Effective treatment is a cornerstone of US gonorrhea control efforts, but success has been complicated by the ability of Neisseria gonorrhoeae (GC) to develop antimicrobial resistance. The organism has developed resistance to nearly every antibiotic used as first-line therapy, including sulfonamides, penicillin, tetracycline, and fluoroquinolones.1,2 The US Centers for Disease Control and Prevention (CDC) periodically updates treatment recommendations based on best available data from the Gonococcal Isolate Surveillance Project, sentinel surveillance of antimicrobial susceptibility, and other mechanisms.3,4 In August 2012, increasing resistance to cephalosporins prompted the CDC to no longer recommend cefixime and to recommend dual therapy with ceftriaxone plus either azithromycin or doxycycline, as first-line therapy for gonorrhea.5
Local health departments can help to ensure adherence to best practices through dissemination of information coupled with surveillance and feedback to providers. As part of the Philadelphia Department of Public Health’s (PDPH) response to increasing local gonorrhea rates and concern with developing resistance, surveillance of treatment adequacy was instituted for all reported GC cases in Philadelphia. The purpose of this evaluation was to assess provider compliance to recently modified GC treatment recommendations and to identify gaps in provider performance.
The PDPH issued a Health Alert to the local health care community on June 18, 2012,6,7 which stressed the preferred treatment for GC as 250 mg of injectable ceftriaxone plus either 1 g of azithromycin or 7 days of doxycycline orally. The alert also informed providers that they would be contacted by PDPH for treatment verification information regarding their GC cases. On July 2, 2012, PDPH STD Control Program began active treatment surveillance for all GC cases reported to the program through electronic laboratory, paper-based, and telephone reporting. For every case without documented treatment within PDPH’s data system, surveillance staff requested the clinician of record provide the following information to PDPH STD Control via secure fax: (1) if treatment was ordered (yes/no), (2) medication name and dosage, and (3) date(s) of treatment. No information was collected from the provider on whether the treatment was directly administered or whether a prescription was written. If no response was received within 2 weeks of initial request, staff called the facility to obtain treatment information. If no treatment was given or treatment could not be verified by the diagnosing facility, disease intervention specialists were assigned to follow up with the patient to ensure that appropriate treatment was given. On August 20, 2013, a second alert was issued reiterating the preferred treatment for GC in conjunction with the formal CDC guideline changes.7
Treatments were documented in the local sexually transmitted disease (STD) surveillance data management system, including date of treatment, medications prescribed, and dosage given. In addition, medical staff reviewed the treatment records and, in the event a case received a fluoroquinolone, the responsible provider was educated on the most current STD treatment guidelines.
From July through December 2012, 3551 GC cases were reported to PDPH. Of these, treatment was documented for 3279 (92%). Of 272 cases where treatment was never documented, the most common reason for lack of treatment was insufficient locating information (n = 133), followed by refusal to come for treatment (n = 33). Of the remaining 106 cases without treatment documented, 21 cases were reported to PDPH with non-Philadelphia addresses. Also, 69 cases during this time period were not reported in a timely manner and were closed without treatment being confirmed. Finally, 16 cases had a documented negative GC test result after the positive case report with no treatment reported. Of the 3279 treated patients, 2845 (87%) were given recommended treatment. One hundred fifty-six GC cases (5%) received an alternative treatment of either dual therapy with cefixime 400 mg plus either 1g azithromycin or doxycycline 7 days twice daily or 2 g azithromycin. Two hundred-fifty GC cases (8%) received cephalosporin-based therapy (ie, ceftriaxone/cefixime only) that did not meet treatment guidelines, and 28 (1%) received fluoroquinolone-based therapy that did not meet treatment guidelines (Table 1). Of the 28 treated with a fluoroquinolone, 18 (64%) were treated by providers who diagnosed no more than 2 cases of GC within the prior 6-month period. If a private provider/clinic diagnosed 3 or more cases within the previous 6 months, they were more likely to use the first-line recommended therapy (79% [385/490]) compared with private providers/clinics who diagnosed 2 or less GC cases (53% [79/148]; Table 1). Use of cefixime was reported most often in facilities where use of injectable medications is problematic, such as high schools and juvenile detention facilities (50% among high schools/juvenile detention vs. 5% overall).
Among those treated, 1437 (44%) were treated the same date the specimen was collected. Among those not treated on the same day, a median of 8 days (mean, 14 days; range, 1–168 days) lapsed between specimen collection and treatment. Disease Intervention Specialist follow-up was needed for 19% (n = 608) of the reported GC cases, with most of these coming from prison/juvenile detention facilities where the person was released before the return of the test result (n = 73), from STD clinics (n = 39), and from nonmedical providers who test with the agreement that PDPH ensures treatment follow-up (n = 64).
Overall, new CDC treatment guidelines for GC have been widely adopted in Philadelphia. We evaluated compliance with the new treatment recommendation soon after the updated guidelines were issued. Providers seemed to adopt the GC treatment modifications quickly, and compliance with guidelines was stable by month throughout the study period. In a prior study after CDC treatment guideline changes for fluoroquinolone use for GC, uptake in cephalosporin use was delayed among cases diagnosed in primary and emergency/urgent care settings.8 Concise communications from PDPH as Health Alerts, in addition to CDC-issued communications, may be responsible for earlier adoption of the new treatment guideline. Three main gaps were identified. First, providers who diagnosed few cases of gonorrhea were less likely to have implemented current treatment recommendations (Table 1). It is unknown whether this represents resistance to change or lack of knowledge. This evaluation did not confirm whether all providers received or read the Health Alert information about GC treatment. Second, direct communication with some providers indicated that the use of injectable medications remains problematic in some settings, including programs conducted by the Health Department (eg, school-based STD screening and treatment). In these cases, the risks and benefits of delaying treatment to send the patient to a location where they could receive injectable therapy versus directly administering an alternate (oral) therapy must be weighed carefully. Finally, only 44% of patients received adequate treatment at the time of specimen collection, with a median delay of 8 days before treatment of the remaining 56%. Although we hypothesize that some GC cases were diagnosed from screening tests performed on asymptomatic individuals for whom same-day treatment would not have been expected, an 8-day median treatment delay, with a range up to 168 days, is not acceptable and should be improved.
There are 2 limitations of note for this study. First, results found in Philadelphia may not be generalizable to other jurisdictions. Based on our own observations, providers with less familiarity treating patients with GC were less likely to adopt the new guidelines. Thus, cities and regions with low GC morbidity might have providers who are slow adopters. Second, PDPH does not have any data to support why provider uptake of new treatment guidelines was so high. We hypothesize that timely and repeated communications through the Health Alert Network contributed.
In conclusion, 87% of cases received first-line recommended therapy for GC, 5% received an acceptable alternate regimen, and 8% received a regimen not currently in the treatment guidelines. Health Departments should conduct enhanced outreach to providers who are unlikely to diagnose GC frequently so that they can be made aware of updates and changes to treatment guidelines. Providers should make efforts to reduce delays in treatment for persons testing positive for GC.
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