For several years fluoroquinolone-resistant gonococci have been prevalent throughout Asia, parts of Europe, and many Pacific islands, including Hawaii, and they recently appeared in significant numbers in California and Massachusetts, where most cases also have been reported among MSM. From January 2002 through September 2003 there were only sporadic cases of fluoroquinolone-resistant gonorrhea in King County, amounting to 1-2% of all cases. In October and November, 11 (15%) of 74 gonococcal isolates had minimal inhibitory concentrations of ciprofloxacin or 4 mg/L or higher, a level of resistance associated with at least a 50% rate of treatment failure with recommended fluoroquinolone regimens. The 11 recent cases all were men, most of whom acknowledged sex with male partners. Many of these quinolone-resistant gonococci also had decreased susceptibility to tetracycline and azithromycin. Treatment failure has been documented in 4 persons infected with resistant strains who were given ciprofloxacin 500 mg orally; 3 of these patients also had been treated with doxycycline or azithromycin.
Effective immediately, health care providers in King County should not use ciprofloxacin or other fluoroquinolones as first line therapy for gonorrhea. In particular, these drugs should be avoided when treating MSM for proven or suspected gonorrhea and should be used with caution, if at all, in other patients.
Alternative treatments for patients with uncomplicated gonorrhea include single doses of cefpodoxime (VantinTM), 400 mg orally, or ceftriaxone (RocephinTM), 125 mg by intramuscular injection. (Cefixime, until recently recommended in a single oral dose of 400 mg, no longer is available in the United States.) Either regimen should be followed with either azithromycin 1.0 g orally (single dose) or doxycycline 100 mg orally twice daily for 7 days, to treat possible coexisting chlamydial infection. When well-documented penicillin allergy or other contraindications preclude treatment with a cephalosporin, patients can be treated with single-dose azithromycin 2.0 g orally once; or ciprofloxacin 500 mg (or another fluoroquinolone) can be given, followed by a test-of-cure 5-7 days after completion of therapy.
Health care providers are encouraged to contact the STD Control Program (206-744-8374) if there are questions.
