Adult Blood Lead Epidemiology and Surveillance—United States, 2008-2009

identifying important shifts in gonococcal epidemiology and antimicrobial susceptibility, its effectiveness should be complemented through partnerships with local health departments and health-care providers. Clinicians should remain vigilant for treatment failures (evidenced by persistent symptoms or a positive follow-up test despite treatment) among patients treated for gonorrhea with CDC-recommended antibiotics and obtain specimens for gonococcal culture from patients with possible treatment failure. Clinicians caring for patients with gonorrhea, particularly MSM in the western United States, might consider having patients return 1 week after treatment for test-of-cure with culture, preferably, or with nucleic acid amplification tests (NAATs). If a patient experiences cefixime treatment failure, clinicians should retreat the patient with 250 mg ceftriaxone intramuscularly and 2 g azithromycin orally. If a patient experiences a ceftriaxone treatment failure, clinicians should consult with an infectious disease expert and CDC regarding re-treatment. These patients should return for tests-of-cure within 1 week, preferably with culture, or, if culture is not available, with NAAT. If the follow-up NAAT result is positive, a specimen for culture should be obtained. Clinicians also should ensure that the patient’s sex partners from the preceding 2 months are tested for gonorrhea (preferably with culture) and empirically treated with ceftriaxone 250 mg intramuscularly and azithromycin 2 g orally. Finally, these treatment failures should be reported to the local or state health department within 24 hours. Laboratorians are requested to report gonococcal isolates with decreased cefixime or ceftriaxone susceptibility ( 0.5 μg/mL) to their local or state health departments within 24 hours of identification. Local and state health departments are requested to report these cases immediately to CDC ([email protected] or 404-639-8659). Isolates can be submitted to CDC’s Neisseria Reference Laboratory for confirmation susceptibility testing.* Local and state health departments also should promote maintenance of local gonococcal culture capacity, despite the widespread use of NAATs. Gonococcal antibiotic susceptibility testing (AST), necessary for identification of resistant isolates, only can be performed with culture specimens. Health departments should establish options for local availability of gonococcal cultures and AST, and consider enhancing surveillance for cephalosporin-resistant gonorrhea. Options for local culture and AST availability might involve building or enhancing local gonorrhea reference laboratory testing capacity, partnering with regional clinical laboratories or academic institutions, or sending isolates to CDC for susceptibility testing. Enhanced surveillance might include monitoring of multiple cases from the same patient reported within 30-60 days, often discarded as presumed duplicates. Finally, effective alternative antibiotics or antibiotic combinations for the treatment of gonorrhea are needed urgently; thus, the development of novel antibiotics and clinical trials to study combinations of existing antibiotics is necessary. The findings in this report are subject to at least two limitations. First, data available in GISP only include results from urethral gonococcal isolates from males attending publicly funded STD clinics. Second, the clinical significance of shifts in MICs below CLSI criteria for decreased susceptibility is unclear, and transient increases and decreases in cephalosporin MICs have been observed previously in GISP. However, in light of similar trends in other regions of the world, the patterns observed in GISP with higher MICs in isolates from the west and MSM, and the ability of N. gonorrhoeae to develop resistance, the increasing MICs to cephalosporins in the United States are concerning. Vigilance of clinicians and enhanced surveillance by local and state health departments will be critical for early detection of treatment failures. Acknowledgments Collaborating state and local health departments. Participating STD clinic and regional laboratory staff members. Alesia Harvey, Michael Grabenstein, Kevin Pettus, Samera Bowers, Gail Bolan, MD, Kimberly Workowski, MD, Div of STD Prevention, National Center for HIV, Hepatitis, STD, and TB Prevention, CDC.