Outpatient sexually transmitted infection testing and treatment ... - BMC Infectious Diseases
Episodes and patient characteristics
In total, 23,537,812 LGUTS episodes (87.4% from women; 12.6% from men) (Additional file 1: Table S4) were analyzed from 12,341,154 patients (Fig. 1). The median age of patients at index was 38 years old (interquartile range 26–51 years), with 46.2% of the cohort aged between 40 and 64 years old. Further patient demographics are shown in Additional file 1: Table S4.
Diagnostic testing patterns and trends
Over the study period, only 17.6% of all episodes received CT/NG testing (Table 1). However, rates of CT/NG testing generally increased over time in all age groups (Additional file 1: Table S5). Those presenting with LGUTS who were most often tested for CT/NG were the 20–24-year-olds; testing occurred in 44.3% and 31.3% of episodes from men and women, respectively, in this group (Table 1). The 40–64-year age bracket was the least likely age group to receive CT/NG testing; only 7.8% and 7.4% of episodes in men and women aged ≥ 40, respectively, received testing. Those aged between 40 and 64 years old most often received non-CT/NG testing. Similar percentages of episodes that received no testing were observed across all age groups for men (18.6–22.9%) and women (12.2–15.8%).
Evolution of antimicrobial therapy over time
Of all episodes included, 44.4% did not receive antibiotics between the index date and return visit or end of episodes. For those episodes in which patients ultimately received treatment within 2 weeks of the index date, 89.3% received treatment within the first 3 days, and 77.7% received it on the index date.
The largest percentage of antimicrobial claims over the study period was for urinary anti-infectives (Table 2a). Of all episodes, 24.7% had a urinary anti-infective claim within the entire episode including up to 14 days of the last visit date. When stratified by year, urinary anti-infective claims increased substantially from 20.8% in 2010 to 30.2% in 2019.
Of antimicrobials prescribed, the second highest claims were for fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin) (19.0%) and there was a 18% relative reduction for fluoroquinolone claims between 2016 and 2017 from 18.1% to 14.8%, respectively (Table 2a), reflective of the Food and Drug Administration restriction in 2016 [23].
Of all episodes, 12.3% had nitroimidazole (e.g., metronidazole) claims within the entire episode including up to 14 days of the last visit date. Ceftriaxone claims gradually increased from 2010 to 2019 (2.2–6.5%; Table 2a), reflective of the changes to the Centers for Disease Control and Prevention (CDC) STI treatment guidelines [12].
Only 66.4% of all episodes in patients diagnosed with NG had an associated antibiotic claim within the entire episode including up to 14 days of the last visit date (Table 2b). From 2010 to 2018, there was a 73% relative reduction for cefixime claims (2.6% to 0.7%) and between 2010 and 2012 these claims fell by 26% (2.6% to 1.9%), indicative of decreased susceptibility of NG strains [24] to cefixime in the US and changes to the STI treatment guidelines in that timeframe [25]. Macrolide, ceftriaxone, and gentamicin claims for those diagnosed with NG generally increased from 2010 to 2019.
Testing and treatment patterns based on specific diagnostic codes
For women diagnosed with PID, 15.0% were tested for CT/NG and 41.9% were prescribed antibiotics within 3 days of diagnosis (Table 3). The age group most and least likely to receive CT/NG testing (days 1–3) were 14–19-year-olds (30.2%) and 40–64-year-olds (7.9%), respectively. The age group most and least likely to receive treatment (days 1–3) were 20–24-year-olds (57.1%) and 40–64-year-olds (28.4%), respectively. Of those women diagnosed with cervicitis, 24.2% received CT/NG testing and 17.1% received antibiotic treatment on days 1–3. The age group most and least likely to receive CT/NG testing and treatment within 3 days were 14–19-year-olds (64.8% tested; 41.9% treated) and 40–64-year-olds (10.3% tested; 10.9% treated), respectively.
For men diagnosed with orchitis/epididymitis, urethritis, and acute prostatitis, 10.3%, 57.7%, and 4.0% received CT/NG testing, respectively, and 58.2%, 61.5%, and 57.5% received antibiotic treatment within 3 days of diagnosis, respectively (Table 3). For all three male-specific diagnoses, the age groups most and least likely to receive CT/NG testing within 3 days were the 20–24-year-olds and 40–64-year-olds respectively, and treatment rates were similar across all age groups.
Testing rates for these specific conditions were similar when extending the time period up to 7 days after diagnosis, therefore almost all testing occurred within 1–3 days (data not shown).
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