Task force issues new gonorrhea guidelines
When you scan your next chart, it gives the medical history of a 19-year-old woman who has been sexually active with multiple partners and inconsistently uses condoms. She reports a painful or burning sensation when urinating and increased vaginal discharge. What is your next move?
Be sure to screen for gonorrhea. Infection from the Neisseria gonorrhoeae bacterium remains the second most common reportable disease in the United States.1 The U.S. Preventive Services Task Force (USPSTF) recently issued revised guidelines for routine gonorrhea screening1, which update earlier 1996 recommendations.2
After reviewing evidence, the task force recommends for routine screening high-risk women and against screening low-risk men and women, with insufficient evidence for screening high-risk men. Risk factors for gonorrhea include a history of previous gonorrhea infection, other sexually transmitted infections, new or multiple sexual partners, inconsistent condom use, sex work, and drug use. Risk factors for pregnant women are the same as for nonpregnant women.
Clinicians will need to assess individual risk based on the local epidemiology of disease, say task force members. Local public health statistics can provide guidance to help identify populations who are at increased risk. Communities with a high prevalence of the sexually transmitted disease (STD) may wish to broaden screening, particularly among sexually active young people.1
Reports of the STD reached an all-time low in 2004, falling 1.5% between 2003 and 2004, according to 2004 national statistics just issued by the Centers for Disease Control and Prevention (CDC).3 Despite this reduction, several significant challenges remain, say CDC officials.
Resistance to fluoroquinolone antibiotics, a first-line treatment for gonorrhea, increased from 4.1% in 2003 to 6.8% in 2004, according to CDC’s sentinel surveillance in 28 cities. This drug resistance is especially worrisome in men who have sex with men, where it was eight times higher than among heterosexuals: 23.8% vs. 2.9%, says the CDC. In light of such findings, the CDC moved in 2004 to remove its recommendation for use of fluoroquinolones as treatment for gonorrhea among men who have sex with men.
Researchers at Johns Hopkins University have developed a rapid test that can detect potential antimicrobial resistance in the bacteria that cause gonorrhea without culturing the organism. Data on the test, which is not commercially available, were presented at the 2004 Interscience Conference on Antimicrobial Agents, Chemotherapy in Washington, DC.4
The test does not require collection, culture, or testing of the bacteria. It uses probe technology to check urine samples or leftover products from other commonly used diagnostic techniques to identify the genes linked to resistance.
The test is only a research assay at this point, says Charlotte Gaydos, DrPH, associate professor in the division of infectious diseases at Johns Hopkins University’s School of Medicine. "Gonococcal resistance to fluoroquinolones is not a large problem in the U.S. at the moment, except in California," she explains. "Whether this assay would ever be available commercially is doubtful, as it answers a research question for surveillance at the present."
When screening for gonorrhea, clinicians can choose to perform a vaginal culture or use newer screening tests, such as nucleic acid amplification tests and nucleic acid hybridization tests, according to the USPSTF guidelines. Vaginal culture offers accurate screening results when transport conditions are suitable, while newer screening tests have demonstrated improved sensitivity and comparable specificity when compared with cervical culture. Some of the newer tests can be used with urine and vaginal swabs, which enables clinicians to screening when a pelvic examination is not performed.
If gonorrhea is detected, clinicians can choose from one of the following treatments: 400 mg cefixime, 125 mg ceftriaxone, 500 mg ciprofloxacin, 400 mg ofloxacin, or 250 mg levofloxacin. All of these medications can be given in a single dose.5
Be vigilant about use of the fluoroquinolones ciprofloxacin, ofloxacin, and levofloxacin; these drugs are not recommended for treatment of gonorrhea infections acquired in Hawaii, California, Asia, the Pacific, and in other areas with increased prevalence of fluoroquinolone resistance.
References
- U.S. Preventive Services Task Force. Screening for gonorrhea: recommendation statement. Ann Fam Med 2005; 3:263-267.
- U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996.
- Centers for Disease Control and Prevention. Trends in Reportable Sexually Transmitted Diseases in the United States, 2004. Atlanta; 2005.
- Giles J, Hardick J, Yuenger J, et al. Rapid detection and characterization of gonococcal resistance determinants in NAAT samples. Presented at the 44th annual Interscience Conference on Antimicrobial Agents, Chemotherapy. Washington, DC; November 2004.
- Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR 2002; 51(RR-6):1-80.
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