The spread of drug-resistant gonorrhea has led the U.S. Centers for Disease Control and Prevention (CDC) to change its guidelines for treating that infection in gay men but not in heterosexuals. The changes were announced at an April 29 telephone news conference and were published that same day in Morbidity and Mortality Weekly Report (MMWR).
Drugs in the fluoroquinolone family, such as Cipro, currently are the standard treatment. But misuse has led to the emergence of drug-resistant strains of gonorrhea. Now the CDC is recommending use of the injectable antibiotics ceftriaxone and cefixime to treat gay men. A pill form of the later should be available shortly.
Gonorrhea is the second most commonly reported infectious disease in the U.S. More than 350,000 cases were reported last year, with much of the data coming from public health clinics, and experts believe the total number of infections is at least 700,000.
Many infections are never reported to public health officials. One reason is the stigma associated with sexually transmitted diseases. But perhaps more importantly, there is no incentive for private physicians to take the time to do so. Nor is the information captured in lab reports because most physicians simply treat a symptomatic infection rather than take the time and expense to send a culture to the lab and wait for the results.
The CDC has tracked the development of drug-resistant gonorrhea as it appeared in Asia and then spread eastward. It recommended switching from fluoroquinolones to other drugs for all cases of gonorrhea in Hawaii in 2000, and expanded that to California in 2002.
Now it is recommending that all men who have sex with men (MSM) be treated with ceftriaxone and cefixime, regardless of where they live in the U.S. Drug resistance appears to be low enough among heterosexuals that the CDC is recommending no changes in treatment guidelines for that population at this time.
Citing data from its surveillance in 30 cities, CDC's director of sexually transmitted diseases (STDs) John Douglas said, 'The proportion of gonorrhea cases resistant to fluoroquinolones more than doubled, from 0.4% in 2002 to 0.9% in 2003.' It was most pronounced in MSM, increasing from 1.8% of cases in 2002 to 4.9% in 2003. A 5% level of resistance generally triggers a change in treatment guidelines.
'The proportion of resistant gonorrhea was twelve times higher among MSM than among heterosexual men in 2003,' Douglas said. The key messages for doctors are to ask men who they are having sex with, and remember that 'travel histories matter.' They also should be alert to the possibility of treatment failure as signaling the presence of drug-resistant gonorrhea.
Kenneth Mayer, a physician with Fenway Community Health that serves the GLBT population in Boston, said, last year 11% of the gonorrhea in gay men in the state was drug-resistant. It was 'nearly six times higher among MSM than among heterosexual men.'
Fenway saw 24 cases of resistant clap last year; this year the total is already up to 10.
Mayer saw this as 'part of an overall trend of increasing cases of gonorrhea,' not just the resistant variety. Gay men are having more unsafe sex and that is resulting in more STDs. Fenway reported treating about 50 cases of the clap in 1988 and about 150 cases last year. Syphilis ballooned from a low 3 cases in 1998 to 51 cases in 2003.
Data from New York City showed that 12.5% of the reported cases of gonorrhea in MSM were drug resistant, that is eight times higher than for heterosexuals in the city.
Dr. Douglas' 'best hunch' explanation of why drug-resistant gonorrhea is higher in gay men is that they tend to travel more and have sex in parts of the world where drug resistance first emerged. They return with a drug-resistant souvenir of that journey.
He pointed out that the drip and pain on urination of urethral gonorrhea draws attention and treatment. But 'anal-rectal infection is less likely to become symptomatic and be detected,' and thus treated. That offers 'a longer carriage of infection' and a longer opportunity to transmit it to other partners.
Dr. Mayer added, there may be a cohort effect; 'Once resistant gonorrhea is introduced into the gay community, people tend to have partners within that subset of individuals and that allows for amplification' of the infection.
'Despite the CDC guidelines, many physicians out in the community continue to use quinolones because they are cheap and easy to administer,' Mayer said.
Douglas said that switching from a pill to an injectable therapy creates 'a barrier to administering treatment' because some physicians do not stock the drug. Some patients also resist injections.
Mayer reminded people that CDC guidelines call for sexually active MSM to be screened for STDs at least twice a year. 'More adherence to that on the part of providers might help curtail the epidemic.'