1. Review of Gonorrhoea (GC) Contacts Gay Men’s Health Service 2012 / 2013 Louise PomeroyMick QuinlanSusan Clarke GMHSGMHSSJH / GMHS 9 th November 2013

2. Introduction Community based genito-urinary medical services for MSM STI screening and management in a non-hospital setting Two evenings a week More than 115 men seen each week

3. Review GC Contacts 2012 - 2013 Total number of STI screens: 20122013 36722736 Total number treated for gonorrhoea: 20122013 (Jan 1 st – Sep 30 th ) 294260 Total number attending as GC contacts: 20122013 7473

4. Indications for treatment of GC UK National Guidelines for the Management of GC in Adults 2011 European Guidelines on Diagnosis and Management of GC in Adults 2012 Both recommend epidemiological treatment of recent sexual partners of confirmed cases of GC infection

5. Testing for GC Nucleic Acid Testing (NAT) Highly sensitive assay (99.7%)

6. Methods We reviewed the management of a cohort of GC contacts attending the GMHS between January 2012 and September 2013 Retrospective review of charts between June 1 st 2012 – June 30 th 2012 Prospective collection of data from July 1 st – September 30 th 2013

7. Method (3) Parameters audited Results of GC NAT testing Time since index contact Epidemiological treatment given or not

8. Results 147 - Total number of GC contacts identified 80 (54%) contacts had GC NAT positive results 59 (40%) contacts had GC NAT negative results 5 (3%) contacts did not have swabs 3 contacts inconclusive/unconfirmed NAT results

9. What is minimum incubation period prior to testing > 3 days – UK National Guidelines for Management of GC in Adults 2011 > 14 days – UK National Guidelines for GC testing 2012 Within days of infection 2012 European Guidelines on Diagnosis and Treatment of GC in Adults

10. Time since contact with index case in 59 GC NAT negative contacts DaysNo time interval recorded ≤ 34 -13> 14 No. of patient (%) 9 (15%) 7 (12%) 21 (35%) 22 (37%) > 3 days72% > 14 days37%

11. Time since contact with index case in 80 GC NAT positive cases DaysNo time interval recorded ≤3≤34 - 14>14 No. of patients (%) 10 (12%) 7 (9%) 20 (25%) 43 (54%) > 3 days = 69% > 14 days = 54%

12. Results - treatment 80 (54%) - GC NAT positive contacts identified  44 (55%) received epidemiological treatment  36 (45%) no epidemiological treatment, (All returned for treatment subsequently)

13. Treatment of contacts 59 GC NAT negative contacts identified  51 (86%) received treatment.  8 (14%) did not receive treatment 5 GC contacts, no swabs taken, received treatment 56 (38%) contacts received empirical treatment with no microbiological evidence of GC infection

14. Emerging Antibiotic Resistance in Gonorrhoea 1940 Sulphonamide resistance 1980 Penicillin and tetracycline resistance 2007 Fluoroquinolone resistance 2003 Possible treatment failure with cefixime - Japan 2009 High level ceftriaxone resistance – Japan 2010/2011 Cefixime failure UK, Norway, Austria 2010/2011Highly ceftriaxone resistant strains in France, Sweden, Spain

15. Increasing international concern over antibiotic resistance in GC Need to optimise use of remaining antibiotics (ceftriaxone and azithromycin) Risk of emergence of untreatable GC infection. Impact on resistance patterns on other organisms Pneumococci Enterococci (eg VRE) MRSA ESBL producing Enterobacteriaceae Clostridium difficile Impact of such resistant organisms on the community e.g. immunocompromised, the elderly, children Risk of adverse events Custodians of a precious resource. WHO has designated ceftriaxone and azithromycin as Critically Important Antibiotics (CIA)

16. EVERY DOSE COUNTS

17. Summary Epidemiological treatment of GC may result in treatment of a significant number of GC contacts (38%) without laboratory evidence of GC infection Majority of these were tested within a time frame considered sufficient for detection if the lower interval of 4 days is taken All patients not receiving empirical treatment returned for treatment, the majority within the week

18. Discussion There is a need to optimise antibiotic usage in gonorrhoea contacts in an era of rapidly emerging antibiotic resistance and for an increased awareness of the need for antibiotic stewardship The policy on management of GC contacts should be reviewed with an increased emphasis on awaiting NAT testing results prior to treatment in this group

19. Audit GC contacts 2012 There is need for comprehensive re-audit with particular emphasis on  Number of patients receiving epidemiological treatment and rational for this approach  Number of contacts requiring re-testing.  Length of time from exposure to index case to time of NAT positivity  Number of contacts failing to return for follow-up or treatment Need to increase awareness of problems of GC antibiotic resistance amongst MSM and seek collaboration in managing problem optimally

20. DOCTORS BLAMED FOR RISE OF SUPERBUGS Irish Independent 29 th October 2013