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Zhong J, Le W, Li X, Su X. Evaluating the efficacy of different antibiotics against Neisseria gonorrhoeae: a pharmacokinetic/pharmacodynamic analysis using Monte Carlo simulation. BMC Infect Dis 2024; 24:104. [PMID: 38238655 PMCID: PMC10797866 DOI: 10.1186/s12879-023-08938-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/19/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND With the widespread use of antibiotics, antimicrobial resistance in Neisseria gonorrhoeae is worsening. The objective of this study was to evaluate the efficacy changes of seven antibiotics in the treatment of N. gonorrhoeae by using Monte Carlo simulation combined with pharmacokinetics/pharmacodynamics/ (PK/PD). METHODS The minimum inhibitory concentration (MIC) of antibiotics against clinical isolates from 2013 to 2020 in Nanjing, China, was determined by agar dilution method. The probability of target attainment (PTA) was estimated at each MIC value and the cumulative fraction of response (CFR) was calculated to evaluate the efficacy of these regimens. RESULTS All dosage regimens of seven antibiotics achieved PTAs ≥ 90% for MIC ≤ 0.06 µg/ml. But when the MIC was increased to 1 µg/ml, PTAs at each MIC value exceeded 90% only for ceftriaxone 1,000 mg and 2,000 mg, zoliflodacin 2,000 mg and 3,000 mg. Among them, the CFR values of each dosing regimen against N. gonorrhoeae only for ceftriaxone, cefixime and zoliflodacin were ≥ 90% in Nanjing from 2013 to 2020. CONCLUSIONS Cephalosporins are still the first-line drugs in the treatment of gonorrhea. However, the elevated MIC values of cephalosporins can lead to decline in clinical efficacy of the conventional dose regimens, and increasing the dose of ceftriaxone to 1,000 mg-2,000 mg may improve the efficacy. In addition, zoliflodacin is possible to be a potential therapeutic agent in the future.
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Affiliation(s)
- Jiaojiao Zhong
- Hospital for Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences &Peking Union Medical College, Nanjing, China
| | - Wenjing Le
- Hospital for Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences &Peking Union Medical College, Nanjing, China
| | - Xuechun Li
- Hospital for Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences &Peking Union Medical College, Nanjing, China
- Department of Dermatology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Xiaohong Su
- Hospital for Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences &Peking Union Medical College, Nanjing, China.
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Ajmal M, Zamir A, Rehman AU, Imran I, Saeed H, Majeed A, Aziz M, Alqahtani F, Rasool MF. Clinical pharmacokinetic of cefixime: a systematic review. Xenobiotica 2023:1-24. [PMID: 37216497 DOI: 10.1080/00498254.2023.2217265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 05/24/2023]
Abstract
Cefixime is an antibiotic from the cephalosporin class used to treat various bacterial infections. The purpose of performing this review is to thoroughly evaluate the pharmacokinetic (PK) data on cefixime.Five databases were systematically searched to identify studies on the PK of cefixime.A total of 38 articles meeting the eligibility criteria were included that provide data on concentration-time profiles or PK parameters such as peak plasma and serum concentration (Cmax), area under the curve (AUC), clearance (CL), and time to reach Cmax (tmax). A dose-dependent increase in AUC and Cmax of cefixime was depicted in healthy volunteers. The clearance of cefixime decreased according to the degree of renal insufficiency among haemodialysis patients. A significant difference in CL was found in comparing fasted and fed states. A biphasic decline in serum concentrations of cefixime was reported when it was taken without probenecid.This review compiles all the reports on the PK of cefixime in healthy and renally impaired patients; the summarized information can be used to optimize cefixime dosing in different disease states. Moreover, cefixime has increased time above MIC value suggesting that it may be an effective treatment for infections caused by certain pathogens.
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Affiliation(s)
- Maria Ajmal
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, 60800, Multan, Pakistan
| | - Ammara Zamir
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, 60800, Multan, Pakistan
| | - Anees Ur Rehman
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, 60800, Multan, Pakistan
| | - Imran Imran
- Department of Pharmacology, Faculty of Pharmacy, Bahauddin Zakariya University, 60800, Multan, Pakistan
| | - Hamid Saeed
- University College of Pharmacy, Allama Iqbal Campus, University of the Punjab, 54000, Lahore, Pakistan
| | - Abdul Majeed
- Department of Pharmaceutics, Faculty of Pharmacy, Bahauddin Zakariya University, 60800, Multan, Pakistan
| | - Majid Aziz
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, 60800, Multan, Pakistan
| | - Faleh Alqahtani
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
| | - Muhammad Fawad Rasool
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, 60800, Multan, Pakistan
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Rowlinson E, Soge OO, Hughes JP, Berzkalns A, Thibault C, Kerani RP, Khosropour CM, Manhart LE, Golden MR, Barbee LA. Prior Exposure to Azithromycin and Azithromycin Resistance Among Persons Diagnosed With Neisseria gonorrhoeae Infection at a Sexual Health Clinic: 2012-2019. Clin Infect Dis 2023; 76:e1270-e1276. [PMID: 36001447 PMCID: PMC10169409 DOI: 10.1093/cid/ciac682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is conflicting evidence on whether prior azithromycin (AZM) exposure is associated with reduced susceptibility to AZM (AZMRS) among persons infected with Neisseria gonorrhoeae (NG). METHODS The study population included Public Health-Seattle and King County Sexual Health Clinic (SHC) patients with culture-positive NG infection at ≥1 anatomic site whose isolates were tested for AZM susceptibility in 2012-2019. We used multivariate logistic regression to examine the association of time since last AZM prescription from the SHC in ≤12 months with subsequent diagnosis with AZMRS NG (minimum inhibitory concentration [MIC], ≥2.0 µg/mL) and used linear regression to assess the association between the number of AZM prescriptions in ≤12 months and AZM MIC level, controlling for demographic, behavioral, and clinical characteristics. RESULTS A total of 2155 unique patients had 2828 incident NG infections, 156 (6%) of which were caused by AZMRS NG. AZMRS NG was strongly associated with receipt of AZM from the SHC in the prior 29 days (adjusted odds ratio, 6.76; 95% confidence interval [CI], 1.76 to 25.90) but not with receipt of AZM in the prior 30-365 days. Log AZM MIC level was not associated with the number of AZM prescriptions within ≤12 months (adjusted correlation, 0.0004; 95% CI, -.04 to .037) but was associated with number of prescriptions within <30 days (adjusted coefficient, 0.56; 95% CI, .13 to .98). CONCLUSIONS Recent individual-level AZM treatment is associated with subsequent AZMRS gonococcal infections. The long half-life and persistence of subtherapeutic levels of AZM may result in selection of resistant NG strains in persons with recent AZM use.
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Affiliation(s)
- Emily Rowlinson
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Olusegun O Soge
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Neisseria Reference Laboratory, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - James P Hughes
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Anna Berzkalns
- HIV/STD Program, Public Health–Seattle and King County, Seattle, Washington, USA
| | - Christina Thibault
- HIV/STD Program, Public Health–Seattle and King County, Seattle, Washington, USA
| | - Roxanne P Kerani
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- HIV/STD Program, Public Health–Seattle and King County, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Lisa E Manhart
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Matthew R Golden
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- HIV/STD Program, Public Health–Seattle and King County, Seattle, Washington, USA
| | - Lindley A Barbee
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- HIV/STD Program, Public Health–Seattle and King County, Seattle, Washington, USA
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Kong FYS, Unemo M, Lim SH, Latch N, Williamson DA, Roberts JA, Wallis SC, Parker SL, Landersdorfer CB, Yap T, Fairley CK, Chow EPF, Lewis DA, Hammoud MA, Hocking JS. Optimisation of treatments for oral Neisseria gonorrhoeae infection: Pharmacokinetics Study (STI-PK project) - study protocol for non-randomised clinical trial. BMJ Open 2022; 12:e064782. [PMID: 36368750 PMCID: PMC9660608 DOI: 10.1136/bmjopen-2022-064782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Neisseria gonorrhoeae infections are common and incidence increasing. Oropharyngeal infections are associated with greater treatment failure compared with other sites and drive transmission to anogenital sites through saliva. Gonococcal resistance is increasing and new treatments are scarce, therefore, clinicians must optimise currently available and emerging treatments in order to have efficacious therapeutic options. This requires pharmacokinetic data from the oral cavity/oropharynx, however, availability of such information is currently limited. METHODS AND ANALYSIS Healthy male volunteers (participants) recruited into the study will receive single doses of either ceftriaxone 1 g, cefixime 400 mg or ceftriaxone 500 mg plus 2 g azithromycin. Participants will provide samples at 6-8 time points (treatment regimen dependent) from four oral sites, two oral fluids, one anorectal swab and blood. Participants will complete online questionnaires about their medical history, sexual practices and any side effects experienced up to days 5-7. Saliva/oral mucosal pH and oral microbiome analysis will be undertaken. Bioanalysis will be conducted by liquid chromatography-mass spectrometry. Drug concentrations over time will be used to develop mathematical models for optimisation of drug dosing regimens and to estimate pharmacodynamic targets of efficacy. ETHICS AND DISSEMINATION This study was approved by Royal Melbourne Hospital Human Research Ethics Committee (60370/MH-2021). The study results will be submitted for publication in peer-reviewed journals and reported at conferences. Summary results will be sent to participants requesting them. All data relevant to the study will be included in the article or uploaded as supplementary information. TRIAL REGISTRATION NUMBER ACTRN12621000339853.
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Affiliation(s)
- Fabian Y S Kong
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for Sexually Transmitted Infections, Department of Laboratory Medicine, Microbiology, Örebro University, Orebro, Sweden
- Institute for Global Health, University College London, London, UK
| | - Shueh H Lim
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- The Crane General Practice, Melbourne, Victoria, Australia
| | - Ngaire Latch
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Deborah A Williamson
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Reference Laboratory, Melbourne, Victoria, Australia
| | - Jason A Roberts
- The University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute, Metro North Health, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Steven C Wallis
- The University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Suzanne L Parker
- The University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
| | | | - Tami Yap
- Melbourne Dental School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - David A Lewis
- Westmead Clinical School and Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, New South Wales, Australia
- Western Sydney Sexual Health Centre, Western Sydney Local Health District, Parramatta, New South Wales, Australia
| | - Mohamed A Hammoud
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Jane S Hocking
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Schörner MA, Mesa D, Barazzetti FH, Martins JM, Machado HDM, Grisard HBDS, Wachter JK, Starick MR, Scheffer MC, Palmeiro JK, Bazzo ML. In vitro selection of Neisseria gonorrhoeae unveils novel mutations associated with extended-spectrum cephalosporin resistance. Front Cell Infect Microbiol 2022; 12:924764. [PMID: 35967879 PMCID: PMC9363574 DOI: 10.3389/fcimb.2022.924764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/30/2022] [Indexed: 11/24/2022] Open
Abstract
The emergence of Neisseria gonorrhoeae strains resistant to extended-spectrum cephalosporins (ESCs) is a worldwide concern because this class of antibiotics represents the last empirical treatment option for gonorrhea. The abusive use of antimicrobials may be an essential factor for the emergence of ESC resistance in N. gonorrhoeae. Cephalosporin resistance mechanisms have not been fully clarified. In this study, we mapped mutations in the genome of N. gonorrhoeae isolates after resistance induction with cefixime and explored related metabolic pathways. Six clinical isolates with different antimicrobial susceptibility profiles and genotypes and two gonococcal reference strains (WHO F and WHO Y) were induced with increasing concentrations of cefixime. Antimicrobial susceptibility testing was performed against six antimicrobial agents before and after induction. Clinical isolates were whole-genome sequenced before and after induction, whereas reference strains were sequenced after induction only. Cefixime resistance induction was completed after 138 subcultures. Several metabolic pathways were affected by resistance induction. Five isolates showed SNPs in PBP2. The isolates M111 and M128 (ST1407 with mosaic penA-34.001) acquired one and four novel missense mutations in PBP2, respectively. These isolates exhibited the highest minimum inhibitory concentration (MIC) for cefixime among all clinical isolates. Mutations in genes contributing to ESC resistance and in other genes were also observed. Interestingly, M107 and M110 (ST338) showed no mutations in key determinants of ESC resistance despite having a 127-fold increase in the MIC of cefixime. These findings point to the existence of different mechanisms of acquisition of ESC resistance induced by cefixime exposure. Furthermore, the results reinforce the importance of the gonococcal antimicrobial resistance surveillance program in Brazil, given the changes in treatment protocols made in 2017 and the nationwide prevalence of sequence types that can develop resistance to ESC.
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Affiliation(s)
- Marcos André Schörner
- Laboratório de Biologia Molecular, Microbiologia e Sorologia, Departamento de Análises Clínicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
- *Correspondence: Marcos André Schörner,
| | - Dany Mesa
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba, PR, Brazil
| | - Fernando Hartmann Barazzetti
- Laboratório de Biologia Molecular, Microbiologia e Sorologia, Departamento de Análises Clínicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
- Laboratório de Bioinformática, Programa de Pós-Graduação em Biotecnologia e Biociências, Departamento de Microbiologia, Imunologia e Parasitologia, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Jéssica Motta Martins
- Laboratório de Biologia Molecular, Microbiologia e Sorologia, Departamento de Análises Clínicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
- Programa de Pós-Graduação em Farmácia, Departamento de Análises Clínicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Hanalydia de Melo Machado
- Laboratório de Biologia Molecular, Microbiologia e Sorologia, Departamento de Análises Clínicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Henrique Borges da Silva Grisard
- Laboratório de Biologia Molecular, Microbiologia e Sorologia, Departamento de Análises Clínicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Julia Kinetz Wachter
- Laboratório de Biologia Molecular, Microbiologia e Sorologia, Departamento de Análises Clínicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Márick Rodrigues Starick
- Programa de Pós-Graduação em Farmacologia, Departamento de Farmacologia, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
- Laboratório de Imunofarmacologia e Doenças Infecciosas, Departamento de Microbiologia, Imunologia e Parasitologia, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Mara Cristina Scheffer
- Laboratório de Microbiologia, Unidade do Laboratório de Análises Clínicas, Hospital Universitário Professor Polydoro Ernani de São Thiago, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Jussara Kasuko Palmeiro
- Centro de Ciências da Saúde, Departamento de Análises Clínicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Maria Luiza Bazzo
- Laboratório de Biologia Molecular, Microbiologia e Sorologia, Departamento de Análises Clínicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
- Programa de Pós-Graduação em Farmácia, Departamento de Análises Clínicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
- Centro de Ciências da Saúde, Departamento de Análises Clínicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
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Barbee LA, St Cyr SB. Management of Neisseria gonorrhoeae in the United States: Summary of Evidence From the Development of the 2020 Gonorrhea Treatment Recommendations and the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infection Treatment Guidelines. Clin Infect Dis 2022; 74:S95-S111. [PMID: 35416971 DOI: 10.1093/cid/ciac043] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Neisseria gonorrhoeae has developed resistance to all first-line recommended therapies, making gonococcal antimicrobial resistance a major public health concern given limited antibiotic options currently and an even smaller antimicrobial development pipeline. Since the release of the Centers for Disease Control and Prevention (CDC) 2015 STD Treatment Guidelines, azithromycin, part of the 2015 dual-drug treatment regimen, has had a rapid rise in resistance. The 2020 CDC Gonorrhea Treatment Recommendations and the 2021 Sexually Transmitted Infections (STI) Treatment Guidelines were developed weighing the priorities of treating the individual, protecting the population, and preventing antimicrobial resistance. METHODS Gonorrhea subject matter experts (SME) generated 8 key questions and conducted a literature review of updated data from 2013 to 2019 on gonorrhea antimicrobial resistance, treatment failures, clinical trials, and other key topics. More than 2200 abstracts were assessed, and 248 clinically relevant articles were thoroughly reviewed. SMEs also evaluated N gonorrhoeae antimicrobial resistance data from the Gonococcal Isolate Surveillance Project (GISP). EVIDENCE Although there have been reports of ceftriaxone treatment failures internationally, GISP data suggest that ceftriaxone minimal inhibitory concentrations (MICs) have remained stable in the United States, with < 0.1% exhibiting an "alert value" MIC (> 0.25 mcg/mL). However, GISP documented a rapid rise in the proportion of isolates with an elevated MIC (≥ 2.0 mcg/mL) to azithromycin-nearly 5% in 2018. At the same time, new pharmacokinetic/pharmacodynamic data are available, and there is greater recognition of the need for antimicrobial stewardship. SUMMARY The 2021 CDC STI Treatment Guidelines now recommend 500mg ceftriaxone intramuscularly once for the treatment of uncomplicated gonorrhea at all anatomic sites. If coinfection with chlamydia has not been excluded, cotreatment with doxycycline 100mg twice daily for 7 days should be added. Few alternative therapies exist for persons with cephalosporin allergies; there are no recommended alternative therapies for N gonorrhoeae infection of the throat.
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Affiliation(s)
- Lindley A Barbee
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,University of Washington, Seattle, Washington, USA.,Public Health - Seattle & King County HIV/STD Program, Seattle, Washington, USA
| | - Sancta B St Cyr
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Quilter LAS, St Cyr SB, Hong J, Asbel L, Bautista I, Carter B, Casimir Y, Denny M, Ervin M, Gomez R, Harvey A, Holderman JL, Johnson K, Kohn RP, Learner ER, Mauk K, Menza T, Mettenbrink C, Nettleton WD, Nicosia KR, Pham CD, Ried C, Schlanger K, Schneider A, Soge OO, Tabidze I, Taylor SN, Tilghman W, Toler C, Weinstock H, Torrone EA. Antimicrobial Susceptibility of Urogenital and Extragenital Neisseria gonorrhoeae Isolates Among Men Who Have Sex With Men: Strengthening the US Response to Resistant Gonorrhea and Enhanced Gonococcal Isolate Surveillance Project, 2018 to 2019. Sex Transm Dis 2021; 48:S111-S117. [PMID: 34475363 DOI: 10.1097/olq.0000000000001548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We investigated differences in gonococcal antimicrobial susceptibility by anatomic site among cisgender men who have sex with men (MSM) using specimens collected through the Centers for Disease Control and Prevention's enhanced Gonococcal Isolate Surveillance Project and Strengthening the US Response to Resistant Gonorrhea. METHODS During the period January 1, 2018-December 31, 2019, 12 enhanced Gonococcal Isolate Surveillance Project and 8 Strengthening the US Response to Resistant Gonorrhea sites collected urogenital, pharyngeal, and rectal isolates from cisgender MSM in sexually transmitted disease clinics. Gonococcal isolates were sent to regional laboratories for antimicrobial susceptibility testing by agar dilution. To account for correlated observations, linear mixed-effects models were used to calculate geometric mean minimum inhibitory concentrations (MICs), and mixed-effects logistic regression models were used to calculate the proportion of isolates with elevated or resistant MICs; comparisons were made across anatomic sites. RESULTS Participating clinics collected 3974 urethral, 1553 rectal, and 1049 pharyngeal isolates from 5456 unique cisgender MSM. There were no significant differences in the geometric mean MICs for azithromycin, ciprofloxacin, penicillin, and tetracycline by anatomic site. For cefixime and ceftriaxone, geometric mean MICs for pharyngeal isolates were higher compared with anogenital isolates (P < 0.05). The proportion of isolates with elevated ceftriaxone MICs (≥0.125 μg/mL) at the pharynx (0.67%) was higher than at rectal (0.13%) and urethral (0.18%) sites (P < 0.05). CONCLUSIONS Based on data collected from multijurisdictional sentinel surveillance projects, antimicrobial susceptibility patterns of Neisseria gonorrhoeae isolates may differ among MSM at extragenital sites, particularly at the pharynx. Continued investigation into gonococcal susceptibility patterns by anatomic site may be an important strategy to monitor and detect the emergence of antimicrobial resistant gonorrhea over time.
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Affiliation(s)
| | - Sancta B St Cyr
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jaeyoung Hong
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lenore Asbel
- Philadelphia Department of Public Health, Philadelphia, PA
| | | | | | | | | | | | | | - Alesia Harvey
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Kimberly Johnson
- New York City Department of Mental Health and Hygiene, New York City, NY
| | - Robert P Kohn
- San Francisco Department of Public Health, San Francisco, CA
| | - Emily R Learner
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kerry Mauk
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | | | - Cau D Pham
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Karen Schlanger
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | | | - Winston Tilghman
- County of San Diego Health & Human Services Agency, San Diego, CA
| | - Cindy Toler
- Guilford County Public Health, Greensboro, NC
| | - Hillard Weinstock
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Elizabeth A Torrone
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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Kong FYS, Hatzis CL, Lau A, Williamson DA, Chow EPF, Fairley CK, Hocking JS. Treatment efficacy for pharyngeal Neisseria gonorrhoeae: a systematic review and meta-analysis of randomized controlled trials. J Antimicrob Chemother 2021; 75:3109-3119. [PMID: 32747940 DOI: 10.1093/jac/dkaa300] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/09/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Rising gonorrhoea rates require highly effective treatments to reduce transmission and prevent development of antimicrobial resistance. Currently the most effective treatments for pharyngeal gonorrhoea remain unclear. This review aimed to estimate treatment efficacy for pharyngeal gonorrhoea. METHODS Online bibliographic databases were searched for the period 1 January 2000 to 17 September 2019 for treatments of gonorrhoea. All randomized controlled trials (RCTs) with data on pharyngeal gonorrhoea among participants aged 15 years or above, published in English, were included. Meta-analyses (random effects) were used to estimate the treatment efficacy, defined as microbiological cure, among currently recommended monotherapies and dual therapies, previously recommended but no longer used regimens and emerging drugs under evaluation. Side effects were also summarized. The study protocol was registered on PROSPERO (CRD42020149278). RESULTS There were nine studies that included 452 participants studying 19 treatment regimens. The overall treatment efficacy for pharyngeal gonorrhoea was 98.1% (95% CI: 93.8%-100%; I2 = 57.3%; P < 0.01). Efficacy was similar for single (97.1%; 95% CI: 90.8%-100.0%; I2 = 15.6%; P = 0.29) and dual therapies (98.0%; 95% CI: 91.4%-100%; I2 = 79.1%; P < 0.01). Regimens containing azithromycin 2 g or ceftriaxone were similarly efficacious. The summary efficacy estimate for emerging drugs was 88.8% (95% CI: 76.9%-97.5%; I2 = 11.2%; P = 0.34). Small sample sizes in each trial was a major limitation. CONCLUSIONS Regimens containing ceftriaxone or azithromycin 2 g, alone or as part of dual therapies are the most efficacious for pharyngeal gonorrhoea. Further pharyngeal-specific RCTs with adequate sample sizes are needed.
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Affiliation(s)
- Fabian Y S Kong
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Christina L Hatzis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Andrew Lau
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Deborah A Williamson
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, Victoria, Australia
| | - Eric P F Chow
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jane S Hocking
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
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9
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Cole MJ, Tan W, Fifer H, Brittain C, Duley L, Hepburn T, Lawrence T, Montgomery AA, Sprange K, Thandi S, Churchward C, Tripodo F, Woodford N, Ross JDC. Gentamicin, azithromycin and ceftriaxone in the treatment of gonorrhoea: the relationship between antibiotic MIC and clinical outcome. J Antimicrob Chemother 2021; 75:449-457. [PMID: 31670808 DOI: 10.1093/jac/dkz436] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 09/05/2019] [Accepted: 09/23/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To investigate the relationship between MIC and clinical outcome in a randomized controlled trial that compared gentamicin 240 mg plus azithromycin 1 g with ceftriaxone 500 mg plus azithromycin 1 g. MIC analysis was performed on Neisseria gonorrhoeae isolates from all participants who were culture positive before they received treatment. METHODS Viable gonococcal cultures were available from 279 participants, of whom 145 received ceftriaxone/azithromycin and 134 received gentamicin/azithromycin. Four participants (6 isolates) and 14 participants (17 isolates) did not clear infection in the ceftriaxone/azithromycin and gentamicin/azithromycin arms, respectively. MICs were determined by Etest on GC agar base with 1% Vitox. The geometric mean MICs of azithromycin, ceftriaxone and gentamicin were compared using logistic and linear regression according to treatment received and N. gonorrhoeae clearance. RESULTS As the azithromycin MIC increased, gentamicin/azithromycin treatment was less effective than ceftriaxone/azithromycin at clearing N. gonorrhoeae. There was a higher geometric mean MIC of azithromycin for isolates from participants who had received gentamicin/azithromycin and did not clear infection compared with those who did clear infection [ratio 1.95 (95% CI 1.28-2.97)], but the use of categorical MIC breakpoints did not accurately predict the treatment response. The geometric mean MIC of azithromycin was higher in isolates from the pharynx compared with genital isolates. CONCLUSIONS We found that categorical resistance to azithromycin or ceftriaxone in vitro, and higher gentamicin MICs in the absence of breakpoints, were poorly predictive of treatment failure.
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Affiliation(s)
| | - Wei Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Clare Brittain
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Tessa Lawrence
- University Hospitals Birmingham NHS Foundation Trust, Whittall Street Clinic, Birmingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Sukhwinder Thandi
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | | | | | - Jonathan D C Ross
- University Hospitals Birmingham NHS Foundation Trust, Whittall Street Clinic, Birmingham, UK
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10
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Barbee LA, Soge OO, Morgan J, Leclair A, Bass T, Werth BJ, Hughes JP, Golden MR. Gentamicin Alone Is Inadequate to Eradicate Neisseria Gonorrhoeae From the Pharynx. Clin Infect Dis 2021; 71:1877-1882. [PMID: 31712813 DOI: 10.1093/cid/ciz1109] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/08/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Centers for Disease Control and Prevention (CDC) guidelines recommend 240 mg gentamicin plus 2 g azithromycin for the treatment of gonorrhea in cephalosporin-allergic patients. The efficacy of gentamicin alone in the treatment of pharyngeal gonorrhea is uncertain. METHODS Between September 2018 and March 2019, we enrolled men who have sex with men with nucleic acid amplification test-diagnosed pharyngeal gonorrhea in a single-arm, unblinded clinical trial. Men received a single 360-mg intramuscular dose of gentamicin and underwent test of cure by culture 4-7 days later. The study measured creatinine at enrollment and test of cure, serum gentamicin concentration postdose to establish peak concentration (Cmax), and standard antimicrobial minimum inhibitory concentrations (MICs) by agar dilution. The trial was designed to establish a point estimate for gentamicin's efficacy for pharyngeal gonorrhea. We planned to enroll 50 evaluable participants; assuming gentamicin was 80% efficacious, the trial would establish a 95% confidence interval (CI) of 66%-90%. We planned interim analyses at n = 10 and n = 25. RESULTS The study was stopped early due to poor efficacy. Of 13 enrolled men, 10 were evaluable, and only 2 (20% [95% CI, 2.5%-55.6%]) were cured. Efficacy was not associated with gentamicin Cmax or MIC. No participants experienced renal insufficiency. The mean creatinine percentage change was +5.2% (range, -6.7% to 21.3%). Six (46%) participants experienced headache, all deemed unrelated to treatment. CONCLUSIONS Gentamicin alone failed to eradicate Neisseria gonorrhoeae from the pharynx. Clinicians should use caution when treating gonorrhea with the CDC's current alternative regimen (gentamicin 240 mg plus azithromycin 2 g) given increases in azithromycin resistance and gentamicin's poor efficacy at the pharynx. CLINICAL TRIALS REGISTRATION NCT03632109.
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Affiliation(s)
- Lindley A Barbee
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA.,Human Immunodeficiency Virus/Sexually Transmitted Disease Program, Public Health-Seattle & King County, Seattle, Washington, USA
| | - Olusegun O Soge
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Jennifer Morgan
- Human Immunodeficiency Virus/Sexually Transmitted Disease Program, Public Health-Seattle & King County, Seattle, Washington, USA
| | - Angela Leclair
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Tamara Bass
- Human Immunodeficiency Virus/Sexually Transmitted Disease Program, Public Health-Seattle & King County, Seattle, Washington, USA
| | - Brian J Werth
- Department of Pharmacy, University of Washington, Seattle, Washington, USA
| | - James P Hughes
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Matthew R Golden
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA.,Human Immunodeficiency Virus/Sexually Transmitted Disease Program, Public Health-Seattle & King County, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
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11
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"Sex in the Time of COVID": Clinical Guidelines for Sexually Transmitted Disease Management in an Era of Social Distancing. Sex Transm Dis 2021; 47:427-430. [PMID: 32541302 PMCID: PMC7448723 DOI: 10.1097/olq.0000000000001194] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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12
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Hook EW, Newman L, Drusano G, Evans S, Handsfield HH, Jerse AE, Kong FYS, Lee JY, Taylor SN, Deal C. Development of New Antimicrobials for Urogenital Gonorrhea Therapy: Clinical Trial Design Considerations. Clin Infect Dis 2021; 70:1495-1500. [PMID: 31538646 DOI: 10.1093/cid/ciz899] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 09/13/2019] [Indexed: 12/31/2022] Open
Abstract
Gonorrhea remains a major public health challenge, and current recommendations for gonorrhea treatment are threatened by evolving antimicrobial resistance and a diminished pipeline for new antibiotics. Evaluations of potential new treatments for gonorrhea currently make limited use of new understanding of the pharmacokinetic and pharmacodynamic contributors to effective therapy, the prevention of antimicrobial resistance, and newer designs for clinical trials. They are hampered by the requirement to utilize combination ceftriaxone/azithromycin therapy as the comparator regimen in noninferiority trials designed to seek an indication for gonorrhea therapy. Evolving gonococcal epidemiology and clinical trial design constraints hinder the enrollment of those populations at the greatest risk for gonorrhea (adolescents, women, and persons infected with antibiotic-resistant Neisseria gonorrhoeae). This article summarizes a recent meeting on the evaluation process for antimicrobials for urogenital gonorrhea treatment and encourages the consideration of new designs for the evaluation of gonorrhea therapy.
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Affiliation(s)
- Edward W Hook
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lori Newman
- National Institute for Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - George Drusano
- Institute for Therapeutic Innovation, University of Florida, Lake Nona, Florida, USA
| | - Scott Evans
- Milken Institute School of Public Health George Washington University, Washington, DC, USA
| | | | - Ann E Jerse
- Uniformed Services University, Bethesda, Maryland, USA
| | - Fabian Y S Kong
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | | | | | - Carolyn Deal
- National Institute for Allergy and Infectious Diseases, Rockville, Maryland, USA
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13
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Unemo M, Ross J, Serwin AB, Gomberg M, Cusini M, Jensen JS. Background review for the '2020 European guideline for the diagnosis and treatment of gonorrhoea in adults'. Int J STD AIDS 2020; 32:108-126. [PMID: 33323071 DOI: 10.1177/0956462420948739] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Gonorrhoea is a major public health concern globally. Increasing incidence and sporadic ceftriaxone-resistant cases, including treatment failures, are growing concerns. The 2020 European gonorrhoea guideline provides up-to-date evidence-based guidance regarding the diagnosis and treatment of gonorrhoea. The updates and recommendations emphasize significantly increasing gonorrhoea incidence; broad indications for increased testing with validated and quality-assured nucleic acid amplification tests (NAATs) and culture; dual antimicrobial therapy including high-dose ceftriaxone and azithromycin (ceftriaxone 1 g plus azithromycin 2 g) OR ceftriaxone 1 g monotherapy (ONLY in well-controlled settings, see guideline for details) for uncomplicated gonorrhoea when the antimicrobial susceptibility is unknown; recommendation of test of cure (TOC) in all gonorrhoea cases to ensure eradication of infection and identify resistance; and enhanced surveillance of treatment failures when recommended treatment regimens have been used. Improvements in access to appropriate testing, test performance, diagnostics, antimicrobial susceptibility surveillance and treatment, and follow-up of gonorrhoea patients are essential in controlling gonorrhoea and to mitigate the emergence and/or spread of ceftriaxone resistance and multidrug-resistant and extensively drug-resistant gonorrhoea. This review provides the detailed background, evidence base and discussions, for the 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults (Unemo M, et al. Int J STD AIDS. 2020).
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Affiliation(s)
- M Unemo
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Microbiology, Örebro University Hospital and Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jdc Ross
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - A B Serwin
- Department of Dermatology and Venereology, Medical University of Białystok, Białystok, Poland
| | - M Gomberg
- Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology, Moscow, Russia
| | - M Cusini
- Department of Dermatology, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milano, Italy
| | - J S Jensen
- Infection Preparedness, Research Unit for Reproductive Tract Microbiology, Statens Serum Institut, Copenhagen, Denmark
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14
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Mehta SN, Stafylis C, Tellalian DM, Burian PL, Okada CM, Millner CE, Mejia CM, Klausner JD. Clinical trial protocol to evaluate the efficacy of cefixime in the treatment of early syphilis. Trials 2020; 21:1009. [PMID: 33298143 PMCID: PMC7725115 DOI: 10.1186/s13063-020-04885-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 11/10/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Syphilis rates have been increasing both in the USA and internationally with incidence higher among men-who-have-sex-with-men and people living with human immunodeficiency virus (HIV) infection. Currently, benzathine penicillin is the recommended treatment for syphilis in all patients. Global shortages and cost increases in benzathine penicillin call for alternative treatment options. This study evaluates the efficacy of oral cefixime for the treatment of early syphilis. METHODS We are conducting a randomized, multisite, open-label, non-comparative clinical trial in Los Angeles and Oakland, CA. Eligible participants are ≥ 18 years old, with primary, secondary, or early latent syphilis (rapid plasma reagin [RPR] titer ≥ 1:8). Patients with HIV infection must have a viral load ≤ 200 copies/mL and CD4+ T cell count ≥ 350 cells/μL during the past 6 months. Participants are randomized to receive either 2.4 M IU benzathine penicillin G intramuscularly once or cefixime 400 mg orally twice a day for 10 days. Participants return at 3, 6, and 12 months post-treatment for follow-up RPR serological testing. The primary outcome is the proportion of participants who achieve ≥ 4-fold RPR titer decrease at 3 or 6 months post-treatment. DISCUSSION Clinical trials evaluating the efficacy of alternative antibiotics to penicillin are urgently needed. TRIAL REGISTRATION Clinicaltrials.gov NCT03660488 . Registered on 4 September 2018.
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Affiliation(s)
- Shivani N. Mehta
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | | | | | - Pamela L. Burian
- Department of Medicine, AIDS Healthcare Foundation, Los Angeles, CA USA
| | - Cliff M. Okada
- Department of Medicine, AIDS Healthcare Foundation, Los Angeles, CA USA
| | - Carl E. Millner
- Department of Medicine, AIDS Healthcare Foundation, Los Angeles, CA USA
| | | | - Jeffrey D. Klausner
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
- Department of Medicine, AIDS Healthcare Foundation, Los Angeles, CA USA
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15
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Unemo M, Ross J, Serwin AB, Gomberg M, Cusini M, Jensen JS. 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults. Int J STD AIDS 2020:956462420949126. [PMID: 33121366 DOI: 10.1177/0956462420949126] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gonorrhoea is a major public health concern globally. Increasing incidence and sporadic ceftriaxone-resistant cases, including treatment failures, are growing concerns. The 2020 European gonorrhoea guideline provides up-to-date evidence-based guidance regarding the diagnosis and treatment of gonorrhoea. The updates and recommendations emphasize significantly increasing gonorrhoea incidence; broad indications for increased testing with validated and quality-assured nucleic acid amplification tests and culture; dual antimicrobial therapy including high-dose ceftriaxone and azithromycin (ceftriaxone 1 g plus azithromycin 2 g) OR ceftriaxone 1 g monotherapy (ONLY in well-controlled settings, see guideline for details) for uncomplicated gonorrhoea when the antimicrobial susceptibility is unknown; recommendation of test of cure (TOC) in all gonorrhoea cases to ensure eradication of infection and identify resistance; and enhanced surveillance of treatment failures when recommended treatment regimens have been used. Improvements in access to appropriate testing, test performance, diagnostics, antimicrobial susceptibility surveillance and treatment, and follow-up of gonorrhoea patients are essential in controlling gonorrhoea and to mitigate the emergence and/or spread of ceftriaxone resistance and multidrug-resistant and extensively drug-resistant gonorrhoea. For detailed background, evidence base and discussions, see the background review for the present 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults (Unemo M, et al. Int J STD AIDS. 2020).
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Affiliation(s)
- M Unemo
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Microbiology, Örebro University Hospital and Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jdc Ross
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - A B Serwin
- Department of Dermatology and Venereology, Medical University of Białystok, Białystok, Poland
| | - M Gomberg
- Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology, Moscow, Russia
| | - M Cusini
- Department of Dermatology, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milano, Italy
| | - J S Jensen
- Infection Preparedness, Research Unit for Reproductive Tract Microbiology, Statens Serum Institut, Copenhagen, Denmark
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16
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Taylor MM, Kara EO, Araujo MAL, Silveira MF, Miranda AE, Branco Coelho IC, Bazzo ML, Mendes Pereira GF, Pereira Giozza S, Bermudez XPD, Mello MB, Habib N, Nguyen MH, Thwin SS, Broutet N. Phase II trial evaluating the clinical efficacy of cefixime for treatment of active syphilis in non-pregnant women in Brazil (CeBra). BMC Infect Dis 2020; 20:405. [PMID: 32522244 PMCID: PMC7288542 DOI: 10.1186/s12879-020-04980-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/17/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Syphilis is a sexually and vertically transmitted infection caused by the bacteria Treponema pallidum for which there are few proven alternatives to penicillin for treatment. For pregnant women infected with syphilis, penicillin is the only WHO-recommended treatment that will treat the mother and cross the placenta to treat the unborn infant and prevent congenital syphilis. Recent shortages, national level stockouts as well as other barriers to penicillin use call for the urgent identification of alternative therapies to treat pregnant women infected with syphilis. METHODS This prospective, randomized, non-comparative trial will enroll non-pregnant women aged 18 years and older with active syphilis, defined as a positive rapid treponemal and a positive non-treponemal RPR test with titer ≥1:16. Women will be a, domized in a 2:1 ratio to receive the oral third generation cephalosporin cefixime at a dose of 400 mg two times per day for 10 days (n = 140) or benzathine penicillin G 2.4 million units intramuscularly based on the stage of syphilis infection (n = 70). RPR titers will be collected at enrolment, and at three, six, and nine months following treatment. Participants experiencing a 4-fold (2 titer) decline by 6 months will be considered as having an adequate or curative treatment response. DISCUSSION Demonstration of efficacy of cefixime in the treatment of active syphilis in this Phase 2 trial among non-pregnant women will inform a proposed randomized controlled trial to evaluate cefixime as an alternative treatment for pregnant women with active syphilis to evaluate prevention of congenital syphilis. TRIAL REGISTRATION Trial identifier: www.Clinicaltrials.gov, NCT03752112. Registration Date: November 22, 2018.
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Affiliation(s)
- Melanie M Taylor
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
- U.S. Centers for Disease Control and Prevention, Division of STD Prevention, Atlanta, GA, USA.
| | - Edna Oliveira Kara
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | | | | | - Ivo Castelo Branco Coelho
- Federal University of Ceará, Ambulatório de IST do Hospital Universitário da Universidade Federal do Ceará, Fortaleza, Brazil
| | | | - Gerson Fernando Mendes Pereira
- Brazil Ministry of Health, Secretariat for Health Surveillance, Department of Chronic Conditions and Sexually Transmitted Infections, Brasília, Brazil
| | - Silvana Pereira Giozza
- Brazil Ministry of Health, Secretariat for Health Surveillance, Department of Chronic Conditions and Sexually Transmitted Infections, Brasília, Brazil
| | | | - Maeve B Mello
- University of Brasília, Brasília, Brazil
- Department of Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization/World Health Organization, Washington, Washington, DC, USA
| | - Ndema Habib
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - My Huong Nguyen
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Soe Soe Thwin
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Nathalie Broutet
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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17
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Assessing Uncertainty in an Anatomical Site-Specific Gonorrhea Transmission Model of Men Who Have Sex With Men. Sex Transm Dis 2020; 46:321-328. [PMID: 30516722 DOI: 10.1097/olq.0000000000000953] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Increased gonorrhea detection highlights the need for additional prevention efforts. Gonorrhea may only be acquired when there is contact between infected and uninfected anatomical sites. With 3 sites of infection, this leads to 7 plausible routes of men who have sex with men (MSM) transmission: urethra-to-rectum, rectum-to-urethra, urethra-to-oropharynx, rectum-to-oropharynx, oropharynx-to-urethra, oropharynx-to-rectum, and oropharynx-to-oropharynx. We characterize the uncertainty and potential importance of transmission from each anatomical site using a deterministic compartmental mathematical model. METHODS We developed a model of site-specific gonococcal infection, where individuals are infected at 0, 1, 2, or all 3 sites. Sexual behavior and infection duration parameters were fixed similar to a recent model analysis of Australian MSM. Markov chain Monte Carlo methods were used to sample the posterior distribution of transmission probabilities that were consistent with site-specific prevalence in American MSM populations under specific scenarios. Scenarios were defined by whether transmission routes may or may not transmit by constraining specific transmission probabilities to zero rather than fitting them. RESULTS Transmission contributions from each site have greater uncertainty when more routes may transmit; in the most extreme case, when all routes may transmit, the oropharynx can contribute 0% to 100% of all transmissions. In contrast, when only anal or oral sex may transmit, transmission from the oropharynx can account for only 0% to 25% of transmission. Intervention effectiveness against transmission from each site also has greater uncertainty when more routes may transmit. CONCLUSIONS Even under ideal conditions (ie, when site-specific gonococcal prevalence, relative rates of specific sex acts, and duration of infection at each anatomical site are known and do not vary), the relative importance of different anatomical sites for gonococcal infection transmission cannot be inferred with precision. Additional data informing per act transmissibility are needed to understand site-specific gonococcal infection transmission. This understanding is essential for predicting population-specific intervention effectiveness.
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