In Reply: We agree with Drs Klausner and Kerndt that antibiotic stewardship is an important component of controlling antibiotic resistance, and we support such efforts as sound clinical and public health practice. For many bacterial pathogens, antibiotic consumption appears to promote the emergence of resistance, and judicious antibiotic use may reduce the prevalence of resistance.1
However, for several reasons, it is not at all clear that improved antibiotic stewardship in the United States would prevent the emergence of cephalosporin resistance in N gonorrhoeae. First, gonococcal resistance is a global phenomenon, and importation of resistant strains from other countries appears to play a large role in the emergence of resistance in the United States. Gonococcal resistance phenotypes tend to emerge initially in East Asia before spreading globally.2 When resistance has emerged in the United States, it has appeared first in geographic regions in relative proximity to Asia such as Hawaii and the West Coast.
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