Canadian Guidelines on Sexually Transmitted Infections: Summary of Recommendations for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Syphilis

Tips for STI screening, treatment and follow-up

Reported cases of STI in Canada are increasing (2016)

121,244 cases of Chlamydia trachomatis (CT)

  • 76% of cases are aged 15 to 29
  • The highest increase in rates is in adults over 40

23,708 cases of Neisseria gonorrhoeae (NG)

  • 57% of cases  are aged 15 to 29
  • The highest increase in rates is in adults over 30 

3,829 cases of infectious Syphilis

  • 92% of cases are men

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Organization: Public Health Agency of Canada

Published: 2019-02-20

Do you know if the person in front of you has ever been screened for sexually transmitted infections (STI)?

In 2018, over 60% of Canadians reported that they had never been screened for STI.

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

STI screening provides an opportunity to discuss transmission, signs and symptoms, risk reduction and preventive measures.


Prenatal Screening

  • Screen at first prenatal visit and repeat based on risk factors
  • Consider repeat screening for syphilis in areas experiencing heterosexual outbreaks, regardless of risk factors

Risk Factor Screening

  • ≥ 25 years old
  • Offer screening and repeat screening based on risk factors

Annual Screening Footnote +

  • < 25 years old
  • Gay, bisexual, and other men who have sex with men (gbMSM) and transgender populations

More frequent STI screening may be appropriate for individuals with behavioural risk factors.

Behavioural risk factors for STI acquisition include but are not limited to: previous STI diagnosis, new sexual partner, multiple or anonymous sexual partners, sexual partner(s) having a STI, condomless sex and sex while under the influence of alcohol or drugs.

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

Screening: Early STI detection in asymptomatic individualsFootnote

Chlamydia trachomatis (CT) AND Neisseria gonorrhoeae (NG)
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

  • Nucleic Acid Amplification Test (NAAT) is highly sensitive and the test of choice when screening asymptomatic individuals for CT and NG
    • Preferred specimens for NAAT are first void urine or self-collected vaginal swab
    • Collect pharyngeal and rectal specimens from individuals with a history of performing oral sex or having receptive anal intercourse, respectively
    • Check with your laboratory for the availability of NAAT for rectal and pharyngeal specimens
  • Collect specimens for both CT and NG due to high rates of co-infection
  • When NG is suspected, collect specimens for NAAT AND culture
    • Culture permits antimicrobial susceptibility testing to guide treatment 
    • Ideally, collect specimens prior to empirical/epidemiological treatment
Syphilis
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

  • Testing algorithms may vary by province and territory

Offer HIV testing when screening for other STIFootnote

Early diagnosis and treatment lead to better health outcomes

Treatment: Preferred STI 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 considered alternate treatment in 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 STI 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:

  • Primary, secondary and early latent syphilis: if at risk of re-infection, monthly until delivery; otherwise 1, 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 Canadian Guidelines on Sexually Transmitted Infections 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 STI guidelines mobile application.

Footnotes

Footnote 1

Offer more frequent screening based on risk factors

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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