15 Minute Overview of Antimicrobial Resistant Gonorrhea

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Antimicrobial Resistance in N. gonorrhoeae: An Overview (PDF Document 2.5 MB - 15 pages)

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Antimicrobial Resistance in N. gonorrhoeae – An Overview

Table of Contents – Presentation Slides

1. Introduction
2. Key Issues
3. Key Issues
4. Key Issues
5. Diagnosis
6. Diagnosis
7. Treatment
8. Treatment
9. Treatment
10. Test of Cure
11. Test of Cure
12. Treatment Failure
13. Reporting
14. Resources
15. Conclusion

Slide #1

Introduction

Progressive antimicrobial resistance in Neisseria gonorrhoeae is an emerging public health threat.

The Public Health Agency of Canada (the Agency) released updated recommendations in July 2013 for the diagnosis, treatment, follow-up and reporting of gonorrhea.

Slide #1 – Speaker's Notes

• Antimicrobial resistant gonorrhea is an emerging public health threat that needs to be addressed.
• Neisseria gonorrhoeae is able to develop resistance to antimicrobials quickly. Effective antibiotic stewardship relies on health professionals working together to make appropriate decisions about control measures, prescription practices and reporting.
• The objectives of this presentation are; to increase awareness of the issue of antimicrobial resistant gonorrhea, and to inform primary care and public health professionals in Canada of 2013 recommendations from the Agency on the diagnosis and management of gonococcal infections.
• This presentation provides an overview of the key issues identified in the revised Gonococcal Infections Chapter of the Canadian Guidelines for Sexually Transmitted Infections.
• For more information and references please see the Agency website.
• The WHO Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae (2012) is intended to enhance the global response to the prevention, diagnosis and control of N. gonorrhoeae infection, and mitigate the health impact of AMR, through enhanced, sustained, evidence-based and collaborative multisectoral action.

Slide #2

Key Issues

Reported cases of gonococcal infection in Canada have increased since 1997.

Gonococcal infections have been resistant to certain antimicrobial drugs.

The problem is worldwide, and is growing.

Gonococcal infections are becoming more difficult to treat.

Potential increase in major sequelae due to prolonged duration of original infection.

Slide #2 – Speaker's Notes

• There has been a gradual and steady increase in reported cases of gonococcal infection in Canada since 1997.
• Gonococcal infections are becoming more difficult to treat and have been resistant to existing drug therapies.
• Antimicrobial resistant gonorrhea is being seen worldwide and is an emerging public health threat needs to be addressed.

Slide #3

Key Issues

Progressive resistance to penicillin, tetracycline and quinolones has emerged.

Treatment failure with third generation oral and injectable cephalosporins has been observed.

To date, resistance particularly observed among MSM. ^{Slide 3 Footnote *}

Slide #3 – Speaker's Notes

• Due to the progressive resistance, the use of penicillin and tetracycline is not recommended. Quinolones are no longer recommended for the treatment of gonorrhea.
• Treatment failure with third generation oral and injectable cephalosporins has also been observed.
• To date, resistance is particularly observed among MSM.

Slide #4

Key Issues

Increasing use of Nucleic Acid Amplification Testing (NAAT) for the diagnosis of gonorrhea.

Why?

• High specificity and sensitivity
• Cost-effective
• Cultures are impractical

Unfortunately the use of NAAT has resulted in less data on antimicrobial susceptibility.

Slide #4 – Speaker's Notes

• Nucleic Acid Amplification Testing (NAAT) is a molecular technique that is used to detect a virus or a bacterium.
• There has been an increase in the use of NAAT for the diagnosis of gonorrhea, due to its high specificity, sensitivity, accessibility, availability and cost.
• Sometimes it can be the only available testing method, and sometimes it is the only option of point of care diagnosis for certain patient populations.
• However, a diagnosis with NAAT provides less data on antimicrobial resistance of the gonococcal strain.
• Diagnosis by culture (that is, the growth of a specimen in a laboratory), does allow for identification of antimicrobial resistance.

Slide #5

Diagnosis

Depending on clinical situation, consider collecting both cultures and NAAT especially in symptomatic patients.

Slide #5 – Speaker's Notes

• When gonococcal infection is suspected, consider collecting both cultures and NAAT especially in symptomatic patients; cultures are critical for improved public health monitoring of antimicrobial resistance patterns of trends.

Slide #6

Diagnosis

Cultures are particularly important in the following situations:

• Suspected pelvic inflammatory disease
• Where there is an increased probability or a suspected treatment failure
• MSM who are symptomatic
• If the infection was acquired in a geographical area with high rates of antimicrobial resistance

Slide #6 – Speaker's Notes

• In addition to determining antimicrobial sensitivities prior to treatment, cultures are particularly important in the following situations:
  • Cases of suspected pelvic inflammatory disease,
  • Where there is an increased probability and a suspected treatment failure
  • For men who have sex with men who are symptomatic,
  • If the infection was acquired in a geographical area with high rates of antimicrobial resistance.

Slide #7

Treatment

Agency's Recommended Treatment 2013:

• Patients should be treated with combination therapy (two antibiotics)
• Monotherapy should be avoided

Slide #7 – Speaker's Notes

• Patients should be treated with combination therapy (two antibiotics) in response to potential antimicrobial resistance.
• This combination therapy also includes effective treatment for chlamydia due to high rates of concomitant infection.
• Monotherapy should be avoided.

Slide #8

Treatment

Patients should be treated with combination therapy (two antibiotics).

• The preferred therapy for uncomplicated anogenital and pharyngeal infection for MSM, adults and youth (≥ 9 years) is: ceftriaxone 250 mg IM PLUS azithromycin 1 g oral
• Another preferred treatment for uncomplicated anogenital infection in adults and youth (≥ 9 years), excluding MSM is:
  cefixime 800 mg oral PLUS azithromycin 1 g oral

Full treatment details at:

http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-6-eng.php

Slide #8 – Speaker's Notes

• The preferred treatment varies by population and infection site. Among MSM, ceftriaxone 250 mg^{Footnote *} intramuscularly PLUS azithromycin 1 g^{Footnote *} orally in a single dose is the sole preferred therapy for uncomplicated anogenital and pharyngeal infection.
• In other (i.e., non-MSM) adults and youth (at least nine years of age), this combination is the preferred therapy for uncomplicated anogenital and pharyngeal infection, whereas for uncomplicated anogenital infection only, cefixime 800 mg^{Footnote *} orally PLUS azithromycin 1 g^{Footnote *} orally in a single dose is also a preferred therapy.
• The full recommendations regarding treatment can be found in the Gonococcal Infections Chapter of the Agency's Sexually Transmitted Infections Guidelines, available online.
• The Agency's guidelines do not supersede any provincial/territorial legislative, regulatory, policy and practice requirements or professional guidelines that govern the practice of health professionals in their respective jurisdictions, whose recommendations may differ due to local epidemiology or context.

Slide #9

Treatment

Full treatment recommendations, including alternative treatments available

The Public Health Agency of Canada's Canadian STI Guidelines

Slide #9 – Speaker's Notes

• For full management recommendations, please refer to the Gonococcal Infections Chapter of the Canadian Guidelines for Sexually Transmitted Infections on the Agency website.

Slide #10

Test of Cure

Test of cure should be completed in all cases; particularly important when:

• Case has persistent symptoms or signs post-therapy
• Cases treated with a regimen other than the preferred treatment
• Case is linked to a drug resistant/treatment failure case and was treated with the same antibiotic
• Pharyngeal infections

Slide #10 – Speaker's Notes

• Test of cure should be completed in all cases. However it is particularly important in the following situations:
  • individuals with persistent signs and symptoms post-therapy,
  • for cases that were treated with a regimen other than the recommended treatment,
  • when a case is linked to another case who was treated with the same antibiotic and who showed documented antimicrobial resistance or treatment failure,
  • and for all pharyngeal infections.
• For further situations for when test of cure should be completed, please refer to the Gonococcal Infections Chapter of the Canadian Guidelines for Sexually Transmitted Infections on the Agency website.

Slide #11

Test of Cure

Test of Cure Post-Treatment
3-7 days later → Culture
2-3 Weeks later → NAAT

All sexual partners within 60 days prior to symptom onset should be notified, tested and empirically treated.

Repeat screening for individuals with a gonococcal infection is recommended 6 months post-treatment.

Slide #11 – Speaker's Notes

• Follow-up cultures for test of cure from all positive sites should be done 3 to 7 days after completion of therapy.
• If NAAT is the only choice for test of cure, tests should not be done for 2 to 3 weeks after treatment to avoid false-positive results due to the presence of non-viable organisms.
• Repeat screening for individuals with a gonococcal infection is recommended 6 months post-treatment.
• All sexual partners within 60 days prior to symptom onset or date of specimen collection (if the patient is asymptomatic) should be notified, tested and empirically treated.

Slide #12

Treatment Failure

TREATMENT FAILURE is defined as one of the following in the absence of reported sexual contact during post-treatment period:

• Positive N. gonorrhoeae on culture taken at least 72 hrs. after treatment
• Positive NAAT taken at least 2-3 weeks after treatment
• Presence of intracellular Gram-negative diplococci on microscopy taken at least 72 hrs. after treatment

Slide #12 – Speaker's Notes

• All suspected treatment failures should be investigated using culture to allow for antimicrobial susceptibility testing.
• Treatment failures are defined as one of the following in the absence of reported sexual contact during the post-treatment period.
  • Positive N. gonorrhoeae on culture taken at least 72 hours after treatment.
  • Positive NAAT taken at least 2-3 weeks after treatment.
  • Presence of intracellular gram-negative diplococci on microscopy taken at least 72 hours after treatment.

Slide #13

Reporting

Should I notify local public health officials?

For cases of gonorrhea?
When treatment failure has occurred?

Yes!

Gonorrhea is a reportable infection. Treatment failure should also be reported.

Slide #13 – Speaker's Notes

• Prompt reporting to local public health officials in all provinces and territories is required for cases of gonorrhea.
• Practitioners are encouraged to notify their local and provincial/territorial public health authorities of treatment failures.

Slide #14

Resources

To access the chapter and additional resources:

http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-6-eng.php

The above based on Public Health Agency of Canada's Canadian STI Guidelines

This document is intended to provide information to public health and clinical professionals and does not supersede any provincial/territorial legislative, regulatory, policy and practice requirements or professional guidelines that govern the practice of health professionals in their respective jurisdictions, whose recommendations may differ due to local epidemiology or context.

Slide #14 – Speaker's Notes

• To access the chapter and additional resources on diagnosis and management, please refer to the Gonococcal Infections Chapter of the Canadian Guidelines for Sexually Transmitted Infections on the Agency website.
• To assist with what you have learned about AMR GC diagnosis, treatment and follow up, refer to the Case Study: Antimicrobial Resistant Gonorrhea on the Agency website.

Slide #15

Conclusion

To successfully address the public health risk of antimicrobial resistant gonorrhea, all primary care and public health professionals must work together.

Slide #15 – Speaker's Notes

• All primary care and public health professionals need to work together to address the public health risk of antimicrobial resistant gonorrhea.