Extragenital testing increases case detection of gonorrhea and chlamydia: The impact of implementing nucleic acid amplification testing.

BACKGROUND: Nucleic acid amplification testing (NAAT) was validated in Ontario in 2018 to test for chlamydia and gonorrhea at extragenital (pharyngeal, rectal) sites. Prior to this validation, extragenital testing could be done only by culture in Ontario. The objective of this study was to determine the number and proportion of gonorrhea and chlamydia cases that were detected exclusively through extragenital (pharyngeal and/or rectal) testing after the implementation of extragenital NAAT for these two infections at Sexual Health Clinic among gay, bisexual, and other men who have sex with men (gbMSM). METHODS: Case and laboratory data from before and after NAAT implementation were used to compare the rates of diagnosis of gonorrhea and chlamydia among gbMSM who presented at Sexual Health Clinics and the percent increase in diagnoses in gbMSM in the entire population. RESULTS: Among gbMSM seen at the clinic after implementation of NAAT testing, 70% of gonorrhea cases and 65% of chlamydia cases were detected exclusively at extragenital sites, corresponding to a four and two-fold increase, respectively, in the average annual number of cases diagnosed. As well, although approximately 50% more pharyngeal than rectal testing occurred, a higher proportion of chlamydia cases were detected rectally than would have been expected; this was not the case for gonorrhea, where most infections were pharyngeal. CONCLUSION: It is important that clinicians perform extragenital testing among gbMSM who have sexual contact involving extragenital sites with more than one partner.

Inconclusive Syphilis Results: A Retrospective Review of Public Health Results.

In the context of increasing syphilis incidence in many Western countries, we sought to better understand the frequency and outcomes associated with inconclusive serologic syphilis results. To accomplish this, we reviewed all inconclusive results that arose from an indeterminant confirmatory treponemal screen (specifically the Treponema pallidum particulate agglutination test), which were reported to Ottawa Public Health from January 1, 2019, through December 31, 2019. Our case review identified that 52 persons generated such test results during the study period, of whom 44.4% were cases requiring treatment, 46.3% were persons without new risk factors or symptoms of syphilis who had been previously treated for this infection, and 9.3% were not syphilis. Overall, these untreated syphilis cases accounted for 8.6% of all new syphilis diagnoses in our local jurisdiction during the study period. These results highlight that case investigation and prompt management of inconclusive syphilis results is an appropriate public health and clinical approach and that such a strategy could contribute to efforts to reduce increasing syphilis incidence.

Infection prevention and control lapse involving medical equipment reprocessing at a family medicine clinic in Ottawa, Ontario, 2018.

BACKGROUND: In April 2018, Ottawa Public Health identified a large-scale infection prevention and control (IPAC) lapse spanning 15 years related to inadequate reprocessing of reusable critical medical equipment used in a family medicine clinic. OBJECTIVES: To describe the public health response to, and estimate the risk of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission from, this IPAC lapse. METHODS: Patients who underwent a procedure of concern (during which reusable equipment may have been used) at this clinic were identified using Ontario Health Insurance Plan data and individually notified. Testing for HBV, HCV and HIV at the Public Health Ontario Laboratory was recommended, and the odds of infection were estimated. RESULTS: Of 4,495 patients possibly exposed to improperly reprocessed equipment, 1,496 (33.3%) underwent testing within six months of notification. The prevalence of HBV, HCV and HIV infection in this group was lower than in the general Canadian population. Among patients first diagnosed with HBV after a procedure of concern, the odds of HBV transmission were not increased when the procedure occurred within seven or 28 days of another patient with a positive HBV test result (OR7 days, age-adjusted=0.59, 95% CI: 0.14-2.51; OR28 days, age-adjusted=1.35, 95% CI: 0.62-2.93). The odds of HCV and HIV transmission could not be estimated because no patient was diagnosed with HCV or HIV after having a procedure of concern within 28 days of another patient with a positive HCV or HIV test result. CONCLUSION: We found no evidence of HBV, HCV or HIV transmission associated with this IPAC lapse. However, transmission cannot be ruled out conclusively because only a third of possibly exposed patients underwent testing.

The antibiotic management of gonorrhoea in Ontario, Canada following multiple changes in guidelines: an interrupted time-series analysis.

OBJECTIVE: This study assessed adherence with first-line gonorrhoea treatment recommendations in Ontario, Canada, following recent guideline changes due to antibiotic resistance. METHODS: We used interrupted times-series analyses to analyse treatment data for cases of uncomplicated gonorrhoea reported in Ontario, Canada, between January 2006 and May 2014. We assessed adherence with first-line treatment according to the guidelines in place at the time and the use of specific antibiotics over time. We used the introduction of new recommendations in the Canadian Guidelines for Sexually Transmitted Infections in 2008 and 2011 and the release of the province of Ontario's Guidelines for the Treatment and Management of Gonococcal Infections in Ontario in 2013 as interruptions in the time-series analysis. RESULTS: Overall, 34 287 gonorrhoea cases were reported between 1 January 2006 and 31 May 2014. Treatment data were available for 32 312 (94.2%). Our analysis included 32 272 (94.1%) cases without either a conjunctival or disseminated infection. Following the release of the 2011 recommendations, adherence with first-line recommendations immediately decreased to below 30%. Adherence slowly increased but did not reach baseline levels before the 2013 guidelines were released. Following release of the 2013 guidelines, adherence again decreased; adherence is slowly recovering but by May 2014, was only approximately 60%. CONCLUSIONS: Due to concerns about antibiotic resistance, gonorrhoea treatment guidelines need to be updated regularly and rapidly adopted in practice. Our study showed poor adherence following dissemination of updated guidelines. Over a year after the latest Ontario guidelines were released, 40% of patients did not receive first-line treatment, putting them at risk of treatment failure and potentially promoting further drug resistance. Greater attention should be devoted to dissemination and implementation of new guidelines.

A systematic review and appraisal of the quality of practice guidelines for the management of Neisseria gonorrhoeae infections.

BACKGROUND: Clinical guidelines help ensure consistent care informed by current evidence. As shifts in antimicrobial resistance continue to influence first-line treatment, up-to-date guidelines are important for preventing treatment failure. A guideline's development process will influence its recommendations and users' trust. OBJECTIVE: To assess the quality of current gonorrhoea guidelines' development processes. DATA SOURCES: Multiple databases. STUDY ELIGIBILITY CRITERIA: Original and current English-language guidelines targeting health professionals and containing treatment recommendations for uncomplicated gonorrhoea in the general adult population. STUDY APPRAISAL AND SYNTHESIS METHODS: Two appraisers assessed the guidelines independently using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Scores were combined as per the AGREE II users' manual. RESULTS: We identified 10 guidelines meeting the inclusion criteria. The quality of the gonorrhoea treatment guidelines varied. Most scored poorly on Rigour of Development; information on the evidence review process and methods for formulating recommendations was often missing. The WHO Guidelines for the Treatment of Neisseria gonorrhoeae and UK National Guideline for the Management of Gonorrhoea in Adults scored the highest on Rigour of Development. Methods to address conflicts of interest were often not described in the materials reviewed. Implementation of recommendations was often not addressed. LIMITATIONS: By limiting our study to English-language guidelines, a small number of guidelines we identified were excluded. Our analysis was limited to either published or online materials that were readily available to users. We could not differentiate between items addressed in the development process but not documented from items that were not addressed. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Gonorrhoea treatment guidelines may slow antimicrobial resistance. Many current guidelines are not in line with the current guideline development best practices; this might undermine the perceived trustworthiness of guidelines. By identifying current limitations, this study can help improve the quality of future guidelines.