Abstract
Sexually transmitted infections (STIs) caused by the bacteria Neisseria gonorrhoeae (gonococcal infections) have increased 63% since 2014 and are a cause of sequelae including pelvic inflammatory disease, ectopic pregnancy, and infertility and can facilitate transmission of human immunodeficiency virus (HIV) (1,2). Effective treatment can prevent complications and transmission, but N. gonorrhoeae's ability to acquire antimicrobial resistance influences treatment recommendations and complicates control (3). In 2010, CDC recommended a single 250 mg intramuscular (IM) dose of ceftriaxone and a single 1 g oral dose of azithromycin for treatment of uncomplicated gonococcal infections of the cervix, urethra, and rectum as a strategy for preventing ceftriaxone resistance and treating possible coinfection with Chlamydia trachomatis (4). Increasing concern for antimicrobial stewardship and the potential impact of dual therapy on commensal organisms and concurrent pathogens (3), in conjunction with the continued low incidence of ceftriaxone resistance and the increased incidence of azithromycin resistance, has led to reevaluation of this recommendation. This report, which updates previous guidelines (5), recommends a single 500 mg IM dose of ceftriaxone for treatment of uncomplicated urogenital, anorectal, and pharyngeal gonorrhea. If chlamydial infection has not been excluded, concurrent treatment with doxycycline (100 mg orally twice a day for 7 days) is recommended. Continuing to monitor for emergence of ceftriaxone resistance through surveillance and health care providers' reporting of treatment failures is essential to ensuring continued efficacy of recommended regimens.
Highlights
What are the implications for public health practice?
Continuing to monitor for emergence of ceftriaxone resistance will be essential to ensuring continued efficacy of recommended regimens
A test-of-cure is unnecessary for persons with uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens; for persons with pharyngeal gonorrhea, a test-of-cure is recommended, using culture or nucleic acid amplification tests 7–14 days after initial treatment, regardless of the treatment regimen
Summary
Availability of sensitive C. trachomatis nucleic acid amplification tests were widespread by 2010, but CDC recommended gonococcal dual therapy with a cephalosporin (ceftriaxone 250 mg IM or cefixime 400 mg orally) and either azithromycin or doxycycline [4] to reflect concerns regarding emerging gonococcal resistance. Since publication of the 2015 Sexually Transmitted Diseases (STD) Treatment Guidelines, concerns regarding antimicrobial stewardship have increased, especially the impact of antimicrobial use on the microbiome and data indicating azithromycin resistance (elevated MICs) for gonorrhea and other organisms [1,3]. Pharmacokinetic and pharmacodynamic modeling has affected the understanding of optimal antimicrobial dosing for N. gonorrhoeae treatment This update provides the rationale for the change in gonorrhea treatment recommendations to a higher dose (500 mg) of ceftriaxone and removal of azithromycin from the recommended regimen. Individual participants evaluated the quality of evidence, provided their input, and discussed findings in the context of the modified rating system used by the U.S Preventive Services Task Force.† CDC staff members independently reviewed tables of evidence,§ individual comments from the participants and professional organizations, and existing guidelines from other organizations to determine if revisions to the 2015 CDC STD Treatment Guidelines were warranted
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