5 Minute Briefing on Antimicrobial Resistant Gonorrhea

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Antimicrobial Resistance in N. gonorrhoeae: In Brief (PDF Document 1.3 MB - 7 pages)

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Antimicrobial Resistance in N. gonorrhoeae: In Brief

Table of Contents – Presentation Slides

1. Introduction
2. Key Issues
3. Diagnosis
4. Treatment
5. Follow-Up
6. Reporting
7. Conclusion

Slide #1

Introduction

Increased action is needed to help prevent and control gonorrhea. Worldwide antimicrobial resistance is an emerging public health threat.

Slide #1 – Speaker's Notes

• Antimicrobial resistant gonorrhea is being seen worldwide and 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 Agency recommendations on the diagnosis and management of gonococcal infections.
• This presentation highlights the key issues identified in the revised Public Health Agency of Canada's (the Agency) 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 existing drug therapies.

Progressive resistance to penicillin, tetracycline and quinolones. Decreased susceptibility to third generation oral and injectable cephalosporins.

Resistance to cephalosporins particularly observed among MSM. ^{Footnote 1}

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 have been resistant to existing drug therapies.
• It is important to note that there is progressive resistance to penicillin, tetracycline and quinolones. Decreased susceptibility to third generation oral and injectable cephalosporins has been observed.
• Resistance to cephalosporins has been particularly observed among Men who have sex with Men (MSM).

Slide #3

Diagnosis

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

Cultures are particularly important in the following situations:

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

Slide #3 – Speaker's Notes

• Due to the need to identify or characterize antimicrobial resistance, consider collecting both cultures and NAAT especially in symptomatic patients; cultures are critical for improved public health monitoring of antimicrobial resistance patterns of trends.
• 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.
• Nucleic Acid Amplification Testing (NAAT) is used frequently for diagnosis of gonorrhea, due to its high specificity, sensitivity, accessibility, availability and cost.
• NAAT is used for point of care diagnosis when cultures are not possible. However the use of NAAT has resulted in less data on antimicrobial resistance.

Slide #4

Treatment

Monotherapy should be avoided in order to help prevent resistance.

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

For MSM, the preferred therapy for uncomplicated anogenital and pharyngeal infection is: ceftriaxone 250 mg IM PLUS azithromycin 1 g oral

For other adults and youth (≥ 9 years), the preferred therapy for uncomplicated anogenital and pharyngeal infection is: ceftriaxone 250 mg IM PLUS azithromycin 1 g oral

For uncomplicated anogenital infection only: cefixime 800 mg oral PLUS azithromycin 1 g oral (not appropriate for pharyngeal infections)

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

Slide #4 – Speaker's Notes

• Patients should be treated with combination therapy (two antibiotics) in response to potential antimicrobial resistance. Monotherapy should be avoided.
• The preferred treatment varies by population and infection site. Among MSM, ceftriaxone 250 mg^{Footnote 2} intramuscularly PLUS azithromycin 1 g^{Footnote 2} 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 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.
• 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 #5

Follow-Up

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 #5 – 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.
• In cases where culture is not available and NAAT is used as a test of cure, specimen collection should be delayed for 2 to 3 weeks after completion of therapy to avoid false positive results.
• 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.
• Repeat screening for individuals with a gonococcal infection is recommended 6 months post-treatment.
• For other 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 #6

Reporting

Cases of gonorrhea must be reported to public health officials.

Treatment failures should also be reported.

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 #6 – Speaker's Notes

• In all provinces and territories, prompt reporting of all cases to local public health officials is required.
• Practitioners are encouraged to notify their local and provincial/territorial public health authorities of treatment failures.
• 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 #7

Conclusion

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

Slide #7 – Speaker's Notes

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