1 in 5 patients with gonorrhea gets wrong treatment

Gonorrhea is the second most common notifiable disease in the United States behind chlamydia, with over 468,000 cases reported in 2016. But unlike chlamydia, which is still reliably treated with antibiotics, gonorrhea has become increasingly drug resistant — potentially even untreatable in some cases — and new research shows that nearly one in five patients in the U.S. may not receive the recommended front-line treatment.

Experts have described Neisseria gonorrhoeae, the bacterium that causes gonorrhea, as “a very smart bug” with an “endless capacity to evolve resistance.” To keep pace, the CDC has revised its gonorrhea treatment guidelines twice in the last 6 years and now recommends a dual therapy of intramuscular ceftriaxone (250 mg) and oral azithromycin (1 g) for the best patient outcomes and to help prevent antimicrobial resistance.

To monitor adherence to the guidelines, Emily J. Weston, MPH, an epidemiologist in the CDC’s Division of STD Prevention, and colleagues analyzed data from 2016 at seven surveillance sites in the U.S. and estimated that 81% of patients with gonorrhea received the recommended first-line treatment, which they characterized as a “high” level of compliance with the recommendations.

According to Weston and colleagues, most patients treated with other regimens received only one antimicrobial, including 3% of all patients who received azithromycin monotherapy, which is not recommended because of concerns about emerging resistance and case reports of treatment failures, Weston and colleagues said. The most frequently prescribed inappropriate regimen for patients with gonorrhea in 2016 was ceftriaxone 250 mg alone, prescribed almost 6% of the time.

A three-dimensional computer-generated image of drug-resistant Neisseria gonorrhoeae diplococcal bacteria.
In 2016, 81% of patients with gonorrhea received the widely recommended first-line treatment.
Source: CDC

“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,” Weston and colleagues wrote in MMWR.

It was the first time that researchers published estimates of adherence to CDC guidelines for gonorrhea since they were updated in 2012 and 2015. The report was based on a random sampling of 9.2% of the 91,719 gonorrhea cases reported from the seven sites in the CDC’s STD Surveillance Network.

According to the sample, there were no differences in the proportion of patients receiving the recommended treatment by patient age or race/ethnicity. But patients treated at STD clinics (91%) — especially men who have sex with men — or family planning/reproductive clinics (94%) were more likely to be treated appropriately than in other provider settings (80%), “indicating high quality of care provided in those settings,” Weston and colleagues wrote.

“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,” they wrote. “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.” – by Gerard Gallagher

Reference:

Weston EJ, et al. MMWR Morb Mortal Wkly Rep. 2018;doi:10.15585/mmwr.mm6716a4.

Disclosures: The authors report no relevant financial disclosures.

Gonorrhea is the second most common notifiable disease in the United States behind chlamydia, with over 468,000 cases reported in 2016. But unlike chlamydia, which is still reliably treated with antibiotics, gonorrhea has become increasingly drug resistant — potentially even untreatable in some cases — and new research shows that nearly one in five patients in the U.S. may not receive the recommended front-line treatment.

Experts have described Neisseria gonorrhoeae, the bacterium that causes gonorrhea, as “a very smart bug” with an “endless capacity to evolve resistance.” To keep pace, the CDC has revised its gonorrhea treatment guidelines twice in the last 6 years and now recommends a dual therapy of intramuscular ceftriaxone (250 mg) and oral azithromycin (1 g) for the best patient outcomes and to help prevent antimicrobial resistance.

To monitor adherence to the guidelines, Emily J. Weston, MPH, an epidemiologist in the CDC’s Division of STD Prevention, and colleagues analyzed data from 2016 at seven surveillance sites in the U.S. and estimated that 81% of patients with gonorrhea received the recommended first-line treatment, which they characterized as a “high” level of compliance with the recommendations.

According to Weston and colleagues, most patients treated with other regimens received only one antimicrobial, including 3% of all patients who received azithromycin monotherapy, which is not recommended because of concerns about emerging resistance and case reports of treatment failures, Weston and colleagues said. The most frequently prescribed inappropriate regimen for patients with gonorrhea in 2016 was ceftriaxone 250 mg alone, prescribed almost 6% of the time.

A three-dimensional computer-generated image of drug-resistant Neisseria gonorrhoeae diplococcal bacteria.
In 2016, 81% of patients with gonorrhea received the widely recommended first-line treatment.
Source: CDC

“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,” Weston and colleagues wrote in MMWR.

It was the first time that researchers published estimates of adherence to CDC guidelines for gonorrhea since they were updated in 2012 and 2015. The report was based on a random sampling of 9.2% of the 91,719 gonorrhea cases reported from the seven sites in the CDC’s STD Surveillance Network.

According to the sample, there were no differences in the proportion of patients receiving the recommended treatment by patient age or race/ethnicity. But patients treated at STD clinics (91%) — especially men who have sex with men — or family planning/reproductive clinics (94%) were more likely to be treated appropriately than in other provider settings (80%), “indicating high quality of care provided in those settings,” Weston and colleagues wrote.

“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,” they wrote. “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.” – by Gerard Gallagher

Reference:

Weston EJ, et al. MMWR Morb Mortal Wkly Rep. 2018;doi:10.15585/mmwr.mm6716a4.

Disclosures: The authors report no relevant financial disclosures.