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Enough to Make You Cringe: Variation by Clinical Setting in Adherence to the Treatment Guidelines for Gonorrhea in California, 2009-2011

Monday, June 10, 2013: 4:22 PM
104 (Pasadena Convention Center)
Richard J. Lechtenberg , University of California, Berkeley, Berkeley, CA
Michael C. Samuel , California Department of Public Health, Richmond, CA
Kyle T. Bernstein , University of California, Berkeley, Berkeley, CA
Nicole Olson , University of California, San Francisco School of Medicine, San Francisco, CA
Carol Kong , University of California, San Francisco School of Medicine, San Francisco, CA
BACKGROUND:  Gonorrhea (GC) is the second most commonly reported communicable disease in both California and the United States. Untreated, it can cause pelvic inflammatory disease (PID), ectopic pregnancy, and infertility.  Over time, GC treatment guidelines have been updated repeatedly as the gonococcus has developed resistance to multiple antimicrobial agents. Currently, only a single class of antibiotics—the cephalosporins—reliably treats infection and the only recommended treatment regimen is ceftriaxone 250 mg and either azithromycin 1 g in a single oral dose ordoxycycline 100 mg BID for 7 days. The objective of this analysis was to identify how adherence to Centers for Disease Control and Prevention (CDC) GC treatment guidelines varies by clinical setting.

METHODS:  Surveillance data were analyzed from a geographically representative probability sample of 3,790 gonorrhea cases reported in California between 2009-2011. Weighted generalized linear models were fit to model cumulative incidence ratios (CIR) for receipt of a non-CDC-recommended treatment regimen (as a binary outcome) with clinical setting the primary “risk” factor of interest. Potential confounders adjusted for in the analysis were: geography (operationalized by eight clusters geographically contiguous of counties) and whether or not the case was a man who has sex with men (MSM).

RESULTS: Overall, 16.7% (15.0, 18.3) of cases received a non-recommended treatment. The settings in which cases were significantly more likely to receive a non-recommended treatment (compared to STD clinics) were: military/VA facilities (CIR: 3.6; 95% CI: 2.0-6.7; p<0.001), emergency rooms/urgent care centers (2.4; 1.6-3.8; p<0.001), private physicians/HMOs (1.9; 1.4-2.7; p <0.001), and family planning facilities (1.7; 1.1-2.4; p=0.008). Additionally, cases treated in San Francisco were more likely to receive a non-recommended treatment (5.39; 3.4- 8.2; p<0.001) and, statewide, MSM cases were less-so (0.63; 0.47- 0.84; p=0.002). Region-specific models suggest some geographic variation in the effect of setting. Ceftriaxone 250 mg alone and azithromycin 1 g alone were the most commonly administered non-recommended treatments.

CONCLUSIONS:  Barriers to adherence to the CDC treatment guidelines for GC appear to be greatest at military/VA facilities and emergency rooms/urgent care centers, and appear to also be experienced by private physicians/HMOs and family planning facilities. These patterns of risk may merit consideration in programming aimed at encouraging adherence to the treatment guidelines. Clarification of the importance of dual treatment with both ceftriaxone and azithromycin/doxycycline may help improve compliance.

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