Gonorrhea Medication
- Author: Nicholas John Bennett, MB, BCh, PhD; Chief Editor: Russell W Steele, MD more...
Medication Summary
In April 2007, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection and associated conditions.[1] Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States and other parts of the world where resistance has become common, but these agents can be considered in areas where quinolone resistance has not yet emerged.
The recommendation was based on analysis of new data from the CDC’s Gonococcal Isolate Surveillance Project (GISP).[9] The data from GISP showed the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone resistant reached 6.7%, an 11-fold increase from 0.6% in 2001. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 250 mg intramuscularly [IM] once as a single dose).
Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented. For more information, see the CDC's Websites on antibiotic-resistant gonorrhea and updated recommended gonococcal treatment regimens (April 2007), or Medscape Medical News's article on the CDC's treatment recommendations for gonorrhea.
Antibiotic agents
Class Summary
Medical therapy requires an antibiotic with efficacy against Neisseria gonorrhoeae. Until several years ago, the treatment of choice involved oral medication for as long as 10 days or an injection; however, patients tend to be poorly compliant with medications for various reasons, and the availability of newer medications has allowed in-office, single-dose, oral treatment to ensure compliance.
Many practitioners presumptively treat patients after obtaining specimens for diagnosis, based on history and examination, because of the risk of poor follow-up, complications, and continuing spread to other partners. In addition, because gonorrhea is often simultaneously diagnosed with chlamydia , many practitioners treat patients for both diseases when treating for either one beyond the newborn period. Diagnosis and treatment of the patient's partner and any partners of the partner are important to prevent reinfection and complications.
Disseminated or complicated infections (eg, endocarditis, meningitis) require more prolonged inpatient therapy. For example, ceftriaxone 50 mg/kg intravenously (IV) twice daily (BID) for 7 days plus a macrolide such as azithromycin administered for simple disseminated infection (10-14 d for meningitis or 28 d for endocarditis). Fluoroquinolones are no longer recommended for gonorrhea because of increased resistance.
If cephalosporins are not an option for disseminated gonorrhea or pelvic inflammatory disease (PID), fluoroquinolones may be considered if the local data suggest antimicrobial susceptibility. For these cases, an infectious disease consultation is essential. Children older than 8 years may omit the macrolide in cases of endocarditis.
Information from the Centers for Disease Control and Prevention (CDC) states that 2 g of oral (PO) azithromycin is effective against uncomplicated gonococcal infection, but it is expensive, causes gastrointestinal (GI) irritation, and is not recommended for treatment of gonorrhea. Although 1 g of azithromycin theoretically meets alternative regimen criteria, it is not recommended because of concerns regarding the possible rapid emergence of antimicrobial resistance. N gonorrhoeae in the United States is not adequately susceptible to penicillins, tetracyclines, and macrolides (eg, erythromycin) for these antimicrobials to be recommended.[1]
Cefixime (Suprax)
Cefixime is the drug of choice (DOC) for treating gonorrhea because of its oral efficacy, single-dose treatment, and lower cost than parenteral medication. Cefixime inhibits bacterial cell wall synthesis by binding to one or more of the PBPs. After a period of unavailability, oral cefixime is now available again in the United States, in tablet and suspension, for the treatment of uncomplicated urogenital or rectal gonorrhea.[10]
Ceftriaxone (Rocephin)
Ceftriaxone is the second drug of choice (DOC) for treatment of gonorrhea and for uncomplicated genitourinary infections because of its higher cost, discomfort with administration, and the additional administration expense of injection.
Ceftriaxone is often used as first-line therapy for disseminated gonococcal infection (DGI), outpatient pelvic inflammatory disease (PID), and pharyngeal infection. Ceftriaxone binds to penicillin-binding proteins (PBPs), inhibiting bacterial cell wall growth.
Spectinomycin (Trobicin)
Spectinomycin is indicated for patients with beta-lactam intolerance and may be used in instances of allergy to cephalosporins. However, this agent is a second-line choice due to its poor efficacy in pharyngitis. Spectinomycin inhibits protein synthesis in bacterial cells; its site of action is the 30S ribosomal subunit, and it is structurally different from related aminoglycosides.
Erythromycin base ( E.E.S., Ery-Tab, EryPed, Ilotycin)
Erythromycin is indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections. This agent inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Azithromycin (Zithromax, Zmax)
Azithromycin is used to treat mild to moderate microbial infections. This agent inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Information from the Centers for Disease Control and Prevention (CDC) states that azithromycin 2 g orally (PO) is effective against uncomplicated gonococcal infection, but it is expensive, causes gastrointestinal irritation, and is not recommended for treatment of gonorrhea.
Although azithromycin 1 g theoretically meets alternative regimen criteria, it is not recommended because of concerns regarding the possible rapid emergence of antimicrobial resistance.
Doxycycline (Adoxa, Vibramycin, Doryx)
Doxycycline inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Silver nitrate
Silver nitrate inhibits growth of both gram-positive and gram-negative bacteria. The germicidal effects of this agent are attributed to precipitation of bacterial proteins by liberated silver ions.
[Guideline] CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6. [Medline]. [Full Text].
Warner L, Stone KM, Macaluso M, Buehler JW, Austin HD. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis. Jan 2006;33(1):36-51. [Medline].
Centers for Disease Control and Prevention. 2009 Sexually transmitted diseases surveillance: gonorrhea. Available at http://www.cdc.gov/STD/stats09/gonorrhea.htm. Accessed 5/27/11.
Mulye TP, Park MJ, Nelson CD, Adams SH, Irwin CE Jr, Brindis CD. Trends in adolescent and young adult health in the United States. J Adolesc Health. Jul 2009;45(1):8-24. [Medline].
Goodyear-Smith F. What is the evidence for non-sexual transmission of gonorrhoea in children after the neonatal period? A systematic review. J Forensic Leg Med. Nov 2007;14(8):489-502. [Medline].
Trent M, Haggerty CL, Jennings JM, Lee S, Bass DC, Ness R. Adverse adolescent reproductive health outcomes after pelvic inflammatory disease. Arch Pediatr Adolesc Med. Jan 2011;165(1):49-54. [Medline].
García PJ, Holmes KK, Cárcamo CP, Garnett GP, Hughes JP, Campos PE, et al. Prevention of sexually transmitted infections in urban communities (Peru PREVEN): a multicomponent community-randomised controlled trial. Lancet. Mar 24 2012;379(9821):1120-8. [Medline].
Whiley DM, Tapsall JW, Sloots TP. Nucleic acid amplification testing for Neisseria gonorrhoeae: an ongoing challenge. J Mol Diagn. Feb 2006;8(1):3-15. [Medline]. [Full Text].
Gonococcal Isolate Surveillance Project (GISP) Annual Report 2005. Sexually Transmitted Disease Surveillance 2005 Supplement. CDC; January 2007. [Full Text].
Availability of cefixime 400 mg tablets--United States, April 2008. MMWR Morb Mortal Wkly Rep. Apr 25 2008;57(16):435. [Medline].
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