Gonorrhea guide: Etiology and epidemiology

Prevention and control of Neisseria gonorrhoeae infections

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Etiology

N. gonorrhoeae is a Gram-negative diplococcusFootnote 1. This highly infectious bacterium colonizes and infects genital mucosa and it may also infect extragenital sites, including the oropharyngeal, conjunctival and anorectal mucosaeFootnote 2.

N. gonorrhoeae can develop antimicrobial resistance (AMR) rapidly and has developed resistance to every class of antimicrobial used to treat itFootnote 3Footnote 4; some of these antibiotics (sulphonamides, penicillins, tetracyclines) are ineffective and are no longer used.

Travel-related ceftriaxone-resistant gonorrhea isolates were reported in Canada in 2017Footnote 5 and 2018Footnote 6 and isolates with decreased susceptibility to cephalosporins (cefixime and ceftriaxone) continue to emerge. Resistance to azithromycin is increasing and treatment failures have been reported in Canada and around the world.

Epidemiology

Gonorrhea is the second most commonly reported STIs in Canada, with a gradual and steady increase in reported cases of gonorrhea since 1997. Gonorrhea may be undiagnosed or unreported because gonorrheal infections are often asymptomatic.

Between 2010—2015, gonorrhea rate was higher among males than among females. In addition, the rate increased at a faster pace in males than females. Adolescents and young adults (15-29 age group) are the most affectedFootnote 8.

More information

Local epidemiological information: Consult your public health unit.

National epidemiological information:

Global epidemiological information:  

Surveillance of antimicrobial resistance in gonorrhea

Antimicrobial-resistant N. gonorrhoeae is a global public health challengeFootnote 3. Surveillance of AMR in N. gonorrhoeae is crucial to monitor trends and inform efforts to prevent and control its spread.

There is a growing shift in Canada towards the use of NAAT instead of culture to test for N. gonorrhoeae. As a result, fewer samples are available for susceptibility testing, making it difficult to generate an accurate picture of drug resistanceFootnote 9.

The national program, Enhanced Surveillance of Antimicrobial-Resistant Gonorrhea (ESAG) integrates epidemiologic and treatment failure data into existing laboratory-based monitoring of antimicrobial-resistant N. gonorrhoeae. ESAG information enables early identification of drug-resistant gonorrhea and assists in identifying appropriate and effective treatment, which helps prevent its spread.

In Canada, N. gonorrhoeae displays high rates of resistance to penicillin, tetracycline, erythromycin and ciprofloxacinFootnote 9. These antimicrobial agents should only be used to treat gonococcal infections if susceptibility is confirmed.

There have been reports of resistance to azithromycin and decreased susceptibility to cephalosporins in Canada. Treatment failures have also been reported with the use of third generation oralFootnote 10Footnote 11 and injectable cephalosporins. Cases of gonorrhea with high-level resistance to both ceftriaxone and azithromycin have been reported in Canada, the United Kingdom, Australia and HawaiiFootnote 12Footnote 13Footnote 5.

References

Footnote 1

Edwards JL, Apicella MA. The molecular mechanisms used by Neisseria gonorrhoeae to initiate infection differ between men and women. Clin Microbiol Rev. 2004;17(4):965-981. doi:10.1128/CMR.17.4.965-981.2004

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Footnote 2

Chan PA, Robinette A, Montgomery M, et al. Extragenital Infections Caused by Chlamydia trachomatis and Neisseria gonorrhoeae: A Review of the Literature. Infect Dis Obstet Gynecol. 2016;2016:5758387. doi:10.1155/2016/5758387

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Footnote 3

Unemo M, Shafer WM. Antimicrobial resistance in Neisseria gonorrhoeae in the 21st century: past, evolution, and future. Clin Microbiol Rev. 2014;27(3):587-613.

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Footnote 4

Tapsall JW, Ndowa F, Lewis DA, Unemo M. Meeting the public health challenge of multidrug- and extensively drug-resistant Neisseria gonorrhoeae. Expert Rev Anti Infect Ther. 2009;7(7):821-834. doi:10.1586/eri.09.63

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Footnote 5

Lefebvre B, Martin I, Demczuk W, et al. Ceftriaxone-Resistant Neisseria gonorrhoeae, Canada, 2017. Emerg Infect Dis. 2018;24(2):381-383.

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Footnote 6

Berenger BM, Demczuk W, Gratrix J, Pabbaraju K, Smyczek P, Martin I. Genetic Characterization and Enhanced Surveillance of Ceftriaxone-Resistant Neisseria gonorrhoeae Strain, Alberta, Canada, 2018. Emerg Infect Dis. 2019;25(9):1660-1667.

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Footnote 7

Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada. Report on sexually transmitted infections in Canada: 2008. Government of Canada. 2010.

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Footnote 8

Choudhri Y, Miller J, Sandhu J, Leon A, Aho J. Gonorrhea in Canada, 2010-2015. Can Commun Dis Rep. 2018;44(2):37-42.

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Footnote 9

Martin I, Jayaraman G, Wong T, Liu G, Gilmour M; Canadian Public Health Laboratory Network. Trends in antimicrobial resistance in Neisseria gonorrhoeae isolated in Canada: 2000-2009. Sex Transm Dis. 2011;38(10):892-898.

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Footnote 10

Allen VG, Mitterni L, Seah C, et al. Neisseria gonorrhoeae treatment failure and susceptibility to cefixime in Toronto, Canada. JAMA. 2013;309(2):163-170

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Footnote 11

Singh AE, Gratrix J, Martin I, et al. Gonorrhea Treatment Failures With Oral and Injectable Expanded Spectrum Cephalosporin Monotherapy vs Dual Therapy at 4 Canadian Sexually Transmitted Infection Clinics, 2010-2013. Sex Transm Dis. 2015;42(6):331-336.

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Footnote 12

Katz AR, Komeya AY, Kirkcaldy RD, et al. Cluster of Neisseria gonorrhoeae Isolates With High-level Azithromycin Resistance and Decreased Ceftriaxone Susceptibility, Hawaii, 2016. Clin Infect Dis. 2017;65(6):918-923.

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Footnote 13

European Centre for Disease Prevention and Control. Extensively drug-resistant (XDR) Neisseria gonorrhoeae in the United Kingdom and Australia – 7 May 2018. Stockholm: ECDC; 2018. https://www.ecdc.europa.eu/sites/default/files/documents/RRA-Gonorrhoea%2C%20Antimicrobial%20resistance-United%20Kingdom%2C%20Australia.pdf

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