Public Health Updates on the Management of Multi-drug Resistant ...

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Public Health Updates on the Management of Multi-drug Resistant ...

ong>Publicong> ong>Healthong> ong>Updatesong> on the Management of Multi-drug Resistant

Gonorrhea (MDR-GC)

Antimicrobial Resistance and ong>Publicong> ong>Healthong> Management ong>Updatesong> from

the ong>Publicong> ong>Healthong> Agency of Canada, November 16, 2012

Dr. Thomas Wong, MD MPH, CCFP, FRCPC

Director, Professional Guidelines and ong>Publicong> ong>Healthong> Practice Division

Centre for Communicable Diseases and Infection Control


ong>Publicong> ong>Healthong> ong>Updatesong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)

Background (1)

About the Canadian Guidelines on Sexually Transmitted Infections

• A ong>Publicong> ong>Healthong> Agency of Canada/ong>Healthong> Canada resource for clinical and

public health officials to guide the prevention and management of STIs

across a diverse patient population since 1988.

• Since 1998, members of an Expert Working Group have served as authors

and reviewers to maintain updated, evidence-based recommendations.

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ong>Publicong> ong>Healthong> ong>Updatesong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)

Background (2)

Focus of today’s update: Neisseria gonorrhoeae (Gonorrhea)

• Gonorrhea is the second most reported sexually transmitted infection in

Canada.

• Who is most affected

» Males are more affected than females, but rates of infection are increasing more

rapidly among females.

» Younger age groups (15 to 25 years) continue to be most affected.

• Clinical manifestations and sequelae:

» Often asymptomatic infection (80% of females, 10-20% of males)

» Infection increases the risk of HIV transmission and acquisition

» High risk of re-infection

» Sequelae

• Pelvic inflammatory disease (PID), chronic pelvic pain, ectopic pregnancy, infertility,

reactive arthritis (oculo-urethro-synovial urethro syndrome)

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ong>Publicong> ong>Healthong> ong>Updatesong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)

Background (3)

• Reported rates of N. gonorrhoeae have increased steadily over the last

decade:

» From 20.1/100,000 (6,189 cases) in 2000 to 33.4/100,000 (11,397 cases) in 2010.

• Antimicrobial resistance in gonorrhea is increasing in Canada and globally,

particularly among men who have sex with men (MSM).

» The ong>Publicong> ong>Healthong> Agency of Canada’s National Microbiology Laboratory has been

conducting susceptibility testing ti of N. gonorrhoeae isolates since the mid-1980’s. Data

generated informs STI Treatment Guidelines.

• There is a high risk of N. gonorrhoeae becoming a ‘superbug’.

In response to observed increases in antimicrobial resistance, updated

treatment recommendations for gonorrhea have been developed.

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ong>Publicong> ong>Healthong> ong>Updatesong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)

Key changes for treatment of Gonorrhea

1. Treatment of choice

2. Increase in dosage

3. Combination therapy

4. Expanded recommendations

» Intramuscular (IM) versus PO treatment

• Especially in MSM and pharyngeal infections

» Culture testing versus nucleic acid amplification testing (NAAT)

» Test of cure

By adopting these recommendations, you can play an important role in

slowing down the development and spread of antimicrobial resistance.

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ong>Publicong> ong>Healthong> ong>Updatesong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)

N. gonorrhoeae: Recommended Treatment of Choice and

Increase in Dose

• Key Recommendations:

» Single dose of ceftriaxone 250 mg IM for pharyngeal infections and in MSM (vs.

the previously recommended 125 mg IM dose) )

» Single dose of cefixime 800 mg PO for uncomplicated cases (vs. the previously

recommended 400mg PO dose)

• Changes are based on rising i minimum i inhibitory concentrations ti (MICs) for

third generation oral and injectable cephalosporins, particularly in MSM.

• Quinolones are no longer recommended for treatment of gonococcal

infection in Canada, due to the rapid increase in resistance.

• With reduced sensitivity to an antimicrobial agent, a higher concentration of

the antimicrobial agent is needed.

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ong>Publicong> ong>Healthong> ong>Updatesong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)

N. gonorrhoeae: Combination Therapy

• All patients treated for gonorrhea should receive combination therapy

regardless of chlamydial test result. The use of two medications optimizes

gonococcal treatment outcomes.

• Preferred combination therapy

» 3rd generation cephalosporin AND azithromycin 1g PO single dose

• Alternate combination therapy

» 3rd generation cephalosporin AND doxycycline 100 mg PO bid x 7 days (unless

contra-indicated, e.g., young children, pregnant women)

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ong>Publicong> ong>Healthong> ong>Updatesong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)

N. gonorrhoeae: Expanded Recommendations (1)

IM versus PO treatment, especially for pharyngeal infections and MSM

• In situations where higher tissue penetration is necessary to achieve cure,

such as pharyngeal infection and complicated cases such as PID and

epididymitis, ceftriaxone 250 mg IM is recommended.

• Due to recent cases of cefixime treatment failures reported primarily in

MSM, ceftriaxone is recommended treatment for MSM.

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ong>Publicong> ong>Healthong> ong>Updatesong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)

N. gonorrhoeae: Expanded Recommendations (2)

Culture versus NAAT

Culture

• Gonorrhea cultures should be done when possible to allow for antimicrobial

sensitivity testing under certain circumstances.

• Cultures permit antimicrobial resistance (AMR) monitoring.

NAAT

• When transport and storage conditions do not permit maintaining the

viability of N. gonorrhoeae, NAAT is ideal.

• Use NAAT to screen asymptomatic individuals. Collection of both culture

and NAAT samples could be considered depending on the clinical situation.

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ong>Publicong> ong>Healthong> ong>Updatesong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)

N. gonorrhoeae: Expanded Recommendations (3)

Test of cure

Follow-up test of cure by culture approximately 4-5 days after the completion of

therapy is essential in any of the following situations:

1. All pharyngeal infections

2. Persistent symptoms or signs post-treatment

3. Cases treated t under a regimen other than the preferred treatmentt t

4. Case who is linked to a drug resistant/treatment failure case and was treated

with the same antibiotic

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ong>Publicong> ong>Healthong> ong>Updatesong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)

Updated Recommendations for your practice

1. Treatment of choice

» Ceftriaxone 250 mg IM, theonly” first-line choice for pharyngeal infections and MSM

» Cefixime 800 mg PO single dose or ceftriaxone 250 mg IM for uncomplicated cases

2. Increase in dosage

» Dosage increases: Cefixime 800 mg and ceftriaxone 250 mg

3. Combination therapy for all patients

» Cefixime 800 mg PO/ceftriaxone 250 mg IM single dose and Azithromycin 1g PO single dose

4. Expanded recommendations

» IM versus PO treatment

• Ceftriaxone 250 mg IM for cases requiring higher tissue penetration to achieve cure

» Culture versus NAAT test

• Culture permits better monitoring of AMR

» Test of cure

• Follow-up culture test 4-5 days after completion of therapy for special cases

By following these treatment recommendations and being vigilant, we can slow

down the development and spread of antimicrobial resistance!

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ong>Publicong> ong>Healthong> ong>Updatesong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)

For more information on the Canadian STI Guidelines and

other resources

• Visit our website: http://www.phac-aspc.gc.ca/std-mts/sti-its/index-eng.phpphac aspc ca/std its/index eng php

• Join the Canadian STI Guidelines Listserv: http://www.phac-aspc.gc.ca/stdmts/sti-its/email-eng

its/email eng.php

• For more information on the Canadian Network for ong>Publicong> ong>Healthong>

Intelligence (CNPHI): www.cnphi-rcrsp.ca p or cnphi _ admin@phac-

aspc.gc.ca

• Contact us:

» Dr. Thomas Wong

Director, Professional Guidelines and ong>Publicong> ong>Healthong> Practice Division

Centre for Communicable Diseases and Infection Control

tom.wong@phac-aspc.gc.ca

aspc gc ca

(613) 941-7539

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