Clinical

ORIGINAL ARTICLE

Effectiveness of gentamicin for gonorrhoea

treatment: systematic review and meta-analysis
Deborah Dowell, Robert D Kirkcaldy
Additional data are
published online only. To view
these les please visit the
journal online (http://dx.doi.org/
10.1136/sextrans-2012050604).
Division of STD Prevention,
Centers for Disease Control and
Prevention, Atlanta, Georgia,
USA
Correspondence to
Dr Deborah Dowell, New York
City Department of Health and
Mental Hygiene, Ofce of the
Commissioner, 42-09 28th
Street, 8-62, Queens,
New York 11101, USA;
ddowell1@health.nyc.gov
Accepted 19 July 2012
Published Online First
23 August 2012

ABSTRACT
Objectives The development of resistance to multiple
antimicrobial agents has limited treatment options for
gonorrhoea. The potential emergence of cephalosporin
resistance in Neisseria gonorrhoeae and cephalosporin
allergy in some patients make it necessary to evaluate
the effectiveness of other available antimicrobial agents.
Gentamicin is widely available in the USA and is used for
gonorrhoea treatment in several countries. We conducted
a systematic review of the medical literature to assess
the effectiveness of gentamicin for treatment of
uncomplicated urogenital gonococcal infections.
Methods Two reviewers assessed relevant articles and
independently selected studies that met prespecied
selection criteria (including systematic enrolment and
assignment to treatment and culture-conrmed diagnosis
and outcome). Summary measures for selected studies
were pooled using inverse variance-weighted averages
with xed effects. Heterogeneity was assessed using I2,
which estimates proportion (0100%) of variability
attributable to heterogeneity between studies. Pooled
percentage with negative follow-up culture was
compared with Centers for Disease Control and
Prevention (CDC) criteria for selection of recommended
therapy (lower 95% CI of efcacy 95%).
Results Twenty-nine potentially relevant studies were
identied; three met inclusion criteria. Two studies used
240 mg intramuscular gentamicin and one used 280 mg.
Percentages with negative culture after single-dose
treatment were 90.7% (n=86), 91.4% (n=220) and
95.0% (n=40). Pooled percentage with negative culture
after single-dose treatment was 91.5% (95% CI 88.1% to
94.0%, I2=0%).
Conclusions Gentamicin does not meet current CDC
criteria for recommended treatment of gonorrhoea.
However, if cephalosporin resistance emerges,
gentamicin may be a useful alternative agent. Evaluation
of additional regimens, including combination therapy, is
warranted.

BACKGROUND
Neisseria gonorrhoeae has demonstrated the ability to
develop resistance to several antibiotics. Penicillin,
tetracycline and uoroquinolones are no longer
considered sufciently effective for the treatment of
gonococcal infections after the emergence of resistance to these antibiotics. Spectinomycin is efcacious but is no longer available in the USA. The
Centers for Disease Control and Prevention (CDC)
currently recommends dual therapy for gonorrhoea
with a cephalosporin (preferably ceftriaxone) and
azithromycin or doxycycline to ensure treatment of
co-occurring pathogens and reecting concern about
Sex Transm Infect 2012;88:589594. doi:10.1136/sextrans-2012-050604

emerging cephalosporin resistance.1 Cephalosporin

minimum inhibitory concentrations (MIC) have
been increasing in Asia, Europe and the USA, and a
growing number of failures of gonorrhoea treatment
with cexime have been reported worldwide.17
With few realistic prospects for novel antibiotics for
gonorrhoea treatment, it is necessary to evaluate the
efcacy of other currently available antibiotics.
Gentamicin is chemically similar to spectinomycin,
but unlike spectinomycin, is widely available in the
USA. Gentamicin is used for gonorrhoea treatment
in several countries, including Malawi. A recent
study found continued susceptibility of gonococcal
isolates in Malawi after 14 years of use as rst-line
treatment for urethritis.8 We conducted a systematic
review of the medical literature and meta-analysis to
assess the effectiveness of gentamicin for the treatment of uncomplicated urogenital gonococcal
infections.

METHODS
We developed and followed a review protocol (see
supplementary text, available online only). We
searched electronic databases (PubMed, EMBASE, the
Cochrane Central Register of Controlled Trials, Web
of Science), registers of ongoing trials (Clinicaltrials.
gov,9 CenterWatch,10 Current Controlled Trials11 and
the WHO International Clinical Trials Registry
Platform),12 and reference lists of found articles for
relevant studies. The PubMed search strategy was
entered as (gentamicin OR gentamicin(MeSH
Terms)) AND (gonorrhoea OR gonococcal OR N
gonorrhoeae OR sexually transmitted diseases OR
sexually transmitted infections OR urethritis
OR cervicitis) OR (gonorrhoea OR N gonorrhoeae OR
sexually transmitted diseases OR sexually transmitted diseases, bacterial(MeSH Terms)). Similar
searches were used for the other databases. Databases
were last searched on 17 June 2012. We did not apply
date or language restrictions. Abstracts were reviewed,
and full text articles were retrieved for studies that
appeared to be trials of gentamicin in patients with
gonococcal infection.
Two reviewers (DD and RDK) assessed relevant
articles and independently selected studies that
met prespecied selection criteria. We included
studies of adolescents and/or adults with uncomplicated urogenital gonococcal infection treated
with single-dose intramuscular (IM) or intravenous
gentamicin (any dose). Patients were considered to
have complicated gonococcal infection if they were
described as having a diagnosis of pelvic inammatory disease or disseminated gonococcal infection.
We required included studies to have used urethral
589

Clinical
or cervical culture for diagnosis of N gonorrhoeae at the time of
treatment and for follow-up cultures of N gonorrhoeae to have
been obtained from the same anatomical site as the initial
infection between 2 and 21 days post-treatment. To minimise
selection bias, we included controlled trials in which assignment to the treatment group was random or systematic and
not based on the severity of symptoms or patient characteristics. In addition, because we believed controlled trials would be
rare, we included single-arm case series, provided that enrolment in the study was systematic (eg, enrolment offered to
consecutive patients) and that any exclusions were prespecied.
Initial agreement and kappa for assessment of studies to be
included was calculated. Discrepancies in judgements regarding
inclusion were adjudicated by discussion. For included studies,
data including numbers of culture-positive patients treated,
numbers with negative test of cure and dose of gentamicin
used were extracted and recorded independently by two
reviewers (DD and RDK) using a data extraction form. Data
were compared, and differences were resolved through
discussion.
Treatment success was dened as the percentage of negative
cultures obtained from initially culture-positive anatomical
sites within 221 days post-treatment. In the primary analysis
we included all participants who received treatment and did
not exclude participants based on perceived re-exposure.
Summary measures of treatment success for all selected studies
were pooled using inverse variance-weighted averages (in which
the weight of each study is the reciprocal of the variance in the
studys estimate of treatment effect) with xed effects. Fixed
effects were assumed because we hypothesised there would be
minimal variability in effect of an antibiotic on different urogenital infections caused by N gonorrhoeae. Heterogeneity was
assessed using I2, which estimates proportion (0100%) of variability attributable to heterogeneity between studies. Pooled
percentage with negative follow-up culture was compared with
CDC criteria for selection of recommended therapy (95% lower
95% CI of efcacy at least 95%) and for alternative treatments
(efcacy of at least 95% with a lower 95% CI of at least
90%).13 Prespecied sensitivity analyses were performed to
determine impact of the following on pooled treatment effect
and precision of the estimate of treatment effect: excluding
trials that were not randomised, controlled trials; excluding
results for patients who reported sexual activity between gentamicin treatment and test of cure; and excluding results for
patients given doses other than 240 mg gentamicin IM.
Sensitivity analyses were also planned to determine impacts of
excluding women, of excluding results for patients given antibiotics in addition to gentamicin between 7 days before treatment and culture test of cure, of excluding patients known to
have symptoms of gonorrhoea for more than 7 days before
treatment, of excluding HIV-negative patients, and of excluding
HIV-positive patients.

RESULTS
We identied 913 records through database searches and reference lists of found articles. We retrieved the full text for the 29
studies among those that appeared to be trials of gentamicin
treatment for gonorrhoea. After independent review and discussion, we agreed that 26 studies (table 1) did not meet prespecied inclusion criteria because they were not treatment trials of
single-dose gentamicin, because we could not conrm that
study enrolment or assignment to treatment was systematic, or
because culture was not used for diagnosis and for test of cure
(gure 1). Agreement for initial judgement on meeting
590

selection criteria was good (93% agreement, =0.713). Three

studies (table 2) met the inclusion criteria. One study was a
randomised, controlled trial that enrolled men with urethral
discharge or dysuria presenting to an outpatient clinic in
Malawi.14 Two were single-arm case series: one that enrolled
men with complaints of urethral discharge presenting to one of
two hospitals in Malawi,15 and one that enrolled men with
uncomplicated acute urethritis presenting to a sexually transmitted diseases clinic in Zambia.16 Two studies used 240 mg
and one study used 280 mg IM gentamicin for single-dose
treatment of gonorrhoea. In the three studies included, the percentages of study participants with negative culture after treatment were 90.7% (95% CI 84.6% to 96.8%), 91.4% (95% CI
87.7% to 95.1%) and 95.0% (95% CI 88.3% to 100.0%). The
pooled percentage with negative culture after single-dose treatment was 91.5% (95% CI 88.1% to 94.0%, I2=0%).
The single randomised controlled trial had a treatment effect
of 95%. A sensitivity analysis excluding patients considered by
authors of the original reports to have been re-exposed to gonorrhoea between treatment and follow-up culture yielded a
treatment effectiveness of 95.1% (95% CI 91.8% to 97.2%,
I2=64%). Restricting analysis to patients treated with 240 mg
IM gentamicin produced similar results (91.8% effectiveness,
95% CI 85.4% to 95.5%, I2=0%) to those from the primary
analysis. Sensitivity analysis excluding women was not done
because no women were enrolled in the studies included.
Analyses excluding results for patients given antibiotics in addition to gentamicin between 7 days before treatment and
culture test of cure or excluding patients known to have symptoms of gonorrhoea for more than 7 days before treatment
were not done because no information was available in the
included reports that would allow the determination of
patients meeting these criteria. While one study reported
overall numbers of HIV-positive patients enrolled in the trial,
effectiveness of gentamicin among HIV-positive patients and of
HIV-negative patients was not reported, so effects of excluding
HIV-negative patients and of excluding HIV-positive patients
could not be determined.
Studies not meeting standards for inclusion but providing
data on gonorrhoea treatment outcomes following IM gentamicin reported success rates ranging from 62.4% to 100.0% based
on clinical examination, Gram stain and/or culture (table 1).
The six studies presenting results specically for women1722
reported successful treatment rates between 92.2% and 96.5%.
Of note, two of these studies, one in English17 and one in
German21 by the same primary author, contain similar descriptions of patients, and it is possible the same patients described
in one study17 included the patients described in the other
study.21 The two studies reporting treatment with other antibiotics in addition to gentamicin23 24 did not provide specic
information on gonorrhoea outcomes. None of the excluded
studies included information about gonorrhoea outcomes by
HIV status. In several of the excluded studies, specic criteria
for reporting successful treatment were not described.

DISCUSSION
A systematic review of the medical literature for trials of singledose gentamicin treatment of culture-conrmed uncomplicated
urogenital gonorrhoea found treatment efcacy of greater than
90% for all studies and a pooled efcacy of 91.5% with a lower
95% condence limit for efcacy of 88.1%. Only one study (a
randomised, controlled trial) found a treatment efcacy of 95%
(with lower 95% condence limit of 88%).14 Based on our
primary analysis, gentamicin does not meet current CDC
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Clinical
Table 1 Studies considered but excluded from the systematic review
Author
Bartunek et al

19

Year

Efficacy of gentamicin for gonorrhoea treatment

Reason for exclusion

1974

95/100 Women (95.0%) with gonorrhoea successfully treated with 280 mg

gentamicin IM1 based on clinical and microscopic exam and culture (specific
criteria for success not specified)
47/51 Women (92.2%) with culture-proven gonorrhoea had negative culture after
240 mg gentamicin IM1
Patient outcome data not presented. All 100 N gonorrhoeae isolates tested from
men presenting with urethral discharge were susceptible to gentamicin (MIC4)
114/116 Men with urethritis of different aetiologies including gonorrhoea had
favourable results following a combination of immunostimulation with gonorrhoea
vaccine, methyluracil and pyrogenal, local therapy, gentamicin (840 mg per
treatment course) and doxycycline
18/19 Men (94.7%) with gonorrhoea treated with 320 mg IM of gentamicin and 9/
10 men (90.0%) with gonorrhoea treated with 240 mg IM of gentamicin were
cured based on clinical exams and culture
Men with gonococcal urethritis were treated with successively higher doses of
gentamicin IM up to 280 mg; all 34 patients (100.0%) given this dose (who
returned for follow up) became asymptomatic
12/14 Men (85.7%) with acute or subacute gonorrhoea treated with 1 mg/kg
gentamicin IM daily for 2 days had negative urethral smears within 3 days after
treatment
40/43 Women (93.0%) and 13/14 men (92.9%) with gonococcal infection were
cured (based on culture between 3rd and 10th day) after 5 mg/kg gentamicin IM;
two women had salpingitis and one man had epididymitis (these three patients
with complications were among those cured)
45/48 Women (93.8%) and 13/14 men (92.9%) with gonococcal infection were
cured (based on culture between 3rd and 10th day) after 5 mg/kg gentamicin IM;
two women had salpingitis and one man had epididymitis
13/14 Women (92.9%) with gonococcal infection treated with 240 mg gentamicin
IM3 days and 9/9 men (100.0%) with gonococcal infection treated with 160 mg
gentamicin IM3 days were cured based on microscopy and culture 2 and 3 days
after treatment
19/22 Men (86.4%) with gonococcal urethritis treated with 240 mg gentamicin IM
were free of discharge and had negative Gram stains at 7 days
Among men with uncomplicated gonorrhoea, 96/111 (86.5%; 6/8 (75.0%) treated
with 160 mg gentamicin IM, 89/101 (88.1%) treated with 240 mg gentamicin IM
and 1/2 (50.0%) treated with 320 mg gentamicin IM) were cured based on Gram
stain and culture at 1 day, 1 week and 2 weeks
15/15 Male patients (100.0%) with acute gonococcal urethritis treated with 280 mg
gentamicin IM were cured based on clinical and bacteriological exam
Among men with acute uncomplicated gonococcal urethritis, 33/38 (86.8%) treated
with 120 mg gentamicin IM daily2 days and 35/40 (87.5%) treated with
gentamicin 240 mg IM1 had negative urethral smears at 1 week
52/55 Men (94.5%) with acute gonococcal urethritis had negative urethral smears
at 35 days after treatment with 240 mg gentamicin IM
19/20 Patients (95.0%) with penicillin-resistant strains of gonorrhoea had negative
cultures at 3 days, 1 week and 2 weeks following treatment with gentamicin
160 mg IM1
12/18 Patients with gonococcal urethritis (66.7%) had negative cultures 4 days after
treatment with 80 mg gentamicin IM daily3 days
Trial of metronidazole versus placebo along with 240 mg IM gentamicin IM1 and
100 mg doxycycline twice a day for 7 days among men with urethritis. 73.5% of
participants had gonorrhoea by urine sediment PCR at enrolment, but neither
outcomes specific to these men nor follow-up tests for gonorrhoea were reported
Not a novel study (review)
Not a novel study (review)
Not a novel study (review)
93/105 Male patients (88.6%) successfully treated (criteria for successful treatment
not described) with 240 mg gentamicin IM1

Non-systematic enrolment or treatment assignment, or not

described

Bowie et al20

1974

Brown et al8

2007

Bukharovich and
Revunov23

1991

Danda et al w5

1976

Felarca et al29

1971

Gomez-Medinaw6

1969

Hantschke et al21

1973

Hantschke et al17

1973

Hantschke and
Mauss22

1970

Iskandar et al w7

1978

Lawrence et al w8

1974

Mirarchi et al w9

1971

Morrison and
Reevesw10

1973

Pandhi et al w11

1989

Pareek and
Chowdhuryw12

1981

Pelfini and Bruniw13

1969

Price et al24

2003

Rajanw14
Reevesw15
Serriw16
Sibouletw17

1983
1974
1969
1972

Strauss and
Hantschkew18
Tan et al18

1973

Yoon et al w19

1988

Zabaneh et al w20

1980

1980

58/62 Patients (93.5%) with gonorrhoea were cured (criteria not specified) with
5 mg/kg gentamicin IM
83/86 Women (96.5%) and 10/10 men (100.0%) with penicillinase-producing N
gonorrhoeae had negative cultures at 3 days, 1 week and 2 weeks after treatment
with gentamicin 280 mg IM1
78/125 Male patients (62.4%) with uncomplicated gonococcal infection treated
with gentamicin 240 mg IM1 had negative Gram stain and culture results at 3
5 days
15/15 Men (100.0%) with gonococcal urethritis had disappearance of urethral
discharge and a negative culture 3 days after treatment with gentamicin 280 mg
IM1

Non-systematic enrolment or treatment assignment, or not

described
Culture not used systematically for diagnosis or outcome
Gentamicin dosing was not single dose

Non-systematic enrolment or treatment assignment, or not

described
Gentamicin dosing was not single dose

Gentamicin dosing was not single dose

Non-systematic enrolment or treatment assignment, or not

described; included complicated gonorrhoea

Non-systematic enrolment or treatment assignment, or not

described; included complicated gonorrhoea
Gentamicin dosing was not single dose

Culture not used systematically for diagnosis or outcome

Culture not used systematically for diagnosis or outcome

Non-systematic enrolment or treatment assignment, or not

described
Culture not used systematically for diagnosis or outcome

Culture not used systematically for diagnosis or outcome

Non-systematic enrolment or treatment assignment, or not
described
Non-systematic enrolment or treatment assignment, or not
described
Culture not used systematically for diagnosis or outcome

Non-systematic enrolment or treatment assignment, or not

described; culture not used systematically for diagnosis or
outcome
Culture not used systematically for diagnosis or outcome
Non-systematic enrolment or treatment assignment, or not
described
Culture not used systematically for diagnosis or outcome

Non-systematic enrolment or treatment assignment, or not

described

IM, intramuscular.

Sex Transm Infect 2012;88:589594. doi:10.1136/sextrans-2012-050604

591

Clinical
Figure 1 Flow of studies included in
the systematic review.

criteria for the recommended or alternative treatment of

gonorrhoea.
Gentamicin has several advantages for the treatment of gonorrhoea. Gentamicin is an aminoglycoside with concentrationdependent bactericidal activity against Gram-negative bacteria.
It binds at the 30S bacterial ribosomal subunit and interferes
with bacterial protein synthesis and initiation of DNA replication.25 26 The mechanism of action differs from that of other
antibiotics recommended for the treatment of gonorrhoea, suggesting that resistance to other antibiotic classes will not
confer resistance to gentamicin. Gentamicin is widely available
and inexpensive. However, gentamicin is only able to be administered intravenously or intramuscularly. In addition, gentamicin is associated with oto and nephrotoxity at high doses and
when used for extended periods of treatment, because toxicity
depends on prolonged trough concentration levels.27 Although
data on the risks of toxicity with single-dose therapy are
limited, the risks appear to be minimal.1618 28 29 Oto or
nephrotoxicity were not observed among the participants of
the studies we included in our analysis, although audiometry
and creatinine clearance were not measured systematically. As a
pregnancy risk category D agent, gentamicin should not be
used for pregnant or breast-feeding women.
Although the efcacy of gentamicin does not meet CDC criteria for a recommended (lower 95% CI of efcacy 95%) or

Table 2

alternative (95% efcacy with lower 95% CI of 90%) treatment, it could potentially prove to be a treatment option if
cephalosporin resistance emerges or for patients with severe
cephalosporin allergy. In an era of dwindling treatment options,
the current CDC criteria for recommended and alternative treatment may need to be reconsidered. It is also worth noting that
the CDC criteria for recommended treatment of gonorrhoea
have been applied to pooled estimates30 including trials that
excluded re-exposed patients in determining efcacy,31w2 and
that these pooled estimates may have been lower if all studies
were analysed according to assigned treatment (intent-to-treat)
without the exclusion of patients who were considered
re-exposed. As an example, the authors of one study that we
included retrospectively excluded patients deemed re-infected.16
Our analysis, based on an intent-to-treat approach, found a
lower efcacy (91.4%) than the original study authors (98.0%),
because we included all patients who were enrolled and received
the study drug. Although it may seem logical to exclude patients
who were re-exposed to N gonorrhoeae after treatment, retrospectively excluding these patients may introduce bias into the
results, particularly when patients who had positive follow-up
cultures were retrospectively evaluated for re-exposure while
patients with negative cultures were not.
Our ndings are subject to several limitations. First, we
found a small number of studies that met selection criteria

Efficacy of single-dose gentamicin for the treatment of gonococcal urethritis

Gentamicin
dosage

Author

Year

Study design

Population

Daly et al15

1997

Single-arm case
series

240 mg IM

Hira et al16

1985

Lule et al14

1994

Controlled trial, with

treatment assigned
to alternate
consecutive patients
Randomised
controlled
trial

107 Men with

gonococcal urethris
in Malawi
220 Men with
gonococcal urethritis
in Zambia
40 Men with
gonococcal urethris
in Malawi

240 mg IM

Pooled inverse weighted

averages of included
studies

280 mg IM

Weight in pooled
analysis

Efficacy of gentamicin
(95% CI)

Culture on
post-treatment
day 7
Culture on
post-treatment
day 14

27.4%

90.7% (84.6 to 96.8%)

65.4%

91.4% (87.7 to 95.1%)

Culture on
post-treatment
day 810

7.2%

Outcome

100%

95.0% (88.3% to 100.0%)

90.7% (88.1%94.0%)

IM, intramuscular.

592

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Clinical
established to exclude studies with a higher risk of bias. We
excluded studies from our evaluation of efcacy for two main
reasons. Either they could not be compared to included studies
because they did not measure outcomes by the same method
(culture) or did not use single-dose gentamicin treatment, and/
or they did not report systematic assignment to treatment.
That is, it is possible that these studies selected patients judged
by investigators to be more likely to respond to treatment
rather than treating all patients with gentamicin. Of the three
studies we included, only one used randomised assignment to
treatment. However, the other two studies did use systematic
assignment to treatment, thus minimising a potential source of
bias. In addition, treatment was found to be as effective in the
single randomised, controlled trial as in the two trials without
control groups.
Second, given the limited patient population in the three
included studies, we cannot be sure that the results apply to
all populations. While none of the information from excluded
trials suggested women would have a lower rate of successful
treatment, none of the included trials included women, so it is
possible the ndings do not apply to women or girls. While we
were unable to analyse the effectiveness of gentamicin for
HIV-positive patients with gonorrhoea, the study that reported
44% of enrolees were HIV positive also reported in the text that
the cure rate for gonorrhoea was not affected by concurrent HIV
infection.14 Therefore, we did not nd evidence that gentamicin
was less effective among HIV-positive patients. All patients
were from two countries (Malawi and Zambia) in sub-Saharan
Africa, and all data included were collected before 1997, and so it
would be important to monitor current in-vitro susceptibility
and clinical effectiveness in these and other settings where gentamicin is used for the treatment of gonorrhoea. As an example,
a recent evaluation of gentamicin susceptibility among N gonorrhoeae isolates in Europe demonstrated that 95% of isolates had
MIC of 8 g/ml or less.w3 Interpreting in-vitro susceptibility
data will be challenging, however, as we lack MIC thresholds for
resistance to gentamicin.
Third, due to the available literature and our study design,
we cannot infer efcacy for non-genital infections. However,
spectinomycin has poor efcacy for the treatment of pharyngeal gonorrhoea,w4 so it is expected that single-dose gentamicin
would also have limited efcacy for pharyngeal gonorrhoea. We
did not nd data regarding the efcacy of gentamicin for rectal
gonorrhoea infections.
Finally, we assumed xed effects rather than random effects
in pooling summary measures of treatment efcacy, which
could potentially underestimate heterogeneity between studies.
Our nding of I2 of 0% for our primary analysis (indicating 0%
of variability was due to heterogeneity between studies) provides reassurance that an assumption of xed effects was
reasonable.
The pooled efcacy of single-dose gentamicin does not meet
CDC criteria for a recommended or alternative therapy for gonorrhoea. However, we are facing the potential emergence of
multidrug-resistant gonorrhoea at a time of dwindling treatment options. Gentamicin may be a treatment option for
patients with severe cephalosporin hypersensitivity or when
gonococcal cephalosporin resistance emerges. A clinical trial
sponsored by the National Institute of Allergy and Infectious
Diseases is currently evaluating the efcacy of a combination of
gentamicin and azithromycin for the treatment of urogenital
gonorrhoea. Evaluation of additional treatment options is
warranted.

Sex Transm Infect 2012;88:589594. doi:10.1136/sextrans-2012-050604

Key messages
The emergence of cephalosporin-resistant gonorrhoea could
leave us with no treatment options that meet the criteria for
recommended gonorrhoea treatment.
A systematic review of gentamicin for gonorrhoea treatment
found gentamicin does not meet current CDC criteria for
recommended gonorrhoea treatment.
Gentamicin may be a useful alternative if cephalosporin
resistance emerges.

Acknowledgements The authors would like to thank Dr Marie Diener-West for

review of summary measure calculations.
Contributors Both authors contributed to the design and conduct of the study and
to the writing of the manuscript.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES
1.

2.

3.
4.

5.
6.

7.

8.
9.
10.
11.
12.
13.
14.

15.

16.

17.
18.
19.
20.
21.
22.

Centers for Disease Control and Prevention (CDC). Cephalosporin susceptibility

among Neisseria gonorrhoeae isolatesUnited States, 20002010. MMWR Morb
Mortal Wkly Rep 2011;60:8737.
Ito M, Yasuda M, Yokoi S, et al. Remarkable increase in Central Japan in 20012002 of
Neisseria gonorrhoeae isolates with decreased susceptibility to penicillin, tetracycline, oral
cephalosporins, and uoroquinolones. Antimicrob Agents Chemother 2004;48:31857.
European Centre for Disease Control and Prevention. Gonococcal antimicrobial
susceptibility surveillance in Europe2010. Stockholm: ECDC, 2012.
Unemo M, Golparian D, Syversen G, et al. Two cases of veried clinical failures
using internationally recommended rst-line cexime for gonorrhoea treatment,
Norway, 2010. Eurosurveillance 2010;15:pii:19721.
Ison C, Hussey J, Sankar K, et al. Gonorrhoea treatment failures to cexime and
azithromycin in England, 2010. Eurosurveillance 2011;16:pii:19833.
Unemo M, Golparian D, Stary A, et al. First Neisseria gonorrhoeae strain with
resistance to cexime causing gonorrhoea treatment failure in Austria, 2011.
Eurosurveillance 2011;16:pii:19998.
Unemo M, Golparian D, Nicholas R, et al. High-level cexime- and
ceftriaxone-resistant Neisseria gonorrhoeae in France: novel penA mosaic allele in a
successful international clone causes treatment failure. Antimicrob Agents
Chemother 2012;56:127380.
Brown LB, Krysiak R, Kamanga G, et al. Neisseria gonorrhoeae antimicrobial
susceptibility in Lilongwe, Malawi, 2007. Sex Transm Dis 2010;37:16972.
Clinicaltrials.gov. http://www.clinicaltrials.gov/ (accessed 19 Jan 2011).
CenterWatch. http://www.centerwatch.com (accessed 19 Jan 2011).
Current Controlled Trials. http://www.controlled-trials.com (accessed 19 Jan 2011).
World Health Organization International Clinical Trials Registry Platform.
http://www.who.int/ictrp/en (accessed 19 Jan 2011).
Newman L, Moran J, Workowski K. Update on the management of gonorrhea in
adults in the United States. Clin Infect Dis 2007;44(Suppl. 3):S84101.
Lule G, Behets FM-T, Hoffman IF, et al. STD/HIV control in Malawi and the search for
affordable and effective urethritis therapy: a rst eld evaluation. Genitourin Med
1994;70:3848.
Daly CC, Hoffman I, Hobbs M, et al. Development of an antimicrobial susceptibility
surveillance system for Neisseria gonorrhoeae in Malawi: comparison of methods.
J Clin Microbiol 1997;35:29858.
Hira SK, Attili VR, Kamanga J, et al. Efcacy of gentamicin and kanamycin in the
treatment of uncomplicated gonococcal urethritis in Zambia. Sex Transm Dis
1985;12:524.
Hantschke D, Strauss P, Linzenmeier G, et al. Treatment of gonorrhoea with single
injections of gentamicin. Br J Vener Dis 1973;49:624.
Tan NJ, Rajan VS, Pang R, et al. Gentamicin in the treatment of infections due to
penicillinase-producing gonococci. Br J Vener Dis 1980;56:3946.
Bartunek J, Kraft D, Meyer-Hausner E. Einmal-Behandlung der Gonorrhoe bei
Frauen mit Gentamycin (in German). Der Hautarzt 1974;25:62234.
Bowie W, Ronald AR, Krywulak W, et al. Gentamicin in the treatment of gonorrhea
in females. Brit J Vener Dis 1974;50:20811.
Hantschke D, Heller W, Straus P, et al. Einmalige sulmycin (gentamycin)-behandlung
der gonorrhoe (in German). Der Hautarzt 1973;24:303.
Hantschke D, Mauss J. (Gonorrhoe-behandlung mit sulmyicn) (in German). Z
Haut-Geschl Kr 1970;45:40712.

593

Clinical
23.

24.

25.
26.

594

Bukharovich MN, Revunov VP. (Combined etiological and pathogenetic therapy of

urogenital UreaplasmaChlamydia-gonococcal infection in men) (in Russian). Antibiot
Khimioter 1991;36:3941.
Price MA, Zimba D, Hoffman IF, et al. Addition of treatment for trichomoniasis to
syndromic management of urethritis in Malawi: a randomized clinical trial. Sex
Transm Dis 2003;30:51622.
Vakulenko S, Mobashery S. Versatility of aminoglycosides and prospects for their
future. Clin Microbiol Rev 2003;16:43050.
Vakulenko S, Mobashery S. Versatility of aminoglycosides and prospects for their
future. Clin Microbiol Rev 2003;16:43050.

27.
28.
29.
30.
31.

Barclay ML, Begg EJ. Aminoglycoside toxicity and relation to dose regimen.
Adverse Drug React Toxicol Rev 1994;13:20734.
Jackson GG, Arcieri G. Ototoxicity of gentamicin in man: a survey and controlled analysis
of clinical experience in the United States. J Infect Dis 1971;124:S1307.
Felarca AB, Laqui EM, Ibarra LM. Gentamicin in gonococcal urethritis of Filipino
males: dosage and response. J Infect Dis 1971;124:S28792.
Moran JS, Levine WC. Drugs of choice for the treatment of uncomplicated
gonococcal infections. Clin Infect Dis 1995;20(Suppl 1):S4765.
Cavenee MR, Farris JR, Spalding TR, et al. Treatment of gonorrhea in pregnancy.
Obstet Gynecol 1993;81:338.

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