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July/August 2012
Patient Care and Science
CDC No Longer Recommends Cefixime as First-Line Treatment for Gonorrhea
Change is due to drug-resistance and critical to preserving last treatment option

The Centers for Disease Control and Prevention (CDC) issued updated treatment guidelines for gonorrhea in the Aug. 10 Morbidity and Mortality Weekly Report (MMWR), no longer recommending the oral antibiotic cefixime as a first-line treatment option for gonorrhea because of laboratory data showing that Neisseria gonorrhoeae is becoming resistant to the drug.

Based on data from CDC’s Gonococcal Isolate Surveillance Project, CDC now recommends combination therapy with ceftriaxone 250 mg intramuscularly and either azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for seven days as the most reliably effective treatment for uncomplicated gonorrhea. CDC no longer recommends cefixime at any dose as a first-line regimen for treatment of gonococcal infections. If cefixime is used as an alternative agent, then the patient should return in one week for a test-of-cure at the site of infection, the new guidelines say.

CDC is urging clinicians to follow the new treatment guidelines, monitor for suspected cases of treatment failure, and report such cases to state or local health departments. Clinicians should also ensure that the patient’s sex partners from the preceding 60 days are evaluated promptly with culture and treated as indicated.

The new recommendation is viewed as critical to preserving the last available treatment option for gonorrhea. As cefixime becomes less effective, continued use of the oral drug might hasten the development of resistance to ceftriaxone, a safe, well-tolerated, injectable cephalosporin and the last antimicrobial that is known to be highly effective against gonorrhea. “It’s only a matter of time until gonorrhea develops resistance to this last remaining cure,” said Kevin Fenton, MD, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, in a press release. “Changing how we treat infections now may buy the time needed to develop new treatment options.”

In some ways, gonorrhea has always been a "canary in the coal mine," because "it picks up resistance very easily," said IDSA Board member Carlos del Rio, MD, FIDSA, an author of the new CDC treatment guidelines, in an interview with USA Today. “Researchers and pharmaceutical companies must prioritize research to identify or develop new, effective drugs or drug combinations,” said Gail Bolan, MD, director of CDC’s Division of STD Prevention, in CDC’s press release.

Although public health officials and ID clinicians agree on the need for new antibiotics, "The pharmaceutical industry has very little incentive to do the research and development for an antibiotic that you take for five to 10 days, compared to something like a cholesterol drug, that you take for the rest of your life,” Dr. del Rio noted. In an interview with Bloomberg Business Week, Robert Guidos, IDSA’s vice president for public policy and government relations, called for options such as a research and development tax credit, or strengthening partnerships between public health officials and private industry.

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