Global Gonorrhea: Problems on the Horizon
Global Gonorrhea: Problems on the Horizon
This is Paul Auwaerter for Medscape Infectious Diseases, speaking from Johns Hopkins University, Division of Infectious Diseases.
It has been 5 years since fluoroquinolones such as ciprofloxacin have been no longer recommended for the treatment of gonococcal infections because of rapidly rising rates of resistance. The World Health Organization estimates that 1% of the world's population has Neisseria gonorrhoeae, one of the most common sexually transmitted diseases. Of course, this infection contributes to infertility, serious infections such as pelvic inflammatory disease, epididymitis, and urethritis, for example, in men.
One of the growing concerns is the rapid evolution of resistance. For some time now, recommendations have been made to use higher doses of ceftriaxone (ie, 250 mg intramuscularly for 1 dose) as well as azithromycin 1 g in an effort not only to treat chlamydia but also to blunt some of the problems with increasing rates of resistance.
Numerous reports have shown reduced trends in susceptibility testing to not only ceftriaxone but also the oral alternatives, such as cefixime, in a number of countries. Two recent reports are especially disturbing. A report from Japan last year commented on high levels of ceftriaxone and cefixime resistance, rendering both drugs unusable. More recently, Unemo and colleagues reported that a second and different strain was detected in Europe, with high levels of resistance that seem to be due to novel altered penicillin-binding proteins.
N gonorrhoeae seem to be bacteria that develop resistance quickly compared with other organisms. It may be heightened, in fact, by the public health strategy of using short courses of antibiotics in people who may not be entirely compliant with their medication, in an effort to staunch the infection and prevent it from being transmitted to others.
A number of people have raised concerns recently about the threat of this quickly emerging resistance. Bolan and colleagues wrote a good perspective highlighting these points. Some of this, of course, is brought about by the wonderful benefits of molecular testing whereby we can have a rapid diagnosis. However, this does not afford a culture that would detect gonorrhea and also give susceptibility testing. We are often left with national surveillance data such as the Gonococcal Isolate Surveillance Project, which has been very helpful but only looks at limited areas.
Although people are treated with ceftriaxone and azithromycin, for example, it is important to have another look after 12 weeks to make sure that there has been an effective cure, especially because of increasing rates of resistance. The patients' partners of the past 2 months are also treated. The concerns of resistance are especially heightened in the western part of the United States because many of these isolates may be coming from the Pacific Rim countries, as well as populations that seem to have higher rates of quickly emerging resistance, such as men who have sex with men.
I would like to close by saying that if we peer into the future to see what's next, we will hear more about problems with ceftriaxone and the fact that cephalosporins may not be relied upon for the treatment of gonorrhea. Will this mean using different drugs, such as carbapenems, or the resuscitation of older drugs such as spectinomycin, which is not currently available but has had some toxicities and resistance in the past? A vaccine against the gonococcus seems quite a distance away and not in the short-term future.
Perhaps there will be a change in strategy where cultures will be important. Follow-up in terms of susceptibility testing may need to be more individualized rather than a global uniform recommendation. Clearly, one of the most important things may be a return to encouraging safe sexual practices. HIV was one of the most effective means of reinforcing this message, but with the advent of antiretroviral therapy, it may have been lessened.
Unfortunately, with the gonococcus perhaps returning to the preantibiotic era, it may be one of the key messages to force people to consider behavioral changes such as safe sexual practices and condom use, as opposed to something as important as HIV.
There is no doubt that more will change with the gonococcus, whether we have new drugs that come up in time or we need other important public health strategies. Hopefully there will be a mix of both, but this seems as pressing as ever in the world of bacteria and antibiotic resistance.
Thanks for listening.
This is Paul Auwaerter for Medscape Infectious Diseases, speaking from Johns Hopkins University, Division of Infectious Diseases.
It has been 5 years since fluoroquinolones such as ciprofloxacin have been no longer recommended for the treatment of gonococcal infections because of rapidly rising rates of resistance. The World Health Organization estimates that 1% of the world's population has Neisseria gonorrhoeae, one of the most common sexually transmitted diseases. Of course, this infection contributes to infertility, serious infections such as pelvic inflammatory disease, epididymitis, and urethritis, for example, in men.
One of the growing concerns is the rapid evolution of resistance. For some time now, recommendations have been made to use higher doses of ceftriaxone (ie, 250 mg intramuscularly for 1 dose) as well as azithromycin 1 g in an effort not only to treat chlamydia but also to blunt some of the problems with increasing rates of resistance.
Numerous reports have shown reduced trends in susceptibility testing to not only ceftriaxone but also the oral alternatives, such as cefixime, in a number of countries. Two recent reports are especially disturbing. A report from Japan last year commented on high levels of ceftriaxone and cefixime resistance, rendering both drugs unusable. More recently, Unemo and colleagues reported that a second and different strain was detected in Europe, with high levels of resistance that seem to be due to novel altered penicillin-binding proteins.
N gonorrhoeae seem to be bacteria that develop resistance quickly compared with other organisms. It may be heightened, in fact, by the public health strategy of using short courses of antibiotics in people who may not be entirely compliant with their medication, in an effort to staunch the infection and prevent it from being transmitted to others.
A number of people have raised concerns recently about the threat of this quickly emerging resistance. Bolan and colleagues wrote a good perspective highlighting these points. Some of this, of course, is brought about by the wonderful benefits of molecular testing whereby we can have a rapid diagnosis. However, this does not afford a culture that would detect gonorrhea and also give susceptibility testing. We are often left with national surveillance data such as the Gonococcal Isolate Surveillance Project, which has been very helpful but only looks at limited areas.
Although people are treated with ceftriaxone and azithromycin, for example, it is important to have another look after 12 weeks to make sure that there has been an effective cure, especially because of increasing rates of resistance. The patients' partners of the past 2 months are also treated. The concerns of resistance are especially heightened in the western part of the United States because many of these isolates may be coming from the Pacific Rim countries, as well as populations that seem to have higher rates of quickly emerging resistance, such as men who have sex with men.
I would like to close by saying that if we peer into the future to see what's next, we will hear more about problems with ceftriaxone and the fact that cephalosporins may not be relied upon for the treatment of gonorrhea. Will this mean using different drugs, such as carbapenems, or the resuscitation of older drugs such as spectinomycin, which is not currently available but has had some toxicities and resistance in the past? A vaccine against the gonococcus seems quite a distance away and not in the short-term future.
Perhaps there will be a change in strategy where cultures will be important. Follow-up in terms of susceptibility testing may need to be more individualized rather than a global uniform recommendation. Clearly, one of the most important things may be a return to encouraging safe sexual practices. HIV was one of the most effective means of reinforcing this message, but with the advent of antiretroviral therapy, it may have been lessened.
Unfortunately, with the gonococcus perhaps returning to the preantibiotic era, it may be one of the key messages to force people to consider behavioral changes such as safe sexual practices and condom use, as opposed to something as important as HIV.
There is no doubt that more will change with the gonococcus, whether we have new drugs that come up in time or we need other important public health strategies. Hopefully there will be a mix of both, but this seems as pressing as ever in the world of bacteria and antibiotic resistance.
Thanks for listening.