Original Title: Infection confirmée à Chlamydia trachomatis ou à Neisseria gonorrhoeae

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

Authors' results and conclusions: RESULTS (#1 THE OUG APPLIES TO PERSONS 14 YEARS OF AGE AND OLDER IN WHOM THE APPROPRIATE MICROBIOLOGICAL TESTS HAVE BEEN PERFORMED AND WHOSE RESULTS SHOW THE PRESENCE OF C. TRACHOMATIS OR N. GONORRHOEAE AND TO THEIR SEXUAL PARTNERS): When such an infection is detected, it is important to check that microbiological tests have been performed for all the exposed sites. If a gonococcal infection has been detected solely by nucleic acid amplification test (NAAT), culture specimens from the infected sites for determining the strain’s susceptibility should be obtained before initiating treatment. However, collecting these specimens should not delay treatment. (#2 THE PREFERRED TREATMENT FOR NON-PREGNANT INDIVIDUALS WITH A CONFIRMED C. TRACHOMATIS INFECTION OR FOR THEIR NON-PREGNANT ASYMPTOMATIC PARTNERS IS DOXYCYCLINE): The terms “first choice of treatment“ (for doxycycline) and “second choice of treatment“ (for azithromycin) have been added to the treatment table in the updated OUG, together with the possible reasons justifying the use of the second choice of treatment. These reasons are an anticipated treatment compliance problem or a doxycycline allergy in the infected individual and an anticipated treatment compliance problem, a doxycycline allergy or the use of expedited partner therapy (EPT) in the asymptomatic partner. In the presence of pregnancy, the first choice of treatment is azithromycin, the second choice being amoxicillin. (#3 THE PREFERRED TREATMENT FOR PERSONS WITH A CONFIRMED N. GONORRHOEAE INFECTION AND FOR THEIR ASYMPTOMATIC PARTNERS IS INTRAMUSCULAR CEFTRIAXONE. THE RECOMMENDED SINGLE DOSE OF INTRAMUSCULAR CEFTRIAXONE HAS BEEN INCREASED TO 500 MG IN THE PRESENT UPDATE (PREVIOUSLY, THE RECOMMENDED DOSE WAS 250 MG): Since ceftriaxone is the antibiotic of choice for treating gonorrhea, the terms “first choice of treatment“ (for ceftriaxone) and “second choice of treatment“ (for the combination of cefixime and azithromycin) have been added to the treatment table in the updated OUG. The first and second choices of treatment are the same for an infected individual and their asymptomatic partners. (#4 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 OUG 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 confirmed C. trachomatis or N. gonorrhoeae infection and of their sexual partners. However, the enhancement and harmonization of the practice will depend on: • The dissemination of the updated OUG and decision algorithm; • The adherence to the changes and the uptake of the recommendations by the health professionals concerned; • The availability of training, if needed; and • The promotion of these tools within the health and social services system.

Authors' recommendations: Following the iterative process with the advisory committee’s members, during which the clinical data and recommendations from the literature, the contextual information and the perspectives of the different stakeholders consulted were triangulated, a series of conclusions and recommendations were drawn up regarding the management of confirmed C. trachomatis or N. gonorrhoeae infections. These recommendations appear in text boxes throughout this report and has been incorporated into the clinical tools stemming from this project, namely an optimal usage guide and a decision algorithm.

Authors' methods: For the purpose of this request, a systematic review of the scientific literature on the best clinical practices for managing confirmed C. trachomatis or N. gonorrhoeae infections was carried out of publications found in bibliographic databases and in other information sources. The data were analyzed from the perspective of contextualizing Québec practice, based mainly on legislative, regulatory and organizational contextual information specific to Québec, on surveillance data on N. gonorrhoeae resistance in Québec and elsewhere in the world, and on the perspectives of the different stakeholders consulted. To gather these perspectives, an advisory committee consisting of clinicians from different specialties and areas of expertise was formed. Lastly, the overall quality of the optimal usage guide and decision algorithm, their acceptability and their applicability were assessed by external reviewers specializing 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 N. gonorrhoeae resistance, the evolution of 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 confirmed C. trachomatis or N. gonorrhoeae infections.

Project Status: Completed

Year Published: 2024

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Outils/Guides_ITSS/INESSS_Rapport-soutien-GUO_ITSS_Chlamydia-Gono.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)