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Original Article
The antibiotic management of gonorrhoea in Ontario, Canada following multiple changes in guidelines: an interrupted time-series analysis
  1. Catherine Dickson1,
  2. Monica Taljaard2,
  3. Dara Spatz Friedman3,
  4. Gila Metz4,
  5. Tom Wong5,
  6. Jeremy M Grimshaw6
  1. 1Medical Resident,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Alta Vista Campus Room, Ottawa, Canada
  2. 2Department of Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Civic Campus, Ottawa, Canada
  3. 3Department of Epidemiologist, Ottawa Public Health, Ontario, Canada
  4. 4Medical Director for Sexual Health, Ottawa Public Health, Ottawa, Canada
  5. 5Office of Population and Public Health, First Nations and Inuit Health Branch, Health Canada, Ottawa, Canada
  6. 6Department of Clinical Epidemiology Program, Ottawa Hospital Research Institute, Center for Practice Changing Research Building, The Ottawa Hospital, General Campus, Ottawa, Canada
  1. Correspondence to Dr Catherine Dickson, Medical Resident, School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Alta Vista Campus Room, Ottawa, ON K1N 6N5, Canada; catherinedickson01{at}gmail.com

Abstract

Objective This study assessed adherence with first-line gonorrhoea treatment recommendations in Ontario, Canada, following recent guideline changes due to antibiotic resistance.

Methods We used interrupted times-series analyses to analyse treatment data for cases of uncomplicated gonorrhoea reported in Ontario, Canada, between January 2006 and May 2014. We assessed adherence with first-line treatment according to the guidelines in place at the time and the use of specific antibiotics over time. We used the introduction of new recommendations in the Canadian Guidelines for Sexually Transmitted Infections in 2008 and 2011 and the release of the province of Ontario’s Guidelines for the Treatment and Management of Gonococcal Infections in Ontario in 2013 as interruptions in the time-series analysis.

Results Overall, 34 287 gonorrhoea cases were reported between 1 January 2006 and 31 May 2014. Treatment data were available for 32 312 (94.2%). Our analysis included 32 272 (94.1%) cases without either a conjunctival or disseminated infection. Following the release of the 2011 recommendations, adherence with first-line recommendations immediately decreased to below 30%. Adherence slowly increased but did not reach baseline levels before the 2013 guidelines were released. Following release of the 2013 guidelines, adherence again decreased; adherence is slowly recovering but by May 2014, was only approximately 60%.

Conclusions Due to concerns about antibiotic resistance, gonorrhoea treatment guidelines need to be updated regularly and rapidly adopted in practice. Our study showed poor adherence following dissemination of updated guidelines. Over a year after the latest Ontario guidelines were released, 40% of patients did not receive first-line treatment, putting them at risk of treatment failure and potentially promoting further drug resistance. Greater attention should be devoted to dissemination and implementation of new guidelines.

  • Sexually Transmitted Diseases

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Footnotes

  • Contributors CD developed the research protocol, worked with Public Health Ontario to obtain the data sets, conducted the data analysis and conducted the majority of the writing of the manuscript. MT provided guidance on the statistical analyses and the interpretation of the results, and revised the manuscript critically for important intellectual content. GM provided guidance on the planning of the manuscript, and revised the manuscript critically for important intellectual content. DSF provided guidance on the planning of the manuscript, assisted with data access, and revised the manuscript critically for important intellectual content. TW provided guidance on the planning of the manuscript, and revised the manuscript critically for important intellectual content. JG provided guidance on the planning of the manuscript, and revised the manuscript critically for important intellectual content.

  • Funding No funding was received for this study. JMG holds a Canada Research Chair for Health Knowledge Transfer and Uptake. The corresponding author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non-exclusive for government employees) on a worldwide basis to the BMJ Publishing Group to permit this article (if accepted) to be published in STI and any other BMJ PGL products and sublicences such use and exploit all subsidiary rights, as set out in our licence http://group.bmj.com/products/journals/instructions-for-authors/licence-forms.

  • Competing interests All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. In accordance with the authorship criteria of the ICMJE, all authors provided final approval prior to the submission of the manuscript, and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval Ottawa Health Science Network Research Ethics Board (OHSN-REB) – IRB00002616, protocol #: 20140074-01H.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data is available. Anyone interested in obtaining the data would need to contact Public Health Ontario.

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