As a professor of public health and a medical consultant for a state-run STD clinic, I greatly appreciated Dr. CamposOutcalt’s article addressing the recently updated STD treatment guidelines (CDC update: Guidelines for treating STDs. J Fam Pract. 2011:60;143-146). The author correctly points out the dosage change recommended for treating uncomplicated gonorrheal infections (increasing the dose of ceftriaxone from 125 to 250 mg) and the rationale for this change (to help combat emerging antibiotic-resistant strains). He also states that dual therapy (azithromycin plus ceftriaxone) is still recommended, both because of the high rate of co-infection with Chlamydia trachomatis and the potential for azithromycin to help eradicate gonorrhea with decreased susceptibility to ceftriaxone.
However, one important change from the 2006 treatment guidelines was not addressed—that dual treatment of gonorrhea (the addition of 1 g oral azithromycin) is now recommended, whether or not a chlamydial infection has been ruled out.1 The 2006 treatment guidelines recommended dual treatment (azithromycin plus a cephalosporin) to cover the possibility of co-infection with C trachomatis, but noted that if chlamydia had been ruled out by a sensitive test such as a nucleic acid amplification test, the azithromycin was unnecessary.2
The continued increase in antibiotic-resistant gonococci is the driving force behind 3 new gonorrhea treatment recommendations: (1) injectible ceftriaxone should be used rather than oral cefixime; (2) the ceftriaxone dose should be doubled from 125 to 250 mg; and (3) 1 g oral azithromycin should be administered (in addition to ceftriaxone), whether or not a chlamydial infection has been ruled out.
Attacking gonorrheal infections with a multidrug regimen will cover the possibility of co-infection with chlamydia, but even if chlamydial co-infection is absent, this strategy will help to decrease the emergence of cephalosporin-resistant isolates. A multidrug therapeutic approach to address the emergence of antimicrobial resistance is similar to the strategy currently used for the treatment of tuberculosis and HIV/AIDS.
Alan R. Katz, MD, MPH
Honolulu