EXECUTIVE SUMMARY
According to a recent study, three-quarters of ED patients who received antibiotics to treat suspected STIs tested negative for such diseases.
- New surveillance data from the CDC’s Gonococcal Isolate Surveillance Program find that resistance is emerging to azithromycin, a first-line antibiotic used to treat gonorrhea. Clinicians are advised to continue with the current guidance for treatment: an oral dose of azithromycin and a single shot of ceftriaxone.
- Public Health Officials Are Focusing On Reducing The Number Of Unnecessary Antibiotic Prescriptions To Combat Antibiotic-resistant Bacteria. Results From Recently Published National Research Indicate At Least 30% Of Antibiotics Prescribed In The United States Are Unnecessary.
With growing resistance to antibiotics noted in the United States, what’s your practice when it comes to prescribing them? According to a recent study, three-quarters of ED patients who received antibiotics to treat suspected STIs tested negative for such diseases.1
To perform the current study, researchers from St. John Hospital & Medical Center in Detroit looked at records of more than 1,103 patients who underwent STI testing in the ED to identify the extent of unnecessary antibiotic use. Genital cultures are commonly collected from patients with STI signs and symptoms; however, results are not immediately available, and antibiotics often are prescribed without a confirmatory diagnosis while patients are in the department.
The analysis indicates that of the 1,103 patients tested, 40% were treated with antibiotics for gonorrhea and/or chlamydia. However, of those treated, 76.6% ultimately tested negative for having an STI. Of the 60% who went untreated, 7% ultimately tested positive for either or both infections.
“We have to find the appropriate balance between getting people tested and treated for STDs, but not prescribing antibiotics to patients who don’t need them,” said Karen Jones, MPH, BSN, RN, infection preventionist at St. John Hospital & Medical Center in a statement accompanying the publication of data. “There is a tricky balance between not furthering antibiotic resistance by overprescribing, but also still getting people treatment for STDs they might have.”
Further examination of the data yields clues about how certain symptoms were associated with positive STI cultures. In male patients, 60.3% with penile discharge and 57.5% with inflammation of the urethra tested positive for gonorrhea and/or chlamydia. In female patients, 25% with inflammation of the cervix and 27% with cervical motion tenderness tested positive for gonorrhea and/or chlamydia. More than one-third (35%) of patients who disclosed that they had more than one sex partner also tested positive for gonorrhea and/or chlamydia.1
“Focusing on these clinical predictors may improve unnecessary antibiotic prescribing in patients without true disease,” said Jones, who served as lead author of the current paper.
What are the latest developments when it comes to STI treatment and antibiotic resistance?
New surveillance data from the CDC’s Gonococcal Isolate Surveillance Program (GISP) find that resistance to azithromycin, a first-line antibiotic used to treat gonorrhea, is emerging, says Robert Kirkcaldy, MD, MPH, medical epidemiologist in the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of STD Prevention. As GISP project officer, Kirkcaldy says findings show that the percentage of isolates showing signs of reduced susceptibility to azithromycin — an indicator of emerging resistance — increased between 2013 and 2014 (from 0.6% to 2.5%).2
“This is the largest percentage since monitoring of this drug began in 1992 and occurred in all geographic regions,” states Kirkcaldy. (For more about the rise of multi-drug resistance, readers can see the Contraceptive Technology Update article, “Threat up for gonorrhea that is multi-drug resistant,” May 2012, at http://bit.ly/29Ve4Yd.)
Neisseria gonorrhoeae, the bacteria that causes gonorrhea, has developed resistance to nearly all of the antibiotics used for gonorrhea treatment: sulfonilamides, penicillin, tetracycline, and fluoroquinolones, such as ciprofloxacin. The CDC recommends a combination gonorrhea therapy consisting of two antibiotics: an oral dose of azithromycin and single shot of ceftriaxone,3 notes Kirkcaldy. Because recent research indicates there were no isolates that exhibited resistance to azithromycin and ceftriaxone, clinicians should continue to use the recommended dual therapy to treat patients with gonorrhea.
However, signs that resistance to these antibiotics may be emerging is concerning, because dual therapy with ceftriaxone plus azithromycin is the only recommended gonorrhea treatment, Kirkcaldy states. While the CDC has taken initial steps, more efforts are needed on multiple fronts to ensure clinicians preserve the last recommended treatment for as long as possible, he says. “It is critical that we ensure local prevention services are available to those who need them by strengthening STD prevention services at the state and local level,” states Kirkcaldy. “Researchers and pharmaceutical companies must jump-start research on new, effective drugs or drug combos, [and] health departments and labs must also help us keep a watchful eye on emerging drug resistance.”
To fight antimicrobial-resistant gonorrhea, the CDC is using the latest advances in genome sequencing techniques to unlock the DNA of the bacterium that causes gonorrhea. This information is critical to the development of new drugs to treat gonorrhea, as well as better tests to find out quickly if a patient’s infection is resistant.
Public health officials believe that this advanced research will tell how the bacteria are changing and help scientists find better ways to prevent gonorrhea. Using these new approaches, CDC officials hope to keep untreatable gonorrhea from becoming a reality.
In the coming year, the CDC plans to identify gene mutations that are responsible for antimicrobial resistance in N. gonorrhoeae, begin developing molecular tests to detect antimicrobial resistance, provide support to state public health laboratories to pilot whole genome sequencing of N. gonorrhoeae, and upload genetic sequences into publicly accessible databases for further study.
According to recently published national research, at least 30% of antibiotics prescribed in the United States are unnecessary.4 The data, published in May 2016 in the Journal of the American Medical Association by the CDC, analyzed the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate.
Scientists used information from the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to obtain a national overview of antibiotic use in doctors’ offices and EDs throughout the United States. The analysis indicates that most unnecessary antibiotics are prescribed for respiratory conditions caused by viruses, including common colds, viral sore throats, bronchitis, and sinus and ear infections. These 47 million excess prescriptions each year put patients at needless risk for allergic reactions or the sometimes deadly diarrhea, Clostridium difficile.
In 2015, the White House issued The National Action Plan for Combating Antibiotic-Resistant Bacteria, which set a goal of reducing inappropriate outpatient antibiotic use by at least half by 2020. To reach this goal, 15% of antibiotic prescriptions (half of the 30% that are unnecessary) must be eliminated by 2020.
Upon the data release, Lauri Hicks, DO, director of the CDC’s Office of Antibiotic Stewardship in the organization’s National Center for Emerging and Zoonotic Infectious Diseases’ Division of Healthcare Quality Promotion and commander in the U.S. Public Health Service, said, “Setting a national target to reduce unnecessary antibiotic use in outpatient settings is a critical first step to improve antibiotic use and protect patients. We must continue to work together across the entire health care continuum to make sure that antibiotics are prescribed only when needed, and when an antibiotic is needed, that the right antibiotic, dose, and duration are selected.”
Money for the fight
In fiscal 2016, Congress appropriated $160 million in new funding to aid the CDC in fighting the spread of antibiotic resistance by doing the following:
- accelerating outbreak detection and prevention in every state;
- enhancing tracking of antibiotic use and resistance mechanisms and resistant infections;
- supporting research to address knowledge gaps;
- informing providers and the general public about antibiotic resistance and appropriate antibiotic use;
- improving antibiotic use by supporting expansion and development of new programs and activities at the local level.
What can healthcare professionals, health systems, and patients do to improve antibiotic use? The CDC outlines the following steps:
- Outpatient healthcare providers can evaluate their prescribing habits and implement antibiotic stewardship activities, such as watchful waiting or delayed prescribing, when appropriate, into their practices.
- Health systems can improve antibiotic prescribing in offices and outpatient facilities within their networks by providing communications training, clinical decision support, patient and healthcare provider education, and feedback to providers on their performance.
- Patients can talk to their healthcare providers about when antibiotics are needed and when they are not. These conversations should include information on patients’ risk for infections by antibiotic-resistant bacteria.
REFERENCES
- Jones KM, Babcock C, Szpunar SM. Antimicrobial stewardship in emergency departments: Improving treatment accuracy for suspected sexually transmitted diseases. Am J Infection Control 2016; doi: 10.1016/j.ajic.2016.04.004.
- Kirkcaldy RD, Harvey A, Papp JR, et al. Neisseria gonorrhoeae antimicrobial susceptibility surveillance — the Gonococcal Isolate Surveillance Project, 27 sites, United States, 2014. MMWR Surveill Summ 2016; 65(No. SS-7):1-19.
- CDC. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64(No. RR-3): 1-137.
- Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA 2016; 315(17):1864-1873.
