Enhanced Surveillance of Antimicrobial-Resistant Gonorrhea System (ESAG): About this dashboard

Welcome to the ESAG Health Infobase dashboard! On this page, you will learn about gonorrhea in Canada, antimicrobial-resistant gonorrhea (more commonly known as antibiotic-resistant gonorrhea), and how Canada monitors antimicrobial-resistant gonorrhea through two important surveillance systems, the Gonococcal Antimicrobial Surveillance Program-Canada (GASP-Canada) and the Enhanced Surveillance of Antimicrobial-resistant Gonorrhea system (ESAG). This page also describes methods for collecting and analyzing ESAG data and some limitations to consider. We recommend reading this page before exploring the ESAG data in the subsequent pages.

On this page

• The ESAG Infobase Platform
• Acknowledgements
• Suggested citation
• Contact us
• Gonorrhea in Canada
• Antimicrobial-resistant gonorrhea
• Federal surveillance of antimicrobial-resistant gonorrhea in Canada
• Methods:
• ESAG case definition
• ESAG data
• Data analysis period
• ESAG variable definitions
• Antimicrobial susceptibility testing of gonorrhea cultures
• Data analysis
• Limitations
• References

The ESAG Health Infobase Platform

The ESAG Health Infobase platform is an interactive data tool that allows users to explore the epidemiologic (ESAG demographic and risk factor characteristics), antimicrobial use appropriateness, and laboratory (antimicrobial (i.e. antibiotic) susceptibility) trends by sex and sexual behaviour) data among ESAG cases.

Acknowledgements

This dashboard was made possible through the collaboration of federal, provincial and territorial public health partners with the Public Health Agency of Canada as well as the GASP-Canada team at the National Microbiology Laboratory in Winnipeg.

Suggested citation

Public Health Agency of Canada (2025). Dashboard on the Enhanced Surveillance of Antimicrobial-resistant Gonorrhea system (ESAG): 2018 to 2023. Available from: Dashboard on the Enhanced Surveillance of Antimicrobial-resistant Gonorrhea (ESAG).

Contact us

For comments or questions regarding this dashboard, the data presented, or to report on antimicrobial-resistant gonorrhea in your jurisdiction, please contact us at sti-hep-its@phac-aspc.gc.ca.

Gonorrhea in Canada

Gonorrhea is a sexually transmitted infection (STI) caused by infection with the bacterium Neisseria gonorrhoeae. Gonorrhea is the second most reported notifiable STI in Canada. In 2023, there were 42,066 gonorrhea cases reported across Canada for a rate of 104.95 cases per 100,000 population of Canada^{Reference 1}. This is three times higher than the rate of gonorrhea cases reported in 2010 (33.5 cases per 100,000 population)^{Reference 1}. Reported case counts and rates of gonorrhea underestimate the true prevalence of gonorrhea in Canada, as many gonorrhea cases are asymptomatic and go undetected.

Gonorrhea spreads easily, is associated with travel-related sexual contact, is often observed alongside chlamydia, and increases the risk of acquisition of HIV^{Reference 2}. Individuals with an N. gonorrhoeae infection, both asymptomatic and symptomatic, may pass on the bacteria to their sexual partners. Those tested for gonorrhea are more likely to be persons who are symptomatic or persons in higher risk categories (e.g., gay, bisexual and other men who have sex with men (GBMSM)) who are routinely screened for STIs and gonorrhea case contacts^{Reference 2}.

Antimicrobial-resistant gonorrhea

While gonorrhea is curable with the appropriate antimicrobials, it remains a serious public health threat in Canada, and globally, as the pathogen N. gonorrhoeae has developed resistance to many antimicrobials over time, including currently recommended treatments in Canada and abroad.

Left unsuccessfully treated (or not treated at all), gonorrhea can cause pelvic inflammatory disease which can lead to infertility or ectopic pregnancies in females and epididymitis in males^{Reference 2}. Furthermore, gonorrhea can also spread to the blood and joints causing disseminated gonococcal infection (DGI), which can become life threatening^{Reference 2}. Gonorrhea can also be passed to a baby at birth and can cause eye infections or DGI in the baby^{Reference 2}.

National surveillance of antimicrobial-resistant gonorrhea in Canada

Continuous monitoring of antimicrobial-resistant gonococcal (AMR-GC) strains, gonorrhea treatment failures, and gonorrhea treatment prescription data linked to epidemiologic data can inform the usefulness and accuracy of gonorrhea treatment guidelines and help in reducing the spread of highly resistant gonorrhea. To this end, the Public Health Agency of Canada (PHAC) monitors AMR-GC through two laboratory-based surveillance systems. The first is PHAC’s NML-led GASP–Canada. GASP-Canada is a passive national surveillance program initiated in the 1980’s which collects and monitors AMR-GC data from antimicrobial susceptibility testing (AST) and the molecular characterization (using N. gonorrhoeae Multi-Antigen Sequence Typing (NG-MAST) sequence types (STs)) of gonorrhea cultures^{Reference 3}. This program has rich laboratory data but limited epidemiologic data on gonococcal (GC) cases.

The second surveillance system is ESAG, which links a subset of GASP-Canada AMR-GC data to epidemiologic and clinical data for an improved understanding of AMR-GC trends across Canada. ESAG started in 2013 and is led by PHAC’s Centre for Communicable Diseases and Infection Control (CCDIC) and the NML. The goal of ESAG is to help inform public health interventions to minimize the spread of antimicrobial resistant N. gonorrhoeae in Canada.

Methods

ESAG case definition

An ESAG case refers to any client 16 years or older that meets the PHAC (i.e., national) definition of a gonorrhea case and had a GC culture analyzed by the PHAC NML or a regional laboratory^{Reference 4}.

ESAG data

ESAG data included linked (via a non-identifying unique ID) de-identified laboratory (antimicrobial susceptibility data), clinical (site of infection, prescribed treatment, and suspected treatment failure) and epidemiologic (demographic and risk behaviour) client-level data from gonorrhea cases.

Clinical and epidemiologic data were extracted from gonorrhea provincial and territorial case report forms and provided by health authorities from the ESAG participating provinces and territories (PTs), Alberta, Manitoba, New Brunswick, Nova Scotia and Northwest Territories. Laboratory data were obtained from GASP-Canada, with the consent of participating PTs. GASP–Canada data include antimicrobial susceptibility and molecular characterization through NG-MAST data.

All ESAG data were entered directly or uploaded into a password-protected, web-accessible, database hosted on the Canadian Network for Public Health Intelligence (CNPHI) platform.

Data analysis period

This dashboard is limited to data from ESAG cases who had GC isolates collected from 2018 through 2023. Alberta, Manitoba, Nova Scotia, and the Northwest Territories provided data for the years 2018-2023. New Brunswick joined ESAG and started providing data in June 2023.

ESAG variable definitions

The following variables were created from the ESAG epidemiologic data:

1. Gender/sex/sexual behaviour:
   The “gender/ sex/ sexual behaviour” variable included the following categories: GBMSM, heterosexual males, males with unknown sexual behaviour, females, and other gender/sex. These were defined as follows,
   • GBMSM: male cases who self-reported their sexual partner(s) as male or male and female
   • Heterosexual males: male cases who only reported having female sexual partners
   • Males with unknown sexual behaviour: male cases that did not have sexual partner information
   • Females: all female cases, regardless of sexual behaviour
   • Other gender/sex: ESAG cases who identified as transgender or gender diverse

   Male and female data were a mix of sex and gender data. This is because some ESAG participating PTs provide sex data, some gender data, and some provide a mix of both.

2. Infection site and type:
   The infection site refers to the location from which the primary culture was collected and determines the infection type. Infection types include:
   • Disseminated gonococcal infection (DGI): Joint, blood, or serum infection site.
   • Pharyngeal infection: Throat infection site.
   • Genital infection: Urethral, urogenital, cervical, or vaginal infection site.
   • Rectal infection: Rectal infection site.
   • Other infections: All other infection sites.
   • Unknown infections: Cases where the infection site was not recorded or could not be determined.

   In accordance with PHAC’s Canadian Guidelines on Sexually Transmitted Infections, in effect from 2018 to 2023, an ‘anogenital infection’ was defined as a GC isolation from cervical, rectal, urogenital, or other anogenital sites (e.g., labia, perineum). Isolations from the throat were categorized as ‘pharyngeal infections’.

3. Reason for medical visit:
   ESAG cases may have had more than one reason for their gonorrhea-related medical visit. However, only one reason was included in the analysis. The reason for medical visit used in data analysis was selected based on the following order of priority (from highest to lowest): test of cure> signs and symptoms> contact with a known gonorrhea case (case contact)> screening for an STI> other.
4. Other adults (gonorrhea treatment prescription data variable):
   ‘Other adults’ refers to heterosexual males and females. This category excludes GBMSM or males with unknown sexual behaviour.
5. Suspected treatment failure:

   Suspected treatment failures included cases who had a positive test of cure or who continued to show signs and symptoms of gonorrhea after initial treatment.

Antimicrobial susceptibility testing of gonorrhea cultures

The Minimum Inhibitory Concentration (MIC) of an antimicrobial therapy (i.e., an antibiotic) that inhibits the growth of N. gonorrhoeae was measured for azithromycin, ceftriaxone, cefixime, ciprofloxacin, erythromycin, penicillin, spectinomycin and tetracycline for all N. gonorrhoeae cultures using agar dilution, or an Etest® (BioMerieux, Laval, Quebec). Etest® was used for the Alberta susceptible cultures which are not sent to the NML. MIC interpretations were based on the Clinical and Laboratory Standards Institute (CLSI) breakpoints except for: cefixime decreased susceptibility (MIC ≥ 0.25 mg/L) and ceftriaxone decreased susceptibility (MIC ≥ 0.125 mg/L)^{Reference 5Reference 6}.GASP-Canada laboratory methods have been previously published and described in greater detail (than what is summarized here) in Antimicrobial susceptibilities of Neisseria gonorrhoeae in Canada, CCDR 51(9) - Canada.ca.

Table 1: The Minimum Inhibitory Concentration (MIC) interpretive standards for azithromycin, ceftriaxone, cefixime, ciprofloxacin, penicillin, spectinomycin and tetracycline

Table notes

• ^a MIC Interpretive Standards as recommended by the Clinical and Laboratory Standards Institute (CLSI 2022) except for cefixime and ceftriaxone ^{Reference 5Reference 6}
• S = Susceptible
• DS = Decreased Susceptibility
• I = Intermediate
• R = Resistant

Data analysis

Selection of primary culture for analysis

Some gonorrhea clients had more than one GC culture collected and analyzed for antimicrobial resistance. If a client had multiple cultures obtained within a 30-day timeframe, the primary culture included in the analysis was the culture that demonstrated the greatest antimicrobial resistance. If more than one culture was received from a client and there was no difference in resistance patterns, the primary culture was prioritized based on the relative likelihood of treatment failure based on the infection type (from highest to lowest likelihood): pharyngeal, rectal, urethral, and cervical. If a client had more than one culture greater than 30 days apart, those cultures were treated as separate ESAG cases as they were likely reinfections.

Prescriber adherence to gonorrhea treatment guidelines analysis

Gonorrhea treatment prescription data were analysed for ESAG cases that:

1. had prescription data,
2. met the above definitions of either GBMSM or Other adults as outlined above,
3. had a primary infection type classified as either anogenital or pharyngeal (criteria ii and iii align with gonorrhea treatment client categories defined by PHAC and PT treatment guidelines)^{Reference 7Reference 8Reference 9}

Thus, clients with an unknown infection type or a type that was neither anogenital nor pharyngeal were excluded from prescriber adherence to gonorrhea treatment guidelines analyses. The number and proportion of prescriptions that aligned with PHAC and PT gonorrhea treatment guidelines were calculated for GBMSM and Other adults, stratified by anogenital or pharyngeal infection type.

AMR-GC trends analysis

AMR-GC trends were analyzed based on sex and sexual behaviour. Results were summarized for GBMSM, heterosexual males, males with unknown sexual behaviour, and females. AMR-GC trends were not presented by female sexual behaviour due to i) small sample sizes or ii) where female sexual behaviour group sample size was sufficient, AMR-GC trends were similar.

Case counts and proportions were calculated for ESAG case characteristics, prescriber adherence to gonorrhea treatment guidelines, and AMR-GC variables.

Limitations

1. Results from ESAG are not representative of all gonorrhea cases or culture-confirmed gonorrhea cases in Canada, since most gonorrhea diagnoses are made using Nucleic Acid Amplification Tests (NAATs). Of the five PTs that provided ESAG data, most cases were reported by Alberta. Additionally, sentinel sites within Nova Scotia and Alberta may not reflect their respective jurisdictions as a whole.
2. Approximately 80.8% of cases captured in ESAG were male, of whom 45.8% were GBMSM. However, in 2022, 65.5% of all gonorrhea cases reported nationally to PHAC were male. However, sexual behaviour data is not available for nationally reported gonorrhea cases^{Reference 1}.
3. Gonorrhea client-level public health data collection may be more likely to be completed within specific medical clinics with client populations which may not be generalizable across the PT or Canada.
4. We assessed prescriber adherence to gonorrhea treatment guidelines using reported client prescription data. However, these calculations do not account for factors that may influence a clinician's decision to prescribe gonorrhea treatment that did not meet treatment guidelines. Some reasons a clinician would prescribe a non-preferred or alternative gonorrhea medication include treating a client with co-morbidities or with known exposure to an infected partner (necessitating dual therapy for gonorrhea and potential co-infections) and local antimicrobial resistance patterns or treatment availability.
5. Tests of cure and treatment failures can be challenging to measure using surveillance data because they rely on the ability to detect negative results. Additionally, not all cases of gonorrhea treatment failure may be reported or detected, so the true extent of suspected treatment failures may be underreported.
6. PTs had a reduced ability to deliver regular and routine gonorrhea screening, care, and public health reporting activities during 2020 and parts of 2021 due to numerous factors related to the COVID-19 pandemic.
7. Data from New Brunswick were only available starting in June 2023, whereas data from the other four PTs cover the full surveillance period from 2018 to 2023. As a result, the inclusion of NB’s partial-year of data may affect the interpretation of aggregate trends over time.

References