Enhanced Surveillance of Antimicrobial-Resistant Gonorrhea System (ESAG): Antimicrobial-resistant gonorrhea

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• Figure 1: The proportion of ESAG cases with gonorrhea cultures that demonstrated resistance (R) and/or decreased susceptibility (DS) to up to five antimicrobials, 2018 to 2023
• Figure 2: Proportion of ESAG cases with gonorrhea cultures demonstrating resistance (R) or decreased susceptibility (DS) to select antimicrobials, 2018 to 2023
• Gonorrhea treatment failures among ESAG cases, 2018 to 2023

Figure 1: The proportion of ESAG cases with gonorrhea cultures that demonstrated resistance (R) and/or decreased susceptibility (DS) to up to five antimicrobials, 2018 to 2023

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What is measured?

The proportion of ESAG cases with gonorrhea cultures that demonstrated resistance (R) and/or decreased susceptibility (DS) to up to five antimicrobials.

Why is this indicator important?

This indicator shows the proportion (in other words, prevalence) of antibiotic-resistance burden as measured by the number of antibiotics a gonococcal isolate is resistant to (for the antibiotics, azithromycin, cefixime, ceftriaxone, ciprofloxacin, spectinomycin, penicillin, or tetracycline) or demonstrates decreased susceptibility towards (for the antibiotics, cefixime and ceftriaxone). An isolate showing decreased susceptibility or resistance to an antibiotic means that the antibiotic may not cure the infection.

Because gonorrhea is treated empirically (meaning that clinicians prescribe medication without knowing which antibiotics are likely to cure or not cure the gonorrhea infection), it’s ideal to have strains of gonorrhea that are susceptible to as many antibiotics as possible. Thus, the best outcome for this indicator is for an isolate to be ‘susceptible to all antimicrobials’. As the number of antibiotics that an isolate is resistant to/shows decreased susceptibility towards goes up, the fewer the number of treatments that would theoretically work to treat a client’s gonorrhea successfully. Thus, ‘R/DS to 5 antimicrobials’ is the worst outcome for this indicator.

Figure 2: Proportion of ESAG cases with gonorrhea cultures demonstrating resistance (R) or decreased susceptibility (DS) to select antimicrobials, 2018 to 2023

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Note: The black dashed line represents the World Health Organization's (WHO's) threshold of AMR-GC concern. The WHO recommends discontinuing an antimicrobial as an empiric treatment for gonorrhea if 5% or more of tested gonococcal isolates show resistance to that antimicrobial.^{Reference 1}

What is measured?

This indicator shows the proportion (prevalence) of gonococcal isolates that were resistant (R) to the antibiotics: azithromycin, cefixime, ceftriaxone, ciprofloxacin, spectinomycin, penicillin, or tetracycline; decreased susceptibility (DS) to cefixime and ceftriaxone; and R/DS to the most prescribed gonorrhea treatment combinations (azithromycin and cefixime or azithromycin and ceftriaxone).

Why is this indicator important?

An isolate showing resistance or decreased susceptibility to an antibiotic implies that the infection may not be effectively cured, underscoring the serious consequences of antibiotic resistance in gonorrhea.

The best outcome for this indicator is for the proportion of isolates demonstrating resistance or decreased susceptibility to a specific antibiotic to be under 5%. The 5% cutoff of concern is represented as dashed lines in Figure 2. Any antibiotic showing resistance or decreased susceptibility at or above 5% warrants attention, as it meets the resistance level at which the World Health Organization advises discontinuing the use of an antibiotic as empiric treatment.^{Reference 1}

Gonorrhea is treated empirically (meaning clinicians prescribe medication without knowing a gonorrhea strain's resistance profile). Thus, it’s ideal to have strains of gonorrhea circulating in a community that would respond (in other words, be susceptible) to:

1. antibiotics that are recommended in gonorrhea treatment guidelines, and
2. ideally, as many antibiotics as are available to treat the infection.

Between 2018 and 2023, the preferred treatment regimens to treat uncomplicated gonorrhea (regardless of the infection site, sexual behaviour, or age), according to PHAC and ESAG participating provincial and territorial guidelines were:

• ceftriaxone 250mg (intramuscular) with azithromycin (1g) (oral) OR
• cefixime 800mg with azithromycin (1g) (oral)

Finally, this indicator provides antibiotic resistance prevalence by the gender/sex/sexual behaviour group. This allows one to identify differences in drug-resistance levels within these populations, prompting one to consider if treatment guidelines should be adjusted accordingly.

Gonorrhea treatment failures among ESAG cases, 2018 to 2023

Between 2018 and 2023, there were no laboratory-confirmed cases of gonorrhea treatment failures. Out of the 21 cases reported by public health authorities as suspected treatment failures, none of the isolates from these cases demonstrated resistance or decreased susceptibility to all prescribed treatment regimens. This suggests that these cases were either reinfected or did not take their medication correctly.

References