STD Quarterly
Stay vigilant in stemming gonorrhea
While strides have been made in stemming gonorrhea, clinicians are advised to keep the sexually transmitted disease (STD) on the radar screen. Preliminary new data from the Centers for Disease Control and Prevention (CDC) show sharp increases in reported gonorrhea cases since 2000 in seven states: Alaska, California, Hawaii, Nevada, Oregon, Utah, and Washington.1
Utah recorded a 206% increase, followed by Hawaii (107%), California (55%), Washington (53%), Oregon (50%), Alaska (48%), and Nevada (40%).1 The CDC estimates more than 700,000 new gonorrhea infections occur each year.2 Gonorrhea is the second most commonly reported notifiable disease in the U.S.3
At this point, the CDC is not able to determine the exact reasons for the recent increases in reported gonorrhea cases in the West, says Lori Newman, MD, a medical epidemiologist with the CDC's Division of STD Prevention. The increases are likely due to a combination of several factors, states Newman, who reported on disease trends at the recent National STD Prevention Conference. For example, providers in the West may be identifying more gonorrhea than in the past through the use of more sensitive testing technology, such as nucleic acid amplification tests, testing for gonorrhea more frequently as a result of the availability of dual testing for both chlamydia and gonorrhea, or participating in expanded outreach and screening efforts, Newman states. "However, the increases in gonorrhea also may reflect true increases in disease," she says.
The agency is facilitating communication between the involved state and local areas to exchange ideas on how to investigate as well as respond to these increases, reports Newman. State and local efforts to investigate these increases include enhanced surveillance efforts and special studies, she notes. "We are also encouraging state and local areas to communicate with patients and providers about the importance of screening for gonorrhea in select populations, prompt diagnosis, appropriate treatment, and partner management of patients with gonorrhea."
Update your treatment
The CDC has just released the latest version of its Sexually Transmitted Diseases Treatment Guidelines. Review the section of gonorrhea to make sure your practice is up to date.4
For treatment of uncomplicated gonococcal infections of the cervix, urethra, and rectum, recommended regimens include:
- Ceftriaxone 125 mg intramuscular in a single dose;
- Or Cefixime 400 mg orally in a single dose;
- Or Ciprofloxacin 500 mg orally in a single dose;
- Or Ofloxacin 400 mg orally in a single dose;
- Or Levofloxacin 250 mg orally in a single dose.
In all cases, treatment for chlamydia should be included if chlamydial infection is not ruled out, the CDC advises.
The quinolones ciprofloxacin, ofloxacin, and levofloxacin should not be used for infections in men who have sex with men (MSM) or in those with a history of recent foreign travel or partners' travel, infections acquired in California or Hawaii, or infections acquired in other areas with increased quinolone-resistant N. gonorrhoeae prevalence, advises the CDC.
In 2004, of 6,322 isolates collected by CDC's Gonococcal Isolate Surveillance Project (GISP), 6.8% were quinolone-resistant.5 However, quinolone resistance in 2004 among heterosexual men outside of California and Hawaii was 1.4%, says Newman.
The CDC's recommended regimens for MSM or heterosexuals with a history of recent travel includes Ceftriaxone 125 mg IM in a single dose or Cefixime 400 mg orally in a single dose, as well as treatment for chlamydia if chlamydial infection is not ruled out.
Cefixime has not been marketed in the United States since October 2002.6 In 2004, Baltimore-based Lupin received Food and Drug Administration (FDA) approval to manufacture generic cefixime, but currently only a 1,000 mg suspension vial is available. The CDC plans to post updates on the availability of cefixime in the United States on its web site, www.cdc.gov/std/treatment.
Alternative regimens for treatment include:
- Spectinomycin 2 g in a single IM dose;
- Or single-dose cephalosporin regimens;
- Or single-dose quinolone regimens.4
While spectinomycin is useful for the treatment of patients who cannot tolerate cephalosporins and quinolones, it is unavailable in the United States. The sole distributor, New York City-based Pfizer, has discontinued U.S. sales of spectinomycin, which it marketed as Trobicin. The CDC and the Food and Drug Administration are working with the company to make the drug available again in the United States, say CDC officials.7
References
- Newman LM. Recent trends in gonorrhea in the United States. Presented at the 2006 National STD Prevention Conference. Jacksonville, FL; May 2006.
- Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: Incidence and prevalence estimates, 2000. Perspect Sex Reprod Health 2004; 36:6-10.
- Centers for Disease Control and Prevention (CDC); Jajosky RA, Hall PA, Adams DA, et al. Summary of notifiable diseases — United States, 2004. MMWR 2006; 53:1-79.
- Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR 2006; 55(RR-11):41-49.
- Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2004 supplement: Gonococcal Isolate Surveillance Project (GISP) annual report, 2004. Atlanta: U.S. Department of Health and Human Services, CDC, National Center for HIV, STD, and TB Prevention; 2005.
- Centers for Disease Control and Prevention. Oral Alternatives to Cefixime for the Treatment of Uncomplicated Neisseria gonorrhoeae Urogenital Infections. Accessed at: www.cdc.gov/STD/treatment/cefixime.htm.
- Centers for Disease Control and Prevention. Notice to readers: Discontinuation of spectinomycin. MMWR 2006; 55:370.
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