Staff,associate specialist and specialty doctors’ national audit on the management of gonorrhoea in the United Kingdom,2015

Introduction

The British Association for Sexual Health and HIV (BASHH) national guideline for the management of gonorrhoea in adults was revised in 2011. Changes since the previous guideline included the use of nucleic acid amplification tests (NAATs) for anogenital and pharyngeal specimens, with the requirement of supplementary testing of reactive tests from low prevalence populations and for rectal and pharyngeal specimens; an update to the recommended first-line treatment to ceftriaxone 500 mg IM and oral azithromycin 1g; a requirement for a test of cure (TOC); the provision of written information and a link for reporting cephalosporin treatment failures. ¹ Five auditable outcome measures were suggested.

In 2012 guidance was issued by the BASHH Clinical Effectiveness Group on Gonorrhoea Testing with regard to supplementary testing, culture and antimicrobial susceptibility testing, and TOC within two weeks. ²

Objective

The aim was to audit national management of gonorrhoea against the standards recommended.

Method

The project was designed by a working group of the BASHH SAS Committee. Staff, associate specialist and specialty (SAS) doctors are doctors working in non-training roles where the doctor has at least four years of postgraduate training, two of those being in the relevant specialty.

It was a retrospective case analysis. An invitation to take part was issued to all those on the BASHH SAS database. A local co-ordinator was designated for each site. Cases seen between August 2014 and July 2015 were eligible for inclusion. A minimum of 40 cases was suggested, but participation was allowed with smaller numbers. Information was submitted electronically. Results for individual clinics were sent to the local co-ordinator for dissemination.

Results

Data for 3233 patients were submitted by 168 doctors from 78 centres: 68% of cases were male, 44% were men who have sex with men, 80% were of white ethnicity. Fifty-eight per cent of men and 41% of women had symptoms. Of the total, 21% were contacts and 86% of infections were thought to have been contracted in the United Kingdom. Pelvic infection and epididymo-orchitis were reported in 7.8 and 0.8% of cases, respectively. Auditable outcome figures are listed in Table 1.

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Table 1.

Auditable outcome measures – results.

Outcome	Recommended (%)	Result (%)
Received first-line treatment or reasons for not giving first-line treatment documented	100	94.2
Screened for or received presumptive treatment for Chlamydia trachomatis	100	97
NAAT for gonorrhoea from the pharynx/rectum should be confirmed by supplementary testing
- Pharynx	100	60.9
- Rectum	100	59.8
Those with a positive gonorrhoea NAAT who also had culture attempted	100	85.8
Culture successful and antimicrobial susceptibility testing done	100	53.9
Offered written information about STIs and their prevention	100	41.3
Test of cure documented	100	60.7
Within two weeks		24.7
Partner notification carried out according to the published standards of the BASHH Clinical Standards Unit	100	91.7

While 82.8% of patients received at least the recommended regimen, 57 (1.8%) received ceftriaxone 1g rather than 500 mg, generally explained as ‘clinic policy’.

Fewer than 2% of patients remained untreated, mainly because of failure to return or their having been treated elsewhere with the regimens not documented.

The outcome measure was met for screening or treatment for chlamydial infection for 94.2% and for partner notification for almost 92%. A total of 2100 contacts were reported as managed within four weeks, 965 (46%) of whom tested positive. This represents 0.65 per index case (performance standard 0.4 for London clinics and 0.6 outside London). ³

Culture was attempted for 85.8% NAAT-positive patients and antimicrobial susceptibility testing for 53.9% of these, while for 31.9% there was no positive culture. A further 118 people had culture and antimicrobial susceptibility testing, but no NAAT.

Antimicrobial susceptibility testing was performed on specimens from 1620 patients (Table 2). Resistance patterns broadly matched Second Generation Surveillance System data from the Gonococcal Resistance to Antimicrobials Surveillance Programme, 2014 and 2015. ⁴

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Table 2.

Antimicrobial resistance. (N = 1620) compared to Second Generation Surveillance System (SGSS) data from the Gonococcal Resistance to Antimicrobials Surveillance Programme, 2014 and 2015.

Antimicrobial	Number	(%)	SGSS data 2014 (%)	SGSS data 2015 (%)
Cefixime	19	(1.2)	0.3	0.6
Ciprofloxacin	405	(25)	30	29
Penicillin	412	(25.4)	25.1	29.3
Spectinomycin	15	(0.9)	0.4	0.2
Tetracycline	205	(12.6)	19.9	20.9
Azithromycin	29	(1.9)	1.3	1.6
None	888	54.8

Discussion

Data from 78 clinics were contributed to this audit. Currently no definitive list of clinics within the UK exists. The most recent available lists 259 clinics (BASHH National Audit Group, 2016, personal communication), but these data are unverified: some clinics may have closed, merged or offer only Level 2 services. Some clinics do not have SAS doctors on staff. The SAS database relies on members keeping it updated. It is likely to contain doctors who no longer work in the specialty and there are those who choose not to be included. One hundred and sixty-eight of the 501 doctors invited (34%) participated. No doctors in Northern Ireland contributed data but there was representation from all BASHH regions within England, Scotland and Wales.

Some records were unavailable because recent tendering to a new provider, changing to electronic records or in-process scanning made the previous year’s records inaccessible.

A reason was provided for 11.2% who did not receive first-line therapy, the commonest being drug allergy (18.2%), clinic policy (9.3%) and presence of rectal chlamydial infection (5.4%). The latter suggests that some clinicians regard the inclusion of azithromycin in the recommended regimen as a treatment for chlamydial infection rather than part of the first-line treatment recommended for gonorrhoea. ⁵ This led to a failure to prescribe azithromycin when doxycycline was used to treat extragenital chlamydial infection. This is of concern as the azithromycin is recommended in the gonorrhoea treatment regimen as an adjunct to ceftriaxone to reduce the risk of development of resistance.

The question about supplementary testing was poorly understood and proved difficult to analyse. It should have been either 100% or 0% for each centre, but this was not the case.

TOC rates for gonorrhoea were low at 60.7%, which is of concern, particularly for those who did not receive first-line treatment. While offer of TOC was not recorded, a TOC was recorded for 60.7% of patients (for 24.7% within two weeks), which falls well below the recommended standard of 100%.

Written information was provided to 36.5% of the total while 4.8% declined this. There was no documentation in the case of 54.9% and the question was not answered in 3.8%. The high rate of partner notification suggests discussion took place, whether with a clinician or a health adviser, and it may be that the offer or provision of written information had been poorly recorded.

Recommendations

With the emergence of highly resistant strains of gonorrhoea, it is vital that management conforms to national guidelines, particularly in terms of ensuring tests of cure and that clinics are alert to changes in treatment recommendations. The provision of written information to patients must improve. Patients diagnosed with gonorrhoea outside of Level 3 services should be referred to such a service for antimicrobial susceptibility testing, first-line treatment, TOC and partner notification. Provision of suboptimal antimicrobial therapy from online sites should be discouraged.