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Treating Genitourinary and Pharyngeal Gonorrhoea with Single Dose Ceftriaxone

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Treating Genitourinary and Pharyngeal Gonorrhoea with Single Dose Ceftriaxone Genitourin Med: first published as 10.1136/sti.65.1.14 on 1 January 1989. Downloaded from Genitourin Med 1989;65:14-17 Treating genitourinary and pharyngeal gonorrhoea with single dose ceftriaxone J CHRISTOPHERSEN,* A C BOLLERUP,t E FROM,$ J 0 R0NNE-RASMUSSEN,§ K QUITZAUII From the *Department ofDermatovenereology, Gentofte Hospital, Hellerup; the tNeisseria Department, Statens Seruminstitut, Copenhagen; the tDepartment ofDermatovenereology, Marselisborg Hospital, Aarhus; the §Department ofDermatovenereology, Bispebjerg Hospital, Copenhagen; and the IlDepartment ofClinical Research, Roche, Denmark suMMARY The efficacy of ceftriaxone 250 mg given as a single intramuscular dose to treat genitourinary and pharyngeal gonorrhoea is compared with the outcome of the Danish standard treatment for uncomplicated genitourinary gonorrhoea, pivampicillin 1-4 g and probenecid 1 g, both given by mouth. The study comprised 327 patients for whom the diagnosis ofgonorrhoea was made by microscopy of a methylene blue stained smear at their first visit to the clinic and for whom the diagnosis was later confirmed by culture of Neisseria gonorrhoeae. One hundred and seventy patients with genitourinary gonorrhoea (18 with and 152 without concomitant pharyngeal infection) were treated with ceftriaxone. One hundred and fifty seven (17 with and 140 without concomitant pharyngeal infection) were treated with pivampicillin. One week after treatment N gonorrhoeae was isolated from none of 18, 1/152, (1%), 11/17 (65%), and 6/140 (4%) patients, respectively. At a second attendance two weeks after treatment no further treatment failure was found. During the study period, a further 52 patients with pharyngeal infection (with or without concomitant genitourinary infection) that was shown by culture only were treated with a single http://sti.bmj.com/ intramuscular injection of 250 mg ceftriaxone. No treatment failure was observed in this group. Only minor adverse drug reactions were seen. Ceftriaxone 250 mg as a single intramuscular injection is therefore safe and effective in treating gonorrhoea, including pharyngeal infection. on September 26, 2021 by guest. Protected copyright. In some parts of the world single dose regimens of against N gonorrhoeae, and has minimum inhibitory penicillin and probenecid for treating uncomplicated concentrations (MICs) within the range 0.0004-0.03 genitourinary gonorrhoea can still be recommended.' pg/ml.'6 This exceptional activity, combined with high The increasing prevalence of penicillinase producing blood concentrations, pronounced tissue penetration, strains of Neisseria gonorrhoeae (PPNG), strains with and a plasma half life of eight hours, make it chromosomally mediated resistance, and spectino- particularly favourable for treating gonorrhoea. mycin resistant strains, have stressed the need for Clinical trials using single doses of 125-250 mg alternative treatment regimens.2 Moreover, single ceftriaxone have produced cure rates of 100% in dose antibiotic regimens have so far been unsatis- uncomplicated gonorrhoea in men and women.'9 The factory for treating pharyngeal gonorrhoea.34 effect of single dose ceftriaxone in pharyngeal gonorr- Ceftriaxone, a new extended range cephalosporin, is hoea is not well known, but results obtained by Judson one of the most active of all antimicrobial agents et al were promising. A single intramuscular dose of 125 mg ceftriaxone cured 30 (93.8%) of 32 pharyngeal Address for reprints: Dr J Christophersen, Department of infections.' Dermatovenereology, Gentofte Hospital, DK-2900 Hellerup, Denmark The present study aimed to evaluate the efficacy ofa single dose regimen of 250 mg ceftriaxone in pharyn- Accepted for publication 17 August 1988 geal gonorrhoea and to compare the cure rate and the 14 Genitourin Med: first published as 10.1136/sti.65.1.14 on 1 January 1989. Downloaded from Treating genitourinary andpharyngeal gonorrhoea with single dose ceftriaxone 15 acceptability ofceftriaxone with those of our standard immunofluorescence test or carbohydrate (glucose, initial treatment of non-PPNG infections acquired in maltose, and sucrose) utilisation tests, or both and by a Denmark (1.4 g pivampicillin by mouth given with 1 g Gram stained smear. probenecid). IN VITRO SUSCEPTIBILITY TESTING Patients and methods Susceptibility to ceftriaxone and penicillin was tested by a plate dilution method with twofold dilution steps The study was undertaken as an open randomised of the antibiotics; the results are expressed as the comparative multicentre study. All patients aged over minimum inhibitory concentrations (MICs). The con- 18 who attended the clinics during March 1986 to centrations of ceftriaxone ranged from 0.064 to February 1987 were invited to participate. We in- 000025 jg/ml and for penicillin from 2-4 to 0 0094 cluded patients who gave their informed consent and pg/ml. Isolates requiring an MIC of penicillin of 1.2 for whom a diagnosis of genitourinary or rectal jg/ml or more were examined for the production of gonorrhoea was made by microscopy of a methylene penicillinase by the chromogenic cephalosporin test. blue stained smear at the initial visit. Patients were During the study period, isolates from all patients excluded if they had received antibiotics in the attending two of the participating dermatovenereo- previous seven days, if they had known or suspected logical outpatient clinics were stored in liquid nitrogen hypersensitivity to cephalosporins, penicillins, or for susceptibility testing. From a third clinic, however, lidocaine or if they had known renal or hepatic only isolates from patients who entered the study were insufficiency. stored. A total of 393 patients were randomised to treat- ment with either ceftriaxone 250 mg given as an Results intramuscular injection or pivampicillin 14 g plus probenecid 1 g given by mouth. Before treatment Table 1 shows the demographic characteristics of the specimens were taken for culture as follows: one each study population. Of 393 patients enrolled in the from the urethra and the rectum and two from the study, 327 (83%), whose diagnosis was confirmed by tonsillar region of each patient; an additional culture ofNgonorrhoeae and who returned for the first specimen was taken from the cervix of each woman. follow up visit, constituted the final study population. Patients for whom the cultures for Ngonorrhoeae were Of the remaining 66 patients, 42 were excluded negative were subsequently excluded from the study. because N gonorrhoeae was not isolated from the Follow up visits were planned on days 7 and 14 after specimens taken at the initial visit, three were not treatment. On each occasion specimens were taken for treated according to the protocol, and 21 did not http://sti.bmj.com/ culture. Ifgonococci persisted or reappeared within 14 return for follow up. days after treatment and the patient had not had The two treatment groups were comparable for age further sexual intercourse, the treatment was con- and sex. Genitourinary infection without pharyngeal sidered to have failed. The reappearance ofgonococci infection was diagnosed in 243 (90%) of 269 men and after negative cultures on two occasions was con- 49 (84%) of 58 women. The remaining 26 (10%) men sidered to be due to reinfection irrespective of the patient's history. on September 26, 2021 by guest. Protected copyright. During the study period a further 52 patients with Table 1 Characteristics ofthe study population of393 pharyngeal infection with or without concomitant patients (figures are numbers (percentages) except where genitourinary or rectal infection, which was shown stated) only by culture, were treated with a single intra- Treatment muscular injection of 250 mg ceftriaxone. The regimen schedule for control visits and cultures was similar to Cefiriaxone Pivampicillin 2SOmg by 1.4 g and that for the first 393 patients. intramuscular probenecid I g injection by mouth CULTURE OF NGONORRHOEAE No treated 198 195 Specimens were transported from the clinics to the Noevaluable* 170 (86) 157 (81) laboratories on charcoal impregnated sterile wooden Sex distribution: applicators in a modified Stuart's medium. Each swab Men 143 (84) 126 (80) Women 27 (16) 31 (20) was streaked on a selective chocolate agar medium Median (range) age (years): containing amphotericin B (2 ug/ml), polymyxin B Men 26 (18-63) 27 (18-56) sulphate (25 IU/mI), lincomycin (1 pg/ml), and Women 23 (18-65) 24 (18-39) trimethoprim lactate (3 sg/ml). Gonococcus like *Patients for whom diagnosis was confirmed by culture of Neisseria oxidase positive colonies were identified by a direct gonorrhoeae and who returned for follow up. Genitourin Med: first published as 10.1136/sti.65.1.14 on 1 January 1989. Downloaded from 16 Christophersen, Bollerup, From, Ronne-Rasmussen, Quitzau Table 2 Outcome oftreatment with cefiriaxone or Table 4 Minimwn inhibitory concentrations ofpenicillinfor pivampicilin andprobenecid in 327patients with 17 strains ofNeisseria gonorrhoeae isolatedfrom patients genitourinary gonorrhoea, 35 with and 292 without with gonorrhoea not cured by treatment with pivampicillin concomitant pharyngeal infection (figures are numbers 1*4 gplusprobenecid 1 g (percentages) ofpatients not cured out ofnumbers treated) No ofisolatesfrom: Treatment regimen MIC (Ug/ml) Genitourinary Pharyngeal Ceftriaxone 250 g by Pivampicillin 1*4 g and ofpenicillin infection infection Infection intramuscular injection probenecid 1 g by mouth <0-15 Susceptible 0 5 Genitourinary 1/152 (1) 6/140 (4) 0-30-0-60 Less Pharyngeal
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