isolates from certain infections be submitted to the Neisseria Reference Laboratory at CDC for confirmation; these infections comprise those that fail to respond to CDC-recommended therapy and isolates determined to exhibit intermediate resistance or resistance (see pg. 6, Recommended Testing and Confirmatory Testing, for a complete list): John Papp, Ph.D. JPapp@cdc.gov; 404-639-3785), Neisseria Reference Laboratory, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Mailstop A12, Atlanta, GA 30333.

Trends

In 1993, ciprofloxacin (a fluoroquinolone) and cephalosporins (ceftriaxone and cefixime) were the recommended treatments for gonorrhea. However, in the late 1990s and early 2000s, ciprofloxacin resistance was detected in Hawaii and the West Coast, and by 2004, ciprofloxacin resistance was detected among men who have sex with men (MSM) with gonorrhea. By 2006, 13.8% of isolates exhibited resistance to ciprofloxacin, and ciprofloxacin resistance was present in all regions of the country, including the heterosexual population. On April 13, 2007, CDC stopped recommending fluoroquinolones as treatment for gonococcal infections for all persons in the United States.

Susceptibility testing for the cephalosporin antibiotics is being conducted in GISP on ceftriaxone, cefixime, and cefpodoxime. CDC has observed recent worrisome trends in decreasing cephalosporin susceptibility, especially to oral cephalosporins such as cefixime. So far, none of the N. gonorrhoeae isolates tested in GISP have exhibited resistance, and CDC has not received any reports of clinical treatment failures to any cephalosporin in the United States.

In 2010, 27.2% of isolates collected in GISP were resistant to penicillin, tetracycline, ciprofloxacin, or a combination of these antimicrobials.

See ARG Statistics.

Challenges

A major challenge to monitoring emerging antimicrobial resistance of N. gonorrhoeae is the substantial decline in capability of laboratories to perform essential gonorrhea culture techniques required for antibiotic susceptibility testing. This decline results from an increased use of newer non-culture-based laboratory technology, such as a diagnostic test called the Nucleic Acid Amplification Test (NAAT). Currently, there is no reliable technology that allows for antibiotic susceptibility testing from non-culture specimens. Increased laboratory culture capacity is needed.

Laboratory Issues

CDC recommends that all state and local health department labs maintain or develop the capacity to perform gonorrhea culture, or form partnerships with experienced laboratories that can perform this type of testing.

See Laboratory Information.