CDC surveillance shows gonorrhea becoming more resistant to antibiotics
Christopher S.Prestel, M.D., FAAP and Larry K.Pickering, M.D., FIDSA, FAAP
MMWR in Review
Kirkcaldy RD, et al. “Neisseria gonorrhoeae Antimicrobial Susceptibility Surveillance — The Gonococcal Isolate Surveillance Project,
27 Sites, United States, 2014.” MMWR Surveill Summ. 2016;65(No. SS-7):1-19, http://dx.doi.org/10.15585/mmwr.ss6507a1.
Approximately half of high school students are sexually active, but few use birth
control and 40% do not use condoms, leaving teens susceptible to pregnancy and sexually
transmitted infections (STIs). Both chlamydia and gonorrhea infections are prevalent
in males and females 15-19 years of age, with 25% of all reported infections occurring
in this age group.
Gonorrhea has been the second most commonly reported nationally notifiable disease
in the U.S since 1995. In 2014, 350,062 cases of gonorrhea were reported. The highest
rates were in the southern U.S., with 131.4 cases per 100,000 population.
Gonococcal infections can occur at any age and involve mucous membranes of the urethra,
cervix, pharynx, rectum and eyes. The most common site of infection is the urethra,
which may be asymptomatic or associated with discharge or pain during urination. Urethral
infections in males are more likely to be symptomatic than genitourinary tract infections
in women and therefore are easier to diagnose.
Cervical infections may lead to pelvic inflammatory disease, which can severely impact
female reproductive health. Infants born to mothers with genital gonococcal infection
may develop neonatal ophthalmia, which can progress to blindness. Disseminated disease
may be further complicated by septic arthritis, meningitis and endocarditis. An untreated
infection may increase the risk of acquiring HIV.
Rapid diagnosis and effective antimicrobial therapy help prevent complications of
gonorrhea and transmission to sexual partners. Based on a patient’s risks and symptoms,
testing may be indicated.
Two options generally are available for diagnosis: nucleic amplification test (NAAT)
and culture. NAATs allow for testing of gonorrhea and chlamydia using urine specimens
or vaginal swabs. It is less invasive than culture but does not provide antimicrobial
susceptibility testing. NAATs are not approved by the Food and Drug Administration
for testing nongenital specimens but may be performed by laboratories that have met
the Clinical Laboratory Improvement Amendment and other regulatory requirements for
In 1986, the Centers for Disease Control and Prevention (CDC) created the Gonococcal
Isolate Surveillance Project (GISP) as a sentinel surveillance system to monitor trends
in antimicrobial susceptibility of N. gonorrhoeae strains in the U.S., to facilitate national treatment recommendations and to establish
research and prevention priorities.
On July 15, the CDC released results of the GISP, which showed that gonorrhea is becoming
more resistant to antibiotics. Development of resistance to tetracycline, penicillin
and ciprofloxacin as well as removal of cefixime as part of first-line therapy in
2012 have mandated regular changes to treatment recommendations.
New data from GISP revealed that azithromycin resistance rates increased from 0.6%
in 2013 to 2.5% in 2014. This represents a more than 300% change in reduced susceptibility
to azithromycin. One hypothesis for this dramatic increase is the high frequency of
azithromycin prescriptions being written for upper respiratory tract infections.
The percentage of reduced susceptibility to ceftriaxone has remained roughly the same
(about 0.2% nationally) over the last 10 years. No cross-resistance has been identified
between ceftriaxone and azithromycin.
These data continue to support the CDC recommendation that dual therapy with intramuscular
ceftriaxone plus oral azithromycin is the only recommended treatment for gonorrhea.
This combination regimen is thought to have a synergistic effect that enhances killing
of N. gonorrhoeae, including strains resistant to one of the agents, and minimizes the potential for
transmission of resistant strains.
Adolescents found to have gonorrhea should be treated with 250 milligrams of ceftriaxone
intramuscularly and 1 gram of oral azithromycin. Additionally, the patient’s sexual
partners within the prior 60 days need to be treated. Ideally, these partners should
come to clinic to receive the same treatment, which can be administered under the
Expedited Partner Therapy treatment approach. This allows treatment in a timely manner
without medical evaluation.
Reinfection by an untreated partner or a new sexual partner is common, making it important
to rescreen all adolescents three months after treatment for gonorrhea or at their
next presentation to medical care.
Antibiotic treatment options for gonorrhea are limited. By using combination ceftriaxone
and azithromycin therapy, it may be possible to halt the further spread of resistant
gonorrhea. It also is important to use azithromycin judiciously for other illnesses
to prevent unnecessary antibiotic pressure on N. gonorrhoeae or other susceptible bacteria.
The AAP Committee on Adolescence states that adolescents should receive comprehensive,
appropriately confidential and developmentally appropriate primary care as recommended
by AAP guidelines (Bright Futures) within a medical home. Recommendations for preventive
pediatric health care include STI/HIV screening every year from 11 through 21 years
of age as recommended in the Red Book.
The Academy recommends the following screening procedure for gonorrhea:
Routinely screen all sexually active females younger than 21 years of age.
Consider annual screening of sexually active young adult males based on risk factors.
Routinely screen sexually active adolescent and young adult men who have sex with
men for pharyngeal, rectal and urethral infection if engaging in receptive oral or
anal intercourse or insertive intercourse.
Screening is recommended every three to six months for patients with multiple or anonymous
These recommendations emphasize the importance of obtaining a thorough sexual history
to identify high-risk patients and to know which anatomical sites should be screened.
The Red Book recommends private time to speak with an adolescent confidentially, without a parent
or guardian present, at every adolescent visit. If an adolescent indicates sexual
activity, it is important to define the partner gender and what type of sex they participate
in to best screen the involved anatomic locations.
Which of the following is true?
a) Dual therapy with ceftriaxone plus azithromycin is the only recommended treatment
b) Gonorrhea is the second-leading nationally notifiable disease in the U.S.
c) Results from nucleic amplification tests do not provide organism susceptibility
d) A vaccine is not available for prevention of infections due to
e) All of the above
Answer: E, all of the above
Dr. Prestel is a post-graduate training fellow in pediatric infectious diseases at
Emory University School of Medicine. Dr. Pickering was editor of the AAP Red Book from 2000-’12. He is adjunct professor of pediatrics at Emory University School of