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


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

In This Article


CDC's gonorrhea treatment recommendations are periodically revised based on the best available evidence of emerging trends in antimicrobial susceptibility. Provider awareness of, and adherence to current treatment recommendations helps ensure that all patients are treated with the most effective therapy and might decrease the development of antimicrobial resistance. Monitoring treatment practices across all provider and diagnostic settings helps identify opportunities for interventions to increase provider adherence. The current analysis provides estimates of treatment practices among all providers diagnosing gonococcal infections in seven of 10 SSuN jurisdictions and are the first published estimates of adherence to CDC recommendations since gonorrhea treatment guidelines were revised in 2012 and in 2015.[2,4]

This analysis documents high levels of compliance with CDC treatment recommendations, with 81% of patients receiving recommended dual therapy for uncomplicated gonorrhea and substantiate high levels of compliance observed in previous analyses of gonorrhea cases reported in jurisdictions participating in SSuN during 2006–2008 and 2010–2012.[5,6] Optimally, all patients diagnosed with uncomplicated gonorrhea should be treated with the recommended regimen to ensure effective treatment and to help forestall the emergence of antimicrobial resistance. However, in practice, many factors might influence provider's adherence to the recommended regimen, including the availability of injectable medications at the time of treatment and patient-reported allergies. In the current analysis, patients diagnosed with gonorrhea in STD and family planning/reproductive health clinics were more likely to be treated with the recommended regimen than were patients diagnosed in other provider settings, similar to observations from earlier studies.[7,8] Across all provider settings, MSM were more likely to be treated with the recommended regimen, and MSM were more likely than non-MSM to receive a diagnosis in STD clinics. However, in stratified analyses by sexual behavior and diagnosing facility type, STD clinics were still more likely to treat with the recommended regimen than were other provider types. Implementation of guidelines in other provider settings might be influenced by a smaller volume of patients with gonorrhea seeking care and services, as providers diagnosing fewer cases might be less familiar with current recommendations.

The majority of patients treated with other regimens were treated with only one antimicrobial, including 3% of all patients treated with azithromycin only and 1.2% with doxycycline alone. Azithromycin monotherapy is not recommended for treatment of gonococcal infections because of concerns about emerging resistance and case reports of treatment failures.[1,2,9] In addition, tetracycline has not been recommended as treatment regimen for gonorrhea since the 1980s because of established chromosomally and plasmid-mediated resistance in the United States.[10] These findings reinforce the imperative for state and local jurisdictions to identify provider settings where patients are receiving inadequate treatment. Additional training and education on the importance of adherence to treatment recommendations might increase the proportion of patients adequately treated and further delay the emergence of antimicrobial-resistant gonorrhea.

The findings in this report are subject to at least four limitations. First, findings are based on enhanced investigations conducted for a random sample of gonorrhea cases in seven jurisdictions; SSuN is not designed to be nationally representative although these jurisdictions reported approximately 20% of all gonorrhea cases in the United States in 2016. Second, although case weights were calculated to account for differing sample fractions across SSuN jurisdictions and for nonresponse, it is possible that unmeasured bias exists. CDC is unable to adjust these data for nonresponse by provider type because the complete distribution by provider type in the underlying population of cases is unknown. If providers who were less likely to treat patients with a recommended therapy were also less likely to respond to investigators, this analysis might overestimate the proportion of patients treated with the recommended regimen. Third, a small number of patients might have had allergies or other clinical scenarios that would have been appropriately treated with an alternative regimen; however, allergies and complications are not documented during SSuN investigations. Consequently, findings might underestimate the proportion of appropriately treated patients with gonorrhea. Finally, treatment information was missing for 6.7% of sampled cases; it is plausible that these patients were treated with the recommended regimen, but investigators were unable to document treatment at the time of the investigation.

Despite the high level of treatment adherence documented in this analysis, improving provider adherence to treatment recommendations for antibiotic use across the full spectrum of health care settings is an integral part of a comprehensive approach to combating the emergence of antimicrobial-resistant gonorrhea. State and local health departments should continue to work with the providers and patients to assure timely detection and treatment of gonorrhea according to current CDC treatment recommendations.[2]