CASE REPORT
Gonococcal Aneurysm of the Ascending Aorta: Case Report and Review of Neisseria gonorrhoeae Endovascular Infections Samuel Markowicz, MD,* James Richards Anstey, MD,* Maya Hites, MD,* Isabel Montesinos, MD, PhD,Þ Sandrine Roisin, MD,Þ Caroline Keyzer, MD, PhD,þ and Frederique Jacobs, MD, PhD*
Abstract: We present the case of a man with a bicuspid aortic valve who presented with persistent fever. Blood cultures yielded Neisseria gonorrhoeae, and the diagnosis of infected mycotic aneurysm was confirmed by detection of the bacterial genome in the aortic wall. The patient was cured with surgery and intravenous ceftriaxone.
N
eisseria gonorrhoeae (NG) is currently the second most common cause of reported sexually transmitted infections in the world, causing 88 million new cases per year.1 Genitourinary infections represent most cases, whereas dissemination is uncommon (1%Y3%). In these disseminated gonococcal infections (DGIs), symptoms generally include joint pain, arthritis, skin lesions, and/or fever; myocarditis, meningitis, and endovascular infections are rarely reported.2 We present the case of a man who shortly after returning from the Philippines developed persistent fever. He was finally diagnosed as having an aortic mycotic aneurysm (MA) due to penicillin and fluoroquinolone-resistant NG. A 65-year-old man was admitted to hospital for a 3-week history of daily fever (up to 39-C) and chills starting a few days after having returned from a 1-month trip to the Philippines. He had no other complaints except for weight loss of 4 kg over the last month. His only medical history was of a bicuspid aortic valve with moderate stenosis. He was retired, had stopped smoking recently, and drank little alcohol. Upon admission, his general status was good, and his body temperature was 37.4-C. Physical examination was normal except for an aortic holosystolic murmur (grade 2/6). Blood analysis showed a white blood cell count of 11,600/mm3 (with 78% of polynuclear leukocytes), a C-reactive protein of 120 mg/L, mild anemia (hemoglobin level, 11.7 g/dL), and a very slight increase in liver enzymes. A thick blood smear for malaria, serological test result (for dengue, hepatitis, HIV, and syphilis), and urinalysis result were negative; a chest x-ray finding was normal. Because a transthoracic echocardiography raised the suspicion of aortic valve endocarditis, a transesophageal echocardiogram was performed that showed a bicuspid aortic valve with aortic atherosclerosis. Nonetheless, even though 6 pairs of blood cultures (taken without prior antibiotic From the Departments of *Infectious Diseases, †Microbiology, and ‡Radiology, Hoˆpital Erasme, Universite´ Libre de Bruxelles, Brussels, Belgium
The authors declare that they have no conflicts of interest. Correspondence: Frederique Jacobs, MD, PhD, Department of Infectious Diseases, Hoˆpital Erasme, Universite´ Libre de Bruxelles, Brussels, Belgium. E-mail: [email protected]. Received for publication September 10, 2013, and accepted November 13, 2013. DOI: 10.1097/OLQ.0000000000000079 Copyright * 2014 American Sexually Transmitted Diseases Association All rights reserved.
Sexually Transmitted Diseases
&
therapy) remained negative, empirical treatment of endocarditis with penicillin and gentamicin was initiated. The patient was transferred to our academic hospital the following day where antibiotics were stopped. One of 6 aerobic blood cultures (taken 5 days after stopping antibiotics) yielded NG after 42 hours of incubation. The strain was A-lactamase positive and was therefore reported resistant to penicillin and amoxicillin. According to Clinical and Laboratory Standards Institute (2013), disk diffusion method was used to determine susceptibility to tetracycline (resistant) and spectinomycine (susceptible). E-tests were used to measure the minimal inhibitory concentration (MIC) to ciprofloxacine (MIC 4 mg/LVresistant) and ceftriaxone (MIC G0.125 mg/LVsusceptible). Treatment with ceftriaxone (2 grams once daily) was given with rapid resolution of fever and inflammatory parameters. No clear sexual history had been taken initially, but the patient finally reported having had only oral sex with female sex workers while overseas, although he never experienced any genitourinary symptoms. N. gonorrhoeae polymerase chain reaction (PCR) on morning urine was negative. No pharyngeal culture or PCR to detect NG was performed. A second transesophageal echocardiogram performed 1 week after the first showed an irregular contour of the posterior wall of the ascending aorta, 5 cm above the aortic root. An aneurysm of 3 cm in diameter involving the posterior part of the ascending aorta was confirmed on thoracic computed tomographic (CT) angiography (Figs. 1 and 2). Replacement of the ascending aorta and aortic valve was performed according to the modified Bentall procedure.3 Culture of an aortic wall specimen remained sterile, but the Abbott RealTime CT/NG assay (Abbott Park, IL) used for amplification of NG genome on the aortic tissue was positive. Ceftriaxone was administered for 6 weeks after surgery with a favorable clinical and biological response. Endovascular infections due to NG are rare and mainly consist of endocarditis. In the preantibiotic era, up to one-quarter of cases of infective endocarditis were caused by NG, but nowadays, it has become extremely rare: only 70 cases have been reported since 1939, with 5 cases since 2000.4,5 This subacute endocarditis mainly affects healthy young people without previous valvular disease. It occurs 3 to 6 weeks after the primary infection and is often preceded by arthritis and/or tenosynovitis. Genitourinary symptoms are often absent. More than half of patients require valve replacement, and mortality rates may reach 19%.6 By contrast, gonococcal MA is exceptional, with only 3 reported cases in addition to ours.7Y9 The characteristics of these patients are presented in Table 1. Unlike endocarditis, MA affects older patients with relative immunosuppression (diabetes mellitus in 2 and corticosteroids in 1 patient). A bicuspid aortic valve was the predisposing factor found in all patients: the associated intrinsic smooth muscle abnormality combined with atherosclerosis can explain the development of infection of the ascending aortic wall.7 None of these patients had concomitant
Volume 41, Number 2, February 2014
111
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Markowicz et al.
Figure 1. CT angiography of the thoracic aorta. Axial (A) and sagittal (B) thin maximum intensity projection (MIP) images showing a posterior aneurysm (arrow) of the ascending aorta.
endocarditis. Genitourinary symptoms were absent in all patients; documentation of genitourinary infection was only performed in our case and was negative. Diagnosis of gonococcal MA was made by detection of NG in blood cultures (3/4 patients) and/or on aortic tissue samples (2/4 patients). In DGI, blood and tissue cultures may remain negative for sustained periods, or might not grow at all because of the fastidious nature of NG and/or intermittent bacteremia.6 Therefore, at least 3 sets of blood cultures should be performed. Even in the absence of symptoms, cultures and PCR for detection of NG on urethral, cervical, rectal, and pharyngeal sites must be performed. The sensitivity of urethral, cervical, and rectal mucosal cultures is unknown in the case of MA but ranges from 25% to 100% in the case of other DGI.10 Nucleic
acid amplification testing offers greater sensitivity than culture for detection of NG and should therefore be considered to make the diagnosis. Both the increasing resistance to multiple classes of antibiotics including tetracyclines, macrolides, and fluoroquinolones and the declining sensitivity to third-generation cephalosporins (especially in men having sex with men) severely limit treatment options for NG. No other antimicrobial is well suited to replace ceftriaxone for gonorrhea, even if 2 combinations of antibiotics (azithromycin with gentamicin or gemifloxacin) have recently shown efficacy in multidrug-resistant NG infections.11 Because nucleic acid amplification testing does not provide information on antibiotic resistance, cultures with susceptibility testing are therefore essential to guide antimicrobial treatment.12
Figure 2. CT angiography of the thoracic aorta. Three-dimensional volume rendering image showing a posterior aneurysm (arrow) of the ascending aorta.
112
Sexually Transmitted Diseases
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Volume 41, Number 2, February 2014
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Gonococcal Aneurysm of the Ascending Aorta
TABLE 1.
Case Reports of N. gonorrhoeae MAs of the Ascending Aorta
Author, year of publication Sex Age, y Comorbidities Valvular disease Clinical features Sexual contact/ travel Genitourinary samples Blood cultures (positive/done) Aortic aneurysm wall Surgery Antibiotics
Case 1
Case 2
Case 3
Our Case
Pa¨tila¨a et al., 20127
Woo et al., 20118
Risher et al., 19949
Markowicz et al., 2013
Male 52 Diabetes mellitus Bicuspid aortic valve Fever and abdominal pain Thailand 6 mo before
Female 38 Systemic lupus (steroids) Bicuspid aortic valve Fever and dyspnea ?
Not done
Male 61 Diabetes mellitus Bicuspid aortic valve Fever and chest pain Female sex worker 2 mo before Not done
Positive (3/3)
Negative
Positive
Male 65 None Bicuspid aortic valve Fever Oral sex in the Philippines (female sex worker) Urine: culture not done, PCR negative Positive (1/6)
Not done
Gram stain and culture: Gram stain, culture, and Gram stain and culture: negative; PCR: not done PCR: all positive negative; PCR: not done Modified Bentall Modified Bentall Modified Bentall Ceftriaxone (2 wk) Ceftriaxone (6 wk) Ceftriaxone-Vancomycin-Gentamicin (6 wk)
All 4 patients with MA were treated with ceftriaxone for 2 to 6 weeks combined with surgical replacement of the ascending aorta and aortic valve. Optimal medical treatment of NG intravascular infections is unknown. In the case of NG endocarditis, a minimum of 4 weeks of treatment with ceftriaxone is recommended by the Centers for Disease Control and Prevention.13 There are no recommendations for MA. In conclusion, sexual history is essential in patients with fever of unknown origin, and endovascular disease due to NG should be considered in the differential diagnosis. Repeated blood cultures and PCR/cultures on tissue samples for detection of NG should be performed, even in the absence of genitourinary symptoms. REFERENCES 1. WHO. Prevalence and Incidence of Selected Sexually Transmitted Infections, Chlamydia trachomatis, Neisseria gonorrhoeae, Syphilis, and Trichomonas vaginalis: Methods and Results Used by WHO to Generate 2005 Estimates. Geneva, Switzerland: WHO, 2011. 2. Miller KE. Diagnosis and treatment of Neisseria gonorrhoeae infections. Am Fam Phys 2006;73:1779Y1784. 3. Cherry C, DeBord S, Hickey C. The modified Bentall procedure for aortic root replacement. AORN J 2006;84:52Y55, 58Y70 4. Cove-Smith A, Klein JL. Gonococcal endocarditis: Forgotten but not quite gone. Scand J Infect Dis 2006;38:696Y697.
Sexually Transmitted Diseases
&
Gram stain and culture: negative; PCR: positive Modified Bentall Ceftriaxone (6 wk)
5. Nie S, Wu Y, Huang L, et al. Gonococcal endocarditis: A case report and literature review. Eur J Clin Microbiol Infect Dis 2013. [Epub ahead of print]. 6. Nielsen US, Knudsen JB, Pedersen LN, et al. Neisseria gonorrhoeae endocarditis confirmed by nucleic acid amplification assays performed on aortic valve tissue. J Clin Microbiol 2009; 47:865Y867. 7. Pa¨tila¨a T, Kurkib T, Ihlberga L. Isolated gonococcal ascending aorta aneurysm. Inter Cardiovasc Thorac Surg 2012;15:183Y185. 8. Woo JS, Rabkin DG, Mokadam NA, et al. Gonococcal ascending aortitis with penetrating ulcers and intraluminal thrombus. Ann Thorac Surg 2011;91:910Y912. 9. Risher WH, McFadden PM. Neisseria gonorrhoeae mycotic ascending aortic aneurysm. Ann Thorac Surg 1994;57:748Y750. 10. Suzaki A, Hayashi K, Kosuge K, et al. Disseminated gonococcal infection in Japan: A case report and literature review. Intern Med 2011;50:2039Y2043. 11. Kidd S, Kirkcaldy R, Weinstock H, et al. Tackling multidrugresistant gonorrhea: How should we prepare for the untreatable? Exp Rev Anti Infect Ther 2012;10:831Y833. 12. Centers for Disease Control and Prevention. Update to CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Recomm Rep 2012;61:31. 13. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2010;55:12.
Volume 41, Number 2, February 2014
113
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Gonococcal Aneurysm of the Ascending Aorta: Case Report and Review of Neisseria gonorrhoeae Endovascular Infections Samuel Markowicz, MD,* James Richards Anstey, MD,* Maya Hites, MD,* Isabel Montesinos, MD, PhD,Þ Sandrine Roisin, MD,Þ Caroline Keyzer, MD, PhD,þ and Frederique Jacobs, MD, PhD*
Abstract: We present the case of a man with a bicuspid aortic valve who presented with persistent fever. Blood cultures yielded Neisseria gonorrhoeae, and the diagnosis of infected mycotic aneurysm was confirmed by detection of the bacterial genome in the aortic wall. The patient was cured with surgery and intravenous ceftriaxone.
N
eisseria gonorrhoeae (NG) is currently the second most common cause of reported sexually transmitted infections in the world, causing 88 million new cases per year.1 Genitourinary infections represent most cases, whereas dissemination is uncommon (1%Y3%). In these disseminated gonococcal infections (DGIs), symptoms generally include joint pain, arthritis, skin lesions, and/or fever; myocarditis, meningitis, and endovascular infections are rarely reported.2 We present the case of a man who shortly after returning from the Philippines developed persistent fever. He was finally diagnosed as having an aortic mycotic aneurysm (MA) due to penicillin and fluoroquinolone-resistant NG. A 65-year-old man was admitted to hospital for a 3-week history of daily fever (up to 39-C) and chills starting a few days after having returned from a 1-month trip to the Philippines. He had no other complaints except for weight loss of 4 kg over the last month. His only medical history was of a bicuspid aortic valve with moderate stenosis. He was retired, had stopped smoking recently, and drank little alcohol. Upon admission, his general status was good, and his body temperature was 37.4-C. Physical examination was normal except for an aortic holosystolic murmur (grade 2/6). Blood analysis showed a white blood cell count of 11,600/mm3 (with 78% of polynuclear leukocytes), a C-reactive protein of 120 mg/L, mild anemia (hemoglobin level, 11.7 g/dL), and a very slight increase in liver enzymes. A thick blood smear for malaria, serological test result (for dengue, hepatitis, HIV, and syphilis), and urinalysis result were negative; a chest x-ray finding was normal. Because a transthoracic echocardiography raised the suspicion of aortic valve endocarditis, a transesophageal echocardiogram was performed that showed a bicuspid aortic valve with aortic atherosclerosis. Nonetheless, even though 6 pairs of blood cultures (taken without prior antibiotic From the Departments of *Infectious Diseases, †Microbiology, and ‡Radiology, Hoˆpital Erasme, Universite´ Libre de Bruxelles, Brussels, Belgium
The authors declare that they have no conflicts of interest. Correspondence: Frederique Jacobs, MD, PhD, Department of Infectious Diseases, Hoˆpital Erasme, Universite´ Libre de Bruxelles, Brussels, Belgium. E-mail: [email protected]. Received for publication September 10, 2013, and accepted November 13, 2013. DOI: 10.1097/OLQ.0000000000000079 Copyright * 2014 American Sexually Transmitted Diseases Association All rights reserved.
Sexually Transmitted Diseases
&
therapy) remained negative, empirical treatment of endocarditis with penicillin and gentamicin was initiated. The patient was transferred to our academic hospital the following day where antibiotics were stopped. One of 6 aerobic blood cultures (taken 5 days after stopping antibiotics) yielded NG after 42 hours of incubation. The strain was A-lactamase positive and was therefore reported resistant to penicillin and amoxicillin. According to Clinical and Laboratory Standards Institute (2013), disk diffusion method was used to determine susceptibility to tetracycline (resistant) and spectinomycine (susceptible). E-tests were used to measure the minimal inhibitory concentration (MIC) to ciprofloxacine (MIC 4 mg/LVresistant) and ceftriaxone (MIC G0.125 mg/LVsusceptible). Treatment with ceftriaxone (2 grams once daily) was given with rapid resolution of fever and inflammatory parameters. No clear sexual history had been taken initially, but the patient finally reported having had only oral sex with female sex workers while overseas, although he never experienced any genitourinary symptoms. N. gonorrhoeae polymerase chain reaction (PCR) on morning urine was negative. No pharyngeal culture or PCR to detect NG was performed. A second transesophageal echocardiogram performed 1 week after the first showed an irregular contour of the posterior wall of the ascending aorta, 5 cm above the aortic root. An aneurysm of 3 cm in diameter involving the posterior part of the ascending aorta was confirmed on thoracic computed tomographic (CT) angiography (Figs. 1 and 2). Replacement of the ascending aorta and aortic valve was performed according to the modified Bentall procedure.3 Culture of an aortic wall specimen remained sterile, but the Abbott RealTime CT/NG assay (Abbott Park, IL) used for amplification of NG genome on the aortic tissue was positive. Ceftriaxone was administered for 6 weeks after surgery with a favorable clinical and biological response. Endovascular infections due to NG are rare and mainly consist of endocarditis. In the preantibiotic era, up to one-quarter of cases of infective endocarditis were caused by NG, but nowadays, it has become extremely rare: only 70 cases have been reported since 1939, with 5 cases since 2000.4,5 This subacute endocarditis mainly affects healthy young people without previous valvular disease. It occurs 3 to 6 weeks after the primary infection and is often preceded by arthritis and/or tenosynovitis. Genitourinary symptoms are often absent. More than half of patients require valve replacement, and mortality rates may reach 19%.6 By contrast, gonococcal MA is exceptional, with only 3 reported cases in addition to ours.7Y9 The characteristics of these patients are presented in Table 1. Unlike endocarditis, MA affects older patients with relative immunosuppression (diabetes mellitus in 2 and corticosteroids in 1 patient). A bicuspid aortic valve was the predisposing factor found in all patients: the associated intrinsic smooth muscle abnormality combined with atherosclerosis can explain the development of infection of the ascending aortic wall.7 None of these patients had concomitant
Volume 41, Number 2, February 2014
111
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Markowicz et al.
Figure 1. CT angiography of the thoracic aorta. Axial (A) and sagittal (B) thin maximum intensity projection (MIP) images showing a posterior aneurysm (arrow) of the ascending aorta.
endocarditis. Genitourinary symptoms were absent in all patients; documentation of genitourinary infection was only performed in our case and was negative. Diagnosis of gonococcal MA was made by detection of NG in blood cultures (3/4 patients) and/or on aortic tissue samples (2/4 patients). In DGI, blood and tissue cultures may remain negative for sustained periods, or might not grow at all because of the fastidious nature of NG and/or intermittent bacteremia.6 Therefore, at least 3 sets of blood cultures should be performed. Even in the absence of symptoms, cultures and PCR for detection of NG on urethral, cervical, rectal, and pharyngeal sites must be performed. The sensitivity of urethral, cervical, and rectal mucosal cultures is unknown in the case of MA but ranges from 25% to 100% in the case of other DGI.10 Nucleic
acid amplification testing offers greater sensitivity than culture for detection of NG and should therefore be considered to make the diagnosis. Both the increasing resistance to multiple classes of antibiotics including tetracyclines, macrolides, and fluoroquinolones and the declining sensitivity to third-generation cephalosporins (especially in men having sex with men) severely limit treatment options for NG. No other antimicrobial is well suited to replace ceftriaxone for gonorrhea, even if 2 combinations of antibiotics (azithromycin with gentamicin or gemifloxacin) have recently shown efficacy in multidrug-resistant NG infections.11 Because nucleic acid amplification testing does not provide information on antibiotic resistance, cultures with susceptibility testing are therefore essential to guide antimicrobial treatment.12
Figure 2. CT angiography of the thoracic aorta. Three-dimensional volume rendering image showing a posterior aneurysm (arrow) of the ascending aorta.
112
Sexually Transmitted Diseases
&
Volume 41, Number 2, February 2014
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Gonococcal Aneurysm of the Ascending Aorta
TABLE 1.
Case Reports of N. gonorrhoeae MAs of the Ascending Aorta
Author, year of publication Sex Age, y Comorbidities Valvular disease Clinical features Sexual contact/ travel Genitourinary samples Blood cultures (positive/done) Aortic aneurysm wall Surgery Antibiotics
Case 1
Case 2
Case 3
Our Case
Pa¨tila¨a et al., 20127
Woo et al., 20118
Risher et al., 19949
Markowicz et al., 2013
Male 52 Diabetes mellitus Bicuspid aortic valve Fever and abdominal pain Thailand 6 mo before
Female 38 Systemic lupus (steroids) Bicuspid aortic valve Fever and dyspnea ?
Not done
Male 61 Diabetes mellitus Bicuspid aortic valve Fever and chest pain Female sex worker 2 mo before Not done
Positive (3/3)
Negative
Positive
Male 65 None Bicuspid aortic valve Fever Oral sex in the Philippines (female sex worker) Urine: culture not done, PCR negative Positive (1/6)
Not done
Gram stain and culture: Gram stain, culture, and Gram stain and culture: negative; PCR: not done PCR: all positive negative; PCR: not done Modified Bentall Modified Bentall Modified Bentall Ceftriaxone (2 wk) Ceftriaxone (6 wk) Ceftriaxone-Vancomycin-Gentamicin (6 wk)
All 4 patients with MA were treated with ceftriaxone for 2 to 6 weeks combined with surgical replacement of the ascending aorta and aortic valve. Optimal medical treatment of NG intravascular infections is unknown. In the case of NG endocarditis, a minimum of 4 weeks of treatment with ceftriaxone is recommended by the Centers for Disease Control and Prevention.13 There are no recommendations for MA. In conclusion, sexual history is essential in patients with fever of unknown origin, and endovascular disease due to NG should be considered in the differential diagnosis. Repeated blood cultures and PCR/cultures on tissue samples for detection of NG should be performed, even in the absence of genitourinary symptoms. REFERENCES 1. WHO. Prevalence and Incidence of Selected Sexually Transmitted Infections, Chlamydia trachomatis, Neisseria gonorrhoeae, Syphilis, and Trichomonas vaginalis: Methods and Results Used by WHO to Generate 2005 Estimates. Geneva, Switzerland: WHO, 2011. 2. Miller KE. Diagnosis and treatment of Neisseria gonorrhoeae infections. Am Fam Phys 2006;73:1779Y1784. 3. Cherry C, DeBord S, Hickey C. The modified Bentall procedure for aortic root replacement. AORN J 2006;84:52Y55, 58Y70 4. Cove-Smith A, Klein JL. Gonococcal endocarditis: Forgotten but not quite gone. Scand J Infect Dis 2006;38:696Y697.
Sexually Transmitted Diseases
&
Gram stain and culture: negative; PCR: positive Modified Bentall Ceftriaxone (6 wk)
5. Nie S, Wu Y, Huang L, et al. Gonococcal endocarditis: A case report and literature review. Eur J Clin Microbiol Infect Dis 2013. [Epub ahead of print]. 6. Nielsen US, Knudsen JB, Pedersen LN, et al. Neisseria gonorrhoeae endocarditis confirmed by nucleic acid amplification assays performed on aortic valve tissue. J Clin Microbiol 2009; 47:865Y867. 7. Pa¨tila¨a T, Kurkib T, Ihlberga L. Isolated gonococcal ascending aorta aneurysm. Inter Cardiovasc Thorac Surg 2012;15:183Y185. 8. Woo JS, Rabkin DG, Mokadam NA, et al. Gonococcal ascending aortitis with penetrating ulcers and intraluminal thrombus. Ann Thorac Surg 2011;91:910Y912. 9. Risher WH, McFadden PM. Neisseria gonorrhoeae mycotic ascending aortic aneurysm. Ann Thorac Surg 1994;57:748Y750. 10. Suzaki A, Hayashi K, Kosuge K, et al. Disseminated gonococcal infection in Japan: A case report and literature review. Intern Med 2011;50:2039Y2043. 11. Kidd S, Kirkcaldy R, Weinstock H, et al. Tackling multidrugresistant gonorrhea: How should we prepare for the untreatable? Exp Rev Anti Infect Ther 2012;10:831Y833. 12. Centers for Disease Control and Prevention. Update to CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Recomm Rep 2012;61:31. 13. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2010;55:12.
Volume 41, Number 2, February 2014
113
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
