What is the impact of rising antibiotic-resistant strains of Neisseria gonorrhoeae (Gonorrhea)?

From the Guidelines

The rise in antibiotic-resistant strains of gonorrhea requires dual therapy with ceftriaxone 500mg as a single intramuscular injection plus azithromycin 1g orally as a single dose, as recommended by the most recent guidelines 1. This combination approach is currently recommended as first-line treatment due to increasing resistance to previous standard therapies. Patients should abstain from sexual activity for 7 days after completing treatment and ensure all recent sexual partners are notified and treated to prevent reinfection. Follow-up testing 1-2 weeks after treatment is essential to confirm cure. Gonorrhea has developed resistance to multiple antibiotic classes over time, including penicillins, tetracyclines, fluoroquinolones, and now some cephalosporins, through mechanisms like altered drug binding sites and efflux pumps that remove antibiotics from bacterial cells. Prevention strategies include consistent condom use, regular STI screening for sexually active individuals, and completing the full course of antibiotics when prescribed. Healthcare providers should stay updated on local resistance patterns as treatment guidelines may change as resistance evolves.

Some key points to consider in the management of gonorrhea include:

• The importance of testing for pharyngeal infection in all cases of urogenital treatment failure, as recommended by the British Association for Sexual Health and HIV guidelines 1.
• The potential use of alternative antimicrobial agents, such as gentamicin, ertapenem, or novel antimicrobials like zoliflodacin and gepotidacin, in cases of treatment failure or resistance 1.
• The need for susceptibility testing to guide treatment decisions, particularly in cases of treatment failure or resistance 1.
• The importance of maintaining culture capacity for N. gonorrhoeae to monitor antimicrobial resistance trends and determine susceptibility to guide treatment following treatment failure 1.

Overall, the management of gonorrhea requires a comprehensive approach that includes prompt diagnosis, effective treatment, and prevention strategies to reduce the spread of antibiotic-resistant strains.

From the Research

Rise in Antibiotic-Resistant Strains of Gonorrhea

• The increase in antibiotic-resistant strains of gonorrhea is a significant concern, with studies indicating a rise in resistance to various antibiotics 2, 3, 4, 5.
• According to a 2014 study, the efficacy of gentamicin plus azithromycin and gemifloxacin plus azithromycin as treatment for uncomplicated gonorrhea was evaluated, with results showing high microbiological cure rates for both combinations 2.
• A 2018 study investigated the in vitro efficacy of 21 dual antimicrobial combinations, including current and alternative WHO-recommended treatment regimens, and found that some novel combinations showed high synergistic effects against Neisseria gonorrhoeae strains, including multi-drug resistant and extensively-drug resistant strains 3.
• The American College of Obstetricians and Gynecologists (ACOG) recommends dual therapy with ceftriaxone and azithromycin for the treatment of gonorrhea, with pregnant women being treated with the same recommended regimen 4.
• The Centers for Disease Control and Prevention (CDC) updated its treatment guidelines for gonococcal infection in 2020, recommending a single 500 mg intramuscular dose of ceftriaxone for treatment of uncomplicated urogenital, anorectal, and pharyngeal gonorrhea, with concurrent treatment with doxycycline if chlamydial infection has not been excluded 5.
• A 2013 study compared retreatment rates for uncomplicated gonorrhea infection between patients receiving ceftriaxone plus azithromycin and those receiving ceftriaxone plus doxycycline, finding no significant difference in retreatment rates between the two groups 6.

Treatment Options

• Ceftriaxone plus azithromycin is the currently recommended first-line regimen for the treatment of gonorrhea 4, 5.
• Alternative treatment options, such as gentamicin plus azithromycin and gemifloxacin plus azithromycin, have shown high efficacy in clinical trials 2.
• Novel combinations, such as gentamicin plus ertapenem and moxifloxacin plus ertapenem, have shown high synergistic effects against Neisseria gonorrhoeae strains in vitro 3.

Resistance and Retreatment

• The rise in antibiotic-resistant strains of gonorrhea is a significant concern, with studies indicating a increase in resistance to various antibiotics 2, 3, 4, 5.
• Retreatment rates for uncomplicated gonorrhea infection are common, highlighting the need for rescreening and better partner therapies 6.
• The use of expedited partner therapy (EPT) has been shown to reduce retreatment rates 6.