Emerging multi-drug resistant gonorrhea is a global concern. In response, we at BCCDC Clinical Prevention Services (CPS) have been working with the Public Health Agency of Canada (PHAC) to produce updates to the Gonorrhea Chapter treatment guidelines. These guidelines were recently released by PHAC and provisionally recommended in BC last year.
Recommendations
The revised guidelines call for an increase in dosing of the oral cephalosporin, cefixime, from 400 to 800 mg (PO, single dose) in all cases used. In men who have sex with men (MSM), the population in which resistance has historically first appeared, the guidelines recommend co-administration with 1 gram of azithromycin (PO, single dose), rather than doxycycline, to routinely cover chlamydia co-infections and to provide additional antimicrobial activity against gonorrhea. This is because azithromycin is more active than doxycycline against gonorrhea, and use of multiple active drugs from different antibiotic classes is thought to prevent development of drug resistance.
In addition, where possible, among MSM or anyone with pharyngeal infection, ceftriaxone 250 mg intramuscular (IM) is preferentially recommended over oral cefixime, in order to achieve more reliable antibiotic levels. This is based on expert opinion, and some jurisdictions in North America have gone to IM ceftriaxone replacing oral cefixime across the board. We agree this is reasonable; however, we also recognize that losing a purely oral outpatient option has consequences to consider in cost, logistics and patient preference.
Trends in BC
We note that very recent research suggests that dual treatment (i.e. any cephalosporin PLUS azithromycin) may be the more important factor in preventing drug resistance than route or dose. Reassuringly, in BC we have recently observed an improvement in GC drug resistance trends. At the current time, we recommend following the Canadian guidelines. We will continue enhanced GC resistance surveillance and update the BC STI treatment guidelines according to local epidemiology in the coming months.
Acknowledgments
The British Columbia Centre for Disease Control and the Provincial Health Services Authority Laboratories.
For further information
- Update to Canadian gonorrhea treatment guidelines: http://www.phac-aspc.gc.ca/std-mts/sti-its/alert/2011/alert-gono-eng.php
- BCCDC STI guidelines: http://www.bccdc.ca/dis-cond/comm-manual/CDManualChap5.htm
- Barbee, L. A., Kerani, R. P., Dombrowski, J. C., Soge, O. O., and Golden, M. R. A retrospective comparative study of 2-drug oral and intramuscular cephalosporin treatment regimens for pharyngeal gonorrhea. Clin.Infect.Dis., Vol. 56, No. 11, 2013, pp. 1539-1545.
- Public Health Microbiology and Reference Laboratory, Neisseria gonorrhoeae Susceptibility Testing Trends: http://www.bccdc.ca/NR/rdonlyres/13199C28-6FBA-4C83-905D-402992FF258A/0/May2013LaboratoryTrends.pdf