Ciprofloxacin (Cipro, and other antibiotics from the fluoroquinolone class, should no longer be used in the USA for the treatment of the sexually transmitted infection gonorrhoea in gay men, the US Centers for Disease Control and Surveillance (CDC) warns in the April 30th edition of Morbidity and Mortality Weekly Report (MMWR).
Drugs from the fluoroquinolone class (ciprofloxacin, oflxacin and levoflaxacin) have been recommended for the treatment of gonorrhoea in the US since 1993. However, in early 2003 concern was expressed about an increase in the instance of cases of gonorrhoea resistant to these drugs in Hawaii and California. In late 2003, fluoroquinolone antibiotics ceased to be recommended for the treatment of gonorrhoea in the UK after instances of gonorrhoea resistant to ciprofloxacin reached almost 10% in some areas, particularly amongst gay men (see link to aidsmap news stories below).
Data gathered by the Gonococcal Isolate Surveillance Project in the US in 2003 showed that, in the first nine months of 2003, the incidence of gonorrhoea resistant to fluoroquinolones was 4.2%, compared with 2.2% in 2003 and less than 1% in 2001. According to these data, the prevalence of resistant gonorrhoea among gay men was particularly high, at 4.9% compared to just 0.4% in heterosexuals.
The MMWR report includes detailed data from 235 patients infected with gonorrhoea in Massachusetts in 2003, and 643 individuals in New York City. In Massachusetts, 10.4% of all gonorrhoea isolates were resistant to fluoroquinoles, compared to just 2.1% in 2002, and 0% in 2001. Over two-thirds of the drug-resistant gonorrhoea isolates came from gay men, and the overall prevalence of fluoroquinole-resistant gonorrhoea among gay men in Massachusetts in 2003 was 11.1%, and 1.8% in heterosexuals.
In New York City, 3.4% of gonorrhoea isolates in 2003 were resistant to standard first-line therapy, and again, over three-quarters of cases involved gay men. The overall prevalence of fluoroquinolone-resistant gonorrhoea amongst gay men was 12.1% and 2.4% amongst heterosexuals.
The authors of the MMWR report note that “local and national data suggest that the prevalence of [fluoroquinolone-resistant gonorrhoea] amongst [gay men] is close to or exceeds 5%. This level of resistance is often used as the level at which a therapeutic regimen should be changed… fluoroquinolones should no longer be used to treat proven or suspected gonococcal infections in [gay men] in the United States.”
First-line treatment for gonorrhoea in gay men should now, the CDC recommends, consist of a 125mg intramuscular injection of ceftriaxone, or 400mg of cefixime orally, or in cases of rectal or urethral infection, a 2g intramuscular injection of spectinomycin.
The authors comment that the lack of oral treatments for gonorrhoea “poses practical problems”. They add that US manufacture of cefixime, the only recommended oral drug now recommended for gonorrhoea treatment in gay men, ceased in 2002. Although US manufacturing recommenced in early 2004, 400mg tablets of cefixime are not yet available.
Individuals who have been infected with gonorrhoea in countries with a high prevalence of fluoroquinolone resistance should also be treated with the new first-line therapies, regardless of their sexual orientation. These countries include Asia, the Pacific islands, California, and England and Wales.
Further information on this website
Gonorrhoea - factsheet
Ciproxfloxacin - overview
Gonorrhoea treatment guidelines need urgent review, say public health officials - news stories
Gonorrhoea is becoming less sensitive to yet another antibiotic, say researchers in Hawaii - news story
Drug resistant strains of gonorrhoea common in Sydney - news story
Ratelle S et al. Increases in fluoroquinolone-resistant Neisseria gonorrhoeae among men who have sex with men: United States, 2003, and revised recommendations for gonorrhoea treatment, 2004. Morbidity and Mortality Weekly Report: 53, 2004.