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Symptoms
Males
Females
No
Symptoms
Is there Rectal or
Pharyngeal Exposures*?
Males and
Females
Culture
AND
Endocervial culture
Urethral Culture (1st)
and
Urine NAAT
and
Urine NAAT
Endocrevical, vaginal
or
NAAT
urine NAAT
* For all symptomatic individuals and asymptomatic men who have sex with men and women with a history of
performing oral sex.
Source: Public Health Agency of Canada (2013)
Adapted from Public Health Ontario (2013)
September 2014
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Treatment Recommendations
Q6: What is the recommended treatment for uncomplicated gonorrhea (ano-genital or
pharyngeal gonorrhea) in Saskatchewan?
A6: Until further notice, first-line treatment for persons above nine years of age (including
pregnant women and nursing mothers) with confirmed or suspected uncomplicated
urogenital gonorrhea (cervix, vagina, pharynx or rectum) and their sex partners is Ceftriaxone
250 mg intramuscularly plus azithromycin 1g orally.
Q7: Why are two antimicrobials recommended to treat gonorrhea?
A7: Treatment of gonorrhea with two antimicrobials is recommended nationally to improve the
efficacy of treatment and delay the emergence and spread of resistance in N. gonorrhoeae.
Cephalosporin-azithromycin combination therapy has also been found to be more effective in
treating pharyngeal infections, which are usually asymptomatic.
Q8: Is azithromycin being used to treat chlamydia or gonorrhea?
A8: Both. Individuals with gonorrhea are commonly co-infected with chlamydia. Azithromycin
treats chlamydia and also acts synergistically with cephalosporin to treat gonorrhea.
Q9: When should treatment be provided?
A9: In general, do not provide treatment for gonorrhea until there is laboratory evidence of
gonorrhea infection. However, provide empiric treatment prior to receiving confirmatory lab
results in the following circumstances:
Patient presents with urethra/cervical mucopurulent discharge:
If the partner is infected with gonorrhea, ceftriaxone and azithromycin should be provided;
OR
If follow-up is not assured, ceftriaxone and azithromycin should be provided; OR
Provide azithromycin to treat chlamydia and if local prevalence of gonorrhea is high (contact
your medical health officer if you require details of local epidemiology), consider treating
with ceftriaxone.
Patient presents without urethral/cervical mucopurulent discharge:
If the individual is at high risk for infection and follow-up is not assured, provide ceftriaxone
and azithromycin; OR
If the sexual partner is infected with gonorrhea, provide ceftriaxone and azithromycin.
Q10: What is the recommendation for second line treatment for gonorrhea?
A10: Because cefixime is currently not available, second line options are Spectinomycin 2 g
intramuscular plus Azithromycin 1 g orally OR Azithromycin 2 g orally (SEE BOX BELOW: Cautions
regarding Azitthromycin). Note: Spectinomycin is only available through Health Canadas Special
Access Programme using Form A http://www.hc-sc.gc.ca/dhp-mps/alt_formats/hpfbdgpsa/pdf/acces/sapf1_pasf1-eng.pdf
September 2014
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Management of Contacts
Q20: Who is a contact?
A20: All partners who have had sexual contact with the case (including oral, anal and vaginal) within
60 days prior to symptom onset or when the specimen was collected if the case was asymptomatic.
If your patient indicates having no partners in the past 60 days, the most recent partner should be
notified (Public Health Agency of Canada, 2013).
Q21: How do I manage a contact?
A21: All contacts should be assessed, tested, treated empirically and counseled.
Q22: What is required as part of an assessment?
A22: In addition to the physical assessment, a risk assessment should be completed to determine if
the contact has more risks than the known exposure. See Attachment Risk Assessment
Questionnaire in the Saskatchewan Communicable Disease Control Manual:
http://www.health.gov.sk.ca/cdc-section5
Q23: What testing is required for contacts?
A23: Testing (culture versus NAAT) should be conducted based on symptoms. See Questions #1
and #4 for Gonorrhea Testing Recommendations (Symptomatic or Asymptomatic Patients).
In addition to completing gonorrhea tests, test contacts for chlamydia, syphilis and HIV due to
the increased risk of co-infection with other STIs. Additional tests should be completed based
on the risk assessment.
Q24: How do I treat a contact?
A24: Give empiric treatment with ceftriaxone 250 mg intramuscularly plus azithromycin 1 g orally as
soon as possible to all sexual contacts of cases regardless of clinical findings and without waiting for
test results (Public Health Agency of Canada, 2013). Empiric treatment is recommended to reduce
the risk of further transmission and the potential of re-infecting their treated partner.
Q25: What counseling should be provided to contacts?
A25: Patient information sheets on gonorrhea and the medications are available. Provide contacts
information about contraindications, side effects, drug interactions and the length of time that they
should abstain from unprotected intercourse (i.e. for 7 days following completion of treatment).
Recommend STI testing every six months for at-risk individuals.
September 2014
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5% Dextrose Injection
Bacteriostatic Water for Injection
For detailed information about the agent used as a diluent for the specific product received from
your local health unit please refer to the product monographs at
http://www.sterimaxinc.com/media/djcatalog/20110503_105815_IIIIAA000.02%20Ceftriaxone_PI
_all%20strengths_REV2.pdf and http://www.alvedapharma.com/PDF/LidocaineEnglish.pdf
September 2014
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http://www.qp.gov.sk.ca/documents/English/Regulations/Regulations/O1-1R1.pdf
Source: http://books.mcgrawhill.com/medical/NursesDrugHandbook/safe_drug_admin/identifying_injection_sites/IdentifyingInjectionSites.php
2
September 2014
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Follow-Up of Individuals
Q33: What is the definition of Gonorrhea Treatment Failure?
A33: Gonorrhea Treatment Failures are defined as treated individuals with confirmed gonorrhea
and a positive test of cure (NAAT or culture) in the absence of risk of reinfection (i.e., patient denies
potential sexual re-exposure) (Public Health Agency of Canada, 2014). False positive results may
occur if a culture was taken less than 4 days after treatment or the NAAT was taken less than 4
weeks after treatment.
Q34: What do I do if I am concerned that my patient has had treatment failure?
A34: If first-line treatment was not used initially, use the first-line treatment, if no
contraindications. Perform a test of cure using culture four to five days post re-treatment.
Report any suspected or confirmed gonorrhea treatment failures to your local public health unit.
Once notified of a suspected or confirmed case of gonorrhea treatment failure, the public health
unit will work with the responsible health care practitioner to provide notification to Saskatchewan
Ministry of Health and to discuss any further public health action that may be required.
Q35: Why do I need to disclose treatment failures to my local Medical Health Officer?
A35: Disclosure is required in order to monitor resistance patterns of multi-drug resistant N.
gonorrhoeae, to ensure individuals are being treated effectively for gonorrhea, and to limit ongoing
transmission. In order to do this, health care practitioners, local public health units and the
Saskatchewan Ministry of Health must work together to make sure each is aware of treatment
failures.
Resources
Q36: Where can I go to get more information?
A36: There are several resources to turn to for more information regarding multi-drug resistant
gonorrhea, and the assessment and management of gonorrhea and sexually transmitted
infections in general.
Your local public health office or medical health officer can answer questions you may have. You
can also access the Saskatchewan Communicable Disease Control Manual online at
http://www.health.gov.sk.ca/communicable-disease-control-manual
Also see The Canadian Guidelines on Sexually Transmitted Infections (Public Health Agency of
Canada): http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/index-eng.php
September 2014
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References
Association of Public Health Laboratories (2014)
http://www.aphl.org/AboutAPHL/publications/Documents/ID_2014Mar_Transportation-ofSpecimens-for-Neisseria-gonorrhoeae-Culture.pdf
British Columbia Centers for Disease Control - http://www.bccdc.ca/dis-cond/az/_g/Gonorrhea/default.htm
Public Health Agency of Canada - http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/indexeng.php and http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-6-eng.php
Public Health Ontario (2013) http://www.publichealthontario.ca/en/eRepository/Guidelines_Gonorrhea_Ontario_2013.pdf
Saskatchewan Communicable Disease Control Manual http://www.health.gov.sk.ca/communicable-disease-control-manual
US Centers for Disease Prevention and Control - http://www.cdc.gov/std/Gonorrhea/
Hill (2012) Gonorrhea Develops Rapid Resistance to Azithromycin. Medscape. Mar 15, 2012.
http://www.medscape.com/viewarticle/760301_print
Centers for Disease Control and Prevention (2011) Neisseria gonorrhoeae with Reduced
Susceptibility to Azithromycin, Morbidity and Mortality Weekly Report. 2011;60(18):579-581
September 2014
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