Table 1

Table 1 - In Vitro Activities of Selected Antimicrobials against Neisseria gonorrhoeae

Antimicrobial	MIC₅₀ (mg/L)	MIC₉₀ (mg/L)	MIC range (mg/L)	Number of strains	Source of isolates (country and year)*	Reference
Cephalosporins
Cefixime	0.008	0.030		6552	USA 2003	CDC 2003 (7)
	<0.002	0.008	<0.002-0.06	150	Germany 1988-92	Schäffer 1995
	<0.015	<0.015	<0.0015-0.12	104	London, United Kingdom n.r. >95	Lewis 1995
	<0.001	0.03	<0.001-8.0	328	Thailand 1990	Clendennen 1992a
	0.015	0.06	0.008-0.12	164	Nairobi, Kenya 1989-90	Plourde 1992
	0.03	0.25	0.002-0.5	211	Fukuoka City, Japan 2002	Tanaka 2004
Cefotaxime	<0.015	0.03	<0.0015-0.12	104	London, United Kingdom n.r. >95	Lewis 1995
	0.001	0.004	0.001-0.016	122	Indonesia 1996	Lesmana 2001
	0.031	0.125	0.004-0.25	79	Japan 1992-93	Tanaka 1995
	0.03	0.06	<0.001-8.0	333	Thailand 1990	Clendennen 1992a
	0.03	1	0.002->8	134	Philippines 1989	Clendennen 1992b
	0.008	0.015	0.004-0.06	130	Mwanza, Tanzania 1992	West 1995
Cefotetan	-	0.5	0.03-8	150	New Orleans, Louisiana, USA 1989	Youssef 1990
Cefoxitin	0.5	1	0.5-1.0	129	Philadelphia, USA 1987	Fekete 1989
	1.0	2	0.03-4	400	Spain 1992-99	Berron 2000
	0.250	1	0.016-2.0	122	Indonesia 1996	Lesmana 2001
	1	2	0.060-8.0	332	Thailand 1990	Clendennen 1992a
	1	4	0.06->8	134	Philippines 1989	Clendennen 1992b
Cefpodoxime	0.008	0.03	0.001-0.125	77	USA (n.r.) >91	Fekete 1991
	0.03	0.125	<0.004->4.0	331	Thailand 1990	Clendennen 1992a
	0.03	2	0.002->4	134	Philippines 1989	Clendennen 1992b
Ceftizoxime	0.004	0.016	0.001-0.016	89	Germany (n.r.) >89	Korting 1989
	0.015	0.03	<0.001->4.0	333	Thailand 1990	Clendennen 1992a
	0.008	0.25	<0.001->4	137	Philippines 1989	Clendennen 1992b
Ceftriaxone	0.004	0.015		6552	USA 2003	CDC 2003 (7)
	0.004	0.008	0.00025-0.016	81	Manaus, Brazil 1998	Dillon 2001a
	0.001	0.001	0.001 - 0.008	81	Buenos Aires, Argentina 1995-96	Famiglietti 2001
	0.004	0.016	0.002-0.064	507	Trinidad, Trinidad and Tobago 1992	Swanston 1997
	0.003	0.01	0.0005-0.12	400	Spain 1992-99	Berron 2000
	<0.007	<0.007	<0.007-0.030	85	Berlin, Germany 1995-97	Wagner 2000
	0.03	2	0.016-2.048	91	Zhanjiang, China 1998-99	Guoming 2000
	0.0312	0.125	0.25-0.002	203	Guangzhoou, China 1997-98	Wenling 2000
	0.015	0.06	0.004-0.5	94	Dhaka, Bangledesh 1997	Bhuiyan 1999
	0.001	0.002	0.001-0.008	122	Jakarta, Indonesia 1996	Lesmana 2001
	0.008	0.03	<0.001-1.0	333	Thailand 1990	Clendennen 1992a
	0.008	0.06	<0.001->1.0	134	Philippines 1989	Clendennen 1992b
	0.004	0.008	0.002-0.060	139	Kigali, Rwanda 1999-2000	Van Dyck 2001
	<0.007	0.015	<0.007 - 0.06	354	Durban, South Africa 1997-2000	Moodley 2001a
	<0.002	0.004	<0.002-0.032	177	Nairobi, Kenya 1995-96	Claeys 1998
	0.015	0.06	0.002-0.25	110	Guanzhou, China 2001	Zheng 2005
	0.004	0.032	<0.001-0.063	91	Cuba 1995-98	Sosa 2003
	0.015	0.06	0.002-0.12	211	Fukuoka City, Japan 2002	Tanaka 2004
	0.004	0.016	0.004-0.03	413	New Zealand 2002	Heffernan 2004
	<0.001	0.008	<0.001-0.032	936	London, U.K. 2003	GRASP 2004
	0.02	0.004	<0.001-0.032	1039	England and Wales excluding London, U.K. 2003	GRASP 2004
cefuroxime	0.032	0.125	0.001 - 0.5	81	Buenos Aires, Argentina 1995-96	Famiglietti 2001
	0.064	0.128	0.008-1	506	Trinidad, Trinidad and Tobago 1992	Swanston 1997
	0.03	0.125	<0.002-0.5	150	Germany 1988-92	Schäffer 1995
	0.5	1	0.06-4.0	94	Dhaka, Bangladesh 1977	Bhuiyan 1999
	0.5	1	<0.030->4.0	333	Thailand 1990	Clendennen 1992a
	0.125	2	0.015->8.0	135	Philippines 1989	Clendennen 1992b
	0.03	0.5	0.016-256	199	Dar es salaam, Tanzania 1993-95	Mbwana 1999
	0.06	0.25	0.008-1	130	Mwanza, Tanzania 1992	West 1995
quinolones
ciprofloxacin	0.004	0.008		6552	USA 2003	CDC 2003 (7)
	0.004	0.008	0.004-0.25	81	Manaus, Brazil 1998	Dillon 2001a
	0.008	0.032	0.001 - 0.5	81	Buenos Aires, Argentina 1995-1996	Famiglietti 2001.
	0.003	0.01	0.001-0.25	400	Spain 1992-99	Berron 2000
	0.007	4	<0.0015-64	81	Spain, 2001	New reference ARREAZA 2005
	<0.007	<0.007	<0.007-8.0	84	Berlin, Germany 1995-97	Wagner 2000
	<0.004	0.008	<0.004-0.06	104	London, United Kingdom n.r. >95	Lewis 1995
	<0.03	1.0	<0.03-4.0	56	Ulaanbaatar, Mongolia n.r. (2001)	Lkhamsuren 2001
	2	2	0.032-2.048	91	Zhanjiang, China 1998-99	Guoming 2000
	0.015	1.0	0.004-4.0	94	Dhaka, Bangladesh 1997	Bhuiyan 1999
	2	8	0.008-64	115	Philippines 1996-97	Aplaxca 2001
	0.004	0.016	0.001-0.016	122	Jakarta, Indonesia 1996	Lesmana 2001
	0.004	0.008	<0.001-2.0	329	Thailand 1990	Clendennen 1992a
	0.004	0.25	<0.001->2.0	135	Philippines 1989	Clendennen 1992b
	0.004	0.008	0.002-0.15	139	Kigali, Rwanda 1999-2000	Van Dyck 2001
	<0.007	0.015	<0.007 - 0.06	354	Durban, South Africa 1997-2000	Moodley 2001a
	<0.007	0.03	<0.007-0.06	204	Durban (urban), South Africa 1999	Moodley 2001b
	<0.007	0.015	<0.007-1.0	156	KwaZulu/Natal (rural), South Africa 1999	Moodley 2001b
	0.002	0.012	0.002-32	199	Dar es salaam, Tanzania 1993-95	Mbwana 1999
	0.004	0.008	0.002-0.015	251	Abidjan, Côte d=Ivoire 1992-93	Van Dyck 1997
	0.004	0.015	0.002-0.06	952	Kinshasa, Congo 1988-1993	Van Dyck 1997
	0.015	0.015	0.001-0.03	40	Nairobi, Kenya 1989-90	Plourde 1992
	0.004	0.015	0.001-0.06	1085	Kigali, Rwanda 1989-90	Van Dyck 1997
	2	8	0.03-32	110	Guangzhou, China 2001	Zheng 2005
	0.008	0.016	0.004-0.063	91	Cuba 1995-98	Sosa 2003
	4	32	0.002-64	211	Fukuoka City, Japan 2002	Tanaka 2004
	0.004	0.06	0.004-4	413	New Zealand 2002	Heffernan 2004
enoxacin	0.25	2	0.008-8.0	79	Japan 1992-93	Tanaka 1995
lomefloxacin	0.016	0.032	<0.008-0.063	196	Canada PCN-sensitive 1988	Talbot 1989
	0.125	1.0	0.004-2.0	79	Japan 1992-93	Tanaka 1995
norfloxacin	0.016	0.032	0.008-0.128	507	Trinidad, Trinidad and Tobago 1992	Swanston 1997
	0.003	0.006	0.001-4	400	Spain 1992-99	Berron 2000
	0.25	16	0.016-32	157	Fukuoka City, Japan 1997-98	Tanaka 2000
	0.03	0.06	0.016-0.5	122	Jakarta, Indonesia 1996	Lesmana 2001
	0.06	0.125	<0.015->4.0	332	Thailand 1990	Clendennen 1992a
	<0.016	0.016	0.016-0.125	177	Nairobi, Kenya 1995-96	Claeys
	0.06	0.125	0.008-0.25	130	Mwanza, Tanzania 1992	West 1995
ofloxacin	0.0039	0.0078	0.002-0.015	100	Brooklyn, New York, USA (n.r.) >92	Glatt 1992
	0.016	0.032	0.002 - 0.5	81	Buenos Aires, Argentina 1995-1996	Famiglietti 2001
	0.03	0.03	0.002-1	400	Spain 1992-99	Berron 2000
	0.008	0.03	<0.002-0.25	150	Germany 1988-92	Schäffer 1995
	0.125	1	0.002-2.0	79	Japan 1992-93	Tanaka 1995
	0.038	0.075	<0.005-2.5	333	Thailand 1990	Clendennen 1992a
	0.038	0.625	0.005->5.0	139	Philippines 1989	Clendennen 1992b
	0.015	0.03	<0.007 - 4	354	Durban, South Africa 1997-2000	Moodley 2001a
	0.008	0.012	0.004-0.032	177	Nairobi, Kenya 1995-96	Claeys 1998
levofloxacin	0.007	0.003	0.002-0.5	400	Spain 1992-99	Berron 2000
	4	8	0.004-32	211	Fukuoka City, Japan 2002	Tanaka 2004
gatifloxacin	1	2	<0.001-8	211	Fukuoka City, Japan 2002	Tanaka 2004
miscellaneous
azithromycin	0.125	0.25		6552	USA 2003	CDC 2003 (7)
	0.125	0.25	0.032-0.5	81	Manaus, Brazil 1998	Dillon 2001a
	0.125	0.5	0.063-8.0	67	St. Vincent 1996	Dillon 2001b
	0.032	0.125	0.016 - 2	81	Buenos Aires, Argentina 1995-1996	Famiglietti 2001
	0.25	2.0	0.063-8.0	69	Georgetown, Guyana 1994-1995	Dillon 2001b
	0.25	0.5	<0.007-1.0	85	Berlin, Germany 1995-97	Wagner 2000
	0.023	0.047	<0.016-0.19	177	Nairobi, Kenya 1995-96	Claeys 1998
	0.25	0.5	0.063-4.0	91	Cuba 1995-98	Sosa 2003
	0.5	1	0.06-2	130	Mwanza, Tanzania 1992	West 1995
	0.12	0.25	0.008-2	211	Fukuoka City, Japan 2002	Tanaka 2004
	0.125	0.25	0.03-4	936	London, U.K. 2003	GRASP 2004
	0.125	0.5	0.03-2	1039	England and Wales excluding London, U.K. 2003	GRASP 2004
spectinomycin	16	16		187	USA 1989-90	Portilla 1992
	8	16	16-16	81	Manaus, Brazil 1998	Dillon 2001a
	8	16	2 - 16	81	Buenos Aires, Argentina 1995-1996	Famiglietti 2001
	32	32	0.5-32	507	Trinidad, Trinidad and Tobago 1992	Swanston 1997
	16	16	4-32	400	Spain 1992-99	Berron 2000
	8	16	0.06-32	85	Berlin, Germany 1995-97	Wagner 2000
	16	128	8-128	90	Zhanjiang, China 1998-99	Guoming 2000
	8	16	4-16	197	Fukuoka City, Japan, 1997-98	Tanaka 2000
	8.0	16.0	4.0-32.0	94	Dhaka, Bangladesh 1977	Bhuiyan 1999
	64	64	8-128	305	Thailand 1990	Clendennen 1992a
	32	32	16->128	117	Philippines 1989	Clendennen 1992b
	32	32	16-32	139	Kigali, Rwanda 1999-2000	Van Dyck 2001
	8	32	<0.007 - >64	354	Durban, South Africa 1997-2000	Moodley 2001a
	4	8	3-12	177	Nairobi, Kenya 1995-96	Claeys
	8	32	8-32	199	Dar es salaam, Tanzania 1993-95	Mbwana 1999
	8	16	4-16	110	Guangzhou, China 2001	Zheng 2005
	16	16	8-16	91	Cuba 1995-98	Sosa 2003
	8	16	4-16	211	Fukuoka City, Japan 2002	Tanaka 2004
	16	32	2-64	936	London, U.K. 2003	GRASP 2004
	16	32	2-64	1039	England and Wales excluding London, U.K. 2003	GRASP 2004
	8	16	2-16	413	New Zealand 2002	Heffernan 2004

* n.r. indicates that dates of specimen isolations were not reported. Number in parentheses is date of publication.

** indicates that lower limit of MIC range was not reported.

Table 2 - Aggregated Results of Clinical Trials

	Pharyngeal infections			Urogenital & rectal infections
Drug regimen	% cured	95% C I		% cured	95% C I
Ceftriaxone 250 mg	99.0	94.4	100	99.2	98.8	99.5
Ciprofloxacin 500 mg^*	97.2	85.5	99.9	99.8	98.7	100
Ciprofloxacin 250 mg	88.5	81.8	95.2	98.7	98.0	99.4
Ceftriaxone 125 mg	94.1	85.6	98.4	98.9	97.9	99.8
Ceftizoxime 500 mg	100	15.8	100	99.2	97.8	99.8
Ofloxacin 400 mg	88.7	68.8	97.8	98.6	97.8	99.4
Gatifloxacin 600 mg	100	82.3	100	99.6	97.7	100
Spectinomycin 2 g	51.8	38.7	64.9	98.2	97.6	99.9
Azithromycin 2 g	100	82.3	100	99.2	97.2	99.9
Gatifloxacin 400 mg	100	63.1	100	99.2	97.1	99.9
Cefoxitin 2g + probenecid 1 g				99.2	97.1	99.9
Cefotaxime 500 mg	45.4	16.7	76.2	97.9	96.7	99.1
Norfloxacin 800 mg	80.0	28.4	99.5	98.0	96.7	99.2
Azithromycin 1 g	100	39.8	100	97.1	95.2	99.0
Cefixime 800 mg	80.0	51.9	95.7	98.4	95.9	99.6
Cefixime 400 mg	92.3	74.9	99.1	97.4	95.9	98.6
Cefuroxime axetil 1 g	56.9	43.3	70.5	96.2	94.8	97.5
Cexpodoxime proxetil 200 mg	78.9	54.5	94.0	96.5	94.3	98.5

*Excludes two published clinical trials among subjects known to be at high risk of harboring fluoroquinolone-resistant strains; ciprofloxacin 500 mg cured only 48 of 72 cervical infections (67%) in one trial (1) and 41 of 66 (62%) in the other (47).

Table 3 - Quinolone Resistance in Strains of Neisseria gonorrhoeae Isolated in Asia and Oceania in 1999, 2001, and 2003

	Number tested			Number less susceptible (%)			Number resistant (%)
Country	1999	2001	2003	1999	2001	2003	1999	2001	2003
ASIA
Brunei	53	52	50	4 (7.5)	1 (2.0)	5 (10.0)	5 (9.4)	10 (19.0)	31 (62.0)
China	591	748	1254	131 (22.1)	83 (11.1)		332 (52.8)	650 (86.9)	1171 (93.4)
Hong Kong SAR	2482	2575	3378	697 (28.1)	235 (9.1)	165 (4.9)	1653 (66.6)	2270 (88.2)	3167 (93.7)
Japan	246	300	200	80 (32.5)	42 (14.0)	17 (12.8)	56 (22.8)	192 (64.0)	154 (77.0)
Korea	86	177	212	61 (71.0)	94 (53.1)	39 (18.4)	14 (16.0)	70 (39.5)	166 (78.3)
Laos		187			11 (5.9)			42 (22.5)
Malaysia	54	30		0 (0)	2 (6.7)		0 (0)	7 (23.3)
Mongolia	56			5 (8.9)			14 (25.0)
Philippines	313	399	111	8 (2.5)	1 (0.2)	11 (9.9)	191 (61.0)	217 (54.3)	62 (55.9)
Singapore	768	741	200	37 (4.8)	35 (4.7)	9 (4.5)	131 (17.0)	207 (27.9)	103 (51.5)
Vietnam	194	168		27 (13.9)	33 (19.6)		69 (35.6)	71 (42.3)
OCEANIA
Australia	3658	3641	3772	500 (13.7)	149 (4.1)	77 (2.0)	128 (3.5)	489 (13.4)	452 (12.0)
New Caledonia	53	57	53	0 (0)		0 (0)	0 (0)		3 (5.7)
New Zealand	638	765	1113	8 (1.3)	20 (2.6)	31 (2.8)	14 (2.2)	77 (10.0)	96 (8.6)
Papua New Guinea	343	96	96	1 (0.3)	0 (0)	0 (0)	5 (1.5)	0 (0)	0 (0)

Data for 1999 are from “Quinolone resistance in strains of Neisseria gonorrhoeae isolated in 15 countries in the WHO WPR in 1999" published in Commun Dis Intell 2000;24:268-270; data for 2001 are from “Surveillance of antibiotic resistance in Neisseria gonorrhoeae in the WHO Western Pacific Region, 2001" published in Commun Dis Intell 2002;26:541-545; and data for 2003 are from “Surveillance of antibiotic resistance in Neisseria gonorrhoeae in the World Health Organization Western Pacific Region, 2003" published in Commun Dis Intell 2005;29:62-64.

Table 4 - Recommended Regimens for the Treatment of Gonococcal Infections in the United States

Diagnosis	Population	Treatment of choice	Alternative Regimen
Uncomplicated urogenital or rectal infection	Heterosexual adults and children >45 kg likely to have acquired infection from a U.S. domestic source outside California or Hawaii	Ceftriaxone 125 mg IM in a single dose OR Cefixime 400 mg orally in a single dose OR Ciprofloxacin 500 mg orally in a single dose OR Ofloxacin 400 mg orally in a single dose OR Levofloxacin 250 mg orally in a single dose PLUS treatment for Chlamydia if chlamydial infection is not ruled out	Spectinomycin 2 g IM in a single dose PLUS treatment for Chlamydia if chlamydial infection is not ruled out
	Homosexual adults and children >45 kg or adults and children>45 kg who may have acquired infection from a California, Hawaii, or foreign source	Ceftriaxone 125 mg IM in a single dose OR Cefixime 400 mg orally in a single dose PLUS treatment for Chlamydia if chlamydial infection is not ruled out	Spectinomycin 2 g IM in a single dose PLUS treatment for Chlamydia if chlamydial infection is not ruled out
	Children who weigh <45 kg	Ceftriaxone 125 mg IM in a single dose	Spectinomycin 40 mg/kg (maximum dose: 2 g) IM in a single dose
Pharyngeal infection	Heterosexual adults and children >45 kg likely to have acquired infection from a U.S. domestic source outside California or Hawaii	Ceftriaxone 125 mg IM in a single dose OR Ciprofloxacin 500 mg orally in a single dose PLUS treatment for Chlamydia if chlamydial infection is not ruled out
	Homosexual adults and children >45 kg or adults and children ≥45 kg who may have acquired infection from a California, Hawaii, or foreign source	Ceftriaxone 125 mg IM in a single dose PLUS treatment for Chlamydia if chlamydial infection is not ruled out
	Children who weigh <45 kg	Ceftriaxone 125 mg IM in a single dose	Spectinomycin 40 mg/kg (maximum dose: 2 g) IM in a single dose may be used, but this therapy is unreliable and should be followed with a test of cure
Eye infection	Adults	Ceftriaxone 1 g IM as a single dose
	Infants	Ceftriaxone 25–50 mg/kg IV or IM in a single dose, not to exceed 125 mg.
Pelvic Inflammatory Disease	Parenteral therapy	Cefotetan 2 g IV every 12 h OR Cefoxitin 2 g IV every 6 h) PLUS Doxycycline 100 mg orally or IV every 12 h OR Clindamycin 900 mg IV every 8h PLUS Gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 h (Single daily dosing may be substituted.)	Ofloxacin 400 mg IV every 12 hours OR Levofloxacin 500 mg IV once daily WITH OR WITHOUT Metronidazole 500 mg IV every 8 h OR Ampicillin/Sulbactam 3 g IV every 6 h PLUS Docycycline 100 mg orally or IV every 12 h)
	Oral therapy	Levofloxacin 500 mg orally once daily for 14 days or Ofloxacin 400 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days OR Ceftriaxone 250 mg IM in a single dose OR Cefoxitin 2 g IM in a single dose and Probenecid 1 g orally administered concurrently as a single dose OR other parenteral third generation cephalosporine PLUS Doxycycline 100 mg orally twice a day for 13 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days
Disseminated infection	Adults and children >45 kg infected with organisms known to be susceptible to fluoroquinolones.	Ceftriaxone 1 g IM or IV every 24 hours Parenteral treatment should be continued for 24‑48 hours after improvement begins; then therapy may be switched to cefixime 400 mg orally twice a day OR ciprofloxacin 500 mg orally twice a day OR ofloxacin 400 mg orally twice a day OR levofloxacin 500 mg orally once a day to complete a full week of antimicrobial therapy.	Cefotaxime 1 g IV every 8 hours OR ceftizoxime 1 g IV every 8 hours OR ciprofloxacin 500 mg IV every 12 hours OR ofloxacin 400 mg IV every 12 hours OR levofloxacin 250 mg IV daily OR spectinomycin 2 g IM every 12 hours. Parenteral treatment should be continued for 24‑48 hours after improvement begins; then therapy may be switched to cefixime 400 mg orally twice a day OR ciprofloxacin 500 mg orally twice a day OR ofloxacin 400 mg orallyl twice a day OR levofloxacin 500 mg orally once a day to complete a full week of antimicrobial therapy.
	Adults and children >45 kg who may be infected with fluoroquinolone-resistant organisms	Ceftriaxone 1 g IM or IV every 24 hours Parenteral treatment should be continued for 24‑48 hours after improvement begins; then therapy may be switched to cefixime 400 mg orally twice a day to complete a full week of antimicrobial therapy.	Cefotaxime 1 g IV every 8 hours OR ceftizoxime 1 g IV every 8 hours OR spectinomycin 2 g IM every 12 hours. Parenteral treatment should be continued for 24‑48 hours after improvement begins; then therapy may be switched to cefixime 400 mg orally twice a day to complete a full week of antimicrobial therapy.
	Newborns	Ceftriaxone 25–50 mg/kg/day IV or IM in a single daily dose for 7 days, with a duration of 10–14 days, if meningitis is documented OR Cefotaxime 25 mg/kg IV or IM every 12 hours for 7 days, with a duration of 10–14 days, if meningitis is documented.