Hamilton Public Health Services (PHS) is notifying healthcare providers of changes to the treatment of uncomplicated gonococcal infections in adults and adolescents (10 years and older). Gonococcal infection, caused by Neisseria gonorrhoeae (NG), is a significant public health concern due to rising antimicrobial resistance (AMR) and increasing infection rates in Canada. In response to increasing rates of infection and AMR, the National Advisory Committee on Sexually Transmitted and Blood-Borne Infections (NAC-STBBI) has released interim guidance, which is now being adopted by Ontario. There will no longer be Ontario-specific gonorrhea treatment guidelines and previous guidance will be removed from Public Health Ontario’s website. 

Key Messages for Health Care Providers

• Recommended first-line treatment for all uncomplicated gonococcal infections, including urethral, endocervical, vaginal rectal and pharyngeal infections, is a single dose of 500 mg of Ceftriaxone intramuscularly (IM). This is a change from the previous recommendation for combined therapy with 250 mg Ceftriaxone (IM) and 1 gram of Azithromycin PO in a single dose.
• Since 500 mg vials of Ceftriaxone are not available in Canada, please continue to use the 250 mg vials to administer the recommended 500 mg dose. It is preferable to administer two separate 250mg injections to reduce the risk of dosing errors. If given as one injection, careful attention should be given to reconstitution to avoid medication administration errors. Each 250mg vial must be reconstituted with 0.9 mL of lidocaine or sterile water to provide a final volume of 2 mL
• If chlamydia has not been excluded by a negative test, concurrent treatment for chlamydia is recommended. Refer to the Chlamydia and LGV guide: Treatment and follow-up - Canada.ca.
• It is recommended to collect a culture, along with specimens for nucleic acid amplification testing (NAAT) when possible, in cases such as: symptomatic patients, suspected treatment failure, infections from areas with high antimicrobial resistance, pelvic inflammatory disease (PID), pregnancy, sexual abuse or assault, or an asymptomatic person notified as a contact of a case.

Test of Cure 
A Test of Cure (TOC) is recommended for all cases of gonorrhea at all positive sites, particularly if a regimen other than ceftriaxone 500 mg IM is used. Recommendations for test of cure depend on timing after treatment completion and patient’s symptom status.

• If a test of cure is done 3 to 21 days after treatment completion, culture is recommended regardless of the patient’s symptom status.
• If test of cure is done after 21 days from treatment completion and the patient is:
  • Asymptomatic – NAAT is recommended.
  • Symptomatic – Both Culture and NAAT are recommended.

Treatment Failure
Treatment failure in gonococcal infections is defined by the absence of sexual contact during the post-treatment period, along with one of the following: presence of Gram-negative intracellular diplococci on microscopy 72 hours after treatment, a positive N. gonorrhoeae culture 72 hours post-treatment, or a positive NAAT 3-4 weeks after treatment. In cases of treatment failure, healthcare providers should notify Hamilton Public Health Services and consider consulting an infectious disease specialist as necessary to determine the appropriate antimicrobial therapy based on susceptibility test results. 

Alternative Treatments
Alternative treatments for uncomplicated gonococcal infections are currently under review by the NAC-STBBI. You can continue to refer to the current alternative treatment regimens per the federal guidelines. 

Ordering Free STI Medications
Healthcare providers can order STI medications by faxing the STI Medication Ordering Form, which is at www.hamilton.ca/hcp, to 905-546-3472.  

Please refer to the federal guidance and supporting documents for further details.

For further information on Gonorrhea treatment and follow-up please refer to the Gonorrhea guide: Treatment and follow-up. 

If you have any questions, call 905-528-5894 to speak with a Public Health Nurse Monday to Friday  8:30am to 4:30pm.