The management of uncomplicated adult gonococcal infection: should test of cure still be routine in patients attending genitourinary medicine clinics?

Abstract

In this retrospective study of the outcome of treatment of 245 patients (87 females and 158 males) with a diagnosis of Neisseria gonorrhoeae infection seen between 1996 and 2002, 81% (95% confidence interval (CI) 74%-86.8%) of the males and 88.5% (95% CI 79.9%-94.3%) of the females attended for a test of cure. At initial presentation, 93% (95% CI 87.9%-96.5%) and 94.3% (95% CI 89.5%-97.4%) of males respectively, had symptoms and signs of gonococcal infection compared with 48.3% (95% CI 37.4%-59.2%) and 44.8% (95% CI 34.1%-55.9%) of females, and this difference was statistically significant (P = 0.005). Initial diagnosis at first visit was made by Gram-stained smear in 88.6% (95% CI 82.6%-93.1%) of males and 32.2% (95% CI 22.6%-43.1%) of females, a statistically significant difference P = 0.001. There were 12 (4.9%) cases of reinfection that rebooked to attend after failing to attend for their test of cure in two females and 10 males. There were two (0.8%) treatment failures amongst the 245 episodes in two males who still had symptoms when they returned for their test of cure. One male had a ciprofloxacin-resistant strain (CRNG) acquired locally and the other one had a betalactamase-producing CRNG/penicillinase-producing N. gonorrhoeae (PPNG) isolate acquired abroad in South America. These patients would have sought to return, as they still had signs and symptoms of gonococcal infection, and they would have been recalled following receipt of the antimicrobial susceptibility report. Post-gonococcal urethritis occurred in 36.3% (95% CI 27.8%-45.4%) of the males who attended for their test of cure, 74.8% (95% CI 67.2%-81.5%) received anti-chlamydial therapy with their standard treatment. In men who received anti-chlamydial therapy the odds ratio of having post-gonococcal urethritis was 0.42 (95% CI 0.17-1.06), P = 0.04. Co-infection with Chlamydia trachomatis was more likely to occur amongst females (43.9%), odds ratio 3.97 (95% CI 2.07-7.67), P < 0.001 than males (16.5%). We have now discontinued routine attendance for a test of cure and encourage our patients to telephone for their results with recall only of patients whose antimicrobial susceptibility indicate inappropriate first line therapy or who are still symptomatic.