Updated treatment recommendations for N. gonorrhoeae
To: Ottawa Physicians and Nurse Practitioners
Date: January 27, 2025
From: Dr. Michelle Foote, Associate Medical Officer of Health
Dear Colleagues,
Please see the attached memo (available only in English) from the Ministry of Health regarding updated treatment recommendations for N. gonorrhoeae.
The Public Health Agency of Canada (PHAC) has provided updated interim guidance on the treatment of N. gonorrhoeae infections, due to changing patterns of antibiotic resistance. The preferred treatment for uncomplicated (urethral, endocervical, vaginal, rectal and pharyngeal) gonococcal infections in adults and adolescents 10 years or older (including pregnant people) is now ceftriaxone 500mg IM as a single dose. Note that this is a higher dose of ceftriaxone than in previous guidance and is now used as a monotherapy; azithromycin is no longer indicated as part of the preferred treatment regimen if C. trachomatis infection has been ruled out. If C. trachomatis infection has not been excluded by a negative test, concurrent treatment for chlamydia is recommended. See PHAC guidance on the treatment of Chlamydia and LGV for further details.
Further guidance is anticipated about the management of complicated gonococcal infections, such as pelvic inflammatory disease, as complicated infections were not included in the interim guidance update.
Updated Treatment Recommendations
Refer to PHAC interim guidance on the treatment of N. gonorrhoeae infections for details on treatment considerations and contraindications. Final treatment recommendations will be provided by PHAC following completion of their review.
Preferred treatment of all uncomplicated infections (interim guidance):
- Ceftriaxone 500mg IM as a single dose (monotherapy)Alternative treatment options (interim guidance):
Alternative treatment options (interim guidance):
- Cefixime 800mg PO in a single dose plus doxycycline 100mg PO BID x 7 days
- Cefixime 800mg PO in a single dose plus azithromycin 1g PO in a single dose
- Azithromycin 2g PO in a single dose plus gentamicin 240mg IM in a single dose
- Gentamicin 240mg IM in a single dose plus doxycycline 100mg PO BID x 7 days
At this time, individuals that have been treated for N. gonorrhoeae infection using the previous preferred treatment (ceftriaxone 250mg plus azithromycin 1g) do not require retreatment. Test of cure is particularly important in this situation when a regimen other than ceftriaxone 500mg IM has been used.
Test of Cure
A test of cure (TOC) is recommended for all sites positive for N. gonorrhoeae. TOC using nucleic acid amplification testing (NAAT) can be obtained at least 3-4 weeks after completion of treatment, and TOC using culture can be obtained at least 3 days after completion of treatment. When treatment failure is suspected more than 3 weeks after completion of treatment, both NAAT and culture are recommended.
Repeat screening continues to be recommended 6 months following treatment.
Publicly funded STI medications
Publicly funded medications for treating STIs can be ordered from OPH and are delivered free-of-charge directly to your clinic. Visit STI Medication Ordering for more details and to place an order.
Previously ordered STI medications can continue to be used prior to their expiry date. Two of the 250mg vials of ceftriaxone can be administered to complete the preferred treatment regimen for N. gonorrhoeae (ceftriaxone 500mg IM as a single dose), and azithromycin tablets can be used for the treatment of chlamydia infections, as indicated. Note that at this time, 500mg vials of ceftriaxone are not available in Canada.
Resources:
- PHAC: Sexually transmitted and blood-borne infections: Guides for health professionals (formerly Canadian Guidelines on STIs).
- Public Health Ontario Laboratory: Test Information Index. Scroll down to N for Neisseria gonorrhoeae.
- Public Health Ontario: Gonorrhea. Treatment guidance is in the process of being removed and updated. Information continues to be available on the epidemiology of gonorrhea infections, including a recently published surveillance report, Gonorrhea in Ontario: Focus in 2023.
- Ottawa Public Health: Order free STI medications and free condoms for clinic waiting rooms.
- GetaKit.ca Online HIV and STI Testing Service: eligible persons in Ottawa can obtain clinically indicated HIV and STI testing services through GetaKit.ca, including at-home HIV self-tests, and requisitions for laboratory-based testing for chlamydia, gonorrhea, syphilis, hepatitis C, and HIV.