Comparing Strategies to Introduce Two New Antibiotics for Gonorrhea: A Modeling Study

Abstract

Background: Drug resistance in Neisseria gonorrhoeae is an urgent public health threat. The anticipated approval of 2 new antimicrobials for gonorrhea prompts the need for evidence-based rollout strategies that minimize drug resistance.

Methods: We used a stochastic compartmental model of men who have sex with men (MSM) in the United States (US) to compare 2 main strategies-equal allocation and sequential drug deployment-for 2 new and 1 existing drug and measured the time for each drug to reach a resistance prevalence threshold of 5%. We conducted broad analyses assessing the sensitivity of our results to wide variation in parameters governing the baseline behavior of the model and drug resistance evolution and fitness.

Results: Compared to the equal allocation strategy, the sequential strategy had reached the resistance prevalence threshold i) for each drug individually in at least as many simulations; ii) for all 3 drugs in at least as many simulations; and iii) for at least as many drugs on average. After 10 years, no equal allocation strategy simulations had met the 5% resistance prevalence threshold for any of the drugs, whereas 99.6% of sequential simulations had for the first drug, of which 3.5% had also met the threshold for the second drug. The sequential strategy was worse for nearly every reasonable combination of model parameters.

Conclusions: In a model of US MSM, the equal allocation strategy for introducing new drugs for gonorrhea matched or outperformed the strategy of sequential introduction in terms of resistance prevalence.

Keywords: Neisseria gonorrhoeae; antimicrobial resistance; transmission-dynamic model; zoliflodacin; gepotidacin.