Design
A cross-sectional study was conducted to collect data on gonorrhoea cases (including all anatomic locations) and antimicrobial management in general practice. The experiences of GPs with the recommended intramuscular administration of third-generation cephalosporins were investigated by a questionnaire.
Setting
The study was performed using the General Practice Department research database of the Amsterdam University Medical Center (AUMC) in southeast-Amsterdam, the Netherlands. Southeast-Amsterdam is a multicultural and low economic status neighborhood with a relatively high prevalence of STI [13]. The database contains anonymized electronic health records of more than 45,500 active patients from 35 GPs in six health centers in southeast-Amsterdam. These data include sex, date of birth, information on patients’ medical history, summaries of consultations, results of diagnostic tests and drug prescriptions. The health problems of the patients are documented as episodes and coded according to the International Classification of Primary Care-1 (ICPC-1).
Data collection
A 6-year period from January 1st 2010 to January 1st 2016 was assessed to determine potential gonorrhoea cases. Details were obtained about all registered episodes coded as gonorrhoea according to the ICPC-1, i.e. Y71 for men and X71 for women. Sometimes symptom-based episode codes from the first visit might not be changed to the definitive gonorrhoea-ICPC after receiving laboratory outcomes. We expected that diagnoses at highest risk for missing gonorrhoea cases due to this missing recoding, were urethritis and epididymitis. Therefore, episodes coded as urethritis and epididymitis for men were collected and checked for a potential underlying gonorrhoea infection that was not recoded as gonorrhoea, respectively ICPC Y99 and Y74. The subcodes Y99.01 and Y99.02, respectively testicular torsion and spermatocele, were excluded.
A period of 2 months before and 2 months after the respective diagnosis was determined as one episode. A case was defined as an episode confirmed to this period, including patients aged 15 years and older who received treatment in general practice. To assess the prescribing practices in the treatment of gonorrhoea, all cases were based on one of the three treatment indications applied in general practice according to the Dutch guideline: positive test outcome (nucleic acid amplification test, culture, gram stain), syndrome management (specific STI-symptoms) or partner management (a confirmed gonorrhoea infection in a sex partner) [6]. Cases that were diagnosed in other settings were excluded (Fig. 1 Inclusion of gonorrhoea cases based on ICPC codes). Details of all registered episodes were extracted together with the following case characteristics: date of birth, date of diagnosis, sex, anatomic location of infection, complication, coinfection (and if documented sexual orientation, ethnicity and HIV-status). An interval of 6 months after respective diagnosis was needed to check the HIV test results, because of the potential HIV window period [6].
Survey design
The 35 GPs currently participating in the General Practice Department research database, concerning all six health centers, were approached by email with an online Dutch questionnaire to explore their experiences with the administration of intramuscular third-generation cephalosporins in the past years. Questions were designed by the authors and sent by head of the General Practice Department research database of the AUMC. Data were obtained on the opinion of three statements: 1) “I experience intramuscular administration of third-generation cephalosporins as a cumbersome procedure”, 2) “I prefer a single intramuscular dose over multiple oral doses (because of compliance)”, 3) “I prefer culture-based oral therapy over immediate blind intramuscular therapy”. The GP could indicate to what extent they were in agreement with each statement on a five point Likert scale. GPs were reminded once to complete the questionnaire.
Data analysis
Descriptive analyses were performed using IBM SPSS Statistics version 23. The annual number and characteristics of diagnosed gonorrhoea infections were assessed. The incidence was calculated based on the yearly registered patients in the participating health centers in southeast-Amsterdam [14]. In addition, the current guideline implementation was demonstrated by reporting the annual percentage of administered first choice treatment according to the guideline. Since the updated guideline was published end of 2013, we defined intramuscular cefotaxime and ceftriaxone in the period 2010 to 2014 as first choice therapy in general practice. Since 2014 only ceftriaxone was defined as first choice treatment. The percentage and variety of alternative antibiotics were reported together with reasons for administration documented in the electronic patient files. This included the number of culture-based alternative antibiotic therapies.
Ethics approval
The quantitative and qualitative data used for the study are anonymized. Therefore, formal assessment by the Medical Ethic Committee was not necessary according to Dutch.