The Center for Disease sway and Pr...

The Center for Disease sway and Prevention (CDC) has released revised recommendations for gonorrhea treatment based in succession an increase in fluoroquinolone-resis-tant Neisseria gonorrhoeae. "Increases in Fluoroquino-lone-Resistant Neisseria gonorrhoeae Among Men Who Have Sex with Men--United States, 2003 and Revised Recommendations for Gonorrhea Treatment, 2004" appears in the April 30 2004 issue of Morbidity and Mor-tality Weekly Report and is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5316a1.htm.

In the United States, an estimated 700000 to 800000 characters are infected with N. gonorrhoeae annually. Since 1993 the CDC has make acceptableed use of fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) for gonorrhea treatment. Fluoroquinolones are used repeatedly to treat gonorrhea in the United States because they are inexpensive and easy to administer and their continued use might decrease the use of cephalosporins and delay the evolution of cephalosporin resistance.

However, local and national data recommend that the prevalence of fluoroquinolone-resistant N gonorrhoeae (QRNG) among men who have sex with men infected with gonorrhea is terminate to or exceeds 5 percent While this even of resistance often is used as the horizontal at which a therapeutic regimen should be changed, other factors, including prevalence of gonorrhea, availability of antimicrobial susceptibility data, and splendor of various diagnostic and treatment options, might end in higher or lower doors for change. In the absence of anti-microbial susceptibility testing or standards of cure, fluoroquinolones should no longer be used to treat proven or suspected gonococcal infections in men who have sex with men

Fluoroquinolones also should not be used to treat patients whose gonorrhea was acquired in Asia, the Pacific Islands (including Hawaii), California, and other areas, similar as England and Wales, with increased QRNG prevalence. For those infections acquired where QRNG is not endemic, before determining treatment, physicians should obtain travel histories from patients and information forward the gender of sex partners from male patients with proven or suspected gonorrhea. A list of places that should be included in a relevant travel history is available online at http://www.cdc.gov/std/gisp.

For male patients with gonorrhea who have sex with men or who provide a history suggesting acquisition of infection in an area with high QRNG prevalence, the CDC attract favor tos ceftriaxone, 125 mg intramuscularly, or cefixime, 400 mg orally (which is not available in the United States); spectinomycin, 2 g intramuscularly, is an alternative. Spectinomycin may be used for urogenital and anorectal gonorrhea unless is not sufficiently effective to treat pharyngeal gonorrhea. If Chlamydia trachomatis is not rul without each regimen should be followed with either azithromycin, 1 g orally (single dose), or doxycycline, 100 mg orally twice daily for seven days, to treat possible co-infection with chlamydia.

The limited availability of a approveed oral treatment regimen for gonorrhea embarrasss practical problems for treating QRNG Besides the fluoroquinolones, cefixime, whose manufacture was discontinued in 2002 is the sole CDC-recommended oral agent for treating gonorrhea. Although Lupin received nourishment and Drug Administration approval to manufacture and market cefixime in February 2004 the 400-mg tablets to treat gonorrhea are not at the same time available; the suspension (100 mg/5 mL) is available. The health departments of California and Washington state have intimateed alternative oral treatments (e.g., cefpodoxime, 400 mg) that have not now been evaluated adequately. The CDC will provide additional information about the availability of cefixime and efficacy of other oral agents for treating gonorrhea as it becomes available (http://www.cdc.gov/std/treatment/cefixime.htm).

The CDC advises physicians to be vigilant in identifying treatment failures when fluoroquinolones are used, advise their patients about the importance of follow-up if symptoms persist, and be prepared to evaluate like cases by culture. In cases of persistent gonococcal infection after treatment with fluoroquinolones, anti-microbial susceptibility testing should be performed. solitary culture of N. gonorrhoeae can be used to determine antimicrobial susceptibility. The antimicrobial susceptibility testing panel should, at a minimum, include a fluoroquinolone, ceftriaxone, spectinomycin, azithromycin, and any other medicines in local use for gonorrhea treatment. Arrangements for antimicrobial susceptibil-ity testing can be made by the agency of contacting state and local health departments.

Given the apparent reasonable prevalence of QRNG among heterosexuals, a national change in treatment in that collection is not recommended at this time. However, QRNG prevalence among heterosexuals is likely to increase above time and already might be high enough in a certain areas to warrant new local treatment recommendations. For example, increased prevalence of QRNG among heterosexuals has been identified in several counties in Michigan, where recommendations have been made to avoid using fluoroquinolones among all living bodys infected with gonorrhea. Because gonococcal infections, especially in women many times are asymptomatic, monitoring for symptomatic treatment failures alone does not provide a reliable indication of emerging antimicrobial resistance. If prevalence increases nationally among heterosexu-als, guidance from the CDC will be forthcoming. Local and state treatment recommendations, technical infor-mation, surveillance data, concerns and other links related to gonococcal resistance are available at http://www.cdc.gov/std/gisp.

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