Recommended Gonorrhea Treatment Regimen Not Received by 20% of Patients in the US

As reports of drug-resistance in gonorrhea infections continue to rise and spread across the world, the US Centers for Disease Control and Prevention (CDC) reports that only 81% of patients infected with uncomplicated gonorrhea are receiving the recommended dual regimen designed to ward off resistance.

Caused by Neisseria gonorrhoeae, gonorrhea is the second most common notifiable disease in the United States. Although incidence of the sexually transmitted disease (STD) reached an all-time national low in 2009, since then, the number of cases has been increasing. According to the CDC, 468,514 cases were reported to state and local health departments in 2016, which was an 18.5% increase from the year before.

Because of the propensity of the bacteria to develop resistance to most antimicrobials used to treat it, the recommended treatment to fight uncomplicated gonorrhea includes 2 antimicrobials: 250mg of ceftriaxone intramuscular (IM) and 1g of azithromycin, oral.

In an attempt to determine if health care providers in the United States are, in fact, adhering to the recommended regimen, CDC investigators reviewed data gleaned from 7 jurisdictions in the United States that participate in the agency’s STD Surveillance Network (SSuN): Baltimore, Maryland; California, excluding San Francisco; Florida; Massachusetts; Multnomah County, Oregon; Minnesota; and Philadelphia, Pennsylvania. The results were stratified by patient characteristics and diagnosing facility type. According to the CDC’s report, “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.”

Surprisingly, only 81.3% (95% CI = 79.2—83.4) of reported patients with uncomplicated gonorrhea received the recommended regimen. Patients who visited family planning/reproductive health clinics for treatment were the most likely to receive the recommended regimen (94%), followed by those who visited an STD clinic (91%). Those patients who were diagnosed in other provider settings received the regimen 81% of the time.

No differences in treatment regimens were found in patients by age or race/ethnicity; however, the percentage of patients treated with the recommended regimen varied by jurisdiction (range = 76.7% to 92.0%). Furthermore, men who have sex with men 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).

Of the patients treated with other regimens, most were treated with only 1 antimicrobial. Approximately 3% of patients were treated with azithromycin only, which is not recommended because of resistance. A total of 1.2% of patients were treated with a tetracycline alone (doxycycline), which has not been part of the treatment regimen since the 1980s, according to the CDC, “because of established chromosomally and plasmid-mediated resistance in the United States.”

These are the first published estimates of adherence to the recommended treatment guidelines for gonorrhea since the CDC revised them in 2012 and 2015. Although 81% of patients received the recommended treatment, these data represent a snapshot of the entire United States, and do not include prescribing information for a majority of states. The CDC investigators conclude that “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.”