Presumptive and Follow-up Treatment for Gonorrhea and Chlamydia Among Patients Attending Public Health Department Clinics in Virginia, 2016

Partner treatment strategies for Chlamydia and Gonorrhea: Time for a reappraisal

OBJECTIVES

Epidemiological treatment for suspected Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections is recommended for exposed partners before laboratory confirmation, within 14 days of exposure to reduce symptoms, break transmission chains, and prevent loss of follow-up. This approach may lead to potential antibiotic overuse by uninfected individuals, thereby enhancing antimicrobial resistance. This study investigated the accuracy of epidemiological treatment for CT and NG.

PATIENTS AND METHODS

Retrospective cross-sectional analysis conducted on asymptomatic exposed partners presumptively treated for CT and/or NG in Lyon's Sexual Health Clinics between January and December 2023. The positive test rate results of exposed and treated patients were assessed, along with the frequency of potential antibiotic overuse (i.e., receiving at least one unnecessary antibiotic treatment). The association of potential antibiotic overuse with pre-exposure prophylaxis for HIV, age, gender, sexual orientation, and type of contact was also evaluated.

RESULTS

Among 141 patients who received epidemiological treatment, the concordance rate between the test and the reported exposure was 44.8 % for CT and 28.1 % for NG. The proportion of potential antibiotic overuse was 59.6 % (84/141). Potential antibiotic overuse was less common among patients exposed to CT than NG (p = 0.006). Self-identified women (compared with men) and heterosexual (compared with those with other sexual orientations) experienced lower rates of potential antibiotic overuse (p = 0.045 and 0.003, respectively).

CONCLUSION

Given the good follow-up at our clinics, waiting for the laboratory diagnosis before initiation of treatment appears reasonable and would avoid nearly 60% of unnecessary antibiotic treatments in CT and/or NG asymptomatic exposed partners.

Factors Associated With Delays in Presentation and Treatment of Gonorrhea, Massachusetts 2015-2019

BACKGROUND

Rates of gonorrhea are increasing across the United States. Understanding and addressing contributing factors associated with longer time to diagnosis and treatment may shorten the duration of infectiousness, which in turn may limit transmission.

METHODS

We used Massachusetts data from the US Centers for Disease Control and Prevention Sexually Transmitted Disease Surveillance Network collected between July 2015 and September 2019, along with routinely reported surveillance data, to assess time from gonorrhea symptom onset to presentation to care, and time from presentation to care to receipt of treatment. Factors associated with longer time to presentation (TTP) and time to treatment (TTT) were assessed using Cox proportional hazard models with a constant time variable.

RESULTS

Among symptomatic patients (n = 672), 31% did not receive medical care within 7 days of symptom onset. Longer TTP was associated with younger age, female gender, reporting cost as a barrier to care, and provider report of proctitis. Among patients with symptoms and/or known contact to gonorrhea (n = 827), 42% did not receive presumptive treatment. Longer TTT was associated with female gender, non-Hispanic other race/ethnicity, and clinics with less gonorrhea treatment experience. Among asymptomatic patients without known exposure to STI (n = 235), 26% did not receive treatment within 7 days. Longer TTT was associated with sexually transmitted disease clinic/family planning/reproductive health clinics and a test turnaround time of ≥3 days.

CONCLUSIONS

Delays in presentation to care and receipt of treatment for gonorrhea are common. Factors associated with longer TTP and TTT highlight multiple opportunities for reducing the infectious period of patients with gonorrhea.

Factors Associated With Chlamydia and Gonorrhea Treatment Completion Among Sexual Health Clinic Patients, Baltimore City, Maryland; 2018 to 2019

BACKGROUND

Prompt and appropriate treatment of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) is critical to prevent transmission and serious sequelae. The objectives were to determine the prevalence of CT/NG treatment completion and identify demographic, behavioral, and clinical factors associated with treatment completion at sexual health clinics in Baltimore City, Maryland.

METHODS

Electronic health record data from patients diagnosed with CT/NG during 2018-2019 were analyzed. Treatment completion was defined as documentation of Centers for Disease Control and Prevention-recommended treatment ≤30 days after testing. Regression was used to assess differences in treatment completion across groups; analyses were stratified by birth sex.

RESULTS

Most of the 2426 male (86%) and 754 (72%) female patients diagnosed with CT/NG completed treatment in ≤30 days; 74% of male and 36% of female patients were treated same-day. Among 890 male patients not treated same-day, treatment completion was associated with other same-day antimicrobial treatments (adjusted prevalence ratio, 0.76 [95% confidence interval, 0.61-0.94]), longer test processing times (≥10 days; 0.78 [0.65-0.95]) infection at multiple anatomic sites (1.49 [1.25-1.76]), and patients with previous clinic visits (1.16 [1.03-1.31]). Among 483 female patients not treated same-day, treatment completion was associated with diagnosis year (2019 vs. 2018; 1.23 [1.05-1.43]) and residential addresses 2 to 5 miles (vs. <2 miles) from clinic (1.25 [1.02-1.53]). Demographic and behavioral characteristics were not associated with treatment completion.

CONCLUSIONS

Substantial proportions of male and female sexual health clinic patients did not complete treatment. Our findings underscore the need for implementation of highly sensitive and specific point-of-care (POC) CT/NG testing to improve treatment completion in this setting.

Findings From a Scoping Review: Presumptive Treatment for Chlamydiatrachomatis and Neisseria gonorrhoeae in the United States, 2006-2021

ABSTRACT

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the 2 most common reported sexually transmitted infections in the United States. Current recommendations are to presumptively treat CT and/or GC in persons with symptoms or known contact. This review characterizes the literature around studies with presumptive treatment, including identifying rates of presumptive treatment and overtreatment and undertreatment rates. Of the 18 articles that met our inclusion criteria, 6 pertained to outpatient settings. In the outpatient setting, presumptive treatment rates, for both asymptomatic and symptomic patients, varied from 12% to 100%, and the percent positive of those presumptively treated ranged from 25% to 46%. Three studies also reported data on positive results in patients not presumptively treated, which ranged from 2% to 9%. Two studies reported median follow-up time for untreated, which was roughly 9 days. The remaining 12 articles pertained to the emergency setting where presumptive treatment rates, for both asymptomatic and symptomic patients, varied from 16% to 91%, the percent positive following presumptive treatment ranged from 14% to 59%. Positive results without presumptive treatment ranged from 4% to 52%. Two studies reported the percent positive without any treatment (6% and 32%, respectively) and one reported follow-up time for untreated infections (median, 4.8 days). Rates of presumptive treatment, as well as rates of overtreatment or undertreatment vary widely across studies and within care settings. Given the large variability in presumptive treatment, the focus on urban settings, and minimal focus on social determinants of health, additional studies are needed to guide treatment practices for CT and GC in outpatient and emergency settings.

Presumptive and Follow-Up Treatment Associated With Gonorrhea and Chlamydia Testing Episodes in Sexually Transmitted Disease Clinics: Impact of Changing Treatment Guidelines for Gonorrhea, Sexually Transmitted Disease Surveillance Network, 2015-2018

Background:

CDC recommendation for treatment of uncomplicated gonorrhea (NG) were revised in December 2020 and include ceftriaxone monotherapy when chlamydial infection was excluded. We evaluated the impact of these revised treatment recommendations using data from a network of STD clinics prior to the change in guidelines.

Methods:

We performed a cross-sectional analysis from 8 STD clinics participating in the STD Surveillance Network from Jan 2015-June 2018 assessing gonorrhea/chlamydia (CT) testing episodes, NAAT results, CT only and NG/CT treatment records, and timing of treatment. We describe the frequency of NG and CT treatment practices and what proportion of patients treated would not have had to receive an anti-chlamydial agent.

Results:

Of 190,589 episodes that occurred during the study period, 67,895 (35.6%) episodes were associated with a treatment record consistent with gonorrhea and/or chlamydia (CT only (n=37,530) or NG/CT (n=30,365)), most (~86%) were prescribed on the same-day as initial testing. Of the 67,895 episodes with corresponding treatment record(s), 42.1% were positive for either NG or CT compared to 3.7% were positive for NG or CT for those not associated with treatment records (n=122,694 episodes). Among 30,365 episodes associated with NG/CT treatment records, monotherapy would only have been indicated for 10.1% (3,081/30,365) of the episodes as they were treated on follow-up and were NG positive and CT negative.

Conclusions:

Treatment was prescribed in one third of NG/CT testing episodes, with the majority provided same day. Despite changes in NG treatment guidelines to ceftriaxone monotherapy, majority of patients would continue to receive an anti-chlamydia agent when treated for gonorrhea in these settings.

Provision of same-day treatment is common in STD clinic patients being treated for gonorrhea and chlamydia, likely resulting in patients continuing to get dual therapy despite recent treatment guideline changes.

Adolescents Accessing School-Based versus Family Planning Clinics: Chlamydia and Gonorrhea Testing and Treatment Outcomes

Simple Summary

Sexually Transmitted Infections, such as gonorrhea and chlamydia, are common in school-aged youths. These infections can cause significant health problems if not identified and treated early. Current estimates of how widespread these infections are among students receiving healthcare in schools, the role school-based clinics may have in gonorrhea and chlamydia testing and treatment, and information on how the COVID-19 pandemic affected testing and treatment, are lacking. This study was conducted in an urban metropolitan area in the United States, and included 2439 patients aged 13–17 years over a 2-year period. The patients were seen at four school-based and five family planning clinics. We found that 35% of those tested in school-based clinics were positive for chlamydia, and 10% were positive for gonorrhea. The rates of these infections were higher than previous reports from school settings (both pre-COVID-19 and the during COVID-19 pandemic). School-based clinics were able to treat patients with gonorrhea and chlamydia much faster (average ~6 days) than the family planning clinics (average ~18 days). This study shows us the critical role that school-based clinics play in the testing and treatment for gonorrhea and chlamydia infections, and the value of strengthening the services these clinics provide.

Abstract

The prevalence and treatment of chlamydia (CT) and gonorrhea (GC) at school-based clinics (SBCs) requires revisiting. To assess whether clinic type influences CT/GC testing and treatment for minors (individuals 13–17 years of age), our study compared four SBCs with five family planning clinics (FPCs) in the Houston, Harris County metropolitan area of Texas, USA for: (1) the prevalence of CT/GC infection (pre-COVID-19 and during COVID-19); (2) treatment rates at the last positive diagnosis; and (3) the time, in days, from testing-to-diagnosis and testing-to-treatment. Between January 2019 and December 2020, 2439 unique patients (1579 at SBCs, 860 at FPCs) were seen. Of the 1924 tests obtained, 39.2% and 15.9% were positive for CT and GC, respectively. The prevalence of CT and GC at SBCs was similar prior to COVID-19 vs. during the COVID-19 pandemic. SBCs were able to provide treatment significantly faster after diagnosis (mean, 6.07 days; 95% CI, 3.22–8.90; 94.7% were within 30 days) than FPCs (mean, 17.60 days; 95% CI, 10.15–25.12; 84.7% were within 30 days) (p = 0.0257). This comparison within our large clinic system, with consistent clinical management protocols, suggests that SBC care may be critical to ensuring optimal sexually transmitted infection management in minors.

How accurate is presumptive Chlamydia trachomatis treatment? A 6-month clinical audit of a walk-in sexual health service

Background Chlamydia trachomatis (chlamydia) is highly prevalent and is an important sexually transmitted infection as it can lead to increased risk of HIV seroconversion; and if left untreated, can cause infertility in women. Clinical guidelines recommend treating chlamydia presumptively when presenting symptomatically; however, clinicians are now questioning this due to increasing prevalence of antimicrobial resistance. Methods To determine the accuracy of presumptive chlamydia treatment practices at a walk-in sexual health service in regional Australia, we audited all same-day screen and treat presentations prescribed azithromycin over a 6-month period in 2018. Results A total of 325 cases were included in the analysis. Over half (54%) the presentations returned negative pathology for all pathogens investigated. One quarter (25%) of presentations were positive for chlamydia, and (4%) reported a dual infection. A further one fifth (20%) were negative for chlamydia but positive for another pathogen. More symptomatic males than females returned positive pathology for chlamydia (8% vs 4%). Conclusions While presumptive treatment is recommended in the current guidelines, our findings indicate this resulted in over-treatment. Considering the increasing resistance patterns for Mycoplasma genitalium, which include azithromycin, presumptive treatments need to balance immediate client care needs against long-term community antimicrobial resistance outcomes. This internal audit provided a feedback mechanism to the walk-in sexual service, enabling modification of practices to provide more precise, individual clinical care within the bounds of current STI guidelines, while balancing wider the objectives of antimicrobial stewardship.