Cephalosporin-Resistant Gonorrhea Increases in the United States

On Friday, the CDC reported the growing resistance of Neisseria gonorrhoeae, the bacterium that causes (not surprisingly) gonorrhea, to the class of antibiotics called cephalosporins. This is concerning because, as the CDC stressed, "No other well-studied and effective antibiotic treatment options or combinations currently are available." Most recently the CDC had recommended dual antibiotic therapy for the treatment of gonorrhea in the United States, consisting of ceftriaxone (the most-effective cephalosporin for the venereal disease) and azithromycin or doxycyline. This recommendation has changed slightly on the basis of data from the CDC-sponsored Gonococcal Isolate Surveillance Project (GISP).

According to GISP, ceftriaxone-resistant N. gonorrhoeae in the United States increased threefold, from 0.1% in 2000 to 0.3% last year. And while the CDC continues to recommend ceftriaxone as part of effective therapy for gonorrhea, the agency appears to be bracing for growing antibiotic resistance—like that seen with N. gonorrhoeae and fluoroquinolones at the turn of the century. The CDC recommends that the other half of currently recommended therapy for uncomplicated gonorrhea should now consist of azithromycin (not doxycycline) because of the sensitivity/resistance patterns of the latest cephalosporin-resistant N. gonorrhoeae isolates.

The history of antibiotic-resistant N. gonorrhoeae is nearly as old as the history of antibiotics. Before the advent of antimicrobial drugs, gonorrhea was treated in a haphazard way with various concoctions, delivered either systemically or locally. One such treatment, prescribed to a victim of Elixir of Sulfanilamide, called for a mixture of zinc sulphate, lead acetate, colorless hydrastis (the herb goldenseal), and bismouth subnitrate, which was to be injected by way of a penis syringe.

Sulfanilamide was the first widely available antibiotic shown to be effective against the venereal disease (see Dees JE, Colston JAC. The use of sulfanilamide in gonococcic infections. J Am Med Assoc. 1937;108:1854-1858). But sulfonamide resistance was reported as early as the mid-1940s, and preferred therapy for gonorrhea became penicillin, until N. gonorrhoeae resistance to this mainstay emerged in the 1960s (see here, here, and here for example) and grew throughout the 1970s. Tetracycline-resistant N. gonorrhoeae emerged in the 1980s (see here for example), and fluoroquinolone-resistant bugs (eg, to ciprofloxacin, ofloxacin) showed up in Hawaii in the mid-90s.

Gram stain showing N. gonorrhoeae diplococci from the CDC/M. Rein (1978).