Gonorrhea Tx in men who have sex with men.
The new recommendation comes after preliminary data showed that drug-resistant gonorrhea cases significantly increased in the United States in 2003, particularly in that population, Dr. John Douglas, director of the CDC's STD prevention programs, said at a press briefing.
The CDC now recommends that men who have sex with men (MSM) be treated with either ceftriaxone 125 mg intramuscularly or cefixime 400 mg orally (not currently available in the United States): Spectinomycin 2 g intramuscularly is an alternative (MMWR 53:335-38, 2004).
The recommendation of an intramuscular injection as first-line therapy creates a "clinical hassle," noted Dr. Karla Schmitt, chief, Bureau of Sexually Transmitted Diseases Prevention and Control at the Florida Department of Health, Tallahassee. "Gonorrhea is mostly treated in the office setting, and offices try to minimize injections for safety reasons." With injections, there are also matters of staffing and related costs as well as acceptance from patients, she added.
Dr. Schmitt noted that the oral agent cefixime will eventually be available in the United States, which is "encouraging." Lupin Pharmaceuticals Inc. of Baltimore received Food and Drug Administration approval to manufacture and market cefixime in February 2004.
But ceftriaxone is the only truly viable treatment at this moment, she said. "Spectinomycin is very difficult to obtain and is not produced in large quantities right now," Dr. Schmitt said.
If spectinomycin is obtained and used, the drug may only be used for urogenital and anorectal gonorrhea; it is not sufficiently effective to treat pharyngeal gonorrhea, according to the CDC.
In cases of gonorrhea in which Chlamydia trachomatis is not ruled out, each regimen should be followed with either azithromycin 1 g orally (single dose) or doxycycline 100 mg orally twice daily for 7 days to treat any possible coinfection, the CDC advised.
Physicians who need to treat a case of gonorrhea but do not stock ceftriaxone in their offices should contact their public health department to obtain the drug or refer the patient to another provider. Dr. Schmitt said.
"All hospitals stock ceftriaxone, which is an antibiotic commonly used in the elderly," she said.
Contacting the local public health department also provides the starting point for partner identification. "Partner identification for gonorrhea is limited in most U.S. locales due to resource constraints but would be available if a resistant strain were suspected," she commented.
The new recommendations for the treatment of gonorrhea in MSM present a host of issues for physicians, including how to detect the disease. "The strains of gonorrhea now are not as virulent as we saw in the 1980s. You do not see the really messy drip and pain as in the past," according to Dr. Schmitt. The majority of patients treated for gonorrhea in Florida are asymptomatic or have mild symptoms. "The great majority of our patients are not identified via symptoms but by routine screening after indicating a history of risky sexual behavior."
Despite the importance of screening for gonorrhea, physicians are not screening enough, said Dr. Kenneth Mayer, medical research director, Fenway Community Health, Boston.
"The absolute number of screenings for gonorrhea did not appreciably increase in Massachusetts in the last few years," he said. Massachusetts has one of the highest rates of quinolone-resistant N. gonorrhoeae (QRNG) in the country.
In cases of suspected gonorrhea, physicians need to ask patients with whom they are having sex to identify MSM and to choose the appropriate therapy, said Dr. Douglas of the CDC.
Travel histories also matter. "We don't really know why quinolone-resistant gonorrhea is happening among MSM. However, our best guess in that MSM have traveled to areas of the world with high rates of quinolone-resistant gonorrhea, such as Asia, the Pacific Islands, including Hawaii, and California [and contracted the disease there], Dr. Douglas said. The disease has then spread elsewhere through sexual "networking" among MSM, he said.
The Internet has facilitated such networking, Dr. Douglas observed. That networking can include sexually active teenagers.
"All pediatricians have to ask the appropriate questions about STDs and sexual activity. The age of initiating sexual activity is getting lower, and we need to be mindful of that," said Dr. Leonard Weiner, director, pediatric infectious diseases, State University of New York, Syracuse.
But the new gonorrhea treatment guidelines only apply to individuals over age 18 years. "The CDC already recommends the nonuse of fluoroquinolones for the treatment of gonorrhea in patients under age 18 in the appropriate locales. So, the current treatment with ceftriaxone stays the same," he said.
Women who have had sex with MSM and may be exposed to resistant strains of gonorrhea should also be treated according to the new guidelines, Dr. Schmitt said.
All pregnant women should be treated with ceftriaxone regardless of the sexual orientation of their partners. "Ceftriaxone is a very effective drug in pregnant women," she said.
There are few data about women and QRNG, Dr. Douglas said. "There is no active surveillance of women, but we are investigating new possibilities," he said.
The lack of QRNG data on women is partly a technical issue. The national CDC-sponsored surveillance system, called the Gonococcal Isolate Surveillance Project (GISP), uses N. gonorrhocae isolates from the first 25 men with gonorrhea attending STD clinics in selected cities each month. The isolates are then sent for testing at regional labs.
"Surveillance is limited to male urethral specimens in part because the Gram stain works in a clinic setting for male specimens.
Female specimens have other naturally occurring flora that interfere with the sensitivity of the culture," Dr. Schmitt said.
At an STD prevention conference in March, a CDC official admitted the agency does not know just how widespread the problem of QRNG is because only 29 cities participate in GISP.
But when data from GISP indicated that the occurrence of QRNG among MSM had increased from 1.8% in 2002 to 4.9% in 2003, the agency created the new guidelines for MSM.
The 5% level of resistance is often used as the level at which a therapeutic regimen should be changed, Dr. Douglas said.
BY NICHOLAS MULCAHY
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|Title Annotation:||Community Psychiatry|
|Publication:||Clinical Psychiatry News|
|Article Type:||Brief Article|
|Date:||Jun 1, 2004|
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