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

<strong>Public</strong> <strong>Health</strong> <strong>Updates</strong> on the Management of Multi-drug Resistant
Gonorrhea (MDR-GC)
Antimicrobial Resistance and <strong>Public</strong> <strong>Health</strong> Management <strong>Updates</strong> from
the <strong>Public</strong> <strong>Health</strong> Agency of Canada, November 16, 2012
Dr. Thomas Wong, MD MPH, CCFP, FRCPC
Director, Professional Guidelines and <strong>Public</strong> <strong>Health</strong> Practice Division
Centre for Communicable Diseases and Infection Control

<strong>Public</strong> <strong>Health</strong> <strong>Updates</strong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)
Background (1)
About the Canadian Guidelines on Sexually Transmitted Infections
• A <strong>Public</strong> <strong>Health</strong> Agency of Canada/<strong>Health</strong> 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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<strong>Public</strong> <strong>Health</strong> <strong>Updates</strong> 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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<strong>Public</strong> <strong>Health</strong> <strong>Updates</strong> 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 <strong>Public</strong> <strong>Health</strong> 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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<strong>Public</strong> <strong>Health</strong> <strong>Updates</strong> 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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<strong>Public</strong> <strong>Health</strong> <strong>Updates</strong> 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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<strong>Public</strong> <strong>Health</strong> <strong>Updates</strong> 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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<strong>Public</strong> <strong>Health</strong> <strong>Updates</strong> 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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<strong>Public</strong> <strong>Health</strong> <strong>Updates</strong> 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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<strong>Public</strong> <strong>Health</strong> <strong>Updates</strong> 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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<strong>Public</strong> <strong>Health</strong> <strong>Updates</strong> on the Management of Multi-drug Resistant Gonorrhea (MDR-GC)
Updated Recommendations for your practice
1. Treatment of choice
» Ceftriaxone 250 mg IM, the “only” 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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<strong>Public</strong> <strong>Health</strong> <strong>Updates</strong> 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 <strong>Public</strong> <strong>Health</strong>
Intelligence (CNPHI): www.cnphi-rcrsp.ca p or cnphi _ admin@phac-
aspc.gc.ca
• Contact us:
» Dr. Thomas Wong
Director, Professional Guidelines and <strong>Public</strong> <strong>Health</strong> 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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