Two weeks ago, the CDC released the long awaited 2015 edition of the Sexually Transmitted Diseases Treatment Guidelines. Rigorous review of relevant national and international STD research over the past decade and a consensus meeting of more than 100 STD experts in Atlanta 2 years ago have culminated in a 200 page document, not counting 60 pages of references.
Many of our colleagues have spent an incredible amount of time in the review process, most of them members of our Association. CDC should be complimented on pulling this report together once again and one person in particular, Dr. Kim Workowski, should be recognized for her long-standing work on the guidelines that earned her the ASTDA Achievement Award back in 2012.
Beyond applauding our colleagues for this wonderful piece of work, what should we do with the new guidelines? Let me offer some suggestions. First, we should take time to read the text cover to cover and then – read it again. This is arguably one of the single most important documents that informs what we do in STD diagnosis, treatment, and prevention in the U.S. and we owe it to those who have put so much time and effort into the process, to take their work seriously.
Second, we should go back to our own STD clinical protocols and standing orders and make sure that they reflect the 2015 guidelines. Yes, this is a tedious process, but it must be done and, fortunately, there is help. Our colleagues in the STD Prevention Training Centers (PTCs) are ready and willing to assist. Moreover, ASTDA has committed its most valuable resource – its membership – to the guidelines process and will also strongly support its dissemination.
Third, the guidelines are (and will always be) a work in progress and we should have a conversation on ambiguities and controversies where science currently is not providing the answers or where the answers appear to be contradictory. Let me start us off with one such topic: gonorrhea treatment. Since August 2012, CDC has moved oral treatment, i.e., oral cefixime “out of the box” of recommended regimens and demoted it to “alternative treatment”. The main reason for this was the growing concern about decreasing susceptibility of the gonococcus to oral cephalosporins. At the same time, the guidelines continue to support (oral) expedited partner treatment (EPT) for both chlamydia and gonorrhea, implying the use of cefixime for gonorrhea EPT.
This is confusing to many STD providers. Why, they ask, do we insist on treating patients with injectable ceftriaxone and let partners “get away” with oral drugs especially when we do not control the use of these oral drugs by partners the way we do directly observed ceftriaxone treatment of patients? Would this practice not facilitate the very development of resistance we are so concerned about? This is a reasonable objection; one that probably explains why EPT is not reaching its full potential, especially for gonorrhea control.
Here’s my response. First, the notion that cephalosporins are the last bulwark against gonorrhea is a bit of a fallacy. For example, “old” drugs like the aminoglycosides have been used effectively for gonorrhea treatment in African countries including Malawi (gentamycin) and Zimbabwe (kanamycin). As the treatment guidelines now report, a recent study demonstrated the efficacy of a combination of a single gentamycin injection and oral azithromycin for uncomplicated gonococcal infections in the U.S. and this regimen is now listed as an alternative treatment.
Second, it is important to point out that the majority of gonococcal isolates collected through the Gonococcal Isolate Surveillance Project (GISP) are still susceptible to most classes of antibiotics, even penicillin. Excluding the isolates collected from men who have sex with men (MSM) that are more likely to exhibit decreased antibiotic susceptibility, the susceptible proportion among heterosexuals is even larger.
Third, the development of resistance to antibiotics does not appear to be a one-way street. Data from CDC presented at last year’s STD Prevention Conference showed that the rising prevalence of gonorrhea strains with decreased susceptibility to cefixime during 2009 and 2010 was actually followed by a decrease in such strains from 2010 through 2013. While it is too early to draw any definitive conclusions, there is a distinct possibility that gonorrhea’s resistance to antibiotics may wax and wane, perhaps dependent on the predominant treatment modality. Thus, some in the field are suggesting the possibility of antibiotic “recycling”; allowing for the use of older antibiotics (including quinolones), as indicated and monitored by ongoing susceptibility profiling.
While all of this is very interesting and while cephalosporin resistance may yet be a matter of time, the data suggest that we do have a window of opportunity where oral drugs are still very effective to treat gonorrhea, specifically among heterosexuals. And, while it may be prudent to treat gonorrhea with ceftriaxone injections whenever possible, this should not come at the detriment of using oral cefixime for EPT. With resources for disease intervention and partner services increasingly being devoted to the follow up of patients with newly diagnosed HIV and syphilis infections, EPT may be the very best thing we have to offer to the partner of patients with gonorrhea and chlamydia. At this time, resistance concerns should not drive our decisions to implement this very effective intervention.
Kees Rietmeijer, MD, PhD
American Sexually Transmitted Diseases Association