STIs on the rise: 'Pragmatic approach' recommended for managing chlamydia and gonorrhea

Faced with rising incidences of chlamydia and gonorrhea, doctors need to take a pragmatic approach that combines routine asymptomatic screening, nucleic amplification testing guided by sexual history, guidance from experts in sexual transmitted infections (STIs) and actions to combat antimicrobial resistance. These were the conclusions of a new review, published in the Canadian Medical Association Journal, undertaken to give clinicians practical tips to identify and manage chlamydia trachomatis and neisseria gonorrhoeae which, along with syphilis, are among the three most commonly reported bacterial STIs in Canada. “They are the ones tracked most diligently by provinces and federally as well,” said study co-author Dr. Troy Grennan, physician lead for the HIV and STI program at the B.C. Centre for Disease Control and a clinical associate professor at the University of British Columbia’s division of infectious diseases. “And the data shows they’re on the rise.” Statistics from the Public Health Agency of Canada show that between 2010 and 2019, cases of chlamydia increased by 33.1% while gonorrhea cases burgeoned by 181.7%. These increases may be attributed in part to improved diagnostics, more screening and contact tracing. “We don’t know all the reasons but increased testing is likely one reason, which is a good thing because it means people are more aware,” said Dr. Grennan. “We can speculate as well that there have been some behaviour changes over the last several years, including a reduction in condom use, that might have translated into an increase in these infections.” Opportunistic screening is critical in identifying asymptomatic incidences of chlamydia and gonorrhea, Dr. Grennan and his co-authors wrote in their review. The current standard in Canada, based on the Canadian Task Force on Preventive Health Care recommendation, calls for annual asymptomatic screening for chlamydia and gonorrhea in all sexually active patients under the age of 30. Read: A different kind of 'morning after pill': An antibiotic to prevent certain STIs? More frequent screening is recommended for patients at higher risk of contracting an STI. However, the authors noted, little evidence exists to guide the optimal screening of screening. They did offer current guidance for particular groups: annual anatomic site-based screening for men who have sex with men and more frequent screening of perhaps every three to six months for at-risk people of any gender including those taking HIV pre-exposure prophylaxis (PrEP), those who recently had an STI, those living with HIV or who have multiple sexual partners. The authors cited a cohort study of 557 gay men and transgender women taking HIV PrEP that concluded semi-annual screening would have led to delayed diagnosis of chlamydia or gonorrhea in more than 30% of patients, compared with quarterly screening. The review underlined the importance of nucleic acid amplification testing at sites of sexual exposure for both symptomatic and asymptomatic chlamydia and gonorrhea. These tests, however, should be guided by a “careful sexual history.” “It's an awkward and difficult conversation for many healthcare providers and patients to have, but I think it’s incredibly important that they do have this discussion about sexual health and sexual history,” said Dr. Grennan. “Taking a sexual history has many potential benefits, including maybe finding out whether there are any symptoms and whether there’s a need for additional testing.” A side benefit of taking a sexual history—examples of questions are provided in the review—is that it normalizes the conversation around sexual health, he added. “There's stigma around this unfortunately so I think it's always important to use each clinical encounter as an opportunity to explore this,” said Dr. Grennan. Read: Updated Canadian guidelines on sexually transmitted and blood-borne infections The review also discussed the common clinical presentations for chlamydia and gonorrhea. Most cases are asymptomatic but some cases may present with genital or extragenital symptoms, which generally also indicate the site of infection. Genital symptoms include urethritis in male patients and cervicitis in female patients. Extragenital symptoms could manifest in various ways, including proctitis, sore throat, cervical lymphadenitis and septic arthritis. When treating chlamydia or gonorrhea, physicians should follow local guidelines, wrote the co-authors. Consulting with an expert in STIs is a good idea, said Dr. Grennan. “Most jurisdictions across Canada would have these experts available to them, either an infectious disease specialist or someone at a specialized sexual health clinic,” he said. Physicians also need to be mindful of antimicrobial resistance, which are occurring at increasing rates in Canada and globally. In Canada, the proportion of multidrug resistant gonorrhea rose to 8.9% from 6.25% between 2012 and 2016, with most isolates identified in Ontario and Quebec. To combat antimicrobial resistance, physicians are advised to perform gonorrhea culture and sensitivity testing when possible to limit unnecessary antimicrobial use, and to forego dual therapy for gonorrhea when chlamydia is excluded. “Whether the widespread discontinuation of dual therapy for gonorrhea would negatively affect clinical outcomes or prevent antimicrobial resistance has not yet been established, however,” wrote the authors. “Treatment can be delayed until test results are available in situations where reliable patient follow-up is likely.” Doctors should consult an STI management expert in cases of confirmed or suspected multi drug-resistant gonorrhea, added the authors. Read: Two new menopause guidelines on sexuality highlight new treatments

STIs on the rise: 'Pragmatic approach' recommended for managing chlamydia and gonorrhea

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