Comparison of cefuroxime and penicillin in the treatment of uncomplicated gonorrhea

Treatment efficacy for rectal Neisseria gonorrhoeae: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Rectal gonorrhoea is a common sexually transmitted infection with increasing antimicrobial resistance requiring optimization of available treatments.

OBJECTIVES

This systematic review aimed to assess the efficacy of current treatments, previously trialled treatments and new emerging treatments for rectal Neisseria gonorrhoeae (NG).

METHODS

Online bibliographic databases were search from 1 January 1946 to 14 August 2020. All randomized controlled trials (RCTs) with rectal NG data among participants aged 15 years or above and published in English were included. Random effects meta-analyses were used to estimate overall treatment efficacy, defined as microbiological cure. Sub-group analyses included stratifying by diagnostic assay, by dual versus monotherapy, and by currently recommended treatments (e.g. ceftriaxone ± azithromycin) versus previously trialled but not recommended treatments (e.g. amoxicillin) versus emerging treatments (e.g. zoliflodacin). The study protocol was registered on PROSPERO (CRD42020202998).

RESULTS

54 studies including 1813 participants and 44 treatment regimens were identified. The overall summary treatment efficacy for rectal NG was 100.0% (95% CI: 99.9%-100.0%; I2 = 0.0%; P = 0.86). Efficacy estimates for monotherapies (100.0%; 95% CI: 99.88%-100.0%; I2 = 0.00%; P = 0.97) and dual therapies (100.0%; 95% CI: 97.65%-100.0%; I2 = 56.24%; P = 0.03) were similar. Efficacy was highest for current treatments (100.00%; 95% CI: 99.96%-100.00%; I2 = 0.00%; P = 0.98) versus emerging treatments (97.16%; 95% CI: 86.79%-100.00%; I2 = 0.00%; P = 0.84). There were no trials exclusively investigating rectal NG and small sample size was a limitation in most trials.

CONCLUSIONS

Currently recommended treatments containing ceftriaxone, as mono or dual therapy, are effective. Emerging drugs such as zoliflodacin may be potentially useful for rectal NG but further data are needed.

Efficacy and Safety of Injectable and Oral Antibiotics in Treating Gonorrhea: A Systematic Review and Network Meta-Analysis

Gonorrhea is the second most frequently reported sexually transmitted infectious disease of bacterial origin in the world. Current empiric therapies rely on broad-spectrum antibiotics. However, treatment options are becoming limited due to the rise of drug-resistant gonorrhea. To control the rise of drug-resistant gonorrhea and to identify alternative treatment options, clinicians will have to increasingly rely on experimental evidence for the treatment of gonorrhea patients. Thus, we performed a systematic review and network meta-analysis of all randomized clinical trials about the efficacy and safety of various antibiotic regimens in adults with gonorrhea. We searched all references in Embase and PubMed from the date of their inception to January 2019, and then an updated search was performed in March 2019. Of the 28,843 identified references, 44 fulfilled our selection criteria. We used a network meta-analysis based on a frequentist approach to evaluate the efficacy and safety of 12 injectable and 11 oral antibiotics. The efficacy of treatments was ranked by p score and inconsistency was assessed by a back-calculation method. Certainty of evidence was evaluated by the GRADE system. For injectable drugs, there was no difference in efficacy between a reference antibiotic and other drugs. However, ceftriaxone had significantly better efficacy than cefuroxime (OR, 12.03; 95% CI 3.73–38.79), cephaloridine (OR, 42.41; 95% CI 8.77–205.07), kanamycin (OR, 5.45; 95% CI 1.25–23.70), penicillin (OR, 13.11; 95% CI 4.48–38.37), and spectinomycin (OR, 4.70; 95% CI 1.62–13.62). Thus, ceftriaxone was the most effective injectable drug (p score of 0.924). As for oral drugs, azithromycin was the most effective compound (p score of 0.8633). There were no significant differences in safety between injectable and oral treatments. In our systematic review of randomized controlled trials, we found azithromycin and ceftriaxone to be the most effective antibiotics for the treatment of gonorrhea. This is in line with current guidelines which recommend a combination therapy of azithromycin and ceftriaxone for the treatment of gonorrhea due to increased antimicrobial resistance. Our analysis identified gentamicin and ofloxacin as alternative therapeutics to treat drug-resistant gonorrhea.

Cephalosporin-probenecid drug interactions

The effect of concurrent probenecid administration on the pharmacokinetics of cephalosporin antibiotics varies with the available cephalosporins. Most cephalosporins are affected to some degree by concurrent probenecid administration, although ceforanide, ceftazidime, ceftriaxone and latamoxef (moxalactam) have no significant changes in pharmacokinetics. For those cephalosporins affected by probenecid, the predominant findings are impairment in renal clearance resulting in increased peak serum concentrations, an increased area under the concentration-time curve (AUC), and both delayed and prolonged recovery of the cephalosporin in the urine. The distribution of the cephalosporins is affected to varying degrees, with reports of increased penetration into ocular, central nervous system and blister fluids noted with some agents. The clinical relevance of the changes in cephalosporin distribution associated with probenecid administration has not been investigated. The dose and timing of probenecid administration appear to be major determinants in any possible interaction. Studies with ceftizoxime and cefoxitin suggest that larger probenecid doses result in greater changes in the pharmacokinetics of cephalosporins. Prolonged probenecid therapy before administration of a cephalosporin did not seem to be as relevant as the probenecid dosage in determining the magnitude of the interaction. Probenecid administration with or immediately before cephalosporin administration appears able to produce these documented changes in cephalosporin pharmacokinetics. The route of administration (oral versus parenteral) of either prolosporin pharmacokinetics. The route of administration (oral versus parenteral) of either probenecid or the cephalosporin does not appear to influence the characteristics of the interactions. The therapeutic efficacy of a combination of a cephalosporin with probenecid has been most thoroughly studied for single-dose treatment of gonorrhoea. The addition of probenecid to cephalosporin therapy results in sustained systemic concentrations adequate for eradication of Neisseria gonorrhoeae. Regimens involving either second or third generation cephalosporins demonstrate good success rates with single-dose therapy. However, the success of ceftriaxone administered alone for treatment of both penicillase-producing and non-penicillase-producing strains of N. gonorrhoeae suggests that the addition of probenecid is unnecessary. The use of probenecid, in combination with cephalosporins, to enhance the treatment of other venereal and systemic infections has preliminary, inconclusive support.

Comparative study of cefuroxime axetil and procaine penicillin in the treatment of uncomplicated gonorrhoea

A total of 311 patients presenting with uncomplicated gonorrhoea were entered into a comparative randomized open-label study and given single-dose treatment with either oral cefuroxime axetil (CAE) or intramuscular procaine penicillin (PP). Neisseria gonorrhoeae was eliminated from 129 (98%) of 131 evaluable patients treated with CAE and 127 (98%) of 129 evaluable patients treated with PP. None of the 4 treatment failures (3 male and 1 female) were caused by beta-lactamase-producing isolates. Both treatments were well tolerated with minor adverse events reported in 3 (2%) of CAE treated patients. We conclude that CAE is an effective, well tolerated treatment for uncomplicated gonorrhoea which has the convenience and acceptability of single-dose oral therapy.

Clinical comparison of single-oral-dose cefuroxime axetil and amoxicillin with probenecid for uncomplicated gonococcal infections in women

Four hundred sixty-six female patients were enrolled in a randomized study that compared the clinical efficacies of single oral doses of cefuroxime axetil and amoxicillin with probenecid in the treatment of uncomplicated gonorrhea. Two hundred ninety-five patients had culture-positive gonococcal infections and completed the investigation. Cure rates for the patients treated with cefuroxime axetil and those treated with amoxicillin with probenecid were high (greater than 95%) for genitorectal infections. Pharyngeal infections, however, were not uniformly eradicated by either cefuroxime axetil (60%) or amoxicillin with probenecid (64%). Approximately 13% of each patient group suffered adverse events, which were gastrointestinal in the majority and were transient. Compared with amoxicillin plus probenecid, cefuroxime axetil in a single oral dose was an equally safe and effective drug for the treatment of uncomplicated gonorrhea in women caused by penicillin-susceptible strains.

Role of cephalosporins in gonorrhoea and other sexually transmitted diseases

Cephalosporins have a role in the treatment of gonorrhoea, and especially infections caused by strains that are penicillin-resistant, either because they produce plasmid-mediated beta-lactamase or they have chromosomally mediated diminished permeability or modified penicillin-binding proteins. Although none of the oral or Group I agents are useful, most of the Group II, III and IV agents are, and especially cefuroxime, cefotaxime, ceftriaxone and cefoxitin. In addition to uncomplicated urethral, cervical or rectal infections, appropriate regimens are also effective for the treatment of pharyngeal infections, disseminated infections and gonococcal ophthalmia. The cephalosporins have no clear role in the treatment of syphilis, granuloma inguinale, Mycoplasma or chlamydial infections or bacterial vaginosis, but ceftriaxone may be effective in chancroid, and cefoxitin in combination with an antichlamydial agent (such as a tetracycline) might be used for the treatment of pelvic inflammatory disease.

Oral cefuroxime axetil compared with oral ampicillin in treating acute uncomplicated gonorrhoea

The efficacy and tolerance of single oral doses of cefuroxime axetil (1.5 g) were compared with oral ampicillin (3 g) for treating acute gonococcal urethritis in 110 men and 30 women. Each dose was given with 1 g probenecid. Of the 62 assessable patients who received ampicillin, two failed to respond to treatment. Of 67 assessable patients who received cefuroxime axetil, one failed to respond. Pencillinase producing strains of Neisseria gonorrhoeae were isolated from five patients; one received ampicillin and failed to respond, whereas the other four received cefuroxime axetil and three were cured. A single oral dose of 1.5 g cefuroxime axetil with 1 g probenecid seemed to be an effective treatment for acute gonococcal urethritis, especially for penicillin resistant strains.

Dose ranging study of cefpimizole (U-63196E) for treatment of uncomplicated gonorrhea in men

We conducted a two-center dose ranging study to evaluate the efficacy, tolerance, and toxicity of cefpimizole, a new cephalosporin, in the treatment of uncomplicated gonorrhea in 96 males. Twelve patients at each center were treated intramuscularly with single doses of 1.0, 0.5, 0.25, and 0.125 g of cefpimizole. All urethral infections were cured at the highest dose, but lower doses produced progressively decreasing cure rates of 90% (0.5 g), 83% (0.25 g), and 71% (0.125 g). Treatment failures of rectal and pharyngeal infections occurred at the highest dose level. Geometric mean MICs for cefpimizole for successfully and unsuccessfully treated volunteers were 0.088 and 0.282 micrograms/ml, respectively. A prominent adverse effect was clinically significant pain at the injection site, which occurred in 57 (59%) of 96 patients. Results of the study demonstrate that cefpimizole offers no advantage over currently available antibiotics in the treatment of uncomplicated gonorrhea in men.

Treating gonococcal infections resistant to penicillin in Bangkok: comparison of cefuroxime and spectinomycin

Gonococcal organisms have become resistant to antimicrobials throughout the world. Such resistance is common in Thailand, where 40% of gonococci produce penicillinase (PPNG strains) and over half the remainder have MICs of penicillin greater than or equal to 1 mg/l. To evaluate the effectiveness of cefuroxime against such resistant organisms, a controlled clinical trial comparing spectinomycin and cefuroxime was conducted at Bangrak Hospital, Bangkok, in 1982-3. Of 472 patients who were randomly assigned to treatment, 365 (77%) yielded positive cultures before treatment and returned for follow up evaluation three to 13 days after treatment. Of the 365 patients, 359 (98%) were cured, and no difference between the two treatment regimens was found either by the sex of the patient or by the presence of PPNG strains. The MIC of cefuroxime against all organisms was less than or equal to 1 mg/l. In vitro susceptibilities of gonococci in Bangkok have not changed appreciably during the past two years. Regimens of cefuroxime and spectinomycin are highly effective even for the relatively resistant gonococci in Bangkok. The pharmacokinetics, in vitro susceptibilities, and effectiveness of cefuroxime encourage evaluation of lower doses of the drug.

Review of the new second-generation cephalosporins: cefonicid, ceforanide, and cefuroxime

The new second-generation cephalosporins, cefonicid, ceforanide, and cefuroxime, have recently become available. These agents are generally less active against gram-positive cocci than first-generation cephalosporins and, at best, equal to cefoxitin and cefamandole against many gram-negative bacteria. Cefuroxime, however, is the most active cephalosporin for beta-lactamase-producing Haemophilus influenzae. These newer agents have superior pharmacokinetic characteristics over cefoxitin and cefamandole. Smaller doses, longer dosing intervals and, potentially, a reduction in total drug cost may be the real advantage of these agents. Open trials and a limited number of comparative studies have documented the effectiveness of cefonicid, ceforanide, and cefuroxime in the treatment of most mild-to-serious infectious diseases, although failures with cefonicid in the treatment of staphylococcal infections have been reported. Notably, cefuroxime has received approval for the treatment of common pediatric bacterial meningitis infections. Replacement of cefamandole or cefoxitin with one of these "longer-acting" agents may be cost-beneficial; however, clinicians must be on alert for the development of bacterial resistance or decreased efficacy.