What is the issue?
Two cases of multi-drug resistant gonorrhoea have been diagnosed in Australia in early 2018. This is of great public health concern. Treatment is complex and may require intravenous antibiotics. Public health officers are closely following up cases and contacts of any reported multi-drug resistant gonorrhoea.
Evidence suggests that one of the Australian cases acquired the infection in Southeast Asia. Drug-resistant gonorrhoea exists in many countries, including Australia. However, these latest cases and a recent one in the United Kingdom, appear to be the first reported that are resistant to all of the antibiotics that have been in routine use against gonorrhoea. It is possible that there are other cases in Australia which have not been detected, especially as NAAT is being performed more frequently than culture.
Victoria has not detected any case of this new multi-drug resistant gonorrhoea strain to date, however antimicrobial resistance is emerging. Decreased susceptibility to ceftriaxone, defined as minimum inhibitory concentration (MIC) 0.06- 0.125 mg/L was reported in 2.1% of culture positive gonorrhoea notifications in 2017. Azithromycin low level resistance (MIC >1.0 mg/L) was reported in 13.5% of the isolates, compared to 5.4% in 2016), with one isolate having high level critical resistance (MIC >256 mg/L). Two high level azithromycin resistant cases have been detected in 2018 to date.
Notifications for gonorrhoea have continuously increased over the last ten years across all Australian jurisdictions, with a total of 28,000 cases reported in 2017. In Victoria, notifications reached a record high in 2017 with a total of 7,309 cases, compared to 6,266 cases in 2016 and 4,866 cases in 2015, representing a 17% and 50% increase respectively, compared to 2015. Notifications are most commonly reported in men (81% of the cases in 2017) and 72% of notifications amongst men are men who have sex with men (MSM), many in urban settings. Notifications amongst women have increased year on year, with 1,368 cases notified in women in 2,017, compared to 1,211 cases in 2016 and 764 in 2015. This represents a 13% and 79% increase respectively, compared to 2015.
Who is at risk?
- Men who have sex with men (MSM)
- Bisexual men
- Heterosexual men and women at higher risk for sexually transmissible infections, especially people with multiple sexual partners, and travellers with sexual partners in countries where gonorrhoea is more prevalent
- Aboriginal and Torres Strait Islander people in remote communities
- Sex workers and their clients, especially in high prevalence countries
Symptoms and transmission
Infection can be asymptomatic, especially in women - 80 per cent of women and 10-15 per cent of men have no symptoms. Pharyngeal, anorectal and cervical infections are often asymptomatic.
- Symptoms in men may include:
- Purulent urethral discharge and dysuria (usually appearing two to seven days after exposure)
- Anorectal symptoms: pruritus, irritation, tenesmus and discharge.
- Symptoms in women may include:
- Abnormal vaginal discharge
- Anorectal symptoms: pruritus, irritation, tenesmus and discharge.
- Complications in men include epididymitis, prostatitis and urethral strictures.
- Complications in women include pelvic inflammatory disease, which can cause ectopic pregnancy, infertility or chronic pelvic pain.
Disseminated gonococcal infection is rare and usually presents with fever, arthritis and skin lesions. Conjunctival infection can occur in neonates born to infected mothers or in adults after eye exposure to genital secretions.
Gonorrhoea can be transmitted by unprotected vaginal, anal and oral sex. Gonorrhoea is of particular public health importance because it increases both susceptibility to acquiring HIV infection and transmissibility of HIV infection.
Diagnosing and screening for gonorrhoea
Clinicians play a vital role in control and prevention through early detection and treatment of cases and their contacts.
Take swabs for culture. Obtaining swabs for culture is crucial for detecting, monitoring, and responding to antimicrobial resistance.
- Take a swab for all symptomatic patients at presentation (e.g. purulent urethral or anal discharge in gay and bisexual men) prior to treatment. Take swabs from all potentially infected sites (e.g. genital, anal, oropharyngeal).
- For NAAT confirmed gonorrhoea (including pharyngeal, rectal and cervical infections), ensure a reflexive culture (culture following a positive NAAT result) is performed and antibiotic susceptibility testing conducted where possible prior to treatment.
Screening of groups at risk is essential for gonorrhoea control and detection of antimicrobial resistance. Screening for gonorrhoea should occur in conjunction with screening for other sexually transmissible infections(STIs).
- Screen MSM at least annually and higher risk MSM up to 3 monthly for gonorrhoea. Swabs from the anus and pharynx should be taken in addition to urine testing for gonorrhoea. Guidelines on screening and testing are available.
- Screen people on HIV pre-exposure-prophylaxis (PrEP) for STIs and HIV every three months.
- Screen bisexual men for STIs and blood borne viruses annually or three monthly if at higher risk.
- Screen pregnant women and women of reproductive age for STIs and blood borne viruses (BBVs) including syphilis.
- Screen heterosexual men and women at higher risk for STIs and BBVs (people with overseas sexual contacts, people with multiple sexual partners, people who inject drugs).
Treatment of cases and contacts
- Treat gonorrhoea with IM ceftriaxone and oral azithromycin according to the treatment guidelines. Ciprofloxacin, penicillin and tetracycline should not be used.
- Seek expert advice from Melbourne Sexual Health Centre about patients with treatment failure, or who are allergic to ceftriaxone, or with complicated infection, and before using alternative treatments. A doctor's only information line is available: 1800 009 903 (Mon-Fri 9:30am-12:30pm, 1:30pm-5:00pm).
- Test and treat all sexual contacts of gonorrhoea cases without waiting for test results. Immediate treatment of contacts prevents re-infection of the index case and further transmission.
- Ensure treatment has been successful:
- Review in one week to assess symptom resolution (if appropriate) and confirm partner notification.
- For pharyngeal, anal or cervical infection, undertake test of cure by NAAT and reflexive culture two weeks after treatment.
- All cases of treatment failure should have a specimen sent for culture.
- Test for re-infection after three months.
- Ensure that all possible attempts are made to contact sexual partners of cases gonorrhoea at the time of diagnosis.
- Innovative partner notification tools are available to contact partners anonymously via SMS or email. You can undertake partner notification at the time of consultation or strongly encourage your patients to contact their partners themselves. Partner notification tools are available at:
- Partner notification officers (PNOs) at the Department of Health & Human Services are available to assist with partner notification. PNOs can contact the sexual partners of a person diagnosed with a STI, provide advice and referral to testing. Any identifying information about your patients is kept confidential. Call 9096 3367 to speak to a PNO (Mon-Fri 8:30am-4.30pm). Call 0412 221 135 for urgent after-hours issues.
- Advise patients to practice safe sex.
- Warn travellers of the added dangers of unprotected sex.
- Provide advice regarding prevention strategies, early symptom recognition and periodic screening to all gay and bisexual men (GBM) and people at high risk for STIs. Advise GBM that gonorrhoea can be transmitted through oral and anal sex. Emphasise that safe sex practices (i.e. condom use) greatly reduce the risk of transmission.
- Counsel PrEP recipients on prevention combination methods (PrEP and condom use, undetectable viral loads) and regular screening for STIs.
- Patient resources available online are listed below (under Patient information).
Department of Health & Human Services
For more information please contact the Communicable Disease Prevention and Control section at the Department of Health and Human Services on 1300 651 160 during business hours.
Learn more about the Chief Health Officer.