Infectious Disease

Within the replace, CDC recommends ceftriaxone alone for uncomplicated gonorrhea

December 18, 2020

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In the updated guidelines published in MMWR on Friday, the CDC recommended an intramuscular dose of 500 mg ceftriaxone for the treatment of uncomplicated gonorrhea.

Since 2010 the CDC had recommended a single dose of 250 mg intramuscular ceftriaxone and 1 g oral azithromycin “to prevent ceftriaxone resistance and to treat possible co-infection with Chlamydia trachomatis”. Saint St. Cyr, 1500; and colleagues from the CDC’s STD Prevention Unit, wrote.

“Growing concerns about antimicrobial control and the potential impact of dual therapy on commensal organisms and concurrent pathogens, coupled with the persistently low incidence of ceftriaxone resistance and the increased incidence of azithromycin resistance, has prompted a reassessment of this recommendation,” they write.

The updated guidelines now recommend adding 100 mg oral doxycycline – not azithromycin – twice daily for 7 days if chlamydial co-infection has not been ruled out.

“Further monitoring of the emergence of ceftriaxone resistance through monitoring and malpractice reporting by health care providers is critical to ensure the continued effectiveness of the recommended therapies,” wrote St. Cyr and colleagues.

In support of the updated recommendation, researchers cited evidence from the MORDOR study showing increased antibiotic resistance in children who received azithromycin twice a year during a mass-dosing campaign in Africa.

“Although dual drug therapy with different modes of action (ceftriaxone and azithromycin) may have mitigated the incidence of decreased susceptibility to ceftriaxone in N. gonorrhoeae, concerns about possible damage to the microbiome and effects on other pathogens diminish the benefits of maintaining dual therapy the recommended treatment regimen, ”they wrote.

In addition, St. Cyr and colleagues cited pharmacokinetic and pharmacodynamic considerations for the update – including the fact that tests showed that the previous dose of 250 mg ceftriaxone was insufficient to eradicate susceptible strains of N. gonorrhoeae – and data showing the changes of azithromycin susceptibility.

The new recommendation of a single 500 mg injection applies to patients weighing less than 300 pounds. For patients weighing more than 300 pounds, the CDC recommends a single intramuscular dose of 1 g of ceftriaxone. For patients with a cephalosporin allergy, a single intramuscular dose of 240 mg gentamicin plus a single oral dose of 2 g azithromycin is an option, according to St. Cyr and colleagues.

“Continued support for efforts to prevent and control gonorrhea remains essential, and preventing antibiotic resistance is vital,” they write. “The high incidence of pharyngeal gonorrhea with significant underscreening and the improved understanding of the individual’s large pharmacokinetic and pharmacodynamic variability contributed to the recommendation for an increased dose of ceftriaxone. These recommendations also include a healing test for people with pharyngeal gonorrhea to ensure eradication or detection of a possible malpractice. “

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Carlos del Rio, MD)

Carlos del Rio, MD

The updated guidelines for the treatment of gonorrhea were developed after reviewing the evidence. The percentage of N. gonorrheae isolates with reduced susceptibility to azithromycin is now a problem and has increased more than seven-fold over the past 5 years. This problem particularly affected men who have sex with men, in whom nearly 10% of the isolates have a decreased susceptibility to azithromycin. As a result, the CDC’s treatment guidelines have been changed and it is now recommended that a single intramuscular dose of 500 mg ceftriaxone be given for uncomplicated gonorrhea. This is double the previously recommended dose of ceftriaxone. Simultaneous use of azithromycin 100 mg PO daily for 7 days is still recommended for the treatment of co-infection with C. trachomatis.

Ceftriaxone is now the only drug available to treat gonorrhea, and the possibility of strains with reduced susceptibility to this drug remains. We could see untreatable gonorrhea in the future. This is why clinical trials testing new drugs for gonorrhea are vital.

Carlos del Rio, MD

Member of the editorial team for infectious diseases

Executive Associate Dean

Emory University School of Medicine

Disclosure: Del Rio does not report any relevant financial information.

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