• If in doubt speak to a senior GUM colleague
• The increasing recognition and development of multidrug resistant N. gonorrhoeae has been the driving force for the recommendation of extended spectrum cephalosporins as the preferred treatment of gonorrhoea

Indications for Treatment

• Identification of intracellular Gram-negative diplococci on microscopy of a smear from the genital tract
• A positive culture for N gonorrhoeae from any site
• A positive NAAT for N gonorrhoea from any site. Supplementary testing is recommended if the PPV (positive protective value) of the test at that site is <90% (discuss with your own Lab)
• Recent sexual partner(s) of confirmed cases of gonococcal infection
• Consider offering on epidemiological grounds following sexual assault

Recommended treatment
1. Uncomplicated gonorrhoea infection at any site in adults:

Ceftriaxone 1g IM single dose (can be used in pregnancy)
(with or without susceptibility testing)

(if known to have an antibiotic allergy please see section below)

Alternative if patient refuses IM injection or IM injection contraindicated
Cefixime 400mg orally single dose with Azithromycin 2g orally single dose (can
use in pregnancy

If β-lactam allergy:
Third generation cephalosporins such as cefixime and ceftriaxone show negligible cross-allergy with
penicillins. Contraindications to the administration of ceftriaxone are hypersensitivity to any
cephalosporin or previous immediate and /or severe hypersensitivity reaction to a penicillin or other
beta-lactam drug. Recommended treatments for patients giving a history of such hypersensitivity:
First choice: Gentamicin* 240mg IM with azithromycin 2g orally as a single dose
Or
Second choice: Spectinomycin 2g IM with Azithromcyin 2g orally as a single dose (does not cover oropharynx, diificult to source)
Or
Third choice: Azithromycin 2g orally single dose

*Stat doses of gentamicin are not associated with toxicity. Please discuss with a senior colleague if patient has history of nephrotoxicity or ototoxicity or mitochondrial mutation. Please see prescribing guidance in BNF for patients <50kg.

Antibiotic allergy and decline/unavailable for injection

MHRA strengthened restrictions in January 2024 stating that fluoroquinolones should only be used when other recommended antibiotics are inappropriate. As at Feb 2024 this applies even to single-dose treatments. Until further information and reassurance is provided following these warnings we are restricting use of fluoro-quinolones even for stat doses.

 For treatment of gonorrhoea with ciprofloxacin, a typical scenario would include

• history of cephalosporin or beta-lactam immediate hypersensitivity excluding cefixime use AND
• contraindication to or decline of gentamicin AND
• susceptibility predicted by NAAT SpeeDx test (if available) or culture

Contraindications include risk of pregnancy; previous fluoroquinolone side effects, aged under 16 or over 60 years, on corticosteroids, known renal impairment, previous organ transplantation, previous convulsions.

If after discussion of the possibility of disabling and irreversible side-effects this remains the best antibiotic please send the patient the following MHRA patient information leaflet by SMS. 

Fluoroquinolone antibiotics (-oxacins): what you need to know about tendons, muscles, joints, nervous system, and psychological side effects 

https://assets.publishing.service.gov.uk/media/65aa9125c69eea0010883840/FQ_Patient_Information_Sheet_-_TO_PUBLISH.pdf

2. Treatment of Complicated Gonococcal infections:
Discuss with senior staff first.

Gonococcal PID

Ceftriaxone 1g IM single dose
plus Metronidazole 400 mg twice daily orally for 14 days
PLUS
Doxycycline 100mg twice daily orally for 14 days
(see PID guidelines www.bashh.org)

Gonococcal Epididymo-orchitis

Ceftriaxone 1g IM single dose
Plus Doxycycline 100mg twice daily orally for 10-14 days

Gonococcal conjunctivitis
Treatment as per uncomplicated GC and the eye should be irrigated with saline/water

Disseminated GC 
clients must be admitted
(see BASHH UK National Guideline on the Management of Gonorrhoea 2018)

All patients diagnosed with gonorrhoea should see a clinician trained in partner notification at diagnosis and at each follow up visit, until partner notification is documented as complete.

For males with urethral symptoms look back period should be two weeks after the development of the symptoms.

In all other cases look back period is three months.

In order to reduce the unnecessary use of antibiotics, we recommend the following as a pragmatic approach:

• For those presenting after 14 days of exposure, we recommend treatment only following a positive test for gonorrhoea
• For those presenting within 14 days of exposure we recommend considering epidemiological treatment based on a clinical risk assessment and following a discussion with the patient. In asymptomatic individuals, it may be appropriate to not give epidemiological treatment, and to repeat testing 2 weeks after exposure.

All patients with gonorrhoea should be advised to return for a test of cure  with extra emphasis given to patients:

• With persistent symptoms or signs
• With pharyngeal infection
• Treated with anything other than first line recommended regimen when antimicrobial susceptibility unknown
• Who acquired infection in the Asia-Pacific region when antimicrobial susceptibility unknown

Advise no sexual intercourse until a negative result of test of cure is available.

Current evidence on the method and timing of TOC is scanty but expert opinion and pragmatic considerations
suggest:

• If asymptomatic – test with NAAT 2 weeks after completion of antibiotic therapy, followed by culture if NAAT positive
• Persisting symptoms or signs – test with culture, performed at least 72 hours after completion of therapy. Consider retreating even if culture negative, NAATs less than two weeks after completion of antibiotic therapy should be considered with caution.

At follow up confirm adherence to treatment and avoidance of sex.

Review antibiotic sensitivities when available. Check carefully the date of specimen collection on all reports – several laboratory reports may be sent on a single isolate. Be careful with results as sensitivities may relate to more than one organism if multiple pathogens identified.

Follow up may be needed for repeat syphilis ± HIV test due to different window periods.