FIGURE 3 Rates of primary and secondary syphilis and gonorrhea in the United States, 1950–1990. Reprinted with permission from ref. 8 (copyright 1994, Blackwell Scientific Publications).

race, and gender observed with syphilis, age-related population shifts have been seen with gonorrhea. Over the last decade, gonorrhea rates have declined among both men and women in all age groups between 15 and 40 years of age except 15- to 19-year-olds (9). As a result, adolescents in this country now have the highest age-specific gonorrhea rates among women and the second highest age-specific rates among men. After adjustment for the proportion of the population which is sexually active, the gap between teenagers and older adults widens even more (11).

Gonorrhea also provides an excellent example of rapid and repeated emergence of new types of antimicrobial resistance. The recognition of penicillinase-producing Neisseria gonorrhoeae in 1976 has been followed by appreciation of an increasingly diverse array of resistance patterns and mechanisms, including both plasmid- and chromosomally mediated resistance to penicillins and tetracyclines, the two former mainstays of treatment (12). Between 1988 and 1991, national surveillance of gonococcal isolates conducted by the Centers for Disease Control and Prevention documented an increase in the proportion of resistant isolates from 21% to 32.4%, more than a 50% increase in only 3 years (9, 13, 14)!

In the United States, as gonorrhea rates have declined, chlamydia rates have climbed, shifting the apparent balance of etiologies of urethritis, cervicitis, and PID. Indeed, in 1991, reported chlamydia cases exceeded reported gonorrhea cases among women for the first time (9).



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