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12-08-2012 | Article

CDC: oral cephalosporins lose punch against gonorrhea

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MedWire News: Oral cephalosporins are no longer recommended for treatment of gonococcal infections, due to the emergence of antimicrobial-resistant gonorrhea, health authorities warn.

Urethral Neisseria gonorrhoeae isolates collected in the USA over the past 6 years show increasing resistance to cefixime, an oral cephalosporin antibiotic that is one of the last remaining defenses against gonorrheal infections, according to the Centers for Disease Control and Prevention (CDC).

Instead of an oral cephalosporin, the CDC now recommends combination therapy with ceftriaxone 250 mg intramuscularly and either azithromycin 1 g orally as a single dose, or doxycycline 100 mg orally twice daily for 7 days for treatment of uncomplicated gonorrhea.

"CDC no longer recommends cefixime at any dose as a first-line regimen for treatment of gonococcal infections. If cefixime is used as an alternative agent, then the patient should return in 1 week for a test-of-cure at the site of infection," write Carlos del Rio (Emory University Atlanta) and colleagues in Morbidity and Mortality Weekly Report.

N. gonorrhoeae are notoriously adaptable organisms with the ability to mutate rapidly and evade susceptibility to entire classes of antibiotics. For example, del Rio et al note, gonorrheal resistance to fluoroquinolones emerged among men having sex with men in Hawaii and California, and then spread across the USA.

"From 2006 to 2010, the minimum concentrations of cefixime needed to inhibit the growth in vitro of N. gonorrhoeae strains circulating in the United States and many other countries increased, suggesting that the effectiveness of cefixime might be waning. Reports from Europe recently have described patients with uncomplicated gonorrhea infection not cured by treatment with cefixime 400 mg orally," they write.

The CDC advises that when a patient has a persistent gonococcal infection after treatment with the recommended combination regimen, clinicians should culture clinical specimens and test the isolates for antimicrobial susceptibility.

If ceftriaxone is not available or contraindicated because of severe allergy for treatment of urogenital or rectal gonorrhea, patients may be treated with either cefixime 400 mg orally plus either azithromycin 1 g orally or doxycycline 100 mg twice daily orally for 7 days (if ceftriaxone is not available), or azithromycin 2 g orally in a single dose if ceftriaxone cannot be given because of severe allergy. Patients treated with alternative regimens should return to the site in 1 week for a test-of-cure at the infected anatomic site, the authors suggest.

By Neil Osterweil, MedWire Reporter