Friday, March 1, 2013

Are We Entering an Era of Untreatable Gonorrhea?

Here is an excellent article on the growing problem of multi-drug resistant gonorrhea that was recently published in the CDC's Morbidity and Mortality Weekly Report (MMWR).

"Gonorrhea" refers to infection with the bacterium Neisseria gonorrhoeae and is a common sexually transmitted disease (over 300,000 cases were reported in the United States in 2011). Gonorrhea can cause significant morbidity: infertility, ectopic pregnancy, infection can facilitate HIV transmission, et cetera. One of the challenges in addressing gonorrhea as a public health problem is that many people who are infected have no symptoms; despite being asymptomatic, these individuals can still transmit the disease on to others.

Prevalence of ciprofloxacin resistance in urethral gonorrhea
isolates in US men, 1990-2007 (source:, MMWR)
Antimicrobial susceptibility results are not commonly available to clinicians who manage these infections. The infections, once identified are usually treated empirically with antibiotics known to be active against the bacterium. The challenge with this approach is that the organism has acquired resistance to the various antimicrobials we use to treat it. For example, we use to use flouroquinolone antibiotics to treat gonorrhea, but these antibiotics are no longer recommended due to high levels of fluoroquinolone resistance (see the graph above).

We currently are using cephalosporins (such as cefixime and ceftriaxone) to treat these infections, although resistance data is now suggesting that we are seeing some resistance emerge to these agents, as well. The problem here is that if we lose the cephalosporins there are no reliable alternative drugs we can use for these infections.

The authors of the MMWR report highlight the need to ramp up gonorrhea prevention efforts, to screen high-risk patients for gonorrhea "at least annually," to treat patients with appropriate doses of antimicrobials (per the CDC guidelines), and for clinicians to be vigilant in looking for cases of resistant gonorrhea.

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