International http://std.sagepub.

com/ Journal of STD & AIDS

An audit of pharyngeal gonorrhoea treatment in a public sexual health clinic in Adelaide, South Australia
A Hustig, C Bell and R Waddell Int J STD AIDS published online 14 June 2013 DOI: 10.1177/0956462412472792 The online version of this article can be found at: http://std.sagepub.com/content/early/2013/06/07/0956462412472792

Published by:
http://www.sagepublications.com

On behalf of:
BASSH IUSTI

Additional services and information for International Journal of STD & AIDS can be found at: Email Alerts: http://std.sagepub.com/cgi/alerts Subscriptions: http://std.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav

>> OnlineFirst Version of Record - Jun 14, 2013 What is This?

Downloaded from std.sagepub.com by guest on July 18, 2013

Int J STD AIDS OnlineFirst, published on June 14, 2013 as doi:10.1177/0956462412472792

AUDIT REPORT

An audit of pharyngeal gonorrhoea treatment in a public sexual health clinic in Adelaide, South Australia
A Hustig
BMBS*,

C Bell

FCAS FAChSHM

and R Waddell

FAChSHM MBBS

*School of Medicine, Flinders University, Adelaide, South Australia 5042, Australia; Clinic 275, Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia

Summary: In recent times there have been changes to guidelines regarding the management of gonorrhoea, from both the Centers for Disease Control and Prevention in 2010 and the British Association for Sexual Health and HIV (BASHH) in 2011. Coinciding with their release we conducted a clinical audit of our treatment protocol for gonorrhoea. In 2010, local data on the minimum inhibitory concentrations for Neisseria gonorrhoeae indicated an increase in local isolates that were less sensitive to ceftriaxone (11.6% c.f. 5.3% in 2009). We have a long history of using 250 mg of ceftriaxone to treat all standard sites of gonorrhoea infection followed with tests of cure in all cases. In a retrospective clinical audit of an 11-year period from 2000 up to and including 2010 we identied six test-of-cure failures over 11 years after treating a total of 215 patients with pharyngeal gonorrhoea. Keywords: Neisseria gonorrhoeae, gonorrhoea, sexually transmitted infection, treatment, pharyngeal gonorrhoea, antibiotics, ceftriaxone, resistance, treatment failure, test of cure

INTRODUCTION
Pharyngeal gonorrhoea is important as is it is asymptomatic in over 90% of cases but still provides a potential source of transmission from oropharynx to urogenital surfaces.1 4 Furthermore it is more difcult to treat than other sites of infection5 as it is thought that pharyngeal concentrations of antimicrobials are not as high as genital and rectal mucosal surfaces.6 Already Neisseria gonorrhoeae has proven resistance to antimicrobial agents including beta-lactams, tetracyclines, uoroquinolones and cexime.7 Due to the recent identication of two pharyngeal ceftriaxone failures in Australia,8 and the H041 strain, the threat is clear that the same is occurring with ceftriaxone. This strain, identied from a pharyngeal swab of an asymptomatic female commercial sex worker in Japan, was found to have a very high minimum inhibitory concentration (MIC) of 2 mg/mL.9 As this increases the duration of free-ceftriaxone above the MIC decreases,9 which is of even more importance when targeting difcult-to-penetrate tissue such as the pharynx. Clinic 275 is an open access state-funded sexual health service in South Australia. It operates on a walk-in basis with no appointments, does not charge for services or treatments and requests no proof of identity. In 2010 the clinic recorded 8595 episodes of care resulting in 17,337 attendances for 6828 individuals.10

gonorrhoea from 2000 up to and including 2010. We developed and used a standardized audit tool to review case-notes and collect data. The data were entered into an Excel spreadsheet for analysis.

RESULTS
Our audit identied six test-of-cure (TOC) failures over 11 years treating a total of 215 patients with pharyngeal gonorrhoea. The rst of these occurred in 2006, with two in 2008 and three in 2010. Throughout this time our treatment practice had not changed. We continued to discourage all sexual encounters between testing, treatment and TOC results. Intramuscular ceftriaxone 250 mg was given to 204 patients (95%) in line with our protocol for treating gonorrhoea at that time; 149 patients (69.6%) received ceftriaxone alone and 55 (25.7%) were given additional azithromycin 1000 mg orally for concurrent chlamydial infection. Following treatment, 174 (80.9%) patients had a TOC. Throughout the 11 years this involved bacterial culture for Neisseria. Six patients failed their TOC but all isolates were fully sensitive to cephalosporins (MIC , 0.03 mg/mL). All six were men, with four having sex with men and two with both men and women. Five of the six failed TOC cases received only ceftriaxone (of 149 patients) and the other received ceftriaxone and additional azithromycin (of 55 patients) for concurrent urethral and rectal chlamydial infection. Following the TOC failure they were all treated with a further dose of 250 mg of ceftriaxone alone. On average patients re-attended for TOC at 9.3 days (range 521 days) after initial treatment for gonorrhoea and were re-treated at an average of 11 days (range 530 days) after their TOC was collected. At each presentation a repeat
DOI: 10.1177/0956462412472792. International Journal of STD & AIDS 2013: 1 2

METHOD
We used our clinic database11 to identify all patients attending Clinic 275 who were diagnosed and treated for pharyngeal
Correspondence to: Alistair Hustig Email: alistair.hustig@internode.on.net

Downloaded from std.sagepub.com by guest on July 18, 2013

................................................................................................................................................

International Journal of STD & AIDS

sexual history was taken and they all reported having abstained from sex during this period.

CONCLUSION
In order to minimize the spread of infection it is essential that pharyngeal gonorrhoea, especially due to its asymptomatic nature, be cured on rst treatment. In light of our ndings, the increased frequency of less sensitive ceftriaxone strains noted locally, and along with changes to CDC and BASHH guidelines, Clinic 275 has changed its guidelines. We now treat uncomplicated gonococcal infections with ceftriaxone 500 mg intramuscularly and azithromycin 1000 mg orally with recall for TOC in all. We hope this helps to arrest the development of antibiotic resistance in this exceedingly adaptable bacterium.
REFERENCES 1 Bignell C, FitzGerald M. UK national guideline for the management of gonorrhoea in adults, 2011. Int J STD AIDS 2011;22:541 7 2 Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Morb Mortal Wkly Rep 2010;59(No. RR-12):49 52.

3 Australian Gonococcal Surveillance Program, Annual Report 2010. Communicable Diseases Intelligence. 2011;35(3):229 36 4 Bernstein KT, Stephens SC, Barry PM, et al. Chlamydia trachomatis and Neisseria gonorrhoeae transmission from the oropharynx to the urethra among men who have sex with men. Clin Infect Dis 2009;49:1793 7 5 Newman LM, Moran JS, Workowski KA. Update on the management of gonorrhea in adults in the United States. Clin Infect Dis 2007;44(Suppl. 3):S84 101 6 Moran JS. Treating uncomplicated Neisseria gonorrhoeae infections: is the anatomic site of infection important? Sex Transm Dis 1995;22:39 47 7 Ohnishi M, Golparian D, Shimuta K, et al. Is Neisseria gonorrhoeae initiating a future era of untreatable gonorrhea? Antimicrob Agents Chemother 2011;55:353845 8 Tapsall J, Read P, Carmody C, et al. Two cases of failed ceftriaxone treatment in pharyngeal gonorrhoea veried by molecular microbiological methods. J Med Microbiol 2009;58(Pt 5):683 7 9 Unemo M, Golparian D, Hestner A. Ceftriaxone treatment failure of pharyngeal gonorrhoea veried by international recommendations, Sweden, July 2010. Euro Surveill 2011;16:1 3. See http://www.eurosurveillance.org/ ViewArticle.aspx?ArticleId=19792 (last checked 29 August 2012) 10 Sexually Transmitted Disease Services. Sentinel Surveillance of Sexually Transmitted Diseases (STDs) in South Australia. Report 2. 2010. 2011. See http://www.stdservices.on.net/publications/ (last checked 29 August 2012) 11 Hart G. Computerization of clinic records: the resource utilization system for a sexually transmitted diseases clinic. Sex Transm Dis 1989;16:1 6 (Accepted 22 November 2012)

Downloaded from std.sagepub.com by guest on July 18, 2013