ORIGINAL STUDY
Factors Associated With Primary Care Physician
Knowledge of the Recommended Regimen
for Treating Gonorrhea
Marta Bornstein, MPH,* Faruque Ahmed, PhD,* Roxanne Barrow, MD, MPH,*
Jami Fraze Risley, PhD,* Sheena Simmons, MPH,* and Kimberly A. Workowski, MD†
Background: The recommended regimen for treating uncomplicated
gonorrhea has changed over time, due to the emergence of antimicrobial re-
sistance. We assessed physician knowledge of the recommendation for
treating uncomplicated urogenital gonorrhea in adolescents and adults
using ceftriaxone and azithromycin dual therapy.
Methods: We analyzed DocStyles 2015 survey data from 1357 primary
care physicians practicing for at least 3 years who provided screening, diag-
nosis, or treatment for sexually transmitted diseases to one or more patients
in an average month. Logistic regression and χ2 analyses were used to iden-
tify factors associated with knowledge of dual therapy.
Results: Among the options of treatment with ceftriaxone alone,
azithromycin alone, both of these, or spectinomycin plus levofloxacin,
64% of physicians correctly preferred ceftriaxone plus azithromycin.
Knowledge of the recommended dual therapy decreased with increasing
years of practice, ranging from 74% among physicians with 3–9 years of
practice to 57% among those practicing for ≥24 years (adjusted odds
ratio, ORa, for ≥24 vs 3–9 years of practice, 0.50; 95% confidence in-
terval [CI], 0.35–0.70). Knowledge of dual therapy decreased with
higher socioeconomic status of patients (ORa for high income vs
poor/lower middle income patients, 0.47; 95% CI, 0.32–0.69). Physi-
cians who pursued continuing medical education using journals, podcasts,
and government health agencies were more likely to report dual therapy
than those who did not use these sources (ORa, 2.09; 95% CI, 1.31–3.33).
Conclusions: Knowledge of the recommended regimen for treating gon-
orrhea decreased with increasing years of practice and with higher socio-
economic status of patients.
G onorrhea is the second most commonly reported notifiable
disease in the United States,1 with an estimated 820,000
new gonococcal infections occurring each year.2 The first-line rec-
ommended regimen for treating gonococcal infections has changed
over time, due to the emergence of antimicrobial resistance. From
1993 to 2010, the Centers for Disease Control and Prevention
(CDC) recommended ceftriaxone or cefixime or ciprofloxacin or
ofloxacin or levofloxacin as the first-line regimen for treatment
of uncomplicated gonococcal infections of the cervix, urethra, or
rectum in adolescents and adults; cotreatment for chlamydia with
azithromycin or doxycycline was recommended if chlamydia
From the *Division of STD Prevention, Centers for Disease Control and
Prevention, Atlanta, GA, and †Department of Medicine, Division
of Infectious Diseases, Emory University, Atlanta, GA
Conflict of interest and sources of funding: None declared.
Disclaimer: The findings and conclusions in this report are those of the
authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention. MB and FA are co-
leads on the manuscript.
Correspondence: Faruque Ahmed, PhD, Centers for Disease Control and
Prevention, 1600 Clifton Rd, Mail Stop E-03, Atlanta, GA 30329.
E‐mail: fahmed@cdc.gov.
Received for publication June 16, 2016, and accepted September 16, 2016.
DOI: 10.1097/OLQ.0000000000000542
Copyright © 2016 American Sexually Transmitted Diseases Association
All rights reserved.
14 Sexually Transmitted Diseases
Copyright © 2016 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
infection was not ruled out.3 In 2010, CDC recommended dual
therapy for gonococcal infections with ceftriaxone (or cefixime
if ceftriaxone was not an option) plus either azithromycin or doxy-
cycline, even if chlamydia test was known to be negative at the
time of treatment, to potentially slow the emergence and spread
of resistance to cephalosporins.4 In 2012, dual therapy with ceftri-
axone plus either azithromycin or doxycycline was recommended
regardless of the chlamydia test results (cefixime was no longer
recommended as a first-line regimen).5–7 Since June 5, 2015, dual
therapy with ceftriaxone plus azithromycin is recommended. In
the context of rapidly changing recommendations for manage-
ment of uncomplicated gonorrhea in the past decade, we assessed
primary care physicians' knowledge of the first-line recommended
regimen for treating uncomplicated urogenital gonorrhea using
ceftriaxone and azithromycin dual therapy as opposed to mono-
therapy with ceftriaxone or azithromycin.
METHODS
Survey
The data were collected through the DocStyles Web-based
survey developed by Porter Novelli with guidance provided by
federal public health agencies and other non-profit and for-profit
clients. A random sample of physicians was selected to match
the American Medical Association's Masterfile of licensed US
physicians for age, gender, and region.8 The 2015 survey included
questions on counseling, screening, alcohol, physical activity, hy-
pertension, human papillomavirus, human immunodeficiency vi-
rus, and sexually transmitted diseases (STDs). The survey also
contained standard general and demographic questions that are in-
cluded every year, such as sources used to pursue continuing med-
ical education (CME). The sampling frame was SERMO's Global
Medical Panel (www.sermo.com), which includes over 330,000
medical professionals in the United States. The panel was primar-
ily recruited at clinicians' place of work (84%) and through online
and face-to-face methods with additional work-place verification
(16%). Panelists were then verified using a double opt-in sign up
process with telephone confirmation at their place of work.
SERMO panelists agree to participate and meet the criteria for
each survey (US clinicians actively seeing patients in an individ-
ual, group, or hospital practice for at least 3 years). To reach the
quotas of 1000 family medicine and internal medicine physicians,
250 pediatricians, and 250 obstetricians/gynecologists, 1794 phy-
sicians were randomly sampled. Respondents were paid an hono-
rarium of US $35–80.
Porter Novelli Public Services (www.porternovelli.com)
conducted the survey from June 4 to June 23, 2015. Of the 1794
physicians sampled, 1500 (84%) completed the survey (Table 1).
Compared with the American Medical Association's master file,
physicians who completed the survey comprised a higher propor-
tion of males (by 10 percentage points). Physicians who responded
that they provided STD screening, diagnosis, or treatment to zero
• Volume 44, Number 1, January 2017
 Recommended Regimen for Treating Gonorrhea

TABLE 1. Physician Response Information, DocStyles Survey, June 2015

No Response
Terminated—Did Terminated or Responded
Physician Randomly Completed Incomplete Not Meet Screening Due to Filled Quota After Survey
Specialty Sampled Survey Survey Criteria* for Specialty† Closed
Family medicine 1122 1000 23 44 10 45
and internal medicine
Pediatrics 325 250 3 23 9 40
Obstetrics/ 347 250 7 14 14 62
gynecology
Total 1794 1500 33 81 33 147

*Practiced in the United States and actively saw patients in an individual, group, or hospital practice for at least 3 years.
†
Quotas were set to reach 1,000 family medicine and internal medicine physicians, 250 pediatricians, and 250 obstetricians/gynecologists.

patients in an average month were excluded from analysis
(n = 143), resulting in a final analytic data set of 1357 physicians.
Analysis of the data was deemed to be exempt from institutional
review board approval because no individual identifiers were in-
cluded in the data file obtained by the CDC.8
Analysis
The main outcome of interest was provider knowledge of
the first-line recommended regimen for treating gonorrhea. This
was measured with the question “Which of the following regimens
is the best option in the case of an 18-year-old man with gonococ-
cal urethritis?” The response options were single dose ceftriaxone
250 mg intramuscularly, single dose azithromycin 1.0 g orally,
both of these, or single dose spectinomycin 2.0 g intramuscularly
plus levofloxacin 500 mg orally for 7 days. Other variables ana-
lyzed included physician specialty; physician gender; years in
practice; physician age; number of practitioners in practice; prac-
tice region; estimated financial situation of the majority of patients
in the respondent's practice; and sources used to pursue CME in
the past year (journals, medical podcasts, government health agen-
cies like CDC or National Institutes of Health, conferences, inter-
net sites, classes, CD-ROM).
χ2 tests were used to examine differences among groups.
The Wald normal approximation was used to calculate 95% confi-
dence interval (95% CI) of proportions. Multivariate logistic re-
gression model was fit using forward selection in SAS PROC
LOGISTIC to ascertain the association between covariates (inde-
pendent variables) and knowledge of dual therapy (dependent
variable). Because of high correlation between years in practice
and physician age (Spearman correlation coefficient = 0.92), phy-
sician age was excluded. Among the CME sources used, journals,
podcasts, and government health agencies were significantly asso-
ciated with knowledge of dual therapy in the univariate analysis
(data not shown), but collinearity between these variables was ob-
served in the model. A composite CME variable was therefore cre-
ated (responses were recoded into 4 categories: all of the 3 CME
sources; 2 of the 3 CME sources; 1 of the 3 CME sources; and
none of the 3 CME sources). The analysis was performed using
SAS software (version 9.3, SAS Institute, Inc., Cary, NC).
RESULTS
The respondents had a median age of 45 years (5th, 95th
percentile: 32, 64) with a median of 15 years in practice (5th,
95th percentile: 5, 31). Overall, 64% of physicians reported that
the best option for treating an 18-year-old man with gonococcal ure-
thritis was ceftriaxone and azithromycin dual therapy (Table 2).
This ranged from 60% of obstetricians/gynecologists to 69% of
family medicine physicians. The proportion reporting ceftriaxone
monotherapy was 19%. The proportion who were not sure was
13% for obstetricians/gynecologists compared with 2%–6% for
the other specialties.
Knowledge of the recommended dual therapy for uncom-
plicated urogenital gonorrhea decreased with increasing years of
practice, ranging from 74% among physicians with three to nine
years of practice to 57% among physicians with ≥24 years of prac-
tice (adjusted odds ratio [ORa] for ≥24 vs 3–9 years of practice,

TABLE 2. Physician Reporting of Best Option for Treating 18-Year-Old Man With Gonococcal Urethritis, DocStyles Survey, June 2015*
Family Medicine Internal Medicine Pediatrics Obstetrics/Gynecology Total
Treatment† (n = 442) (n = 450) (n = 216) (n = 249) (n = 1357)
Ceftriaxone 250 mg intramuscularly 69% (64–73) 61% (56–65) 66% (59–72) 60% (54–66) 64% (61–67)
in a single dose plus azithromycin
1 g orally in a single dose
Ceftriaxone 250 mg 18% (14–21) 22% (18–26) 19% (14–25) 18% (13–23) 19% (17–21)
intramuscularly in a single dose
Azithromycin 1 g orally in a single dose 10% (7–12) 11% (8–14) 9% (5–13) 7% (4–10) 10% (8–11)
Spectinomycin 2 g in a 2% (1–3) 1% (0–2) 0% (0–0) 2% (0–4) 1% (1–2)
single intramuscular dose plus levofloxacin
500 mg orally for 7 d
Not sure 2% (1–4) 6% (3–8) 6% (3–9) 13% (9–17) 6% (5–7)

Numbers represent proportion (95 percent CI) reporting listed treatment (column percentages).
*Among 1500 physicians who completed the survey, 143 physicians who responded that they provided STD screening, diagnosis, or treatment services to
zero patients in an average month were excluded (among these 143 excluded physicians, 45% reported ceftriaxone plus azithromycin dual therapy and 22%
reported that they were not sure).
†
The difference between provider types is significant with P < 0.001.

Sexually Transmitted Diseases • Volume 44, Number 1, January 2017 15

Copyright © 2016 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Ahmed et al.

TABLE 3. Factors Associated With Reporting Best Option for Treating 18-Year-Old Man With Gonococcal Urethritis using Ceftriaxone and
Azithromycin Dual Therapy, DocStyles Survey, June 2015
Variable n Percent Reporting Dual Therapy (95% CI) Adjusted Odds Ratio (95% CI)§
Specialty
Family medicine 442 69 (64–73)* 1 (referent)
Internal medicine 450 61 (56–65) 0.71 (0.54–0.94)
Pediatrics 216 66 (59–72) 0.86 (0.60–1.23)
Obstetrics/gynecology 249 60 (54–66) 0.73 (0.52–1.02)
Physician gender
Male 931 62 (59–65)* 1 (referent)
Female 426 69 (64–73) 1.26 (0.98–1.64)
Years in practice
3–9 345 74 (69–78)‡ 1 (referent)‡
10–15 404 64 (59–69) 0.68 (0.49–0.94)
16–23 297 60 (55–66) 0.59 (0.42–0.84)
≥ 24 311 57 (51–62) 0.50 (0.35–0.70)
No. practitioners in practice
Solo 168 60 (52–67)
2–5 490 65 (61–69)
≥6 699 64 (61–68)
Practice region
Midwest 315 64 (59–69)
South 434 62 (57–66)
Northeast 332 66 (61–71)
West 276 66 (60–72)
Financial situation (household income) of majority of patients
Poor to lower middle (<US $50,000) 410 72 (67–76)‡ 1 (referent)‡
Middle (US $50,000–99,999) 470 64 (59–68) 0.77 (0.57–1.02)
Upper middle (US $100,000–249,999) 318 60 (54–65) 0.59 (0.43–0.81)
High (≥US $250,000) 159 53 (45–61) 0.47 (0.32–0.69)
CME using journals, podcasts, or government health agencies like CDC or NIH
None of the 3 CME sources 195 57 (50–64)‡ 1 (referent)†
One of the 3 CME sources 594 61 (57–65) 1.14 (0.81–1.59)
Two of the 3 CME sources 405 67 (63–72) 1.44 (1.01–2.07)
All of the 3 CME sources 163 75 (69–82) 2.09 (1.31–3.33)

*P < 0.05.
†
P < 0.01.
‡
P < 0.001.
§
Using multivariate logistic regression model, adjusted simultaneously for specialty, gender, years in practice, financial situation of patients, and CME.
NIH, National Institutes of Health.

0.50; 95% CI, 0.35–0.70) (Table 3). Knowledge of the recom-
mended dual therapy decreased with higher socioeconomic status
of patients, ranging from 72% among physicians providing care to
mostly poor/lower middle income patients to 53% among physi-
cians with mostly high income patients (ORa for high income vs
poor/lower middle income patients, 0.47; 95% CI, 0.32–0.69)
(Table 3). Physicians reporting using journals, podcasts, and gov-
ernment agencies (all 3 sources) to pursue CME were more likely
to report dual therapy compared with those who used none of these
3 sources (ORa, 2.09; 95% CI, 1.31–3.33) (Table 3). Gender and
physician specialty showed statistically significant differences in
univariate analyses, but the differences were of borderline statisti-
cal significance in the multivariate analysis (P < 0.10). Subgroup
analysis showed that female physicians were significantly more
likely than male physicians to report dual therapy among the fam-
ily medicine and internal medicine subgroup (ORa, 1.64; 95% CI,
1.16–2.30), but not in the pediatrician and obstetrician/gynecologist
subgroup (ORa, 0.83; 95% CI, 0.55–1.26) (data not shown).
DISCUSSION
Our findings indicate that physician knowledge of the rec-
ommended regimen for treating uncomplicated urogenital gonor-
rhea using ceftriaxone and azithromycin dual therapy decreased
with increasing years of provider practice and with higher socioeco-
nomic status of patients. Knowledge of the recommended dual ther-
apy was higher among physicians who reported using journals,
podcasts, and government agencies for pursuing CME.
Prior studies have evaluated provider adherence to CDC
STD Treatment Guidelines recommendations for treating gonor-
rhea. The STD Surveillance Network data from 6 city and state
health departments were used to assess gonorrhea treatment prac-
tices following revisions of CDC guidelines in December 2010.9
Among gonorrhea cases reported by providers (STD clinics,
hospital/emergency departments, family planning and reproduc-
tive health, private provider, public clinic) to the STD Surveillance
Network, use of dual therapy with ceftriaxone plus azithromycin
or doxycycline increased from 34% in 2010 to 65% in 2012. Data
on laboratory-confirmed gonorrhea cases reported to the Chicago
Department of Public Health (CDPH) before (April 2011 to July
2012) and after (August 2012 to December 2012) release of the
August 2012 CDC treatment guidelines update for treating gonor-
rhea was used to assess adherence.10 Use of ceftriaxone plus either
azithromycin or doxycycline increased from 61% to 81% for cases
reported by CDPH providers (93% of these cases were reported by
STD clinics) and from 55% to 59% for those from non-CDPH pro-
viders (eg, hospitals, community health centers, private providers).
A study conducted by the Philadelphia Department of Public

16 Sexually Transmitted Diseases • Volume 44, Number 1, January 2017

Copyright © 2016 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

Health (PDPH) assessed the effect of issuing a health alert regard-
ing the 2012 CDC update to the treatment for gonorrhea to pro-
viders (private doctors/clinics, PDPH run clinics, reproductive
health/prenatal clinics, emergency rooms/hospitals, juvenile de-
tention facilities, prisons, STD clinics).11 Among gonorrhea cases
reported to PDPH during the 6 months after the health alert, use of
ceftriaxone and either azithromycin or doxycycline was 87% over-
all and 73% among cases reported by private doctors/clinics.
Our study results are consistent with these earlier studies,
but we extend the findings by showing that knowledge of primary
care physicians varies by years of practice, socioeconomic status
of patients, and sources used for pursuing CME. Our finding of
a decrease in physician knowledge of gonococcal dual therapy
with higher socioeconomic status of patients might be explained
by the fact that providers with higher-income patients likely care
for fewer gonorrhea patients. Decreasing STD prevalence with in-
creasing household income has been observed for all race/ethnic
groups, and providers in locations with lower incidence of gonor-
rhea have been reported to use nonrecommended treatment regi-
mens for gonorrhea more often than those in higher incidence
locations.12,13 The finding that certain sources used for pursuing
CME were associated with increased knowledge of dual therapy
for gonorrhea is intriguing. A Cochrane systematic review found
that CME has a small but varied effect on professional practice.14
Our finding that female family and internal medicine physicians
have greater knowledge of gonococcal dual therapy is consistent
with earlier reports that female physicians obtain sexual histories
and screen for STDs more often than male physicians.15–18
A strength of our study is that we assessed physician
knowledge of the recommended gonococcal dual therapy directly
using a survey rather than using administrative data or medical re-
cords that may be influenced by completeness of documentation
or data capture.19 Another strength is that we excluded physicians
who usually do not provide STD services. There are potential lim-
itations. First, our case scenario was based on treatment for a male
patient. Obstetricians/gynecologists see female patients only,
which might explain the higher proportion who responded that
they were not sure of the treatment regimen. However, our find-
ings were similar when we restricted the analysis to family medi-
cine physicians, internal medicine physicians, and pediatricians
(data not shown). Second, the study sample may not be represen-
tative of all US primary care physicians. However, the respondents
were diverse in terms of specialty, number of practitioners in prac-
tice, geographic region, and years in practice. It is unlikely that the
trends observed with increasing years of practice and socioeco-
nomic status, which persisted even after controlling for several po-
tential confounding variables, can be explained by sampling bias.
Third, we did not assess knowledge of nurse practitioners and phy-
sician assistants who provide treatment to patients with gonorrhea.
Fourth, we did not ascertain physicians' preference for treating pa-
tients using second-line alternate regimens (eg, cefixime in lieu of
ceftriaxone). Fifth, it is heartening that two thirds of physicians un-
derstood that the combination of ceftriaxone and azithromycin is
preferred over either drug alone. However, selecting this regimen
among the limited response options provided does not assure its
use in a similar proportion of patients, because we did not assess
other recently recommended regimens, such as ceftriaxone plus doxy-
cycline, or continued use of ciprofloxacin or other fluoroquinolones.
Finally, we asked about physician preference, which may not al-
ways translate into actual practice.
Our study helps elucidate factors that are associated with
physician knowledge of the recommended regimen for treating
gonorrhea. Potential barriers to guideline adherence include lack
of awareness, lack of familiarity, lack of agreement, and inertia
of previous practice.20 Further research is needed for identifying
Sexually Transmitted Diseases • Volume 44, Number 1, January 2017
Copyright © 2016 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Recommended Regimen for Treating Gonorrhea
underlying reasons for variation in physician knowledge with
years in practice, socioeconomic status of patients, and source
used for pursuing CME, including understanding of the rationale
for dual therapy and the determinants of physician choice. Re-
search is also needed on the use of other regimens for gonorrhea
treatment. It is important to enhance physician understanding of
and compliance with dual therapy for gonorrhea, due to concerns
about emergence of antimicrobial resistance.
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