GARY M. FELDMAN, M.D., FAAP, FABMG Public Health Officer
	COUNTY OF RIVERSIDE PUBLIC HEALTH DISPATCH
COMMUNITY HEALTH AGENCY • DEPARTMENT OF PUBLIC HEALTH • 4065 COUNTY CIRCLE DRIVE, RIVERSIDE, 92503
VOL. 8, No. 3		SUMMER 2002

INCREASING FLUOROQUINOLONE RESISTANT GONORRHEA NOTED IN CALIFORNIA

Due to a growing problem with fluoroquinolone resistant gonorrhea, the California Department of Health Services recently issued treatment guidelines for California. Although resistance data specific to Riverside County is not collected, data from the Gonococcal Isolate Surveillance Project (GISP) document the concern with antimicrobial resistance. Locally, in Riverside County, 640 cases of gonorrhea were reported in 2001, compared to 502 cases in 1995. Reports of gonorrhea and other Communicable diseases should be called to (909) 358-5107, or FAXED to 909-358-5102.

TREATMENT OF GONORRHEA IN CALIFORNIA

 National Gonorrhea Treatment Guidelines

Sexually transmitted disease (STD) treatment guidelines from the Centers for Disease Control and Prevention include fluoroquinolones (ciprofloxacin, levofloxacin, and ofloxacin) as first-line therapy for uncomplicated gonococcal infections. However, fluoroquinolones are no longer recommended for the treatment of gonorrhea in areas where fluoro-quinolone resistance is prevalent. Until recently, these areas included Asia and the Pacific, including Hawaii. California has now been added to the list of areas where fluoroquinolones should not be used as a first line therapy to treat gonorrhea. (CDC, 2002. Guidelines can be viewed at: www.cdc.gov/std)

Increasing Fluoroquinolone Resistance in California

Antimicrobial resistance surveillance in California has demonstrated a prevalence of ciprofloxacin-resistant gonorrhea of nearly 5% in second half of 2001 and nearly 7% in the first quarter of 2002. Prior to this time period, the level of ciprofloxacin resistance was low (0.2% in 1998, 0.6% in 1999, 1.1% in 2000, 2.5% in 2001) according to data from the national Gonococcal Isolate Surveillance Project (GISP), which provides antibiotic susceptibility testing on gonococcal isolates from male patients with urethral infections (the first 25 each month) seen in sentinel STD clinics. The GISP surveillance system includes 4 sites in California: San Francisco, Orange County, Long Beach, and San Diego, all of which have experienced a similar increase in cases.

New California Gonorrhea Treatment Guidelines

In response to this increase in fluoroquinolone-resistant gonorrhea in California, the California Department of Health Services Sexually Transmitted Disease Control Branch and the California STD Controllers Association issue the following recommendations:

1. Avoid the use of fluoroquinolones (ciprofloxacin, ofloxacin, and levofloxacin) to treat gonorrhea in California.
2. Instead, antibiotics of choice to treat uncomplicated gonococcal infections of the cervix, urethra, and rectum include:
   • Ceftriaxone 125 mg intramuscularly in a single dose
   • OR Cefixime 400 mg orally in a single dose
3. Alternative antibiotic regimens for the treatment of uncomplicated gonococcal infections of the cervix, urethra, and rectum include:
   • Spectinomycin 2 g intramuscularly in a single dose
   • OR Single dose injectable cephalosporins:
     • Ceftizoxime 500 mg intramuscularly
     • Cefoxitin 2 g intramuscularly with Probenecid 1 g orally
     • OR Cefotaxime 500 mg intramuscularly
4. 4. The antibiotic of choice to treat gonococcal infections of the pharynx:
   • Ceftriaxone 125 mg intramuscularly in a single dose
   • Cefixime is not recommended by the CDC to treat pharyngeal infections because of a relative lack of published data demonstrating efficacy. However, providers may chose cefixime because of the ease of oral administration. If cefixime is used to treat pharyngeal infection, a test-of-cure (TOC) is recommended.
5. For patients with significant anaphylaxis-type (IgE-mediated) allergies to penicillin, where the use of cephalosporins is a concern or patients with allergies to cephalosporins:
   • Spectinomycin 2 g intramuscularly in a single dose
   • OR Fluoroquinolone with test-of-cure (TOC)1
   • OR Azithromycin 2 g orally in a single dose with test-of-cure (TOC)1
6. For the treatment of pelvic inflammatory disease (PID), the CDC guidelines should be followed. However, if the gonorrhea test is positive in a patient receiving a fluoroquinolone regimen, a test-of-cure (TOC)1 should be performed.
7. Co-treatment of chlamydia in patients with gonorrhea is still recommended unless chlamydia infection has been ruled out using sensitive test technology (e.g. nucleic acid amplification test, or NAATs). Recommended antibiotics for the treatment of chlamydial infection include:
   • Azithromycin (1 g orally in a single dose)
   • OR Doxycycline (100 mg orally twice a day for 7 days).

Clinicians need to be alert to the failure of any patient to respond to recommended therapy. If clinicians encounter a treatment failure after a recommended regimen in the absence of reexposure, they need to take whatever steps are necessary to culture the organism.

Note: Resistant isolates have ciproflosacin Minimum Inhibitory Concentration (MIC) > or = 1 ug/mL. Isolates with decreased susceptibility have ciprofloxacin MIC 0.125 - 0.5 ug/mL. STD Clinic Sites: Long Beach, Orange, San Diego, San Francisco Source: California Department of Health Services, STD Control Brand and CDC Preliminary 2001 Data

Question or concerns regarding these recommendations should be addressed to:

Gail Bolan, MD, Chief,
California Department of Health Services
STD Control Branch
1947 Center Street, Suite 201,
Berkeley, CA 94704
Phone: 510-540-2657

1 Ideally, the test-of-cure should be both a culture test so that the isolate can be tested for antimicrobial susceptibility and a nucleic acid amplification test to maximize sensitivity. If only a non-culture test is used, positive results should be followed up with a culture and susceptibility testing before the patient receives an alternative treatment

ACIP ISSUES REVISED GENERAL RECOMMENDATIONS ON IMMUNIZATIONS

The Advisory Committee on Immunization Practices (ACIP) periodically publishes an update to its General Recommendations on Immunization. These recommendations primarily address issues related to vaccine usage, simultaneous administration of multiple vaccines, use of vaccines with immunoglobulin preparations, and contra-indications and precautions for vaccine administration. The updated General Recommendations were published on February 8 of this year (MMWR 2002; 51[no. RR-2]: 1-34) and the Key changes are summarized below.

Four-Day Grace Period

Since 1994, ACIP has recommended that doses of vaccines separated by less than the recommended minimal interval not be considered part of a primary series. ACIP continues to recommend that vaccine doses not be given at less than the minimal intervals or earlier than the minimum age. However, in clinical practice, vaccine doses are sometimes inadvertently given at less than the minimal interval, or younger than the minimum age. In an effort to increase the flexibility of the childhood immunization schedule, ACIP now recommends that doses given up to 4 days earlier than the minimum interval or age, be counted as valid. Exceptions to the use of this 4-day grace period are instances in which local or state health regulations require doses of a vaccine be administered on or after a specific age. Based on changes recently implemented by the State of California Immunization Branch, and adopted by Riverside County, Department of Public Health, the 4-day rule can be used when assessing MMR, polio, DTaP/DTP/DT and Td (if appropriate) for school entry, and MMR and Hib for childcare facility entry.

In cases where the 4-day grace period is applicable, doses of a vaccine administered 5 or more days before the minimal interval or age must be repeated as age-appropriate. The repeated dose should follow the invalid dose by the recommended minimum interval.

SPECIAL NOTE: The 4-day grace period cannot be used for the rabies vaccine because of the vaccine's unique administration schedule.

Non-Simultaneous Administration of Live Vaccines

Simultaneously administering all vaccines for which a person is eligible is important because it increases the probability that infants and children will be fully immunized at the appropriate age. Since 1983, ACIP has recommended that live-virus vaccines not administered on the same day be administered at least 30 days apart because of concerns that the vaccine given first could interfere with the response to the vaccine given second. Until this update, ACIP had not given guidance on what to do if two live-virus vaccines not administered on the same day were inadvertently administered less than 30 days apart. ACIP now recommends that in such instances, the vaccine given second be repeated at least 4 weeks (28 days) after its invalid dose. (Please note that APIC has shortened the period for spacing two live-viral vaccines not administered on the same day from 30 to 28 days). An exception to this recommendation is yellow fever vaccine, which can be given anytime, including within 28 days, after the measles vaccine.

It is important to remember than an inactivated vaccine can be administered either simultaneously or at any time before or after a different inactivated vaccine or a live-viral vaccine.

Non-Standard Route or Site of Administration And Non-Standard Doses

Previously, ACIP, recommended that any vaccination using less than the standard dose or using a non-standard route or site of administration not be counted and that the person be re-vaccinated according to age-appropriate requirements. ACIP now advises that repeated doses of vaccines, which should have been administered subcutaneously but were given intramuscularly, is not necessary (i.e., MMR, varicella, IPV, pneumococcal polysaccharide, and anthrax). However, hepatitis B vaccine administered other than intramuscularly into the anterolateral thigh or deltoid must be repeated, as must rabies vaccine given into a gluteal site.

The use of multiple reduced doses that together equal a full-dose, or use of the smaller doses than recommended is not endorsed by ACIP. Such doses are not counted as valid, and persons so immunized should be re-vaccinated according to age, unless serologic testing indicates that an adequate immunologic response has been achieved.

Management of Pre-term Infants Whose Mothers are HBsAg Positive or Whose HBsAg Status is Unknown

Premature infants whose mothers are HBsAg positive or whose HBsAg status is unknown should be given both hepatitis B vaccine and HBIG within 12 hours of birth. (Formerly, infants born to mothers with unknown HBsAg status would have only been recommended to receive the first dose of hepatitis B vaccine within the first 12 hours). For infants weighing less than 200 grams who receive a dose of hepatitis B vaccine before leaving the nursery, the first dose should not be counted towards completion of the hepatitis B series, and three additional doses of hepatitis B vaccine should be given beginning when the infant is one month old.

The full text of the updated General Recommendations on Immunization is available on the National Immunization Program's web site at www.cdc.gov/nip/ or can be linked to from www.lapublichealth.org/ip.

Please contact Karon Jones, Immunization Coordinator, at (909 358-5568, if you have questions on these guidelines.

County of Riverside – Community Health Agency
Department of Public Health
Quarterly Morbidity Report
REPORTED CASES OF SPECIFIED NOTIFIABLE DISEASES

~ = New Syphilis sub-groups included as of 01/02
+ = Effective 6/01, revision in definition for reporting acute and chronic Hepatitis B.
* = excluding Haemophilus influenza/meningococcal infections
ˆ = Effective 11/01, new diseases added to report

Source: Disease Control Program, Department of Public Health, Community Health Agency, County of Riverside, CMR Reporting
Compiled: Health Statistics Branch, Department of Public Health, Community Health Agency, County of Riverside
RL 4/15/2002

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