Tables of Evidence

Note: Updated recommendations for treating uncomplicated gonorrhea infections in adolescents and adults are found in the MMWR special policy note titled, “2020 Update to CDC’s Treatment for Gonococcal Infections,” published in December 2020.

Gonorrhea (December 17, 2020)

Search Strategy

During 2018, CDC staff members and subject matter experts identified essential questions regarding gonorrhea treatment to update the 2015 STD Treatment Guidelines (1). A literature search of PubMed, Embase, and Medline databases conducted for January 2013–May 2019 using the parameters (gonorrhea[MeSH]) OR (gonococcal[all fields] OR gonorrhea[all fields] OR “Neisseria gonorrhoeae”[all fields]) AND (treatment[MeSH] OR antibiotic[MeSH] OR therapy) generated >2,200 abstracts. Titles and abstracts were assessed, and 248 clinically relevant articles were reviewed. Abstracts from STD conferences held during 2015–2018 and on the National Institutes of Health website (https://clinicaltrials.govexternal icon) were also reviewed.

GISP susceptibility data from January 2013 to May 2019 were also reviewed. GISP monitors gonorrhea antimicrobial susceptibility patterns in the United States through monthly testing of urethral isolates from 25 symptomatic men in each of 25–30 STD specialty care clinics (2). Regional laboratories conduct antimicrobial susceptibility testing by agar dilution to determine MICs for selected antimicrobials. Although the Clinical and Laboratory Standards Institute (CLSI) has not established N. gonorrhoeae resistance breakpoints for ceftriaxone, cefixime, or azithromycin, CLSI categorizes isolates with MICs of ≤0.25 μg/mL as susceptible for ceftriaxone and cefixime, and those with MICs of ≤1.00 μg/mL as susceptible for azithromycin (3,4). To identify isolates with elevated MICs, GISP uses the following “alert values” to identify potential emerging resistance: MIC ≥0.125 μg/mL for ceftriaxone, ≥0.25 μg/mL for cefixime, and ≥2 μg/mL for azithromycin (2).

1. Workowski KA, Bolan GA; CDC. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-3). PMID:26042815

2. CDC. Sexually transmitted disease surveillance 2018. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. icon

3. Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing. 30th ed. Wayne, PA: Clinical and Laboratory Standards Institute; 2020. iconexternal icon

4.  Kersh EN, Allen V, Ransom E, et al. Rationale for a Neisseria gonorrhoeae susceptible-only interpretive breakpoint for azithromycin. Clin Infect Dis 2020;70:798–804. PMID:30963175

Page last reviewed: December 18, 2020
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