Antimicrobial Resistance in N. gonorrhoeae A Review 2014

Antimicrobial Resistance in N. gonorrhoeae A Review 2014

Antimicrobial Resistance in N. gonorrhoeae A Review 2014 Antimicrobial Resistance in N. gonorrhoeae A Review 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 2014 Antimicrobial Resistance in N. gonorrhoeae A Review

OBJECTIVES To promote: To increase awareness and knowledge of the status of antimicrobial resistance of N. gonorrhoeae Appropriate laboratory testing Optimal use of antibiotics Test-of-cure recommendations Proper action on detecting, reporting and re-treatment in cases of documented or suspected treatment failure 2014

Antimicrobial Resistance in N. gonorrhoeae A Review BACKGROUND Antimicrobial resistance occurs when bacteria, fungi, viruses, or parasites develop the ability to resist the effects of antimicrobial drugs used to kill them or slow their growth A recent report from the World Health Organization (2014) identified antimicrobial resistance as a global threat Results from this study showed a significant increase in antimicrobial resistance worldwide Warned about the possibility of a post-antibiotic era in which common infectionscan kill. 2014 Antimicrobial Resistance in N. gonorrhoeae A Review BACKGROUND Aligns with World Health Organisations Global Action

Plan to Control the Spread and Impact of Antimicrobial Resistance in Neisseria gonorrhoeae (2012) Identified antimicrobial resistant gonorrhea as the next drug resistant superbug 2014 Antimicrobial Resistance in N. gonorrhoeae A Review EPIDEMIOLOGY Reported cases of gonococcal infection in Canada have increased since 1997 Most affected: Males 2024 years of age

Females 1519 years of age Infection rates are increasing more rapidly among females than among males. A network of people with high-transmission activities may play a key role in current prevalence levels and in sustaining infections within a community. 2014 Antimicrobial Resistance in N. gonorrhoeae A Review KEY ISSUES Gonococcal infections have been resistant to certain antibiotics

The problem is worldwide, and is growing Gonococcal infections are becoming more difficult to treat. Potential increase in major sequelae due to prolonged duration of original infection 2014 Antimicrobial Resistance in N. gonorrhoeae A Review KEY ISSUES Progressive resistance to penicillin, tetracycline and quinolones has emerged

To date, resistance particularly observed among MSM* Treatment failure with third generation oral and injectable cephalosporins has been observed * Men Who Have Sex With Men 2014 Antimicrobial Resistance in N. gonorrhoeae A Review AT RISK Individuals who have had sexual contact with a person with a confirmed or suspected gonococcal infection Individuals with a history of other STIs, including HIV

Individuals who have had unprotected sex with a resident of an area with high gonorrhea burden and/ or high risk of antimicrobial resistance Individuals with a history of previous gonococcal infection 2014 Antimicrobial Resistance in N. gonorrhoeae A Review AT RISK Sex workers and their sexual partners Individuals who have had sex with multiple partners Street-involved youth and other homeless populations

Sexually active youth < 25 years of age Men who have unprotected sex with men 2014 Antimicrobial Resistance in N. gonorrhoeae A Review MANIFESTATIONS Youth ( 9 years) and Adults Neonates and Infants Ophthalmia Neonatorum Children Females

Both Males Urethritis Cervicitis Pharyngeal Infection Urethritis Vaginitis Pelvic Inflammatory

Disease Conjunctivitis Conjunctivitis Conjunctivitis Proctitis Sepsis Disseminated gonococcal infection* Epididymitis Pharyngeal Infection

Urethritis Perihepatitis Proctitis Disseminated gonococcal infection* Bartholinitis Disseminated gonococcal infection* *e.g., arthritis, dermatitis, endocarditis, meningitis 2014

Antimicrobial Resistance in N. gonorrhoeae A Review SYMPTOMS Females Males Often asymptomatic *Often symptomatic Vaginal discharge Urethral discharge Dysuria Dysuria

Abnormal vaginal bleeding Urethral itch Lower abdominal pain Deep dyspareunia Testicular pain and/or swelling or symptoms of epididymitis Rectal pain and discharge (with proctitis) Rectal pain and discharge (with proctitis) In both females and males, rectal and pharyngeal infections are more likely to be asymptomatic 2014

Antimicrobial Resistance in N. gonorrhoeae A Review MAJOR SEQUELAE Youth ( 9 years) and Adults Females Males Pelvic inflammatory disease Epididymo-orchitis Infertility Ectopic pregnancy Reactive arthritis (oculourethro-synovial syndrome)

Chronic pelvic pain Infertility (rare) Reactive arthritis (oculo-urethrosynovial syndrome) Disseminated gonococcal infection * Disseminated gonococcal infection* *e.g., arthritis, dermatitis, endocarditis, meningitis 2014 Antimicrobial Resistance in N. gonorrhoeae A Review DIAGNOSIS

Depending on clinical situation, consider collecting both cultures and NAAT especially in symptomatic patients 2014 Antimicrobial Resistance in N. gonorrhoeae A Review NAAT Increase in the number of cases diagnosed due to higher sensitivity and specificity of test NAAT may be the only available testing method in some jurisdictions However, culture is strongly recommended because

it allows for testing of antimicrobial susceptibility Where NAAT is routinely used, sentinel surveillance mechanisms using culture are important to ensure continued monitoring for antimicrobial resistance 2014 Antimicrobial Resistance in N. gonorrhoeae A Review CULTURE Critical for improved public health monitoring of antimicrobial resistance and trends Provides clinicians with important case management information Cultures obtained less than 48 hours after

exposure may give false negative results 2014 Antimicrobial Resistance in N. gonorrhoeae A Review DIAGNOSIS Cultures are particularly important in the following situations: In suspected pelvic inflammatory disease Where there is an increased probability or a suspected treatment failure In symptomatic MSM If the infection was acquired in a geographical area with high rates of antimicrobial resistance

2014 Antimicrobial Resistance in N. gonorrhoeae A Review SPECIMENS Asymptomatic Patients Take specimen from any exposed site Cervical or vaginal culture or NAAT Urethral culture or NAAT Rectal culture or validated NAAT and/or Pharyngeal culture or validated NAAT Urine NAAT if urethral swab or pelvic examination is not practical 2014

Antimicrobial Resistance in N. gonorrhoeae A Review SPECIMENS *Symptomatic Patients * Take specimen from any exposed site Cervical or vaginal culture or NAAT Urine NAAT if urethral swab or pelvic exam not practical Urethral culture or NAAT if patient has urethral syndrome * Rectal culture or validated NAAT if anogenital symptoms 2014

Antimicrobial Resistance in N. gonorrhoeae A Review MANAGEMENT Appropriate samples based on site of exposure and test type should be obtained prior to treatment Presumptive treatment is to be provided for: Syndromic management: Or if patient is being treated as a contact Mucopurulent cervicitis Non-gonococcal urethritis Epididymitis Pelvic inflammatory disease When making treatment decisions, relevant history, physical

examination and epidemiologic factors should be considered 2014 Antimicrobial Resistance in N. gonorrhoeae A Review TREATMENT Monotherapy should be avoided To help prevent the spread of antimicrobial resistant gonorrhea Using medications with two different mechanisms of action may also improve treatment efficacy Combination therapy also provides effective treatment for chlamydia given high rates of

concomitant infections 2014 Antimicrobial Resistance in N. gonorrhoeae A Review TREATMENT Cephalosporins Cefixime treatment failures in MSM have recently been documented Ceftriaxone + azithromycin is recommended as the preferred treatment for gonococcal infections in MSM 2014

Antimicrobial Resistance in N. gonorrhoeae A Review TREATMENT Azithromycin should not be used as monotherapy. Resistance has been reported. Exception: when cephalosporins are contraindicated Azithromycin History of anaphylactic reaction to penicillin Allergy to cephalosporins Cross-sensitivity between penicillin and 2nd or 3rd generation cephalosporins is low, but if patient has history of immediate hypersensitivity reaction to penicillin, may also react to cephalosporins 2014

Antimicrobial Resistance in N. gonorrhoeae A Review TREATMENT Uncomplicated anogenital infection (urethral, rectal) and pharyngeal infection 9 years of age Preferred treatment Ceftriaxone 250 mg IM in a single dose + Azithromycin 1 g PO in a single dose Full treatment details at: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-6-eng.php 2014 Antimicrobial Resistance in N. gonorrhoeae A Review TREATMENT Uncomplicated anogenital infection (urethral, rectal) only

in adults and youth ( 9 years), excluding MSM is: Preferred treatment Cefixime 800 mg PO in a single dose + Azithromycin 1 g PO in a single dose Full treatment details at: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-6-eng.php 2014 Antimicrobial Resistance in N. gonorrhoeae A Review TREATMENT Due to the rapid increase in quinolone-resistant gonorrhea, quinolones are no longer recommended Quinolones should ONLY be given as an alternative treatment IF:

Antimicrobial susceptibility testing is available and quinolone susceptibility is demonstrated OR Quinolones Local quinolone resistance is under 5% AND a test of cure can be performed. 2014 Antimicrobial Resistance in N. gonorrhoeae A Review TREATMENT Full treatment recommendations, including alternative treatments available The Public Health Agency of Canadas Canadian STI Guidelines: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-6-eng.php

2014 Antimicrobial Resistance in N. gonorrhoeae A Review CONTROL Case finding and partner notification are critical in controlling infection Local public health authorities may assist with partner notification and with appropriate referral for clinical evaluation, testing, treatment and health education Gonococcal infections are reportable in all provinces and territories; positive test results should be reported to local public health authorities

2014 Antimicrobial Resistance in N. gonorrhoeae A Review PARTNER NOTIFICATION All sexual partners within 60 days prior to symptom onset or date of specimen collections (if asymptomatic) should be notified, tested and empirically treated without waiting for test results The length of time for the trace-back period should be extended in the following circumstances: If the index case states that there were no partners during the recommended trace-back period, the most recent partner should be notified If all partners traced test negative, the last partner prior to the trace-back period should be notified If partners are exposed between testing and treatment, additional time between the date of testing and date of treatment could be included

2014 Antimicrobial Resistance in N. gonorrhoeae A Review TEST OF CURE Test of Cure Post-Treatment 2 3 Weeks later NAAT 3 7 days later Culture 2014 Antimicrobial Resistance in N. gonorrhoeae A Review TEST OF CURE Case has persistent

symptoms or signs post-therapy Test of cure should be completed in all cases; particularly important when: Pharyngeal infections Case is linked to a drug resistant/treatment failure case and was treated with the same antibiotic Cases treated with a regimen other than

the preferred treatment 2014 Antimicrobial Resistance in N. gonorrhoeae A Review TEST OF CURE Cultures from all positive sites should also be done in the following situations: There is re-exposure to an untreated partner Compliance is uncertain Case is a child Disseminated gonococcal infection is diagnosed Women undergoing

therapeutic abortion who tests positive gonococcal infection Infection occurs during pregnancy 2014 Antimicrobial Resistance in N. gonorrhoeae A Review 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 hours after treatment

Positive NAAT taken at least 23 weeks after treatment Presence of intracellular Gram-negative diplococci on microscopy taken at least 72 hours after treatment 2014 Antimicrobial Resistance in N. gonorrhoeae A Review REPORTING Local public health should be promptly notified of treatment failures Allows provincial and territorial STI programs to quickly identify emerging patterns of antimicrobial resistance within their jurisdictions Enables provincial and territorial to collaborate with the Public Health Agency of Canada to issue

timely electronic alerts 2014 Antimicrobial Resistance in N. gonorrhoeae A Review REPEAT SCREENING Repeat screening for individuals with a gonococcal infection is recommended 6 months posttreatment 2014 Antimicrobial Resistance in N. gonorrhoeae A Review SURVEILLANCE National enhanced surveillance protocol to integrate epidemiologic and treatment failure data into existing laboratory-based monitoring of antimicrobial resistant

gonorrhea Important to rapidly identify changes in antimicrobial susceptibility and assess risk factors associated with the development of resistance Enables early identification and prevention of the spread of drug-resistant gonorrhea and assists in identifying appropriate treatment regimens 2014 Antimicrobial Resistance in N. gonorrhoeae A Review PREVENTION Provide information to encourage consistent safe sex practices Counsel on sequelae and on potential impacts on reproductive system

Explain the need to abstain from unprotected sex until at least 3 days after completion of treatment and no more symptoms Discuss the risk of re-infection 2014 Antimicrobial Resistance in N. gonorrhoeae A Review CONCLUSION To successfully address the public health risk of antimicrobial resistant gonorrhea, primary care and public health professionals need to work together. 2014

Antimicrobial Resistance in N. gonorrhoeae A Review RESOURCES To access the chapter and additional 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 Canadas Canadian STI Guidelines 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. 2014

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