Ceftriaxone: new preferred treatment for all types of gonorrhea infection
Gonorrhea is more common in large cities, inner-city areas, populations with lower overall levels of education and people with lower socioeconomic status.
Sometimes referred to as "the clap," gonorrhea may produce signs and symptoms such as a burning sensation when urinating or a thick discharge from the penis or vagina. Many people experience mild or no signs or symptoms. Left untreated, gonorrhea can cause serious complications, especially in women.
Gonorrhea is caused by bacteria. It is very contagious. The bacteria can enter the body through any body opening, such as the mouth, vagina, penis, or rectum. Gonorrhoea is caused by Neisseria gonorrhoeae.N. gonorrhoeae is a gram-negative diplococcus. Specific serological reactions serve to distinguish gonococci from other species of Neisseria and permit serogrouping of gonococcal strains.Many people with gonorrhea also have chlamydia (another sexually transmitted disease). Because of this, you may be given more than 1 drug to treat both diseases.
Asymptomatic carriers are more likely to transmit the disease than people with overt infections. Similarly, anorectal and pharyngeal infections, which are not uncommon in women and men who have sex with men, frequently remain asymptomatic but constitute a potential source of transmission.The life cycle of the bacterium was studied using a variety of cell culture systems. These studies have shown that the bacterium not only adheres to the epithelial cells but also penetrates and transits across the epithelial layer and exits into the subepithelial space where the symptoms of the disease are actually elicited.
Gonorrhea is most often spread by sexual intercourse. In men, the infection usually starts as an infection of the urethra. (The urethra is the tube that urine passes through.) In women, the bacteria usually first infect the cervix. (The cervix is the opening of the uterus inside the vagina). The bacteria can infect the throat or rectum after oral or anal sex.
As compared with standard referral of partners, providing medication for the sexual partners of patients with gonorrhea or chlamydial infection without requiring the partners' prior medical evaluation significantly reduced persistent or recurrent infections among participants. Patients offered expedited treatment of their partners more often reported that their partners had been treated and less often reported having sex with untreated partners. Failure to treat sex partners and sex with an untreated partner were both associated with an elevated risk of infection at follow-up and represent a direct causal link between the intervention and the study's primary, biologic outcome.
The usual laboratory of bacteriology has an essential role in isolation, bacteriological diagnostic and testing of resistance towards antibiotics of gonococcal infections.The overall rate of gonorrhea is now increasing, after a steady decline for the past 2 decades, according to the Centers for Disease Control and Prevention. More than 355,000 cases of gonorrhea were reported in the United States in 1998. More than 5% of people between the ages of 18 and 35 have an infection with gonorrhea that they do not know about. New strains are more easily spread and are resisting treatment even with strong antibiotics.
The mainstay of treatment is the appropriate use of antibiotics. While penicillin was the most common antibiotic used to treat gonorrhea up until the 1970s, an increase in antibiotic resistance has led to a decline in its use. Recommendations for first choice treatment of gonorrhea must therefore depend on local information on resistance patterns and it is not possible to make treatment recommendations that are applicable to all parts of the world.
The Centers for Disease Control and Prevention (CDC) no longer recommends antibiotics known as fluoroquinolones (ciprofloxacin, ofloxacin, and levofloxacin) as a treatment for gonorrhea in the United States. This limits the options available to treat gonorrhea, one of the most common sexually transmitted diseases in the United States.
The recommendation was prompted by new data released today in CDC’s Morbidity and Mortality Weekly Report (MMWR) showing that fluoroquinolone-resistant gonorrhea is now widespread in the United States among heterosexuals and men who have sex with men (MSM). The data showed the proportion of drug-resistant cases among heterosexuals rising above the recognized threshold of 5 percent for changing treatment recommendations. CDC had recommended fluoroquinolones no longer be used to treat gonorrhea in MSM when this threshold was crossed in earlier years.
The new data, from CDC’s Gonococcal Isolate Surveillance Project (GISP) in 26 U.S. cities, showed that among heterosexual men, the proportion of gonorrhea cases that were fluoroquinolone-resistant Neisseria gonorrhoeae (QRNG) reached 6.7 percent in the first half of 2006, an 11-fold increase from 0.6 percent in 2001.
Recommended options for treating gonorrhea are now limited to a single class of antibiotics known as cephalosporins. Public health officials believe the lack of treatment options underscores the need for accelerated research into new drugs, as well as increased efforts to monitor for emerging drug resistance, especially to cephalosporins.
“There is also an urgent need for new, effective medicines to treat gonorrhea. We are running out of options to treat this serious disease,” said Dr. Kevin Fenton, Director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “Increased vigilance in monitoring for resistance to all available drugs is essential.”
While significant resistance to cephalosporins has not been observed to date, CDC is working with state and local health departments to monitor emerging cephalosporin resistance. CDC is urging health departments to maintain or develop capacity to perform cultures for Neisseria gonorrhoeae and to assess any gonorrhea treatment failures for possible resistance. In addition, CDC is working with the World Health Organization to strengthen international efforts to monitor for the emergence of cephalosporin resistance and with government and industry partners to identify and evaluate promising new drug regimens. These additional measures are critical for the control of gonorrhea.
Oral fluoroquinolones were recommended as first-line treatments for gonorrhea in 1993. But drug resistant cases have increased steadily in recent years, rising first in the western United States and then among MSM nationwide. In 2000 and in 2002, CDC recommended that fluoroquinolones not be used to treat gonorrhea infections acquired in Hawaii and California, respectively. And in 2004, CDC recommended that these drugs no longer be used to treat MSM with these infections.
The new CDC analysis shows an increase in the past five years in the overall proportion of gonorrhea cases that are fluoroquinolone-resistant – from less than 1 percent in 2001 to 13.3 percent in the first half of 2006. The analysis also indicated that fluoroquinolone resistance is widespread geographically. Resistant cases were seen across the United States in the first half of 2006 (in 25 of the 26 cities in the analysis), and sharp increases occurred among heterosexual males from 2004 to 2006 in several cities, including Philadelphia (from 1.2 percent to 26.6 percent of gonorrhea cases) and Miami (from 2.1 percent to 15.3 percent). In addition, the analysis showed QRNG continued to rise among MSM; 38 percent of MSM gonorrhea cases were QRNG in the first half of 2006, compared to 1.6 percent in 2001.
Within the class of cephalosporins, CDC now recommends ceftriaxone, available as an injection, the preferred treatment for all types of gonorrhea infection (genital, anal, and throat). For genital and anal gonorrhea, there are some alternative oral cephalosporin treatments that physicians can consider, but there are currently no recommended alternatives for pharyngeal infection.
“New treatment recommendations are critical if we are to continue to see progress in controlling gonorrhea,” said Dr. John Douglas, director of the Division of STD Prevention. “We cannot afford to lose ground against a disease that continues to affect roughly 700,000 Americans each year.”