Gonorrhea Cases in the U.S. Becoming Increasingly Drug Resistant

By John Henry Dreyfuss, MDalert.com staff.

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  • Gonorrhea is the second most commonly reported notifiable disease in the United States; 350,062 gonorrhea cases were reported in 2014.
  • Infection is often asymptomatic so the number of cases is very likely under reported.
  • Treatment with ceftriaxone 250mg as a single intramuscular dose plus azithromycin 1g orally is thought by CDC experts to still be effective.
  • The number of U.S. cases of gonorrhea where strains showed "decreased susceptibility" to a key antibiotic, azithromycin, increased significantly from 0.6% in 2013 to 2.5% in 2014.

Cases of drug-resistant gonorrhea (Figures 1 and 2) more than quadrupled in the U.S. between 2013 and 2014, according to a report from the Centers for Disease Control and Prevention (CDC). The CDC report warns that "the future of current treatment options [for gonorrhea] may be in jeopardy," in a recent edition of Morbidity and Mortality Weekly Report.

Figure 1. Gram-stained Neisseria gonorrhoeae from a urethral swab.
(Sources: Wikipedia/CDC.)

Gonorrhea is the second most commonly reported notifiable disease in the United States; 350,062 gonorrhea cases were reported in 2014, the CDC report explains. “Sexually transmitted infections caused by Neisseria gonorrhoeae are a cause of pelvic inflammatory disease in women, which can lead to serious reproductive complications including tubal infertility, ectopic pregnancy, and chronic pelvic pain. Prevention of sequelae and of transmission to sexual partners relies largely on prompt detection and effective antimicrobial treatment. However, treatment has been compromised by the absence of routine antimicrobial susceptibility testing in clinical care and evolution of antimicrobial resistance to the antibiotics used to treat gonorrhea.”

Figure 2. Neisseria gonorrhoeae.
(Source: Public Domain Images.)

Gonorrhea Resistance

"The confluence of emerging drug resistance and very limited alternative options for treatment creates a perfect storm for future gonorrhea treatment failure in the U.S.," said Jonathan Mermin, MD, MPH, Director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and Tuberculosis Prevention.

Jonathan Mermin, MD, MPH

"History shows us that bacteria will find a way to outlast the antibiotics we're using to treat it," Dr. Mermin said. "We are running just one step ahead in order to preserve the remaining treatment option for as long as possible."

For now, the multidrug therapy that the CDC recommends for gonorrhea "still works," the agency said, and there's not yet been a U.S. case where treatment completely failed.

However, agency researchers report that the number of U.S. cases of gonorrhea where strains showed "decreased susceptibility" to a key antibiotic, azithromycin, increased significantly from 0.6% in 2013 to 2.5% a year later.

The CDC analysts suggested that azithromycin "will be next in the long line of antibiotics to which gonorrhea bacteria have become resistant -- a list that includes penicillin, tetracycline and fluoroquinolones," the CDC said.

"It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persist," said Gail Bolan, MD, Director of the CDC's Division of Sexually Transmitted Disease Prevention.

Gail Bolan, MD

The CDC report notes that more than 800,000 cases of gonorrhea are estimated to occur in the United States each year. This number differs from the number reported (above) because infection often occurs without symptoms. The CDC estimates that less than half of all cases are ever diagnosed. Cases of gonorrhea are increasingly faster among men than women, no matter then men’s sexual preference or orientation, the agency said.

“In 2014, the rate of reported gonorrhea cases was higher in the southern United States (131.4 per 100,000 population) than in the Midwestern, western, and northeastern regions of the country. The reported case rate among women decreased from 108.0 per 100,000 population to 101.3 per 100,000 population during 2011–2014 but beginning in 2009, the reported case rate among men increased from 91.0 per 100,000 population to 120.1 per 100,000 population in 2014,” the report explains.

CDC Recommendations for Treatment

CDC recommends that gonococcal infections be treated with ceftriaxone 250mg as a single intramuscular dose and azithromycin 1g orally. The combination regimen is thought to have a synergistic effect that enhances killing of N. gonorrhoeae resistant to one of the antimicrobials and minimizes potential for transmission of resistant strains. Patients with cephalosporin allergies should be treated with azithromycin 2g plus either gentamicin or gemifloxacin, the report explains.


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