Resistance means ciprofloxacin should no longer be used to treat gonorrhoea in South Africa, says study

Michael Carter
Published: 28 July 2008

Ciprofloxacin should no longer be used for the first-line treatment of gonorrhoea in South Africa, researchers recommend in a study published in the online edition of Sexually Transmitted Infections. They found a high prevalence of ciprofloxacin-resistant gonorrhoea amongst men with the infection in Cape Town and Johannesburg. Furthermore their research showed the presence of ciprofloxacin resistance was associated with infection with HIV.

Gonorrhoea with resistance to ciprofloxacin has been detected in Europe, the Pacific and the US, and the drug is no longer recommended for first-line treatment for gonorrhoea in many countries. World Health Organization (WHO) guidelines recommend that first-line treatment for gonorrhoea should be changed if it fails to achieve a cure in 5% of cases. The current study found resistance rates of 27% amongst men in Cape Town and 32% in Johannesburg, and the investigators recommend that ceftriaxone injections should now be used for first-line gonorrhoea treatment in South Africa.

Most cases of male urethritis in South Africa are caused by the sexually transmitted infection gonorrhoea, and current South African guidelines recommend that a single 500mg dose of the antibiotic ciprofloxacin should be used as first-line treatment for the infection.

As with other countries in the Pacific and Europe, cases of gonorrhoea with resistance to ciprofloxacin were first reported in South Africa in 2003. This prompted health authorities in South Africa to conduct a study to determine the prevalence of ciprofloxacin-resistant gonorrhoea in the country. At this time, 7% of men in Cape Town and 11% in Johannesburg were found to have gonorrhoea with resistance to the antibiotic.

Investigators repeated this study in 2007, and obtained anonymous urethral and blood samples from a total of 288 men (139 in Cape Town, 149 in Johannesburg) treated for presumptive gonorrhoea. The urethral samples were cultured for resistance to gonorrhoea and the blood samples were tested for HIV. All the patients were provided with a single dose of ciprofloxacin and a week of treatment with doxycycline and asked to return for tests to see if their treatment was successful.

Results showed that 27% of the gonorrhoea samples from Cape Town and 32% of those from Johannesburg had resistance to ciprofloxacin. This represented a 2.9 fold increase in the prevalence of ciprofloxacin resistance in Cape Town, and a 1.9 fold increase in Johannesburg in three years.

The investigators also found a statistically significant association between the presence of ciprofloxacin-resistant gonorrhoea and infection with HIV. Their analysis showed that of the 81 men with gonorrhoea resistant to ciprofloxacin, 42% were infected with HIV compared to an HIV prevalence of 29% amongst men with gonorrhoea that was still sensitive to treatment with ciprofloxacin (p = 0.034).

Only 33 of the men returned after a week to see if their treatment had been successful. Tests showed that the persistence of gonorrhoea was significantly associated with resistance to ciprofloxacin (p < 0.0005).

The investigators therefore recommend that ciprofloxacin should no longer be used for first-line gonorrhoea treatment in South Africa. They found no resistance to ceftriaxone, and recommend that this drug should now be first choice for the treatment of gonorrhoea.

But although ceftriaxone is on the WHO essential drugs list, it has to be administered by an injection into muscle. Oral treatment with cefixime or cefpodomine would, the investigators believe, be preferable, not only because they are easier to administer but also because of “the HIV risk associated with occupational needlestick injuries in countries with high HIV prevalence amongst [sexually transmitted infection] patients”. However, they note that neither of these drugs are on the WHO essential drugs list.


Lewis A.L. et al. Escalation in the relative prevalence of ciprofloxacin resistant gonorrhoea among men with urethral discharge in two South African cities – association with HIV seropositivity. Sex Transm Infect, online edition, 2nd July 2008.

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