Objectives. We evaluated the impact of revised national treatment recommendations on fluoroquinolone use for gonorrhea in selected states.

Methods. We evaluated gonorrhea cases reported through the Sexually Transmitted Disease Surveillance Network as treated between July 1, 2006 and May 31, 2008, using interrupted time series analysis. Outcomes were fluoroquinolone treatment overall, by area, and by practice setting.

Results. Of 16 126 cases with treatment dates in this period, 15 669 noted the medication used. After revised recommendations were released, fluoroquinolone use decreased abruptly overall (21.5%; 95% confidence interval [CI] = 15.9%, 27.2%), in most geographic areas evaluated, and in sexually transmitted disease clinics (28.5%; 95% CI = 19.0%, 37.9%). More gradual decreases were seen in primary care (8.6%; 95% CI = 2.6%, 14.6%), and in emergency departments, urgent care, and hospitals (2.7%; 95% CI = 1.7%, 3.7%).

Conclusions. Fluoroquinolone use decreased after the publication of revised national guidelines, particularly in sexually transmitted disease clinics. Additional mechanisms are needed to increase the speed and magnitude of changes in prescribing in primary care, emergency departments, urgent care, and hospitals.

More than 700 000 gonorrhea infections are estimated to occur in the United States each year.1 In 2008, 112 cases per 100 000 population were reported2—well above the Healthy People 2010 target of 19 cases per 100 000 population.3 Infection can cause pelvic inflammatory disease with long-term consequences including ectopic pregnancy, infertility, and chronic pelvic pain and may increase HIV transmission.4 Effective treatment is critical both to prevent sequelae in affected patients and to prevent the spread of infection to others. Treatment is challenging because of the ease with which Neisseria gonorrhoeae develops resistance to antimicrobials and the increased frequency of N. gonorrhoeae infections that are resistant to multiple classes of antimicrobials, including sulfanilamides, penicillin, tetracyclines, and, most recently, fluoroquinolones.5,6

The World Health Organization and the Centers for Disease Control and Prevention (CDC) have suggested that an antibiotic should no longer be routinely recommended for treatment of an infection when prevalence of infections resistant to that antibiotic exceeds 5%.7 Because of the increasing prevalence of fluoroquinolone-resistant N. gonorrhoeae above this threshold in specific areas and populations, fluoroquinolones were no longer recommended for treatment of gonococcal infections in Hawaii in 2000,8 in California in 2002,9 and for men who have sex with men in 2004.10 Prevalence of ciprofloxacin-resistant N. gonorrhoeae among heterosexual men in the Gonococcal Isolate Surveillance Project increased from 0.6% in 2001 to 6.7% in the first 6 months of 2006.11 Because of this increase, revised CDC guidelines that no longer recommended fluoroquinolones for the treatment of gonorrhea were published in Morbidity and Mortality Weekly Report on April 13, 2007, leaving cephalosporins as the only class of antimicrobials available in the United States recommended for gonorrhea treatment.11 These recommendations updating the CDC's STD Treatment Guidelines were sent to state and local health departments in a dear colleague letter and were announced at a national press conference timed to correspond with the Morbidity and Mortality Weekly Report article. This announcement received extensive media attention.12–16 It is not known how many providers were reached or how providers responded to the revised recommendations.

Previous studies have found that 78% of physicians either owned a copy of the CDC's STD Treatment Guidelines or knew how to access the guidelines17 and that adherence to sexually transmitted disease (STD) care guidelines was greater in STD clinics than in general medical clinics.18 However, little is known about practice changes after guideline revisions. To evaluate the impact of revised CDC guidelines on fluoroquinolone use, we used data from the STD Surveillance Network (SSuN). We employed interrupted time series analysis to evaluate the impact of revised guidelines on fluoroquinolone use and to determine whether impact varied by geographic area or by practice setting.

• Quantitative data - Quantitative data were used during the intervention

• Human - All activities regarding organisations and individuals involved in health products and services

• Healthcare delivery