Gonorrhea:Decreased Susceptibility to Oral Cephalosporins and New Treatment Guidelines

We are writing to inform you about two recent developments related to sexually transmitted infections in New Mexico: 1) the emergence of Neisserria gonorrhoeae with decreased susceptibility to oral cephalosporins. 2) New treatment guidelines for gonorrhea.

Recently the emergence of Neisseria gonorrhoeae isolates that are less susceptible to oral third generation cephalosporins commonly used to treat gonorrhea, including cefpodoxime (Vantin) and cefixime (Suprax) have been seen in New Mexico and in other parts of the United States and the world. In addition, treatment failures with oral cephalosporins are being reported in Japan, Greece, Russia, and most recently in Europe. In New Mexico, the gonococci with decreased susceptibility to cefpodoxime (Vantin) were also resistant to penicillin, tetracycline, and quinolones. Some new evidence suggests that treating gonorrhea with two drugs is superior to using only one.

In response to these new developments and in concert with the newly revised STD Treatment Guidelines from the Centers for Disease Control and Prevention, the New Mexico Department of Health has revised treatment protocols for gonorrhea. We will cease using cefpodoxime as a treatment for gonorrhea in our public health offices. Ceftriaxone PLUS azithromycin is the recommended regimen for all cases of uncomplicated uro-genital and pharyngeal gonococcal infections. Dual antibiotic therapy (i.e. a cephalosporin PLUS azithromycin) should be used for ALL cases of gonorrhea, regardless of chlamydia infection status. Listed below are the new recommended treatment regimens.

Uncomplicated genital/ rectal infections

Recommended regimen

  • Ceftriaxone 250 mg IM as a single dose
PLUS
  • Azithromycin 1.0 g PO as a single dose

Alternative regimen (if ceftriaxone not available):

  • Cefixime 400 mg PO as a single dose
PLUS
  • Azithromycin 1.0 g PO as a single dose

Pharyngeal infections

Recommended regimen

  • Ceftriaxone 250 mg IM as a single dose
PLUS
  • Azithromycin 1.0 g PO as a single dose

**oral therapy is NOT recommended for pharyngeal infections due to low treatment efficacy with oral cephalosporin

Doxycycline 100 mg PO BID x 7 days may be substituted for azithromycin in those clients unable to take azithromycin. Azithromycin is the preferred second antibiotic due to higher levels of resistanceto tetracyclines among gonococcal isolates at a local and national level.

Any person with suspected cephalosporin treatment failure or resistance should have culture and susceptibility testing of relevant clinical specimens. Expert clinical consultation with thePublic Health Department’s Infectious Disease Bureau Medical Director, or another infectious disease expert, should be sought to guide treatment and the case should be directly reported to state STD program.

In addition, we emphasize the importance of treating an infected patient’s partner(s), including the options of partner referral to your local NM Department of Health office and expedited partner therapy.

In New Mexico in 2011, approximately 40% of all reported gonococcal infections in menreported a risk factor male sex partners (MSM). CDC and the NM Department of Health recommend that providers screen all sexually active MSM for gonorrhea, chlamydia, syphilis, and HIV (if the patient is not previously HIV diagnosed) at least annually. Screen MSM patients for gonorrhea and chlamydia at all exposed anatomical sites (oral, rectal, urethral). Many local laboratories will now accept pharyngeal and rectal specimens, in addition to urine specimens, for gonorrhea and chlamydia testing using nucleic acid amplification tests.

Thank you for your hard work helping to treat and prevent HIV and other STDs. We will continue to keep you informed as we learn more about any changes in the susceptibility of N. gonorrhoeae in our community.

  • The new 2010 CDC Sexually Transmitted Disease Treatment Guidelines may be accessed at:
  • The NM STD Program may be contacted at: 505-476-1778 or 476-3636.
  • Dr. Linda Gorgos, Medical Director, Infectious Disease Bureau may be contacted at 505-476-3668 or 505-977-7134