45 Minute Review of Antimicrobial Resistant Gonorrhea

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Antimicrobial Resistance in N. gonorrhoeae – A Review

Table of Contents – Presentation Slides

1. Introduction
2. Objectives
3. Background
4. Background
5. Epidemiology
6. Key Issues
7. Key Issues
8. At Risk
9. At Risk
10. Manifestations
11. Symptoms
12. Major Sequelae
13. Diagnosis
14. NAAT
15. Culture
16. Diagnosis
17. Specimens
18. Specimens
19. Management
20. Treatment
21. Treatment
22. Treatment
23. Treatment
24. Treatment
25. Treatment
26. Treatment
27. Control
28. Partner Notification
29. Test of Cure
30. Test of Cure
31. Test of Cure
32. Treatment Failure
33. Reporting
34. Repeat Screening
35. Surveillance
36. Prevention
37. Conclusion
38. Resources

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 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 #2

Objectives

To increase awareness and knowledge of the status of antimicrobial resistance of N. gonorrhoeae.

To promote:

• Appropriate laboratory testing
• Optimal use of antibiotics
• Test-of-cure recommendations
• Proper action on detecting, reporting and re-treatment in cases of documented or suspected treatment failure

Slide #2 – Speaker's Notes

• 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.
  • The presentation aims to promote appropriate laboratory testing, optimal use of antibiotics, test-of-cure recommendations, and the proper action on detecting, reporting and re-treatment in cases of documented or suspected treatment failure.
• For more information and references please see the Agency website.

Slide #3

Background

Antimicrobial resistance occurs when bacteria, fungi, viruses, or parasites develop the ability to resist the effects of antimicrobial drugs used to kill them or slow their growth.

A recent report from the World Health Organization (2014) identified antimicrobial resistance as a global threat.

Results from this study showed a significant increase in antimicrobial resistance worldwide.

Warned about the possibility of a post-antibiotic era "in which common infections...can kill."

Slide #3 – Speaker's Notes

• Antimicrobial resistance occurs when bacteria, fungi, viruses, or parasites develop the ability to resist the effects of antimicrobial drugs that are used to kill them or to slow their growth.
• There has been a significant increase in antimicrobial resistance worldwide, and it has been identified as a global threat in a 2014 report from the World Health Organization.
  • The report also warned about the possibility of a post-antibiotic era.

Slide #4

Background

Aligns with World Health Organisation's "Global Action Plan to Control the Spread and Impact of Antimicrobial Resistance in Neisseria gonorrhoeae (2012)."

Identified antimicrobial resistant gonorrhea as the next drug resistant 'superbug.'

Slide #4 – Speaker's Notes

• The Public Health Agency of Canada has identified antimicrobial resistance as a public health priority.
• This aligns with the World Health Organisation's "Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae"
• The World Health Organisation's plan aims to enhance the global response to the prevention, diagnosis and control of N. gonorrhoeae infection, and mitigate the health impact of antimicrobial resistance, through enhanced, sustained, evidence-based and collaborative multisectoral action.

Slide #5

Epidemiology

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

Most affected:

• Males 20-24 years of age
• Females 15-19 years of age
• Infection rates are increasing more rapidly among females than among males.

A network of people with high-transmission activities may play a key role in current prevalence levels and in sustaining infections within a community.

Slide #5 – Speaker's Notes

• There has been a gradual and steady increase in reported cases of gonococcal infection in Canada since 1997.
• In Canada, those most affected by gonorrhea are males (aged 20-24 years old) and females (aged 15-19 years old).
  • Infection rates are increasing more rapidly among females than among males.
• A network of people with high transmission activities may play a key role in current prevalence levels and in sustaining infections within a community.

Slide #6

Key Issues

Gonococcal infections have been resistant to certain antibiotics.

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 #6 – Speaker's Notes

• Gonococcal infections are becoming more difficult to treat and have been resistant to existing drug therapies.
• Antimicrobial resistant gonorrhea is being seen worldwide.
• Potential increase in major sequelae (such as pelvic inflammatory disease or epididymitis) because original infection lasts longer.
• Antimicrobial resistant gonorrhea is an emerging public health threat needs to be addressed.

Slide #7

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. ^{Footnote *}

Slide #7 – 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 particularly observed among Men who have sex with Men (MSM).

Slide #8

At Risk

Individuals who have had sexual contact with a person with a confirmed or suspected gonococcal infection.

Individuals with a history of other STIs, including HIV.

Individuals who have had unprotected sex with a resident of an area with high gonorrhea burden and/or high risk of antimicrobial resistance.

Individuals with a history of previous gonococcal infection.

Slide #8 – Speaker's Notes

Some individuals are more at risk than others of contracting gonorrhea:

• Individuals who have had sexual contact with a person who has been confirmed or is suspected of having a gonoccocal infection.
• Individuals with a history of other sexually transmitted infections (STIs), including HIV-AIDS.
• Individuals who have had unprotected sex with a resident of an area with a high gonorrhea burden and/or high risk of antimicrobial resistance.
• Individuals with a history of previous gonococcal infection.

Slide #9

At Risk

Sex workers and their sexual partners.

Individuals who have had sex with multiple partners.

Street-involved youth and other homeless populations.

Sexually active youth < 25 years of age.

Slide #9 – Speaker's Notes

Some individuals are more at risk than others of contracting gonorrhea:

• Sex workers and their sexual partners.
• Individuals who have had sex with multiple partners.
• Street-involved youth and other homeless populations.
• Sexually active youth under 25 years old.
• Men who have unprotected sex with men.

Slide #10

Manifestations

Slide #10 – Speaker's Notes

• This slide lists manifestations of gonococcal infections in youth (≥ 9 years old) and adults.

Slide #11

Symptoms

In both females and males, rectal and pharyngeal infections are more likely to be asymptomatic.

Slide #11 – Speaker's Notes

• Symptoms of a gonococcal infection vary between sexes.
• Females are often asymptomatic.
• Males are often symptomatic.
• In both sexes, rectal and pharyngeal infections are more likely to be asymptomatic.

Slide #12

Major Sequelae

Slide #12 – Speaker's Notes

• Gonococcal infections can result in various major sequelae.
• This slide lists the major sequelae by sex (female or male) in youth (≥ 9 years old) and adults.

Slide #13

Diagnosis

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

Slide #13 – 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 #14

NAAT

Increase in the number of cases diagnosed due to higher sensitivity and specificity of test.

NAAT may be the only available testing method in some jurisdictions.

However, culture is strongly recommended because it allows for testing of antimicrobial susceptibility.

Where NAAT is routinely used, sentinel surveillance mechanisms using culture are important to ensure continued monitoring for antimicrobial resistance.

Slide #14 – 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 #15

Culture

Critical for improved public health monitoring of antimicrobial resistance and trends.

Provides clinicians with important case management information.

Cultures obtained less than 48 hours after exposure may give false negative results.

Slide #15 – Speaker's Notes

• Due to the need to identify or characterize antimicrobial resistance, consideration should be given to collecting both cultures and NAAT especially in symptomatic patients.
• Cultures are critical for improving public health monitoring of antimicrobial resistance and trends.
• Additionally, cultures provide clinicians with important case management information.
• Note that cultures obtained less than 48 hours after exposure may give false negative results.

Slide #16

Diagnosis

Cultures are particularly important in the following situations:

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

Slide #16 – 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 #17

Specimens

Asymptomatic Patients

Take specimen from any exposed site

• Cervical or vaginal culture or NAAT
• Urethral culture or NAAT
• Rectal culture or validated NAAT and/or Pharyngeal culture or validated NAAT
• Urine NAAT if urethral swab or pelvic examination is not practical

Slide #17 – Speaker's Notes

• In ASYMPTOMATIC patients, specimens should be taken from any exposed site.
• For asymptomatic females, a cervical or vaginal culture or NAAT should be used.
• For asymptomatic males, a urethral culture or NAAT should be used.
• For either females or males (asymptomatic), a rectal and/or pharyngeal culture or validated NAAT should be used.
• Urine NAAT can be used if a urethral swab or pelvic examination is not practical.

Slide #18

Specimens

Symptomatic Patients

Take specimen from any exposed site

• Cervical or vaginal culture or NAAT
• Urine NAAT if urethral swab or pelvic exam not practical
• Urethral culture or NAAT if patient has urethral syndrome
• Rectal culture or validated NAAT if anogenital symptoms

Slide #18 – Speaker's Notes

• In SYMPTOMATIC patients, specimens should be taken from the following sites:
  • For symptomatic females, a cervical or vaginal culture or NAAT should be used. However, a urine NAAT can be used if a urethral swab or pelvic examination is not practical. If the patient has a urethral syndrome, a urethral culture or NAAT can be used.
  • For symptomatic males with anogenital symptoms, a rectal culture or validated NAAT should be used.

Slide #19

Management

Appropriate samples based on site of exposure and test type should be obtained prior to treatment.

Presumptive treatment is to be provided for:

Mucopurulent cervicitis

Non-gonococcal urethritis

Epididymitis

Pelvic inflammatory disease

When making treatment decisions, relevant history, physical examination and epidemiologic factors should be considered.

Slide #19 – Speaker's Notes

• For the management of gonococcal infections, appropriate samples should be obtained prior to treatment, based on the site of exposure and on the test type. However, presumptive treatment may be required for syndromic management (such as mucopurulent cervicitis, non-gonococcal urethritis, epididymitis or pelvic inflammatory disease) or if the patient is being treated as a contact.
• When making treatment decisions, you should consider other information, such as relevant history, physical examination and epidemiologic factors.

Slide #20

Treatment

Monotherapy should be avoided.

To help prevent the spread of antimicrobial resistant gonorrhea.

Using medications with two different mechanisms of action may also improve treatment efficacy.

Combination therapy also provides effective treatment for chlamydia given high rates of concomitant infections.

Slide #20 – 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.
• Using medications with two different mechanisms of action may also improve treatment efficacy.
• Monotherapy should be avoided.

Slide #21

Treatment

Cephalosporins

Cefixime treatment failures in MSM have recently been documented.

Ceftriaxone + azithromycin is recommended as the preferred treatment for gonococcal infections in MSM.

Slide #21 – Speaker's Notes

• Cefixime (cephalosporin) treatment failures have recently been documented in men who have sex with men (MSM).
• Ceftriaxone PLUS azithromycin is recommended as the preferred treatment for gonococcal infections in men who have sex with men (MSM).

Slide #22

Treatment

Azithromycin

Azithromycin should not be used as monotherapy. Resistance has been reported.

Exception: when cephalosporins are contraindicated
- Allergy to cephalosporins

History of anaphylactic reaction to penicillin:
Cross-sensitivity between penicillin and 2^nd or 3^rd generation cephalosporins is low, but if patient has history of immediate hypersensitivity reaction to penicillin, may also react to cephalosporins.

Slide #22 – Speaker's Notes

• Azithromycin should not be used as monotherapy, as resistance to this antibiotic has been reported.
• The exception is when cephalosporins are contraindicated; if the patient has a history of anaphylactic reaction to penicillin or if the patient is allergic to cephalosporins.
• Note that the cross-sensitivity between penicillin and second or third generation cephalosporins is low, but if the patient does have a history of immediate hypersensitivity reaction to penicillin, they may also react to cephalosporins.
• If cephalosporins are administered to patients hypersensitive to penicillin, a protocol (e.g., epinephrine, airway management, etc.) to respond to serious reactions should be in place.

Slide #23

Treatment

Uncomplicated anogenital infection (urethral, rectal) and pharyngeal infection ≥ 9 years of age

Preferred treatment

Ceftriaxone 250 mg IM in a single dose + Azithromycin 1 g PO in a single dose

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

Slide #23 – Speaker's Notes

• The preferred treatment varies by population and infection site. Among MSM, ceftriaxone 250 mg^{Footnote 1} intramuscularly PLUS azithromycin 1 g^{Footnote 1} 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.
• 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 #24

Treatment

Uncomplicated anogenital infection (urethral, rectal) only in adults and youth (≥ 9 years), excluding MSM is:

Preferred treatment

Cefixime 800 mg PO in a single dose + Azithromycin 1 g PO in a single dose

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

Slide #24 – Speaker's Notes

• For non-MSM uncomplicated anogenital infection only, cefixime 800 mg^{Footnote 2} orally PLUS azithromycin 1 g^{Footnote 2} 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.

Slide #25

Treatment

Quinolones

Due to the rapid increase in quinolone-resistant gonorrhea, quinolones are no longer recommended.

Quinolones should ONLY be given as an alternative treatment IF:

Antimicrobial susceptibility testing is available and quinolone susceptibility is demonstrated

OR

Local quinolone resistance is under 5% AND a test of cure can be performed.

Slide #25 – Speaker's Notes

• Due to the rapid increase in gonorrhea that is resistant to quinolones, quinolones are no longer recommended.
• However, quinolones may be given as an alternate treatment if:
  • Antimicrobial susceptibility testing is available and it is demonstrated that the gonococcal strain is susceptible
    • OR
  • Local quinolone resistance is under 5% AND a test of cure can be performed.

Slide #26

Treatment

Full treatment recommendations, including alternative treatments available

The Public Health Agency of Canada's Canadian STI Guidelines

Slide #26 – 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.
• 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 #27

Control

Case finding and partner notification are critical in controlling infection.

Local public health authorities may assist with partner notification and with appropriate referral for clinical evaluation, testing, treatment and health education.

Gonococcal infections are reportable in all provinces and territories; positive test results should be reported to local public health authorities.

Slide #27 – Speaker's Notes

• A critical step in controlling gonococcal infections is to conduct effective case finding and partner notification.
• Local public health authorities may assist with partner notification and with appropriate referral for clinical evaluation, testing, treatment and health education.

IMPORTANT: Gonorrhea is a reportable infection in all provinces and territories. All positive test results should be reported to local public health authorities.

Slide #28

Partner Notification

All sexual partners within 60 days prior to symptom onset or date of specimen collections (if asymptomatic) should be notified, tested and empirically treated without waiting for test results.

The length of time for the trace-back period should be extended in the following circumstances:

• If the index case states that there were no partners during the recommended trace-back period, the most recent partner should be notified
• If all partners traced test negative, the last partner prior to the trace-back period should be notified
• If partners are exposed between testing and treatment, additional time between the date of testing and date of treatment could be included

Slide #28 – Speaker's Notes

• All sexual partners within 60 days prior to symptom onset (or date of specimen collections, if patient is asymptomatic) should be notified, tested and empirically treated without waiting for test results.
• The 60 trace-back period should be extended in the following situations:
  • If the index case states that there were no partners during the 60 day trace back period, in which case the most recent partner should be notified.
  • If all of the partners that were trace tested negative then the last partner prior to the trace-back period should be notified.
  • If partners are exposed between testing and treatment, additional time may be required.

Slide #29

Test of Cure

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

Slide #29 – Speaker's Notes

• Test of cure should be completed for all patients.
• 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 2-3 weeks after treatment to avoid false-positive results due to the presence of non-viable organisms.

Slide #30

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 #30 – Speaker's Notes

• Test of cure 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 #31

Test of Cure

Cultures from all positive sites should also be done in the following situations:

• There is re-exposure to an untreated partner
• Disseminated gonococcal infection is diagnosed
• Infection occurs during pregnancy
• Compliance is uncertain
• Case is a child
• Women undergoing therapeutic abortion who tests positive gonococcal infection

Slide #31 – Speaker's Notes

• In addition to the situations mentioned in the previous slide
  • (individuals with persistent signs and symptoms post-therapy, cases that were treated under 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, or all pharyngeal infections)
• cultures from all positive sites should also be conducted in the following situations:
  • If there has been re-exposure to an untreated partner
  • If disseminated gonococcal infection is diagnosed
  • If infection has occurred during pregnancy
  • If compliance is uncertain
  • If the case is a child
  • Or if the case is a woman who is undergoing therapeutic abortion and tests positive for a gonococcal infection (as she has an increased risk of pelvic inflammatory disease).

Slide #32

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 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 #32 – 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 #33

Reporting

Local public health should be promptly notified of treatment failures.

Allows provincial and territorial STI programs to quickly identify emerging patterns of antimicrobial resistance within their jurisdictions.

Enables provincial and territorial to collaborate with the Public Health Agency of Canada to issue timely electronic alerts.

Slide #33 – Speaker's Notes

• Practitioners are encouraged to notify their local and provincial/territorial public health authorities of treatment failures.
• The reporting of treatment failures allows provincial and territorial sexually transmitted infections programs to quickly identify emerging patters of antimicrobial resistance within their jurisdictions.
• Provincial and territorial programs can then collaborate with the Agency to issue timely alerts, if necessary.

Slide #34

Repeat Screening

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

Slide #34 – Speaker's Notes

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

Slide #35

Surveillance

National enhanced surveillance protocol to integrate epidemiologic and treatment failure data into existing laboratory-based monitoring of antimicrobial resistant gonorrhea.

Important to rapidly identify changes in antimicrobial susceptibility and assess risk factors associated with the development of resistance.

Enables early identification and prevention of the spread of drug-resistant gonorrhea and assists in identifying appropriate treatment regimens.

Slide #35 – Speaker's Notes

• The Agency has been working with the provinces and territories to establish an enhanced surveillance system which will help integrate epidemiologic and treatment failure data into existing laboratory-based monitoring of antimicrobial resistant gonorrhea.
• This information will be important to quickly identify changes in susceptibility and to assess the risk factors that are associated with the development of resistance.
• Early identification and prevention of the spread of drug-resistant gonorrhea will be enabled which will assist in identifying appropriate treatment regimes.

Slide #36

Prevention

Provide information to encourage consistent safe sex practices.

Counsel on sequelae and on potential impacts on reproductive system.

Explain the need to abstain from unprotected sex until at least 3 days after completion of treatment and no more symptoms.

Discuss the risk of re-infection.

Slide #36 – Speaker's Notes

• Information should be provided to the patient regarding the prevention of infection by gonorrhea and other sexually transmitted infections.
• Information should be provided to encourage safe sex practices.
• The patient should be counseled on sequelae and on the potential impacts on the reproductive system.
• It is important to explain the need to abstain from unprotected sex until at least 3 days after completion of treatment and until there are no more symptoms.
• A discussion should be had with the patient regarding the risk of re-infection.

Slide #37

Conclusion

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

Slide #37 – Speaker's Notes

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

Slide #38

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 #38 – 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.