Review finds disparity in presumptive chlamydia and gonorrhea treatment rates despite CDC guidelines

A Regenstrief Institute-led review of studies on proactive health services for chlamydia and gonorrhea has found that rates of presumptive treatment—antibiotics prior to laboratory test confirmation—varies widely.

The U.S. Centers for Disease Control and Prevention recommends presumptive treatment of individuals with symptoms of or known contact with these infections to decrease likelihood of secondary infections as well as poor outcomes.

The healthcare settings of all 18 of the studies reviewed were within the U.S. and patients were age 14 and older. Presumptive treatment rates were found to differ both geographically and within care settings such as emergency departments or clinics. The reviewers noted that race and ethnicity were inconsistently reported in the studies.

Chlamydia and gonorrhea are the two most common sexually transmitted infections in the U.S. While treatment decisions are dependent on individual clinician discretion, the CDC Sexually Transmitted Diseases Treatment Guidelines include recommendations for treatment of either of the two diseases before confirmation of infection.

"Test results for chlamydia and gonorrhea aren't available at the time of a medical visit, so patients can be lost to follow-up if not treated at the time of testing, increasing the potential for chlamydia and gonorrhea to be untreated and to spread," said review senior author Brian Dixon, Ph.D., MPA, the interim director of Regenstrief Institute's Center for Biomedical Informatics and director of public health informatics at Regenstrief and Indiana University Fairbanks School of Public Health. "In the U.S., we have very high rates of sexually transmitted diseases, and especially during the pandemic, increasing rates of sexually transmitted disease activity. This has a lot of negative consequences, especially for pregnant women and babies, so we should be presumptively treating."

Chlamydia and gonorrhea are the two most common notifiable sexually transmitted diseases in the U.S. Effective and timely treatment is critical to avoid potential future complications related to ongoing infection, including pelvic inflammatory disease and ectopic pregnancy in women, and infertility in both women and men. Both diseases are often asymptomatic in women.

"When we looked at the data from the studies, we saw rates of presumptive treatment for some areas that were very low, but for some that were very high. When averaged out, we saw roughly 42 percent. One emergency department was presumptively treating 84 percent while another ED was proactively treating at a much, much lower rate," said Katie Allen, B.S., a Regenstrief data scientist who is corresponding author of the study. "It's important to get into the nuances and figure out not only where variation is occurring, but also, why its occurring. Most of the 18 studies we reviewed focused on urban areas and also didn't consider social determinants of health, which might be impactful."

The review highlights the need to:

• Create communication vehicles to persuade individuals to seek clinical care for sexually transmitted diseases.
• Develop antibiotic stewardship strategies for clinical application.
• Encourage greater discussion of policy as well as clinical questions focused on populations and sub-populations.

Having surveyed presumptive care for chlamydia and gonorrhea landscape in this review, the Regenstrief researchers are currently analyzing data on presumptive treatment of chlamydia and gonorrhea from the Indiana Network for Patient Care, one of the nation's oldest and largest health information exchanges. This study will go beyond existing studies of presumptive care, which typically focus on one clinic or healthcare system, to examine care of chlamydia and gonorrhea by multiple health systems in metropolitan Indianapolis, one of the largest metro areas in the country.

The research is published in the journal Sexually Transmitted Diseases.