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Gonococcal Treatment Failure Due to Cephalosporin Resistance Now in North America

Summary and Comment |
January 9, 2013

Gonococcal Treatment Failure Due to Cephalosporin Resistance Now in North America

  1. Richard T. Ellison III, MD

Cefixime-resistant strains in Toronto were highly related to those isolated in Europe.

  1. Richard T. Ellison III, MD

Antibiotic resistance in Neisseria gonorrhoeae is of increasing concern, with azithromycin-resistant strains identified in California in 2011 (JW Infect Dis Jun 8 2011) and treatment failures in Asia and Europe because of rising minimum inhibitory concentrations (MICs) for cephalosporins. In July 2011, the CDC reported a rising prevalence of N. gonorrhoeae isolates with reduced susceptibility to cefixime and ceftriaxone among men attending publicly funded sexually transmitted disease (STD) clinics in the U.S. (JW Infect Dis Jul 20 2011), and now treatment failure caused by such strains has been identified in patients treated at a Toronto STD clinic.

Researchers retrospectively reviewed the clinical outcomes of patients who were treated with oral cefixime for culture-confirmed gonococcal infection at this facility between May 2010 and April 2011. Of 291 patients, 133 returned for test-of-cure visits. Nine patients met the definition of treatment failure (positive test-of-cure culture yielding N. gonorrhoeae identical to the original isolate; denial of sexual reexposure), for an overall clinical failure rate of 7% and failure rates for urethral, pharyngeal, and rectal infections of 5% (4 of 76 infections), 29% (2 of 7), and 8% (3 of 39), respectively. The cefixime MICs for seven of these nine gonococcal isolates were ≥0.12 μg/mL, and the relative risk for treatment failure associated with isolates with cefixime MICs ≥0.12 μg/mL — compared to isolates with lower MICs — was 13.1. Sequence analysis revealed an altered penicillin-binding protein in seven of the nine resistant strains and showed that the resistant strains in Toronto were highly related to those seen in Europe.

Comment

These findings confirm the concern that oral cefixime can no longer be considered reliable treatment for gonococcal infection. As noted by editorialists, the common use of nucleic acid amplification tests in the U.S. has led to a decrease in laboratory capacity for N. gonorrhoeae culture — and thus for antimicrobial-susceptibility testing. Rebuilding this capacity should be a public health priority.

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