Article Figures & Data
Tables
- Table 1.
Baseline Characteristics of Patients With Chlamydia or Gonorrhea in Primary Care, Overall and by Treatment Status (2018-2022)
Chlamydiaa Gonorrheaa Characteristic Overall (N = 6,678) Not treated (n = 1,650) Treated (n = 5,028) Overall (N = 2,206) Not treated (n = 671) Treated (n = 1,535) Gender, No. (%) Male 1,827 (27.4) 599 (32.8) 1,228 (67.2) 747 (33.9) 363 (48.6) 384 (51.4) Female 4,845 (72.6) 1,048 (21.6) 3,797 (78.4)b 1,459 (66.1) 308 (21.1) 1,151 (78.9) Age group, No. (%) 10-19 years 1,829 (27.4) 427 (23.3) 1,402 (76.7) 554 (25.1) 131 (23.6) 423 (76.4) 20-29 years 3,593 (53.8) 861 (24.0) 2,732 (76.0) 1,078 (48.9) 316 (29.3) 762 (70.7) 30-39 years 841 (12.6) 232 (27.6) 609 (72.4) 334 (15.1) 123 (36.8) 211 (63.2) 40-49 years 248 (3.7) 66 (26.6) 182 (73.4) 126 (5.7) 42 (33.3) 84 (66.7) 50-59 years 123 (1.8) 46 (37.4) 77 (62.6) 87 (3.9) 48 (55.2) 39 (44.8) 60-69 years 39 (0.6) 13 (33.3) 26 (66.7) 24 (1.1) <11 15 (62.5) 70-79 years <11 <11 0 (0) <11 <11 <11 ≥80 years 0 (0) 0 (0) 0 (0) <11 <11 0 (0) Race, No. (%) Asian 61 (0.9) 19 (31.1) 42 (68.9) 16 (0.7) <16 <16 Hispanic 1,203 (18.0) 280 (23.3) 923 (76.7) 308 (14.0) 99 (32.1) 209 (67.9) Non-Hispanic Black 1,527 (22.9) 412 (27.0) 1,115 (73.0) 656 (29.7) 225 (34.3) 431 (65.7) Non-Hispanic White 2,842 (42.6) 658 (23.2) 2,184 (76.8) 877 (39.8) 232 (26.5) 645 (73.5) Other, unknown, missing 1,045 (15.7) 281 (26.9) 764 (73.1) 349 (15.8) 109 (31.2) 240 (68.8) Residence, No. (%)c Urban 4,179 (62.6) 1,041 (24.9) 3,138 (75.1) 1,481 (67.1) 527 (35.6) 954 (64.4) Suburban 1,159 (17.4) 261 (22.5) 898 (77.5) 430 (19.5) 71 (16.5) 359 (83.5) Rural 1,325 (19.8) 344 (26.0) 981 (74.0) 289 (13.1) 67 (23.2) 222 (76.8) Unknown <16 <16 <16 <16 <16 0 (0) SDI, median (IQR)d 57 (33-72) 57 (33-73) 57 (31-72) 57 (36-72) 59 (46-77) 57 (34-70) Coinfectione Yes 1,299 (19.5) 304 (23.4) 995 (76.6) 1,278 (57.9) 301 (23.6) 977 (76.4) No 5,379 (80.6) 1,346 (25.0) 4,033 (75.0) 928 (42.1) 370 (39.9) 558 (60.1) IQR = interquartile range; SDI = social deprivation index.
Notes: Treatment status was based on administration/prescription of treatment within 30 days after the positive test. American Family Cohort analysis requires cell suppression; therefore, for small cell sizes, we masked actual counts and proportions for cell sizes<16 (for adult patients) and <11 (for pediatric patients) but >1.
↵a Group assignment was based on a positive test, although patients could have also had a diagnosis code for the infection.
↵b Denominator was 5,025 patients because 3 patients were missing their gender identities.
↵c Ascertained from percentage of population for the zip code: urban (>60% urban), rural (>60% rural), or suburban (40%-60% urban or rural).
↵d Based on county. Possible values range from 1 to 100, with higher values indicating greater socioeconomic deprivation.
↵e Coinfection with chlamydia and gonorrhea, based on positive test for the index infection (chlamydia or gonorrhea) plus an additional infection of the other type on the same date based on either a diagnosis code or a positive test.
Treatment measure Chlamydiaa (n = 6,678) Gonorrheaa (n = 2,206) Chlamydia with gonorrhea coinfectionb (n = 1,299) Gonorrhea with chlamydia coinfectionb (n = 1,278) Treated, No. (%) 5,028 (75.3) 1,535 (69.6) 995 (76.6) 977 (76.5) Time to treatmentc Within 7 days, No. (%) 4,286 (85.2) 1,296 (84.4) 848 (85.2) 811 (83.0) Within 8-15 days, No. (%) 551 (11.0) 171 (11.1) 106 (10.7) 118 (12.1) Within 16-30 days, No. (%) 191 (3.8) 68 (4.4) 41 (4.1) 48 (4.9) Median (IQR), days 3 (1-6) 3 (1-6) 3 (2-6) 4 (2-6) Mean (SD), days 4.5 (4.8) 4.6 (5.1) 4.6 (4.9) 4.9 (5.1) Chlamydia treatment Antibiotic regimen, No. (%)d Amoxicillin 61 (1.2) NA <16 NA Amoxicillin, azithromycin 22 (0.4) <16 Amoxicillin, doxycycline <16 0 (0) Amoxicillin, doxycycline, levofloxacin 0 (0) 0 (0) Amoxicillin, levofloxacin <16 <16 Azithromycin 4,220 (83.9) 876 (88.0) Azithromycin, doxycycline 49 (1.0) <16 Azithromycin, erythromycin <16 0 (0) Azithromycin, levofloxacin <16 <16 Doxycycline 645 (12.8) 88 (8.8) Doxycycline, erythromycin <16 <16 Doxycycline, levofloxacin <16 0 (0) Erythromycin <16 <16 Levofloxacin <16 0 (0) Multiple regimens, No. (%)e 83 (1.7) 21 (2.1) Recommended treatment of doxycycline, No. (%) Anyf 702 (14.0) 98 (9.8) As monotherapy 645 (12.8) 88 (8.8) Gonorrhea treatment Antibiotic regimen, No. (%)d Azithromycin NA 914 (59.5) NA 647 (66.2) Azithromycin, cefixime 17 (1.1) <16 Azithromycin, cefixime, ceftriaxone <16 0 (0) Azithromycin, ceftriaxone 390 (25.4) 228 (23.3) Azithromycin, ceftriaxone, gentamicin <16 0 (0) Azithromycin, gemifloxacin <16 <16 Cefixime <16 <16 Cefotaxime 0 (0) 0 (0) Ceftriaxone 202 (13.2) 92 (9.4) Ceftriaxone, gentamicin 0 (0) 0 (0) Gentamicin <16 0 (0) Multiple regimens, No. (%)e 412 (26.8) 237 (24.3) Recommended treatment of ceftriaxone, No. (%) Anyg 594 (38.7) As monotherapy 202 (13.2) IQR =interquartile range; NA = not applicable.
↵a Group assignment was based on a positive test, although patients could have also had a diagnosis code for the infection.
↵b Coinfection was based on positive test for the index infection (chlamydia or gonorrhea) plus an additional infection of the other type on the same date based on either a diagnosis code or a positive test.
↵c Among patients who were treated.
↵d American Family Cohort analysis requires cell suppression; therefore, for small cell sizes we performed masking of actual counts and proportions for cell sizes <16 (for adult patients) and <11 (for pediatric patients) but >1.
↵e Received more than 1 regimen on the same day.
↵f Any receipt of doxycycline, whether alone or in combination with other antibiotics. Any receipt of doxycycline was required for treatment to be classified as recommended treatment.
↵g Any receipt of ceftriaxone, whether alone or in combination with other antibiotics. Any receipt of ceftriaxone was required for treatment to be classified as recommended treatment.
- Table 3.
Fully Adjusted Time Ratios and Differences in Days to Treatment vs Reference Group for Patients With Chlamydia or Gonorrhea
Chlamydiaa Gonorrheaa Characteristic Time ratio (95% Cl)b P value Difference, daysc Time ratio (95% Cl)b P value Difference, daysc SDI quintiled Quintile 1 Ref … Ref Ref … Ref Quintile 2 0.94 (0.79-1.12) .49 −0.18 0.76 (0.56-1.05) .10 −0.71 Quintile 3 0.91 (0.77-1.08) .28 −0.26 0.65 (0.48-0.87) .00 −1.05 Quintile 4 1.12 (0.92-1.35) .27 0.35 0.90 (0.64-1.26) .53 −0.31 Quintile 5 1.02 (0.82-1.27) .86 0.06 1.03 (0.70-1.53) .88 0.10 Age group 10-19 years 0.94 (0.85-1.04) .21 −0.18 0.90 (0.76-1.08) .26 −0.29 20-29 years Ref … Ref Ref … Ref 30-39 years 1.06 (0.94-1.21) .35 0.19 1.09 (0.87-1.37) .44 0.28 40-49 years 0.87 (0.70-1.10) .25 −0.38 0.72 (0.50-1.04) .08 −0.83 50-59 years 1.61 (1.12-2.30) .01 1.82 1.38 (0.83-2.27) .21 1.13 60-69 years 1.17 (0.63-2.17) .62 0.50 0.57 (0.26-1.29) .18 −1.28 Residence Urban 0.96 (0.84-1.09) .51 −0.13 1.25 (1.02-1.53) .03 0.74 Rural 1.06 (0.92-1.21) .45 0.17 1.17 (0.92-1.49) .19 0.52 Suburban Ref … Ref Ref … Ref Race Asian 0.98 (0.62-1.55) .92 −0.07 1.48 (0.51-4.33) .47 1.45 Hispanic 0.98 (0.85-1.14) .82 −0.05 0.91 (0.68-1.22) .53 −0.27 Non-Hispanic Black 1.17 (1.04-1.33) .01 0.52 0.91 (0.74-1.11) .34 −0.28 White Ref … Ref Ref … Ref Other, unknown, missing 1.36 (1.20-1.55) .00 1.09 1.21 (0.97-1.51) .09 0.63 Sex: female (Ref = male) 0.62 (0.55-0.70) .00 −1.14 0.38 (0.29-0.48) .00 −1.87 Coinfection: yes (Ref = no) 1.14 (1.02-1.28)e .02 0.43 0.89 (0.74-1.07)f .21 −0.33 Ref = reference group; SDI = social deprivation index; STI = sexually transmitted infection.
Note: Assuming the median time to treatment of 3 days for chlamydia and 3 days for gonorrhea (Table 2).
↵a Group assignment was based on a positive test, although patients could have also had a diagnosis code for the infection.
↵b The ratio of the time to treatment between the indicated group and the reference group, adjusted for all other variables in this table. Estimated using a multivariate shared frailty parametric Weibull accelerated failure time (AFT) model to account for patients who may have had multiple STIs throughout the study period. Shared frailty models were estimated both with and without the shared frailty component, and the likelihood ratio test of the theta parameter indicated shared frailty effects existed; therefore, all final models accounted for multiple STI patient episodes that could have occurred during the study period.
↵c The increase (in the case of positive values) or decrease (in the case of negative values) in number of days with respect to the median time to treatment of 3 days.
↵d Range is from least deprived (quintile 1: SDI of 0-20) to most deprived (quintile 5: SDI of 81-100).
↵e The time to treatment is based on the relevant antibiotics that would be prescribed for chlamydia, regardless of gonorrhea coinfection.
↵f The time to treatment is based on the relevant antibiotics that would be prescribed for gonorrhea, regardless of chlamydia coinfection.
Additional Files
SUPPLEMENTAL DATA IN PDF FILE BELOW
- Hao_Supp_App_Supp_Tables_1-4.pdf -
Supplemental Appendix. The PRIME Registry
Supplemental Table 1. List of all codes to identify chlamydia and gonorrhea infections
Supplemental Table 2. List of all codes to identify confirmed tests
Supplemental Table 3. List of all medications for chlamydia and gonorrhea to classify medication classes and detailed descriptions
Supplemental Table 4. The fully adjusted time ratios as well as the difference in number of days compared to fixed referent groups, for patients who received a diagnosis of chlamydia or gonorrhea without a confirmed positive test
- Hao_Supp_App_Supp_Tables_1-4.pdf -
PLAIN-LANGUAGE SUMMARY
Original Research
Many Patients With Chlamydia and Gonorrhea Are Not Receiving CDC-Recommended Treatment in Primary Care
Background and Goal:Prompt treatment of chlamydia and gonorrhea following a confirmed diagnosis is essential to prevent complications and reduce transmission. Adherence to the Centers for Disease Control (CDC) treatment guidelines in primary care settings remains a concern. This study aimed to quantify the overall treatment rate for chlamydia and gonorrhea and identify factors associated with treatment delays and disparities.
Study Approach:Researchers analyzed electronic health record data from the PRIME registry, which includes information from over 2,000 primary care clinicians across the United States. The study included patients diagnosed with chlamydia or gonorrhea between 2018 and 2022 and assessed whether they received appropriate antibiotic treatment within 30 days of diagnosis.
Main Results:6,678 cases of chlamydia and 2,206 cases of gonorrhea confirmed by a positive test were identified.
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75.3% of chlamydia cases and 69.6% of gonorrhea cases were treated within 30 days.
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More than 80% of treated patients received antibiotics within 7 days of diagnosis.
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Only 14% of chlamydia cases were treated with the recommended doxycycline and only 38.7% of gonorrhea cases were treated with the recommended ceftriaxone.
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Women, young adults (ages 10-29), and suburban residents were more likely to receive treatment.
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Time to treatment of chlamydia was longer for patients aged 50-59 years and for non-Hispanic Black patients.
Why It Matters:Many patients with chlamydia and gonorrhea in primary care settings do not receive the recommended treatment. This gap in care may contribute to ongoing STI transmission and adverse health outcomes, particularly among marginalized populations.
Treatment of Chlamydia and Gonorrhea in Primary Care and Its Patient-Level Variation: An American Family Cohort Study
Shiying Hao, PhD, et al
Center for Population Health Sciences, School of Medicine, Stanford University, Stanford, California
An accompanying episode of the Annals of Family Medicine Podcast, featuring study authors Shiying Hao, PhD, and Neil Kamdar, MA, will be available here beginning 9am EDT March 25.
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