Abstract
Increasing rates of gonococcal (GC) infection and antimicrobial resistant (AMR) GC, are a serious public health concern for Canada and around the world. Previously recommended treatments are ineffective against many of the gonorrhea strains circulating today. The current recommendation for combination therapy is now being threatened by globally emerging and increasingly resistant strains. It is important that coordinated efforts be made now to ensure these new global strains do not become established in Canada. Otherwise, we will be faced with the possibility of persistent GC infection which can lead to pelvic inflammatory disease, infertility and chronic pelvic pain in women; and epididymitis in men. The presence of GC can also increase the risk of HIV acquisition and transmission.There are a number of reasons why we are facing this public health threat. GC infection is often asymptomatic and it is highly transmissible. People may hesitate to seek testing (or to offer testing). Treatment is complex: recommendations vary by site of infection and risk of resistance. Sexual contact during travel is an important source of imported emerging resistant global strains. The new screening and diagnostic Nucleic Acid Amplification Test (NAAT) is excellent but has decreased the number of cultures being done and therefore our capacity to track AMR-GC.There are four key actions that clinicians and front-line public health professionals can take to stem the increase in rates of GC and drug resistant GC. First, normalize and increase GC screening based on risk factors and emphasize the need for safer sex practices. NAAT is useful for screening, but culture is still needed for extra-genital sites. Second, conduct pretravel counselling and include a travel history as part of the risk assessment. Third, use culture along with NAAT to establish the diagnosis and follow up for test-of-cure. Finally, refer to the most current Canadian Guidelines on Sexually Transmitted Infections or provincial/territorial recommendations on combination therapies for patients and their contacts as recommendations may have changed in response to evolving AMR-GC trends.
Highlights
Increasing antimicrobial resistance (AMR) in Neisseria gonorrhoeae, seen both domestically and internationally, combined with rising rates of gonococcal (GC) infection, are a serious public health concern
Clinicians and front-line public health professionals are well placed to proactively screen and treat patients testing positive for GC or AMR-GC, and counsel all those at risk, on the risks of sexually transmitted infection (STI) and travel
Cultures are needed for diagnosis when possible, and to assess treatment effectiveness, to prevent ongoing transmission and allow for effective monitoring of AMR
Summary
Increasing antimicrobial resistance (AMR) in Neisseria gonorrhoeae, seen both domestically and internationally, combined with rising rates of gonococcal (GC) infection, are a serious public health concern. In Canada and globally, isolates are exhibiting decreased susceptibilities to the extended-spectrum cephalosporins and increasing resistance to azithromycin, and treatment failures have been reported [8,9,10,11] In this issue, Martin et al identify that between 2012 and 2016, the proportion of MDR-GC isolates increased from 6.2% to 8.9% and that XDR-GC was rare (0.1% over the same 4-year period) [7]. The recent reports of the novel strain FC428 in travel-related AMR-GC cases in Canada reminds us that certain parts of the world, most Southeast Asia, have seen the emergence of novel resistant strains (MDR and XDR) that pose a risk to Canadians. Discomfort with taking a sexual history and performing genital exams, and a lack of time due to competing medical priorities, have been cited as barriers to STI testing [41,42,43,44]
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