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 followup and reporting of go ID: 600643
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Slide1
Antimicrobial Resistance in
N. gonorrhoeae
A ReviewSlide2
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
– A ReviewSlide3
OBJECTIVES
To promote:
Test-of-cure
recommendations
Optimal
use of antibiotics
Appropriate
laboratory testing
Proper action on detecting, reporting and re-treatment in cases of documented or suspected treatment failure
To increase awareness and knowledge of the status of antimicrobial resistance of
N. gonorrhoeae
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide4
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
infections…can
kill.”
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide5
BACKGROUND
Aligns with World Health
Organisation’s
“
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’
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide6
Reported cases of gonococcal infection in Canada have increased since
1997
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.
EPIDEMIOLOGY
M
ales 20–24 years of age
F
emales 15–19 years of age
Most affected:
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide7
KEY ISSUES
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
Gonococcal infections
have been resistant to certain antibiotics
Gonococcal infections are becoming more difficult to treat.
Potential increase
in major sequelae due to prolonged duration of original infection
The problem is worldwide, and is growingSlide8
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
– A Review
*
Men Who Have Sex With MenSlide9
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
Individuals who have had sexual contact with a person with a confirmed or suspected gonococcal
infection
AT RISK
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide10
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
AT RISK
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide11
*e.g., arthritis, dermatitis, endocarditis,
meningitis
Ophthalmia
Neonatorum
Conjunctivitis
Sepsis
Disseminated
gonococcal
infection*
Urethritis
Vaginitis
Conjunctivitis
Pharyngeal
Infection
Proctitis
Disseminated
gonococcal
infection*
Cervicitis
Pelvic
Inflammatory
Disease
Urethritis
Perihepatitis
Bartholinitis
Urethritis
Epididymitis
Pharyngeal
Infection
Conjunctivitis
Proctitis
Disseminated
gonococcal
infection*
Neonates and
I
nfants
Children
Females
Males
Both
MANIFESTATIONS
Youth (≥ 9 years) and Adults
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide12
Females
Males
Vaginal
discharge
Dysuria
Abnormal
vaginal
bleeding
Lower abdominal
painDeep dyspareunia Rectal pain and discharge
(with proctitis)
Urethral
discharge
Dysuria
Urethral itch
Testicular
pain and/or
swelling or symptoms of epididymitis
Rectal
pain and discharge
(with proctitis)
SYMPTOMS
Often asymptomatic
Often
s
ymptomatic
In both females and males, rectal and pharyngeal infections are more likely to be asymptomatic
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
*Slide13
*e.g., arthritis, dermatitis, endocarditis,
meningitis
MAJOR SEQUELAE
Females
Males
Pelvic inflammatory disease
Infertility
Ectopic pregnancy
Chronic pelvic pain
Reactive arthritis (oculo-urethro-synovial
syndrome
)
Disseminated gonococcal infection*
Epididymo-orchitis
Reactive arthritis (oculo-urethro-synovial
syndrome)
Infertility (rare)
Disseminated gonococcal infection *
Youth (≥ 9 years) and Adults
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide14
DIAGNOSIS
Depending on clinical situation, consider collecting
both cultures and NAAT
especially in symptomatic patients
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide15
However, culture
is strongly recommended because it allows for testing of antimicrobial
susceptibility
NAAT
may be the only available testing method in some
jurisdictions
Where
NAAT is routinely used, sentinel surveillance mechanisms using culture are important to ensure continued monitoring for antimicrobial
resistance
Increase in the number of cases diagnosed due to higher sensitivity and specificity of test
NAAT
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide16
CULTURE
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
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
resultsSlide17
DIAGNOSIS
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
In symptomatic MSM
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
In suspected
pelvic inflammatory disease
Cultures are
particularly important
in the following situations:Slide18
SPECIMENS
Take specimen from any exposed site
Urine NAAT if urethral swab or pelvic examination is not practical
Cervical or vaginal culture or NAAT
Urethral cultur
e or NAAT
Rectal culture or validated NAAT and/or
P
haryngeal culture or validated NAAT
Asymptomatic
Patients
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide19
SPECIMENS
Rectal
culture or
validated NAAT
if
anogenital symptoms
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
*Symptomatic
Patients
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
Take specimen from any exposed site
*
*Slide20
Appropriate samples based on site of exposure and test
type
should be obtained prior to treatment
When making treatment decisions, relevant history, physical examination and epidemiologic factors should be
considered
MANAGEMENT
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
S
yndromic management:
Mucopurulent cervicitis
Non-gonococcal urethritis
Epididymitis
Pelvic inflammatory disease
Or if patient is being treated as a contact
Presumptive
treatment is to be
provided for: Slide21
Combination therapy also provides effective treatment for chlamydia given high rates of concomitant infections
Using medications with two different mechanisms of action may also improve treatment efficacy
To help prevent the spread of antimicrobial resistant gonorrhea
Monotherapy
should be
avoided
TREATMENT
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide22
Cefixime treatment failures in MSM have recently been documented
Ceftriaxone + azithromycin is recommended as the preferred treatment for gonococcal infections in MSM
TREATMENT
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
CephalosporinsSlide23
Azithromycin should not be used as monotherapy. Resistance has been reported.
Exception: when cephalosporins are contraindicated
Cross-sensitivity between penicillin and 2
nd
or 3
rd
generation cephalosporins is low, but if patient has history of immediate hypersensitivity reaction to penicillin, may also react to cephalosporins
Allergy to cephalosporins
History of anaphylactic reaction to penicillin
TREATMENT
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
AzithromycinSlide24
Uncomplicated anogenital
infection (urethral, rectal
) and pharyngeal infection ≥ 9 years of age
TREATMENT
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
Full treatment details at:http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-6-eng.php
Preferred
treatment
Ceftriaxone 250
mg
IM
in a single
dose
Azithromycin
1 g PO in a single
dose
+Slide25
Preferred
treatment
TREATMENT
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
Uncomplicated anogenital
infection (urethral, rectal) only in adults and youth (≥ 9 years), excluding MSM is:
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.phpSlide26
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
Local quinolone resistance is under 5% AND a test of cure can be performed.
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
TREATMENT
QuinolonesSlide27
TREATMENT
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
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.phpSlide28
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
Case finding and partner notification are critical in controlling
infection
CONTROL
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide29
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 partners are exposed between testing and treatment, additional
time
between
the date of testing and date of
treatment could be included
If all partners traced
test
negative, the last partner prior to the trace-back period should be notified
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
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide30
TEST OF CURE
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
2
–
3 Weeks later NAAT
Test of Cure Post-Treatment
3 – 7 days later → CultureSlide31
T
est 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
– A ReviewSlide32
Compliance is
uncertain
Disseminated gonococcal infection is
diagnosed
Cultures from
all positive sites should
also be done in
the following situations:
Antimicrobial Resistance in
N. gonorrhoeae – A Review
TEST OF CURE
Case is a child
There is re-exposure to an untreated partner
Infection occurs during
pregnancy
Women undergoing therapeutic
abortion who tests positive gonococcal infectionSlide33
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 2
–
3 weeks after treatment
Presence of intracellular Gram-negative diplococci on microscopy taken at least 72 hours after treatment
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide34
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
Local public health should be promptly notified of
treatment failures
REPORTING
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide35
Repeat screening for individuals with a gonococcal infection is recommended 6 months
post-treatment
Antimicrobial Resistance in
N. gonorrhoeae
– A Review
REPEAT SCREENINGSlide36
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
National
enhanced surveillance protocol
to
integrate epidemiologic and treatment failure data into existing laboratory-based monitoring of antimicrobial resistant
gonorrhea
SURVEILLANCE
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide37
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
PREVENTION
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide38
CONCLUSION
To successfully address the public health risk of antimicrobial resistant gonorrhea, primary care and public health professionals need to work together.
Antimicrobial Resistance in
N. gonorrhoeae
– A ReviewSlide39
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 GuidelinesTo 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
– A Review