Gonorrhea: Who’s at risk and what do we do about it?

Priya Gulati, MD Emory Family & Preventive Medicine Resident Physician

Family physicians regularly complete STD testing as part of routine preventive visits. It is not a surprise that overprescribing creates antibiotic resistance, and this has now been identified as an issue with gonorrhea. Much like the common cold and resulting resistance to zpack, gonorrhea is progressively becoming a resistant organism to standard therapy.

The Center for Disease Control & Prevention (CDC) began monitoring the emergence of antibiotic resistant gonorrhea in the U.S. with the Gonococcal Isolate Surveillance Project (GISP) in 1986. In 2013, the CDC listed N. gonorrhoeae as one of three organisms posing the highest threat to human health. Although antibiotic resistant gonorrhea has so far been concentrated on the west coast of the U.S., it is clear from the CDC’s threat assessment that public health professionals across the country, including Georgia, need to be concerned. Decreased susceptibility of gonorrhea to antibiotics is expected to continue, so state and local surveillance for antimicrobial resistance is crucial for guiding local therapy recommendations.

As primary care providers, it is imperative to do our part to prevent the spread of antibiotic resistance in cases of gonorrhea. So how is this accomplished?

It is critical to report all cases to a local health department within 7 days, including patient demographics, lab testing, and treatment. If cephalosporin treatment failure is suspected (based on persistent symptoms 3-5 days after appropriate therapy without new sexual contact), clinicians should perform culture and antimicrobial susceptibility testing of relevant specimens, consult an infectious disease specialist, and report the case to the Georgia Department of Public Health. Isolates should be saved in case they need to be sent on for further testing.

On the basis of experience with other microbes that have developed antimicrobial resistance rapidly, a theoretical basis exists for combination therapy using two antimicrobials with different mechanisms of action to improve treatment efficacy and potentially slow the emergence and spread of resistance. Therefore, CDC recommends prescribing dual antibiotic therapy for all gonorrhea cases with 250 mg ceftriaxone IM+ 1 g azithromycin PO on the same day, preferably simultaneously and under direct observation; monotherapy is no longer recommended. Azithromycin is preferred as the second antimicrobial over doxycycline.

Clinicians should also ensure patients’ sexual partners are treated appropriately to prevent further transmission.

Additionally, primary care providers should be diligent about screening at risk populations, assessing screening appropriateness on a case by case basis:  Patients <25 years old, with a prior previous history of STD, with report of new or multiple partners/report of inconsistent condom use, men who have sex with men, sex workers or drug users.

By implementing these strategies and identifying at risk populations more effectively, primary care providers in Georgia can help mitigate the risk of antibiotic resistant gonorrhea.

Additional guidelines for treatment shortages, individuals with allergies, pregnant women and children are available at https://www.cdc.gov/std/tg2015/gonorrhea.htm.