treatment of gonorrhoea

Last edited 07/2021 and last reviewed 07/2021

Refer to GUM clinic for management of this condition.

Indications for therapy are:

  • 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. gonorrhoeae from any site, Supplementary testing is recommended if the positive predictive value of the test is <90%
  • recent sexual partner(s) of confirmed cases of gonococcal infection
  • consider offering on epidemiological grounds following sexual assault (1)

Gonorrhoea can be treated easily with the use of appropriate antimicrobials. The aim of therapy should be to ensure that more the 95% of uncomplicated infections respond to first-line therapy (2). Before starting treatment, consider local antibiotic resistance patterns and follow local guidelines if these exist.

  • for uncomplicated anogenital infection in adults
    • recommended treatment
      • ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g oral as a single dose
    • alternative regimens include (all the agents below should be accompanied by azithromycin 1 g oral as a single dose)
      • cefixime 400 mg oral as a single dose
        • is no longer recommended as the first choice for treatment in the UK due to decreasing susceptibility of gonorrhoea to cefixime
      • fluoroquinolone
        • are no longer recommended as first-line therapies for gonococcal infections due to the high prevalence of resistance worldwide
        • use Ciprofloxacin only if susceptibility is known prior to treatment and the isolate is sensitive to ciprofloxacin at all sites of infection
          • ciprofloxacin - 500 mg, single oral dose (5)

    Note:

    • these alternative regimens mentioned above do not comprise all effective treatment regimens, but reflect clinical practice in the UK
    • clinicians are also recommended to regularly review local and national trends in gonococcal antimicrobial resistance
    • cases of failure of cephalosporin therapy should be reported to the Health Protection Agency using on-line forms
  • for pharyngeal infections
    • recommended treatment include
      • ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g as a single dose or
      • ciprofloxacin 500 mg orally as a single dose or ofloxacin 400 mg orally as a single dose if N. gonorrhoeae known to be quinolone sensitive

    Note:

    • a lower efficacy (<90%) in eradicating N. gonorrhoeae from the pharynx than from genital infection has been demonstrated in single-dose antimicrobial treatment
    • for gonococcal infection in pregnancy - see linked item

Patient should refrain from sexual intercourse till they and their partner(s) have completed treatment. If azithromycin is used, this will be 7 days after the treatment was given (1).

Routine testing for C. trachomatis infection should be carried out in all adults with gonorrhoea since co infection is common (present in 35% of heterosexual men and 41% of women with gonorrhoea) (1).

Furthermore, sexual partner notification should be pursued in all patients identified with gonococcal infection

  • males with symptomatic urethral infection should notify all partners with whom they had sexual contact within the preceding 2 weeks or their last partner if longer than 2 weeks
  • patients with asymptomatic infection or infection at other sites should notify all partners within the preceding 3 months (1).

Referral to secondary care for treatment is recommended for neonates with suspected gonococcal ophthalmia neonatorum (4).

Key points (5):

  • antibiotic resistance is now very high
  • use IM ceftriaxone if susceptibility not known prior to treatment
  • use Ciprofloxacin only if susceptibility is known prior to treatment and the isolate is sensitive to ciprofloxacin at all sites of infection
  • refer to GUM
  • Test of cure is essential

Reference:

Related pages:

follow up and test of cure

empirical treatment of undiagnosed urethritis in a male

co-amoxiclav

4-quinolones

tetracyclines

gonorrhoea in pregnancy