The gonorrhoea care cascade in general practice: a descriptive study to explore gonorrhoea management utilising electronic medical records

J. Jung; J. L. Goller; P. Chondros; J. Ong; R. Biezen; D. Pires; D. Capurro; N. Faux; J. A. Manski-Nankervis

doi:10.1071/SH24140

RESEARCH ARTICLE (Open Access)

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The gonorrhoea care cascade in general practice: a descriptive study to explore gonorrhoea management utilising electronic medical records

J. Jung

^A ^B ^C ^* , J. L. Goller

^D , P. Chondros ^A , J. Ong

^C ^E ^F , R. Biezen ^A , D. Pires ^B ^G , D. Capurro ^B ^G , N. Faux ^H and J. A. Manski-Nankervis ^A ^I

+ Author Affiliations

- Author Affiliations

^A Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Carlton, Vic, Australia.

^B Centre for Digital Transformation of Health, University of Melbourne, Carlton, Vic, Australia.

^C Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic, Australia.

^D Melbourne School of Population and Global Health, University of Melbourne, Carlton, Vic, Australia.

^E Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Vic, Australia.

^F Faculty of Infectious Disease, London School of Hygiene and Tropical Medicine, London, UK.

^G School of Computing and Information Systems, Faculty of Engineering & Information Technology, University of Melbourne, Carlton, Vic, Australia.

^H Melbourne Data Analytic Platform, University of Melbourne, Carlton, Vic, Australia.

^I Family Medicine and Primary Care, LKC Medicine, Nanyang Technological University, Singapore, Singapore.

^* Correspondence to: changjune.jung@unimelb.edu.au

Handling Editor: Huachun Zou

Sexual Health 22, SH24140 https://doi.org/10.1071/SH24140

Submitted: 7 July 2024 Accepted: 1 January 2025 Published: 30 January 2025

© 2025 The Author(s) (or their employer(s)). Published by CSIRO Publishing. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

Abstract

Background

Gonorrhoea notification rates in Australia have more than doubled between 2014 and 2019. We explored gonorrhoea testing patterns and management of gonorrhoea infection in general practice.

Methods

We analysed de-identified electronic medical record data for individuals who attended 73 Australian general practices (72 in the state of Victoria) between January 2018 and December 2020. The ‘care cascade’ model was utilised to explore gonorrhoea detection and management. Descriptive analysis and logistic regression were used to investigate factors associated with gonorrhoea testing, treatment and retesting.

Results

During the study period, there were a total of 1,027,337 clinical episodes. Of these, 5.6% (n = 57,847, 95% confidence interval [CI] 4.5–6.7) involved a gonorrhoea test and 1.1% (n = 637, 95% CI 0.8–1.4) tested positive. Of the 637 gonorrhoea cases, 48.4% (n = 308, 95% CI 29.8–67.0) had an Australian guideline-recommended dual antibiotic prescription (ceftriaxone and azithromycin) recorded. Of 329 cases without a dual antibiotic prescription, 84.2% (n = 277, 95% CI 77.5–90.9) had reattended the clinic. Among the 206 gonorrhoea cases with dual antibiotic prescription recorded in 2018 and 2019, 32.0% (n = 66, 95% CI 25.3–38.8) were retested from 6 weeks to 6 months post-treatment. Of the 140 gonorrhoea cases that were not retested, 54.3% (n = 76, 95% CI 46.8–61.8) reattended the clinic within 6 months of treatment.

Conclusion

The low proportion of gonorrhoea cases prescribed recommended antibiotics and retested within recommended timeframes suggests opportunities for integrating Australian STI guidelines into primary care. Further exploration of care pathways is warranted to determine if care was provided but not recorded, provided elsewhere or not provided.

Keywords: care cascade, epidemiology, general practice, gonorrhoea, primary care, routinely collected clinical data, sexually transmitted infection, STI.

Introduction

Gonorrhoea infection, caused by the bacterium Neisseria gonorrhoeae, is the second most common notified sexually transmissible infection (STI) in Australia¹ and can infect various sites, including the eyes, urogenital tract, oropharynx and rectum. Gonorrhoea infections in the oropharynx, rectum and female urogenital tract are often asymptomatic, which can result in delayed diagnosis. Untreated gonorrhoea infection in males is a risk factor for onward transmission to females, which may lead to serious complications, including pelvic inflammatory disease, ectopic pregnancy, infertility and adverse pregnancy outcomes.²^,³

The ‘care cascade’ is an epidemiological tool that has been used to identify gaps in the management of medical conditions, such as human immunodeficiency virus (HIV) and chlamydia,⁴^,⁵ by exploring their management in sequential steps. For gonorrhoea infection, the care cascade consists of three steps: (1) testing, (2) treatment and (3) retesting. Australian guidelines recommend STI screening every 3 months for men who have sex with men (MSM),⁶ whereas opportunistic STI screening at least annually is recommended for all young sexually active people.⁶^,⁷ Guidelines also recommend dual antibiotic treatment with ceftriaxone with azithromycin for gonorrhoea infection, and retesting at 3 months after treatment to detect reinfection as gonorrhoea reinfection is common.⁶

The gonorrhoea notification rate in Australia has increased more than two-fold over recent years, from 68 per 100,000 people in 2014 to 133 per 100,000 people in 2022.¹ General practitioners (GPs) are the first point of contact in the Australian healthcare system, and approximately 80% of Australians consulted a GP between 2018 and 2020.⁸ An estimated 37,000 GPs work across 8147 general practices in Australia.⁹ Although most STI tests and diagnoses in Australia occur in general practice,¹⁰ the management of gonorrhoea infection in general practice has not been well described. In this study, we utilised the ‘care cascade’ to explore the gonorrhoea management of individuals who attended general practices between 1 January 2018 and 31 December 2020.

Methods

Study design and population

We conducted a descriptive study to explore the pattern of gonorrhoea testing, treatment and retesting in 73 Australian general practices (72 in the state of Victoria). We used routinely collected general practice data which were obtained from the Patron repository, which is part of the Data for Decision research initiative at the Department of General Practice and Primary Care, The University of Melbourne.¹¹

The dataset included the demographic characteristics of patients; the geographical remoteness of general practices; the names, dates and results of pathology investigations performed; and the names and dates of prescribed medications.

Data were included for patients if they had attended a participating general practice at least once between 1 January 2018 and 31 December 2020 and were aged between 16 and 89 years at the time of their attendance.

Variables and data management

We identified patients who had been tested for gonorrhoea infection by exploring investigation names containing ‘gonorrhoea’, or ‘ctng’, or ‘ng’ only, or investigation results containing gonorrhoea nucleic acid amplification or gonorrhoea culture results. We included gonorrhoea tests from pharyngeal, urogenital and rectal sites, and we excluded swabs taken from the eye. We created outcomes to align with the gonorrhoea care cascade and defined them as follows:

Gonorrhoea testing – the proportion of gonorrhoea tests (pharyngeal, urogenital or rectal) performed at least once among clinical episodes of individuals who attended a GP clinic at least once during the study period.
Gonorrhoea positivity – the proportion of individuals with gonorrhoea tests who had at least one positive test result in any of the tests performed (pharyngeal, urogenital or rectal). Gonorrhoea tests with equivocal or indeterminate results, or those without recorded test results, were excluded.
Gonorrhoea treatment – the proportion of gonorrhoea cases that had recorded prescriptions of both ceftriaxone and azithromycin. We aimed to investigate first-line gonorrhoea treatment regimens – ceftriaxone and azithromycin. Therefore, we only included gonorrhoea cases that had records of these two antibiotics prescribed within 31 days from the sample collection date for reasons that timely antibiotic treatment is important. We did not explore the presence of second-line or other alternative antibiotic prescriptions.
Gonorrhoea retesting – the proportion of gonorrhoea cases with two antibiotic prescriptions that were retested between 6 weeks and 6 months (42–182 days). The retesting period was measured from the date of the ceftriaxone prescription to the sample collection date of the next gonorrhoea test. Rather than the guideline-recommended retesting period (3 months), we extended our retesting period up to 6 months to provide sufficient time for patients to reattend a clinic after being notified. We did not calculate the retested proportion for gonorrhoea cases diagnosed in 2020, as our data did not extend to 2021 to allow time for follow-up of all cases diagnosed in 2020. We also explored the test results of gonorrhoea cases without ceftriaxone or azithromycin prescriptions that were retested between 2 weeks and 6 months from their sample collection date as a proxy for whether these cases were treated without documentation or elsewhere.

Tenofovir disoproxil (TD)/emtricitabine (FTC) is an antiretroviral medication used for HIV infection treatment and pre-exposure prophylaxis (PrEP). A higher prevalence of STIs is observed in people living with HIV and PrEP users.¹²^,¹³ We identified patients who were prescribed TD/FTC at least once during the study period and used the presence of TD/FTC as a surrogate marker of this risk group for contracting STIs.

Explanatory categorical variables were created for calendar years (2018–2020), general practice location (metropolitan, regional, rural), sex (male, female, other), TD/FTC medication use (yes, no) and age group (16–19 years, 20–24 years, 25–29 years, 30–39 years, 40–49 years, 50–59 years and 60–89 years). Metropolitan clinics were defined as clinics located in the Modified Monash Model (MMM)¹⁴ category 1, regional clinics in MMM category 2–3 and rural clinics in MMM category 4–5 areas. There were no participating clinics located in the MMM category 6–7 areas.

In consideration that most patients with a TD/FTC prescription were males, we conducted a subgroup analysis of the gonorrhoea care cascade in males (Supplementary material Tables S2 and S3).

Statistical analysis

Data were analysed using R 4.2.2 and RStudio statistical software 2022.12.0, build 353.¹⁵ Each of our gonorrhoea care cascade events (a–d) were summarised as counts and percentages for the overall study period and by calendar year, clinic location, sex, TD/FTC medication and age group.

We investigated whether there were relationships between each of our explanatory variables (year, clinic location, sex, TD/FTC medication and age group) and outcomes (gonorrhoea testing, positivity, treatment and retesting) using univariable and multivariable logistic regression models with robust standard errors to adjust for the clustering effect of general practice. Estimates were reported as unadjusted odds ratios (OR) for the univariable model and adjusted odds ratios (aOR) for the multivariable model, with 95% confidence interval (CI) values and P-values. The intracluster correlation coefficient (ICC) for each outcome was estimated using one-way analysis of variance and was reported with 95% CI. The ICC is defined as the proportion of the true total variation in the outcome that can be attributed to the differences between general practices.¹⁶

Ethics

This study was approved by the Human Ethics Committee of the University of Melbourne (2022-20894-27314-5).

Results

Study sample characteristics

There were 1,027,337 clinical episodes of 527,647 individuals aged 16–89 years who attended the 73 general practices between January 2018 and December 2020, with 302,426 individuals contributing data to more than one calendar year. Seven of 73 general practices were multisite general practices that had more than one clinic in different locations within the same MMM region. The number of individuals who attended metropolitan general practices in 2020 (n = 206,845) was lower than that in 2019 (n = 218,466), whereas those in regional and rural clinics remained unchanged (Table 1). Of the clinical episodes, 61.3% (n = 629,962) were from individuals attending metropolitan general practices. Females had more clinical episodes than males (55.2% vs 44.3%) (Table 2). The distribution of the ICC for our study outcomes ranged from 0 to 0.527 (Table S1).

Table 1.Total number of individuals attending clinics by years and clinic locations.

Clinic location	Year	Number of clinics	Total number of individuals attended	Average number of individuals attended (per GP clinic)
Metropolitan clinics	2018	42 ^A	205,011	4881
	2019	42 ^A	218,466	5201
	2020	42 ^A	206,485	4916
Regional clinics	2018	10 ^B	48,512	4851
	2019	10 ^B	52,473	5247
	2020	10 ^B	52,311	5231
Rural clinics	2018	21 ^C	77,602	3695
	2019	21 ^C	82,411	3924
	2020	21 ^C	84,066	4003

^A Two were multisite general practices (both had two clinics).

^B Two were multisite general practices (one had three clinics and the other had two clinics).

^C Three were multisite general practices (one had four clinics, another had three clinics and the third had two clinics).

Table 2.Factors associated with gonorrhoea testing and positivity.

	Gonorrhoea testing								Gonorrhoea positivity
	Clinical episodes	Tests performed	Unadjusted			Adjusted			Test performed ^A	Positive cases	Unadjusted			Adjusted
	N	n (%)	OR ^B	95% CI	P	aOR ^C	95% CI	P	N	n (%)	OR ^B	95% CI	P	aOR ^C	95% CI	P
Overall ^D	1,027,337	57,847 (5.63)							57,653	637 (1.10)
Year ^D					<0.001			0.001					0.08			0.13
2018	331,125	19,168 (5.79)	Ref			Ref			19,003	191 (1.01)	Ref			Ref
2019	353,350	20,855 (5.90)	1.02	0.97–1.08		1.01	0.95– 1.07		20,842	257 (1.23)	1.23	1.00–1.51		1.13	0.91–1.40
2020	342,862	17,824 (5.20)	0.89	0.83–0.96		0.90	0.83– 0.97		17,808	189 (1.06)	1.06	0.79–1.41		0.92	0.67–1.26
GP location ^D					<0.001			0.028					0.25			0.25
Metropolitan	629,962	35,751 (5.68)	Ref			Ref			35,570	447 (1.26)	Ref			Ref
Regional	153,296	13,605 (8.87)	1.62	0.92–2.85		1.69	1.04– 2.75		13,598	118 (0.87)	0.69	0.42–1.12		0.77	0.56–1.05
Rural	244,079	8491 (3.48)	0.60	0.45–0.80		0.90	0.71– 1.13		8845	72 (0.85)	0.67	0.32–1.42		0.99	0.48–2.04
Sex					<0.001			<0.001					<0.001			<0.001
Male	454,648	15,310 (3.37)	Ref			Ref			15,246	445 (2.92)	Ref			Ref
Female	567,466	42,337 (7.46)	2.31	1.93–2.77		2.35	1.99– 2.77		42,209	189 (0.45)	0.15	0.12–0.19		0.20	0.17–0.25
Other	191	17 (8.90)	2.80	1.66–4.72		1.47	0.95– 2.26		17	1 (5.88)	2.08	0.24–17.77		2.77	0.34–22.5
TD/FTC Med ^D					<0.001			<0.001					<0.001			<0.001
No	1,026,122	56,838 (5.54)	Ref			Ref			56,645	501 (0.88)	Ref			Ref
Yes	1215	1009 (83.05)	85.53	66.39–105.09		121.38	91.37–161.26		1008	136 (13.49)	17.48	13.91–21.95		7.35	5.64–9.58
Age group (years) ^D					<0.001			<0.001					<0.001			<0.001
16–19	51,628	4644 (9.00)	Ref			Ref			4618	39 (0.84)	Ref			Ref
20–24	82,471	11,383 (13.80)	1.62	1.37–1.92		1.62	1.41–1.86		11,334	133 (1.17)	1.39	1.00–1.94		1.07	0.76–1.51
25–29	100,186	12,707 (12.68)	1.47	1.14–1.90		1.48	1.21–1.80		12,654	146 (1.15)	1.37	0.92–2.04		0.92	0.58–1.47
30–39	197,150	16,072 (8.15)	0.90	0.70–1.16		0.92	0.76–1.11		16,030	197 (1.23)	1.46	1.00–2.14		0.96	0.63–1.47
40–49	162,131	6808 (4.20)	0.44	0.35–0.56		0.45	0.38–0.55		6794	77 (1.13)	1.35	0.81–2.24		0.87	0.58–1.30
50–59	153,373	3262 (2.13)	0.22	0.17–0.28		0.23	0.18–0.28		3253	37 (1.14)	1.35	0.81–2.26		0.82	0.52–1.27
60–89	280,398	2971 (1.06)	0.11	0.08–0.14		0.12	0.09–0.14		2970	8 (0.27)	0.32	0.16–0.62		0.24	0.12–0.46

CI, confidence interval.

^A Excludes gonorrhoea tests performed that had indeterminate/equivocal result (n = 32) or did not have test results (n = 162).

^B Unadjusted odds ratio (OR) were estimated using univariable regression model with robust standard errors.

^C Adjusted odds ratio (aOR) were estimated using multivariable regression model with robust standard errors, including all explanatory variables (year, clinic location, sex, TD/FTC medication and age group) in the same model.

^D Includes 5032 clinical episodes of 4376 individuals with missing sex in gonorrhoea testing and 181 clinical episodes of 176 individuals with missing sex in gonorrhoea positivity.

Of the patients who had TD/FTC prescription at least once during the study period, 97.7% (n = 1187) were males.

Gonorrhoea testing and positivity

Overall, 5.6% of clinical episodes (n = 57,847) involved a gonorrhoea test (Table 2). Gonorrhoea testing in 2018 and 2019 was similar (5.8% and 5.9% respectively) but was lower in 2020 (5.2%, aOR 0.90, 95% CI 0.83–0.97). Gonorrhoea testing was higher in regional clinics (8.9%, aOR 1.69, 95% CI 1.04–2.75) than metropolitan clinics (5.7%), among females (7.5%, aOR 2.35, 95% CI 1.99–2.77) than males, those with TD/FTC prescriptions (83.1%, aOR 121.38, 95% CI 91.37–161.26) than those without, and 20–24-year-olds (13.8%, aOR 1.62, 95% CI 1.41–1.86) and 25–29-year-olds (12.7%, aOR 1.48, 95% CI 1.21–1.80) than 16–19-year-olds (9.0%).

Among those tested, gonorrhoea positivity was approximately 1.0% each year (Table 2). Gonorrhoea positivity was higher in metropolitan clinics (1.3%) than in other regions (0.9%), among males (2.9%) than females (0.5%, aOR 0.20, 95% CI 0.20–0.25) and those with TD/FTC prescriptions (13.5%, aOR 7.35, 95% CI 5.64–9.58) than those without (0.9%). Of males with gonorrhoea, 30.6% (n = 136) had TD/FTC prescriptions (Table S2), whereas none of the females with gonorrhoea had TD/FTC prescriptions. Gonorrhoea positivity was approximately 1.1% in all age groups except 16–19-year-olds (0.8%) and 60–89-year-olds (0.3%).

Of the gonorrhoea tests performed, 0.3% (n = 162) did not have test results and 0.1% (n = 32) had indeterminate/equivocal test results. These 194 gonorrhoea tests were excluded from the denominator of gonorrhoea positivity.

Gonorrhoea treatment (antibiotic prescription pattern)

Overall, 48.4% (n = 308) of the gonorrhoea cases had recorded prescriptions of both ceftriaxone and azithromycin antibiotics within 31 days from the sample collection date (Table 3). The proportion of gonorrhoea cases with recorded prescriptions of the two antibiotics was lower in regional (15.3%, aOR 0.11, 95% CI 0.02–0.47) and rural clinics (27.8%, aOR 0.18, 95% CI 0.04–0.82) than in metropolitan clinics (45.0%), and was higher in 2020 (54.0%, aOR 1.73, 95% CI 1.06–2.83) than in 2018 (45.0%) and 2019 (46.7%).

Table 3.Factors associated with gonorrhoea treatment and retesting.

	Gonorrhoea treatment (ceftriaxone and azithromycin antibiotic prescription pattern)								Gonorrhoea retesting in 2018 and 2019 (retesting 6 weeks–6 months after treatment) ^A
	Positive cases	Cases with dual antibiotics	Unadjusted			Adjusted			Cases with dual antibiotics	Retested case	Unadjusted			Adjusted
	N	n (%)	OR ^B	95% CI	P	aOR ^C	95% CI	P	N	n (%)	OR ^B	95% CI	P	aOR ^C	95% CI	P
Overall ^D	637	308 (48.35)							206	66 (32.04)
Year ^D					0.27			0.08					0.03			0.05
2018	191	86 (45.03)	Ref			Ref			86	23 (26.74)	Ref			Ref
2019	257	120 (46.69)	1.07	0.66–1.73		1.25	0.78–2.02		120	43 (35.83)	1.53	1.02–2.29		1.55	1.00–2.40
2020	189	102 (53.97)	1.43	0.89–2.31		1.73	1.06–2.83		–	–	–	–		–	–
GP location ^D					0.03			0.007					0.14			0.11
Metropolitan	447	270 (60.4)	Ref			Ref			177	61 (34.46)	Ref			Ref
Regional	118	18 (15.25)	0.12	0.02–0.57		0.11	0.02–0.47		15	3 (20.00)	0.48	0.12–1.81		0.53	0.11–2.43
Rural	72	20 (27.78)	0.25	0.05–1.17		0.18	0.04–0.82		14	2 (14.29)	0.32	0.08–1.19		0.27	0.07–0.97
Sex					0.73			0.29					0.03			<0.001
Male	445	212 (47.64)	Ref			Ref			140	37 (26.43)	Ref			Ref
Female	189	95 (50.26)	1.11	0.61–2.03		1.26	0.82–1.92		65	29 (44.62)	2.24	1.06–4.73		4.99	2.29–10.90
Other	1	0 (0)	–	–		–	–		–	–	–	–		–	–
TD/FTC Med ^D					0.93			0.09					0.002			<0.001
No	501	254 (50.70)							180	50 (27.78)	Ref			Ref
Yes	136	54 (39.71)	0.64	0.29–1.43		0.55	0.27–1.10		26	16 (61.54)	4.16	1.68–10.29		9.09	2.84–29.06
Age group (years) ^D					0.14			0.19					0.17			0.02
16–19	37	16 (43.24)	Ref			Ref			12	4 (33.33)	Ref			Ref
20–24	131	67 (51.15)	1.37	0.69–2.73		1.12	0.56–2.23		46	9 (19.57)	0.49	0.15–1.60		0.36	0.09–1.50
25–29	149	77 (51.68)	1.40	0.67–2.93		1.13	0.53–2.38		49	15 (30.61)	0.88	0.28–2.73		0.83	0.20–3.52
30–39	198	96 (48.48)	1.24	0.56–2.71		0.95	0.51–1.77		64	25 (39.06)	1.28	0.38–4.35		1.77	0.42–7.55
40–49	76	33 (43.42)	1.01	0.44–2.28		0.72	0.33–1.57		20	8 (40.00)	1.33	0.34–5.21		1.40	0.36–5.44
50–59	38	18 (47.37)	1.18	0.44–3.15		1.04	0.40–2.73		14	5 (35.71)	1.11	0.19–6.52		1.43	0.18–11.54
60–89	8	1 (12.50)	0.19	0.02–1.90		0.18	0.02–1.91		1	0 (0)	–	–		–	–

CI, confidence interval.

^A Retested proportion in 2020 was not calculated due to lack of data in 2021.

^B Unadjusted odds ratio (OR) were estimated using univariable regression model with robust standard errors.

^C Adjusted odds ratio (aOR) were estimated using multivariable regression model with robust standard errors, including all explanatory variables (year, clinic location, sex, TD/FTC medication and age group) in the same model.

^D Includes two clinical episodes of two individuals with missing sex in gonorrhoea treatment and one clinical episode of one individual with missing sex in gonorrhoea retesting.

Of those without recorded prescriptions of ceftriaxone and azithromycin (n = 329), consisting of 5.2% (n = 17) having only ceftriaxone prescriptions, 42.2% (n = 139) having only azithromycin prescriptions and 52.6% (n = 173) being without ceftriaxone or azithromycin prescriptions, 84.2% (n = 277) reattended clinics within 31 days from the sample collection date (or from the antibiotic prescription date if either ceftriaxone or azithromycin was prescribed) but did not have recorded prescriptions of the two antibiotics.

Gonorrhoea retesting

Among the gonorrhoea cases that had recorded prescriptions of ceftriaxone and azithromycin in 2018 and 2019 (n = 206), 7.8% (n = 16) were retested between 2 and 6 weeks (15–41 days), and 32.0% (n = 66) were retested between 6 weeks and 6 months (42–182 days) after treatment (Table 3). Gonorrhoea retesting was higher in metropolitan clinics (34.5%) than in rural clinics (14.3%, aOR 0.27, 95% CI 0.07–0.97), among females (44.6%, aOR 4.99, 95% CI 2.29–10.90) than males (26.4%), and those with TD/FTC prescriptions (61.5%, aOR 9.09, 95% CI 2.84–29.06) than those without (27.8%). Gonorrhoea retesting was above 30% in all age groups except 20–24-year-olds (20%). Of the gonorrhoea cases not retested within 6 weeks–6 months (42–182 days) (n = 140), 54.3% (n = 76) reattended the clinic within 6 months of treatment. Overall, 9.1% (n = 6) of those who were retested for gonorrhoea had positive results.

Of 173 gonorrhoea cases without recorded prescriptions of ceftriaxone and azithromycin, 6.4% (n = 11) were retested between 2 and 6 weeks (15–41 days) from the sample collection date and all of them had negative test results. 35.3% (n = 61) were retested between 6 weeks and 6 months (42–182 days) from the sample collection date and 95.1% of those (n = 58) had negative gonorrhoea results.

The gonorrhoea care cascade in males had similar care patterns and associated factors with the analyses that included all patients (Tables S2 and S3).

Discussion

In this study, we explored the gonorrhoea care cascade in general practice. We found, for patients attending general practice between 2018 and 2020, that gonorrhoea tested proportions were highest (over 80%) for individuals who had HIV infection or were taking PrEP. For diagnosed gonorrhoea cases, only half had the guideline-recommended antibiotic prescription recorded and only one-third were retested within the recommended time frame. We also identified that 84% of those without the guideline-recommended antibiotic prescription, and 54% of those without a retest, reattended within the relevant period, which may indicate missed opportunities for treatment and retesting.

For the testing step, we found that the odds of gonorrhoea testing were over 100-fold higher for patients with a TD/FTC prescription compared to those without. TD/FTC medication has been widely used as an HIV PrEP therapy in Australia since 2018,¹⁷ and Australian guidelines recommend 3 monthly STI tests for people with HIV PrEP therapy.⁶ Our study showed that the majority of TD/FTC prescription occurred in males (98%) and suggests that much gonorrhoea testing for males is influenced by them being on PrEP. We also observed higher gonorrhoea testing but lower positivity in females than males. Previous studies¹^,⁵ showed that more chlamydia testing was performed in females. Concurrent testing for gonorrhoea along with chlamydia testing is likely to contribute to the higher gonorrhoea testing rates observed in females. Higher gonorrhoea diagnoses in males than females may be due to different indications for testing and testing guidelines and higher prevalence of gonorrhoea infection in MSM, especially those using HIV PrEP.¹^,¹²^,¹³ Gonorrhoea infection in the male urethra often causes urethral symptoms, whereas gonorrhoea infections in the female urogenital tract are often asymptomatic.¹⁸ In addition, current Australian STI guidelines recommend 3 monthly STI screening tests for MSM, resulting in detecting more asymptomatic oropharynx and rectal gonorrhoea infections in males than those in females. These two explanations may result in a higher gonorrhoea positivity in males than females. In addition, we found that gonorrhoea testing was lower in 2020 along with the lower patient attendance rate in metropolitan clinics. This is consistent with other studies showing COVID-19 pandemic restrictions resulted in a reduction in STI screening tests and clinic visits to primary care and sexual health services.¹⁹^,²⁰ COVID-19 restrictions imposed in Melbourne during 2020²¹ may have resulted in lower gonorrhoea testing in 2020.

For the treatment step, we found that approximately half of the gonorrhoea cases, especially those in regional and rural clinics, did not have the recommended dual antibiotic prescriptions recorded. We also found that 96% of gonorrhoea cases without recorded ceftriaxone or azithromycin antibiotic prescriptions retested between 2 weeks and 6 months had negative test results. Due to data privacy, we were not able to contact clinics or view clinical notes to explore the reasons for these findings. However, given that most cases without a recorded antibiotic prescription retested had negative results, it is possible that the infections were treated but that data were unavailable for this analysis. For example, antibiotic prescriptions may not be recorded in the electronic record if a handwritten prescription or ceftriaxone and azithromycin were provided directly to patients. Alternatively, patients may have been referred and treated elsewhere. Other possible explanations could be that ceftriaxone only was prescribed if clinicians followed the UK or USA guidelines,²²^,²³ or that azithromycin only was prescribed due to ceftriaxone allergy or patients refusing intramuscular ceftriaxone injection or, finally, that the patient was not treated appropriately. The Australian government has developed an electronic health record system, My Health Record, where different healthcare professionals can view summaries of their patient’s health information, including government-subsidised prescription medication.²⁴ In 2023, more than 90% of Australians registered on My Health Record.²⁵ Utilising My Health Record could be an effective mechanism for examining gonorrhoea prescribing, treatment patterns and better understanding any identified gaps. My Health Record also can provide a platform for clinicians to monitor their patients’ treatment history when their patients are referred to other services.

For our retesting step, the low retested proportion is of concern, as undiagnosed reinfection can result in serious reproductive health complications.²^,³ Our study finding is consistent with other international studies where the proportion of people retested ranged from 15.1% to 43.0%.²³^,²⁶^,²⁷ There appeared to be opportunities for retesting given that half of those who were not retested reattended after treatment.

Our study had several limitations. First, our study findings could not be generalised nationally, as virtually all the general practices in this study were in Victoria. Second, we also included only patients with ceftriaxone and azithromycin prescriptions and did not explore other antibiotic prescriptions that may be appropriate for some patients with gonorrhoea infection, especially those with ceftriaxone and/or azithromycin allergies. Third, although review of clinical notes would help to understand the reasons for a lack of prescription or prescribing that did not adhere to the guidelines, it was not possible within this present study. Furthermore, as our retesting period included 6 weeks–3 months periods, cases that were performed for a ‘test-of-cure’ rather than a ‘retesting-for-reinfection’ may have been included. Lastly, we were not able to identify individuals who attended different clinics for their antibiotic prescriptions and retesting, which may result in overestimating treatment and retesting gaps.

An important strength of our study is the large sample size and a low risk of detection bias due to it involving retrospective analyses of routinely collected clinical data and because we did not implement any intervention. In addition, the ICC provided in our study can inform the design of future cluster-based research in primary care settings.

To our knowledge, this is the first study to explore the gonorrhoea care cascade of patients attending Australian general practices. Inadequate treatment combined with inadequate retesting increases the risk of reinfection, anti-microbial resistance and onward transmission. Further work in integrating Australian STI guidelines into primary routine care and understanding care pathways for people with gonorrhoea infection is indicated, and the use of My Health Record may support better understanding and offer solutions for where to target gaps in care.

Supplementary material

Supplementary material is available online.

Data availability

The data that support this study cannot be publicly shared due to ethical or privacy reasons and may be shared upon reasonable request to the corresponding author if appropriate.

Conflicts of interest

Jason Ong is the co-Editor-in-Chief of Sexual Health. To mitigate this potential conflict of interest they had no editor-level access to this manuscript during peer review. The authors have no further conflicts of interest to declare.

Declaration of funding

Salary support for Jun Jung was provided by the Duncan Leary Philanthropic Trust through the Centre for Digital Transformation of Health, University of Melbourne.

Acknowledgements

This research used de-identified patient data from the Patron primary care data repository (extracted from consenting general practices), that has been created and is operated by the Department of General Practice, The University of Melbourne: www.gp.unimelb.edu.au/datafordecisions. We thank participating general practices who shared their data and made this study possible.

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