Updated Gonorrhea Guidelines

Alert Date
Location
Canada

Updated Gonorrhea Guidelines

To address the growing problem of multi-drug resistant gonorrhea and reduce the associated risk of long-term consequences, Public Health Ontario released the Ontario Gonorrhea Testing and Treatment Guide 2nd edition. We would like to take this opportunity to provide a brief update about these recommendations. For more information, please refer to the complete guide available on www.publichealthontario.ca.

N. gonorrheae is a disease of public health significance, according to the Health Protection and Promotion Act, R.S.O., 1990. All suspected and confirmed gonorrhea cases and treatment failures must be reported to the Health Unit by the next working day. Please refer to the attached Gonorrhea Investigation and Reporting form also available on our website. Prompt notification of treatment failures will allow us to quickly identify emerging patterns of antimicrobial resistance.

LOCAL EPIDEMIOLOGY

Gonorrhea is the second most frequently reported bacterial sexually transmitted infection (STI) in Ontario, after chlamydia. In 2018, there were 181 lab confirmed cases of gonorrhea reported in Windsor and Essex County. This is in comparison to 156 reported cases in 2017.

  • In 2017 as well as 2018, 63% of cases in WEC were treated according to Public Health Ontario’s (PHO; 2013) “Guidelines for Testing and Treatment of Gonorrhea in Ontario”.

DIAGNOSIS OF GONORRHEA CASES

Clinical Evidence:  Individuals with infection may not present with any symptoms.  Symptoms usually appear within 2 to 7 days of exposure and vary between women and men as seen in the following table.

SYMPTOMS
WOMEN MEN
  • Vaginal discharge
  • Dysuria
  • Abnormal vaginal bleeding
  • Lower abdominal pain
  • Deep dyspareunia
  • Rectal pain and discharge with proctitis
  • Urethral discharge
  • Dysuria
  • Urethral itch
  • Testicular pain and/or swelling or symptoms of epididymitis
  • Rectal pain and discharge with proctitis

When to test:

  • All sexually active individuals who have signs and symptoms of gonorrhea should be tested at the urogenital sites where they report unprotected sexual exposure and signs/symptoms.
  • Screen asymptomatic sexually active individuals with risk factors, including:
    • Men who have unprotected sex with men (MSM);
    • People who engage in sex work and their sexual contacts;
    • Known sexual contacts of those infected with gonorrhea;
    • Sexually active youth under 25 years of age; or
    • People who have had sex with multiple partners.
  • Concurrently test for chlamydia and other STBBIs, given risk for coinfection.

How to test:

Symptomatic at Any Sites

Males
Urethral Discharge
YES NO
Urine NAAT
(first-line)
or
Urethral Culture AND Urine NAAT		 Urine NAAT
Females
Pelvic Exam
YES NO
Cervical NAAT
or Vaginal NAAT
(either is first-line)
or
Cervical Culture
AND any NAAT
or
Urine NAAT		 Vaginal
NAAT
(first-line)
or
Urine NAAT

MANAGEMENT OF GONORRHEA CASES

First Line Treatment

  • Ceftriaxone 250 mg IM single dose AND Azithromycin 1 gram PO single dose

Alternative therapeutic options are only considered if first-line therapy is not possible and must be followed by a test of cure.

Treat the following:

  • All lab-confirmed patients;
  • Patients with an epidemiological link to a gonorrhea cases (contacts);
  • Based on clinical assessment and/or risk behaviors following testing, but before results are available;
  • Following sexual assault.

Positive Indications for Treatment, Including Empiric Therapy

First-line therapy(recommended)
Ceftriaxone 250 mg IM+ Azithromycin 1 g PO
Should a test of cure be considered?
A test of cure is recommended when first-line therapy is not used, and in other specific clinical situations, including infection in pregnancy, and pharyngeal gonorrhea.

Alternative therapeutic options

Consider only if first-line therapy is not possible and must be followed by a test of cure. These are:

Patients with severe reaction to penicillin or cephalosporins
Gentamicin 240 mg IM in 2 separate 3-mL 40 mg/mL
injections + Azithromycin 2 g PO
OR
Gemifloxacin 320 mg PO + Azithromycin 2g PO
OR
Azithromycin 2 g PO
(dual therapy options preferred)

Patients with severe reaction to macrolides
Ceftriaxone 250 mg IM
OR
Ceftriaxone 250 mg IM
+ Doxycycline(if specimen is susceptible)
100 mg PO BID x 7 days

Cefixime 400 mg PO + azithromycin 1 g PO. Use of ceflxime could potentially accelerate the development of resistance to Ceftriaxone, which is the only remaining antimicrobial that is safe, well-tolerated, and highly effective at all anatomic sites.
YES NO
Rescreen 6 months post-treatment
or
every 3 months if at on-going hight risk
 Test of cure
Culture 3-7 days post-treatment
(first-line)
or
NAAT 2-3 weeks post-treatment
(second-line)

Clinicians can order provincially funded drugs, at no cost, through the Health Unit. Complete and fax the STI Medication Request Form for gonorrhea or chlamydia medications. Gentamicin is only available through Health Canada’s Special Access Program, ordered through the Health Unit.

Education and Counselling: Educate patients and contacts about:

  • Infection and mode of transmission;
  • Safer sex practices (e.g. use of condoms, screening if at risk, contraception), and
  • Abstaining from unprotected sexual exposure until 3 days post treatment and the case/contacts are asymptomatic.

Test of Cure and Rescreening:

  • Test of cure by culture is recommended in specific clinical situations (e.g., all children and pregnant women, all pharyngeal infections, if compliance is uncertain and when first line therapy was not possible due to a contraindications such as penicillin allergy)
    • Culture  3-7 days post-treatment (first-line) OR
    • NAAT 2-3 weeks post-treatment.
  • Rescreen individuals with gonococcal infection at 6 months post-treatment.

Treatment Failures: For suspected or confirmed gonorrhea treatment failures (i.e. treated individuals with confirmed gonorrhea and a positive test of cure without risk of reinfection, notify the Health Unit. We will assist to notify provincial authorities of the treatment failure. Ensure culture and sensitivity testing is done. It is strongly recommended that treatment be guided by susceptibility test results.

SCREENING OF CONTACTS

Encourage and support your patients to notify sexual partners for evaluation, testing and treatment as soon as possible to prevent further transmision. The Health Unit will also contact clinicians if your patient is deemed a contact and provide recommendations for empiric therapy. Report probable or diagnosed cases immediately to the Health Unit.  Refer the the “Gonorrhoea Investigation and Reporting Form” included in this update. Please note a contact recommended for screening is defined as:

  • A person who have had sexual contact with the case within 60 days prior to symptom onset or date of specimen collection.  The exposure may have been unprotected sex with no precautions taken or protected with varying degrees of precaution used.

MORE INFORMATION

Our website (www.wechu.org) is a useful reference for health care providers.  For additional information or consultation, please call the Health Unit during regular office hours @ 519-258-2146 ext. 1420.

Additional Resources:

  • Canadian Guidelines on Sexually Transmitted Infections:
    https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/sexually-transmitted-infections.html#toc
  • Ontario Gonorrhea Testing and Treatment Guide, 2nd Edition;
    www.publichealthontario.ca/en/eRepository/guide-gonorrhea
  • Public Health Ontario Laboratory Test Directory:
    https://www.publichealthontario.ca/en/ServicesAndTools/LaboratoryServices/Pages/Index.aspx
  • STI Medication Ordering Form