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Background: In August 2012, given concerns about decreasing susceptibility of gonorrhea to antibiotics, CDC changed its guidelines to recommend dual antibiotic therapy with intramuscular ceftriaxone plus either azithromycin or doxycycline for treatment of gonorrhea. We sought to identify the range of barriers to adhering to current gonorrhea treatment guidelines among California healthcare providers.
Methods: California Project Area (CPA, excludes San Francisco and Los Angeles) surveillance data were analyzed to identify gonorrhea cases with treatment and provider name between October 1, 2012 and March 31, 2013. Non-adherent providers were identified based on reporting ≥2 gonorrhea cases treated with oral cephalosporins or ≥1 case treated with an oral cephalosporin and ≥1 treated with IM ceftriaxone without dual therapy. We conducted a telephone survey to assess barriers to recommended treatment among these providers.
Results: Between October 2012 and March 2013, there were 10,625 gonorrhea cases reported in CPA; 5,220 cases (49.1%) had treatment and provider name available. Among these cases, 3,690 (70.7%) received CDC-recommended regimen, 108 (2.1%) received oral cephalosporins, 765 (14.7%) received ceftriaxone without dual therapy, 136 (2.6%) received azithromycin 2g, and 521 (10%) received other treatment. We identified 27 non-adherent providers and successfully surveyed 17 (63%). The most common barriers reported included concerns about allergic reaction, patient refusal, unaware of updated guidelines, presumptive treatment for chlamydia without repeat dosing for dual treatment, IM ceftriaxone not-in-stock, patient must obtain medication off-site, and reimbursement challenges.
Conclusions: Because of incompleteness of gonorrhea treatment data in the state surveillance system, overall estimates of treatment adherence should be interpreted with caution. However, the barriers to guideline-adherent treatment identified in this survey remain useful in considering potential interventions, such as provider education about treatment when patients are allergic or after presumptive treatment for chlamydia, enhanced communication regarding updated guidelines, and technical assistance with dispensing IM ceftriaxone onsite.