Drugs of Choice for the Treatment of Uncomplicated Gonococcal Infections

Abstract

Resistance of Neisseria gonorrhoeae to antimicrobial agents continues to spread and intensify. Choosing an antimicrobial regimen requires knowledge of the comparative efficacy of candidate regimens, as delineated in properly conducted clinical trials; their activity against N. gonorrhoeae in vitro; and their pharmacokinetics and toxicity. We tabulated the results of trials of single-dose antimicrobial therapy for uncomplicated gonococcal infection published after 1980. Thirty regimens comprising 21 antimicrobial drugs have been shown to be highly effective for rectal and urogenital infections; the agents involved are cefixime, cefodizime, cefotaxime, cefoxitin, ceftizoxime, ceftriaxone, cefuroxime, cefuroxime axetil, ciprofloxacin, fleroxacin, norfloxacin, ofloxacin, pefloxacin, temafloxacin, azithromycin, aztreonam, netilmicin, rifampin plus erythromycin stearate, sisomicin, and spectinomycin. Few regimens have been shown to be highly effective against pharyngeal infections. Among those antimicrobial agents available for the treatment of uncomplicated gonococcal infections in the United States, ceftriaxone (125 mg), cefixime (400 mg), ciprofloxacin (500 mg), and ofloxacin (400 mg) appear to offer the best balance of proven efficacy and safety.

2012 European guideline on the diagnosis and treatment of gonorrhoea in adults

“…[56][57][58][59][60]71,72 This correlates with the pharmacokinetic properties of the individual antimicrobials. Treatment with spectinomycin has poor efficacy at eradicating pharyngeal gonorrhoea.…”

“…40,[56][57][58][59][60] The safety of azithromycin in pregnancy has not been confirmed but clinical experience indicates that it may be safely used. It should only be used under medical supervision if the expected benefit to the mother is thought to be greater than the possible risk to the foetus.…”

“…16 Test of cure is particularly important to perform to ensure effective eradication of pharyngeal infection, which is substantially harder to treat than genital and anorectal infections. [56][57][58][59][60]71,72 When symptoms persist after treatment, culture is recommended to identify persisting infection and for antimicrobial sensitivity testing and may be performed 3-7 days after completion of therapy, possibly supplemented a week later with a NAAT for increased sensitivity if culture is negative. Tests of cure in asymptomatic patients can be performed with a NAAT 2 weeks after completion of treatment and ideally, all positives should be cultured and antibiotic susceptibility testing performed before further treatment is given [IV; C].…”

Neisseria gonorrhoeae Strain with High-Level Resistance to Spectinomycin Due to a Novel Resistance Mechanism (Mutated Ribosomal Protein S5) Verified in Norway

“…Nevertheless, spectinomycin remains an effective option for treatment, with the exception of pharyngeal gonorrhea (4,(21)(22)(23)(24)(25). Verified resistance to spectinomycin is exceedingly rare worldwide, e.g., in the U.S. Gonococcal Isolate Surveillance Project (GISP), established in 1986 (http://www.cdc.gov/std/gisp), and the European Gonococcal Antimicrobial Surveillance Programme (EURO-GASP), initiated in 2004 (26,27), only five spectinomycin-resistant isolates (all between 1988 and 1990) and no isolates, respectively, have been identified.…”

Cultivation of Neisseria gonorrhoeae in Liquid Media and Determination of Its In Vitro Susceptibilities to Quinolones

“…Moran and Levine proposed "therapeutic time" as a pharmacodynamic parameter for the treatment of gonorrhea, whereby the therapeutic time was defined as the interval between the time the peak plasma concentration was reached and the time the plasma concentration dropped to less than four times the MIC 90 (18). According to that report, an effective gonococcal cure was expected when the value of the therapeutic time was 10 h or more according to all antimicrobial regimens, including the use of quinolones.…”