Routine Pharyngeal Gonorrhea Test of Cure: Is It an Effective Cephalosporin-Resistant Gonorrhea Control Strategy?

The Centers for Disease Control and Prevention recommends test of cure (TOC) for persons with pharyngeal gonorrhea (GC) 7 to 14 days after treatment. We investigated the yield and feasibility of routine pharyngeal GC TOC to detect treatment failures.

During May 2021-July 2022, 4 US sexually transmitted disease clinics implemented pharyngeal GC TOC. Sites collected demographic, clinical, and behavioral data on all treated pharyngeal GC and positive TOC cases. Cases were dispositioned with the suspected reason for positive TOC. To assess perceived feasibility, sites participated in qualitative interviews.

During the study period, 1968 pharyngeal GC infections were diagnosed. Among 1829 treated cases, 97.3% (n = 1777) received ceftriaxone and 45.7% (n = 836) returned for TOC, varying by site (range, 35.5%-70.8%). Among those with TOC, 4.7% (n = 39) were positive by nucleic acid amplification test. Of these, 48.7% had culture attempted; 6 positive TOCs (15.4%) were also positive by culture. Most positive TOCs (66.7%) were attributed to reinfection (n = 13) or false-positive results (n = 13). Six (15.4%) were treatment failures. Four failed recommended treatment and had a positive culture: 2 were susceptible to ceftriaxone and 2 did not have antimicrobial susceptibility results. Seven positive TOC (17.9%) had insufficient data to disposition. Sites perceived TOC to be feasible, although substantial resources were required.

Routine pharyngeal GC TOC yielded 5% positivity, although treatment failure was rare (<1%), and no cases of cephalosporin-resistant GC were identified. Low TOC return rates, limited culture collection, and limited culture yield highlight challenges to determining the cause of a positive TOC and the limitations of TOC in identifying cephalosporin resistance.