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1 February 2006

Volume 42, Number 3
Clinical Infectious Diseases 2006;42:337–345
© 2005 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2006/4203-0006$15.00
DOI: 10.1086/498899
MAJOR ARTICLE

Azithromycin‐Resistant Syphilis Infection: San Francisco, California, 2000–2004

Samuel J. Mitchell,1,2

Joseph Engelman,1

Charlotte K. Kent,1

Sheila A. Lukehart,3

Charmie Godornes,3 and

Jeffrey D. Klausner1

1STD Prevention and Control Services, San Francisco Department of Public Health, San Francisco, California; 2Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia; and 3Department of Medicine, University of Washington, Seattle

Background.The incidence of syphilis has been increasing in the United States since reaching a nadir in 2000. Several clinical trials have demonstrated that treatment with oral azithromycin may be useful for syphilis control. After reports of azithromycin treatment failures in San Francisco, we investigated the clinical and epidemiologic characteristics of patients with syphilis due to azithromycin‐resistant Treponema pallidum infection.

Methods.We reviewed city‐wide case reports and conducted molecular screening for patients seen at the San Francisco metropolitan STD clinic (San Francisco City Clinic) to identify patients who did not respond to azithromycin treatment for syphilis or who were infected with azithromycin‐resistant T. pallidum. We conducted an epidemiologic investigation and retrospective case‐control study to identify risk factors for acquiring syphilis due to azithromycin‐resistant T. pallidum.

Results.From January 2000 through December 2004, molecular screening of 124 samples identified 46 azithromycin‐resistant T. pallidum isolates and 72 wild‐type T. pallidum isolates. Six instances of treatment failure were identified through record review. In total, we identified 52 case patients (one of whom had 2 episodes) and 72 control patients. All case patients were male and either gay or bisexual, and 31% (16 of 52) were infected with human immunodeficiency virus. Investigation of patient‐partner links and a retrospective case‐control study did not reveal a sexual network or demographic differences between cases and controls. However, 7 case patients had recently used azithromycin, compared with 1 control patient. Surveillance data demonstrated that azithromycin‐resistant T. pallidum prevalence increased from 0% in 2000 to 56% in 2004 among syphilis cases observed at the San Francisco City Clinic.

Conclusions.Azithromycin‐resistant T. pallidum is widespread in San Francisco. We recommend against using azithromycin for the management of syphilis in communities where macrolide‐resistant T. pallidum is present and recommend active surveillance for resistance in sites where azithromycin is used.

Received 5 May 2005; accepted 24 August 2005; electronically published 28 December 2005.

Reprints or correspondence: Dr. Jeffrey D. Klausner, San Francisco Dept. of Public Health, STD Prevention and Control Services, 1360 Mission St., Ste. 401, San Francisco, CA 94103 ().

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