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Editor,—In the recently published UK national guidelines on sexually transmitted infections and closely related conditions1 ciprofloxacin 500 mg orally as a single dose has been recommended for uncomplicated anogenital infection due to Neisseria gonorrhoeae in adults. However, some studies have shown that an oral dose of 250 mg of ciprofloxacin is an effective treatment for uncomplicated gonorrhoea.2,3
In our department, we have been using ciprofloxacin 250 mg as a single oral dose as first line treatment for uncomplicated gonococcal urethritis and cervicitis and 500 mg of oral dose of ciprofloxacin for rectal and pharyngeal infections since 1997. We reviewed case notes of patients with uncomplicated gonococcal infections who attended our department between 1 January 1999 and 31 December 1999. A total of 61 patients with a positive culture were analysed. Of the 61 patients 42 patients with gonococcal urethritis and cervicitis were treated with ciprofloxacin 250 mg as a single oral dose. Eleven patients were treated with 500 mg of ciprofloxacin. Of the 11 patients five had rectal or pharyngeal infections, two were infected with a strain less sensitive to ciprofloxacin, four were initially treated with 250 mg of ciprofloxacin and subsequently given 500 mg of ciprofloxacin when rectal/pharyngeal cultures were found to be positive. Five patients with pregnancy or risk of pregnancy were treated with 3 g amoxycillin with 1 g probenecid and three patients (two pregnant patients with history of allergy to penicillin and one patient infected with a strain resistant to penicillin and less sensitive to ciprofloxacin) were treated with 2 g of intramuscular spectinomycin. In the group treated with 250 mg of ciprofloxacin, 35 (83%) patients, and in the groups treated with 500 mg ciprofloxacin, amoxycillin, and spectinomycin, all patients attended for at least one repeat smear and culture. In all tested cases repeat smear and cultures were negative. Of seven patients who defaulted for test of cure despite repeated recall letters, five were below the age of 19. The strains isolated in three patients were less sensitive to ciprofloxacin (see table 1). Of the three patients two had infection due to penicillinase producing Neisseria gonorrhoeae (PPNG) and they contracted the infection in Thailand. Two of these patients were treated with a single oral dose of 500 mg of ciprofloxacin and one patient was treated with 2 g of intramuscular spectinomycin and subsequently culture became negative.
The proportion of quinolone resistant Neisseria gonorrhoeae isolates is rising throughout the world and the levels of resistance in these isolates have risen substantially in recent years.4 In Britain, ciprofloxacin resistance is associated with imported cases especially from the Far East5 and high level resistance to ciprofloxacin has also been reported.6 However, treatment failure remains low especially if the infection is acquired within the United Kingdom.5 Moreover, it has been reported that failure rate of ciprofloxacin treatment is lower than the percentage of ciprofloxacin resistant isolates and therefore in vitro resistance to ciprofloxacin may not translate into clinical treatment failure.4
A single oral dose of 100 mg ciprofloxacin has been reported to be effective in eradicating uncomplicated urethral gonorrhoea in men.2 In our study a single oral dose of 250 mg of ciprofloxacin was found to be effective for treating uncomplicated gonococcal urethritis and cervicitis. However, consideration may be given to a higher dose of ciprofloxacin or other alternatives when the infection may have been acquired in locations where resistant strains are endemic.