Population-Level Provider Compliance With Provincial Treatment Guidelines for the Management of Gonorrhea in Adolescents and Adults in Alberta, Canada; 2000 to 2019 : Sexually Transmitted Diseases

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Population-Level Provider Compliance With Provincial Treatment Guidelines for the Management of Gonorrhea in Adolescents and Adults in Alberta, Canada; 2000 to 2019

Ugarte-Torres, Alejandra MD, MPH; Diaz Pallares, Carolina MD; Niruban, John S. MBBS, MSc; Smyczek, Petra MD; Gratrix, Jennifer MSc; Strong, David MD, MPH, MSc§; Singh, Ameeta E. BMBS, MSc‡,¶

Author Information
Sexually Transmitted Diseases 50(1):p 11-20, January 2023. | DOI: 10.1097/OLQ.0000000000001721

Gonorrhea is the second most common notifiable infection in the Canadian province of Alberta.1 From 2000 to 2019, the incidence of cases of gonorrhea increased 7-fold.1 Gonorrhea is a major public health concern because of its possible complications and sequelae, the increased risk of transmission and acquisition of HIV, and the increasing antimicrobial resistance to drugs previously and currently recommended for its treatment.2 The control of gonorrhea has relied on measures of primary prevention, screening, and management with an effective, accessible, and inexpensive antimicrobial, partner notification, and active surveillance.3

Alberta's sexually transmitted infection (STI) treatment guidelines provide recommendations for screening, diagnosis, and treatment of STIs including gonococcal infection in adolescents and adults.4 These guidelines have been updated over time in response to the emergence of antimicrobial resistance and the availability of antimicrobials with activity against Neisseria gonorrhoeae. Since the introduction of the first provincial treatment guideline in 1995, there have been 5 new updates. The present study aimed to examine the provider compliance to provincial gonorrhea treatment guidelines in Alberta from 2000 to 2019 and to identify possible patient, infection, or health care provider characteristics associated with lower provider compliance to treatment guidelines.


Study Design

This is a retrospective population-based study of the provider compliance with Alberta treatment guidelines for the management of gonococcal infections from January 1, 2000, to December 31, 2019, in individuals 16 years and older. In Alberta, all positive gonorrhea results are reported to the provincial STI program according to the Public Health Act. Oral treatment is dispensed for free to patients at the time of the encounter and is recommended as observed therapy. In 2012, prepackaged oral antibiotics started to be distributed to clinics and hospitals to treat chlamydia and gonorrhea. When injectable drugs are required, these are administered during the clinic visit or hospital stay free of cost. Treating providers are required to submit a Notification of STI form with the treatment information. All cases not meeting treatment guidelines are referred to the provincial team of Partner Notification Nurses (PNNs) who follow up with the treating provider and patient to ensure retreatment according to guidelines or a test of cure. We obtained deidentified data from the Communicable Disease Reporting System for cases from 2000 to 2016 and the Communicable Disease and Outbreak Management system for 2017 to 2019. Both reporting systems compiled data from the Notification STI form, containing the same variables.

A unique case of gonorrhea was defined as an individual with one or multiple sites of gonococcal infection (genital and extragenital) identified on the same date. Infection with gonorrhea was defined as a positive nucleic acid amplification test result and positive N. gonorrhoeae culture from urogenital (vaginal, cervical, urine, urethra), rectal, or pharyngeal sites. Provider compliance with treatment guidelines was defined as the selection and administration of preferred or alternative antibiotics recommended by treatment guidelines, and the dose was the same or higher as the guideline recommendation. Provider noncompliance with treatment guidelines was defined as treatment with drugs not listed in the guideline, or the dose of the recommended or alternative drugs used was lower than the dose listed in the current guideline, as summarized in Table 1. During the study period, 5 different treatment guidelines were released (1998, 2003, 2008, 2012, and 2018). In these guidelines, the recommended treatment for gonorrhea has been a combination of 2 different drugs with different mechanisms of action to prevent the emergence of antimicrobial resistance. The second drug is also active for the management of chlamydial infections.

TABLE 1 - Summary of Alberta Treatment Guidelines for Gonorrhea, 2000 to 2019
Guideline Year Population
Anatomic Site
Anatomic Site
1998 Adolescents/adults*
Urethral, cervical, rectal, pharyngeal (all sites)
 Recommended Ciprofloxacin 500 mg po SD
Cefixime 400 mg po SD
Ceftriaxone 250 mg IM SD
Azithromycin 1 g po SD
Doxycycline 100 mg po bid × 7 d
Cefixime 400 mg po SD
Ceftriaxone 250 mg IM SD
Azithromycin 1 g po SD
Erythromycin 250 mg qid × 14 d
Erythromycin 500 mg qid × 7 d
 Alternative N/A
2003 Adolescents/adults*
Urogenital, rectal sites
Pharyngeal site
plus coverage against chlamydia
Ciprofloxacin 500 mg po SD*
Cefixime 400 mg po SD
Ciprofloxacin 500 mg po SD
Cefixime 400 mg po SD
Cefixime 400 mg po SD
plus coverage against chlamydia
Ceftriaxone 125 mg IM SD Ceftriaxone 250 mg IM SD Ceftriaxone 125 mg IM SD
Spectinomycin 2 g IM SD
2008 Adolescents/adults*
Urethral, cervical, rectal, pharyngeal (all sites)
 Recommended Cefixime 400 mg po SD
Ceftriaxone 125 mg IM SD
All patients should be also treated for CT: azithromycin 1 g po SD
Doxy 100 mg po bid × 7 d
Ciprofloxacin contraindicated
Co-Rx for CT: amoxicillin 500 mg tid po × 7 d
 Alternative Spectinomycin 2 g IM SD
2012 Adolescents/adults
Heterosexual, pregnant
Urethral, cervical, rectal
 Recommended Cefixime 800 mg po SD
Azithromycin 1 g po SD
Ceftriaxone 250 mg IM SD
Azithromycin 1 g po
 Alternative Spectinomycin 2 g IM SD
Azithromycin 1 g po SD
Azithromycin 2 g SD
Cefixime 800 mg po SD
Azithromycin 1 g po SD
2018 Adolescents/adults
Urethral, cervical, rectal
 Recommended Cefixime 800 mg po SD
Azithromycin 1 g po SD
Ceftriaxone 250 mg IM SD
Azithromycin 1 g po SD
 Alternative Ceftriaxone 250 mg IM SD
Azithromycin 1 g po SD
Azithromycin 2 g po SD
Gentamicin 240 mg IM SD
Azithromycin 2 g po SD
Gemifloxacin 320 mg po SD
Cefixime 800 mg po SD
Azithromycin 1 g po SD
Azithromycin 2 g po SD
Gentamicin 240 mg IM SD
Azithromycin 2 g po SD
Gemifloxacin 320 mg po SD
Gentamicin or gemifloxacin not recommended
*Only to be used if susceptibility testing is available.
Only for penicillin/cefixime allergy.
bid indicates twice a day; IM, intramuscularly; po, orally; qid, 4 times a day; tid, 3 times a day.

Data extracted from the Communicable Disease Reporting System and Communicable Disease and Outbreak Management included age, sex, partners' sex, race/ethnicity, pregnancy status, infection site(s), testing modality (molecular testing, culture), coinfection with chlamydia, date of diagnosis, gonococcal complications (epididymo-orchitis, pelvic inflammatory disease, disseminated disease), and geographic area where treatment was provided (metro center, metro influenced, urban, and moderate urban-influenced were grouped as urban areas; rural, rural center, and remote areas were grouped as rural areas), as defined by Alberta Health5; treating provider setting was categorized as STI clinic, community-based general practitioner, community-based specialist, hospital, acute care center, reproductive health clinic, and correctional facilities, based on the information of location (hospital vs. community) and credentials of treating provider entered in the reportable form. This study was approved by the Research Ethics Board of the University of Alberta (REB-Pro00026513).

Statistical Analysis

Provider compliance with treatment guidelines was coded using a stepwise procedure. First, cases were categorized based on the drugs used (guideline-recommended drugs vs. drugs not listed in guidelines), those cases treated with guideline-recommended drugs were further categorized based on the treatment dose (recommended dose and higher dose vs. lower dose), and finally, the cases treated with the drugs and dose according to guidelines were categorized based on the duration of treatment (recommended duration vs. shorter duration). We coded cases that were treated according to treatment guidelines (drugs, dose, and duration) versus those cases who did not (provider-noncompliant). Only cases with full information on treatment including drugs, dose, and duration of treatment were included in the analysis to ascertain compliance with treatment guidelines.

Patients, infections, and health care providers' characteristics were described using percentages for categorical data, and median and SD for continuous data. Time to treatment was calculated based on the difference in days from the date the sample was collected to the time of the administration of the treatment.

Effect measurement was reported with prevalence ratios (PRs). Prevalence difference (PD) of provider compliance was calculated for all the patient, infection, and provider characteristics. Complicated gonococcal infections were not included in the analysis because of a lack of specific recommendations for the management of these infections in the treatment guidelines where it is suggested to consult an infectious disease specialist. Statistical analysis was done on STATA version 14.2 (StataCorp, College Station, TX).


A total of 58,742 specimens of confirmed gonorrhea were identified during the study period. A total of 15,867 specimens were excluded: 13,500 because of duplication of samples of the same anatomical site collected simultaneously for culture and nucleic acid amplification test, 560 specimens corresponded to individuals younger than 16 years, and 1800 specimens had missing treatment information (drug, dose, and duration). We included 42,875 unique cases of gonorrhea in the study analysis (Fig. 1). The cases excluded had no significant differences in patient, provider, and infection characteristics compared with the cases included in the study (data not shown).

Figure 1:
Flow diagram of gonorrhea cases included in the study.

During the 20-year study period, an overall average of 80.3% of provider compliance with Alberta treatment guidelines was achieved. There was variability in the uptake of the guidelines throughout the studied years. The average uptakes for the guidelines released in 1998, 2003, 2008, 2012, and 2018 were 80.5% (range, 76.6%–83.5%), 78.2% (77.1%–83.4%), 67.8% (65.9%–68.5%), 82.7% (54.7%–89.7%), and 87.2% (85.9%–88.4%), respectively. Interestingly, the first quarter of 2012, after the introduction of the updated guideline, had the lowest compliance rate at 32%. In general, the average time to reach the previous average compliance to treatment guidelines after the introduction of an updated guideline was 1 year (Fig. 2). Throughout the study period, 964 cases labeled as provider-compliant with treatment guidelines were treated with a higher dose of antibiotic(s) than the recommended dose at the time of the guideline. Cefixime was given in higher doses in 515 cases, ceftriaxone in 32 cases, azithromycin (in combination with other recommended agent) in 406 cases, and ciprofloxacin in 11 cases.

Figure 2:
Percentage of compliance to Alberta treatment guidelines for the management of gonorrhea cases by quarters of the year from 2000 to 2019.

Patient Characteristics

A total of 24,979 patients were men (58.3%; Table 2). The mean ± SD age was 29 ± 9.8 years, and 95.6% of the cases were between the ages of 16 to 49 years. A majority of cases were diagnosed among individuals self-identifying as White (17,258 cases; 40.3%), followed by First Nations (12,085 cases; 28.2%) and Afro-Caribbean Black (2,481 cases; 5.8%).

TABLE 2 - Provider Compliance With Provincial Treatment Guidelines for Gonorrhea, Alberta, 2000 to 2019
compliant (n = 34,411)
Provider-noncompliant (n = 8464) Total (N = 42,875) Prevalence Ratio Prevalence Difference
(Per 100)
n % n % n % 0.8
Patient's characteristics
  Male 21,107 84.5 3872 15.5 24,979 58.3 1.2 9
  Female 13,517 75.5 4379 24.5 17,896 41.6
 Pregnant (yes)* 849 68.4 393 31.6 1242 6.9 0.89 −8
 Age group, y
  16–19 5122 77.3 1506 22.7 6628 15.5 0.90 −8
  20–29 16,294 80 4072 20 20,366 47.5 1 0
  30–39 8458 81.9 1876 18.2 10,334 24.1 1.02 2
  40–49 2966 81.7 665 18.3 3631 8.5 1.01 2
  50–59 1190 81.8 265 18.2 1455 3.4 1.01 2
  60–69 335 82.9 69 17.1 404 1 1.03 3
  70–79 41 82 9 18 50 0.1 1.03 3
  >80 5 71.4 2 28.6 7 0.02 0.89 −9
 Sexual behavior
  Heterosexual 14,001 80.3 3445 19.8 17,446 53.2 0.92 −7
  MSM 5105 87.5 729 12.5 5834 15.4 1.08 7
  Bisexual 395 90.4 42 9.6 437 1.2 1.09 8
  WSW 111 74 39 26 150 4.9 0.9 −8
  White 14,176 82.1 3082 17.9 17,258 40.3 1.03 3
  Afro-Caribbean Black 2090 84.2 391 15.8 2481 5.8 1.05 4
  Asian 1470 82.5 312 17.5 1782 4.2 1.03 3
  First Nations 9774 80.1 2311 19.9 12,085 28.2 1 0
  Metis 1608 80.9 378 19.1 1986 4.6 1 0
  Inuit 48 84.2 9 15.8 57 0.1 1.05 4
  Middle East 153 89.5 18 10.5 171 0.4 1.11 9
  Hispanic 179 88.2 24 11.8 203 0.5 1.1 8
  Unknown 5126 74.8 1726 25.2 6852 15.9 0.91 −7
Gonococcal infection characteristics
 Site of infection
  Cervical 5343 68.9 2409 31.1 7752 18.1 0.84 −13
  Vaginal 853 75.6 275 24.4 1128 2.6 0.95 −4
  Pharynx 3284 86.7 503 13.3 3787 9.9 1.08 7
  Rectum 2102 83.9 402 16.1 2504 5.9 1.05 4
  Urine 15,030 80.6 3616 19.4 18,646 45.4 1.01 1
  Urethra 7730 86.4 1212 13.6 8944 21.6 1.02 2
 Reason for visit
  Symptomatic 14,359 85.2 2492 14.8 16,851 49.3 1.09 9
  Contact 3449 87.0 515 12.9 3964 13.8 1.1 10
  STI screening 7177 85.4 1224 14.6 8401 29.7 1.1 10
  Sexual assault 223 90.6 23 9.4 245 1 1.17 17
  Therapeutic abortion 214 68.2 100 31.9 314 1.4 0.86 −11
 Presenting symptoms§
  Dysuria 8673 86.5 1353 13.9 10,026 23.4 1.04 4
  Rectal symptoms 658 84.1 125 15.9 783 1.8 1.01 1
 Physical examination
  Vaginal discharge 3429 75.4 1121 25.6 4550 57.1 0.91 −8
  Cervical discharge 961 73.9 339 26.1 1300 20.1 0.88 −14
  Friable cervix 424 76.5 130 23.5 554 9.0 0.92 −6
  Urethral discharge 8857 87.6 1256 12.4 10,113 46.9 1.1 6
 Chlamydia coinfection 3158 84.5 579 15.5 3737 8.7 1.05 5
Treatment provider's characteristics
 Geographic area
  Urban 27,856 80.7 6655 19.28 34,511 80.5 1 0
  Rural 6768 80.9 1596 19.1 8364 19.3
 Treating HCP setting**
  Community general 5388 84.4 993 15.6 6381 43.4 1.03 3
  Community specialist 136 83.4 27 16.6 163 1.2 1.03 3
  STI clinic 4026 91.7 367 8.4 4393 31.9 1.14 12
  Hospital/Acute care/ED 917 66.7 458 33.3 1375 10 0.75 −21
  Reproductive health clinic 596 86.1 96 13.9 692 5 1.02 1
  Correctional facility 643 94.7 36 5.3 679 4.9 1.11 10
 Same-day treatment 16,961 84.8 3030 15.2 19,991 46.8 1.09 8
 Treatment from time of diagnosis, mean ± SD, d 6.6 17.2 8.1 17.5 6.9 17.3
*Percentage of self-reported pregnancy status (out of the total women).
Information was available only in 23,868 cases.
Data only available in 34,197 cases.
§Data only available in 27,297 cases.
May include rectal pain, rectal discharge, and rectal bleeding. Data only available in 26,721 cases.
Geographic area where the patient was treated. Data available on 42,712 cases.
**Data were only available on 13,754 cases, including cases from 2000, 2010, 2011, and 2017 to 2019.
HCP indicates health care provider; WSW, women having sex with women.

Women self-reported being pregnant in 6.8% of cases. Men were more likely to be treated by providers with regimens recommended by the guidelines as compared with women (PR of 1.2, PD of 9), meaning that, among men, there were 9 excess cases of provider compliance per 100 compared with women. Only 31.6% of self-reported pregnant women received guideline-recommended treatment compared with 68.4% of nonpregnant women (PR 0.89, PD −8). In addition, providers showed lower uptake of compliance to guidelines among individuals of extremes of age, age group 16 to 19 years (77.3%; PR, 0.90; PD, −8) and older than 80 years (71.4%; PR, 0.89; PD, −9) compared with the overall provider-compliance rate of 80.3%. In contrast, treatment provided to men having sex with men (MSM; 87.5%; PR, 1.08; PD, 7) and bisexual men (90.4%; PR, 1.09; PD, 8) had the highest rates of provider compliance to treatment guidelines. Provider compliance with treatment guidelines was greater than 80% for all race/ethnicity groups except for individuals reported as “unknown” race/ethnicity (74.8%; PR, 0.91; PD, −7). Provider compliance to treatment guidelines rates was lower among women from all race/ethnicities compared with men except those from the Middle East (89.5% vs. 89.5%, respectively; PR, 1) as shown in Table 3.

TABLE 3 - Provider Compliance with Provincial Treatment Guidelines for Gonorrhea by Sex, Alberta, 2000 to 2019
Patient's Characteristics Provider Compliant (n = 34,411) Provider Noncompliant (n = 8464) Prevalence Ratio Prevalence Difference
Women % Men Women Men
N % N % N % N %
13,517 75.5 21,107 84.5 4379 24.5 3872 15.5 0.9 −9
Age group, y
 16–19 3355 75.9 1803 81.7 1067 24.1 403 18.3 0.92 −6
 20–29 6731 75.4 9680 84.7 2200 24.6 1753 15.3 0.89 −9
 30–39 2556 75.7 5951 85.5 819 24.3 1008 14.5 0.88 −10
 40–49 678 75.5 2297 84.1 220 24.5 436 15.9 0.89 −9
 50–59 166 73.8 1024 83.3 59 26.2 206 16.8 0.88 −8
 60–69 29 69.1 306 84.5 13 30.9 56 15.5 0.81 −15
 70–79 1 50 40 83.3 1 50 8 16.7 0.6 −33
 >80 0 0 5 0 0 2 28.6
Sexual behavior*
 Heterosexual 10,156 77.1 3845 89.9 3017 22.9 428 10 0.86 −13
 White 4365 75.5 9811 85.5 1417 24.5 1665 14.5 0.88 −10
 Afro-Caribbean Black 377 75 1713 86.6 126 25 265 13.4 0.86 −12
 Asian 314 74.7 1156 84.9 106 25.3 206 15.1 0.88 −10
 First Nations 5687 77.6 4087 85.9 1641 22.4 670 14.1 0.9 −8
 Metis 859 77.3 749 85.6 252 22.7 126 14.4 0.9 −8
 Inuit 28 77.8 20 95.2 8 22.2 1 4.8 0.82 −17
 Middle East 17 89.5 136 89.5 2 10.5 16 10.5 1 0
 Hispanic 21 84 158 88.8 4 16 20 11.2 0.95 −5
 Unknown 1823 69 3303 78.4 818 30.9 908 21.6 0.88 −9
Site of infection
 Throat 977 86.7 2324 87.4 150 13.3 336 12.4 0.99 −1
 Rectum 671 80.8 1441 86.1 159 19.2 233 13.9 0.93 −5.3
 Urine 5451 78.7 9628 82.2 1477 21.3 2089 17.8 0.96 −3
Reason for testing
 Symptomatic 3848 80.1 10,511 87 924 19.4 1568 13 0.92 −7
 Contact a case 1144 82.4 2308 89.6 244 17.6 268 10.4 0.92 −7
 Screening 1972 77.5 5222 89.2 573 22.5 634 10.8 0.88 −12
 Sexual assault 207 91.6 18 94.7 19 8.4 1 5.26 0.96 −3
Presenting symptoms
 Rectal symptoms 148 76.7 510 86.4 45 23.3 80 13.6 0.89 −9.7
Chlamydia coinfection 1553 84 1605 85.1 297 16.1 282 14.9 0.99 −1
Multisite infection 1402 85.1 1596 90.6 245 14.9 165 9.4 0.94 −6
Geographic area
 Urban 10,177 74.7 17,679 84.7 3450 25.3 3205 15.3 0.88 −10
 Rural 3314 78.2 3454 83.7 924 21.8 672 16.2 0.93 −6
Treating HCP setting§
 Community general 2500 83.9 2914 85.7 481 16.1 486 14.3 0.98 −2
 Community specialist 75 77.3 61 92.4 22 22.7 5 7.5 0.84 −15
 STI clinic 1096 90.8 2944 92.4 111 9.2 242 7.5 0.98 −2
 Hospital/Acute care/ED 380 60.8 589 78.5 245 39.2 161 21.5 0.77 −18
 Sexual and reproductive health clinic 398 89 224 91.4 49 11 21 8.5 0.97 −2
 Correctional facility 272 95.1 371 94.4 14 4.9 22 5.1 1.01 1
Same-day treatment 3862 76.4 13,099 87.7 1195 23.6 1835 12.3 0.87 −11
Treatment from time of diagnosis (IQR), d 9.7 0–10 4.5 0–5 9.9 0–10 6.3 0–7
*Data available only in 23,868 cases.
Data available only in 31,197 cases.
May include rectal pain, rectal discharge, and rectal bleeding.
§Data available only in 13,754 cases, including cases from 2000, 2010, 2011, and 2017 to 2019.
HCP indicates health care provider; IQR, interquartile range.

Infection Characteristics

Of 42,875 unique cases, a similar proportion of cases corresponding to urogenital sites were collected for women and men (88.6% vs. 82.3%, respectively; Table 2). Specimens from extragenital sites (throat and rectal) represented almost 16% of the total samples collected; they were more commonly collected in men (68%) than women (32%). Provider compliance with treatment guidelines was lower for women compared with men for infections at any anatomic site, except for the throat (86.7 vs. 87.4, respectively; PR, 0.99).

The majority of infections were symptomatic (49.3%), and they had higher rates of provider compliance with guideline recommendations compared with asymptomatic cases (85.2% vs. 77.8%; PR, 1.09; PD, 9). Women with abnormal vaginal discharge, cervical discharge, or friable cervix on physical examination had lower rates of provider compliance with treatment guidelines (75.4% [PR 0.9; PD, −8], 73.9% [PR 0.88; PD, −14], and 76.5% [PR, 0.92; PD, −6], respectively). Complications of N. gonorrhoeae including pelvic inflammatory disease (n = 545), epididymo-orchitis (n = 200), and disseminated gonorrhea (n = 9) were uncommon, representing 1.75% of the total cases.

Treatment Provider's Characteristics

Treating provider setting information was only available for 13,754 cases; Supplementary Table (https://links.lww.com/OLQ/A871) shows the characteristics of these cases, showing similar trends of rates of provider compliance with guidelines compared with the cases with treating setting data. Eighty-one percent of cases included in the analysis, were treated in urban areas. Overall, the rates of provider compliance with the treatment guidelines were similar among rural and urban areas (80.7% vs. 80.9%, respectively; PR, 1; Table 2).

Overall, provider compliance with treatment guidelines was higher in settings with STI nurse-led programs: STI clinics (91.7%; PR, 1.14; PD, 12) and correctional facilities (94.7%; PR, 1.11; PD, 10). In contrast, management of gonorrhea in hospitals, emergency departments (EDs), or urgent care centers was associated with lower rates of provider compliance (66.7%; PR, 0.75; PD, −21). Gonococcal infections among women were more likely to have lower rates of provider compliance to treatment guidelines throughout all treatment settings compared with men, especially in hospitals and urgent care centers (60.8%; PR, 0.77; PD, −18), and community specialists (77.3%; PR, 0.84; PD, −15), except in corrections facilities where the compliance was exceptionally high and similar to men (95.1% vs. 94.4%, respectively; PR, 1.01; PD, 1), as shown in Table 3.

Antimicrobial Use Patterns

From 2000 to 2006, the guideline-preferred antibiotic to treat gonorrhea was ciprofloxacin in combination with a second drug, followed by cefixime (range, 15%–22%) with <5% of ceftriaxone use. In 2008, cefixime was introduced as the preferred agent, it took 9 years to fully stop using ciprofloxacin. Since 2012, with the introduction of specific recommendations for the management of infections in MSM and pharyngeal infections, the usage of ceftriaxone increased from 5% to up to 35% in 2014. From 2012 to 2019, there has been a slow but steady increase in the use of azithromycin monotherapy from 3.5% to 6% (Fig. 3).

Figure 3:
Antimicrobial usage trend for the treatment of gonorrhea in Alberta from 2000 to 2019.


This retrospective population-based study found high rates of provider compliance with the treatment guidelines for the management of gonococcal infections of 80.3% among individuals 16 years and older over 20 years in Alberta, Canada. We surmise that this level of compliance was achieved owing to the role of the PNNs in the centralized STI program following up on all cases that did not meet treatment based on guidelines, allowing the PNN to inform providers on appropriate management and availability of prepackaged STI medications for the treatment of gonorrhea and chlamydia provided by the provincial health program.

The goal of treatment guidelines is to provide recommendations on treatment based on a review of evidence and the assessment of the benefits and harms of alternative care options, to optimize patient care and reduce medical errors.6,7 In the case of gonorrhea, it also provides evidence-based recommendations for the appropriate management of these infections based on local susceptibility data and the availability of antibiotics. Previous studies addressing compliance with treatment guidelines for gonorrhea are scarce. A similar population-based study conducted in England from 2001 to 2011 found that 40% of gonococcal infections received treatment according to guidelines.8 Similarly, a small study conducted in Estonia identified levels of compliance of 62% among 451 episodes.9 A large Canadian population-based study reported rates of compliance to treatment guidelines dropped below 30% within the first year of the release of new guidelines, and it took 2 years to reach 60% uptake.10

Our study found significant variation in the time to uptake of the new guideline after its introduction. On average, it took 1 year to reach the compliance rate observed before the release of the new guideline. Compliance was lowest (32%) after the introduction of the 2012 guideline, which incorporated multiple changes including specific recommendations for the treatment of pharyngeal infections and infections in MSM, increased doses of cefixime and ceftriaxone, and high-dose azithromycin as a single agent in case of allergy to cephalosporins. It is interesting that, despite the multiple changes in this guideline, compliance improved in less than a year to more than 82%, which exceeded the previous (54.7%) rate of compliance. This rapid uptake was due likely to several factors: there was wide dissemination of the guidelines via a letter to all health care providers in the province highlighting the change of preferred treatment, and all cases that were not treated according to guidelines were reviewed by a PNN who reached out to testing providers to ensure guideline-compliant treatment. In addition, in response to rising rates of gonorrhea, a provincial STI services nurse-led test and treat program was implemented in September 2014 creating more opportunities for case management.

Similar studies focused on compliance to treatment guidelines after the removal of ciprofloxacin, as the recommended treatment, have found that the time to adoption of changes has ranged from 2 to 5 years after the release of new treatment guidelines,9,11 but none of these studies reached an adherence level greater than 70% at the end of the study period. In a retrospective study in Belgium, Schweikardt et al.12 found that it took 5 years to reach 50% compliance with the new recommendations after the removal of ciprofloxacin.

We identified several characteristics associated with low provider compliance with guidelines based on patient sex, patient race/ethnicity, and treatment provider setting. First, provider compliance was lower when treating women with a PR of 0.89 compared with men; men had 9 excess cases of provider compliance per 100 compared with women. This lower level of provider compliance when treating women compared with men was present in all the characteristics analyzed. Other studies have reported similar findings; for example, Tisler-Sala and colleagues9 found that treatment of gonococcal infections among women, compared with men, was significantly less likely to be guideline adherent (30.1% vs. 73.9%, respectively). Some possible explanations for this finding could be that gonorrhea in women is less likely to be accurately diagnosed based on a syndromic approach (including clinical symptoms or physical examination) without a point-of-care test to distinguish gonorrhea from bacterial vaginosis, vaginal candidiasis, trichomoniasis, or other causes of cervicitis. Gaydos and colleagues13 found that 57% of women with gonorrhea diagnosed with a syndromic approach in an ED in the United States were not treated according to the Centers for Disease Control and Prevention (CDC) guidelines. Similarly, Kane et al.14 found that women were more likely to be treated with regimens noncompliant with CDC guidelines compared with men (38% vs. 42%).

Pregnant women also had a lower rate of provider-guideline compliant treatment of 68.4% compared with the overall uptake of 80.3%, likely secondary to concerns about adverse effects on mother and infant. In contrast, the addition of specific treatment recommendations for MSM in 2012 may have simplified the selection of antibiotics to treat gonorrhea in this group and thus increased the likelihood of adherence to the recommendations. Our findings are similar to other studies that highlight a sex disparity in the medical management of women relative to men. For example, women are less likely to receive guideline-based diagnosis and treatment for myocardial infarction,15,16 heart failure, and anticoagulation for atrial fibrillation.17–19 These findings collectively support the need for accurate diagnostic tools to decrease this sex disparity.

It is interesting that we found differences in provider compliance with the treatment guidelines among those classified as race/ethnicity unknown, but not among Afro-Caribbean Black or First Nations peoples. People with unknown race/ethnicity represented almost 16% of our study population, and they had a PD of provider compliance of 7 less cases per 100, compared with the rest of the race/ethnicities. Race/ethnicity data collection may not have been accurate; it is also possible that other factors, for example, language barrier, may have contributed to difficulties in ascertaining symptoms, in addition to possible implicit bias and even racism resulting in incorrect clinical diagnosis and treatment. There are no studies that have examined the role of ethnicity in the treatment of gonorrhea, but non-English language concordance is well recognized to be a barrier to quality of care and clinical outcomes.20

We found that gonococcal infections treated in hospitals, urgent care centers, or EDs had a PD of provider compliance of 21 less cases per 100 compared with any other treating provider setting. Adherence to guidelines in EDs has been explored in several studies. In a small retrospective study in a single ED in the United States, Kane et al.14 found even lower rates of adherence to treatment guidelines for the management of gonococcal infections of 40%. Other studies have shown that management and documentation of sexual histories are suboptimal for cases that present to ED.21,22 Merchant et al.,23 in a retrospective study of male adult patients attending the ED with a clinical diagnosis of gonorrhea urethritis, found that 87% received a CDC-recommended empiric treatment for gonorrhea, likely representing the study with the highest compliance to treatment guidelines. Settings with computerized decision support systems may facilitate the management of conditions based on guideline recommendations.24

An important finding from our study was that nurse-led programs were associated with the highest provider compliance with treatment guidelines. In the 3 STI clinics, initial assessment, testing, and treatment are provided by registered nurses using a standardized medical directive of STI best practice with support from an STI physician. In addition, the province has a team of PNNs who provide similar assessment, testing, and treatment in several provincial correctional facilities. This may have contributed to knowledge translation and standardized management of STIs.

Monitoring the trends in the selection of antibiotics for the treatment of gonococcal infections allows for the surveillance of appropriate usage of medications as a strategy to prevent the emergence of resistance. We found a slow increase in the use of azithromycin as monotherapy. By 2016, gonococcal resistance to azithromycin at a national level was reported to be 7%,25 above the World Health Organization threshold recommended of less than 5% resistance.26 Because azithromycin is one of the most common antibiotics prescribed in the community in Canada,27 monitoring of azithromycin resistance in gonorrhea is imperative. At present, ceftriaxone and cefixime resistance remain low (no isolates with ceftriaxone minimum inhibitory concentration ≥0.125 mg/L and 0.1% of isolates with cefixime minimum inhibitory concentration ≥0.25 mg/L) were found in Alberta in 2021, thus allowing continued use of both agents at currently recommended doses in our setting (unpublished data, Alberta STI services, June 20, 2022).

One of the main strengths of our study is that it is the largest population-based study reported to date examining provider compliance with provincial treatment guidelines for gonorrhea in a Canadian province for 20 years. Our study does have several limitations. First, given the retrospective nature of the study, there was a significant amount of missing data including health providers setting in 67.9% of cases, sexual behavior was not reported in 55.6% of cases, and there was no follow-up of data. Despite a large amount of lack of data about the treating provider, the rates of provider compliance with treatment guidelines were similar to the cases included in the analysis. Even more, the trend of lower provider compliance was similar to the cases included in the analysis, specifically when treating women, heterosexual individuals, women having sex with women, and individuals labeled as unknown race/ethnicity and vaginal or cervical infection sites. Thus, we believe that given these similar trends in provider-compliance rates, there was no bias in the analysis. Second, pregnancy status was self-reported. Likely pregnancy status and race/ethnicity may not have been collected appropriately possibly overemphasizing the racial disparities. Another limitation of this study is that we only assessed the antimicrobial treatment recommendations of the guidelines, and did not explore screening practices, counseling, and education about safe sex, abstinence recommendations after treatment, partner notification, and test of cure.

Compliance with treatment guidelines should be monitored on an ongoing basis as part of a broader strategy to control the ongoing rising rates of gonorrhea in our province. There are several innovative ways to facilitate the distribution and usage of treatment guidelines, and we anticipate that our findings will be used to plan the implementation of some of these strategies in our province. The incorporation of guideline-based management into electronic medical records for treatment pathways and decision support systems has been shown to increase adherence to treatment guidelines.28,29 In more recent years, the use of smartphone applications has facilitated access to treatment information and has been used by health care providers to support antimicrobial stewardship and reduce antimicrobial resistance30 and improve the accessibility to gonorrhea treatment guidelines in Alberta.

Our study found the highest rates of provider compliance (80%) with treatment guidelines for gonorrhea of any population-based study to date. We attribute this to a combination of public health initiatives in our province, of which the most important was nurse-led programs. However, we identified disparities in guideline provider compliance for women and in settings that were not nurse-led, highlighting areas that can be targeted for additional interventions to improve compliance.


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