Gentamicin is inferior to ceftriaxone in treating patients with gonorrhea

Reference

Ross JDC, Brittain C, Cole M, et al, for the G-ToG trial team. Gentamicin compared with ceftriaxone for the treatment of gonorrhoea (G-ToG): a randomised non-inferiority trial. Lancet 2019;393(10190):2511-2520.

Synopsis

Globally, gonococcal resistance to ceftriaxone is growing, so these authors attempted to see if gentamicin might be as effective. They included 720 patients between the ages of 16 years and 70 years who attended sexual health clinics in England for uncomplicated gonorrhea (genital, pharyngeal, rectal). The patients were randomized to receive a single intramuscular dose of 500 mg ceftriaxone (n = 362) or 240 mg gentamicin (n= 358). They used nucleic acid amplification testing from first-void urine or from swabs of the urethra, cervix, vagina, pharynx, or rectum. All participants also received a single dose of 1 g oral azithromycin. The ceftriaxone was also mixed with lidocaine; the gentamicin was not. The researchers re-tested the patients at the previously infected anatomic sites 2 weeks after treatment. The final analysis only included those patients who had follow-up testing and those whose samples were correctly collected: 85% for the ceftriaxone-treated patients and 82% for the gentamicin-treated patients. Among those treated with ceftriaxone, 98% had a negative follow-up test result compared with only 91% of the gentamicin-treated patients. The difference was even greater among patients with gonococcal pharyngitis: 96% "cure" for ceftriaxone versus 80% for gentamicin. The rate of adverse events was comparable between the 2 treatment groups: nausea, vomiting, dizziness, change in glomerular filtration rate, and so forth. Nearly all patients in each group reported injection site pain, but the degree of pain was lower in those receiving ceftriaxone (21 on a scale of 100) than gentamicin (36/100), but this is an unfair comparison since the ceftriaxone volume was 2 mL, compared with 6 mL for gentamicin, and the ceftriaxone was mixed with lidocaine.