Multi-drug resistant gonorrhea update

Advisory Alert

May 12, 2023

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To: Local Health System Partners

FOR IMMEDIATE ATTENTION

Please note this is an updated Advisory Alert from our original alert sent on April 3, 2023 entitled ‘Multi-drug resistant gonorrhea identified’. Additional information was shared in the May 3, 2023 Public Health Ontario posting, ‘Detection of ceftriaxone non-susceptible Neisseria gonorrhoea in Ontario’. The post is attached to this Advisory Alert for reference.

Updates include:

The recommended effective treatment for MDR gonorrhea has been identified as one dose of Ceftriaxone (250 mg IM) and azithromycin (1 gm po).
At a minimum, gonorrhoeae culture is recommended plus NAAT for the following scenarios:
- Symptomatic patients, when antimicrobial resistance is suspected
- Test of cure
- Pelvic inflammatory disease (PID)
- Pregnancy
- Sexual abuse or sexual assault
When screening asymptomatic men who have sex with men (MSM), collect additional NAAT pharyngeal and rectal samples.

Important information regarding ceftriaxone non-susceptible gonorrhea in Ontario

Recent international reports from Europe and USA have identified a multi-drug resistant strain of Neisseria gonorrhoeae. Through routine provincial disease surveillance activities, an Ontario patient with no known travel history was recently identified as having a gonorrhea infection with a similar resistance pattern. For instance, a reduced susceptibility to ceftriaxone and cefixime, as well as resistance to ciprofloxacin, penicillin, and tetracycline, which suggests circulation of this multi-drug resistant strain within Ontario. Currently, treatment with one dose of Ceftriaxone (250 mg IM) and Azithromycin (1 gm po) has been deemed effective as demonstrated by a negative test of cure.

In this context, and per the attached post, the Ministry of Health is recommending:

For all patients with suspected gonorrhea infection, collect swabs for gonorrhoeae culture as well as specimens for NAAT testing for N. gonorrhoeae from all potentially exposed sites (i.e. urethral/cervical, pharyngeal, rectal). It is recommended to collect both types of specimens for patients given that NAAT is more sensitive, and culture allows assessment for drug sensitivity. Swabs should be received within 48 hours if possible but will be accepted by Public Health Ontario Laboratory up to 72 hours after collection. For additional details on specimen collection and submission, please see the Public Health Ontario Test Information Index.
- Additionally, gonorrhoeae culture is recommended plus NAAT for the following scenarios:
  - Symptomatic patients, when antimicrobial resistance is suspected
  - Pelvic inflammatory disease (PID)
  - Pregnancy
  - Sexual abuse or sexual assault
As per the Canadian Guidelines on Sexually Transmitted Infections (CGSTI), test of cure is currently recommended for all positive cases of gonorrhoeae at all positive sites. Culture is the preferred method for test of cure and should be performed 3-7 days after completion of treatment. If culture is not available, test of cure by NAAT will also be accepted and should be performed at 2-3 weeks post-treatment.
When screening asymptomatic men who have sex with men (MSM), it is recommended to collect additional NAAT pharyngeal and rectal samples.
- These sites are often reservoirs of asymptomatic infections. Consider those sites for other person depending on their sexual practices and symptoms.

Current CGSTI guidance advises to re-screen persons with gonorrhea infection at 6 months post-treatment or else at the first follow-up appointment within 12 months, given risks of re-infection due to ongoing or repeat exposure.

Health care practitioners are asked to call the Sexual Health Clinic at 705.522.9200, ext. 482 (toll-free 1.866.522.9200) to report a case with multi-drug resistant gonorrhea infection, or for additional information.

Sincerely,

Original Signed By

Dr. Penny Sutcliffe
Medical Officer of Health and Chief Executive Officer

NOTE: All Advisory Alerts are found on our website.

This item was last modified on April 4, 2024