Original Title: Approche syndromique : traitement pharmacologique

Authors' objectives: The last update of the Institut national d’excellence en santé et en services sociaux’s optimal usage guide on the syndromic approach and decision algorithm for the epidemiological treatment of asymptomatic partners was done in 2020. Since Neisseria gonorrhoeae resistance to antibiotics continues to increase and changes have been made to certain recommendations in the national and international guidelines, it was considered advisable to revise the contents of the optimal usage guide and decision algorithm in light of the new, available data and guidelines.

Authors' results and conclusions: RESULTS (#1 THE OPTIMAL USAGE GUIDE CONCERNS THE MANAGEMENT OF PERSONS 14 YEARS OF AGE AND OLDER WITH A CLINICAL SYNDROME CONSISTENT WITH A SEXUALLY TRANSMITTED AND BLOODBORNE INFECTION BEFORE THE LABORATORY TEST RESULTS ARE OBTAINED (SYNDROMIC APPROACH) AND OF THEIR SEXUAL PARTNERS): Management involves ordering the appropriate microbiological tests for all the exposed sites. A culture to screen for N. gonorrhoeae is still a test of choice if signs or symptoms are present, in addition to obtaining a specimen to check for Chlamydia trachomatis and N. gonorrhoeae with a nucleic acid amplification test (NAAT). (#2 THE RECOMMENDED EMPIRICAL TREATMENT FOR A SUSPECTED SEXUALLY TRANSMITTED AND BLOOD-BORNE INFECTION SHOULD COVER AT LEAST C. TRACHOMATIS INFECTION AND N. GONORRHOEAE INFECTION): C. trachomatis and N. gonorrhoeae are the sexually transmitted pathogens most often responsible for the clinical syndromes included in this optimal usage guide. (#3 IF THE PATIENT IS NOT PREGNANT, THE PREFERRED EMPIRICAL TREATMENT FOR A PRESUMED C. TRACHOMATIS INFECTION IS DOXYCYCLINE): Azithromycin is a second choice of empirical treatment for chlamydia and is to be used when a treatment compliance problem is anticipated or if the person is allergic to doxycycline. In the presence of pregnancy, the first choice of empirical treatment is azithromycin, and the second choice is amoxicillin. (#4 THE PREFERRED EMPIRICAL TREATMENT FOR A PRESUMED N. GONORRHOEAE INFECTION IS INTRAMUSCULAR CEFTRIAXONE. THE RECOMMENDED SINGLE DOSE OF INTRAMUSCULAR CEFTRIAXONE USED FOR THE EMPIRICAL TREATMENT OF GONORRHEA HAS BEEN INCREASED TO 500 MG IN THIS UPDATE (PREVIOUSLY, THE RECOMMENDED DOSE WAS 250 MG): The first choice of empirical treatment for an N. gonorrhoeae infection is now intramuscular ceftriaxone for all (including in the presence of pregnancy or breastfeeding), this regardless of the infected or exposed sites. Since an oral treatment must be available in situations where intramuscular administration is refused, contraindicated or impossible, the orally administered cefixime-azithromycin combination is a second choice for the treatment of a presumed gonococcal infection. (#5 WHEN NAAT DETECTS THE PRESENCE OF C. TRACHOMATIS, IT IS IMPORTANT TO DETERMINE IF A TEST OF CURE IS INDICATED. IF N. GONORRHOEAE IS DETECTED BY NAAT OR CULTURE, A TEST OF CURE IS ALWAYS RECOMMENDED. THE RECOMMENDED TEST OF CURE FOR A CONFIRMED C. TRACHOMATIS OR N. GONORRHOEAE INFECTION IS NAAT PERFORMED AS SOON AS POSSIBLE, STARTING 3 WEEKS AFTER THE END OF TREATMENT (PREVIOUSLY, THE TEST OF CURE BY NAAT FOR N. GONORRHOEAE WAS RECOMMENDED STARTING 2 WEEKS AFTER THE END OF TREATMENT; THE INTERVAL WAS INCREASED TO 3 WEEKS IN ORDER TO BE IN LINE WITH THE RECOMMENDATION FOR C. TRACHOMATIS AND TO DECREASE THE LIKELIHOOD OF OBTAINING A POSITIVE NAAT RESULT CAUSED BY THE PERSISTENCE OF RESIDUAL GENETIC MATERIAL (NONVIABLE BACTERIA): The recommendations concerning the preferred test of cure and when it should be performed are now the same for C. trachomatis and N. gonorrhoeae infections, namely, NAAT performed as soon as possible, starting 3 weeks after the end of treatment. If the specimen is obtained during the 3 weeks following treatment, N. gonorrhoeae screening should be done by culture. CONCLUSION: The update of the optimal usage guide and of the decision algorithm is based on clinical practice recommendations, which were supplemented with the perspectives of the stakeholders consulted and contextualized for Québec practice. These tools should help enhance and harmonize the practice and contribute to the effective management of persons with a clinical syndrome consistent with a sexually transmitted and blood-borne infection and of their sexual partners.

Authors' methods: A systematic review of the best clinical practices for managing clinical syndromes potentially associated with a sexually transmitted and blood-borne infection was conducted in accordance with Institut national d’excellence en santé et en services sociaux’s usual standards. The data were analyzed from the perspective of contextualizing the practice in Québec, based mainly on legislative, regulatory and organizational contextual elements specific to Québec and on the perspectives of the different stakeholders consulted. An advisory committee consisting of clinicians from different specialties and areas of expertise was created to gather the stakeholders’ perspectives. Lastly, the overall quality of the optimal usage guide and decision algorithm and their acceptability and applicability were assessed by external reviewers who are specialists in the field of interest and by future users who did not participate in the project.

Authors' identified further research: The advisability of updating the recommendations will be determined in 4 years from the date of publication, on the basis of the advances in the scientific data, changes in clinical practices, any significant changes in additional background documents published for example by the Ministère de la Santé et des Services sociaux or the Institut national de santé publique du Québec, and the health and social services system’s needs in terms of future work on the management of clinical syndromes potentially due to a sexually transmitted and blood-borne infection.

Project Status: Completed

Year Published: 2024

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Outils/Guides_ITSS/INESSS_ITSS_App-Syndrome_Rapport.pdf

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)