1. Antimicrobial Resistance in N. gonorrhoeae – An Overview 2014 INTRODUCTION Progressive antimicrobial resistance in Neisseria gonorrhoeae is an emerging public health threat The Public Health Agency of Canada(the Agency) released updated recommendations in July 2013 for the diagnosis, treatment, follow- up and reporting of gonorrhea Antimicrobial Resistance in N. gonorrhoeae – An Overview

2. 2014 KEY ISSUES Gonococcal infections have been resistant to certain antimicrobial drugs The problem is worldwide, and is growing Gonococcal infections are becoming more difficult to treat Reported cases of gonococcal infection in Canada have increased since 1997 Potential increase in major sequelae due to prolonged duration of original infection Antimicrobial Resistance in N. gonorrhoeae – An Overview

3. 2014 KEY ISSUES Progressive resistance to penicillin, tetracycline and quinolones has emerged Treatment failure with third generation oral and injectable cephalosporins has been observed To date, resistance particularly observed among MSM* Antimicrobial Resistance in N. gonorrhoeae – An Overview * Men Who Have Sex With Men

4. Antimicrobial Resistance in N. gonorrhoeae – An Overview 2014 KEY ISSUES Increasing use of Nucleic Acid Amplification Testing (NAAT) for the diagnosis of gonorrhea Unfortunately the use of NAAT has resulted in less data on antimicrobial susceptibility Why? High specificity & sensitivity Cost-effective Cultures are impractical Antimicrobial Resistance in N. gonorrhoeae – An Overview

5. 2014 DIAGNOSIS Depending on clinical situation, consider collecting both cultures and NAAT especially in symptomatic patients Antimicrobial Resistance in N. gonorrhoeae – An Overview

6. 2014 DIAGNOSIS Cultures are particularly important in the following situations: Where there is an increased probability or a suspected treatment failure If the infection was acquired in a geographical area with high rates of antimicrobial resistance MSM who are symptomatic Antimicrobial Resistance in N. gonorrhoeae – An Overview Suspected pelvic inflammatory disease

7. Antimicrobial Resistance in N. gonorrhoeae – An Overview 2014 TREATMENT Monotherapy should be avoided Patients should be treated with combination therapy (two antibiotics) Agency’s Recommended Treatment 2013 Antimicrobial Resistance in N. gonorrhoeae – An Overview

8. 2014 TREATMENT Full treatment details at: http://www.The Agency-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-6-eng.php Patients should be treated with combination therapy (two antibiotics) The preferred therapy for uncomplicated anogenital and pharyngeal infection for MSM, adults and youth (≥ 9 years )is: ceftriaxone 250 mg IM PLUS azithromycin 1 g oral Another preferred treatment for uncomplicated anogenital infection in adults and youth (≥ 9 years), excluding MSM is: cefixime 800 mg oral PLUS azithromycin 1 g oral Antimicrobial Resistance in N. gonorrhoeae – An Overview

9. 2014 TREATMENT Full treatment recommendations, including alternative treatments available The Public Health Agency of Canada’s Canadian STI Guidelines: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-6-eng.php Antimicrobial Resistance in N. gonorrhoeae – An Overview

10. 2014 Test of cure should be completed in all cases; particularly important when: Pharyngeal infections Cases treated with a regimen other than the preferred treatment Case is linked to a drug resistant/treatment failure case and was treated with the same antibiotic Case has persistent symptoms or signs post-therapy TEST OF CURE Antimicrobial Resistance in N. gonorrhoeae – An Overview

11. 2014 Antimicrobial Resistance in N. gonorrhoeae – An Overview TEST OF CURE 3-7 days later  Culture All sexual partners within 60 days prior to symptom onset should be notified, tested and empirically treated 2-3 Weeks later  NAAT Repeat screening for individuals with a gonococcal infection is recommended 6 months post-treatment Test of Cure Post-Treatment Antimicrobial Resistance in N. gonorrhoeae – An Overview

12. 2014 TREATMENT FAILURE 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 Antimicrobial Resistance in N. gonorrhoeae – An Overview

13. 2014 Should I notify local public health officials? REPORTING When treatment failure has occurred? Yes Gonorrhea is a reportable infection. Treatment failure should also be reported. For cases of gonorrhea? Antimicrobial Resistance in N. gonorrhoeae – An Overview

14. 2014 RESOURCES http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-6-eng.php The above based on Public Health Agency of Canada’s Canadian STI Guidelines To access the chapter and additional resources: This document is intended to provide information to public health and clinical professionals and does 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. Antimicrobial Resistance in N. gonorrhoeae – An Overview

15. 2014 CONCLUSION To successfully address the public health risk of antimicrobial resistant gonorrhea, all primary care and public health professionals must work together. Antimicrobial Resistance in N. gonorrhoeae – An Overview