Report on the Enhanced Surveillance of Antimicrobial-resistant Gonorrhea (ESAG): 2018 to 2021
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Organization: Public Health Agency Of Canada
On this page
- 1.0. Key Messages
- 2.0. Introduction
- 3.0. Methods
- 4.0. Results
- 4.1. Number of gonorrhea cultures provided by ESAG participating PTs, 2018 to 2021
- 4.2. Case characteristics
- 4.3. Antimicrobial-use appropriateness
- 4.3.1. Federal and provincial/territorial gonorrhea treatment guidelines, 2018 to 2021
- 4.3.2. Antimicrobial-use appropriateness among ESAG cases, 2018 to 2021
- 4.3.3. Gonorrhea treatment failure among ESAG cases, 2018 to 2021
- 4.3.4. Antimicrobial susceptibility among ESAG cases, 2018 to 2021
- 4.3.4.a. AMR-GC burden among ESAG cases and by sex/sexual behaviour
- 4.3.4.b. AzithromycinR, cefiximeDS, and ceftriaxoneDS among all ESAG cultures and by sex/sexual behaviour
- 4.3.4.c. The most prevalent resistant antimicrobials and other antimicrobial resistance trends among all ESAG cases and by sex/sexual behaviour
- 4.3.5. Case characteristics and sequence types of ESAG cases with cultures demonstrating azithromycinR, cefiximeDS, or ceftriaxoneDS, 2018 to 2021
- 4.3.5.a. Case characteristics and sequence types of ESAG cases with cultures demonstrating azithromycinR
- 4.3.5.b. Case characteristics and sequence types of ESAG cases with cultures demonstrating cefiximeDS
- 4.3.5.c. Case characteristics and sequence types of ESAG cases with cultures demonstrating ceftriaxoneDS
- 4.4. Sequence Typing
- 5.0. Data Quality and Limitations
- 6.0. Discussion
- 7.0. Conclusion
- 8.0. References
- Appendix 1. List of supplementary figures and tables
- Appendix 2. Comparison of GASP-Canada and ESAG 2021 results
- Appendix 3. Drug resistance (R) and decreased susceptibility (DS) to selected antimicrobials by province or territory, 2018 to 2021
1. Key messages
- Neisseria gonorrhoeae, the bacteria that causes gonorrhea, is considered a serious public health threat since it has been increasingly developing resistance to antimicrobial drugs recommended as treatment.
- The Public Health Agency of Canada (PHAC) launched the Enhanced Surveillance of Antimicrobial-Resistant Gonorrhea (ESAG) system in 2013 to better understand the current trends of antimicrobial-resistant N. gonorrhoeae. ESAG results inform the development of treatment guidelines and public health interventions to minimize the spread of antimicrobial-resistant gonorrhea (AMR-GC) in Canada.
- Between 2018 to 2021, there were a total of 3,377 ESAG cases with a primary culture. These data represent, on average, 19.8% of all N. gonorrhoeae cultures submitted to the National Microbiology Laboratory (NML) and 2.5% of all gonorrhea cases reported to the Canadian Notifiable Diseases Surveillance System (CNDSS) across Canada for the years 2018 to 2021. Of these 3,377 ESAG cases,
- 83.0% of cases were reported by Alberta, 14.3% by Manitoba, 1.8% by Nova Scotia, and 0.9% by the Northwest Territories
- most cases were male (80.2%, n=2709), of which an average of 55.5% were among gay, bisexual and other men who have sex with men (GBMSM)
- the largest proportion of cases were between 20 and 39 years of age (average proportion 72.8%, range: 70.1% to 75.4%)
- the most common primary site of gonococcal (GC) infection varied by sex and sexual behaviour. Among GBMSM cases, rectal (average: 39.3%) and pharyngeal (average: 34.6%) infections were the most reported primary infection sites. In contrast, genital infections were most reported among heterosexual males (average: 90%) and males with unknown sexual behaviour (average: 52.5%).
- 30.3% of cases were reported in 2018 (n=1022), 29.6% (n=999) in 2019, 21.1% (n=711) in 2020, and 19.1% (n=645) in 2021.
- Among ESAG cases with an anogenital (defined as a cervical, rectal, or urogenital GC swab isolation site) or pharyngeal primary infection site, from 2018 to 2021, the overall prescriber adherence to PHAC and provincial or territorial (PT) gonorrhea treatment guidelines was high (average of 91.4% adherence to PHAC guidelines and 89.5% adherence to PT guidelines) and mostly stable. Prescriber adherence to treatment guidelines was similar by sexual behaviour and site of infection; GBMSM cases were mostly prescribed the recommended regimen of azithromycin 1 g with ceftriaxone 250 mg and all other adult cases were mostly prescribed the recommended regimen of azithromycin 1 g with cefixime 800 mg.
- From 2018 to 2020, AMR-GC prevalence (as indicated by resistance to at least one tested antimicrobial) among ESAG cases was stable. However, AMR-GC prevalence increased from 69.3% in 2020 to 77.4% in 2021. This corresponded with the near-doubling of cases with GC cultures demonstrating resistance or decreased susceptibility to two different antimicrobials, from 24.8% in 2020 to 44.5% in 2021.
- In 2021, AMR-GC burden was highest among GBMSM (85.2% of cultures isolated from GBMSM were resistant to at least one tested antimicrobial), followed by heterosexual males (73.5% of cultures from heterosexual males were resistant to at least one tested antimicrobial) and females (66.7% of all GC cultures isolated from females were resistant to at least one tested antimicrobial). Resistance to ciprofloxacin and tetracycline was high among all sexual behaviour groups but highest among GBMSM.
- From 2018 to 2020, the number and proportion of ESAG cases with decreased susceptibility to cefixime (cefiximeDS) was very low and stable (<1%). However, from 2020 to 2021, the number of ESAG cases with cefiximeDS increased nearly threefold from six (0.8%) in 2020 to 22 (3.4%) in 2021. Of the 32 cefiximeDS cases, 19 were GBMSM (59.4%).
- ESAG cases with decreased susceptibility to ceftriaxone (ceftriaxoneDS) declined in number and proportion from eight (0.8%) cases in 2018 to one case (0.2%) in 2021.
- The number of cases with resistance to azithromycin (azithromycinR) increased (mostly among GBMSM) from 18 (1.8%) in 2018 to 78 cases (7.8%) in 2019. However, this number decreased sharply to eight cases (1.1%) in 2020 and 12 cases (1.9%) in 2021 (below the World Health Organization's (WHO's) 5% cut-off of concern).
- No ESAG cases demonstrated both azithromycinR and cefiximeDS or ceftriaxoneDS (the PT and PHAC recommended and most prescribed antimicrobial regimens). CefiximeDS and ceftriaxoneDS was detected in one case in each of 2018, 2020, and 2021, and three cases in 2019.
- Between 2020 and 2021, of all the tested antimicrobials, ciprofloxacin resistance was most prevalent at 46.6% in 2020 increasing to 63.1% in 2021. The second most prevalent antibiotic resistance detected among ESAG cases was tetracycline resistance (45.9% in 2020 and 58.6% in 2021). Prior to this, tetracycline resistance was most prevalent at 52.1% in 2018 and 51.8% in 2019. Erythromycin resistance has declined annually and sharply from 30.0% in 2018 to 8.5% in 2021. The prevalence of penicillin resistance was relatively stable from 2018 to 2020 (6.8% in 2018, 7.2% in 2019 and 8.2% in 2020) but dropped to 3.9% in 2021.
- There were 14 cases reported by public health authorities as treatment failures. However, none demonstrated resistance or decreased susceptibility to all prescribed treatment regimens suggesting these cases were either reinfected or did not take their medication correctly.
- Between 2018 and 2020, there were 396 unique N. gonorrhoeae multiantigen sequence typing (NG-MAST) sequence types (STs) identified from 3,377 N. gonorrhoeae isolates collected from ESAG cases. Overall, there were no clear trends of increasing or decreasing prevalence of azithromycinR, cefiximeDS or ceftriaxoneDS among the top 10 sequence types for each year.
2. Introduction
Gonorrhea is a sexually transmitted infection (STI) caused by an infection with the bacterium N. gonorrhoeae. Gonorrhea is the second most reported notifiable STI in Canada. In 2021, there were 32,192 gonorrhea cases reported, to the Canadian Notifiable Diseases Surveillance System (CNDSS), for a national rate of 84.2 cases per 100,000 population.Footnote 1 Prior to the COVID-19 pandemic, reported rates of gonorrhea tripled from 2010 (33.5 cases per 100,000 population) to 2019 (94.4 cases per 100,000 population). Between 2019 and 2021, the gonorrhea rate declined by 14%. This was likely influenced by the reduced demand for and access to gonorrhea screening, care, and public health reporting due to pandemic-related prevention measures.Footnote 2 Reported case counts and rates of gonorrhea underestimate the true prevalence of gonorrhea in Canada, as many gonorrhea cases are asymptomatic and go undetected and thus, are not reported.
Gonorrhea spreads easily, is associated with travel related sexual contact, is often observed alongside chlamydia, and increases the risk of acquisition of HIV. Individuals with an N. gonorrhoeae infection, both asymptomatic and symptomatic, may pass on the bacteria to their sexual partners. Those tested for gonorrhea are more likely to be persons who are symptomatic or persons in higher risk categories (e.g., GBMSM) who are routinely screened for STIs and gonorrhea case contacts.Footnote 3
While gonorrhea is curable with the appropriate antibiotics, it remains a serious public health threat in Canada, and globally, as the pathogen, N. gonorrhoeae, has developed resistance to most antibiotics over time, including currently recommended treatments in Canada and abroad. Furthermore, the prevalence of AMR-GC cultures has increased over time-the proportion of Canadian cultures resistant to at least one tested antimicrobial tripled from one-quarter of cultures in 2000 to almost three-quarters (73%) in 2021.Footnote 2
Left unsuccessfully or not treated at all, gonorrhea can cause pelvic inflammatory disease which can lead to infertility or ectopic pregnancies in females and epididymitis in men.Footnote 2 In about one percent of cases, gonorrhea can also spread to the blood causing disseminated gonococcal infection (DGI), which can become life threatening. Gonorrhea can also be passed to a baby at birth and can cause eye infections or DGI for the baby.Footnote 3
Continuous monitoring of AMR-GC strains, GC treatment failures, and gonorrhea treatment prescription data linked to epidemiologic data can inform the usefulness and accuracy of gonorrhea treatment guidelines and help in reducing the spread of highly resistant gonorrhea. To this end, PHAC monitors AMR-GC through two laboratory-based surveillance systems.
The first is PHAC's NML led Gonococcal Antimicrobial Surveillance Program (GASP - Canada). GASP-Canada is a passive national surveillance program initiated in the 1980's which collects and monitors AMR-GC data from antimicrobial susceptibility testing (AST) and the molecular characterization (using NG-MAST STs) of gonorrhea cultures.Footnote 2 This program has rich laboratory data but limited epidemiologic data on GC cases.
The second surveillance system is ESAG, which links a subset of GASP-Canada AMR-GC data to epidemiologic and clinical data for an improved understanding of AMR-GC trends across Canada. ESAG started in 2013 and is led by PHAC's Centre for Communicable Diseases and Infection Control (CCDIC) and the NML. The goal of ESAG is to help inform public health interventions to minimize the spread of antimicrobial resistant N. gonorrhoeae in Canada.
This report summarizes ESAG data from 2018 to 2021. Alberta, Manitoba, Nova Scotia (Central Zone Health Authority only), and the Northwest Territories provided clinical and epidemiologic data. Additional Canadian jurisdictions are making efforts to link their AMR-GC GASP-Canada data to epidemiologic and clinical data to include in future ESAG analyses.
3. Methods
3.1. ESAG case definition
An ESAG case refers to any client 16 years or older that meets the PHAC (i.e., national) definition of a gonorrhea case and has a GC culture analyzed either by the PHAC NML or a regional laboratory.Footnote 4 If a client had multiple cultures obtained within a 30-day timeframe, the primary culture included in the analysis, was the culture that demonstrated the greatest antimicrobial resistance. When there was no difference in resistance patterns, the primary culture was prioritized based on the relative likelihood of treatment failure at the site of infection, in the following order (from the highest likelihood of treatment failure to lowest): pharyngeal, rectal, urethral, and cervical cultures. Only the primary culture data was used in data analyses. If a client had more than one culture greater than 30 days apart, those cultures were treated as separate ESAG cases as they were likely reinfections.
3.2. ESAG data
ESAG data includes linked (via a non-identifying unique ID) de-identified laboratory (AMR-GC resistance profile and NG-MAST sequence type), clinical (site of infection/culture, prescribed treatment, and suspected treatment failure) and epidemiologic (demographic and risk behaviour) client-level data from gonorrhea cases.
Clinical and epidemiologic data were extracted from routine/enhanced gonorrhea provincial and territorial case report forms and provided by health authorities from the ESAG participating PTs, Alberta, Manitoba, Nova Scotia and Northwest Territories. Laboratory data were obtained, with the consent from participating PTs, from GASP-Canada. GASP-Canada data include Antimicrobial Susceptibility Testing (AST) data and molecular characterization through N. gonorrhoeae Multi-antigen Sequence Typing (NG-MAST) data.
All ESAG data were entered directly or uploaded into a password-protected, web-accessible, jurisdictionally filtered database hosted on the Canadian Network for Public Health Intelligence (CNPHI) platform.
3.3. Data analysis period
Although ESAG was initiated in 2013, this report is limited to data from ESAG cases who had GC isolates collected from 2018 through 2021 data because this period reflects the latest PHAC gonorrhea treatment guidelines (last updated in June 2017).Footnote 5
3.4. ESAG variables created
The following variables were created from the ESAG epidemiologic data:
i) Sex: The 'sex' variable is a mix of sex and gender data as some PTs provide sex data, some gender, and some a mix of both.
ii) Sexual behaviour:
Cases reported as male who self-reported their sexual partner as male, or both male and female, were categorized as 'GBMSM'. 'Heterosexual males' included male cases who only reported having female partners. Finally, 'males with unknown sexual behaviour' was defined as male cases that did not have sexual partner information.
iii) Primary infection site (infection site) variables:
The primary infection site is the site of infection from which the primary culture was collected. Infection sites included pharyngeal (throat), genital (urethral, urogenital, cervical, or vaginal), rectal, and other. In concordance with PHAC's Canadian Guidelines on Sexually Transmitted Infections, an 'anogenital infection' was defined as a cervical, rectal, or urogenital GC swab isolation site, as well as isolation sites in which 'other' was specified as an anogenital anatomical site (e.g., labia, perineum).Footnote 6 GC isolation sites specified as throat were categorized as 'pharyngeal infections'.
iv) Reason for medical visit:
ESAG cases may have had one or more reasons for their medical visit. However, only one reason was included in the results output. The reason for medical visit included in all analyses was selected based on the following order: test of cure, signs and symptoms, contact with a known gonorrhea case (case contact), screening for a STI, and other.
v) Gonorrhea treatment prescription data variable:
'Other adults' includes heterosexual males, females, and transgender people. It does not include GBMSM or males with unknown sexual behaviour.
3.5. Laboratory Methods
3.5.1. Antimicrobial susceptibility testing of gonorrhea cultures
The Minimum Inhibitory Concentration (MIC) of an antimicrobial therapy (i.e., an antibiotic) which inhibits the growth of N. gonorrhoeae, was determined for azithromycin, ceftriaxone, cefixime, ciprofloxacin, erythromycin, penicillin, spectinomycin and tetracycline for all N. gonorrhoeae cultures using agar dilution, or an Etest®(BioMerieux, Laval, Quebec). Etest®was used for the Alberta susceptible cultures which were not sent to the NML. MIC interpretations were based on the Clinical and Laboratory Standards Institute (CLSI) breakpoints except for: cefixime decreased susceptibility (defined as a MIC ≥ 0.25 mg/L); ceftriaxone decreased susceptibility (MIC ≥ 0.125 mg/L); and erythromycin resistance (MIC ≥ 2.0 mg/L) (refer to supplementary appendices A and B for details; supplementary appendices A-I are available upon request at sti-hep-its@phac-aspc.gc.ca).Footnote 7,Footnote 8,Footnote 9
3.5.2. Sequence typing for N. gonorrhoeae cultures
Sequence typing was achieved for all cultures submitted to the NML using the NG-MAST method that incorporates the amplification of the porin gene (porB) and the transferrin-binding protein gene (tbpB).Footnote 2 DNA sequences of both strands were assembled, and compared using DNAStar, Inc. software. The resulting sequences were submitted to the PubMLST NG-MAST database to determine the sequence types (ST). NG-MAST testing was not performed on the susceptible isolates whose cultures were not submitted to the NML. NG-MAST is highly distinctive and can be used to investigate gonorrhea treatment failures and outbreaks. NG-MAST STs have also shown a close association with antimicrobial resistance (AMR).Footnote 2
GASP-Canada laboratory methods have been previously published and described in greater detail than what is summarized here.Footnote 10
3.5.3. Data Analysis
Gonorrhea treatment prescription data was analysed for ESAG cases that i) had prescription data, ii) met the above definitions of either GBMSM or other adults and iii) had either an anogenital or pharyngeal primary site of infection (ii and iii match the gonorrhea treatment client defining categories from PHAC and PT treatment guidelines). Thus, clients with an unknown or 'other' infection site were excluded from this analysis.Footnote 6,Footnote 11,Footnote 12,Footnote 13 The number and proportion of prescriptions that matched i) PHAC and ii) PT gonorrhea treatment guidelines was calculated among a) GBMSM and b) other adults stratified by an anogenital or pharyngeal gonococcal infection site.Footnote 6,Footnote 11,Footnote 12,Footnote 13
AMR-GC trends were explored by sex and sexual behaviour categories. Results are summarized by GBMSM, heterosexual males, males with unknown sexual behaviour, and females. AMR-GC trends are not presented by female sexual behaviour due to either i) small sample size or and ii) where female sexual behaviour group sample size was sufficient, similar AMR-GC trends.
Case counts and proportions were calculated for case characteristics, prescriber adherence to gonorrhea treatment guidelines, and AMR-GC variables. Percent changes in case count proportions were calculated using non-rounded numbers.
4. Results
4.1 Number of gonorrhea cultures provided by ESAG participating PTs, 2018 to 2021
From 2018 to 2021, there were 3,377 primary cultures (representing 3,377 ESAG cases) included in the analysis described in this report. Overall, the number of primary cultures decreased annually from 1022 cultures reported in 2018 to 645 cultures reported in 2021. These cultures represent, on average, 19.8% (range: 18.2%-22.7%) of all N. gonorrhoeae cultures submitted to the NML and 2.5% (range: 2.0%-2.8%) of all gonorrhea cases reported to CNDSS across Canada for the years 2018 to 2021.Footnote 2, Footnote 14, Footnote 15, Footnote 16, Footnote 17 From 2018 to 2021, the majority of ESAG data came from Alberta (83.0%), followed by Manitoba (14.3%), Nova Scotia (1.8%), and the Northwest Territories (0.9%) (Table 1). From 2018 to 2021, these provinces accounted for an average of 18% of the Canadian population.Footnote 18 For the number and rate of gonorrhea cases reported to CNDSS among ESAG participating PTs, please see supplementary appendix C.
Province or territory | 2018 | 2019 | 2020 | 2021 | Total | |||||
---|---|---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | n | % | |
Alberta |
812 |
79.5% |
803 |
80.4% |
587 |
82.6% |
600 |
93.0% |
2,802 |
83.0% |
Manitoba |
174 |
17.0% |
155 |
15.5% |
116 |
16.3% |
39 |
6.0% |
484 |
14.3% |
Nova Scotia |
31 |
3.0% |
24 |
2.4% |
1 |
0.1% |
5 |
0.8% |
61 |
1.8% |
Northwest Territories |
5 |
0.5% |
17 |
1.7% |
7 |
1.0% |
1 |
0.2% |
30 |
0.9% |
Total |
1022 |
100.0% |
999 |
100.0% |
711 |
100.0% |
645 |
100.0% |
3,377 |
100.0% |
4.2. Case characteristics
Characteristics of ESAG cases are summarised in Table 2 and described below.
4.2.1. Sex and sexual behaviour of ESAG cases, 2018 to 2021
From 2018 to 2021, ESAG cases were mostly identified as male (average: 80.2%; range: 78.0% to 82.1%, n= 2709). Among males, an average of 55.5% (range: 51.6% to 59.7%) were GBMSM and 31.7% (range: 29.3% to 35.6%) were heterosexual. Annual proportions for these populations were relatively stable over the years, while the proportion of males with unknown sexual behaviour decreased from 16.8% in 2018 to 4.6% in 2021. (Note: The increase in males with unknown sexual behaviour are primarily reported in Manitoba, Northwest territories and Nova scotia.) An average of 19.1% (n=645) of cases were reported as female. Among female ESAG cases, most reported having sex with male partners (average of 62.2%, range: 55.6% to 68.1%). Females with unknown sexual behaviour ranged from 10.8% (13/120, 2021) to 32.5% (41/126, 2020). Finally, 0.2% (n=8) of ESAG cases were identified as transgender and 0.2% (n=5) were unknown.
4.2.2. Age distribution among ESAG cases, 2018 to 2021
Between 2018 and 2021, most ESAG cases were between 20 and 39 years of age (average: 72.8%, range: 70.1% to 75.4%). The largest proportion of cases were in the 25-to-29 (average: 22.0%, range: 17.5% to 25.9%) and 30-to-34-year age categories (average: 21.6%, range: 19.0% to 24.4%).
4.2.3. Reason for medical visit among ESAG cases, 2018 to 2021
Between 2018 and 2021, most ESAG cases were tested for gonorrhea because of experiencing GC signs/symptoms (average: 58.4%; range: 53.2% to 69.0%). This was followed by STI screening (average: 12.6%; range: 9.0% to 15.0%) and because of case contacting (i.e., were contacted because a sexual partner had tested GC positive) (average: 10.2%; range: 8.4% to 11.8%). Eight cases (four cases in each 2020 and 2021) sought a "test of cure". There were two cases (one in each 2018 and 2019) who were tested as potential "re-exposures" (Table 3). On average, 18.4% (range: 8.5% to 21.9%) of cases had an unknown reason for medical visit. Heterosexual males, GBMSM, and females, were primarily tested for GC due to signs and symptoms (average: 92.3%, 58.6% and 49.6%, respectively), followed by STI screening (average: 5.9%, 19.7% and 12.0%, respectively).
4.2.4. Primary site of infection among ESAG cases, 2018 to 2021
Between 2018 and 2021, the most common site of infection that corresponded with the primary culture (the primary infection site) varied by sex and sexual behaviour (Table 4). Among GBMSM cases, rectal (average 39.3%, range: 37.4% to 43.7%) and pharyngeal infections (average of 34.6%, range: 25.4% to 38.1%) were more common than genital infections (average of 26.1%, range: 24.6% to 30.8%). In contrast, genital infections were the most reported infection site among heterosexual males (average of 90%, range: 92.1% to 99.5%) and males with unknown sexual behaviour (average of 52.5%, range: 20.0% to 59.5%).
Over the reporting period, there was a decrease in the proportion of males with unknown sexual behaviour that had pharyngeal infections, from 20.9% (29/139) in 2018 to 8.3% (2/24) in 2021. Subsequently, there was an increase in males with unknown sexual behaviour reporting 'other' infection sites during this period, from 3.6% (5/139) in 2018 to 37.5% (9/24) in 2021 (Table 4).
Among females, from 2018 to 2021, the most reported primary infection sites were genital (average of 35.2%, range: 31.3% to 41.7%) and pharyngeal (average of 32.4%, range: 30.9% to 33.6%).
Case characteristics | 2018 | 2019 | 2020 | 2021 | Total | ||||
---|---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | n | |
SexFootnote a | |||||||||
Male |
827 |
80.9% |
779 |
78.0% |
584 |
82.1% |
519 |
80.5% |
2709 |
Female |
191 |
18.7% |
217 |
21.7% |
126 |
17.7% |
120 |
18.6% |
654 |
TransgenderFootnote b |
4 |
0.4% |
2 |
0.2% |
0 |
0.0% |
2 |
0.0% |
8 |
OtherFootnote b |
0 |
0.0% |
0 |
0.0% |
1 |
0.1% |
0 |
0.0% |
1 |
Unknown |
0 |
0.0% |
1 |
0.1% |
0 |
0.0% |
4 |
0.6% |
5 |
Total by sex |
1022 |
100.0% |
999 |
100.0% |
711 |
100.0% |
645 |
100.0% |
3377 |
Sexual Behaviour | |||||||||
Male sexual behaviour | |||||||||
GBMSMFootnote c |
443 |
53.6% |
402 |
51.6% |
334 |
57.2% |
310 |
59.7% |
1489 |
Heterosexual males |
245 |
29.6% |
253 |
32.5% |
171 |
29.3% |
185 |
35.6% |
854 |
Males with unknown sexual behaviour |
139 |
16.8% |
124 |
15.9% |
79 |
13.5% |
24 |
4.6% |
366 |
Total male by sexual behaviourFootnote c |
827 |
100.0% |
779 |
100.0% |
584 |
100.0% |
519 |
100.0% |
2709 |
Female sexual behaviourFootnote d | |||||||||
Female - male sex partner |
130 |
68.1% |
132 |
60.8% |
70 |
55.6% |
77 |
64.2% |
409 |
Female - female sex partner |
2 |
1.0% |
2 |
0.9% |
0 |
0.0% |
1 |
0.8% |
5 |
Female - sex with both |
30 |
15.7% |
34 |
15.7% |
15 |
11.9% |
29 |
24.2% |
108 |
Female - unknown |
29 |
15.2% |
49 |
22.6% |
41 |
32.5% |
13 |
10.8% |
132 |
Total female by sexual behaviour |
191 |
100.0% |
217 |
100.0% |
126 |
100.0% |
120 |
100.0% |
654 |
Sex/sexual behaviourFootnote e | |||||||||
GBMSMFootnote c |
443 |
43.3% |
402 |
40.2% |
334 |
47.0% |
310 |
48.1% |
1489 |
Heterosexual male |
245 |
24.0% |
253 |
25.3% |
171 |
24.1% |
185 |
28.7% |
854 |
Males with unknown sexual behaviour |
139 |
13.6% |
124 |
12.4% |
79 |
11.1% |
24 |
3.7% |
366 |
Females |
191 |
18.7% |
217 |
21.7% |
126 |
17.7% |
120 |
18.6% |
654 |
TransgenderFootnote b |
4 |
0.4% |
2 |
0.2% |
0 |
0.0% |
2 |
0.3% |
8 |
OtherFootnote b |
0 |
0.0% |
0 |
0.0% |
1 |
0.1% |
0 |
0.0% |
1 |
Unknown |
0 |
0.0% |
1 |
0.1% |
0 |
0.0% |
4 |
0.6% |
5 |
Total sex/sexual behaviour |
1022 |
100.0% |
999 |
100.0% |
711 |
100.0% |
645 |
100.0% |
3377 |
Age (years)Footnote f | |||||||||
16-19 |
29 |
2.8% |
35 |
3.5% |
18 |
2.5% |
16 |
2.5% |
98 |
20-24 |
151 |
14.8% |
142 |
14.2% |
104 |
14.6% |
88 |
13.6% |
485 |
25-29 |
265 |
25.9% |
213 |
21.3% |
152 |
21.4% |
113 |
17.5% |
743 |
30-34 |
197 |
19.3% |
244 |
24.4% |
135 |
19.0% |
153 |
23.7% |
729 |
35-39 |
157 |
15.4% |
127 |
12.7% |
120 |
16.9% |
99 |
15.3% |
503 |
40-44 |
88 |
8.6% |
105 |
10.5% |
58 |
8.2% |
67 |
10.4% |
318 |
45-49 |
54 |
5.3% |
58 |
5.8% |
51 |
7.2% |
47 |
7.3% |
210 |
50-54 |
31 |
3.0% |
31 |
3.1% |
28 |
3.9% |
27 |
4.2% |
117 |
55-59 |
36 |
3.5% |
28 |
2.8% |
28 |
3.9% |
22 |
3.4% |
114 |
60+ |
14 |
1.4% |
15 |
1.5% |
17 |
2.4% |
13 |
2.0% |
59 |
Total by age group |
1022 |
100.0% |
998 |
99.9% |
711 |
100.0% |
645 |
100.0% |
3376 |
Sex work | |||||||||
Yes |
52 |
5.1% |
49 |
4.9% |
35 |
4.9% |
21 |
3.3% |
157 |
No |
729 |
71.3% |
674 |
67.5% |
460 |
64.7% |
474 |
73.5% |
2337 |
Unknown |
241 |
23.6% |
276 |
27.6% |
216 |
30.4% |
150 |
23.3% |
883 |
Total by sex work |
1022 |
100.0% |
999 |
100.0% |
711 |
100.0% |
645 |
100.0% |
3377 |
|
Reason for medical visit | 2018 | 2019 | 2020 | 2021 | Total | ||||
---|---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | n | |
GBMSM | |||||||||
Signs/Symptoms |
227 |
51.2% |
201 |
50.0% |
224 |
67.1% |
205 |
66.1% |
857 |
STI Screening |
109 |
24.6% |
105 |
26.1% |
48 |
14.4% |
43 |
13.9% |
305 |
Case contact |
81 |
18.3% |
67 |
16.7% |
46 |
13.8% |
47 |
15.2% |
241 |
Test of cure |
N/A |
N/A |
N/A |
N/A |
3 |
0.9% |
4 |
1.3% |
7 |
Other |
0 |
0.0% |
4 |
1.0% |
10 |
3.0% |
7 |
2.3% |
21 |
Unknown |
26 |
5.9% |
25 |
6.2% |
3 |
0.9% |
4 |
1.3% |
58 |
Total |
443 |
100.0% |
402 |
100.0% |
334 |
100.0% |
310 |
100.0% |
1489 |
Heterosexual males | |||||||||
Signs/Symptoms |
229 |
93.5% |
228 |
90.1% |
161 |
94.2% |
169 |
91.4% |
787 |
STI Screening |
8 |
3.3% |
12 |
4.7% |
4 |
2.3% |
11 |
5.9% |
35 |
Case contact |
3 |
1.2% |
11 |
4.3% |
3 |
1.8% |
5 |
2.7% |
22 |
Test of cure |
N/A |
N/A |
N/A |
N/A |
1 |
0.6% |
0 |
0.0% |
1 |
Other |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
Unknown |
5 |
2.0% |
2 |
0.8% |
2 |
1.2% |
0 |
0.0% |
9 |
Total |
245 |
100.0% |
253 |
100.0% |
171 |
100.0% |
185 |
100.0% |
854 |
Males with unknown sexual behaviour | |||||||||
Signs/Symptoms |
3 |
2.2% |
1 |
0.8% |
0 |
0.0% |
0 |
0.0% |
4 |
STI Screening |
1 |
0.7% |
1 |
0.8% |
0 |
0.0% |
0 |
0.0% |
2 |
Case contact |
2 |
1.4% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
2 |
Test of cure |
N/A |
N/A |
N/A |
N/A |
0 |
0.6% |
0 |
0.0% |
0 |
Other |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
Unknown |
133 |
95.7% |
122 |
98.4% |
79 |
100.0% |
24 |
100.0% |
358 |
Total |
139 |
100.0% |
124 |
100.0% |
79 |
100.0% |
24 |
100.0% |
366 |
Female | |||||||||
Signs/Symptoms |
92 |
48.2% |
99 |
45.8% |
58 |
46.0% |
70 |
58.3% |
319 |
STI Screening |
21 |
11.0% |
32 |
14.8% |
12 |
9.5% |
15 |
12.5% |
80 |
Case contact |
35 |
18.3% |
19 |
8.8% |
11 |
8.7% |
14 |
11.7% |
79 |
Test of cure |
N/A |
N/A |
N/A |
N/A |
0 |
0.6% |
0 |
0.0% |
0 |
Other |
0 |
0.0% |
1 |
0.5% |
2 |
1.6% |
4 |
3.3% |
7 |
Unknown |
43 |
22.5% |
65 |
30.1% |
43 |
34.1% |
17 |
14.2% |
168 |
Total |
191 |
100.0% |
216 |
100.0% |
126 |
100.0% |
120 |
100.0% |
653 |
All casesFootnote a | |||||||||
Signs/Symptoms |
551 |
53.9% |
531 |
53.2% |
444 |
62.4% |
445 |
69.0% |
1971 |
STI Screening |
141 |
13.8% |
150 |
15.0% |
64 |
9.0% |
71 |
11.0% |
426 |
Case contact |
121 |
11.8% |
97 |
9.7% |
60 |
8.4% |
69 |
10.7% |
347 |
Test of Cure |
0 |
0.0% |
0 |
0.0% |
4 |
0.6% |
4 |
0.6% |
8 |
Other |
1 |
0.1% |
7 |
0.7% |
12 |
0.0% |
11 |
0.2% |
31 |
Unknown |
208 |
20.4% |
214 |
21.9% |
127 |
19.5% |
45 |
8.5% |
594 |
Total |
1022 |
100.0% |
999 |
100.0% |
711 |
100.0% |
645 |
100.0% |
3377 |
N/A: Not available |
Sex / sexual behaviour | 2018 | 2019 | 2020 | 2021 | Total | ||||
---|---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | n | |
GBMSM | |||||||||
Rectum |
172 |
38.8% |
151 |
37.6% |
146 |
43.7% |
116 |
37.4% |
585 |
Pharynx |
161 |
36.3% |
151 |
37.6% |
85 |
25.4% |
118 |
38.1% |
515 |
Genital |
110 |
24.8% |
99 |
24.6% |
103 |
30.8% |
76 |
24.5% |
388 |
Other |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
Unknown |
0 |
0.0% |
1 |
0.2% |
0 |
0.0% |
0 |
0.0% |
1 |
Total |
443 |
100.0% |
402 |
100.0% |
334 |
100.0% |
310 |
100.0% |
1489 |
Heterosexual males | |||||||||
Rectum |
0 |
0.0% |
1 |
0.4% |
0 |
0.0% |
0 |
0.0% |
0 |
Pharynx |
3 |
1.2% |
20 |
7.9% |
4 |
2.3% |
1 |
0.5% |
28 |
Genital |
242 |
98.8% |
232 |
91.7% |
167 |
97.7% |
184 |
99.5% |
825 |
Other |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
Unknown |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
Total |
245 |
100.0% |
253 |
100.0% |
171 |
100.0% |
185 |
100.0% |
853 |
Males with unknown sexual behaviour | |||||||||
Rectum |
32 |
23.0% |
19 |
15.3% |
6 |
7.6% |
0 |
0.0% |
57 |
Pharynx |
29 |
20.9% |
25 |
20.2 |
5 |
6.3% |
2 |
8.3% |
61 |
Genital |
70 |
50.4% |
62 |
50.0% |
47 |
59.5% |
12 |
50.0% |
191 |
Other |
5 |
3.6% |
6 |
4.8% |
2 |
2.5% |
9 |
37.5% |
22 |
Unknown |
3 |
2.2% |
12 |
9.7% |
19 |
24.1% |
1 |
4.2% |
35 |
Total |
139 |
100.0% |
124 |
100.0% |
79 |
100.0% |
24 |
100.0% |
366 |
Female | |||||||||
Rectum |
52 |
27.2% |
57 |
26.3% |
23 |
18.3% |
25 |
20.8% |
157 |
Pharynx |
59 |
30.9% |
73 |
33.6% |
41 |
32.5% |
39 |
32.5% |
212 |
Genital |
67 |
35.1% |
68 |
31.3% |
41 |
32.5% |
50 |
41.7% |
226 |
Other |
8 |
4.2% |
8 |
3.7% |
2 |
1.6% |
4 |
3.3% |
22 |
Unknown |
5 |
2.6% |
11 |
5.1% |
19 |
15.1% |
2 |
1.7% |
37 |
Total |
191 |
100.0% |
217 |
100.0% |
126 |
100.0% |
120 |
100.0% |
654 |
All casesFootnote a | |||||||||
Rectum |
258 |
25.2% |
229 |
22.9% |
175 |
24.6% |
142 |
22.0% |
804 |
Pharynx |
252 |
24.7% |
269 |
26.9% |
136 |
19.1% |
164 |
25.4% |
821 |
Genital |
490 |
47.9% |
463 |
46.3% |
358 |
50.4% |
323 |
50.1% |
1634 |
Other |
13 |
1.3% |
14 |
1.4% |
4 |
0.6% |
13 |
2.0% |
44 |
Unknown |
9 |
0.9% |
24 |
2.4% |
38 |
5.3% |
3 |
0.5% |
74 |
Total |
1022 |
100.0% |
999 |
100.0% |
711 |
100.0% |
645 |
100.0% |
3377 |
N/A: Not available |
4.3. Antimicrobial-use appropriateness
4.3.1. Federal and provincial/territorial gonorrhea treatment guidelines, 2018 to 2021
PHAC has been taking emerging AMR-GC trends into consideration in the ongoing gonorrhea treatment guideline development. From 2018 to 2021, PHAC's gonorrhea treatment guidelines was the version dated July 2017 (Table 5).Footnote 6 PHAC guidelines recommends prescribers follow PT-specific gonorrhea treatment guidelines over their own, as PT-specific guidelines reflect local gonorrhea and AMR-GC trend data. Among ESAG participating PTs, Alberta, Manitoba, and Northwest Territories all have PT specific guidelines, while Nova Scotia follows PHAC's GC treatment guidelines.Footnote 11, Footnote 12, Footnote 13
PHAC (and, thus, Nova Scotia), Alberta, and Manitoba's GC treatment recommendations depend on, i) the site of infection: anogenital or pharyngeal and ii) the client's sexual behaviour: GBMSM or other adults (other adults include youth >8 years old and non-GBMSM adults). Furthermore, therapeutic regimens are defined as 'preferred' or 'alternative'. Alternative treatments are recommended when there are contraindications to preferred treatments or if there are indications of emerging resistance or reduced drug supplies. Thus, provided alternative treatment criteria are met, it is appropriate to prescribe either the preferred or alternative therapy to a client. The Northwest Territories treatment guidelines recommend the same preferred and alternative treatment regimens for uncomplicated gonorrhea regardless of the site of infection or the client's sexual behaviour. See supplementary appendix D for detailed provincial and territorial treatment guidelines.
In general, PHAC and all ESAG participating PT guidelines recommend a preferred or alternative dual therapy consisting of a third-generation cephalosporin (cefixime 800mg or ceftriaxone 250mg) in combination with azithromycin (1g) to treat uncomplicated gonorrhea regardless of the infection site, sexual behaviour, or age of the client.
Anogenital Infections |
Pharyngeal Infections |
|||
---|---|---|---|---|
Preferred Therapy |
Alternative Therapy |
Preferred Therapy |
Alternative Therapy |
|
GBMSM |
Ceftriaxone 250 mg IMFootnote a + Azithromycin 1 g POFootnote a |
Cefixime 800 mg POFootnote a+ Azithromycin 1 g POFootnote a OR |
Ceftriaxone 250 mg IMFootnote a+ Azithromycin 1 g POFootnote a |
Cefixime 800 mg POFootnote a+ Azithromycin 1 g POFootnote a |
Cefixime 800 mg POFootnote a + Doxycycline 100 mg POFootnote b OR Ceftriaxone 250 mg IMFootnote a+ Doxycycline 100 mg POFootnote b OR Azithromycin 2 g POFootnote a+ Gentamicin 240 mg IM/IVFootnote c OR Gentamicin 240 mg IMFootnote d + Doxycycline 100 mg POFootnote b, Footnote e OR Azithromycin 2 g POFootnote a + Ciprofloxacin 500 mg POFootnote a, Footnote f OR Azithromycin 2 g POFootnote a+ Gemifloxacin 320 mg POFootnote a, Footnote f |
||||
Other Adults |
Ceftriaxone 250 mg IMFootnote a+ Azithromycin 1 g POFootnote a |
Cefixime 800 mg POFootnote a+ Doxycycline 100 mg POFootnote b OR Ceftriaxone 250 mg IMFootnote a + Doxycycline 100 mg POFootnote b OR Azithromycin 2g POFootnote a + Gentamicin 240 mg IMFootnote c, Footnote d OR Gentamicin 240 mg IMFootnote d + Doxycycline 100 mg POFootnote b, Footnote e OR Azithromycin 2 g POFootnote a+ Ciprofloxacin 500 mg POFootnote a, Footnote f OR Azithromycin 2 g POFootnote a+ Gemifloxacin 320 mgFootnote a, Footnote f |
Ceftriaxone 250 mg IMFootnote a+ Azithromycin 1 g POFootnote a |
Cefixime 800 mg POFootnote a + Azithromycin 1g POFootnote a |
Cefixime 800 mg POFootnote a + Azithromycin 1g POFootnote a |
||||
Note: PO=taken orally; IM=intramuscular; IV=intravenous
|
4.3.2. Antimicrobial-use appropriateness among ESAG cases, 2018 to 2021
ESAG measures the appropriateness of antimicrobial use by comparing the gonorrhea treatment regimens prescribed to ESAG cases to the treatments recommended in PHAC and reporting PT gonorrhea treatment guidelines. Adherence to treatment recommendations has been associated with reducing the development of AMR.Footnote 19 To date, there is no known target for the ideal proportion of GC treatment guideline prescriber adherence to limit AMR-GC emergence.Footnote 19
Figure 1 shows the proportion of i) GBMSM and ii) other adult ESAG cases who were prescribed a PHAC or reporting PT preferred or alternative treatment regimen (see Tables 6, 7, 8, 9 for details) versus all other treatment regimens by infection site. Across the report period, the overall prescriber adherence to PHAC and reporting PT gonorrhea treatment guidelines was high (average of 91.4% adherence to PHAC guidelines and 89.5% adherence to PT guidelines) and relatively stable (range adherence to guidelines: (PHAC: 88.4% to 94.6%); (PT: 87.3% to 91.6%). Overall, however, prescriber adherence to PT-specific treatment guidelines was slightly lower than to PHAC treatment guidelines.
Results were similar among GBMSM and other adults. Prescriber adherence was mostly stable over time for all groups except for other adults with pharyngeal infections. Across 2018 to 2021, prescriber adherence to PHAC and PT guidelines was high and stable for GBMSM with anogenital (PHAC average of 92.8%; PT average of 86.7%) and pharyngeal infections (PHAC average of 88.4%; PT average of 89.4%). Prescriber adherence was similarly high among other adults with anogenital (PHAC average of 93.7%; PT average of 91.7%) and pharyngeal infections (PHAC average of 92.8%; PT average of 90.2%).
Figure 1. The proportion of ESAG cases (among all ESAG cases who were prescribed treatment) who were prescribed a PHAC or PT preferred or alternative gonorrhea treatment regimen versus other prescribed treatment(s) among GBMSM and other adults, 2018 to 2021

Figure 1A - Text description
Treatment | 2018 | 2019 | 2020 | 2021 | |
---|---|---|---|---|---|
PT |
Preferred or alternative |
84% |
87% |
89% |
87% |
PT |
Other treatment |
16% |
13% |
11% |
13% |
PHAC |
Preferred or alternative |
88% |
94% |
95% |
94% |
PHAC |
Other treatment |
12% |
6% |
5% |
6% |

Figure 1B - Text description
Treatment | 2018 | 2019 | 2020 | 2021 | |
---|---|---|---|---|---|
PT |
Preferred or alternative |
89% |
88% |
89% |
92% |
PT |
Other treatment |
11% |
12% |
11% |
8% |
PHAC |
Preferred or alternative |
88% |
85% |
89% |
92% |
PHAC |
Other treatment |
13% |
15% |
11% |
8% |

Figure 1C - Text description
Treatment | 2018 | 2019 | 2020 | 2021 | |
---|---|---|---|---|---|
PT |
Preferred or alternative |
92% |
91% |
90% |
94% |
PT |
Other treatment |
8% |
9% |
10% |
6% |
PHAC |
Preferred or alternative |
93% |
94% |
92% |
96% |
PHAC |
Other treatment |
7% |
6% |
8% |
4% |

Figure 1D - Text description
Treatment | 2018 | 2019 | 2020 | 2021 | |
---|---|---|---|---|---|
PT |
Preferred or alternative |
85% |
98% |
84% |
95% |
PT |
Other treatment |
15% |
2% |
16% |
5% |
PHAC |
Preferred or alternative |
88% |
94% |
95% |
94% |
PHAC |
Other treatment |
12% |
6% |
5% |
6% |
Note: Anogenital infections include rectal, cervical, urogenital and vaginal infections. Pharyngeal infections refer to throat infections. Other treatment includes cases prescribed a regimen that was i) known and was not a preferred or alternative treatment or ii) incomplete or unknown.
The following sections summarize the treatment regimens prescribed to ESAG cases, the frequency of these prescriptions, and whether they were recommended as per PHAC or participating PT gonorrhea treatment guidelines. The presented proportions of ESAG cases prescribed a preferred or alternative treatment are conservative.
4.3.2.a. Gonorrhea treatments prescribed among GBMSM cases, 2018 to 2021
Gonorrhea treatments prescribed among GBMSM cases with anogenital or pharyngeal infections
From 2018 to 2021, GBMSM cases were mostly prescribed the PHAC and PT recommended preferred regimen of azithromycin 1 g plus ceftriaxone 250 mg to treat anogenital infections (average: 82.9%; range: 81.4% to 84.3%) (Table 6) and pharyngeal infections (average: 86.7%; range: 85.3% to 90.7%) (Table 7). This was followed by ceftriaxone 250 mg plus doxycycline 100 mg-an alternative treatment regimen listed only in the PHAC GC treatment guidelines for anogenital infections (average: 6.3% range: 4.3% to 9.1%). While not recommended by any guideline for pharyngeal infections, it was also prescribed for pharyngeal infections (average: 4.4%; range: 2.5% to 6.0%). The proportion of GBMSM anogenital cases prescribed the PHAC and PT recommended alternative regimen of azithromycin 1 g plus cefixime 800 mg remained relatively low across all years (average: 3.5%; range: 2.4% to 6.4%). All other prescribed regimens combined accounted for less than 3.8% of GBMSM anogenital cases and 4.4% of GBMSM pharyngeal cases.
Gonorrhea treatment regimen | Preferred (P) or alternative treatment (A) according to PHAC or PT guidelines | Number and proportion of GBMSM cases prescribed treatment for anogenital infections | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
2018 | 2019 | 2020 | 2021 | Total | ||||||||||
PHAC | Alta. | Man. | NSFootnote a | N.W.T. | n | % | n | % | n | % | n | % | n | |
Azithromycin 1 g, Ceftriaxone 250 mg |
P |
P |
P |
P |
P |
227 |
81.4% |
210 |
84.3% |
205 |
82.3% |
157 |
84.0% |
799 |
Ceftriaxone 250 mg, Doxycycline 100 mg |
A |
NR |
NR |
A |
NR |
12 |
4.3% |
15 |
6.0% |
14 |
5.6% |
17 |
9.1% |
58 |
Other-unspecified |
NR |
NR |
NR |
NR |
NR |
16 |
5.7% |
12 |
4.8% |
7 |
2.9% |
3 |
1.6% |
38 |
Azithromycin 1 g, Cefixime 800 mg |
A |
A |
A |
A |
A |
7 |
2.5% |
6 |
2.4% |
16 |
6.4% |
5 |
2.7% |
34 |
Azithromycin 2 gFootnote b |
NR |
NR |
A |
NR |
A |
6 |
2.2% |
1 |
0.4% |
1 |
0.4% |
2 |
1.1% |
10 |
Azithromycin 2 g, Other-unspecified |
NR |
NR |
NR |
NR |
NR |
2 |
0.7% |
2 |
0.8% |
1 |
0.4% |
0 |
0.0% |
5 |
Doxycycline 100 mg |
NR |
NR |
NR |
NR |
NR |
0 |
0.0% |
1 |
0.4% |
1 |
0.4% |
2 |
1.1% |
4 |
Cefixime 800 mg, Doxycycline 100 mgFootnote c |
A |
NR |
NR |
A |
NR |
0 |
0.0% |
1 |
0.4% |
1 |
0.4% |
0 |
0.0% |
2 |
Ceftriaxone 250 mg, Other-unspecified |
NR |
NR |
NR |
NR |
NR |
1 |
0.4% |
0 |
0.0% |
1 |
0.4% |
0 |
0.0% |
2 |
Azithromycin 1 g, Ceftriaxone 250 mg, Doxycycline 100mg PO BID x 14 days |
NR |
NR |
NR |
NR |
NR |
2 |
0.7% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
2 |
Azithromycin 1 g, Ceftriaxone 250 mg, Doxycycline 100mg PO BID x 14 days plus Metronidazole 500mg PO BID x 14 days |
NR |
NR |
NR |
NR |
NR |
2 |
0.7% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
2 |
Benzathine Penicillin G 2,400,000 units |
NR |
NR |
NR |
NR |
NR |
0 |
0.0% |
1 |
0.4% |
1 |
0.4% |
0 |
0.0% |
2 |
Azithromycin 1 g |
NR |
NR |
NR |
NR |
NR |
1 |
0.4% |
1 |
0.4% |
0 |
0.0% |
0 |
0.0% |
2 |
Ceftriaxone 250 mg |
NR |
NR |
NR |
NR |
NR |
1 |
0.4% |
0 |
0.0% |
0 |
0.0% |
1 |
0.5% |
2 |
Azithromycin 2 g, Ceftriaxone 250 mg |
NR |
NR |
NR |
NR |
NR |
1 |
0.4% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
Cefixime 800 mg |
NR |
NR |
NR |
NR |
NR |
1 |
0.4% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
Total |
279 |
100.0% |
249 |
100.0% |
249 |
100.0% |
187 |
100.0% |
964 |
|||||
Note: Preferred is indicated in the table as P, alternative is indicated as A and not recommended is indicated by NR.
|
Gonorrhea treatment regimen | Preferred (P) or alternative treatment (A) according to PHAC or PT guidelines | Number and proportion of GBMSM cases prescribed treatment for pharyngeal infections | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
2018 | 2019 | 2020 | 2021 | Total | ||||||||||
PHAC | Alta. | Man. | NSFootnote a | N.W.T. | n | % | n | % | n | % | n | % | n | |
Azithromycin 1 g, Ceftriaxone 250 mg |
P |
P |
P |
P |
P |
137 |
85.6% |
128 |
85.3% |
72 |
85.7% |
107 |
90.7% |
444 |
Ceftriaxone 250 mg, Doxycycline 100 mg |
NR |
NR |
NR |
NR |
NR |
4 |
2.5% |
9 |
6.0% |
4 |
4.8% |
5 |
4.2% |
22 |
Other-unspecified |
NR |
NR |
NR |
NR |
NR |
8 |
5.0% |
7 |
4.7% |
4 |
4.8% |
2 |
1.7% |
21 |
Azithromycin 1 g, Cefixime 800 mg |
A |
A |
A |
A |
A |
3 |
1.9% |
0 |
0.0% |
3 |
3.6% |
1 |
0.8% |
7 |
Azithromycin 2 gFootnote b |
NR |
NR |
A |
NR |
A |
2 |
1.3% |
2 |
1.3% |
0 |
0.0% |
0 |
0.0% |
4 |
Azithromycin 2 g, Other-unspecified |
NR |
NR |
NR |
NR |
NR |
1 |
0.6% |
0 |
0.0% |
1 |
1.2% |
0 |
0.0% |
2 |
Azithromycin 2 g, Gentamicin 240mg IM in 2 separate 3-mLFootnote c |
NR |
A |
NR |
NR |
NR |
0 |
0.0% |
2 |
1.3% |
0 |
0.0% |
0 |
0.0% |
2 |
Ceftriaxone 250 mg, Other-unspecified |
NR |
NR |
NR |
NR |
NR |
1 |
0.6% |
0 |
0.0% |
0 |
0.0% |
1 |
0.8% |
2 |
Doxycycline 100 mg |
NR |
NR |
NR |
NR |
NR |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
2 |
1.7% |
2 |
Azithromycin 1 g |
NR |
NR |
NR |
NR |
NR |
1 |
0.6% |
1 |
0.7% |
0 |
0.0% |
0 |
0.0% |
2 |
Ceftriaxone 250 mg |
NR |
NR |
NR |
NR |
NR |
1 |
0.6% |
1 |
0.7% |
0 |
0.0% |
0 |
0.0% |
2 |
Cefixime 800 mg |
NR |
NR |
NR |
NR |
NR |
1 |
0.6% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
Azithromycin 1 g, Ceftriaxone 250 mg, Gentamicin 240mg IM in 2 separate 3-mL injections of 40mg/mL solution |
NR |
NR |
NR |
NR |
NR |
1 |
0.6% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
Total |
160 |
100.0% |
150 |
100.0% |
84 |
100.0% |
118 |
100.0% |
512 |
|||||
Note: Preferred is indicated in the table as P, alternative is indicated as A and not recommended is indicated by NR.
|
4.3.2.b. Gonorrhea treatments prescribed among other adults in ESAG, 2018 to 2021
Gonorrhea treatments prescribed among other adults include heterosexual males, females, transgender and other sex. Other adults exclude males with unknown sexual behaviour and GBMSM.
Gonorrhea treatments prescribed among other adults with anogenital infections
Between 2018 and 2021, most other adults with anogenital infections were prescribed the PHAC, Alberta, and Manitoba recommended regimen of cefixime 800 mg with azithromycin 1 g (average of 86.2%; range: 86.4% to 88.4%) (Table 8). This was followed by the PHAC, Manitoba and Nova Scotia alternative preferred regimen, the Northwest Territory's only preferred treatment and Alberta's alternative regimen, azithromycin 1g with ceftriaxone 250 mg (average of 4.1%; range: 3.2% to 5.2%) (Table 8). The combined average (from 2018 to 2021) of reporting for all other unique prescription regimens ranged from 0.1% to 1.8%.
Gonorrhea treatments among other adults with pharyngeal infections
From 2018 to 2021, the most frequently prescribed therapy among other adults with pharyngeal infections was the alternative regimen of azithromycin 1 g with cefixime 800 mg (average 50.4%: range: 43.2% to 56.3%) which is recommended by all ESAG participating PTs (Table 9). This was followed by the preferred regimen (recommended by all ESAG participating PTs) of azithromycin 1g with ceftriaxone 250 mg (average 39.4%; range: 33.9% to 43.2% (16/37) in 2021). The combined average (from 2018 to 2021) proportion of prescriptions for all other unique treatment regimens ranged from 0.3% to 2.7%.
Gonorrhea treatment regimen | Preferred (P) or alternative (A) according to PT guidelines | Number and proportion of other adult cases prescribed treatment for anogenital infections | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
2018 | 2019 | 2020 | 2021 | Total | ||||||||||
PHAC | Alta. | Man. | NSFootnote a | N.W.T. | n | % | n | % | n | % | n | % | n | |
Azithromycin 1 g, Cefixime 800 mg |
P |
P |
P |
P |
A |
306 |
88.4% |
299 |
86.4% |
190 |
86.4% |
219 |
88.0% |
1,014 |
Azithromycin 1 g, Ceftriaxone 250 mg |
P |
A |
P |
P |
P |
11 |
3.2% |
14 |
4.0% |
9 |
4.1% |
13 |
5.2% |
47 |
Ceftriaxone 250mg, Doxycycline 100mgFootnote b |
A |
NR |
NR |
A |
NR |
3 |
0.9% |
9 |
2.6% |
4 |
1.8% |
5 |
2.0% |
21 |
Ceftriaxone 250 mg, Other-unspecified |
NR |
NR |
NR |
NR |
NR |
8 |
2.3% |
0 |
0% |
8 |
3.6% |
1 |
0.4% |
17 |
Other-unspecified |
NR |
NR |
NR |
NR |
NR |
5 |
1.4% |
3 |
0.9% |
2 |
0.9% |
1 |
0.4% |
11 |
Azithromycin 1 g |
NR |
NR |
NR |
NR |
NR |
1 |
0.3% |
2 |
0.6% |
2 |
0.9% |
3 |
1.2% |
8 |
Cefixime 800 mg, Doxycycline 100 mgFootnote b |
A |
NR |
NR |
A |
NR |
2 |
0.6% |
4 |
1.2% |
0 |
0% |
3 |
1.2% |
9 |
Azithromycin 2 g, Other-unspecified |
NR |
NR |
NR |
NR |
NR |
2 |
0.6% |
0 |
0% |
3 |
1.4% |
1 |
0.4% |
6 |
Ceftriaxone 250mg, Doxycycline 100mg with Metronidazole 500mg |
NR |
NR |
NR |
NR |
NR |
0 |
0% |
4 |
1.2% |
0 |
0% |
1 |
0.4% |
5 |
Azithromycin 2 gFootnote b |
NR |
NR |
A |
NR |
A |
4 |
1.2% |
1 |
0.3% |
0 |
0% |
0 |
0% |
5 |
Cefixime 800 mg, Azithromycin 1 g, Benzathine Penicillin G 2,400,000 units |
NR |
NR |
NR |
NR |
NR |
0 |
0% |
3 |
0.9% |
1 |
0.5% |
1 |
0.4% |
5 |
Azithromycin 2 g, Gentamicin 240mg IM in 2 separate 3-mL injections of 40mg/mL solutionFootnote c |
A |
A |
NR |
A |
NR |
0 |
0% |
2 |
0.6% |
0 |
0% |
1 |
0.4% |
3 |
Azithromycin 1 g, Other-unspecified |
NR |
NR |
NR |
NR |
NR |
0 |
0% |
2 |
0.6% |
0 |
0% |
0 |
0% |
2 |
Azithromycin 1 g, Cefixime 800 mg, Doxycycline 100mg PO BID x 14 days |
NR |
NR |
NR |
NR |
NR |
2 |
0.6% |
0 |
0% |
0 |
0% |
0 |
0% |
2 |
Benzathine Penicillin G 2,400,000 units |
NR |
NR |
NR |
NR |
NR |
0 |
0.0% |
0 |
0.0% |
1 |
0.5% |
0 |
0% |
1 |
Levofloxacin 500mg PO OD x 14 days with metronidazole 500mg PO BID x 14 days |
NR |
NR |
NR |
NR |
NR |
0 |
0% |
1 |
0.3% |
0 |
0% |
0 |
0% |
1 |
Azithromycin 2g, Gemifloxacin 320mg PO SDFootnote d |
A |
A |
NR |
A |
NR |
0 |
0% |
1 |
0.3% |
0 |
0% |
0 |
0% |
1 |
Ceftriaxone 250 mg |
NR |
NR |
NR |
NR |
NR |
0 |
0% |
1 |
0.3% |
0 |
0% |
0 |
0% |
1 |
Cefixime 800 mg |
NR |
NR |
NR |
NR |
NR |
1 |
0.3% |
0 |
0% |
0 |
0% |
0 |
0% |
1 |
Cefixime 400 mg |
NR |
NR |
NR |
NR |
NR |
1 |
0.3% |
0 |
0% |
0 |
0% |
0 |
0% |
1 |
Total |
346 |
100% |
346 |
100% |
220 |
100% |
249 |
100% |
1,161 |
|||||
Note: Preferred is indicated in the table as P, alternative is indicated as A and not recommended is indicated by NR.
|
Gonorrhea treatment regimen | Preferred (P) or alternative (A) according to PT Guidelines | Number and proportion of other adult cases prescribed treatment for pharyngeal infections | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
2018 | 2019 | 2020 | 2021 | Total | ||||||||||
PHAC | Alta. | Man. | NSFootnote a | N.W.T. | n | % | n | % | n | % | n | % | n | |
Azithromycin 1 g, Cefixime 800 mg |
A |
A |
A |
A |
A |
30 |
50.8% |
49 |
56.3% |
19 |
43.2% |
19 |
51.4% |
117 |
Azithromycin 1 g, Ceftriaxone 250 mg |
P |
P |
P |
P |
P |
20 |
33.9% |
36 |
41.4% |
18 |
40.9% |
16 |
43.2% |
89 |
Other-unspecified |
NR |
NR |
NR |
NR |
NR |
1 |
1.7% |
1 |
1.1% |
2 |
4.5% |
1 |
2.7% |
5 |
Ceftriaxone 250 mg, Doxycycline 100 mg |
NR |
NR |
NR |
NR |
NR |
0 |
0.0% |
0 |
0.0% |
2 |
4.5% |
1 |
2.7% |
5 |
Azithromycin 2 g, Other-unspecified |
NR |
NR |
NR |
NR |
NR |
2 |
3.4% |
0 |
0.0% |
1 |
2.3% |
0 |
0.0% |
3 |
Azithromycin 2 gFootnote b |
NR |
NR |
A |
NR |
A |
2 |
3.4% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
2 |
Ceftriaxone 250 mg, Other-unspecified |
NR |
NR |
NR |
NR |
NR |
2 |
3.4% |
0 |
0.0% |
1 |
2.3% |
0 |
0.0% |
1 |
Azithromycin 1 g, Cefixime 800 mg, Doxycycline 100mg PO BID x 14 days |
NR |
NR |
NR |
NR |
NR |
1 |
1.7% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
Azithromycin 1 g, Ceftriaxone 250 mg, Cefixime 800 mg, Penicillin 600 mg, BID x 10 days |
NR |
NR |
NR |
NR |
NR |
0 |
0.0% |
1 |
1.1% |
0 |
0.0% |
0 |
0.0% |
1 |
Azithromycin 1 g |
NR |
NR |
NR |
NR |
NR |
0 |
0.0% |
0 |
0.0% |
1 |
2.3% |
0 |
0.0% |
1 |
Ceftriaxone 250 mg |
NR |
NR |
NR |
NR |
NR |
1 |
1.7% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
Total |
59 |
100.0% |
87 |
100.0% |
44 |
100.0% |
37 |
100.0% |
226 |
|||||
Note: Preferred is indicated in the table as P, alternative is indicated as A and not recommended is indicated by NR.
|
4.3.2.c. Gonorrhea treatment among males with unknown sexual behaviour in ESAG, 2018 to 2021
Treatments prescribed for males with unknown sexual behaviour are listed in supplementary appendix E. These cases were primarily reported by Manitoba (88.6%, 171/193). Most males with unknown sexual behaviour who had anogenital infections were prescribed azithromycin 1 g plus cefixime 800 mg (average: 41.3%). The second most common treatment prescribed for this group, was azithromycin 1 g plus ceftriaxone 250 mg (average: 22.2%). Males with unknown sexual behaviour who had pharyngeal infections were primarily prescribed either the preferred or alternative treatment regimens (average: 90.2%).
4.3.3. Gonorrhea treatment failure among ESAG cases, 2018 to 2021
Between 2018 and 2021, there were 14 ESAG cases reported as GC treatment failures (6/956 (0.6%) in 2018 and 8/935 (0.9%) in 2019; 92.8% (13) cases were male, 64.3% (nine) cases were GBMSM; 78.6% (11) were anogenital infections). Six cases were prescribed azithromycin 1 g and cefixime 800 mg, five cases ceftriaxone 250 mg and azithromycin 1 g, one case azithromycin 1 g, one case azithromycin 2 g and gentamicin 240 mg, and one case had unspecified treatment. Of the 13 reported treatment failures with available prescription data, none demonstrated decreased susceptibility/resistance to all treatments in their prescribed regimen; thus, none were confirmed treatment failures (supplementary appendix F). The case with unspecified treatment was resistant to ciprofloxacin, penicillin, and tetracycline. As none of these drugs are among the most recommended and prescribed therapies, it is unlikely that this case was a true treatment failure. The reported treatment failures may have been re-infections or individuals who did not take their treatment as prescribed.
4.3.4. Antimicrobial susceptibility among ESAG cases, 2018 to 2021
4.3.4.a. AMR-GC burden among ESAG cases and by sex/sexual behaviour
The proportion of ESAG cases that were susceptible to all tested antimicrobials (i.e., azithromycin, ceftriaxone, cefixime, ciprofloxacin, erythromycin, penicillin, spectinomycin and tetracycline) was relatively stable from 2018 to 2020 and was an average of 29.6% from 2018 to 2021 (Figure 2A, Figure 3A). (For a breakdown by PT, please see Appendix 3). Among all ESAG cases, GBMSM had the highest burden of AMR-GC compared to heterosexual males, males with unknown sexual behaviour and females (Figures 2B, 2C, 2D, 2E, 3B, 3C, 3D, 3E). Among GBMSM, the proportion susceptible to all antibiotics declined from 25.9% in 2018 to 14.8% in 2021 (42.9% decline). Among heterosexual males, the proportion susceptible to all antibiotics was an average of 40.0% from 2018 to 2020 but dropped sharply to only approximately a quarter of the population (26.5%) in 2021 (Figures 2B and 3B). In contrast, among males with unknown sexual behaviour group, the proportion susceptible to all antibiotics increased from 15.8% in 2018 to 37.5% in 2021 (Figure 2D and 3D). Meanwhile, among females, the proportion susceptible to all antibiotics has fluctuated mildly from 2018 to 2021 (four-year average of 36.1%) (Figure 2E and 3E).
From 2020 to 2021, the proportion of cases with resistance or decreased susceptibility (R/DS) to two antimicrobials sharply increased among GBMSM (from 31.4% in 2020 to 56.1% in 2021) and heterosexual males (from 19.9% in 2020 to 37.3% in 2021), and females (from 11.1% in 2020 to 29.2% in 2021) (Figure 3B, 3C, and 3E).
Figure 2. Proportion of ESAG cultures demonstrating resistance (R) to azithromycin, ciprofloxacin, erythromycin, spectinomycin, penicillin, or tetracycline or decreased susceptibility (DS) to cefixime and ceftriaxone, among all ESAG cases and by sex/sexual behaviour, 2018 to 2021

Figure 2A - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
CefiximeDS |
1 |
0.1% |
3 |
0.3% |
6 |
0.8% |
22 |
3.4% |
CeftriaxoneDS |
8 |
0.8% |
3 |
0.3% |
2 |
0.3% |
1 |
0.2% |
AzithromycinR |
18 |
1.8% |
78 |
7.8% |
8 |
1.1% |
12 |
1.9% |
CiprofloxacinR |
439 |
43.0% |
444 |
44.4% |
331 |
46.6% |
407 |
63.1% |
TetracyclineR |
532 |
52.1% |
517 |
51.8% |
326 |
45.9% |
378 |
58.6% |
PenicillinR |
69 |
6.8% |
72 |
7.2% |
58 |
8.2% |
25 |
3.9% |
ErythromycinR |
307 |
30.0% |
248 |
24.8% |
123 |
17.3% |
55 |
8.5% |
SpectinomycinR |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Susceptible to all antibiotics tested |
301 |
29.5% |
290 |
29.0% |
218 |
30.7% |
146 |
22.6% |
Total |
1022 |
100.0% |
999 |
100.0% |
711 |
100.0% |
645 |
100.0% |

Figure 2B - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
CefiximeDS |
1 |
0.2% |
0 |
0.0% |
4 |
1.2% |
14 |
4.5% |
CeftriaxoneDS |
1 |
0.2% |
0 |
0.0% |
1 |
0.3% |
0 |
0.0% |
AzithromycinR |
14 |
3.2% |
57 |
14.2% |
4 |
1.2% |
8 |
2.6% |
CiprofloxacinR |
280 |
63.1% |
269 |
66.9% |
239 |
71.6% |
241 |
77.7% |
TetracyclineR |
212 |
47.7% |
209 |
52.0% |
170 |
50.9% |
213 |
68.7% |
PenicillinR |
26 |
5.9% |
30 |
7.5% |
34 |
10.2% |
16 |
5.2% |
ErythromycinR |
158 |
35.6% |
90 |
22.4% |
26 |
7.8% |
20 |
6.5% |
SpectinomycinR |
0 |
0.0% |
0 |
0.0% |
0 |
0. 0% |
0 |
0.0% |
Susceptible to all antibiotics tested |
115 |
25.9% |
79 |
19.7% |
67 |
20.1% |
46 |
14.8% |
Total GBMSM |
444 |
100.0% |
402 |
100.0% |
334 |
100.0% |
310 |
100.0% |

Figure 2C - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
CefiximeDS |
0 |
0.0% |
1 |
0.4% |
1 |
0.6% |
4 |
2.2% |
CeftriaxoneDS |
0 |
0.0% |
1 |
0.4% |
0 |
0.0% |
0 |
0.0% |
AzithromycinR |
2 |
0.8% |
7 |
2.8% |
3 |
1.8% |
1 |
0.5% |
CiprofloxacinR |
59 |
24.1% |
76 |
30.0% |
56 |
32.7% |
108 |
58.4% |
TetracyclineR |
120 |
49.0% |
136 |
53.8% |
77 |
45.0% |
96 |
51.9% |
PenicillinR |
12 |
4.9% |
24 |
9.5% |
14 |
8.2% |
3 |
1.6% |
ErythromycinR |
32 |
13.1% |
47 |
18.6% |
26 |
15.2% |
10 |
5.4% |
SpectinomycinR |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Susceptible to all antibiotics tested |
98 |
40.0% |
96 |
37.9% |
74 |
43.3% |
49 |
26.5% |
Total heterosexual males |
245 |
100.0% |
253 |
100.0% |
171 |
100.0% |
185 |
100.0% |

Figure 2D - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
CefiximeDS |
0 |
0.0% |
1 |
0.8% |
0 |
0.0% |
0 |
0.0% |
CeftriaxoneDS |
7 |
5.0% |
1 |
0.8% |
1 |
1.3% |
0 |
0.0% |
AzithromycinR |
2 |
1.4% |
4 |
3.2% |
0 |
0.0% |
3 |
12.5% |
CiprofloxacinR |
63 |
45.3% |
52 |
41.9% |
14 |
17.7% |
2 |
8.3% |
TetracyclineR |
90 |
64.7% |
61 |
49.2% |
29 |
36.7% |
9 |
37.5% |
PenicillinR |
25 |
18.0% |
6 |
4.8% |
2 |
2.5% |
1 |
4.2% |
ErythromycinR |
77 |
55.4% |
62 |
50.0% |
35 |
44.3% |
10 |
41.7% |
SpectinomycinR |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Susceptible to all antibiotics tested |
22 |
15.8% |
30 |
24.2% |
28 |
35.4% |
9 |
37.5% |
Total males with unknown sexual behaviour |
139 |
100.0% |
124 |
100.0% |
79 |
100.0% |
24 |
100.0% |

Figure 2E - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
CefiximeDS |
0 |
0.0% |
1 |
0.5% |
1 |
0.8% |
4 |
3.3% |
CeftriaxoneDS |
0 |
0.0% |
1 |
0.5% |
0 |
0.0% |
1 |
0.8% |
AzithromycinR |
0 |
0.0% |
9 |
4.1% |
1 |
0.8% |
0 |
0.0% |
CiprofloxacinR |
37 |
19.4% |
46 |
21.2% |
22 |
17.5% |
53 |
44.2% |
TetracyclineR |
109 |
57.1% |
110 |
50.7% |
49 |
38.9% |
56 |
46.7% |
PenicillinR |
6 |
3.1% |
12 |
5.5% |
8 |
6.3% |
5 |
4.2% |
ErythromycinR |
40 |
20.9% |
48 |
22.1% |
36 |
28.6% |
15 |
12.5% |
Susceptible to all antibiotics tested |
64 |
33.5% |
84 |
38.7% |
49 |
38.9% |
40 |
33.3% |
Total female |
191 |
100.0% |
217 |
100.0% |
126 |
100.0% |
120 |
100.0% |
Note: Red dashed line represents the World Health Organization's (WHO) threshold of AMR-GC concern ≥5%: Resistance level at which WHO recommends that the use of an antimicrobial in empiric treatment is discontinued.
Figure 3. Proportion of ESAG cases with GC cultures demonstrating resistance (R) and/or decreased susceptibility (DS) to none or up to five antimicrobialsNote de bas de page a, among all ESAG cases and by sex/sexual behaviour, 2018 to 2021

Figure 3A - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
Susceptible to all |
301 |
29% |
290 |
29% |
218 |
31% |
146 |
23% |
R/DS to 1 |
330 |
32% |
323 |
32% |
234 |
33% |
161 |
25% |
R/DS to 2 |
183 |
18% |
212 |
21% |
176 |
25% |
287 |
45% |
R/DS to 3 |
162 |
16% |
92 |
9% |
66 |
9% |
43 |
7% |
R/DS to 4 |
38 |
4% |
80 |
8% |
15 |
2% |
8 |
1% |
R/DS to 5 |
8 |
1% |
2 |
0% |
2 |
0% |
0 |
0% |
Total |
1022 |
100% |
999 |
100% |
711 |
100% |
645 |
100% |

Figure 3B - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
Susceptible to all |
115 |
26% |
79 |
20% |
67 |
20% |
46 |
15% |
R/DS to 1 |
106 |
24% |
130 |
32% |
111 |
33% |
58 |
19% |
R/DS to 2 |
101 |
23% |
109 |
27% |
105 |
31% |
174 |
56% |
R/DS to 3 |
103 |
23% |
36 |
9% |
47 |
14% |
25 |
8% |
R/DS to 4 |
17 |
4% |
48 |
12% |
4 |
1% |
7 |
2% |
R/DS to 5 |
1 |
0% |
0 |
0% |
0 |
0% |
0 |
0% |
Total GBMSM |
443 |
100% |
402 |
100% |
334 |
100% |
310 |
100% |

Figure 3C - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
Susceptible to all |
98 |
40% |
96 |
38% |
74 |
43% |
49 |
26% |
R/DS to 1 |
96 |
39% |
83 |
33% |
44 |
26% |
59 |
32% |
R/DS to 2 |
27 |
11% |
35 |
14% |
34 |
20% |
69 |
37% |
R/DS to 3 |
21 |
9% |
20 |
8% |
12 |
7% |
7 |
4% |
R/DS to 4 |
3 |
1% |
18 |
7% |
6 |
4% |
1 |
1% |
R/DS to 5 |
0 |
0% |
1 |
0% |
1 |
1% |
0 |
0% |
Total heterosexual males |
245 |
100% |
253 |
100% |
171 |
100% |
185 |
100% |

Figure 3D - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
Susceptible to all |
22 |
16% |
30 |
24% |
28 |
35% |
9 |
38% |
R/DS to 1 |
43 |
31% |
31 |
25% |
25 |
32% |
7 |
29% |
R/DS to 2 |
28 |
20% |
39 |
31% |
23 |
29% |
6 |
25% |
R/DS to 3 |
26 |
19% |
19 |
15% |
2 |
3% |
2 |
8% |
R/DS to 4 |
13 |
9% |
5 |
4% |
1 |
1% |
0 |
0% |
R/DS to 5 |
7 |
5% |
0 |
0% |
0 |
0% |
0 |
0% |
Total males with unknown sexual behaviour |
139 |
100% |
124 |
100% |
79 |
100% |
24 |
100% |

Figure 3E - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
Susceptible to all antibiotics tested |
64 |
34% |
84 |
39% |
49 |
39% |
40 |
33% |
R/DS to 1 |
84 |
44% |
78 |
36% |
53 |
42% |
36 |
30% |
R/DS to 2 |
26 |
14% |
29 |
13% |
14 |
11% |
35 |
29% |
R/DS to 3 |
12 |
6% |
16 |
7% |
5 |
4% |
9 |
8% |
R/DS to 4 |
5 |
3% |
9 |
4% |
4 |
3% |
0 |
0% |
R/DS to 5 |
0 |
0% |
1 |
0% |
1 |
1% |
0 |
0% |
Total female |
191 |
100% |
217 |
100% |
126 |
100% |
120 |
100% |
- Note de bas de page a
-
GC cultures were tested for resistance to azithromycin, ciprofloxacin, erythromycin, penicillin, spectinomycin and tetracycline and decreased susceptibility to cefixime and ceftriaxone.
4.3.4.b. AzithromycinR, cefiximeDS, and ceftriaxoneDS among all ESAG cultures and by sex/sexual behaviour
From 2018 to 2021, no cultures demonstrated azithromycinR and cefiximeDS or azithromycinR and ceftriaxoneDS (the most recommended and prescribed antimicrobial regimens) (Table 10). In general, azithromycinR, cefiximeDS, and ceftriaxoneDS prevalence was low across the reporting years (Figure 4A). From 2018 to 2020, the prevalence of cefiximeDS was <1% and stable. However, from 2020 to 2021, the number (and proportion) of ESAG cultures demonstrating cefiximeDS increased nearly threefold from six (0.8%) in 2020 to 22 (3.4%) in 2021. In contrast, cultures demonstrating ceftriaxoneDS declined in number and proportion from 8 (0.8%) in 2018 to one (0.2%) in 2021. The frequency of cultures that demonstrated azithromycinR increased from 18 (1.8%) in 2018 to 78 (7.8%) in 2019. However, this number decreased sharply to eight (1.1%) in 2020 and 12 (1.9%) in 2021.
Figure 4B, 4C, 4D, 4E shows a close-up of the within group proportions of azithromycinR, cefiximeDS and ceftriaxoneDS by sex/sexual behaviour. From 2018 to 2019, the prevalence of azithromycinR cultures increased, but this was followed by a sharp decline in azithromycinR prevalence in 2020 and 2021 among GBMSM (3.2% in 2018, 14.2% in 2019, 1.2% in 2020, 2.6% in 2021), heterosexual males (0.8% in 2018, 2.8% in 2019, 1.8% in 2020, 0.5% 2021) and females (0.0% in 2018, 4.1% in 2019, 0.8% in 2020, 0.0% in 2021).) In contrast, the prevalence of azithromycinR in cultures isolated from males with unknown behaviour was very low from 2018 to 2020 but then increased from 0.0% in 2020 to 12.5% (3/24 cases) in 2021.
The within sex/sexual behaviour group prevalence of ceftriaxoneDS, was very low, <0.9%, for all years, except in 2018, when the proportion was 5.0% in cultures isolated from males with unknown sexual behaviour. The prevalence of cefiximeDS was also relatively low (<5%) for all sex/sexual behaviour groups, but there was a trend of increasing cefiximeDS across the years among GBMSM (0.2% in 2018 to 4.5% in 2021), heterosexual males (0.0% in 2018 to 2.2% in 2021) and females (0.0% in 2018 to 3.3% in 2021) but not among males with unknown sexual behaviour.
Among cases who identified as transgender or were of unknown or other gender/sex, there were no cultures identified as azithromycinR, cefiximeDS or ceftriaxoneDS (results not shown).
Figure 4. Proportion of ESAG cases with cultures demonstrating resistance (R) to azithromycin or decreased susceptibility (DS)Note de bas de page a to cefixime and ceftriaxone, among all ESAG cases and by sex/sexual behaviour, 2018 to 2021

Figure 4A - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
CefiximeDS |
1 |
0.1% |
3 |
0.3% |
6 |
0.8% |
22 |
3.4% |
CeftriaxoneDS |
8 |
0.8% |
3 |
0.3% |
2 |
0.3% |
1 |
0.2% |
AzithromycinR |
18 |
1.8% |
78 |
7.8% |
8 |
1.1% |
12 |
1.9% |

Figure 4B - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
CefiximeDS |
1 |
0.2% |
0 |
0.0% |
4 |
1.2% |
14 |
4.5% |
CeftriaxoneDS |
1 |
0.2% |
0 |
0.0% |
1 |
0.3% |
0 |
0.0% |
AzithromycinR |
14 |
3.2% |
57 |
14.2% |
4 |
1.2% |
8 |
2.6% |

Figure 4C - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
CefiximeDS |
0 |
0.0% |
1 |
0.4% |
1 |
0.6% |
4 |
2.2% |
CeftriaxoneDS |
0 |
0.0% |
1 |
0.4% |
0 |
0.0% |
0 |
0.0% |
AzithromycinR |
2 |
0.8% |
7 |
2.8% |
3 |
1.8% |
1 |
0.5% |

Figure 4D - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
CefiximeDS |
0 |
0.0% |
1 |
0.8% |
0 |
0.0% |
0 |
0.0% |
CeftriaxoneDS |
7 |
5.0% |
1 |
0.8% |
1 |
1.3% |
0 |
0.0% |
AzithromycinR |
2 |
1.4% |
4 |
3.2% |
0 |
0.0% |
3 |
12.5% |

Figure 4E - Text description
2018 | 2019 | 2020 | 2021 | |||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
CefiximeDS |
0 |
0.0% |
1 |
0.5% |
1 |
0.8% |
4 |
3.3% |
CeftriaxoneDS |
0 |
0.0% |
1 |
0.5% |
0 |
0.0% |
1 |
0.8% |
AzithromycinR |
0 |
0.0% |
9 |
4.1% |
1 |
0.8% |
0 |
0.0% |
- Note de bas de page a
-
R/DS: Resistant or decreased susceptibility.
Note: Red dashed line represents the World Health Organization (WHO) threshold of AMR-GC concern ≥5%: Resistance level at which WHO recommends that the use of an antimicrobial in empiric treatment is discontinued.Footnote 20
Antimicrobial R/DS | 2018 | 2019 | 2020 | 2021 | Total | ||||
---|---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | n | |
AzithromycinR + CefiximeDS |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
AzithromycinR + CeftriaxoneDS |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
CefiximeDS + CeftriaxoneDS |
1 |
0.1% |
3 |
0.3% |
1 |
0.1% |
1 |
0.2% |
6 |
Total |
1 |
3 |
1 |
1 |
6 |
||||
|
4.3.4.c. The most prevalent resistant antimicrobials and other antimicrobial resistance trends among all ESAG cases and by sex/sexual behaviour
Among all ESAG cultures, between 2018 and 2020, of all the tested antimicrobials, ciprofloxacin resistance (ciprofloxacinR) was most prevalent at 46.6% in 2020 increasing to 63.1% in 2021, followed by tetracycline resistance (tetracyclineR) at 45.9% in 2020 and 58.6% in 2021 (Figure 3A). Prior to this, tetracyclineR was most prevalent at 52.1% in 2018 and 51.8% in 2019, followed by ciprofloxacinR. Erythromycin resistance (erythroymicR) has declined annually and sharply from 30.0% in 2018 to 8.5% in 2021. Penicillin resistance rates were relatively stable from 2018 to 2020 (6.8% in 2018, 7.2% in 2019 and 8.2% in 2020) but dropped to 3.9% in 2021.
By sex and sexual behaviour (Fig 3B, 3C, 3D, 3E), in 2021, the within group proportions of ciprofloxacinR and tetracyclineR were highest among cultures collected from GBMSM (77.7% ciprofloxacin; 68.7% tetracycline; increasing proportions over time), heterosexual males (58.4% ciprofloxacin; 51.9% tetracycline) and females (44.2% ciprofloxacin; 46.7% tetracycline). ErythromycinR was most prevalent in cultures isolated from males with unknown sexual behaviour (this group has showed sharp declines in the prevalence of ciprofloxacinR and tetracyclineR over time). Antimicrobial resistance was similar by infection site among GBMSM and other adults (supplementary appendix G).
4.3.5. Case characteristics and sequence types of ESAG cases with cultures demonstrating azithromycinR, cefiximeDS, or ceftriaxoneDS, 2018 to 2021
4.3.5.a. Case characteristics and sequence types of ESAG cases with cultures demonstrating azithromycinR
Between 2018 and 2021, there were 116 ESAG cases with N. gonorrhoeae cultures demonstrating azithromycinR (Table 11). Most of these cultures were collected from males (90.5%, (105/116)); of which, 79.0% (83) were GBMSM, 34.6% (44) were 30-39 years old, and 61.9% (65) reported anogenital infections. One case (1.3%, 1/78), in 2019, was reported as a suspected treatment failure. Most cases were observed in 2019 (78/116, 67.2% of total isolates with azithromycinR).
2018 | 2019 | 2020 | 2021 | Total | ||||||
---|---|---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | n | % | |
Isolates with azithromycinR |
18 |
1.8% |
78 |
7.8% |
8 |
1.1% |
12 |
1.9% |
116 |
3.4% |
Total isolates |
1022 |
100.0% |
999 |
100.0% |
711 |
100.0% |
645 |
100.0% |
3377 |
100.0% |
Sequence type (ST) | ||||||||||
ST-12302 |
4 |
22.20% |
33 |
42.30% |
3 |
37.50% |
0 |
0.00% |
40 |
34.5% |
ST-16288 |
3 |
16.70% |
20 |
25.60% |
1 |
12.50% |
0 |
0.00% |
24 |
20.7% |
ST-3935 |
1 |
5.60% |
5 |
6.40% |
0 |
0.00% |
0 |
0.00% |
6 |
5.2% |
ST-11508 |
0 |
0.00% |
2 |
2.60% |
0 |
0.00% |
2 |
16.70% |
4 |
3.4% |
ST-11724 |
0 |
0.00% |
0 |
0.00% |
0 |
0.00% |
4 |
33.30% |
4 |
3.4% |
ST-14698 |
3 |
16.70% |
1 |
1.30% |
0 |
0.00% |
0 |
0.00% |
4 |
3.4% |
ST-4357 |
1 |
5.60% |
2 |
2.60% |
0 |
0.00% |
0 |
0.00% |
3 |
1.7% |
STs not listed (≤ 2 or unknown)Footnote a |
6 |
33.30% |
15 |
23.10% |
4 |
50.00% |
6 |
50.00% |
31 |
19.0% |
Total AzithromycinR |
18 |
100.0% |
78 |
100.0% |
8 |
100.0% |
12 |
100.0% |
116 |
100.0% |
Sex | ||||||||||
Male |
18 |
100.0% |
68 |
87.2% |
7 |
87.5% |
12 |
100.0% |
105 |
90.5% |
Female |
0 |
0.0% |
9 |
11.5% |
1 |
12.5% |
0 |
0.0% |
10 |
8.6% |
Total AzithromycinR |
18 |
100.0% |
78 |
100.0% |
8 |
100.0% |
12 |
100.0% |
116 |
100.0% |
Male sexual behaviour | ||||||||||
GBMSM |
14 |
77.8% |
57 |
83.8% |
4 |
57.1% |
8 |
66.7% |
83 |
79.0% |
Heterosexual male |
2 |
11.1% |
7 |
10.3% |
3 |
42.9% |
1 |
8.3% |
13 |
12.4% |
Male unknown |
2 |
11.1% |
4 |
5.1% |
0 |
0.0% |
3 |
25.0% |
9 |
8.6% |
Total Male AzithromycinR |
18 |
100.0% |
68 |
100.0% |
7 |
100.0% |
12 |
100.0% |
105 |
100.0% |
Female sexual behaviour | ||||||||||
Sex with both male and female |
0 |
0.0% |
1 |
11.1% |
0 |
0.0% |
0 |
0.0% |
1 |
10.0% |
Sex with female |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Sex with male |
0 |
0.0% |
4 |
44.4% |
1 |
100.0% |
0 |
0.0% |
5 |
50.0% |
Unknown |
0 |
0.0% |
4 |
44.4% |
0 |
0.0% |
0 |
0.0% |
4 |
40.0% |
Total Female AzithromycinR |
0 |
0.0% |
9 |
100.0% |
1 |
100.0% |
0 |
0.0% |
10 |
100.0% |
Sex and Age | ||||||||||
Male (years old) | ||||||||||
< 20 |
0 |
0.0% |
1 |
1.5% |
0 |
0.0% |
0 |
0.0% |
1 |
1.0% |
20-29 |
6 |
33.3% |
23 |
33.8% |
2 |
28.6% |
5 |
41.7% |
36 |
25.0% |
30-39 |
8 |
44.4% |
26 |
38.2% |
4 |
57.1% |
6 |
50.0% |
44 |
34.6% |
40-49 |
4 |
22.2% |
12 |
17.6% |
0 |
0.0% |
1 |
8.3% |
17 |
12.5% |
50-59 |
0 |
0.0% |
6 |
8.8% |
1 |
14.3% |
0 |
0.0% |
7 |
6.7% |
60+ |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Total Male AzithromycinR |
18 |
100.0% |
68 |
100.0% |
7 |
100.0% |
12 |
100.0% |
105 |
100.0% |
Female (years old) | ||||||||||
< 20 |
0 |
0.0% |
3 |
33.3% |
0 |
0.0% |
0 |
0.0% |
3 |
33.3% |
20-29 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
30-39 |
0 |
0.0% |
3 |
33.3% |
1 |
100.0% |
0 |
0.0% |
4 |
44.4% |
40-49 |
0 |
0.0% |
1 |
11.1% |
0 |
0.0% |
0 |
0.0% |
1 |
11.1% |
50-59 |
0 |
0.0% |
2 |
22.2% |
0 |
0.0% |
0 |
0.0% |
2 |
11.1% |
60+ |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Total Female AzithromycinR |
0 |
0.0% |
9 |
100.0% |
1 |
100.0% |
0 |
0.0% |
10 |
100.0% |
Infection type | ||||||||||
Male | ||||||||||
Anogenital |
10 |
55.6% |
45 |
66.2% |
5 |
71.5% |
5 |
41.7% |
65 |
61.9% |
Pharyngeal |
8 |
44.4% |
23 |
33.8% |
2 |
28.5% |
5 |
41.7% |
38 |
36.2% |
Unspecified |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
2 |
16.7% |
2 |
1.9% |
Total Male AzithromycinR |
18 |
100.0% |
68 |
100.0% |
7 |
100.0% |
12 |
100.0% |
105 |
100.0% |
Female | ||||||||||
Anogenital |
0 |
0.0% |
5 |
55.5% |
0 |
0.0% |
0 |
0.0% |
5 |
50.0% |
Pharyngeal |
0 |
0.0% |
3 |
33.3% |
1 |
12.5% |
0 |
0.0% |
4 |
40.0% |
Unspecified |
0 |
0.0% |
1 |
11.1% |
0 |
0.0% |
0 |
0.0% |
1 |
10.0% |
Total Female AzithromycinR |
0 |
0% |
9 |
100.0% |
1 |
100.0% |
0 |
0.0% |
10 |
100.0% |
Province or territory | ||||||||||
Alberta |
13 |
72.2% |
67 |
85.9% |
8 |
100.0% |
9 |
75.0% |
97 |
83.6% |
Manitoba |
3 |
16.7% |
7 |
9.0% |
0 |
0.0% |
3 |
25.0% |
13 |
11.2% |
Nova Scotia |
2 |
11.1% |
4 |
5.1% |
0 |
0.0% |
0 |
0.0% |
6 |
5.2% |
Northwest territories |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Total AzithromycinR |
18 |
100.0% |
78 |
100.0% |
8 |
100.0% |
12 |
100.0% |
116 |
100.0% |
Suspected treatment failureFootnote b | ||||||||||
Yes |
0 |
0.0% |
1 |
1.3% |
0 |
0.0% |
0 |
0.0% |
1 |
0.9% |
No |
18 |
100.0% |
77 |
98.7% |
8 |
100.0% |
12 |
100.0% |
115 |
98.3% |
Total AzithromycinR |
18 |
100.0% |
78 |
100.0% |
8 |
100.0% |
12 |
100.0% |
116 |
100.0% |
|
There were 31 typable sequence types with azithromycinR identified between 2018 and 2021 (supplementary appendix H). Table 11 and Figure 5 shows the seven most common sequence types (STs) (i.e., STs associated with azithromycinR in more than two ESAG cases). The most identified NG-MAST ST was ST-12302, followed by ST-16288. These two STs accounted for 85.2% of all azithromycinR cases from 2018 to 2021 (Table 11).
In 2018, ST-16288 and ST-12302 were identified in 83 and 40 isolates, respectively (Figure 5). However, only 4% and 10% of these isolates, respectively, were identified as azithromycinR. In 2019, these STs were identified much less frequently (in 16 and 24 isolates, respectively); however, the majority of these isolates demonstrated azithromycinR (75.0% and 92.0%, respectively). The prevalence of these STs dwindled in 2020 to four and eight isolates, respectively, in 2020 and zero in 2021.
In 2021, ST-11724 was identified for the first time (since 2018) in only four isolates but 100.0% of these isolates were azithromycinR. ST-11508 (in the top ten STs identified among ESAG cases in 2019, 2020 and 2021) was present in all reporting years, but it was only in 2019 and 2021 that the ST demonstrated azithromycinR in 6.7% (2/30) and 18.2% (2/11) of isolates with this ST, respectively. All other STs associated with azithromycinR occurred infrequently and varied highly by year (Figure 5).

Figure 5 - Text description
Year | ST | AzithromycinR | Total | % |
---|---|---|---|---|
2018 |
ST-12302 |
4 |
40 |
10% |
ST-16288 |
3 |
83 |
4% |
|
ST-3935 |
1 |
6 |
17% |
|
ST-11508 |
0 |
6 |
0% |
|
ST-11724 |
0 |
0 |
0% |
|
ST-14698 |
3 |
10 |
30% |
|
ST-17283 |
2 |
3 |
67% |
|
2019 |
ST-12302 |
22 |
24 |
92% |
ST-16288 |
12 |
16 |
75% |
|
ST-3935 |
5 |
6 |
83% |
|
ST-11508 |
2 |
30 |
7% |
|
ST-11724 |
0 |
0 |
0% |
|
ST-14698 |
1 |
1 |
100% |
|
ST-17283 |
0 |
0 |
0% |
|
2020 |
ST-12302 |
3 |
8 |
38% |
ST-16288 |
1 |
4 |
25% |
|
ST-3935 |
0 |
3 |
0% |
|
ST-11508 |
0 |
46 |
0% |
|
ST-11724 |
0 |
0 |
0% |
|
ST-14698 |
0 |
0 |
0% |
|
ST-17283 |
0 |
0 |
0% |
|
2021 |
ST-12302 |
0 |
0 |
0% |
ST-16288 |
0 |
0 |
0% |
|
ST-3935 |
0 |
2 |
0% |
|
ST-11508 |
2 |
11 |
18% |
|
ST-11724 |
4 |
4 |
100% |
|
ST-14698 |
0 |
0 |
0% |
|
ST-17283 |
0 |
0 |
0% |
Note: This figure shows the most frequently observed STs associated with AzithromycinR (among all ESAG isolates collected from 2018 to 2021), for a given calendar year. The total number of ESAG cultures with a given ST is shown in grey and the number of isolates (for a given ST) with AzithromycinR are shown in yellow. The data labels on the bars are the proportion of isolates that demonstrated AzithromycinR for each ST.
4.3.5.b. Case characteristics and sequence types of ESAG cases with cultures demonstrating cefiximeDS
Between 2018 and 2021, there were 32 ESAG cases with GC cultures demonstrating cefiximeDS (Table 12). Among these, 81.3% (26) of cultures were collected from males, of which 73.1% (19) were GBMSM and 23.1% (6) were heterosexual. Therefore, the burden of cefiximeDS was slightly higher among GBMSM compared to baseline ESAG characteristics. Of the six (18.8%) female cases with cultures demonstrating cefiximeDS, five (83.3%) were females who had sex with males. CefiximeDS was most frequently observed among males 30-39 years old (38.5%, 10 cases) and 40-49 years old (26.9%, 7 cases) and females between 20-29 years old (50.0%). The primary infection site varied between males and females; among male cases with cefiximeDS cultures, 18 (69.2%) reported an anogenital infection, while five female cases (83.3%) reported a pharyngeal infection.
Of the 11 NG-MAST STs associated with cefiximeDS, ST-17261 was identified most frequently. It was first observed in cultures from four ESAG cultures in 2020, which accounted for 66.7% of the cefiximeDS cultures typed in 2020. In 2021, it was observed in 11 cultures (50.0% of the cefiximeDS cultures typed in that year) (Table 12). However, among the 94 isolates (out of 3,377 isolates) with the ST-17261, cefiximeDS was detected in zero cultures in 2018, 9.5% (4/42) in 2020 and 22.4% (11/49) in 2021 (Figure 6). All other STs associated with cefiximeDS occurred infrequently and varied highly by year.
2018 | 2019 | 2020 | 2021 | Total | ||||||
---|---|---|---|---|---|---|---|---|---|---|
n | % | n | % | n | n | % | n | % | n | |
Isolates with cefiximeDS |
1 |
0.1% |
3 |
0.3% |
6 |
80.0% |
22 |
410.0% |
32 |
0.9% |
Total isolates |
1022 |
100.0% |
999 |
100.0% |
711 |
100.0% |
645 |
100.0% |
3377 |
100.0% |
Sequence type | ||||||||||
ST-17261 |
0 |
0.0% |
0 |
0.0% |
4 |
66.7% |
11 |
50.0% |
15 |
46.9% |
ST-16639 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
4 |
18.2% |
4 |
12.5% |
ST-5308 |
1 |
100.0% |
2 |
66.7% |
0 |
0.0% |
0 |
0.0% |
3 |
9.4% |
ST-19757 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
2 |
9.1% |
2 |
6.3% |
ST-nontypeable |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
4.5% |
1 |
3.1% |
ST-11477 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
4.5% |
1 |
3.1% |
ST-19921 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
4.5% |
1 |
3.1% |
ST-10451 |
0 |
0.0% |
0 |
0.0% |
1 |
16.7% |
0 |
0.0% |
1 |
3.1% |
ST-6778 |
0 |
0.0% |
1 |
33.3% |
0 |
0.0% |
0 |
0.0% |
1 |
3.1% |
ST-19810 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
4.5% |
1 |
3.1% |
ST-17267 |
0 |
0.0% |
0 |
0.0% |
1 |
16.7% |
0 |
0.0% |
1 |
3.1% |
ST-19820 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
4.5% |
1 |
3.1% |
Total CefiximeDS |
1 |
100.0% |
3 |
100.0% |
6 |
100.0% |
22 |
100.0% |
32 |
100.0% |
Sex | ||||||||||
Male |
1 |
100.0% |
2 |
66.7% |
5 |
83.3% |
18 |
81.8% |
26 |
81.3% |
Female |
0 |
0.0% |
1 |
33.3% |
1 |
16.7% |
4 |
18.2% |
6 |
18.8% |
Total CefiximeDS |
1 |
100.0% |
3 |
100.0% |
6 |
100.0% |
22 |
100.0% |
32 |
100.0% |
Male sexual behaviour | ||||||||||
GBMSM |
1 |
100.0% |
0 |
0.0% |
4 |
80.0% |
14 |
77.8% |
19 |
73.1% |
Heterosexual male |
0 |
0.0% |
1 |
50.0% |
1 |
20.0% |
4 |
22.2% |
6 |
23.1% |
Male unknown |
0 |
0.0% |
1 |
50.0% |
0 |
0.0% |
0 |
0.0% |
1 |
3.8% |
Total Male CefiximeDS |
1 |
100.0% |
2 |
100.0% |
5 |
100.0% |
18 |
100.0% |
26 |
100.0% |
Female sexual behaviour | ||||||||||
Sex with both male and female |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
25.0% |
1 |
16.7% |
Sex with female |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Sex with male |
0 |
0.0% |
1 |
100.0% |
1 |
100.0% |
3 |
75.0% |
5 |
83.3% |
Female unknown |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Total Female CefiximeDS |
0 |
0.0% |
1 |
100.0% |
1 |
100.0% |
4 |
100.0% |
6 |
100.0% |
Sex and Age | ||||||||||
Male (years old) | ||||||||||
< 20 |
0 |
0.0% |
1 |
33.3% |
0 |
0.0% |
0 |
0.0% |
1 |
3.8% |
20-29 |
1 |
100.0% |
0 |
0.0% |
1 |
20.0% |
3 |
16.7% |
5 |
19.2% |
30-39 |
0 |
0.0% |
0 |
0.0% |
2 |
40.0% |
8 |
44.4% |
10 |
38.5% |
40-49 |
0 |
0.0% |
1 |
33.3% |
2 |
40.0% |
4 |
22.2% |
7 |
26.9% |
50-59 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
2 |
11.1% |
2 |
7.7% |
60+ |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
5.6% |
1 |
3.8% |
Total Male CefiximeDS |
1 |
100.0% |
2 |
66.7% |
5 |
100.0% |
18 |
100.0% |
26 |
100.0% |
Female (years old) | ||||||||||
< 20 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
20-29 |
0 |
0.0% |
1 |
33.3% |
0 |
0.0% |
2 |
50.0% |
3 |
50.0% |
30-39 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
2 |
50.0% |
2 |
33.3% |
40-49 |
0 |
0.0% |
0 |
0.0% |
1 |
100.0% |
0 |
0.0% |
1 |
16.7% |
50-59 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
60+ |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Total Female CefiximeDS |
0 |
0.0% |
1 |
33.3% |
1 |
100.0% |
4 |
100.0% |
6 |
100.0% |
Infection type | ||||||||||
Male | ||||||||||
Anogenital |
0 |
0.0% |
2 |
100.0% |
3 |
60.0% |
13 |
72.2% |
18 |
69.2% |
Pharyngeal |
1 |
100.0% |
0 |
0.0% |
2 |
40.0% |
5 |
27.8% |
8 |
30.8% |
Total Male CefiximeDS |
1 |
100.0% |
2 |
100.0% |
5 |
100.0% |
18 |
100.0% |
26 |
100.0% |
Female | ||||||||||
Anogenital |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
25.0% |
1 |
16.7% |
Pharyngeal |
0 |
0.0% |
1 |
100.0% |
1 |
100.0% |
3 |
75.0% |
5 |
83.3% |
Total Female CefiximeDS |
0 |
0.0% |
1 |
100.0% |
1 |
100.0% |
4 |
100.0% |
6 |
100.0% |
Province or territory | ||||||||||
Alberta |
1 |
100.0% |
2 |
66.7% |
6 |
100.0% |
22 |
100.0% |
31 |
96.9% |
Manitoba |
0 |
0.0% |
1 |
33.3% |
0 |
0.0% |
0 |
0.0% |
1 |
3.1% |
Nova Scotia |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Northwest territories |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Total CefiximeDS |
1 |
100.0% |
3 |
100.0% |
6 |
100.0% |
22 |
100.0% |
32 |
100.0% |
Suspected treatment failureFootnote a | ||||||||||
Yes |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
No |
1 |
100.0% |
3 |
100.0% |
6 |
100.0% |
22 |
100.0% |
32 |
100.0% |
Total CefiximeDS |
1 |
100.0% |
3 |
100.0% |
6 |
100.0% |
22 |
100.0% |
32 |
100.0% |
|

Figure 6 - Text description
Year | ST | CefiximeDS | Total | % |
---|---|---|---|---|
2018 |
ST-17261 |
0 |
3 |
0% |
ST-16639 |
0 |
0 |
0% |
|
ST-5308 |
1 |
1 |
100% |
|
ST-19757 |
0 |
0 |
0% |
|
ST-nontypeable |
0 |
0 |
0% |
|
ST-11477 |
0 |
0 |
0% |
|
ST-19921 |
0 |
0 |
0% |
|
ST-10451 |
0 |
29 |
0% |
|
ST-6778 |
0 |
0 |
0% |
|
ST-19810 |
0 |
0 |
0% |
|
ST-17267 |
0 |
0 |
0% |
|
ST-19820 |
0 |
0 |
0% |
|
2019 |
ST-17261 |
0 |
0 |
0% |
ST-16639 |
0 |
0 |
0% |
|
ST-5308 |
1 |
1 |
100% |
|
ST-19757 |
0 |
0 |
0% |
|
ST-nontypeable |
0 |
0 |
0% |
|
ST-11477 |
0 |
0 |
0% |
|
ST-19921 |
0 |
0 |
0% |
|
ST-10451 |
0 |
34 |
0% |
|
ST-6778 |
1 |
1 |
100% |
|
ST-19810 |
0 |
0 |
0% |
|
ST-17267 |
0 |
0 |
0% |
|
ST-19820 |
0 |
0 |
0% |
|
2020 |
ST-17261 |
4 |
42 |
10% |
ST-16639 |
0 |
0 |
0% |
|
ST-5308 |
0 |
0 |
0% |
|
ST-19757 |
0 |
4 |
0% |
|
ST-nontypeable |
0 |
0 |
0% |
|
ST-11477 |
0 |
10 |
0% |
|
ST-19921 |
0 |
0 |
0% |
|
ST-10451 |
1 |
31 |
3% |
|
ST-6778 |
0 |
0 |
0% |
|
ST-19810 |
0 |
0 |
0% |
|
ST-17267 |
1 |
1 |
100% |
|
ST-19820 |
0 |
0 |
0% |
|
2021 |
ST-17261 |
11 |
49 |
22% |
ST-16639 |
4 |
5 |
80% |
|
ST-5308 |
0 |
0 |
0% |
|
ST-19757 |
2 |
16 |
13% |
|
ST-nontypeable |
1 |
13 |
8% |
|
ST-11477 |
1 |
114 |
1% |
|
ST-19921 |
1 |
1 |
100% |
|
ST-10451 |
0 |
1 |
0% |
|
ST-6778 |
0 |
0 |
0% |
|
ST-19810 |
1 |
1 |
100% |
|
ST-17267 |
0 |
0 |
0% |
|
ST-19820 |
1 |
2 |
50% |
Note: This figure shows STs associated with cefiximeDS (among all ESAG isolates collected from 2018 to 2021), for a given calendar year. The total number of ESAG cultures with a given ST is shown in grey and the number of isolates (for a given ST) with cefiximeDS are shown in yellow. The data labels on the bars are the proportion of isolates that demonstrated cefiximeDS for each ST.
4.3.5.c. Case characteristics and sequence types of ESAG cases with cultures demonstrating ceftriaxoneDS
From 2018 to 2021, the proportion of ESAG GC cultures demonstrating ceftriaxoneDS declined annually from 0.8% (8/1022) in 2018 to 0.2% (1/645) in 2021 (period average of 0.4% (14/3377)) (Table 13). Of the 14 ceftriaxoneDS cultures, 12 (85.7%) were collected from males. Most of these male cases (9, 75.0%) had an unknown sexual behaviour and a primary anogenital infection site (7, 58.3%), and were 20-29 years old (6, 50.0%). No cases were attributed to treatment failures (Table 13).
There were six NG-MAST STs identified among ESAG cultures demonstrating ceftriaxoneDS between 2018 and 2021. ST-7856 was identified most frequently and accounted for half (average of 50.0%; 7/14) of ceftriaxoneDS cases (all were from 2018) (Table 13). Among all 27 (out of 3,377 cases) ESAG isolates identified as ST-7856 (only identified in the years 2018 and 2020), 26.0% (7/27) demonstrated ceftriaxoneDS in 2018 and zero in 2020 (Figure 7). All other STs associated with ceftriaxoneDS occurred infrequently and varied highly by year (Figure 7).
2018 | 2019 | 2020 | 2021 | Total | ||||||
---|---|---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | n | % | |
Isolates with ceftriaxoneDS |
8 |
0.8% |
3 |
0.3% |
2 |
0.3% |
1 |
0.2% |
14 |
0.4% |
Total isolates |
1022 |
100.0% |
999 |
100.0% |
711 |
100.0% |
645 |
100.0% |
3377 |
100.0% |
Sequence type | ||||||||||
ST-7856 |
7 |
87.5% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
7 |
50.0% |
ST-5308 |
1 |
12.5% |
2 |
66.7% |
0 |
0.0% |
0 |
0.0% |
3 |
21.4% |
ST-6778 |
0 |
0.0% |
1 |
33.3% |
0 |
0.0% |
0 |
0.0% |
1 |
7.1% |
ST-16639 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
100.0% |
1 |
7.1% |
ST-10386 |
0 |
0.0% |
0 |
0.0% |
1 |
50.0% |
0 |
0.0% |
1 |
7.1% |
ST-17261 |
0 |
0.0% |
0 |
0.0% |
1 |
50.0% |
0 |
0.0% |
1 |
7.1% |
Total CeftriaxoneDS |
8 |
100.0% |
3 |
100.0% |
2 |
100.0% |
1 |
100.0% |
14 |
100.0% |
Sex | ||||||||||
Male |
8 |
100.0% |
2 |
100.0% |
2 |
100.0% |
0 |
0.0% |
12 |
85.7% |
Female |
0 |
0.0% |
1 |
33.3% |
0 |
0.0% |
1 |
100.0% |
2 |
14.3% |
Total CeftriaxoneDS |
8 |
100.0% |
3 |
100.0% |
2 |
100.0% |
1 |
100.0% |
14 |
100.0% |
Male sexual behaviour | ||||||||||
GBMSM |
1 |
12.5% |
0 |
0.0% |
1 |
50.0% |
0 |
0.0% |
2 |
16.7% |
Heterosexual male |
0 |
0.0% |
1 |
50.0% |
0 |
0.0% |
0 |
0.0% |
1 |
8.3% |
Male unknown |
7 |
87.5% |
1 |
50.0% |
1 |
50.0% |
0 |
0.0% |
9 |
75.0% |
Total Male CeftriaxoneDS |
8 |
100.0% |
2 |
100.0% |
2 |
100.0% |
0 |
0.0% |
12 |
100.0% |
Female sexual behaviour | ||||||||||
Sex with both male and female |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Sex with female |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Sex with male |
0 |
0.0% |
1 |
0.0% |
0 |
0.0% |
1 |
100.0% |
2 |
100.0% |
Female unknown |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Total Female CeftriaxoneDS |
0 |
0.0% |
1 |
0.0% |
0 |
0.0% |
1 |
100.0% |
2 |
100.0% |
Sex and Age |
||||||||||
Male | ||||||||||
< 20 |
0 |
0.0% |
1 |
50.0% |
0 |
0.0% |
0 |
0.0% |
1 |
8.3% |
20-29 |
6 |
75.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
6 |
50.0% |
30-39 |
0 |
0.0% |
0 |
0.0% |
1 |
50.0% |
0 |
0.0% |
1 |
8.3% |
40-49 |
2 |
25.0% |
1 |
50.0% |
1 |
50.0% |
0 |
0.0% |
4 |
33.3% |
50-59 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
60+ |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Total Male CeftriaxoneDS |
8 |
100.0% |
2 |
100.0% |
2 |
100.0% |
0 |
0.0% |
12 |
100.0% |
Female | ||||||||||
< 20 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
20-29 |
0 |
0.0% |
1 |
100.0% |
0 |
0.0% |
1 |
100.0% |
2 |
100.0% |
30-39 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
40-49 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
50-59 |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
60+ |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Total Female CeftriaxoneDS |
0 |
0.0% |
1 |
0.0% |
0 |
0.0% |
1 |
100.0% |
2 |
100.0% |
Infection type |
||||||||||
Male | ||||||||||
Anogenital |
4 |
50.0% |
2 |
100.0% |
1 |
50.0% |
0 |
0.0% |
7 |
58.3% |
Pharyngeal |
4 |
50.0% |
0 |
0.0% |
1 |
50.0% |
0 |
0.0% |
5 |
41.7% |
Total Male CeftriaxoneDS |
8 |
100.0% |
2 |
100.0% |
2 |
100.0% |
0 |
0.0% |
12 |
100.0% |
Female | ||||||||||
Anogenital |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
100.0% |
1 |
50.0% |
Pharyngeal |
0 |
0.0% |
1 |
0.0% |
0 |
0.0% |
0 |
0.0% |
1 |
50.0% |
Total Female CeftriaxoneDS |
0 |
0.0% |
1 |
0.0% |
0 |
0.0% |
1 |
100.0% |
2 |
100.0% |
Province or territory | ||||||||||
Alberta |
1 |
12.5% |
2 |
66.7% |
1 |
50.0% |
1 |
100.0% |
5 |
35.7% |
Manitoba |
7 |
87.5% |
1 |
33.3% |
1 |
50.0% |
0 |
0.0% |
9 |
64.3% |
Nova Scotia |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Northwest territories |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
Total CeftriaxoneDS |
8 |
100.0% |
3 |
100.0% |
2 |
100.0% |
1 |
100.0% |
14 |
100.0% |
Suspected treatment failureFootnote a | ||||||||||
Yes |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
0 |
0.0% |
No |
8 |
100.0% |
2 |
66.7% |
2 |
100.0% |
1 |
100.0% |
13 |
92.9% |
Total CeftriaxoneDS |
8 |
100.0% |
3 |
100.0% |
2 |
100.0% |
1 |
100.0% |
14 |
100.0% |
|

Figure 7 - Text description
Year | ST | CeftriaxoneDS | Total | % |
---|---|---|---|---|
2018 |
ST-7856 |
7 |
27 |
26% |
ST-5308 |
1 |
1 |
100% |
|
ST-6778 |
0 |
0 |
0% |
|
ST-16639 |
0 |
0 |
0% |
|
ST-10386 |
0 |
0 |
0% |
|
ST-17261 |
0 |
3 |
0% |
|
2019 |
ST-7856 |
0 |
0 |
0% |
ST-5308 |
1 |
1 |
100% |
|
ST-6778 |
1 |
1 |
100% |
|
ST-16639 |
0 |
0 |
0% |
|
ST-10386 |
0 |
0 |
0% |
|
ST-17261 |
0 |
0 |
0% |
|
2020 |
ST-7856 |
0 |
2 |
0% |
ST-5308 |
0 |
0 |
0% |
|
ST-6778 |
0 |
0 |
0% |
|
ST-16639 |
0 |
0 |
0% |
|
ST-10386 |
1 |
1 |
100% |
|
ST-17261 |
1 |
42 |
2% |
|
2021 |
ST-7856 |
0 |
0 |
0% |
ST-5308 |
0 |
0 |
0% |
|
ST-6778 |
0 |
0 |
0% |
|
ST-16639 |
1 |
5 |
20% |
|
ST-10386 |
0 |
0 |
0% |
|
ST-17261 |
0 |
49 |
0% |
Note: This figure shows STs associated with ceftriaxoneDS (among all ESAG isolates collected from 2018 to 2021), for a given calendar year. The total number of ESAG cultures with a given ST is shown in grey and the number of isolates (for a given ST) with ceftriaxoneDS are shown in yellow. The data labels on the bars are the proportion of isolates that demonstrated ceftriaxoneDS for each ST.
4.4. Sequence Typing
There were 396 unique NG-MAST STs identified from 3377 N. gonorrhoeae isolates, collected from ESAG cases between 2018 and 2021. The top 10 most frequently observed STs represented slightly more than half of all identified STs within each reporting year (Table 14).
Number of isolates | 2018 | 2019 | 2020 | 2021 | ||||
---|---|---|---|---|---|---|---|---|
n | % | n | % | n | % | n | % | |
With a top 10 ST for a given year |
491 |
57.4% |
476 |
55.8% |
301 |
54.0% |
332 |
52.9% |
Total isolates |
855 |
100.0% |
853 |
100.0% |
557 |
100.0% |
628 |
100.0% |
2018 | 2019 | 2020 | 2021 | |
---|---|---|---|---|
AzithromycinR | ||||
AzithromycinR in top 10 STs |
7 |
25 |
0 |
3 |
Total AzithromycinR (N) |
18 |
55 |
8 |
11 |
Proportion (%) |
38.9% |
45.5% |
0.0% |
27.3% |
CefiximeDS | ||||
CefiximeDS in top 10 STs |
0 |
0 |
5 |
15 |
Total CefiximeDS (N) |
1 |
2 |
6 |
22 |
Proportion (%) |
0.0% |
0.0% |
83.3% |
68.2% |
CeftriaxoneDS | ||||
CeftriaxoneDS in top 10 STs |
7 |
0 |
1 |
0 |
Total CeftriaxoneDS (N) |
8 |
2 |
2 |
1 |
Proportion (%) |
87.5% |
0.0% |
50.0% |
0.0% |
There was no clear trend in the proportion of ESAG cases with cultures that had a top 10 ST and demonstrated either azithromycinR, cefiximeDS or ceftriaxoneDS (Table 15). The proportion of cultures, with one of the top 10 STs, with AzithromycinR varied across the years but declined overall (38.9%, 7/18 cases in 2018; 45.5%, 25/55 in 2019; 0.0%, 0/8 in 2020; and 27.3%, 3/11 in 2021).
While cultures demonstrating cefiximeDS and ceftriaxoneDS occurred infrequently across all reporting years, cefiximeDS was mostly detected in cultures from cases with a top 10 ST for the years 2020 (83.3%, 5/6 cases) and 2021 (68.2%, 15/22 cases) only. CeftriaxoneDS was mostly detected in cultures that were among the top 10 STs for the year 2018 (87.5%, 7/8 cases) and half of cultures in 2020 (50.0%, 1/2 cases) only.
Figures 8, 9, 10, 11 show the top 10 STs by the number of isolates with that ST, the number of isolates with that ST meeting the cut-offs for azithromycinR, cefiximeDS or ceftriaxoneDS, and the proportion of ESAG cases with those STs by i) sexual behaviour and ii) the primary infection type for the years 2018 to 2021. (ST changes across this time period among the 10 most frequent STs are shown in supplementary appendix I). The most prevalent STs varied across the reporting years by type, frequency and in their resistance profiles. Below, the discussion is focused on those 10 STs associated with cefiximeDS, ceftriaxoneDS, and azithromycinR.
Figure 8: The 10 most frequent NG-MAST sequence types in N. gonorrhoeae isolates and the proportion by sex and sexual behaviour and by infection type, 2021.

Figure 8A - Text description
NG- MAST Sequence type | AzithromycinR | CefiximeDS | CeftriaxoneDS | Total isolates with ST for this year |
---|---|---|---|---|
ST-13062 |
0 |
0 |
0 |
10 |
ST-11508 |
2 |
0 |
0 |
11 |
ST-non typeable |
1 |
1 |
0 |
13 |
ST-19872 |
0 |
0 |
0 |
17 |
ST-16065 |
0 |
0 |
0 |
17 |
ST-19757 |
0 |
2 |
0 |
17 |
ST-8890 |
0 |
0 |
0 |
19 |
ST-17261 |
0 |
11 |
0 |
49 |
ST-11461 |
0 |
0 |
0 |
61 |
ST-11477 |
0 |
1 |
0 |
118 |

Figure 8B - Text description
NG- MAST Sequence type | GBMSM | Heterosexual males | Males with unknown sexual behaviour | Females |
---|---|---|---|---|
ST-13062 |
10.0% |
60.0% |
0.0% |
30.0% |
ST-11508 |
0.0% |
0.0% |
63.6% |
36.4% |
ST-nontypeable |
38.5% |
38.5% |
0.0% |
23.1% |
ST-19872 |
11.8% |
52.9% |
0.0% |
35.3% |
ST-16065 |
17.6% |
58.8% |
0.0% |
23.5% |
ST-19757 |
88.2% |
11.8% |
0.0% |
0.0% |
ST-8890 |
21.1% |
47.4% |
0.0% |
31.6% |
ST-17261 |
87.8% |
8.2% |
2.0% |
2.0% |
ST-11461 |
23.0% |
52.5% |
1.6% |
23.0% |
ST-11477 |
89.8% |
7.6% |
0.8% |
1.7% |

Figure 8C - Text description
NG- MAST Sequence type | Anogenital | Other | Pharyngeal | Unknown |
---|---|---|---|---|
ST-13062 |
8 |
0 |
2 |
0 |
ST-11508 |
3 |
7 |
0 |
1 |
ST-nontypeable |
9 |
0 |
4 |
0 |
ST-19872 |
14 |
0 |
3 |
0 |
ST-16065 |
16 |
0 |
1 |
0 |
ST-19757 |
12 |
0 |
5 |
0 |
ST-8890 |
15 |
0 |
4 |
0 |
ST-17261 |
34 |
0 |
15 |
0 |
ST-11461 |
50 |
0 |
11 |
0 |
ST-11477 |
77 |
0 |
41 |
0 |
Figure 9: The 10 most frequent NG-MAST sequence types in N. gonorrhoeae isolates and the proportion by sex and sexual behaviour and by infection type, 2020

Figure 9A - Text description
NG- MAST Sequence type | AzithromycinR | CefiximeDS | CeftriaxoneDS | Total isolates with ST for this year |
---|---|---|---|---|
ST-11477 |
0 |
0 |
0 |
10 |
ST-18360 |
0 |
0 |
0 |
12 |
ST-11933 |
0 |
0 |
0 |
14 |
ST-16065 |
0 |
0 |
0 |
14 |
ST-8890 |
0 |
0 |
0 |
20 |
ST-5985 |
0 |
0 |
0 |
26 |
ST-10451 |
0 |
1 |
0 |
31 |
ST-17261 |
0 |
4 |
1 |
42 |
ST-11508 |
0 |
0 |
0 |
46 |
ST-11461 |
0 |
0 |
0 |
86 |

Figure 9B - Text description
NG- MAST Sequence type | GBMSM | Heterosexual males | Males with unknown sexual behaviour | Females |
---|---|---|---|---|
ST-11477 |
100.0% |
0.0% |
0.0% |
0.0% |
ST-18360 |
100.0% |
0.0% |
0.0% |
0.0% |
ST-11933 |
0.0% |
0.0% |
71.4% |
28.6% |
ST-16065 |
28.6% |
50.0% |
0.0% |
21.4% |
ST-8890 |
10.0% |
70.0% |
0.0% |
20.0% |
ST-5985 |
34.6% |
34.6% |
7.7% |
23.1% |
ST-10451 |
51.6% |
35.5% |
0.0% |
12.9% |
ST-17261 |
97.6% |
2.4% |
0.0% |
0.0% |
ST-11508 |
0.0% |
0.0% |
54.3% |
45.7% |
ST-11461 |
90.7% |
4.7% |
4.7% |
0.0% |

Figure 9C - Text description
NG- MAST Sequence type | Anogenital | Other | Pharyngeal | Unknown |
---|---|---|---|---|
ST-11477 |
8 |
0 |
2 |
0 |
ST-18360 |
9 |
0 |
3 |
0 |
ST-11933 |
13 |
0 |
0 |
1 |
ST-16065 |
12 |
0 |
2 |
0 |
ST-8890 |
18 |
0 |
2 |
0 |
ST-5985 |
24 |
0 |
2 |
0 |
ST-10451 |
23 |
0 |
8 |
0 |
ST-17261 |
27 |
0 |
15 |
0 |
ST-11508 |
15 |
3 |
3 |
25 |
ST-11461 |
63 |
0 |
23 |
0 |
Figure 10: The 10 most frequent NG-MAST sequence types in N. gonorrhoeae isolates and the proportion by sex and sexual behaviour and by infection type, 2019

Figure 10A - Text description
NG- MAST Sequence type | AzithromycinR | CefiximeDS | CeftriaxoneDS | Total isolates with ST for this year |
---|---|---|---|---|
ST-8890 |
0 |
0 |
0 |
26 |
ST-11508 |
2 |
0 |
0 |
30 |
ST-13489 |
0 |
0 |
0 |
33 |
ST-12302 |
33 |
0 |
0 |
36 |
ST-14994 |
1 |
0 |
0 |
42 |
ST-11461 |
0 |
0 |
0 |
46 |
ST-5441 |
0 |
0 |
0 |
48 |
ST-10451 |
0 |
0 |
0 |
52 |
ST-5985 |
0 |
0 |
0 |
68 |
ST-16065 |
0 |
0 |
0 |
95 |

Figure 10B - Text description
NG- MAST Sequence type | GBMSM | Heterosexual males | Males with unknown sexual behaviour | Females |
---|---|---|---|---|
ST-8890 |
7.7% |
53.8% |
0.0% |
38.5% |
ST-11508 |
0.0% |
0.0% |
50.0% |
50.0% |
ST-13489 |
0.0% |
48.5% |
0.0% |
51.5% |
ST-12302 |
86.1% |
11.1% |
2.8% |
0.0% |
ST-14994 |
33.3% |
2.4% |
59.5% |
4.8% |
ST-11461 |
78.3% |
6.5% |
13.0% |
2.2% |
ST-5441 |
29.2% |
45.8% |
6.3% |
18.8% |
ST-10451 |
15.4% |
51.9% |
9.6% |
23.1% |
ST-5985 |
23.9% |
49.3% |
4.5% |
22.4% |
ST-16065 |
92.6% |
4.2% |
0.0% |
3.2% |

Figure 10C - Text description
NG- MAST Sequence type | Anogenital | Pharyngeal | Other | Unknown |
---|---|---|---|---|
ST-8890 |
22 |
4 |
0 |
0 |
ST-11508 |
9 |
1 |
8 |
12 |
ST-13489 |
30 |
3 |
0 |
0 |
ST-12302 |
26 |
10 |
0 |
0 |
ST-14994 |
24 |
17 |
0 |
1 |
ST-11461 |
35 |
11 |
0 |
0 |
ST-5441 |
41 |
7 |
0 |
0 |
ST-10451 |
26 |
25 |
0 |
1 |
ST-5985 |
60 |
8 |
0 |
0 |
ST-16065 |
58 |
37 |
0 |
0 |
Figure 11: The 10 most frequent NG-MAST sequence types in N. gonorrhoeae isolates and the proportion by sex and sexual behaviour and by infection type, 2018

Figure 11A - Text description
NG- MAST Sequence type | AzithromycinR | CefiximeDS | CeftriaxoneDS | Total isolates with ST for this year |
---|---|---|---|---|
ST-5624 |
0 |
0 |
0 |
22 |
ST-7856 |
0 |
0 |
7 |
27 |
ST-14994 |
0 |
0 |
0 |
27 |
ST-10451 |
0 |
0 |
0 |
29 |
ST-3671 |
0 |
0 |
0 |
33 |
ST-12302 |
4 |
0 |
0 |
40 |
ST-5441 |
0 |
0 |
0 |
45 |
ST-16065 |
0 |
0 |
0 |
73 |
ST-16288 |
3 |
0 |
0 |
83 |
ST-5985 |
0 |
0 |
0 |
112 |

Figure 11B - Text description
NG- MAST Sequence type | GBMSM | Heterosexual males | Males with unknown sexual behaviour | Females |
---|---|---|---|---|
ST-5624 |
72.7% |
4.5% |
13.6% |
9.1% |
ST-7856 |
22.2% |
0.0% |
74.1% |
3.7% |
ST-14994 |
48.1% |
3.7% |
48.1% |
0.0% |
ST-10451 |
0.0% |
58.6% |
17.2% |
24.1% |
ST-3671 |
0.0% |
3.0% |
54.5% |
42.4% |
ST-12302 |
85.0% |
7.5% |
5.0% |
2.5% |
ST-5441 |
31.1% |
48.9% |
2.2% |
17.8% |
ST-16065 |
93.2% |
4.1% |
0.0% |
2.7% |
ST-16288 |
92.8% |
3.6% |
0.0% |
3.6% |
ST-5985 |
4.5% |
47.3% |
10.7% |
37.5% |

Figure 11C - Text description
NG- MAST Sequence type | Anogenital | Pharyngeal | Other | Unknown |
---|---|---|---|---|
ST-5624 |
17 |
5 |
0 |
0 |
ST-7856 |
18 |
9 |
0 |
0 |
ST-14994 |
14 |
12 |
1 |
0 |
ST-10451 |
24 |
4 |
0 |
1 |
ST-3671 |
18 |
4 |
7 |
4 |
ST-12302 |
23 |
17 |
0 |
0 |
ST-5441 |
42 |
3 |
0 |
0 |
ST-16065 |
45 |
28 |
0 |
0 |
ST-16288 |
56 |
27 |
0 |
0 |
ST-5985 |
102 |
10 |
0 |
0 |
In 2021, three of the top ten STs were associated with cefiximeDS (ST-11477, ST-17261, ST-19757) and one demonstrated azithromycinR (ST-11508). There was no ceftriaxoneDS detected from the top ten STs in 2021. While ST-11477 was the most frequently observed ST in 2021 (18.3%, 118/645), only one isolate with ST-11477 demonstrated cefiximeDS (0.8%, 1/118) and none demonstrated azithromycinR or ceftriaxoneDS (Figure 8A). This ST was primarily observed in isolates collected from males (98.3%, 116/118), specifically GBMSM (89.8%, 106/118) and among ESAG cases with anogenital infections (65.3%, 77/118) (Figure 8B and 8C).
Also in 2021, ST-19757 newly emerged as one of the top 10 STs (n=17; 5th most common ST). ST-19757 was associated with cefiximeDS in two cases (11.8%, 2/17) and was predominantly detected among GBMSM (88.2%, 15/17) followed by heterosexual males (11.8%, 2/17). In addition, there were two cases (2/11, 18.2%) of ST -11508 (the 9th most common ST in 2021) demonstrating azithromycinR in 2021, all cases were among males with unknown sexual behaviour (63.6%, 7/11) and females (36.4%, 4/11). Interestingly, this ST has been in the top 10 ST since 2019 (9th top ST in 2019; 2nd top ST in 2020) and was associated with azithromycinR in 2019 (6.7%, 2/30), but not in 2020 (0.0% 0/46).
In 2021 and 2020, ST-17261 emerged as the third most observed ST (16.3% (49/301) in 2021 and 13.9%, (42/301) in 2020) and was associated with the most resistance of the top 10 STs for these years. Specifically, this ST was associated with cefiximeDS in 2021 (22.4%, 11/49) and 2020 (9.5%, 4/42) and ceftriaxoneDS (2.4%, 1/42) in 2020 (Figure 8A and Figure 9A). In both years, ST-17261 was mostly detected among GBMSM (87.8% (43/49) in 2021; 97.6% (41/42) in 2020) followed by heterosexual males (8.2% (4/49) in 2021; 2.4% (1/42) in 2020). In 2021, ST-17261 was also detected among females (2.0%, 1/43) and males with unknown sexual behaviour (2.0%, 1/43). ST-17261 was not a top ten ST prior to 2020.
In 2020, ST-10451 (N=31; 4th top ST) and ST-17261 were the only two STs among the top 10 STs to demonstrate reduced drug susceptibility (Figure 9A). ST-10451 was associated with cefiximeDS (2.4%, 1/31) and was primarily observed among GBMSM (51.6%, 16/31), followed by heterosexual males (35.5%, 11/31) and females (12.9%, 4/31) (Figure 9B). While also, a top 10 ST in 2018 and 2019, there were zero instances of reduced drug susceptibility for those years.
In 2019, in addition to ST-11508, ST-14994 and ST-12302 were also associated with azithromycinR (Figure 10A).Footnote 21 None of the top ten STs in 2019 were associated with ceftriaxoneDS or cefiximeDS. Both ST-14994 and ST-12302 were also in the top 10 STs in 2018. The proportion of ST-14994 isolates with azithromycinR increased from 2.6% (1/39) in 2019 from 0.0% in 2018, while the proportion of azithromycinR cases of ST-12302 increased from 10.0% (4/40) to 91.7% (33/36). In 2019, ST-14994 was primarily identified among males with unknown sexual behaviour (59.5%, 25/42) followed by GBMSM (33.3%, 14/42); meanwhile, ST-12302 was primarily detected among GBMSM (86.1%, 31/36). However, both STs disappeared from the top 10 ST in 2020 and 2021.
In 2018, ST-16288 (2nd top ST in 2018) and ST-12302 (5th top ST in 2018) were associated with azithromycinR (10.0%, 4/40 for ST-16288 and 3.6%, 3/83 for ST-12302) (Figure 11A). Additionally, ST-7856 (9th top ST in 2018) was associated with ceftriaxoneDS (25.9%, 7/27). ST-16288 was predominantly detected among GBMSM (92.8%, 77/83) while ST-7856 was predominantly detected among males with unknown sexual behaviour (74.1%, 20/27). The prevalence of both STs declined after 2018 as neither were in the top STs for 2019, 2020, or 2021. No decreased susceptibility to cefixime was observed from isolates with any of the top 10 NG-MAST STs in 2018.
5. Data Quality and Limitations
5.1. Data Quality
During this reporting period, the variables 'sex work status' and 'travel-related GC infection' which have been shown in previous ESAG reports could not be presented due to insufficient data collection.
5.2. Limitations and considerations
- Results from ESAG are not representative of all gonorrhea cases or culture-confirmed gonorrhea cases in Canada, since most gonorrhea cases are diagnosed by NAATs. Of the four provinces and territories that provided 2018 to 2021 ESAG data, most ESAG data came from Alberta. Additionally, sentinel sites within Nova Scotia may not be representative of this province as a whole. Aggregated results should be interpreted with caution.
- Approximately 80.5% of cases captured in ESAG were male, of which 55.5% were GBMSM. However, in 2021, 62.9% of all gonorrhea cases reported nationally to PHAC were male (sexual orientation data is unavailable for nationally reported gonorrhea cases).Footnote 1
- Gonorrhea client-level public health data collection may be more likely to be completed within certain medical clinics with client populations which may not be generalizable across the PT or Canada.
- The reported proportions of cases prescribed a recommended preferred or alternative gonorrhea treatment are conservative. The availability of recommended antimicrobials, reporter error (for example, erroneously reporting prescriptions used to treat co-infections/co-morbidities or providing incomplete gonorrhea prescription treatment information), and co-morbidity or risk behaviour considerations, are all possible reasons for not meeting recommended gonorrhea treatment guidelines. For example, PHAC gonorrhea treatment guidelines recommend considering chlamydia treatment (i.e., azithromycin 1 g (in a single dose) and doxycycline 100 mg (for 7 days)) alongside gonorrhea treatment if a sexual partner is found to have gonorrhea or if follow-up is not assured.
- Tests of cure and treatment failures can be difficult to measure using surveillance data because they rely on the ability to detect negative results. Additionally, it is unknown how well gonorrhea treatment failures are detected or reported by jurisdictions. Thus, treatment failures may be underreported.
- PTs had a reduced ability to deliver regular and routine gonorrhea screening, care, and public health reporting activities during 2020 and parts of 2021 due to numerous factors related to the COVID-19 pandemic.
6. Discussion
This is the fourth ESAG results report describing AMR-GC trends overall and among key groups and GC treatment prescribing practices among ESAG participating PTs. In the previous ESAG 2015 to 2017 report, ESAG participating PTs increased the number of gonorrhea cultures collected over time.Footnote 5 However, from 2018 and onward, the number of cultures among ESAG PTs decreased each year. The COVID-19 pandemic may also have contributed to this decrease, with many PTs having to adapt and change their strategies for STBBI care (see limitations section).Footnote 22 Changes in PT data collection methods over this period may have also played a role in the decrease in ESAG cases and can not be ruled out.
After three years of stability (2018 to 2020), AMR-GC prevalence (as indicated by resistance to at least one tested antimicrobial) among ESAG cases increased from 69.3% in 2020 to 77.4% in 2021. In 2021, AMR-GC burden was highest among ESAG cases who were GBMSM (85.2%), followed by heterosexual males (73.5%) and females (66.7%). Resistance to ciprofloxacin and tetracycline was high among all sexual behaviour groups but highest among GBMSM. This is important information to continuously monitor as early studies have documented the short-term effectiveness of doxycycline as post-exposure prophylaxis for bacterial STI among cisgender GBMSM and transgender women.Footnote 23,Footnote 24 As a result, some doxycycline are recommending or considering its use as post exposure prophylaxis in the GBMSM population.Footnote 23
Between 2018 and 2021, while there were 14 reports of suspected treatment failure, laboratory resistance profiles showed that none demonstrated resistance to all prescribed treatment regimens suggesting these clients were either reinfected or did not take their medication correctly, or at all (as most of the prescribed therapies for these clients were one-time doses). Thus, there were no confirmed treatment failures among ESAG cases with gonorrhea treatment prescriptions over the period. This is in the context of stable and high adherence to gonorrhea treatment guidelines and despite 3.4% of cases (116/3377) demonstrating azithromycinR, 0.4% (14) demonstrating ceftriaxoneDS, and 0.9% (32) demonstrating cefiximeDS. The discrepancy between the suspected and confirmed treatment failures among ESAG cases reinforces PHAC's recommendation of culturing isolates when antibiotic resistance is suspected and performing a test of cure for all positive sites in all GC cases.Footnote 25
Encouragingly, the vast majority of GBMSM and other adult ESAG cases were prescribed either the PHAC or PT-described preferred or alternative gonorrhea therapy across all reporting years (average of 91.4% adherence to PHAC guidelines and 89.5% adherence to PT guidelines). High adherence to PHAC guidelines has been observed in previous ESAG reports. This is the first report that summarizes PT-specific GC treatment guideline adherence (adherence was slightly higher to PHAC versus PT guidelines). Among all GBMSM cases, the majority received the anogenital and pharyngeal preferred therapy of azithromycin with ceftriaxone. This was followed, though infrequently, by ceftriaxone and doxycycline, which is not a PT-recommended regimen; although, it is a PHAC-recommended alternative therapy for anogenital infections. Among other adults (i.e., non-GBMSM ESAG cases), most were prescribed azithromycin and cefixime (one of the two preferred treatment regimens for anogenital infections but an alternative regimen for pharyngeal infections). This finding has been noted in previous ESAG reports and may be because the client was first diagnosed by NAAT and treated as an anogenital infection, and later found to also have a pharyngeal infection. For all people, pharyngeal infections are often asymptomatic and possibly screened less frequently.
Despite its high prescriber rate, isolates with ceftriaxoneDS have remained few, with no increasing trend, for all sexual behaviour groups, which is encouraging and supports its widespread recommendation in national and PT treatment guidelines. Footnote 6, Footnote 11, Footnote 12, Footnote 13 Of the 14 ceftriaxoneDS cases, the majority (eight) occurred in 2018 (three in 2019, two in 2020 and one in 2021) and nine cases were among males with unknown sexual behaviour, which makes data difficult to interpret. Very few (two) cases were GBMSM or female.
While the prevalence was low, cefiximeDS has been rising since 2019 for GBMSM (0.0% in 2019 to 4.5% in 2021) and since 2018 for those who are most often prescribed this drug, heterosexual males (0.0% in 2018 to 2.2% in 2021) and females (0.0% in 2018 to 3.3% in 2021). Although, a greater than baseline proportion of all cefiximeDS ESAG cases were among GBMSM. The WHO recommends carefully watching any antimicrobial whose prevalence is above 5.0% of isolates or is rapidly rising.Footnote 21 Future reports will be informative of cefiximeDS trends within these populations.
AzithromycinR prevalence was similar in 2018 to what was observed in the previous ESAG report, but increased to 7.8% in 2019 followed by a sharp drop to 1.9% in 2021 overall (these trends were also observed by sexual behaviour group).Footnote 5 Between 2018 and 2021, the majority of the azithromycinR ESAG cases were disproportionately among males (90.5%), of which, 79.0% were GBMSM. Similar azithromycinR trends were observed in the latest GASP report, where it was noted that azithromycinR decreased significantly between 2017 (11.7%) and 2021 (7.6%) (p<0.001). However, the GASP report noted a significant increase (p<0.001) in the proportion of cultures with an azithromycin minimum inhibitory concentration of ≥1mg/L (2017=22.2% to 2021=28.1%).Footnote 14 For further comparisons between ESAG and GASP-Canada 2021 results, see Appendix 2, in this document). AzithromycinR was driven by the STs, ST-16288 and ST-12302. Fortunately, the prevalence of these STs dwindled to four and eight ESAG isolates, respectively, in 2020 and zero in 2021.
7. Conclusion
The ESAG system continued to monitor N. gonorrhoeae antimicrobial susceptibility, clinician prescribing practices, reason for medical care visit, and treatment failure data by demographic and sexual behaviour variables from 2018 to 2021. This data supplements PHAC's laboratory-based passive surveillance of AMR-GC through GASP-Canada. The ESAG data for 2018 to 2021 demonstrated a low prevalence, overall, to the most prescribed and recommended GC treatments of ceftriaxoneDS and cefiximeDS, although a slight increase in cefiximeDS among ESAG cases (particularly among GBMSM) was observed in 2021. It also showed a lowered prevalence of azithromycinR in 2020 and 2021 compared to in 2018 and 2019.
Gonorrhea treatment resistant to azithromycin and ceftriaxone are a global concern and have been reported in several countries world-wide. Aside from Canada, ceftriaxoneR has been documented in Australia, Austria, China, Denmark, France, Japan, Slovenia, Sweden, and the United Kingdom.Footnote 2,Footnote 26,Footnote 27,Footnote 28,Footnote 29,Footnote 30,Footnote 31,Footnote 32,Footnote 33,Footnote 34,Footnote 35,Footnote 36
ESAG demonstrates the possibility of improved AMR-GC surveillance by integrating existing local/ provincial/ territorial GC and national laboratory surveillance. ESAG has allowed for the monitoring of GC antimicrobial susceptibility despite the decreasing use of culture in clinical practice for gonorrhea diagnosis and antimicrobial susceptibility testing. As Canada faces increasing numbers of gonorrhea cases and the continued evolution, emergence and spread of AMR-GC, efforts are ongoing to recruit additional ESAG sites to allow the collection of more representative data.
The continuous monitoring of AMR-GC patterns via surveillance is of paramount importance to ensure the effectiveness of the recommended antimicrobials to treat GC infection. ESAG can play an important role in assessing and monitoring the effectiveness of GC treatment options and for the success of Canadian initiatives to combat AMR-GC.
Appendix 1. List of supplementary figures and tables
Supplementary figures and tables are available upon request at sti-hep-its@phac-aspc.gc.ca.
- Appendix A: Antimicrobial Resistance Criteria and WHO Access, Watch, Reserve (AWaRe) Classifications
- Table 1. Neisseria gonorrhoeae antimicrobial resistance criteria
- Table 2. The WHO Access, Watch, Reserve (AWaRe) antimicrobial classifications for evaluation and monitoring
- Appendix B: Neisseria gonorrhoeae Antimicrobial Resistance Characterization Definitions
- Appendix C: Number and rate of gonorrhea cases reported to CNDSS among ESAG participating provinces and territories, 2018 to 2021
- Appendix D: Neisseria gonorrhoeae treatment guidelines among ESAG participating provinces and territories
- Appendix E: List of treatments prescribed among males with unknown sexual behavior by infection site, ESAG 2018-2021
- Table 1. Proportion of males with unknown sexual behavior with anogenital or pharyngeal infections, ESAG 2018 to 2021
- Table 2. Treatments prescribed for anogenital infections among males with unknown sexual behavior, ESAG 2018 to 2021
- Table 3. Treatments prescribed for pharyngeal infections among males with unknown sexual behavior, ESAG 2018 to 2021
- Appendix F: Neisseria gonorrhoeae treatment failures among ESAG cases, 2018 to 2021
- Appendix G: Number and proportion of cases demonstrating resistance to azithromycin, ciprofloxacin, erythromycin, spectinomycin, penicillin, or tetracycline or decreased susceptibility to cefixime and ceftriaxone by sex/sexual behaviour, ESAG 2018 to 2021
- Table 1: Number and proportion of cases demonstrating resistance to azithromycin, ciprofloxacin, erythromycin, spectinomycin, penicillin, or tetracycline or decreased susceptibility to cefixime and ceftriaxone among males, ESAG 2018 to 2021
- Table 2: Number and proportion of cases demonstrating resistance to azithromycin, ciprofloxacin, erythromycin, spectinomycin, penicillin, or tetracycline or decreased susceptibility to cefixime and ceftriaxone by sex/sexual behaviour among females, ESAG 2018 to 2021
- Figure 1: Proportion of cases demonstrating resistance to azithromycin, ciprofloxacin, erythromycin, spectinomycin, penicillin, or tetracycline or decreased susceptibility to cefixime and ceftriaxone by sex/sexual behaviour among females, ESAG 2018 to 2021
- Appendix H: Number and proportion of cases with GC cultures demonstrating resistance and/or decreased susceptibility to none or up to five antimicrobials by sex/sexual behaviour, ESAG 2018 to 2021
- Table 1: Number and proportion of cases with GC cultures demonstrating resistance and/or decreased susceptibility to none or up to five antimicrobials, among males, ESAG 2018 to 2021
- Table 2: Number and proportion of cases with GC cultures demonstrating resistance and/or decreased susceptibility to none or up to five antimicrobials by sex/sexual behaviour among females, ESAG 2018 to 2021
- Figure 1: Proportion of cases with GC cultures demonstrating resistance and/or decreased susceptibility to none or up to five antimicrobials by sex/sexual behaviour among females, ESAG 2018 to 2021
- Appendix I: Distribution of Antimicrobial Resistance among GBMSM and other adults, and by infection site according to the Canadian treatment guidelines, ESAG 2018 to 2021
- Appendix J: The number of NG-MAST sequence types demonstrating resistance to azithromycin, ESAG 2018 to 2021
- Appendix K: Number of isolates for the top 30 Neisseria gonorrhoeae isolates NG-MAST sequence types, ESAG 2018 to 2021.
Appendix 2. Comparison of GASP-Canada and ESAG 2021 results
GASP-Canada 2021 report results | ESAG 2021 report results | ESAG vs GASP - Canada results comparison summary |
---|---|---|
Culture data | ||
There were 3,439 of cultures reported to GASP-Canada in 2021- 9.9% increase since 2020 (n= 3130). While the number of GC cultures across Canada increased slightly between 2020 (n=3,130) and 2021 (n=3,439), there were 30% less than what was seen in 2019 (n=4,859). |
There were 645 cultures (cases) reported to ESAG in 2021- 9.3% decrease from 2020 (n=711). There was a steady decline in the number of ESAG cases from 2018 to 2021 (1022 cases in 2018, 999 cases in 2019, 711 cases in 2020 and 645 cases in 2021. |
Difference in trends: GASP-Canada saw an increase in the number of submitted GC cultures from 2020 to 2021. ESAG saw a decline in the number of GC cultures (cases) from 2020 to 2021. |
In 2021, most AMR-GC data comes from Quebec (n=1561), followed by Ontario (n=886) and Alberta (n=783). |
83.0% of ESAG cases were reported by Alberta, 14.3% by Manitoba, 1.8% by Nova Scotia, and 0.9% by the Northwest Territories. |
Different main PT data sources. |
Case characteristics | ||
In 2021, 71.2% of N. gonorrhoeae GASP-Canada cultures were from individuals between the ages of 21 and 40. |
Between 2018 and 2021, 72.8% of ESAG cases were between 20 and 39 years of age. |
Similar ages of ESAG and GASP-Canada cases. |
In 2021, 84.4% of cultures were primarily collected from males and 15.1% (438/2,909) from females. |
Between 2018 and 2021, 80.4% of ESAG cases were male and 19.1% of cases were female. |
Very similar proportions of male and female ESAG and GASP-Canada cases. ESAG also presents data by sexual behavior. GASP-Canada does not collect sexual behaviour data. |
In 2021, the most prevalent primary gonococcal isolation site in males was the penis/urethra (56.8%) and for females it was the throat (33.8%, 148/438). |
Between 2018 and 2021, the most prevalent primary gonococcal isolation site for males and females was genital (34.6% for females and 51.8% for males). It was followed by the rectum for males (23.7%) and the pharynx for females (32.4%). Among males, the primary GC infection site was, among GBMSM, rectal (39.3%) and pharyngeal (34.6%) and among heterosexual males, the penis/urethra (i.e., genital) (26.1%). |
Similar primary isolation site by sex. ESAG also presents data by sexual behavior. GASP-Canada does not collect sexual behaviour data. |
AMR-GC Trends | ||
In 2021, over 70% (72.7%, n=2,501/3,349) of GC cultures submitted to GASP-Canada were resistant to at least one antibiotic. |
In 2021, over 70% (77.4%, n=499/645) of GC cultures submitted to ESAG were resistant to at least one antibiotic. |
Similar results - GASP-Canada and ESAG reported that over 70% of cultures were resistant to at least 1 antibiotic in 2021. |
No significant change in the proportion of GASP-Canada GC cultures that demonstrated ceftriaxoneDS was detected between 2017 (0.55%) and 2021 (0.6%) (p>0.001). However, one ceftriaxone resistant isolate was identified. |
CeftriaxoneDS declined in number and proportion from 8 (0.8%) cases in 2018 to one case (0.2%) in 2021. All ESAG cultures were susceptible to ceftriaxone in 2020 and 2021. |
Slightly different results: In 2021, a marginally larger proportion of ceftriaxoneDS GC cultures were detected among GASP-Canada cultures (0.6%) than among ESAG cultures (0.2%). Over the reporting periods, ceftriaxoneDS prevalence trends remained stable among GASP-Canada GC cultures, while they decreased marginally among ESAG GC cultures. |
CefiximeDS increased significantly from 0.6% in 2017 to 1.5% in 2021 (p<0.001), but also decreased significantly from the 2.8% reported in 2020 (p<0.001) The 2020 higher proportion of isolates with cefiximeDS was primarily caused by isolates identified as ST-16639 in Ontario and Québec. The proportion of this ST decreased from 3.3% (n=53/1,590) in 2020 to 1.3% (n=26/2,006) in 2021. |
From 2018 to 2020, the number and proportion of ESAG GC cultures demonstrating cefiximeDS increased from 0.1% in 2018 to 3.4% in 2021. |
In 2021, a larger proportion of cefiximeDS cultures were detected among ESAG cultures (3.4%) than among GASP-Canada cultures (1.5%). Over the reporting periods, there was an increase in the proportion of ESAG and GASP-Canada cultures demonstrating cefiximeDS. The trends have fluctuated between 2020 and 2021 for GASP-Canada; while ESAG maintained a steady increase. |
AzithromycinR prevalence increased from 7.6% in 2018 to 11.7% of cases in 2019 and declined to 6.10% and 7.6% of cases in 2020 and 2021, respectively. |
AzithromycinR increased from 18 cases (1.8%) in 2018 to 78 cases (7.8%) in 2019. However, this number decreased sharply to eight cases (1.1%) in 2020 and 12 cases (1.9%) in 2021. |
In 2021, a larger proportion of azithromycinR cultures were detected among GASP-Canada cultures (7.6%) than among ESAG cultures (1.9%). Overall, there was a decrease in the proportion of ESAG and GASP-Canada cultures demonstrating azithromycinR from 2019 to 2021 after a rise in cases in 2019. |
CiprofloxacinR prevalence remained high and stable (between 49% and 57%) from 2017 to 2021 |
CiprofloxacinR was the most prevalent AMR-GC in 2021 (63.1%) and in 2020 (46.6%). It was the second most prevalent AMR-GC in 2019 (44.0%) and 2018 (43.0%). |
Very similar findings: Ciprofloxacin resistance and Tetracycline resistance prevalence was high among ESAG and GASP-Canada cultures. |
TetracyclineR prevalence fluctuated but remained high and stable in 2017 to 2020 (between 40% and 50%). In 2021, it was at an all-time high of 65.9%. |
TetracyclineR was the most prevalent AMR-GC at 52.1% in 2018 and 51.8% in 2019 and the second most prevalent AMR-GC in 2020 (45.9%)and 2021 (58.6%). |
|
ErythromycinR fluctuated from 2017 to 2021. The prevalence was around 60% in 2017 but declined annually to around 30% in 2020. It then increased to 51.5% in 2021. |
ErythromycinR has declined annually and sharply from 30% in 2018 to 8.5% in 2021. |
Different results: In 2021, erythromycinR prevalence was much higher among GASP-Canada cultures (51.5%) than among ESAG cultures (8.5%). ErythromycinR prevalence has fluctuated over time for GASP-Canada but declined for ESAG. |
From 2017 to 2021, penicillin was below 7%. |
PenicillinR rates were relatively stable from 2018 to 2020 (6.8% in 2018, 7.2% in 2019 and 8.2% in 2020) but dropped to 3.9% in 2021, which is below the WHO's cut-off of concern (5%). |
PenicillinR trends were similar in both groups; although, in 2021, prevalence is slightly lower in ESAG cultures (3.9%) than in GASP-Canada cultures (7.0%). |
In 2021, the most frequently detected NG-MAST sequence type in Canada was ST-19875 (15.3%, n=306), followed by ST-11477 (n=137) and ST-17972 (n=127). Approximately 20.3% of ST-19875 isolates were identified with AziR, While ST-11477 was primarily resistant to ciprofloxacin and tetracycline, And ST-17972 isolates were primarily resistant ciprofloxacin and erythromycin. * The ST-19875 was first identified in 2020 in low numbers (n=22) and only in Québec. In 2021, this ST type has spread to five more provinces. * From 2017 to 2020, ST-12302 and ST-14994 were the most prevalent, while in 2021, they were the eighth and ninth most prevalent STs, respectively. While the number of isolates with ST-12302 (n=47) has been decreasing, in 2021, 15 other STs were identified with two or fewer base pair differences compared to ST-12302 (this cluster made n= 144 of isolates). 61.8% (n=89/144) were AziR accounting for 34.1% (n=89/261) of AziR isolated in 2021. |
ST-11477 was the most frequently observed ST in 2021 (18.3%, 118/645), only one isolate with ST-11477 demonstrated cefiximeDS (0.8%, 1/118) and none demonstrated azithromycinR or ceftriaxoneDS. ST-11461 and ST-17261 are the second and third most common STs observed in 2021. ST-12302 was the 5th most frequently observed ST in 2018 and the 8th most frequently observed ST in 2019. More than 50% of the isolates with ST-12302 in 2019 were AziR. Note that ST-19875 and ST-17972 did not rank in the top 10 most frequent STs for ESAG in any year between 2018 and 2021. |
Different findings: Different trends of STs between the GASP-Canada and ESAG samples. |
Appendix 3. Drug resistance (R) and decreased susceptibility (DS) to selected antimicrobialsFootnote a by province or territory, 2018 to 2021
Susceptibility | Alberta | Manitoba | Northwest Territories | Nova Scotia | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
2018 | 2019 | 2020 | 2021 | 2018 | 2019 | 2020 | 2021 | 2018 | 2019 | 2020 | 2021 | 2018 | 2019 | 2020 | 2021 | |
Susceptible to all |
267 (32.9%) |
236 (29.4%) |
177 (30.2%) |
130 (21.7%) |
28 (16.1%) |
48 (31.0%) |
41 (35.3%) |
16 (41.0%) |
0 (0.0%) |
1 (5.9%) |
0 (0.0%) |
0 (0.0%) |
6 (19.4%) |
5 (20.8%) |
0 (0.0%) |
0 (0.0%) |
R/DSFootnote b to 1 |
267 (32.9%) |
272 (33.9%) |
188 (32.0%) |
146 (24.3%) |
56 (32.2%) |
39 (25.2%) |
40 (34.5%) |
14 (35.9%) |
3 (60.0)% |
10 (58.8%) |
6 (85.7%) |
0 (0.0%) |
4 (12.9%) |
2 (8.3%) |
0 (0.0%) |
1 (20.0%) |
R/DS to 2 |
141 (17.4%) |
155 (19.3%) |
144 (24.5%) |
275 (45.8%) |
37 (21.3%) |
42 (27.1)% |
31 (26.7%) |
7 (17.9%) |
1 (20.0%) |
5 (29.4%) |
1 (14.3%) |
1 (100.0%) |
4 (12.9%) |
10 (41.7%) |
0 (0.0%) |
4 (80.0%) |
R/DS to 3 |
120 (14.8%) |
66 (8.2%) |
62 (10.6%) |
41 (6.8%) |
26 (14.9%) |
21 (13.5%) |
3 (2.6)% |
2 (5.1%) |
1 (20.0%) |
1 (5.9%) |
0 (0.0%) |
0 (0.0%) |
15 (48.4%) |
4 (16.7%) |
1 (100.0%) |
0 (0.0%) |
R/DS to 4 |
16 (2.0%) |
72 (9.0%) |
14 (2.4%) |
8 (1.3%) |
20 (11.5%) |
5 (3.2%) |
3 (0.9%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
2 (6.5%) |
3 (12.5%) |
0 (0.0%) |
0 (0.0%) |
R/DS to 5 |
1 (0.1%) |
2 (0.2%) |
2 (0.3%) |
2 (0.0%) |
7 (4.0%) |
5 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
Total |
812 (100.0%) |
803 (100.0%) |
587 (100.0%) |
600 (100.0%) |
174 (100.0%) |
155 (100.0%) |
116 (100.0%) |
39 (100.0)% |
5 (100.0%) |
17 (100.0%) |
7 (100.0%) |
1 (100.0%) |
31 (100.0%) |
24 (100.0%) |
1 (100.0%) |
5 (100.0%) |
|
References
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Maubaret C, Caméléna F, Mrimèche M, Braille A, Liberge M, Mainardis M, Guillaume C, Noel F, Bébéar C, Molina JM, Lot F, Chazelle E, Berçot B. Two cases of extensively drug-resistant (XDR) Neisseria gonorrhoeae infection combining ceftriaxone-resistance and high-level azithromycin resistance, France, November 2022 and May 2023. Euro Surveill [Internet]. 2023;28(37). Available from: https://doi.org/10.2807/1560-7917.ES.2023.28.37.2300456
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Berçot B, Caméléna F, Mérimèche M, Jacobsson S, Sbaa G, Mainardis M, Valin C, Molina JM, Bébéar C, Chazelle E, Lot F, Golparian D, Unemo M. Ceftriaxone-resistant, multidrug-resistant Neisseria gonorrhoeae with a novel mosaic penA-237.001 gene, France, June 2022. Euro Surveill [Internet]. 2022;27(50). Available from: https://doi.org/10.2807/1560-7917.ES.2022.27.50.2200899
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Poncin T, Fouere S, Braille A, Camelena F, Agsous M, Bebear C, Kumanski S, Lot F, Mercier-Delarue S, Ngangro Ndeindo Ndeikoundam, Salmona M, Schnepf N, Timsit J, Unemo M, Bercot B. Multidrug-resistant Neisseria gonorrhoeae failing treatment with ceftriaxone and doxycycline in France, November 2017. Euro Surveill [Internet]. 2018;23(21). Available from: https://doi.org/10.2807/1560-7917.ES.2018.23.21.1800264
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Unemo M, Golparian D, Potočnik M, Jeverica S. Treatment failure of pharyngeal gonorrhoea with internationally recommended first-line ceftriaxone verified in Slovenia, September 2011. Euro. Surveill [Internet]. 2012;17(25). Available from: https://doi.org/10.2807/ese.17.25.20200-en
- Footnote 32
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Unemo M, Golparian D, Hestner A. Ceftriaxone treatment failure of pharyngeal gonorrhoea verified by international recommendations, Sweden, July 2010. Euro. Surveill [Internet]. 2011;16(6). Available from: https://doi.org/10.2807/ese.16.06.19792-en
- Footnote 33
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Golparian D, Ohlsson AK, Janson H, Lidbrink P, Richtner T, Ekelund O, Fredlund H, Unemo M. Four treatment failures of pharyngeal gonorrhoea with ceftriaxone (500 mg) or cefotaxime (500 mg), Sweden, 2013 and 2014. Euro Surveill [Internet]. 2014;19(30). Available from: https://doi.org/10.2807/1560-7917.ES2014.19.30.20862
- Footnote 34
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Day M, Pitt R, Mody N, Saunders J, Rai R, Nori A, Church H, Mensforth S, Corkin H, Jones J, Naicker P, Khan WM, Thomson Glover R, Mortimer K, Hylton C, Moss E, Pasvol TJ, Richardson A, Sun S, Woodford N, Mohammed H, Sinka K, Fifer H. Detection of 10 cases of ceftriaxone-resistant Neisseria gonorrhoeae in the United Kingdom, December 2021 to June 2022. Euro Surveill [Internet]. 2022 Nov;27(46). Available from: https://doi.org/10.2807/1560-7917.ES.2022.27.46.2200803
- Footnote 35
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Eyre DW, Town K, Street T, Barker L, Sanderson N, Cole MJ, Mohammed H, Pitt R, Gobin M, Irish C, Gardiner D, Sedgwick J, Beck C, Saunders J, Turbitt D, Cook C, Phin N, Nathan B, Horner P, Fifer H. Detection in the United Kingdom of the Neisseria gonorrhoeae FC428 clone, with ceftriaxone resistance and intermediate resistance to azithromycin, October to December 2018. Euro Surveill [Internet]. 2019;24(10). Available from: https://doi.org/10.2807/1560-7917.ES.2019.24.10.1900147
- Footnote 36
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Eyre DW, Sanderson ND, Lord E, Regisford-Reimmer N, Chau K, Barker L, Morgan M, Newnham R, Golparian D, Unemo M, Crook DW, Peto TEA, Hughes G, Cole MJ, Fifer H, Edwards A, Andersson MI. Gonorrhoea treatment failure caused by a Neisseria gonorrhoeae strain with combined ceftriaxone and high-level azithromycin resistance, England, February 2018. Euro Surveill [Internet]. 2018;23(27). Available from: https://doi.org/10.2807/1560-7917.ES.2018.23.27.1800323
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