Timing of Antibiotic Therapy for Neisseria Gonorrhoeae Infection

What Is the Issue? Gonorrhea is the second most prevalent sexually transmitted infection in Canada. It is caused by Neisseria gonorrhoeae and can be treated with antibiotic therapy. However, gonorrhoeae has developed antibiotic resistance, which may decrease the efficacy of current therapy. Antibiotic therapy can be administered after a positive gonorrhoeae test, but the turnaround time of laboratory testing may result in patients being lost to follow-up (i.e., not returning to the clinic after test results are available). Presumptive or empiric antibiotic therapy can be given before the laboratory confirmation of gonorrhoeae to individuals at high risk of gonorrhea or those with uncertain follow-up; however, such treatment may lead to overtreating those without N. gonorrhoeae, increasing the risk of antibiotic resistance and possible side effects to the individuals. It is important to understand the ideal timing of antibiotic therapy that balances concerns of antibiotic resistance and timely patient care. What Did We Do? To inform decisions about timing of antibiotic therapy for the treatment of adults and adolescents with suspected uncomplicated gonorrhoeae infection, CADTH sought to identify and summarize literature comparing the clinical effectiveness and safety of delaying antibiotic therapy until confirmatory results of testing for N. gonorrhoeae infection are available, versus empiric treatment before test results are available. A research information specialist conducted a literature search of the peer-reviewed and grey literature published since January 1, 2013. What Did We Find? We did not find any studies directly evaluating the clinical effectiveness and safety of delayed antibiotic treatment compared to presumptive treatment for uncomplicated gonorrhoeae infections in adult and adolescent populations. We included 2 nonrandomized studies that compared the rates of accurate treatment and overtreatment in individuals who received presumptive treatment and those who did not. In the 2 studies, gonorrhoeae test positivity rates in the presumptive treatment group were less than 50%, suggesting that less than half of the patients in this group received accurate presumptive treatment. We also found high overtreatment rates, which were up to 90% in the included studies. The certainty of these findings is very low due to methodological limitations of the included studies. We also identified 5 single-arm studies that evaluated these outcomes in individuals who received presumptive therapy. The findings are generally consistent with the 2 included studies. What Does It Mean? Available evidence points to high rates of overtreatment when presumptive antibiotics are given. Results also suggest that there is value in clinical assessment in detecting gonorrhoeae infections. The downstream clinical effectiveness implications of these results for antimicrobial resistance or increasing spread of N. gonorrhoeae are unclear. Contextual factors, such as the local prevalence of gonorrhoeae infection and potential barriers to care that could hinder post-test follow-up for certain individuals or groups, may also be useful considerations when making decisions about appropriate timing for N. gonorrhoeae antibiotic therapy.