A study yesterday in the Annals of Family Medicine indicates that many patients with chlamydia and gonorrhea infections aren't receiving guideline-adherent treatment in primary care settings.
The study, conducted by researchers at Stanford University and the Centers for Disease Control and Prevention (CDC) in a large convenience sample representing the US primary care population, found that roughly 30% of chlamydia and gonorrhea patients did not receive any treatment for their infections. Among those treated, only 14.0% of chlamydia and 38.7% of gonorrhea patients received the CDC-recommended first-line antibiotic.
The study also found that treatment rates and receipt of timely treatment varied by patient race and ethnicity, gender, and age.
The authors of the study say the relatively large population of untreated chlamydia and gonorrhea infections is problematic because they could result in severe long-term health consequences for patients and contribute to ongoing transmission of the sexually transmitted infections (STIs).
Higher treatment rates for women, White patients
For the study, the researchers examined data on chlamydia and gonorrhea treatment from the PRIME registry, which captures clinical data from 2,000 primary care clinicians across the United States.
Their primary aim was to quantify the treatment rate and assess adherence to treatment guidelines for these two STIs. The co-primary outcomes were the time to first treatment and the antibiotic administered in the 30-day follow-up period. They also wanted to examine the potential impact of social determinants of health on treatment selection.
The authors note that the incidence of chlamydia and gonorrhea, which are two of the most common STIs, has risen dramatically in the United States over the past two decades. According to CDC data, the annual incidence of chlamydia rose 22% and gonorrhea rose 98% from 2009 to 2022.
"Because of the high prevalence of these and other STIs in the United States, considerable public health resources are committed to STI-related care," they wrote.
At the same time, STI screening, diagnosis, and treatment has been increasingly performed in primary care settings. But research on what STI treatment looks like in primary care settings, rather than sexual health clinics, has been limited.
From 2018 through 2022, the researchers identified 6,678 cases of chlamydia and 2,206 cases of gonorrhea confirmed by a positive test. Of these cases, 5,028 (75.3%) chlamydia episodes and 1,535 (69.6%) gonorrhea episodes were treated within 30 days of the positive test result.
Women had substantially higher treatment rates than men for both infections (chlamydia, 78.4% vs 67.2%; gonorrhea, 78.9% vs 51.4%), non-Hispanic White patients had the highest treatment rates of all racial/ethnic groups (76.8% for chlamydia and 73.5% for gonorrhea), and suburban residents had the highest treatments rates for both infections overall (77.5% and 83.5%, respectively).
For all treated chlamydia infections, 14.0% of patients received doxycycline—the CDC's recommended treatment—alone or with another antibiotic. Most chlamydia patients (83.9%) received azithromycin. For all treated gonorrhea infections, only 38.7% received CDC-recommended ceftriaxone alone or in combination with another antibiotic.
The study authors say the observed preference for antibiotics that don't adhere to treatment guidelines could be driven by several clinical considerations. For example, a single dose of azithromycin for chlamydia infections may be preferred over a 7-day course of doxycycline because of concerns about patient adherence. For gonorrhea, azithromycin may have been chosen because it can be taken orally, whereas ceftriaxone is injected.
"Our findings, together with findings of higher rates of use of recommended regimens in sexually transmitted disease clinics reported in other studies, suggest that additional education and training may be needed for primary care clinicians to improve adherence," they wrote.
Time to treatment varies by race, age, gender
When the researchers examined time to treatment, they found that it took a median of 3 days from the test result for treatment to be initiated.
Non-Hispanic Black patients and those with other, unknown, or missing race/ethnicity had longer time to treatment for chlamydia than non-Hispanic White patients, with adjusted time ratios (aTRs) of 1.17 (95% confidence interval [CI], 1.04 to 1.33) and 1.36 (95% CI, 1.20 to 1.55), respectively. Time to treatment was longer for patients aged 50 to 59 years (aTR, 1.61; 95% CI, 1.12 to 2.30) compared with those aged 20 to 29 years, and shorter for women than for men (aTR, 0.62; 95% CI, 0.55 to 0.70).
For gonorrhea infections, urban residents had longer time to treatment than suburban residents (aTR, 1.25; 95% CI, 1.02 to 1.53) and women had shorter time to treatment than men (aTR, 0.38; 95% CI, 0.29 to 0.48).
The authors say that while the findings point to the need for rapid diagnostic tests to reduce turnaround time, further research is needed to understand and address non-adherence to treatment guidelines and the barriers to timely treatment for certain groups.
"Given the importance of timely treatment for these STIs to curb the spread of infection, there remains substantial opportunity to improve treatment rates across all patient groups, with particular attention directed to those in vulnerable populations," the authors concluded. "Additional incentives may be needed to promote adherence to clinical practice guidelines and thereby ensure timely treatment and selection of the appropriate antibiotic regimen."
