Clinical Practice Guideline
TITLE: Antibiotic Treatment for Uncomplicated Chlamydia & Gonorrhea Infections
APPROVED BY: Healthy Sexuality & Harm Reduction Working Group
Date
Revised
 Population and Public Health
March 2003
 February 3, 2012
 January 2014
Date
TARGET
REVIEW
DATE
PAGE
1 of 8
2016
1.0 Purpose
1.1. To improve and focus efforts to treat priority populations for gonorrhea and
chlamydia infections.
2.0 Scope and Goal
2.1. Antibiotic treatment for uncomplicated chlamydia and gonorrhea may be offered
to clients who meet the Antibiotic Treatment Eligibility Criteria, by Public
Health Nurses (PHNs) with the Healthy Sexuality and Harm Reduction
(HSnHR) team who have the competency to perform these practices.
3.0 Background
3.1. The prevention and control of sexually transmitted infections (STIs) are
important components of a comprehensive communicable disease control
strategy. While it is beneficial for all citizens of the Winnipeg Health Region to
have a regular primary care provider, many people do not access care due to
health, social and/or economic inequities. Not accessing care poses a potential
health risk to the individuals themselves and to the community. In order to
improve and focus efforts to test and treat priority populations at risk for
chlamydia and gonorrhea infections, PHNs with competency to do this practice
may offer antibiotic treatment for chlamydia and gonorrhea to eligible clients.
This guideline is developed primarily for outreach sexual health services
provided by HSnHR PHNs (i.e. Corrections facilities, Street Connections,
bathhouse clinics) and should be used in only exceptional circumstances in the
context of case and contact management.
3.2. These guidelines are developed using the principles recommended in the
Guideline for Shared Competencies and Delegated Physician Services (College
of Physicians and Surgeons of Manitoba and College of Registered Nurses of
Manitoba, 2002) as indicated in the following 6 sections.
3.2.1. These guidelines are based on shared competencies and collaboration
between the Medical Officer of Health (MOH) and PHNs with the knowledge
and skill to perform these practices.
3.2.2. Staff competency for these practices includes access to all current
sexually transmitted and bloodborne infection (STBBI) guidelines and
resources (Healthy Sexuality and Harm Reduction team’s clinical practice
guidelines, Manitoba Health’s Communicable Diseases Management
Protocols, Public Health Agency of Canada’s Canadian Guidelines on
Sexually Transmitted Infections). Where there are differences between
provincial and national guidelines, provincial guidelines apply. The MOH or
designated back-up MOH is available for immediate consultation as
required.
Clinical Practice Guideline
TITLE: Antibiotic Treatment for Uncomplicated Chlamydia & Gonorrhea Infections
APPROVED BY: Healthy Sexuality & Harm Reduction Working Group
Date
Revised
 Population and Public Health
March 2003
 February 3, 2012
 January 2014
Date
TARGET
REVIEW
DATE
PAGE
2 of 8
2016
3.2.3. Mechanisms to maintain quality and safety will include regular peer review
at team meetings, regular consultation with the MOH through the CD
Coordinator, and an annual random chart audit by the CD Coordinator (at
least 5 charts per nurse). Every month, the PHN will send to the
Administrative Secretary2 (AY2) a list of clients who received a shared
competency function from the PHN. When guidelines and shared
competencies are not followed, this will be documented, investigated and
evaluated with the PHN by the MOH in collaboration (as appropriate) with a
designated individual (Team Manager, Clinical Nurse Specialist, CD
Coordinator). Bi-annual performance reviews with the team manager are
required.
3.2.4. All WRHA guidelines for documentation and storage of records will be
followed according to existing WRHA standards and protocols.
3.2.5. Continued and ongoing competence will be maintained through ongoing
education and review of practice. Reliable provincial and national guidelines
are available and updated regularly, and are used by PHNs for each shared
competency. PHNs are competent healthcare professionals with skills in
teaching about risks, benefits, side effects and reporting of adverse events.
3.3.
Competence
Physician:
The MOH’s (Dr. Pierre Plourde) professional qualifications include
a Certificate of Special Competence, Infectious Diseases, Royal
College of Physicians of Canada (FRCPC)
In the absence of the above-named MOH, consultation is available
through Dr Joss Reimer or Dr Bunmi Fatoye at the WRHA. Drs
Reimer and Fatoye have advanced professional qualifications
including Certification with the Royal College of Physicians of
Canada (FRCPC).
Public Health Nurse:
PHN competence will include a Baccalaureate Degree in Nursing
with recent PHN experience, in addition to an orientation to
specialized healthy sexuality and harm reduction services.
Competency will normally be achieved over a 6 month full-time
period. As determined in concert with the PHN and staff advisor,
this apprenticeship will begin when the PHN has shown
competency in management of sexually transmitted infections with
the Healthy Sexuality and Harm Reduction team. Maintenance of
competency will be achieved through ongoing review of practice in
Clinical Practice Guideline
TITLE: Antibiotic Treatment for Uncomplicated Chlamydia & Gonorrhea Infections
APPROVED BY: Healthy Sexuality & Harm Reduction Working Group
Date
Revised
 Population and Public Health
March 2003
 February 3, 2012
 January 2014
Date
TARGET
REVIEW
DATE
PAGE
3 of 8
2016
team meetings with the Manager, MOH, Clinical Nurse Specialist
and CD Coordinator and annual chart audits.
4.0 Definitions
Uncomplicated Chlamydia trachomatis Genital Infection: C. trachomatis causes
a broad range of clinical syndromes, infecting mainly mucosal membranes such as
the cervix, rectum, urethra, throat & conjunctiva. Persistent low-grade clinically
unapparent infections are also common. Genital infections caused by C.
trachomatis often go unrecognized as they are asymptomatic in up to 70% of
infected women and in up to 50% of infected men. When symptomatic infection
occurs, urethritis is the most common presentation in men. Cervicitis and increased
vaginal discharge are the most common presentations in women. Symptoms usually
begin two to six weeks after infection. In males with urethritis, symptoms include
dysuria, urethral itch and urethral discharge. Chlamydial urethritis may be
indistinguishable from gonococcal urethritis on clinical grounds. (Manitoba Health
and Healthy Living, 2008A).
Uncomplicated Gonorrhea Genital Infection: Urethral discharge and dysuria
(usually without urinary frequency) are the major symptoms of genital infection in
men. Urethral itch may also occur. A small percentage of gonococcal infections in
males are asymptomatic. Infection in women is often asymptomatic but symptoms
may include lower abdominal pain, abnormal vaginal discharge, deep dyspareunia,
vaginal bleeding after intercourse and dysuria (often without urgency or frequency)
(Manitoba Health and Healthy Living, 2008B).
Complicated Chlamydia and Gonorrhea Infection: Complicated C. trachomatis
and N. gonorrhoeae infections include (but are not limited to) epididymitis, pelvic
inflammatory disease (PID), and conjunctival gonorrhea infections. Men with
epididymitis may present with unilateral swollen epididymis or testicle or both,
dysuria, fever and occasionally shaking chills. For men under the age of 35, the
usual etiology of epididymitis is C. trachomatis. PID results from the ascending
spread of microorganisms from the vagina to endocervix, and common etiologic
agents include C. trachomatis, and N. gonorrhoeae. Diagnosis may be difficult
because of the wide variation in presenting symptoms, however PID should be
suspected in women presenting with lower abdominal tenderness, uterine/adnexal
tenderness, or cervical motion tenderness (Manitoba Health, Communicable
Disease Control Branch, 2008).
5.0 Procedure
5.1. Determine eligibility using the Antibiotic Treatment Eligibility Criteria
Clinical Practice Guideline
TITLE: Antibiotic Treatment for Uncomplicated Chlamydia & Gonorrhea Infections
APPROVED BY: Healthy Sexuality & Harm Reduction Working Group
Date
Revised
 Population and Public Health
March 2003
 February 3, 2012
 January 2014
Date
TARGET
REVIEW
DATE
PAGE
4 of 8
2016
5.2. Assess the client’s health status and sexual health history.
5.3. Obtain informed consent ensuring client has appropriate information and
capacity to give such consent
5.4. Assess according to eligibility criteria
5.5. Administer a single dose oral treatment of azithromycin 1g for uncomplicated
urethral, rectal, nasopharyngeal or endocervical Chlamydia infection.
5.6. Administer cefixime 800 mg for uncomplicated urethral, rectal, endocervical, or
nasopharyngeal Gonorrhea infection, under direct observation. If cephalosporin
treatment is contraindicated but treatment with azithromycin is not, an alternate
treatment for uncomplicated gonorrhea of 2 g azithromycin may be provided
(See Eligibility Criteria).
5.7. All clients treated for gonorrhea should be also receive treatment for chlamydia,
unless chlamydial infection has been ruled out.
5.8. Ensure the standards of care (below) are met
5.9. If the client is pregnant/breastfeeding, discuss the risk/benefit of treatment as
well as other treatment options
5.10.
If vomiting occurs within 1 hr of antibiotic administration and client finds
intact tablets in the vomit, reassess regarding reimplementation of this
delegation guideline
6.0 Standards of Care The PHN will:
6.1. Offer treatment to clients who meet Antibiotic Treatment Eligibility Criteria
6.2. Review risks of infection and benefits of treatment including the value of
Primary Care for all health/STBBI needs
6.3. Review the need to abstain from unprotected sex for 5 days post-treatment
6.4. Directly observe client taking the single dose oral antibiotics
6.5. Interview for sex contacts and counsel on importance of partner notification
6.6. Offer risk/harm reduction and prevention information and resources
6.7. Discuss appropriate follow up for clients who meet the criteria for when test-ofcure/follow up screening is recommended (Management of Gonococcal
Infections, WRHA Clinical Practice Guideline)
6.8. Document on the WRHA Client Record as per professional and regional
standards.
o Antibiotic Treatment Eligibility Criteria met by client, including allergy
assessment
o Primary Care for STBBI recommended/supported by PHN
o Type, dose, route, time and direct observation of medication provided
o Risk/harm reduction education and resources offered and/or provided
Clinical Practice Guideline
TITLE: Antibiotic Treatment for Uncomplicated Chlamydia & Gonorrhea Infections
APPROVED BY: Healthy Sexuality & Harm Reduction Working Group
Date
Revised
 Population and Public Health
March 2003
 February 3, 2012
 January 2014
Date
TARGET
REVIEW
DATE
PAGE
5 of 8
2016
Antibiotic Treatment Eligibility Criteria
AT LEAST 1 OF THE FOLLOWING 3 CRITERIA
Client did not or is unlikely to attend a primary care provider for treatment, due to
health, social and/or economic inequities
AND AT LEAST 1 OF THE FOLLOWING 3 CRITERIA
Diagnosed with uncomplicated gonorrhea and/or chlamydia AND whose primary
care provider has been consulted AND whose primary care provider has agreed that
the PHN may provide the treatment according to Sexually Transmitted Infections
Treatment Guidelines (Manitoba Health and Healthy Living, 2008C)
Named as a contact to a case of gonorrhea and/or chlamydia.
Presents to the PHN with clinical symptoms of uncomplicated chlamydia and/or
gonorrhea as per Sexually Transmitted Infections Treatment Guidelines (Manitoba
Health and Healthy Living. 2008C)
AND
Client is able to understand the information, benefits and risks that are relevant to
making a decision to be treated. If there are any doubts about the individual’s
capacity to consent, the treatment should not be provided by the PHN, and the client
should be referred to a physician/nurse practitioner for medical assessment
AND meets 1 of the following criteria
For clients with Gonorrhea, client has no known allergies (cephalosporin allergy or
anaphylactic reaction to penicillin) or chronic illness that would be a contraindication
to cefixime as per the Sexually Transmitted Infections Treatment Guidelines
(Manitoba Health and Healthy Living, 2008C).
Cross reactivity with second and third generation cephalosporins for individuals
with penicillin allergies is extremely rare (Apter et al. 2006; Pichichero, & Casey,
2007).For clients with a history of Type 1 reactions to penicillin– (i.e. immediate
hypersensitivity with systemic manifestations of anaphylaxis) treatment with
cephalosporins (Cefixime) is not recommended
Where no contraindications to azithromycin treatment exists and the client has a
contraindication to cephalosporin treatment (history of severe allergic
reaction/analphylactic reaction to penicillin) the PHN may provide an alternate
treatment for uncomplicated gonorrhea with 2 grams azithromycin. A test of cure
is recommended following treatment with non-preferred regimens.
Azithromycin 2 gm should only be considered as an alternate treatment option if
there is a history of severe allergy to cephalosporins, or history of anaphylaxis
following treatment with penicillin. The risk of treatment failure and
Clinical Practice Guideline
TITLE: Antibiotic Treatment for Uncomplicated Chlamydia & Gonorrhea Infections
APPROVED BY: Healthy Sexuality & Harm Reduction Working Group
Date
Revised
 Population and Public Health
March 2003
 February 3, 2012
 January 2014
Date
TARGET
REVIEW
DATE
PAGE
6 of 8
2016
gastrointestinal side effects should be discussed. 2 gm azithromycin is
contraindicated in pregnancy and lactation (Manitoba Health, Communicable
Disease Control Branch, 2008)
For clients with Chlamydia, client has no known allergies or chronic illness that
would be a contraindication to azithromycin as per the Sexually Transmitted
Infections Treatment Guidelines (Manitoba Health and Healthy Living, 2008C).
AND
Client is at least 16 years of age. For those clients between the ages of 13 and 15,
a reasonable attempt must be made by the nurse to obtain parental/legal guardian
consent prior to treatment. For street involved youth, the persistent refusal to
disclose guardianship will be considered a reasonable attempt to locate
parents/guardians, and the mature minor provision will be followed
7.0 References
Apter, A., Kinman, J., Bilker, W., Herlim, M., Margolis, D., Lautenbach, E.,
Hennessy, S., & Strom, B. (2006). Is there cross-reactivity between penicillins and
cephalosporins? The American Journal of Medicine,119,(354) e11-20. doi:
10.1016/j.amjmed.2005.10.052
College of Physicians and Surgeons of Manitoba and College of Registered Nurses
of Manitoba (2002), (Guideline No. 132) Guidelines for Shared Competencies and
Delegated Physician Services –revised. Retrieved from:
http://www.cpsm.mb.ca/guidelines/132.php.
Manitoba Health and Healthy Living (2008A, April) Communicable Disease
Management Protocol Chlamydia trachomatis (D through K Serovars) Infection.
http://www.gov.mb.ca/health/publichealth/cdc/protocol/chlamydia.pdf.
Manitoba Health and Healthy Living (2008B, April) Communicable Disease
Management Protocol. Gonorrhea.
http://www.gov.mb.ca/health/publichealth/cdc/protocol/gonorrhea.pdf
Manitoba Health and Healthy Living (2008C), Communicable Disease Management
Protocols. : http://www.gov.mb.ca/health/publichealth/cdc/protocol/index.html.
Pichichero, M.E., & Casey, J.R. (2007). Safe use of selected cephalosporins in
penicillin-allergic patients: A meta-analysis. Otolaryngology-Head and Neck Surgery,
136, 340-347. Doi: 10.1016/j.otohns.2006.10.007.
Clinical Practice Guideline
TITLE: Antibiotic Treatment for Uncomplicated Chlamydia & Gonorrhea Infections
APPROVED BY: Healthy Sexuality & Harm Reduction Working Group
Date
Revised
 Population and Public Health
March 2003
 February 3, 2012
 January 2014
Date
TARGET
REVIEW
DATE
PAGE
7 of 8
2016
Public Health Agency of Canada (2013). Gonococcal infections chapter revised. In:
Public Health Agency of Canada (2006). Canadian Guidelines on Sexually
Transmitted Infections. : http://www.phac-aspc.gc.ca/std-mts/sti_2006/sti_intro2006eng.php.
Clinical Practice Guideline
TITLE: Antibiotic Treatment for Uncomplicated Chlamydia & Gonorrhea Infections
APPROVED BY: Healthy Sexuality & Harm Reduction Working Group
Date
Revised
 Population and Public Health
March 2003
Date
 February 3, 2012
 January 2014
TARGET
REVIEW
DATE
2016
Acknowledgment of Shared Competency and Collaborative Practice for
Antibiotic Treatment for Uncomplicated Chlamydia & Gonorrhea.
_____________________________
_______________
Dr. Pierre Plourde
Date
_____________________________
_______________
PHN (sign and print name)
Date
PAGE
8 of 8