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Antibiotic-Resistant Gonorrhea Basic Information

Antibiotic-Resistant Gonorrhea: An Overview

Antibiotic resistance is the ability of bacteria to resist the effects of the drugs used to treat them. This means the bacteria are no longer killed by a drug that used to kill them before. The bacteria are then free to keep multiplying. Gonorrhea has developed resistance to nearly all of the antibiotics used for its treatment. We are currently down to one last recommended and effective class of antibiotics, cephalosporins, to treat this common infection. This is an urgent public health threat because gonorrhea control in the United States largely relies on our ability to successfully treat the infection.

Gonorrhea is skilled at outsmarting the antibiotics that are used to kill it. For this reason, we must continuously monitor for antibiotic resistance and encourage the research and development of new drugs for gonorrhea treatment.

Surveillance

Surveillance for resistant gonorrhea in the United States is conducted through several projects: the Gonococcal Isolate Surveillance Project (GISP), the enhanced Gonococcal Isolate Surveillance Project (eGISP), and Strengthening the United States Response to Resistant Gonorrhea (SURRG). Antibiotic susceptibility testing is an activity common to each project.

Gonorrhea has decreased susceptibility to a given antibiotic when laboratory results indicate that higher-than-expected levels of an antibiotic are needed to stop its growth.

The Clinician’s Role in Surveillance

Clinicians are asked to report any gonorrhea specimen with decreased cephalosporin susceptibility and any gonorrhea cephalosporin treatment failure to CDC through their state or local public health authority.

In the United States, reports of apparent failures of gonorrhea to respond to treatment with CDC-recommended therapies should be reported to Sancta St Cyr, MD, MPH (gispinfo@cdc.gov; 404-718-5447). Surveillance and Data Management Branch, Division of STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Mailstop E02, Atlanta, GA 30333.

CDC also recommends that isolates from certain infections be submitted to the Neisseria Reference Laboratory at CDC for confirmation: 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.  These infections comprise those that do not respond to CDC-recommended therapy. See pg. 6, Recommended Testing and Confirmatory Testing for a complete list.

Timeline of Antibiotic Resistance and Changing Treatment Recommendations

In 1993, ciprofloxacin, a fluoroquinolone, and two 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. By 2004, ciprofloxacin- resistant gonorrhea had significantly increased among men who have sex with men (MSM) leading to the discontinuation of the drug in this population. By 2006, nearly 14% of gonorrhea samples were resistant to ciprofloxacin. Ciprofloxacin resistance was present in all regions of the country and in the heterosexual population. On April 13, 2007, CDC stopped recommending fluoroquinolones as empiric treatment for gonorrhea altogether. The cephalosporins, either cefixime or ceftriaxone, were the only remaining recommended treatments.

Similar to trends observed elsewhere in the world, CDC has observed worrisome trends of decreasing cephalosporin susceptibility, especially to the oral cephalosporin cefixime. To preserve cephalosporins for as long as possible, CDC made the following changes to its STD Treatment Guidelines:

  • In 2010, CDC changed its treatment recommendations to recommend dual therapy* for the treatment of gonorrhea and increased the recommended dose of ceftriaxone to 250 mg.
  • Following continued declines in cefixime susceptibility, CDC updated its recommendations in 2012 to recommend ceftriaxone plus either azithromycin or doxycycline as the only first-line treatment.
  • CDC’s 2015 STD Treatment Guidelines now recommend only one regimen of dual therapy for the treatment of gonorrhea—the injectable cephalosporin ceftriaxone, plus oral azithromycin.

Gonorrhea’s susceptibility to azithromycin declined during 2013-2016. At this time, azithromycin remains a recommended part of dual therapy and is also the backbone of every alternative treatment option. Antibiotic resistance to cephalosporins, azithromycin and other drugs continues to be monitored nationally. An animated video with a historical timeline of drug-resistant gonorrhea in the U.S. is also available.

CDC has not received any reports of verified clinical treatment failures to any cephalosporin in the United States.

*The use of dual therapy for the treatment of gonorrhea is important for two reasons: 1) to ensure clinical cure in this era of increasing antibiotic resistance; and 2) to prevent further development of resistance.

See Gonorrhea Statistics.

Laboratory Challenges

Culture testing is when bacteria is first grown on a nutrient plate and is then exposed to known amounts of an antibiotic to determine the bacteria’s susceptibility to the antibiotic. A major challenge to monitoring emerging resistant gonorrhea is the substantial decline in the use of gonorrhea culture testing by many clinicians, as well as the reduced capability of many laboratories to perform the gonorrhea culture techniques required for antibiotic susceptibility testing. The decline in culture testing results from an increased use of newer laboratory technology, such as a diagnostic test called the Nucleic Acid Amplification Test (NAAT). Currently, there is no well-studied, reliable technology that allows for antibiotic susceptibility testing from nonculture specimens. Increased laboratory culture capacity is needed.

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.

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