Changes in Gonorrhea Treatment Guidance for Health Care Providers

To: Health Care Professionals in Niagara
From: Clinical Services Division, Niagara Region Public Health
Reference: Changes in Gonorrhea Treatment Guidance for Health Care Providers
Date: April 7, 2025

Gonococcal infection, caused by Neisseria gonorrhoeae (NG), is a significant public health concern due to the growing threat of antimicrobial resistance (AMR) and the increasing number of reported NG infection cases. The National Advisory Committee on Sexually Transmitted and Blood-Borne Infections (NAC-STBBI) recently issued interim guidance for the preferred treatment of uncomplicated NG infections, which has been adopted by the Public Health Agency of Canada (PHAC). As a result, Ontario-specific gonorrhea treatment guidelines have been discontinued and removed from the Public Health Ontario website. This memo outlines considerations and recommendations for health care providers pertaining to the new treatment guidance.

First-Line Treatment for Uncomplicated Gonococcal Infections

The updated first-line treatment for adults and adolescents (10 years and older) with uncomplicated gonorrhea is a single 500 mg intramuscular (IM) dose of ceftriaxone. This regimen applies to infections of the urethra, cervix, rectum, and pharynx. If chlamydia trachomatis has not been excluded, concurrent chlamydia treatment is advised. With 500mg vials of ceftriaxone unavailable in Canada, health care providers should use two 250mg vials to provide the necessary treatment.

Alternative Treatment Options

In cases where ceftriaxone administration is not feasible (e.g., lack of access to IM injections, patient refusal, or cephalosporin allergy), alternative regimens are available. Consult the Interim Guidance for the Treatment of Uncomplicated Gonococcal Infection for alternative treatment options. Note that alternative regimens are under ongoing review by the NAC-STBBI.

Importance of Test of Cure (TOC)

A test of cure (TOC) is recommended for all positive gonorrhea cases, particularly when alternative treatments are used and in pharyngeal infections. This helps ensure effectiveness of the therapy and monitor for potential treatment failure. Recommendations for TOC is dependent on timing after treatment completion and symptom status:

• When TOC is performed within 3 to 21 days after completion of treatment, a culture should be performed regardless of symptom status
• When TOC is performed 21 to 28 days after completion of treatment (residual nucleic acids from dead bacteria produce positive results less than 3 weeks after treatment)
  • Asymptomatic: Nucleic Acid Amplification Test (NAAT) is recommended
  • Symptomatic: both culture and NAAT are recommended
• If treatment failure is suspected more than 3 weeks after treatment both NAAT and culture should be performed

NG Culture Recommendations

Cultures are less sensitive than NAAT but provide the opportunity for antimicrobial susceptibility determination.  Recommendations for when to perform an NG culture (together with a NAAT) include:

• In presence of symptoms compatible with cervicitis, urethritis, pelvic inflammatory disease (PID), epididymitis, proctitis or pharyngitis
• When NG infection is confirmed by NAAT only, as long as it does not delay treatment
• For TOC when treatment failure is suspected
• In pregnant individuals
• When an asymptomatic individual is notified as a contact of an NG infected case
• When sexual abuse/assault is suspected
• If the infection might have been acquired in countries or areas with high rates of AMR (e.g. travel to South-East Asia)
• When NG infection is confirmed by NAAT only, as long as it does not delay treatment

Resistance and Special Considerations

The updated treatment guidance emphasizes antimicrobial resistance (AMR) profiles, noting that specific resistance patterns (e.g., to cephalosporins or azithromycin) may require alternative therapies. In cases where both cephalosporins and azithromycin are ineffective, gentamicin or ertapenem may be used, but these treatments should be reserved for exceptional circumstances, under the guidance of an infectious disease specialist.

Follow-Up and Partner Notification

As part of comprehensive care, it is critical to ensure follow-up testing, notification, and treatment for all sexual partners. Treatment adherence and symptom resolution should be monitored, particularly when non-standard therapies are used.

More Information

• To order free STI medication from the Niagara Region Sexual Health program visit our website and use the online medication order form
• For further information, please contact the Niagara Region Sexual Health program at 905-688-3817