Many UK GPs Using Drugs No Longer Recommended for Gonorrhea

Diana Phillips

June 03, 2015

Many family physicians in the United Kingdom are prescribing antimicrobials that are no longer recommended for gonorrhea, according to a new study. This increases the risk for antimicrobial-resistant strains of the sexually transmitted infections (STIs).

In a population-based study published in the June issue of BMJ Open, general practice physicians prescribed ciprofloxacin for 42% of patients they treated for gonorrhea in 2007 and 20% of those with the infection in 2011. The drug was discontinued as a recommended therapy for gonorrhea in 2005. During the same period, GPs prescribed a recommended antimicrobial for more than 90% of patients with chlamydia, according to lead author Sally Wetten, MSc, from the HIV & STI Department, Public Health England, London, United Kingdom, and colleagues.

The investigators analyzed longitudinal electronic health records in the Clinical Practice Research Datalink and national STI surveillance databases for 2000 to 2011, focusing specifically on chlamydia and gonorrhea, which are the two most commonly diagnosed bacterial STIs in the United Kingdom.

During the study period, the estimated rate of chlamydia diagnoses per 100,000 population in general practices increased from 22.8 (95% confidence interval [CI], 22.4 - 23.2) in 2000 to 29.3 (95% CI, 28.8 - 29.7) in 2011 (P < .001). The proportion treated increased from 59.5% to 78.4% (P = .001).

During the same period, the diagnosis rate of gonorrhea per 100,000 population in general practices ranged between 3.2 (95% CI, 3 - 3.3) and 2.4 (95% CI, 2.2 - 2.5; P = .607). The proportion treated ranged between 32.7% and 53.6% (P = .26).

General practitioners diagnosed between 9% and 16% of chlamydia cases and between 6% and 9% of gonorrhea cases in England. With respect to treatment for chlamydia, "each year, over 90% of treated episodes were given a [British Association for Sexual Health and HIV] recommended regimen," the authors write, noting that over the course of the study period, the use of azithromycin increased steadily and accounted for 70.6% of treatments in 2011, whereas doxycycline use declined from 63.6% to 23.1%. "A small number of non-recommended regimens were identified, although this decreased from 7.0% to 1.5% of treatments from 2000 to 2011," they state.

For gonorrhea, approximately 40% of patients managed in the general practice setting received a recommended treatment regimen each year. Ciprofloxacin was the most commonly prescribed antibiotic, accounting for 41% of treated episodes, "and continued to be used after the change in national treatment guidelines favoring cephalosporins in 2005," according to the authors. Cefixime and ceftriaxone were increasingly prescribed beginning in 2005 and were the most commonly prescribed antibiotics in 2011.

"A high proportion of non-recommended regimens were prescribed [for gonorrhea] including doxycycline, azithromycin and other macrolides," the authors write, noting that the proportion fluctuated, decreasing from 67% in 2000 to 39% in 2004, and then increasing to 65% in 2011, with amoxicillin and ampicillin accounting for 90% of these episodes.

Current gonorrhea treatment guidelines recommend intramuscular administration of ceftriaxone with concomitant oral azithromycin.

The discrepancy between appropriate general practitioner prescribing practices for chlamydia and gonorrhea may be a reflection of decreased awareness among general practitioners of gonorrhea treatment guideline revisions "due to the relative infrequency of cases seen," the authors suggest.

"Our study emphasizes the importance of training and continuing professional development for non-specialists managing STIs, especially those which require complex management," the authors write.

"Treatment of infections with reduced susceptibility or resistance to the prescribed therapy may inadvertently facilitate onward transmission and risks infection complications."

General practitioners should be alert to changing national treatment guidelines, and ongoing monitoring of diagnoses and treatment of STIs outside genitourinary medicine services "is essential for estimating the burden of STIs in the population and to ensure treatments remain appropriate and effective," the authors conclude.

In terms of gonorrhea prescribing habits in the United States, the Centers for Disease Control and Prevention established the STD Surveillance Network in 2005 to improve the capacity of national, state, and local STD programs to detect, monitor, and rapidly respond to trends in STIs, according to Rajiv B. Gala, MD, a fellow with the American College of Obstetrics and Gynecology. "Twelve collaborating local and state health departments contributed data to the network during 2013. While the prescribing habits were not broken down by provider types, the antimicrobial agents given to patients for gonorrhea therapy appear to be highly compliant with the current recommendations," he said in an interview.

"The proportion of patients treated with ceftriaxone 250 mg increased from 84% in 2011 to 96.9% in 2013. Only 1.7% of patients were treated with azithromycin 2 g as monotherapy," explained Dr Gala. Dr Gala is on the faculty at Ochsner Medical Center Department of Obstetrics and Gynecology and is an associate professor of obstetrics-gynecology at the University of Queensland/Ochsner Clinical School in New Orleans, Louisiana. "Among those treated with ceftriaxone, 95.4% were also treated [with] azithromycin 1g, 4.0% were also treated with doxycycline, and only 0.5% did not receive a recommended second antimicrobial agent."

Considering the recent rise in ciprofloxacin-resistant gonorrhea — from 9.6% in 2009 to 16.1% in 2013, according to Dr Gala — inappropriate prescribing habits "will potentially contribute to a further rise in the prevalence of resistant strains of gonorrhea," he said.

Populations in which ciprofloxacin-resistant strains of gonorrhea are found should also be taken into consideration when planning provider education, Dr Gala recommended. "In 2013, 27.7% of isolates from men who have sex with men were ciprofloxacin resistant, whereas only 9.8% of isolates from men who have sex with women exhibited ciprofloxacin resistance."

The authors and Dr Gala have disclosed no relevant financial relationships.

BMJ Open. 2015;5:e007776. Full text

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