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Battling Antibiotic-Resistant Bugs

Created Jun 14 2018, 11:00 AM by Lippincott Solutions
  • Gonorrhea
  • CDC
  • public health nursing
  • infection prevention

Every year, more than 100 million people worldwide develop the sexually transmitted disease gonorrhea, with health consequences such as infertility, transmission of the disease to newborn babies, and increased risk of HIV infections. Gonorrhea is caused by bacteria that can rapidly develop resistance to all known antibiotics.

These "superbugs" are becoming increasingly difficult to treat. Gonorrhea has progressively developed resistance to the antibiotic drugs prescribed to treat it. Following the spread of gonococcal fluoroquinolone resistance, the cephalosporin antibiotics have been the foundation of recommended treatment for gonorrhea, according to the Centers for Disease Control and Prevention (CDC). The emergence of cephalosporin-resistant gonorrhea significantly complicates the ability of providers to treat gonorrhea successfully, since we have few antibiotic options left that are simple, well-studied, well-tolerated and highly effective.

Timeline of Antibiotic Resistance and Changing Treatment Recommendations

Antibiotic resistance is the ability of the bacteria to defy the effects of the drugs used to treat them. The bacteria are free to keep multiplying. Gonorrhea has developed resistance to nearly all of the antibiotics used for its treatment. Health care practitioners are currently down to one last recommended and effective class of antibiotics, cephalosporins, to treat this common infection. This is an urgent public health threat because gonorrhea control in the United States largely relies on our ability to successfully treat the infection.

Back in the 1990's, ciprofloxacin, a fluoroquinolone, and two cephalosporins (ceftriaxone and cefixime) were the recommended treatments for gonorrhea. However, in the late 1990s and early 2000s, ciprofloxacin resistance was detected in Hawaii and the West Coast. By 2004, ciprofloxacin-resistant gonorrhea had significantly increased, leading to the discontinuation of the drug for treating gonorrhea. By 2006, nearly 14% of gonorrhea samples were resistant to ciprofloxacin. On April 13, 2007, the CDC stopped recommending fluoroquinolones as empiric treatment for gonorrhea altogether. The cephalosporins drugs were the only remaining recommended treatments.

The CDC has observed worrisome trends of decreasing cephalosporin susceptibility, especially to the oral cephalosporin cefixime. To preserve cephalosporins for as long as possible, CDC made the following changes to its STD Treatment Guidelines:

  • In 2010, CDC changed its treatment recommendations to recommend dual therapy for the treatment of gonorrhea and increased the recommended dose of ceftriaxone to 250 mg. The use of dual therapy is important to ensure clinical cure in this era of increasing antibiotic resistance and to prevent further development of resistance.
  • Following continued declines in cefixime susceptibility, CDC updated its recommendations in 2012 to recommend ceftriaxone plus either azithromycin or doxycycline as the only first-line treatment.
  • CDC’s 2015 STD Treatment Guidelines now recommend only one regimen of dual therapy for the treatment of gonorrhea—the injectable cephalosporin ceftriaxone, plus oral azithromycin.

Gonorrhea’s susceptibility to azithromycin declined during 2013-2016. At this time, azithromycin remains a recommended part of dual therapy and is also the backbone of every alternative treatment option. Antibiotic resistance to cephalosporins, azithromycin, and other drugs continues to be monitored nationally.

The Clinician’s Role in Surveillance

Gonorrhea is the second most commonly reported infectious disease, after chlamydia. According to the CDC, symptoms in men include: a burning sensation when urinating; white, yellow, or green discharge from the penis; and painful or swollen testicles.

Most women with gonorrhea do not have any symptoms. But they can include: painful or burning sensation when urinating, increased vaginal discharge, and vaginal bleeding between periods. Women with gonorrhea can give the infection to babies during childbirth, so as a general rule, pregnant women are tested.

Clinicians are asked to report any gonorrhea specimen with decreased cephalosporin susceptibility and any gonorrhea cephalosporin treatment failure to CDC through their state or local public health authority.

Because gonorrhea is skilled at outsmarting the antibiotics that are used to kill it, the healthcare community must continuously monitor for antibiotic resistance and encourage the research and development of new drugs for gonorrhea treatment.