Fluoroquinolones should no longer be used to treat Neisseria gonorrhoeae in men who have sex with men, according to the Centers for Disease Control and Prevention.
The new recommendation comes after preliminary data showed that drug-resistant gonorrhea cases significantly increased in the United States in 2003, particularly in that population, Dr. John Douglas, director of the CDC's STD prevention programs, said at a press briefing.
The CDC now recommends that men who have sex with men (MSM) be treated with either ceftriaxone 125 mg intramuscularly or cefixime 400 mg orally (not currently available in the United States): Spectinomycin 2 g intramuscularly is an alternative (MMWR 53:335-38, 2004).
The recommendation of an intramuscular injection as first-line therapy creates a "clinical hassle," noted Dr. Karla Schmitt, chief, Bureau of Sexually Transmitted Diseases Prevention and Control at the Florida Department of Health, Tallahassee. "Gonorrhea is mostly treated in the office setting, and offices try to minimize injections for safety reasons." With injections, there are also matters of staffing and related costs as well as acceptance from patients, she added.
Dr. Schmitt noted that the oral agent cefixime will eventually be available in the United States, which is "encouraging." Lupin Pharmaceuticals Inc. of Baltimore received Food and Drug Administration approval to manufacture and market cefixime in February 2004.
But ceftriaxone is the only truly viable treatment at this moment, she said. "Spectinomycin is very difficult to obtain and is not produced in large quantities right now," Dr. Schmitt said.
If spectinomycin is obtained and used, the drug may only be used for urogenital and anorectal gonorrhea; it is not sufficiently effective to treat pharyngeal gonorrhea, according to the CDC.
In cases of gonorrhea in which Chlamydia trachomatis is not ruled out, each regimen should be followed with either azithromycin 1 g orally (single dose) or doxycycline 100 mg orally twice daily for 7 days to treat any possible coinfection, the CDC advised.
Physicians who need to treat a case of gonorrhea but do not stock ceftriaxone in their offices should contact their public health department to obtain the drug or refer the patient to another provider. Dr. Schmitt said.
"All hospitals stock ceftriaxone, which is an antibiotic commonly used in the elderly," she said.
Contacting the local public health department also provides the starting point for partner identification. "Partner identification for gonorrhea is limited in most U.S. locales due to resource constraints but would be available if a resistant strain were suspected," she commented.
The new recommendations for the treatment of gonorrhea in MSM present a host of issues for physicians, including how to detect the disease. "The strains of gonorrhea now are not as virulent as we saw in the 1980s. You do not see the really messy drip and pain as in the past," according to Dr. Schmitt. The majority of patients treated for gonorrhea in Florida are asymptomatic or have mild symptoms. "The great majority of our patients are not identified via symptoms but by routine screening after indicating a history of risky sexual behavior."
Despite the importance of screening for gonorrhea, physicians are not screening enough, said Dr. …