Multidrug-Resistant (MDR) Gonorrhea Identified in Ontario and NEW HIV Testing Guidelines

Background

Hamilton Public Health Services (PHS) is notifying health care providers of a first of its kind MDR strain of Neisseria gonorrhoeae (N. gonorrhoeae) identified in Ontario. The identified MDR strain has reduced susceptibility to cefixime and ceftriaxone, as well as resistance to ciprofloxacin, penicillin, and tetracycline. The isolate was susceptible to azithromycin. Although MDR strains of N. gonorrhoeae have been reported in Europe and the USA, the Ontario case has no known travel history. This suggests that circulation of multi-drug resistant N. gonorrhoeae is likely occurring within Ontario.

Physician Action

When testing, N. gonorrhoeae culture plus a nucleic acid amplification test (NAAT) is recommended for the following scenarios:

1. Symptomatic patients, when antimicrobial resistance is suspected
2. Pelvic inflammatory disease
3. Pregnancy
4. Sexual abuse or sexual assault

NOTE: A NAAT is more sensitive, while a culture will provide antibiotic susceptibility information, which is important for optimizing treatment.
When screening asymptomatic men who have sex with men (MSM), collect additional NAAT pharyngeal and rectal samples. These sites are often reservoirs of asymptomatic infection. These sites should be considered for all persons depending on their sexual practices.

Treatment

First line treatment in Ontario, for suspected or confirmed gonorrhea cases, is Ceftriaxone 250 mg IM and Azithromycin 1 gm po x 1 dose

• Please refer to the Ontario Gonorrhea Testing and Treatment Guide, 2nd Ed. (Nov 2018) for further details. Ontario’s guidelines are currently under review.
• NOTE: Re-treatment is not required for those who are treated as per other evidence-based guidelines such as the US Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines, 2021

Patients should be instructed to abstain from sex for 7 days after they (and their partners) have completed treatment and symptoms have resolved. General counselling on sexually transmitted and bloodborne infections (STBBI) should be provided.

Treatment Failure

Treatment failure is defined as an absence of reported sexual contact during the post-treatment period AND one of the following:

• Presence of intracellular Gram-negative diplococci on microscopy in specimens taken at least 72 hours after treatment completion (for penile urethral swabs only);
• Positive N. gonorrhoeae on culture taken at least 72 hours after treatment completion;
• Positive N. gonorrhoeae NAAT taken at least 2-3 weeks post-treatment.

In the event of cephalosporin treatment failure, consultation with an infectious disease specialist is recommended.

Clinical Follow-up

• Test of cure is recommended for all positive cases of N. gonorrhoeae, at all positive sites.
  • A culture is the preferred method for test of cure and should be obtained three to seven days after treatment completion.
  • If a culture is not possible, test of cure by a NAAT is acceptable and should be obtained two to three weeks after treatment completion.
  • NOTE: If the NAAT is done earlier than two weeks, there is a higher risk of a false positive result. If clinical failure or resistance to treatment is suspected, a culture is essential to guide treatment.
• Repeat gonorrhea screening is recommended six months post-treatment for all individuals with N. gonorrhoeae infection.
• Consider offering testing for other STBBIs including syphilis, chlamydia, HIV and hepatitis C, as appropriate, if not already completed.

New HIV Testing Guidelines

The release of the Ontario Guidelines for Providers Offering HIV Testing represents a progressive step forward in efforts toward the elimination of new HIV infections in Ontario.

The guidelines recommend:

• Streamlined testing and counselling for people at risk of HIV infection
• A stronger focus on identifying symptoms of acute and chronic HIV
• Routine testing for members of populations with higher rates of HIV
• Reducing the current HIV testing window period for definitively diagnosing HIV from 3 months to 6 weeks, to reflect advances in testing technologies.

The guidelines also include:

• A one-page algorithm of Ontario’s testing recommendations,
• Person-centered standards for HIV counselling and support, including guidance on referrals and follow-up, and
• A resource list.

Reporting Requirements:

Gonorrhea and AIDS are reportable to the Medical Officer of Health under the Health Protection and Promotion Act, R.S.O. 1990, c. H.7.
Reporting to Hamilton Public Health Services:
To report Gonorrhea cases, call PHS Monday to Friday, 8:30 am to 4:30 pm at 905-528-5894 or fax 905-546-4078.