Health Alert Template for Gonorrhea with Reduced Susceptibility

Instructions

The template health alert below can be adapted and used by a health department to notify local public health practitioners, clinicians, public health laboratories, and public information officers about a case, cluster or isolate of reduced susceptibility N. gonorrhoeae in their jurisdiction. It is customizable – you should use data from your jurisdiction to make it relevant to your community. You can customize this article further by including additional details about the public health event, why it is of public health significance, and links to local resources.

Summary

 

  • As of [date], [health department] has identified [insert description of case, cluster, or isolates, timeframe, location]. [NOTE: Discuss what resistance patterns you are seeing and among what population.]
  • CDC-recommended treatment is still highly effective for gonorrhoeae. To date, CDC has not identified a confirmed case of unsuccessful gonorrhea treatment (with CDC-recommended therapy) in the United States because of resistance to recommended therapy.
  • Providers should continue using CDC recommended treatment for gonorrhea (250mg Ceftriaxone IM x 1 AND 1gm of azithromycin orally x 1) (see CDC treatment guidelines: https://www.cdc.gov/std/tg2015/gonorrhea.htm).
  • Report immediately (within 24 hours) to the health department any suspected cases of gonorrhea treatment failure (i.e., someone with persistent symptoms or who remains infected despite recommended therapy) to [Name] at [Phone], or after hours [number]. The health department can provide guidance on treatment and testing recommendations.
  • [Jurisdictions can consider including] Laboratories are encouraged to maintain all gonorrhoeae isolates demonstrating reduced susceptibility to cephalosporins or azithromycin until further notice.

 

Background

 

The [health department]/ has identified [description of case, cluster, or isolates, timeframe, location].

[Insert statement about why this is of public health significance, which may include characteristics of the public health event (e.g., the first such case, an increase in cases, the largest cluster), that reduced susceptibility was detected to one or both of the antibiotics in the only remaining CDC-recommended treatment for gonorrhea (ceftriaxone plus azithromycin).]

Neisseria gonorrhoeae, the bacterium causing gonorrhea, has progressively developed resistance to the antibiotics prescribed to treat it. Following the spread of gonococcal fluoroquinolone resistance, the cephalosporin antibiotics have been the foundation of recommended treatment for gonorrhea. Based on experience with other microbes that have developed antimicrobial resistance rapidly, a theoretical basis exists for combination therapy using two antimicrobials with different mechanisms of action (e.g., a cephalosporin plus azithromycin) to improve treatment efficacy and potentially slow the emergence and spread of resistance to cephalosporins. Health care providers should stay up to date on CDC treatment guidelines. Following the recommended treatment guidelines every time may help slow the emergence of antibiotic resistance. The current CDC recommended treatment for gonorrhea is 250mg Ceftriaxone IM x 1 AND 1gm of azithromycin orally x 1 (administered simultaneously). (https://www.cdc.gov/std/tg2015/gonorrhea.htm.)

Identification of N. gonorrhoeae infections with reduced antibiotic susceptibility can be a sign of emerging resistance.  CDC-recommended treatment is still highly effective. To date, CDC has not identified a confirmed case in the United States of unsuccessful gonorrhea treatment due to resistance to recommended therapy.

 

Actions for Providers/Recommendations:

 

  • Screen for gonorrhea using nucleic acid amplification tests (NAATs):
    • Women: annually in sexually active women <25 years old and women ≥25 with risk factors for STDs.
    • Men who have sex with men: annually in all sexually active men who have sex with men and every 3 to 6 months in those with increased risk. Screening should be performed at all anatomic sites of sexual exposure, using pharyngeal swabs, rectal swabs, and either urethral swabs or urine specimens.
    • Persons living with HIV: at initial HIV care visit and at least annually.
    • Pregnant women:
      • During the first trimester if <25 years old (or ≥25 years old if at increased risk).
        • If infected, treat immediately and retest within 3 months.
      • Again during the third trimester if at increased risk (risk factors include a new partner, multiple partners, a sex partner with concurrent partners, a sex partner with an STD, any STD during pregnancy, and exchange of sex for food or housing).
    • Rescreen all persons with gonorrhea three months after the initial diagnosis of gonorrhea.
    • Conduct a test of cure if a case of pharyngeal gonorrhea is treated with an alternative regimen or symptoms persist following treatment.
  • Treat gonorrhea (urethritis, cervicitis, and extra-genital gonorrhea) with dual therapy: ceftriaxone 250 mg intramuscularly once and azithromycin 1g orally once whenever possible. (https://www.cdc.gov/std/tg2015/gonorrhea.htm) Ensure the patient’s partners in the last 60 days are treated and tested. [Include information on expedited partner therapy (EPT) if legal in your state.]
  • Remain vigilant for patients not responding to CDC recommended treatment. Contact [local STD program] if possible treatment failures identified by calling [Name] at [Phone], after hours [Phone]. Symptoms that persist after treatment should be evaluated by culture for gonorrhoeae (with or without simultaneous NAAT), and any gonococci isolated should be tested for antimicrobial susceptibility.
  • All persons who are diagnosed with gonorrhea should be screened for other STDs, including chlamydia, syphilis, and HIV. CDC STD screening recommendations can be found at https://www.cdc.gov/std/tg2015/screening-recommendations.htm

 

Resources