Background
Guidelines differ on first-line treatment of Gonorrhea (NGI). European and Australian guidelines recommend ceftriaxone (CRO) + azithromycin (AZM) to target resistant strains and minimize resistance emergence, while the CDC and UK favor CRO monotherapy due to increasing AZM resistance and concerns about cross-resistance in other pathogens.
Follow-up also differ: the CDC advises a test-of-cure (TOC) only for pharyngeal infection, while others suggest it universally, especially when using alternative therapies.
Although Italy is highly-burdened by antimicrobial resistance, our national and local ecology present a CRO decreased-susceptibility NG as low as 8%. In this context, the study compares the effectiveness of CRO 1g IM monotherapy versus combination in eradicating NGIs.
Methods
All NGIs diagnosed at our clinic between January 2022 and August 2024, with a TOC performed at 28 days ±7, were retrospectively analyzed.
Diagnoses were made using NAATs on pharyngeal, anal, vaginal swabs, and urine sample.
Data collected included HIV status, PrEP use, symptoms of infection, antibiotic treatment, NAAT TOC results.
Descriptive statistics were reported as counts and percentages, statistical analysis was performed using Pearson χ² or Fischer exact tests.
Results
A total of 202 infections were identified: 41% anal, 40.5% pharyngeal, 18% urethral, and 0.5% vaginal. Of these, 61% involved PrEP-users, 27% PWH, and 12% people without HIV not in PrEP.
79% of infections (119/150) were asymptomatic, predominantly in pharyngeal (48%) and anal sites (47%). Urethral site were more likely to be symptomatic (n 16/31, 52%) than the others (p <0.001).
CRO monotherapy was used in 54% of cases, while CRO+AZM in 39% of cases. Gentamicin±AZM was given in 5 cases due to allergy.
Combination therapy was mainly found to be used in symptomatic cases (58% vs 19%; p <0.001), since treatment was usually given before microbiological results.
TOC was negative in 99% of cases, with only 3 infections testing positive after CRO treatment. In the first case CRO was repeated resulting in a negative TOC. The second was a reinfection and in the last one a TOC was repeated one week later with a negative result.
Conclusions
In a low-prevalence resistance setting CRO monotherapy is as effective as combination with AZM for treating NGIs, suggesting that CRO alone may be preferred to limit antibiotic use.
For the same reason, the high treatment success rate may suggest that TOC may be unnecessary to reduce hospital visits and over-medication.