Sir, We read with interest the article by Thakur et al.1 reporting that Neisseria gonorrhoeae isolates from Canada were largely susceptible (about 85%) to antimicrobial therapy no longer indicated for its treatment. Currently, physicians are experiencing relapse and failure due to the increase in infections caused by gonococci with reduced susceptibility to cephalosporins,2 which are the recommended therapy. Therefore repurposing old drugs such as penicillin and ciprofloxacin as suggested by Thakur et al.1 might be of interest. Moreover, Davido et al.3 support this idea and highlighted that aztreonam might be helpful, especially in case of allergy to β-lactams or when the patient is suspected of resistance. Yet aztreonam has not been taken into account in the latest guidelines for the treatment of gonorrhoea. Indeed, the latest review of the literature issued by the US CDC in 1995,4 which served as a baseline, did not retain aztreonam as a highly effective drug against gonorrhoea because of lack of efficacy against pharyngeal infection (66.6%), although this finding was based on a very small sample size (n = 3).5 Since this publication, no new data have become available in order to assess adequately the efficacy of aztreonam, especially because fluoroquinolones and cephalosporins have been widely used in the treatment of gonorrhoea in the last two decades. Currently, WHO tolerates a resistance rate up to 5% for the molecules that can be used to treat gonorrhoea,6 which is exactly what aztreonam fulfils. In 1983, the first report of single-dose aztreonam treatment in acute uncomplicated gonococcal urethritis in men reported 100% efficacy.7 In 1992, one in vitro study revealed that, among 333 gonococcal isolates, none was resistant to aztreonam (MIC <8 mg/L).8 More recently, some strains of N. gonorrhoeae with reduced susceptibility to ceftriaxone [H041 (MIC 2 mg/L), F89 (MIC 1 mg/L) and A8806/G140106 (MIC 0.5 mg/L)] have been described, but none was tested against aztreonam.9,10 One major concern about using aztreonam in practice is that EUCAST breakpoints are not defined for the use of aztreonam against N. gonorrhoeae isolates.11 Nevertheless, as Thakur et al.1 reminded us, gonorrhoea is mostly diagnosed by PCR testing, which does not permit antimicrobial susceptibility testing. It is of note that aztreonam has the same route of administration as ceftriaxone, but has the advantage of a lack of disturbance of the gut flora due to lower biliary excretion (<1%) than ceftriaxone (45%), as mentioned in the summary of product characteristics. Altogether, we believe that the data presented by Thakur et al.1 together with those by Davido et al.3 support the rethinking of the management of gonococcal infections, especially when patients are infected by strains with reduced susceptibility to ceftriaxone or are known to be allergic to β-lactams. Acknowledgements We would like to thank all our colleagues, in particular Azzam Saleh-Mghir and Dr Pierre De Truchis, for their unfailing support. Transparency declarations None to declare. References 1 Thakur SD, Levett PN, Horsman GB et al. High levels of susceptibility to new and older antibiotics in Neisseria gonorrhoeae isolates from Saskatchewan (2003–15): time to consider point-of-care or molecular testing for precision treatment? J Antimicrob Chemother 2018; 73: 118– 25. Google Scholar CrossRef Search ADS PubMed 2 Yu R, Yin Y, Wang G et al. Worldwide susceptibility rates of Neisseria gonorrhoeae isolates to cefixime and cefpodoxime: a systematic review and meta-analysis. PLoS One 2014; 9: e87849. Google Scholar CrossRef Search ADS PubMed 3 Davido B, Dinh A, Senard O et al. Repurposing an old drug: aztreonam as a new treatment strategy for gonorrhoea. J Antimicrob Chemother 2017; 72: 1466– 8. Google Scholar PubMed 4 Moran JS, Levine WC. Drugs of choice for the treatment of uncomplicated gonococcal infections. Clin Infect Dis 1995; 20 Suppl 1: S47– 65. Google Scholar CrossRef Search ADS PubMed 5 Tait IB, Winning J, Sleigh JD. Single dose aztreonam in treating gonorrhoea. Genitourin Med 1987; 63: 13– 5. Google Scholar PubMed 6 WHO. WHO Guidelines for the Treatment of Neisseria gonorrhoeae . Geneva, Switzerland: WHO, 2016. http://apps.who.int/iris/bitstream/10665/246114/1/9789241549691-eng.pdf. 7 Miller LK, Sanchez PL, Berg SW et al. Effectiveness of aztreonam, a new monobactam antibiotic, against penicillin-resistant gonococci. J Infect Dis 1983; 148: 612. Google Scholar CrossRef Search ADS PubMed 8 Clendennen TE, Echeverria P, Saengeur S et al. Antibiotic susceptibility survey of Neisseria gonorrhoeae in Thailand. Antimicrob Agents Chemother 1992; 36: 1682– 7. Google Scholar CrossRef Search ADS PubMed 9 Deguchi T, Yasuda M, Hatazaki K et al. New clinical strain of Neisseria gonorrhoeae with decreased susceptibility to ceftriaxone, Japan. Emerg Infect Dis 2016; 22: 142– 4. Google Scholar CrossRef Search ADS PubMed 10 Lahra MM, Ryder N, Whiley DM. A new multidrug-resistant strain of Neisseria gonorrhoeae in Australia. N Engl J Med 2014; 371: 1850– 1. Google Scholar CrossRef Search ADS PubMed 11 EUCAST. Breakpoint Tables for Interpretation of MICs and Zone Diameters, Version 7.1, 2017. http://www.eucast.org. © The Author 2017. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please email: firstname.lastname@example.org.
Journal of Antimicrobial Chemotherapy – Oxford University Press
Published: Mar 1, 2018
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