Neisseria gonorrhoeae Treatment Failure and Susceptibility to Cefixime in Toronto, Canada

Importance Although cephalosporins are the cornerstone of treatment of Neisseria gonorrhoeae infections, cefixime is the only oral antimicrobial option. Increased minimum inhibitory concentrations (MICs) to cefixime have been identified worldwide and have been associated with reports of clinical failure. Objective To assess the risk of clinical treatment failure of N gonorrhoeae infections associated with the use of cefixime. Design, Setting, and Population A retrospective cohort study of culture-positive N gonorrhoeae infections at a single sexual health clinic in Toronto, Canada, that routinely performs test of cure. The cohort comprised N gonorrhoeae culture-positive individuals identified between May 1, 2010, and April 30, 2011, treated with cefixime as recommended by Public Health Agency of Canada guidelines. Main Outcome Measures Cefixime treatment failure, defined as the repeat isolation of N gonorrhoeae at the test-of-cure visit identical to the pretreatment isolate by molecular typing and explicit denial of reexposure. Results There were 291 N gonorrhoeae culture-positive individuals identified. Of 133 who returned for test of cure, 13 were culture positive; 9 patients were determined to have experienced cefixime treatment failure, involving urethral (n=4), pharyngeal (n=2), and rectal (n=3) sites. The overall rate of clinical treatment failure among those who had a test of cure was 6.77% (95% CI, 3.14%-12.45%; 9/133). The rate of clinical failure associated with a cefixime MIC of 0.12 mu g/mL or greater was 25.0% (95% CI, 10.69%-44.87%; 7/28) compared with 1.90% (95% CI, 0.23%-6.71%; 2/105) of infections with cefixime MICs less than 0.12 mu g/mL, with a relative risk of 13.13 (95% CI, 2.88-59.72; P < .001). Conclusion and Relevance The rate of clinical failure following treatment of N gonorrhoeae infections with cefixime was relatively high at a Toronto clinic and was associated with elevated MICs. JAMA. 2013; 309(2):163-170