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STBBI: Guides for health professionals: Summary of Recommendations for Chlamydia trachomatis (CT),Neisseria gonorrhoeae (NG) and Syphilis

Tips for screening, treatment and follow-up of bacterial STBBI

Reported cases of STBBI in Canada are increasing (2019)

139,386 cases of Chlamydia trachomatis (CT)

  • 74% of cases were aged 15 to 19
  • 58% of cases were female

35,443 cases of Neisseria gonorrhoeae (NG)

  • 51% of cases were aged 15 to 29
  • 66% of cases were male

9,245 cases of infectious Syphilis

  • 72% of cases were male
  • Among females aged 15 to 39 years, rates were 18 times higher than in 2010

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Organization: Public Health Agency of Canada

Published: 2023-08-11

Type: Infographic

ISBN: 978-0-660-47378-9

Cat: HP40-250/2023E-PDF

Pub.: 220748

Do you know if the person in front of you has ever been screened for sexually transmitted and blood-borne infections (STBBI)?

In 2018, over 50% of Canadians reported that they had never been screened for STBBI.

Normalize discussions about sexual health and offer STBBI screening to sexually active people as part of routine care.

Offer annual screening to:

  • Individuals < 25 years old
  • Gay, bisexual and other men who have sex with men (gbMSM)
  • Transgender persons

Offer screening to people ≥ 25 years old based on risk factorsFootnote +

Offer screening routinely during pregnancy

CT and NG:

  • Screen in the 1st trimester or at the 1st prenatal visit AND in the 3rd trimester
  • Screen during labour if: no prenatal screening has occurred (no results are available) OR 3rd trimester screening did not occur OR follow-up for a positive result was not completed

Syphilis:

  • Screen in the 1st trimester or at the 1st prenatal visit
  • Screen between 28 and 32 weeks of pregnancy AND during labour in areas experiencing outbreaks AND for people at ongoing risk for infectionFootnote +

More frequent screening may be appropriate for those with ongoing risk factors for STBBIFootnote +

STBBI are often asymptomatic. Screen for one STBBI, screen for all!

Screening: Early STBBI detection in asymptomatic individualsFootnote †

Chlamydia trachomatis (CT) AND Neisseria gonorrhoeae (NG)
Figure 1. Text version below.
Figure 1 - Text Equivalent

Image 1 depicts a flow chart of the different specimens and laboratory tests that may be used for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) screening. First void urine samples can be tested for CT and NG using Nucleic Acid Amplification Testing (NAAT). Urethral, vaginal or cervical swabs can be tested for CT and NG using NAAT and/or culture for NG. Rectal or pharyngeal swabs can be tested for CT and NG using NAAT, if available, and/or culture.

Tips

Offer HIV testing when screening for other STBBIFootnote †

Syphilis
Figure 1. Text version below.
Figure 2 - Text Equivalent

Image 2 depicts the flow chart of syphilis screening using blood samples. Laboratories will use blood samples to perform syphilis serology using an algorithm combining non-treponemal and treponemal tests.

Tips

Offer HIV testing when screening for other STBBI.Footnote †

Early diagnosis and treatment lead to better health outcomes

Treatment: Preferred STBBI treatment in the absence of contraindications, allergies or pregnancy
Chlamydia trachomatis (CT) Neisseria gonorrhoeae (NG) Syphilis
  • Doxycycline 100 mg PO bid for 7 days

OR

  • Azithromycin 1 g PO in a single dose

For anogenital and pharyngeal infections

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

OR

For anogenital infections

  • Cefixime 800 mg PO in a single dose PLUS Azithromycin 1 g PO in a single dose

Note: Cefixime is not the preferred treatment for gbMSM

For infectious syphilis (primary, secondary and early latent)

  • Long-acting benzathine penicillin G 2.4 million units IM in a single dose

For late latent syphilis

  • Long-acting benzathine penicillin G 2.4 million units IM weekly for 3 doses

Tips

  • For NG infections, always use combination therapy to prevent resistance and treat possible CT co-infection
    • The use of two antimicrobials with different mechanisms of action may improve treatment efficacy and prevent or delay the emergence and spread of resistant NG
    • Ceftriaxone 250 mg IM in a single dose PLUS Azithromycin 1 g PO in a single dose is the recommended treatment for pharyngeal NG and for gbMSM
  • For CT infections, consider using Azithromycin if poor compliance is expected
  • Individuals and their partners should abstain from sexual contact until the completion of a multiple-dose treatment or for 7 days after a single-dose treatment
  • All partners who have had sexual contact with the individual within 60 days prior to specimen collection or onset of symptoms, should be tested and treated

Tips

  • Inform individuals of potential Jarisch-Herxheimer reaction to penicillin treatment
  • Consider penicillin desensitization for individuals with a penicillin allergy, followed by treatment with long-acting benzathine penicillin G
    • There is no satisfactory alternative treatment to penicillin for the treatment of syphilis in pregnancy
  • Individuals and partners should abstain from sexual contact for 7 days after treatment
  • All sexual partners or perinatal contacts should be tested and treated according to the individual's stage of infection and date of specimen collection or onset of symptoms:
    • Primary syphilis: 3 months
    • Secondary syphilis: 6 months
    • Early latent syphilis: 1 year
    • Late latent/tertiary: individual's long-term sexual partner(s) and children as appropriate
Follow-up: post STBBI screening and treatment interventions including test of cure (TOC)
Chlamydia trachomatis (CT) Neisseria gonorrhoeae (NG) Syphilis

TOC using NAAT 3 - 4 weeks after the completion of treatment is recommended only when:

  • Compliance to treatment is suboptimal
  • Unresolved or persistent symptoms are present
  • Alternate treatment regimen was prescribed
  • Individual is pregnant or prepubertal

Routine TOC is recommended:

  • Using culture, 3-7 days after completion of treatment; and/or
  • Using NAAT 2-3 weeks after completion of treatment
TOC is of particular importance when:
  • Treatment failure and resistant NG are suspected
  • Compliance to treatment is suboptimal
  • Unresolved or persistent symptoms are present
  • Alternate treatment regimen was prescribed
  • Individual is pregnant or prepubertal
  • Pharyngeal infection was detected

Indications for post-treatment monitoring and follow-up serology:

  • Infectious syphilis (primary, secondary and early latent): 3, 6 and 12 months
  • Late latent and tertiary syphilis: 12 and 24 months
  • Neurosyphilis: 6, 12 and 24 months
  • Co-infection with HIV: 3, 6, 12 and 24 months and yearly thereafter
  • Pregnancy:
    • Primary, secondary and early latent syphilis: monthly until delivery if at risk of re-infection or 1, 3, 6 and 12 months
    • Late latent syphilis: at time of delivery and 12 and 24 months

Tips

  • When test of cure (TOC) is indicated, specimens should be collected from all positive sites
  • TOC using NAAT should be performed at recommended post-treatment interval to avoid detection of residual genetic material
  • In addition to TOC, repeat screening is recommended 3 to 6 months post-treatment due to risk of reinfection
 Tips
  • Post-treatment serology is used to assess treatment response
  • Consult a colleague or specialist experienced in syphilis management if the serologic response to treatment is inadequate

Consult the STBBI: Guides for health professionals for more detailed information.

Recommendations 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.

Additional info:

Learn more: visit Canada.ca and search Sexual Health or download the Canadian STBBI Guides mobile application.

Footnotes

Footnote 1

Risk factors for STBBI acquisition include but are not limited to: previous STBBI diagnosis, new sexual partners, multiple or anonymous sexual partners, sexual partners having a STBBI, condomless sex and sex while under the influence of alcohol or drugs

Return to footnote + referrer

Footnote 2

For HIV specific guidance consult the HIV Factsheet: Screening and Testing available on Canada.ca

Return to footnote † referrer

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