Important Notice - Public Health Information Update on the Treatment for Gonococcal Infection

Public Health Agency of Canada Issued Important Notice on GONOCOCCAL INFECTION

December 21, 2011

To: Clinical and public health professionals

Subject: Updated guidelines for the management of gonococcal infection

In response to increasing gonococcal antimicrobial resistance being observed in Canada and globally, the Canadian treatment guidelines for gonorrhea are being revised. An updated version of the gonorrhea chapter for the Canadian Guidelines on Sexually Transmitted Infections drafted by the Public Health Agency of Canada (PHAC), in consultation with an Expert Working Group, will be available in due course. In the interim, we recommend that you consider the following information in the management of gonorrhea.

In order to provide information to guide the management of individual cases and to improve public health monitoring of trends in antimicrobial resistance patterns, gonorrhea cultures should be done when possible to allow for antimicrobial sensitivity testing under the following circumstances:

1. In men who have sex with men (MSM), cultures are recommended in symptomatic patients prior to treatment. Nucleic acid amplification testing (NAAT) should continue to be used for screening asymptomatic individuals. Due to increased sensitivity of NAAT over culture, both gonococcal culture and NAAT may be indicated.
2. For all cases, test of cure with an appropriate sample for gonococcal culture is recommended for any of the following situations:
   1. All pharyngeal infections
   2. Persistent symptoms or signs post-treatment
   3. Cases treated using a regimen other than the preferred treatment
   4. Case who is linked to a drug resistant/treatment failure case and was treated with that same antibiotic

Based on safety, efficacy and rising ceftriaxone and cefixime minimum inhibitory concentrations (MIC), it is recommended that higher doses of cephalosporins be used (i.e. a single dose of ceftriaxone 250 mg intramuscularly or cefixime 800 mg¹ orally for individuals 9 years of age or older) to reduce the risk of gonococcal treatment failure.

Due to recent cases of cefixime treatment failures reported primarily in MSM, ceftriaxone 250 mg intramuscularly is recommended as the preferred treatment for gonococcal infections in this population.

In situations where adequate tissue penetration is necessary to achieve cure (e.g., pharyngeal infection and in combination therapy for complicated cases such as pelvic inflammatory disease or epididymitis), ceftriaxone 250 mg intramuscularly is preferred as more efficacy data are available for this agent than for oral cefixime 800 mg in such cases.

Due to the rapid increase in quinolone resistant Neisseria gonorrhoeae, quinolones such as ciprofloxacin and ofloxacin are no longer recommended for the treatment of gonococcal infections in Canada. However, in some circumstances, such as an anaphylactic allergy to penicillin or known sensitivity to a third generation cephalosporin, a single dose of ciprofloxacin 500 mg OR a single dose of ofloxacin 400 mg may be considered as an alternative treatment option (unless contraindicated) ONLY IF:

a) Antimicrobial susceptibility testing is available and quinolone susceptibility is demonstrated;

OR

b) Local quinolone resistance is under 5% AND a test of cure can be performed.

Quinolones are not recommended in pre-pubertal children if other options are appropriate. Clinicians may base their treatment choices on local epidemiological data, if available.

Empiric treatment for Chlamydia is recommended for all patients treated for gonococcal infection regardless of chlamydial test results because of the high co-infection risk. A one gram single oral dose of Azithromycin is the preferred Chlamydia co-treatment option due to the dual cephalosporin-azithromycin therapeutic effect on gonorrhea, significant rates of tetracycline resistant gonorrhea and concerns regarding compliance with a seven-day doxycycline treatment. However, oral doxycycline as an alternate treatment option for Chlamydia can be used at 100 mg twice a day for 7 days if compliance is not a concern.

Notifications on future updates to the Canadian Guidelines on Sexually Transmitted Infections will be distributed through the Guidelines’ Listserv e-mail notification service. To subscribe to the Listserv, please visit our website: Canadian Guidelines on Sexually Transmitted Infections.

Please share this notice with other colleagues who may benefit from this information.

1. Cefixime 800 mg is higher than the dosage listed in the product monograph for the treatment of gonococcal infection.