Important note: Information in this article was accurate in December, 2004. The state of the art may have changed since the publication date. 
Gonorrhea is a sexually transmitted infection caused by certain bacteria (N. gonnorhoeae) that can live in the mouth, throat, genitals and anus. These bacteria can be spread through sex as well as from an infected mother to baby during delivery.
Like many sexually transmitted diseases, infection with gonorrhea can make people more susceptible to HIV infection. Also, gonorrhea appears to weaken the immune system's ability to control HIV in people with HIV/AIDS.
Infection with gonorrhea-causing bacteria may not cause symptoms. However, some men may experience the following when they have gonorrhea:
Most women with gonorrhea do not usually have symptoms of this infection. When symptoms do occur they can include the following:
In both men and women who have had anal sex, gonorrhea can cause the following in the anus:
Both men and women who become infected with gonorrhea-causing bacteria can also develop sore throats.
Use of latex condoms plays a key role in preventing the spread of gonorrhea.
Until recently, the antibiotic ciprofloxacin (Cipro) has been a mainstay in the treatment of gonorrhea. But in 2003 scientists at Health Canada warned that rates of gonorrhea were rising in this country. Moreover, cases of gonorrhea that are resistant to ciprofloxacin were also rising.
Both ciprofloxacin and another antibiotic, ofloxacin (Floxin), belong to a class of antibiotics called fluroquinolones (FQ). Once rates of FQ resistance reach between 3% and 5%, this class of drug cannot be recommended for the treatment of gonorrhea. Overall rates of FQ-resistant gonorrhea in Canada are less than 3%. However, Health Canada warns that individual provinces and territories may have higher rates—as high as 10%—of drug resistance.
FQ are not recommended for the treatment of gonorrhea for people in the following locations:
In addition, independent of the Health Canada update, recent reports from other countries suggest that FQ resistance is also a problem in Amsterdam and New Zealand.
Health Canada recommends that the following people with gonorrhea not be treated with FQs:
This point is important because the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta has found that there are high rates of FQ-resistant gonorrhea among men who have sex with men in New York and Massachusetts (and elsewhere in that country). In some cases, the rates of antibiotic resistance are sometimes greater than 5%. Therefore, unless American physicians are certain that their MSM patients do not have FQ-resistant gonorrhea the CDC recommends that alternative antibiotics be used.
Health Canada recommends the following treatment options in people 9 years or older (except for pregnant or nursing women) where there is no suspected resistance to FQ and patients have no history of allergy to cephalosporin or penicillin antibiotics:
If FQ are not recommended for a patient or geographic area of Canada then the options are:
If FQ are not recommended for a patient or geographic area and the patient is allergic to cephalosporins or penicillin, then the following are options:
Special Access Programme
c/o Therapeutic Products Directorate
Finance Building, 2nd floor
PL 0202C1, Tunney's Pasture
Ottawa, ON K1A 1B9
Telephone: 613.941.2108
Fax: 613.941.3194
http://www.hc-sc.gc.ca/hpfb-dgpsa/tpd-dpt/edrp.html
The overall shift in the guidelines has been from the use of FQ to cefixime, which is increasingly being used to treat gonorrhea. The final version of the guidelines will be published in 2005. As with all bacterial infections, it is only a matter of time before resistance to cefixime develops. Already, there are reports from Hawaii of N. gonnorhoeae becoming less susceptible to this antibiotic. So far, this does not appear to be a major problem in Canada.
REFERENCES
1. Sarwal S, Wong T, Sevigny C, and Ng LK. Increasing incidence of ciprofloxacin-resistant Neisseria gonorrhoeae infection in Canada. CMAJ. 2003 Apr 1;168(7):872-3.
2. Mann J, Kropp R, Wong T, et al. Gonorrhea treatment guidelines in Canada: 2004 update. CMAJ. 2004 Nov 23;171(11):1345-6.
3. Ison CA, Mouton JW, Jones K, et al. Which cephalosporin for gonorrhoea? Sex Transm Infect. 2004 Oct;80(5):386-8.
4. Ng LK, Martin I, Lau A; The National Gonococcal Surveillance Program Members. Trends of chromosomally mediated antimicrobial resistance in Neisseria gonorrhoeae in Canada: 1994-1999. Sex Transm Dis. 2003 Dec;30(12):896-900.
5. Kaul R, Rowland-Jones SL, Gillespie G, et al. Gonococcal cervicitis is associated with reduced systemic CD8+ T cell responses in human immunodeficiency virus type 1-infected and exposed, uninfected sex workers. J Infect Dis. 2002 May 15;185(10):1525-9.
6. Boulton IC and Gray-Owen SD. Neisserial binding to CEACAM1 arrests the activation and proliferation of CD4+ T lymphocytes. Nat Immunol. 2002 Mar;3(3):229-36.
7. Chen A, Boulton IC, Pongoski J, et al. Induction of HIV-1 long terminal repeat-mediated transcription by Neisseria gonorrhoeae. AIDS. 2003 Mar 7;17(4):625-8.
8. Kolader M, Peerbooms PG, Vader PC, et al. The rise in fluoroquinolone-resistant Neisseria gonorrhoeae among people attending the Municipal Health Service's clinic for sexually transmitted diseases in Amsterdam, The netherlands; cefotaxime now first-choice treatment for uncomplicated gonorrhoea. Ned Tijdschr Geneeskd. 2004 Oct 23;148(43):2129-32. (Dutch).
9. Heffernan H, Brokenshire M, Woodhouse R, et al. Antimicrobial susceptibility among Neisseria gonorrhoeae in New Zealand in 2002. N Z Med J. 2004 Apr 02;117(1191):U817.
10. Habib AR and Fernando R. Efficacy of azithromycin 1g single dose in the management of uncomplicated gonorrhoea. Int J STD AIDS. 2004 Apr;15(4):240-2.
11. Wang SA, Lee MV, O'Connor N, et al. Multidrug-resistant Neisseria gonorrhoeae with decreased susceptibility to cefixime-Hawaii, 2001. Clin Infect Dis. 2003 Sep 15;37(6):849-52.
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