Adherence to CDC Recommendations for the Treatment of Uncomplicated Gonorrhea — STD Surveillance Network, United States, 2016

Emily J. Weston, MPH; Kimberly Workowski, MD; Elizabeth Torrone, PhD; Hillard Weinstock, MD; Mark R. Stenger, MA

Disclosures

Morbidity and Mortality Weekly Report. 2018;67(16):473-476. 

In This Article

Abstract and Introduction

Introduction

Gonorrhea, the sexually transmitted disease (STD) caused by Neisseria gonorrhoeae, is the second most common notifiable disease in the United States after chlamydia; 468,514 cases were reported to state and local health departments in 2016, an increase of 18.5% from 2015.[1]N. gonorrhoeae has progressively developed resistance to most antimicrobials used to treat the infection.[2] As a result, CDC recommends two antimicrobials (250 mg of ceftriaxone [IM] plus 1 g of azithromycin [PO]) for treating uncomplicated gonorrhea to improve treatment efficacy and, potentially, to slow the emergence and spread of antimicrobial resistance. To monitor adherence to the current CDC-recommended regimen for uncomplicated gonorrhea, CDC reviewed enhanced data collected on a random sample of reported cases of gonorrhea in seven jurisdictions participating in the STD Surveillance Network (SSuN) and estimated the proportion of patients who received the CDC-recommended regimen for uncomplicated gonorrhea, by patient characteristics and diagnosing facility type. In 2016, the majority of reported patients with gonorrhea (81%) received the recommended regimen. There were no differences in the proportion of patients receiving the recommended regimen by age or race/ethnicity; however, patients diagnosed with gonorrhea in STD (91%) or family planning/reproductive health (94%) clinics were more likely to receive this regimen than were patients diagnosed in other provider settings (80%). These data document high provider adherence to CDC gonorrhea treatment recommendations in specialty STD clinics, indicating high quality of care provided in those settings. Local and state health departments should monitor adherence with recommendations in their jurisdictions and consider implementing interventions to improve provider and patient compliance with gonorrhea treatment recommendations where indicated.

SSuN is a CDC-supported, sentinel surveillance project comprised of 10 selected state and city health departments that conduct investigations to collect supplementary information on a random sample of gonorrhea cases reported from all health care providers/reporting sources in their jurisdictions (https://www.cdc.gov/std/ssun/default.htm). These investigations include contacting the diagnosing provider to verify treatment and conducting patient interviews to collect behavioral and demographic information. Case weights were developed to account for local sample fractions and adjust for nonresponse by patient sex and age group, allowing CDC to produce estimates representative of all reported gonorrhea cases in these jurisdictions.[3]

Analyses were restricted to seven of the 10 SSuN jurisdictions (Baltimore, Maryland; California, excluding San Francisco; Florida; Massachusetts; Multnomah County, Oregon; Minnesota; and Philadelphia, Pennsylvania) with documented treatment information (antimicrobials and dosages) for ≥90% of cases with complete investigations. Cases with missing patient treatment information (6.7%) were excluded from further analysis. Based on provider report of treatment provided, patients treated with the recommended dual therapy for uncomplicated gonorrhea (i.e., 250 mg dose of ceftriaxone [IM] plus 1 g dose of azithromycin [PO]) were classified as having received the recommended regimen. All other patients were classified as having received other regimens. Weighted estimates of the number and proportion of patients treated with the recommended regimen and corresponding 95% confidence intervals (CI) were calculated. Prevalence ratios (PRs) were estimated to identify differences in documented treatment by patient characteristics and diagnosing facility type. Gay, bisexual, and other men who have sex with men (MSM) were defined as any male patient reporting male sex partners in the previous 2–3 months or reporting their sexual orientation as gay or bisexual.

In 2016, a total of 91,719 gonorrhea cases were reported in the seven participating SSuN jurisdictions. Among these, 8,393 (9.2%) were randomly sampled; complete provider investigations were obtained for 3,213 cases for a response rate of 38%. Overall, 93.3% of these patients had a treatment documented and were included in the analysis.

Based on weighted analysis,* CDC estimated that 81.3% (95% CI = 79.2–83.4) of reported patients with gonorrhea in these SSuN jurisdictions were treated with the recommended dual therapy for uncomplicated gonorrhea (Table 1). The percentage of patients treated with this regimen varied by jurisdiction (range = 76.7% to 92.0%). There were no differences by patient age or race/ethnicity (Table 2). Although not statistically significant, women were somewhat less likely than men to receive the recommended regimen (79.3% versus 82.5%; PR = 0.96, 95% CI = 0.91–1.02). MSM were more likely to receive the recommended regimen compared with heterosexual men and women (84.8% versus 79.4%; PR = 1.07, 95% CI = 1.01–1.13). Patients diagnosed with gonorrhea in family planning/reproductive health clinics were more likely to receive the recommended regimen than were patients diagnosed in other provider settings (93.8% versus 79.5%; PR = 1.18, 95% CI = 1.13–1.23). Similarly, patients diagnosed in STD clinics were more likely to receive the recommended regimen than were patients diagnosed in other provider settings (90.8% versus 79.8%; PR = 1.14, 95% CI = 1.08–1.20). When stratified by sexual behavior, patients whose gonorrhea was diagnosed in STD and family planning/reproductive health clinics were more likely to be treated with the recommended regimen whether or not they were MSM.

Overall, 18.7% (95% CI = 16.6–20.8) of patients received other regimens (Table 1). The most frequent other regimens reported were ceftriaxone 250 mg only (5.9%), ceftriaxone any dosage and doxycycline (4.4%), and azithromycin only (3.1%). Fewer than 0.5% of patients were treated with a regimen suggesting treatment of a patient with a cephalosporin allergy (e.g., azithromycin plus either gentamicin or gemifloxacin) or a patient with a complicated gonococcal infection (e.g., azithromycin plus either cefotaxime or ceftizoxime).

*Case weights developed based on proportion sampled in each jurisdiction; nonresponse adjustments developed by gender and age group. All analyses were conducted using statistical software with linearized Taylor-Series 95% confidence intervals.

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