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Which cephalosporin for gonorrhoea?
  1. C A Ison1,
  2. J W Mouton2,
  3. K Jones3,
  4. on behalf of the North Thames Audit Group,
  5. K A Fenton4,
  6. D M Livermore1
  1. 1Specialist and Reference Microbiology Division, Health Protection Agency, Colindale, London NW9 5HT, UK
  2. 2Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital C-70, Weg door Jonkerbos 100, 6532 sz Nijmegen, Netherlands
  3. 3Centre for Sexual Health and HIV Research, Mortimer Market, London WC13 6AU, UK
  4. 4Communicable Disease Surveillance Centre, Health Protection Agency, London NW9 5EQ, UK
  1. Correspondence to:
 Professor Catherine Ison
 Sexually Transmitted Bacteria Reference Laboratory, Specialist and Reference Microbiology Division, Health Protection Agency, 61 Colindale Avenue, London NW9 5HT, UK;


The recommended treatment for gonorrhoea in the United Kingdom has, until recently, included the fluoroquinolone, ciprofloxacin, which consequently was used by most genitourinary medicine clinics. In 2002 national surveillance data showed that resistance to ciprofloxacin had risen to a prevalence of 9.8% (9% in 2003), indicating that the target of >95% efficacy in first line therapy was no longer achievable. The third generation cephalosporins, ceftriaxone (intramuscular) or cefixime (oral), are the recommended alternatives, but recent audit data reveal other cephalosporins are currently being used to treat gonorrhoea, notably including cefuroxime (intramuscular or, often, oral). A pharmacodynamic analysis was undertaken to determine whether all these regimens were equally potent. Ceftriaxone, 250 (or 500) mg intramuscularly, or cefixime, 400 mg orally, were calculated to give free drug concentrations above the MIC90 for 22–50 hours post dose whereas the cefuroxime regimens being used were pharmacodynamically borderline, achieving this target for only 6.8–11.2 hours and raising the spectre that continued use may select for stepwise increases in resistance, as occurred with penicillin. We therefore underscore that ceftriaxone or cefixime should be the agents of choice to replace ciprofloxacin, as recommended in the new treatment guidelines, and that cefuroxime is a poor substitute.

  • gonorrhoea
  • antimicrobial resistance
  • cephalosporins

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  • Conflicts of interest: None.

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