Gonorrhoea

In the right clinical topic?

Age from 13 years onwards

This PRODIGY topic covers the diagnosis and management of gonorrhoea infection in men and women.

This PRODIGY topic does not cover the empirical treatment of urethritis or vaginal discharge or the management of disseminated gonorrhoea, complications of gonorrhoea (for example epididymitis), gonorrhoea infection of the eyes, or gonorrhoea in children.

There are separate PRODIGY topics on Bacterial vaginosis, Candida - female genital, Chlamydia - uncomplicated genital, Pelvic inflammatory disease,Scrotal swellings, Trichomoniasis, Urethritis - male, and Vaginal discharge.

The target audience for this PRODIGY topic is healthcare professionals working within the NHS in England, and providing first contact or primary health care. Patient information from the Family Planning Association (fpa) is intended to be printed and given to people with this condition or their carers.

How up-to-date is this topic?

Changes

Version 1.5, revision planned in 2013.

Last revised in November 2011

September 2011 — updated to reflect the revised UK National Guideline for the Management of Gonorrhoea in Adults 2011, published by the British Association for Sexual Health and HIV (BASHH) [BASHH, 2011b]. Issued in November 2011.

• The main changes to recommendations include:
• First-line treatment for gonorrhoea is now ceftriaxone 500 mg by intramuscular injection plus azithromycin 1 g orally.
• A test of cure is now recommended for all people after treatment for gonorrhoea.

May 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic [NPC, 2011]. Issued in June 2011.

September 2010 — minor update. The figures for new diagnoses of gonorrhoea in 2008/9 have been added [HPA, 2010], and the lower age limit for quinolone prescriptions has been raised from 16 to 18 years. Issued in September 2010.

October 2009 — minor update. Minor change to wording of basis regarding amoxicillin use in pregnant and breastfeeding women. Issued in October 2009.

October 2009 — minor update. Recommendations from the National Institute of Health and Clinical Excellence on when to suspect sexual abuse has been added to the Diagnosis section [NICE, 2009]. Issued in October 2009.

July to September 2009 — this is a new PRODIGY topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Knowledge update

New evidence

Evidence-based guidelines

Guidelines published since the last revision of this topic:

• BASHH (2011) UK national guideline for the management of gonorrhoea in adults 2011. British Association for Sexual Health and HIV.www.bashh.org [Free Full-text (pdf)] *New recommendations from this guideline have been incorporated into this PRODIGY topic*
• HPA and BASHH (2010) Guidance for gonorrhoea testing in England and Wales. British Association for Sexual Health and HIV. www.bashh.org [Free Full-text (pdf)] *New recommendations from this guideline have been incorporated into this PRODIGY topic*
• BASHH (2010) United Kingdom national guideline on the management of sexually transmitted infection and related conditions in children and young people (2009). British Association for Sexual Health and HIV. www.bashh.org [Free Full-text (pdf)]

A new GRASP report has been published by the HPA:

• HPA (2011) GRASP 2010 report. The Gonococcal Resistance to Antimicrobials Surveillance Programme. Health Protection Agency. www.hpa.org.uk[Free Full-text]

HTAs (Health Technology Assessments)

No new HTAs since 1 June 2009.

Economic appraisals

No new economic appraisals relevant to England since 1 June 2009.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 June 2009.

Primary evidence

No new randomized controlled trials published in the major journals since 1 June 2009.

New policies

No new national policies or guidelines since 1 June 2009.

New safety alerts

No new safety alerts since 1 June 2009.

Changes in product availability

No changes in product availability since 1 June 2009.

Goals and outcome measures

Goals

• To refer all people with gonorrhoea (suspected or confirmed) to a genito-urinary medicine (GUM) clinic or other local specialist sexual health service, where possible.
• When referral is not possible:
• To treat laboratory-confirmed gonorrhoea
• To swab and treat empirically people with suspected gonorrhoea
• To give information and advice about gonorrhoea and sexual health
• To notify and manage the person's sexual partners
• To follow up people after treatment for gonorrhoea

QIPP — Options for local implementation

• Antibiotic prescribing – especially quinolones and cephalosporins
• Review and, where appropriate, revise current prescribing practice and use implementation techniques to ensure prescribing is in line with Health Protection Agency (HPA) guidance.
• Benchmark and review the total volume of antibiotic prescribing against local and national data.
• Benchmark and review the use of quinolones and cephalosporin prescribing against local and national data.

[NPC, 2011]

Background information

What is it?

• Uncomplicated gonorrhoea is caused by localized infection with the diplococcus bacterium Neisseria gonorrhoeae. It primarily affects the mucous membranes of the urethra, endocervix, rectum, pharynx, and conjunctiva.
• Disseminated gonorrhoea may present as septic arthritis or dermatitis. It is much less common than uncomplicated gonorrhoea, occurring in less than 1% of people.
• Gonorrhoea is almost always sexually transmitted in adults. It is transmitted by direct inoculation of secretions from one mucous membrane to another, through genital–genital, genital–anorectal, orogenital, or oro–anal contact. Infection of the eye most commonly results from autoinoculation.

[Bignell, 2009; Marrazzo et al, 2010; BASHH, 2011b]

How common is it?

• Uncomplicated gonorrhoea is most common in young adults (15–25 years of age) and affects a disproportionate amount of people from ethnic minority groups [Bignell, 2009].
• In 2010, the Gonococcal Resistance to Antimicrobials Surveillance Programme indicated that the prevalence of gonorrhoeal infection was related to sexual activity [HPA, 2011].
• Men who have sex with men accounted for most cases of infection; most of these men were white, and just less than a third had coexisting HIV infection.
• Co-infection with chlamydia was identified in 38% of heterosexual men and 40% of women. Overall, 29% of people reported previously being infected with gonorrhoea.
• Recent sex abroad was reported by 14% of people, and over half of people reported two or more sexual partners in the preceding 3 months.
• In 2010, the Health Protection Agency reported on the incidence of gonorrhoea in 2008–2009 [HPA, 2010].
• The incidence of newly diagnosed gonorrhoea in the UK increased by 6%, from 16,629 cases in 2008 to 17,385 cases in 2009.
• Young people, aged less than 25 years, experience the highest rates of sexually transmitted infections. In those attending GUM clinics in 2009, 50% of gonorrhoea diagnoses were in those aged less than 25 years.
• In contrast to heterosexual men, sexually transmitted infections are common in men who have sex with men of any age; 36% of gonorrhoea diagnoses in 2009 were in men who have sex with men.

What are the complications and prognosis?

• Men
• Acute complications that may rarely occur include epididymitis, penile lymphangitis, peri-urethral abscess, acute prostatitis, seminal vesiculitis, and infection of Tyson's and Cowper's glands.
• Urethral stricture is now considered a rare complication of gonococcal urethritis.
• Women
• The natural history of gonorrhoeal infection is less understood than in men. As gonorrhoea is often asymptomatic in women, it may remain undiagnosed for long periods (along with coexisting infections of Chlamydia trachomatis and Trichomonas vaginalis).
• Bartholin's abscess may present as a local complication of infection, although it is usually caused by more than one pathogen.
• Pelvic inflammatory disease is thought to occur in 10–20% of women who contract gonorrhoea. The main concerns of pelvic inflammatory disease are infertility and peri-hepatitis caused by ascending infection.
• See the PRODIGY topic on Pelvic inflammatory disease for further information.
• Gonorrhoea in pregnancy is associated with spontaneous abortion, premature labour, early rupture of fetal membranes, perinatal mortality, and gonococcal conjunctivitis in the newborn.
• Disseminated gonorrhoea is a rare but potentially serious complication of gonococcal infection and may result in arthritis-dermatitis syndrome, gonococcal bacteraemia, and gonococcal endocarditis.

[Marrazzo et al, 2010]

Management

Which scenario?

• Scenario: Diagnosis: covers when to suspect a diagnosis of gonorrhoea, how to confirm the diagnosis, and when to suspect sexual abuse.
• Scenario: Management: covers the management of people with suspected or confirmed gonorrhoea infection.

Scenario: Diagnosis of gonorrhoea

When should I suspect gonorrhoea in a man?

• A diagnosis of gonorrhoea may be suspected on the basis of history, symptoms, and examination.

History

• Sexual intercourse with an infected person.

Symptoms

• Genital infection is usually symptomatic in men.
• Symptoms usually develop 2–5 days after exposure, although they may appear after 10 days or more.
• Major symptoms include:
• Urethral discharge in 80% of men. Initially it is often scant and mucoid, becoming overtly purulent after 1–2 days.
• Pain or difficulty urinating (dysuria) in about 50% of men. Usually there is no effect on frequency or urgency of urination.
• Genital infection is asymptomatic in a small proportion (less than 10%) of men.
• Rectal infection is asymptomatic in most men (about 75%), but may cause acute proctitis. This presents as anal pruritus, pain and spasm of the anal sphincter (tenesmus), purulent discharge, or bleeding.
• Pharyngeal infection is asymptomatic in 90% of men, but may cause overt pharyngitis.

Examination

• Examination commonly reveals a mucopurulent or purulent urethral discharge. Less commonly, there may be epididymal tenderness or swelling, or balanitis.

Basis for recommendation

• Sexual intercourse with an infected person is the over-riding risk factor for acquiring gonorrhoea [Marrazzo et al, 2010].
• The risk of transmission from an infected woman to her male partner is about 20% per episode of unprotected intercourse.
• The risk of transmission from an infected man to his female partner is between 50–70% per episode.
• The risk of transmission by anal intercourse has not been formally quantified but is thought to be high.
• The description of symptoms and examination in men is taken from the UK national guideline for the management of gonorrhoea [BASHH, 2011b] and from expert opinion in a textbook [Marrazzo et al, 2010].

When should I suspect gonorrhoea in a woman?

• Gonorrhoea may be suspected on the basis of history, symptoms, and examination.

History

• Sexual intercourse with an infected person.

Symptoms

• Uncomplicated urogenital infection causes no symptoms in up to 50% of women.
• Where present, symptoms usually develop within 10 days and include:
• Increased or altered vaginal discharge in up to 50% of women.
• Pain or difficulty urinating (dysuria) in 12% of women. Usually there is no effect on urgency or frequency of urination.
• Intermenstrual bleeding and, less commonly, postcoital bleeding.
• Pelvic or abdominal pain, with possible pain on intercourse (dyspareunia), if there is ascending infection (see the PRODIGY topic on Pelvic inflammatory disease).
• Rectal gonorrhoea may occur, but tends to cause symptoms (anal pruritus, pain and spasm of the anal sphincter [tenesmus], purulent discharge, or bleeding) that are less severe than in men.
• Pharyngeal infection is asymptomatic in 90% of women, but it may cause overt pharyngitis.

Examination

• In most women, no abnormal findings are present on examination.
• Examination may show:
• Most commonly, purulent or mucopurulent endocervical discharge, or easily induced endocervical bleeding. However, this is not a sensitive predictor of cervical infection (occurring in less than 50% of women).
• Less commonly, purulent discharge from the urethra.
• Abdominal tenderness if pelvic inflammatory disease is present.

Basis for recommendation

• Sexual intercourse with an infected person is the over-riding risk factor for acquiring gonorrhoea [Marrazzo et al, 2010].
• The risk of transmission from an infected woman to her male partner is about 20% per episode of unprotected intercourse.
• The risk of transmission from an infected man to his female partner is between 50–70% per episode.
• The risk of transmission by anal intercourse has not been formally quantified but is thought to be high.
• The description of symptoms and examinations in women is taken from the UK national guideline for the management of gonorrhoea [BASHH, 2011b] and from expert opinion in a textbook [Marrazzo et al, 2010].

How do I confirm a diagnosis of gonorrhoea?

• Ideally, refer all people with suspected gonorrhoea to a genito-urinary medicine (GUM) clinic or other local specialist sexual health service for confirmation of diagnosis.
• If the person is unwilling or unable to attend a GUM clinic or other local specialist sexual health service, follow local guidelines for testing for gonorrhoea.
• In men this may include:
• A first pass urine sample.
• A urethral swab.
• A rectal swab if rectal symptoms are present, or in men who have sex with men (MSM).
• A pharyngeal swab if pharyngeal symptoms are present, or in MSM.
• For more information, see the section on Assessment in the PRODIGY topic on Urethritis - male.
• In women this may include:
• Endocervical and urethral swabs.
• A rectal swab if rectal symptoms are present, or in women who are sexual contacts of me with confirmed infection.
• A pharyngeal swab if pharyngeal symptoms are present.
• See the PRODIGY topic on Vaginal discharge for further information.
• Sexual contacts of people with confirmed infection should be offered testing as above and empirical treatment for gonorrhoea (see Scenario: Management).
• If empirical treatment is not given, a second set of tests should be performed in people who present within 3 days of sexual contact. These tests should usually be done 14 days after contact.

Basis for recommendation

• Genito-urinary medicine clinics and specialist sexual health services have the resources to ensure effective diagnosis and treatment of gonorrhoea, as well as screening for other sexually transmitted infections (including HIV), counselling, follow up, and contact tracing (partner notification).

Investigations in primary care

Recommendations for testing for Neisseria gonorrhoeae are based on the UK national guideline for the management of gonorrhoea [BASHH, 2011b] and supported by Guidance for gonorrhoea testing in England and Wales [BASHH and HPA, 2010] and a review article in the medical literature [Bignell et al, 2006].

• Diagnosis of gonorrhoea is confirmed by detection of N gonorrhoeae at an infected site.
• Investigations will be guided by the clinical setting, storage and transport to the laboratory, local prevalence of infection, and the range of tests available locally. Therefore PRODIGY recommends that practitioners confirm which testing methods are used locally.
• Microscopy of gram-stained genital specimens offers 90–95% sensitivity in men with urethral discharge, enabling immediate diagnosis in men with symptomatic genital infection. In men with no symptoms, sensitivity is reduced to 50–75%. Microscopy has poor sensitivity in women (37–50% for endocervical samples and 20% for urethral samples), and is not usually recommended for urethral samples in women. Microscopy is not generally recommended for diagnosing rectal or pharyngeal infection.
• Culture allows identification of N gonorrhoeae and antimicrobial susceptibility testing, which is important as antibiotic resistance increases. It is a relatively inexpensive, specific, and sensitive test at genital sites in both men and women. In women, culture ideally requires endocervical and urethral swabs for maximum sensitivity. However, this may not always be possible in primary care. Culture is the only widely validated diagnostic test for rectal and pharyngeal infection.
• Nucleic acid amplification testing (NAAT) offers high sensitivity (greater than 96%) in both symptomatic and asymptomatic infection.
• In men, first pass urine and urethral swabs show similar sensitivity for detecting N gonorrhoeae.
• In women, vaginal and endocervical swabs show similar sensitivity for detecting N gonorrhoeae. The sensitivity for a urine specimen is lower in women, and NAAT testing of urine in women is therefore not recommended.

When should I suspect sexual abuse?

• Consider the possibility of sexual abuse in any child or young person with gonorrhoea, particularly in the following circumstances:
• The child is younger than 13 years of age, unless there is clear evidence of mother-to-child transmission during birth, or of blood contamination.
• The young person is 13 to 15 years of age, unless there is clear evidence of mother-to-child transmission during birth, blood contamination, or that the sexually transmitted infection (STI) was acquired from consensual sexual activity with a peer.
• The young person is 16 to 17 years of age and there is no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity, and there is a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or with a person in a position of trust (such as a teacher, sports coach, minister of religion) or there is concern that the young person is being exploited.
• Follow appropriate child protection procedures and refer to a paediatrician if necessary.

Basis for recommendation

• These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline When to suspect child maltreatment [NICE, 2009].

What else might it be?

• Men
• Other causes of penile discharge include:
• Non-gonococcal urethritis caused by Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, or Trichomonas vaginalis (see the PRODIGY topic on Urethritis - male).
• Physiological discharge (small amounts of clear or mucoid discharge upon sexual excitement).
• Subpreputial infection (for example candidiasis).
• Acute prostatitis — may present with: blood-tinged urethral discharge; dysuria, frequency, and urgency; fever; or penile, perineal, and rectal pain. The prostate is swollen and tender.
• Herpes simplex virus infection — can present with herpetic lesions on the urethral meatus.
• Women
• Chlamydia. It is not possible to distinguish gonorrhoeal infection from chlamydia in women by clinical features alone, and the infections coexist in about a third of women.
• See the PRODIGY topic on Chlamydia - uncomplicated genital for further information.
• Other causes of vaginal discharge.
• See the PRODIGY topics on Vaginal discharge, Candida - female genital, Bacterial vaginosis, Trichomoniasis, and Pelvic inflammatory disease.

Basis for recommendation

• Information on differential diagnoses is based on expert opinion in a review article [Adler, 2004] and on the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) [HPA, 2011].

Scenario: Management of gonorrhoea

How should I manage a person with gonorrhoea in primary care?

• Ideally, refer all people with confirmed or suspected gonorrhoea to a genito-urinary medicine (GUM) clinic or other local specialist sexual health service.
• If these services cannot be accessed within a reasonable time, or if the person is unwilling to attend despite receiving appropriate information and advice:
• Treat for gonorrhoea:
• Following a positive identification of Neisseria gonorrhoeae by microscopy, culture, or nucleic acid amplification testing (NAAT) (see Scenario: Diagnosis).
• If a diagnosis of gonorrhoea is suspected from symptoms and examination (see Scenario: Diagnosis) — treat empirically whilst waiting for laboratory confirmation.
• If the person is a recent sexual partner(s) of someone with confirmed gonococcal infection.
• If possible, take swabs for culture before giving antibiotics if gonorrhoea was diagnosed by NAAT. This will enable sensitivity testing and identification of resistant strains.
• Offer screening for other sexually transmitted infections (STIs) and for HIV.
• Encourage patient-led partner notification.
• Partners should be screened for STIs and treated empirically for gonorrhoea whilst awaiting results.
• Advise the person to abstain from sex until they and any partners have completed treatment; if azithromycin is used, this will be 7 days after treatment is given.
• Follow-up after 1 week to verify the success of treatment.
• Test of cure is recommended for all people who have been treated for gonorrhoea.
• Advise the person to practice safe sex in the future.

Basis for recommendation

These recommendations are based on the British Association for Sexual Health and HIV UK National Guideline for the Management of Gonorrhoea in Adults [BASHH, 2011b].

When should I refer or admit a person with gonorrhoea?

• Ideally, refer all people with suspected or confirmed gonorrhoea to a genito-urinary medicine (GUM) clinic or other local specialist sexual health service.
• Referral is particularly important in:
• Men who have complications caused by gonorrhoea (such as epididymitis or prostatitis).
• Women who are pregnant.
• Women with suspected ascending infection (see the PRODIGY topic on Pelvic inflammatory disease).
• Admit:
• People with suspected disseminated gonorrhoea (systemic symptoms may be present, such as fever, malaise, joint pain and swelling, and rash).
• Women with pelvic inflammatory disease if it is severe or there are complications.

Basis for recommendation

Referral

• Genito-urinary medicine clinics and other specialist sexual health services have the resources to ensure effective diagnosis and treatment of gonorrhoea, as well as screening for other sexually transmitted infections (including HIV), counselling, follow up, and contact tracing (partner notification).
• Men who are suspected of having complications caused by gonorrhoea require specialist management (for example extended courses of antibiotics) [Bignell, 2009; Marrazzo et al, 2010].
• Gonorrhoea in pregnancy is associated with spontaneous abortion, premature labour, early rupture of fetal membranes, perinatal mortality, and gonococcal conjunctivitis in the newborn [Marrazzo et al, 2010].

Admission

• Admission is required for disseminated gonorrhoea because it can develop into life-threatening infection (for example gonococcal meningitis). Treatment in secondary care will typically involve higher doses of an intramuscular or intravenous cephalosporin for up to a week [Bignell, 2009].
• The recommendation to admit a woman with pelvic inflammatory disease that is severe or has complications is based on expert opinion in guidelines from the Royal College of Obstetricians and Gynaecologists and the British Association for Sexual Health and HIV [RCOG, 2009; BASHH, 2011a].

Sexually transmitted infection and HIV screening

• Screening for other sexually transmitted infections is in line with guidelines from BASHH and the Health Protection Agency [RCGP and BASHH, 2006; HPA, 2008; BASHH, 2011b].

How should I treat a person with gonorrhoea in primary care?

Treat gonorrhoea in primary care only if specialist services cannot be accessed within a reasonable time, or if the person is unwilling to attend despite receiving appropriate information and advice.

• Treatment is indicated following a positive identification of Neisseria gonorrhoeae by microscopy, culture, or nucleic acid amplification testing (NAAT) (see Scenario: Diagnosis).
• Empirical treatment is indicated for:
• People with suspected gonorrhoea, whilst waiting for laboratory confirmation of the diagnosis.
• Recent sexual partner(s) of people with confirmed gonococcal infection.

For confirmed or suspected uncomplicated anogenital gonorrhoea, prescribe:

• Ceftriaxone 500 mg intramuscular (IM) injection as a single dose, plus azithromycin 1 g orally as a single dose.
• If an IM injection is contraindicated or refused, offer cefixime 400 mg orally as a single dose, plus azithromycin 1 g orally as a single dose.
• If cephalosporins are contraindicated (for example the person has a true allergy to penicillin-type antibiotics), consider a fluoroquinolone (ciprofloxacin 500 mg, single oral dose or ofloxacin 400 mg, single oral dose) plus azithromycin 1 g, single oral dose.
• Only prescribe a fluoroquinolone if the infection is known to be sensitive to fluoroquinolones (that is, culture and sensitivity results are available for the person or recent sexual partners).
• If these regimens are unsuitable or unavailable, contact the local microbiology or genito-urinary medicine clinic for advice.

For confirmed pharyngeal gonorrhoea, prescribe:

• Ceftriaxone 500 mg intramuscular (IM) injection as a single dose, plus azithromycin 1 g orally as a single dose.
• If an IM injection is contraindicated or refused, offer oral cefixime (400 mg loading dose, followed by 200 mg twice a day for 3 days) plusazithromycin 1 g orally as a single dose.
• Note this regimen is off-label and is recommended on the basis of expert opinion rather than trial-based evidence.
• If cephalosporins are contraindicated (for example the person has a true allergy to penicillin-type antibiotics), consider a fluoroquinolone (ciprofloxacin 500 mg, single oral dose or ofloxacin 400 mg, single oral dose).
• Only prescribe a fluoroquinolone if the infection is known to be sensitive to fluoroquinolones (that is, culture and sensitivity results are available for the person or recent sexual partners).

Basis for recommendation

Treatment recommendations are based on the National guideline on the diagnosis and treatment of gonorrhoea in adults, published by the British Association for Sexual Health and HIV (BASHH) [BASHH, 2011b].

Treatment with antibiotics

• Good evidence from several comparative randomized controlled trials (RCTs) supports the use of antibiotics in the treatment of gonorrhoea. Historically, cephalosporins, fluoroquinolones, and macrolides have produced microbiological cure rates in excess of 95% in these trials [Moran and Levine, 1995].

Choice of antibiotics

• Since the introduction of sulphonamides in the 1930s, there has been growing evidence of gonococcal resistance to many classes of antibiotics[Workowski et al, 2008]. Therefore, antibiotic recommendations are mainly based on current gonococcal sensitivity to antibiotics, rather than historical evidence of their efficacy from RCTs [Tyson, 2005].
• Surveillance data in England and Wales show significant levels of N. gonorrhoeae resistance to penicillin (20% in 2010), tetracyclines (69% in 2010), and ciprofloxacin (36% in 2010) [HPA, 2011].
• Cephalosporins are recommended first line because N. gonorrhoeae is largely sensitive to this drug class, although resistance to cefixime is increasing [HPA, 2011]. Ceftriaxone and cefixime are third-generation cephalosporins that have shown evidence of a cure rate greater than 95% in RCTs (the accepted level of effectiveness) [Moran and Levine, 1995].
• Confirmed therapeutic failure to cefixime is rare, and is undocumented for ceftriaxone in England and Wales.
• In 2010, no isolates were reported as having decreased susceptibility to ceftriaxone, although a trend of increasing MIC drift has been observed [HPA, 2011]. Concerns about increasing resistance to cephalosporins have led to an increase in the recommended dose of ceftriaxone to 500 mg. Ceftriaxone is less convenient than cefixime but was shown to give a 100% cure rate in one trial of people with uncomplicated infection [Zajdowicz et al, 1983], and in one trial which included people with pharyngeal infection [Christophersen et al, 1989].
• In 2009, 1.2% of gonococcal isolates demonstrated reduced susceptibility to cefixime at a MIC of 0.25 mg/L or more; in 2010 this rose to 6.3% [HPA, 2011]. In 2011, three cases of failure with cefixime treatment were reported [BASHH, 2011b]. The use of cefixime for the treatment of gonorrhoea is off-label [ABPI Medicines Compendium, 2010b], but one RCT showed it to be effective at a single oral dose of 400 mg (cure rate 96%, 95% CI 94 to 98)[Handsfield, 1991]. Because treatment failure has been reported with cefixime it should only be used if an intramuscular injection is contraindicated or refused.
• Alternative injectable or oral cephalosporins offer no advantage over ceftriaxone or cefixime.
• Azithromycin (1 g) is recommended by BASHH as add-on therapy for uncomplicated anogenital infection to delay the onset of widespread resistance to cephalosporins [BASHH, 2011b]. Improved eradication of pharyngeal gonorrhoea has been reported with the addition of azithromycin to a cephalosporin.
• Ciprofloxacin and ofloxacin are fluoroquinolones that are recommended if cephalosporins are contraindicated, most commonly because of documented beta-lactam allergy (allergy to penicillins, cephalosporins, and associated antibiotics). Between 1% and 10% of people with penicillin allergy are thought to have cross-sensitivity to cephalosporins [Workowski et al, 2008].
• Good evidence from RCTs indicates that fluoroquinolones have been effective in the treatment of gonorrhoea [Bignell, 1996]. However, evidence from surveillance data indicates that there is endemic resistance of gonorrhoeal isolates to ciprofloxacin, with a prevalence of around 36% [HPA, 2011]. Therefore, it is important that the sensitivity of the infection is known before treatment with a fluoroquinolone is prescribed.
• High-dose azithromycin (2 g as a single dose) was shown to be effective at eradicating N. gonorrhoeae in one open-label randomized controlled trial (98.9% eradication rate). However, it was associated with a high level of gastrointestinal irritation [Handsfield et al, 1994]. A high level of resistance to azithromycin has been observed in the UK [Chisholm et al, 2009]. Because there is no apparent rationale for prescribing high-dose azithromycin in preference to a cephalosporin or a fluoroquinolone, PRODIGY does not recommend this regimen in primary care.
• BASHH also recommends intramuscular spectinomycin (2 g as a single dose) plus azithromycin as an alternative regimen. However, PRODIGY does not recommend this regimen for use in primary care because spectinomycin is not currently being manufactured in the UK and may be difficult to obtain.

Pharyngeal gonorrhoea

• In general, single-dose antimicrobials have demonstrated lower efficacy in pharyngeal infection than in anogenital infection. Failure has been reported with ceftriaxone.
• For treatment of pharyngeal gonorrhoea, BASHH recommends ceftriaxone plus azithromycin first line [BASHH, 2011b]. However, because ceftriaxone may not be readily available in primary care, some experts recommend an alternative 3-day regimen of cefixime (plus azithromycin) on the basis of pharmacokinetic principles [Horner, Personal Communication, 2009]. This is reasonable, as a test of cure is always recommended for pharyngeal gonorrhoea (see Follow-up).
• Because of widespread quinolone resistance, treatment with ciprofloxacin or ofloxacin is only recommended if N. gonorrhoeae is known to be quinolone sensitive. In this case supplementary azithromycin is not necessary, unless additional antibiotics are needed to cover for Chlamydia trachomatis.

Empirical treatment

• As it is not possible to accurately differentiate between infection with N. gonorrhoeae and Chlamydia trachomatis by clinical features alone, and the infections often coexist, empirical treatment aims to cover both organisms [RCGP and BASHH, 2006].
• As the recommended regimens for empirical treatment now include azithromycin 1 g, which will also treat C. trachomatis, further additional empirical treatment for chlamydia is no longer necessary.
• For more information, see the PRODIGY topic on Chlamydia - uncomplicated genital.

What treatment should I prescribe for a pregnant or breastfeeding woman with gonorrhoea in primary care?

• For confirmed or suspected uncomplicated gonorrhoea, prescribe:
• Ceftriaxone 500 mg intramuscular (IM) injection as a single dose, plus azithromycin 1 g orally as a single dose.
• If IM ceftriaxone is unavailable or unsuitable, offer cefixime 400 mg as a single oral dose plus azithromycin.
• Do not prescribe a fluoroquinolone for a woman who is pregnant or breastfeeding. Seek specialist advice if a cephalosporin is contraindicated, for example if the woman has a true allergy to penicillin.

Basis for recommendation

Treatment recommendations for women who are pregnant or breastfeeding are based on the National guideline on the diagnosis and treatment of gonorrhoea in adults, published by the British Association for Sexual Health and HIV (BASHH) [BASHH, 2011b].

Treatment with antibiotics

• Good evidence from several comparative randomized controlled trials (RCTs) supports the use of antibiotics in the treatment of gonorrhoea. Historically, cephalosporins, fluoroquinolones, and macrolides have produced microbiological cure rates in excess of 95% in these trials [Moran and Levine, 1995].

Choice of antibiotics

• Since the introduction of sulphonamides in the 1930s, there has been growing evidence of gonococcal resistance to many classes of antibiotics[Workowski et al, 2008]. Therefore, antibiotic recommendations are mainly based on current gonococcal sensitivity to antibiotics, rather than historical evidence of their efficacy from RCTs [Tyson, 2005].
• Surveillance data in England and Wales shows significant levels of N. gonorrhoeae resistance to penicillin (20% in 2010), tetracyclines (69% in 2010), and ciprofloxacin (36% in 2010) [HPA, 2011].
• Cephalosporins are recommended first line because N. gonorrhoeae is largely sensitive to this drug class, although resistance to cefixime is increasing [HPA, 2011]. There is evidence from a meta-analysis of two comparative randomized controlled trials that cefixime and ceftriaxone are effective in the treatment of confirmed gonorrhoea in pregnant women [Brocklehurst, 2002].
• Confirmed therapeutic failure to cefixime is rare, and is undocumented for ceftriaxone in England and Wales.
• In 2010, no isolates were reported as having decreased susceptibility to ceftriaxone, although a trend of increasing MIC drift has been observed [HPA, 2011]. Concerns about increasing resistance to cephalosporins have led to an increase in the recommended dose of ceftriaxone to 500 mg. Ceftriaxone is less convenient than cefixime but was shown to give a 100% cure rate in one trial of people with uncomplicated infection [Zajdowicz et al, 1983], and in one trial which included people with pharyngeal infection [Christophersen et al, 1989].
• In 2009, 1.2% of gonococcal isolates demonstrated reduced susceptibility to cefixime at a MIC of 0.25 mg/L or more; in 2010 this rose to 6.3% [HPA, 2011]. In 2011, three cases of failure with cefixime treatment were reported [BASHH, 2011b]. The use of cefixime for the treatment of gonorrhoea is off-label [ABPI Medicines Compendium, 2010b], but one RCT showed it to be effective at a single oral dose of 400 mg (cure rate 96%, 95% CI 94 to 98)[Handsfield, 1991]. Because treatment failure has been reported with cefixime it should only be used if an intramuscular injection is contraindicated or refused.
• Alternative injectable or oral cephalosporins offer no advantage over ceftriaxone or cefixime.
• Azithromycin (1 g) is recommended by BASHH as add-on therapy for uncomplicated anogenital infection to delay the onset of widespread resistance of cephalosporins [BASHH, 2011b]. Improved eradication of pharyngeal gonorrhoea has been reported with the addition of azithromycin to a cephalosporin.
• BASHH also recommends intramuscular spectinomycin (2 g as a single dose) plus azithromycin as an alternative regimen for women who are pregnant or breastfeeding. However, PRODIGY does not recommend this regimen for use in primary care because spectinomycin is not currently being manufactured in the UK and may be difficult to obtain.

Safety of antibiotics in pregnancy

• The benefits of antibiotics for gonorrhoea outweigh the risks in pregnancy.
• Left untreated, gonorrhoea in pregnancy is associated with spontaneous abortion, premature labour, early rupture of fetal membranes, perinatal mortality, and gonococcal conjunctivitis in the newborn [Marrazzo et al, 2010].
• Cefixime and ceftriaxone are not specifically licensed in pregnancy but 'are not known to be harmful' [BNF 61, 2011]. Although cephalosporins cross the placenta, there is no evidence from animal studies to indicate that they are toxic to the embryo or the fetus, and no harms have been shown in observational studies of pregnant women who have been exposed to cephalosporins [Schaefer et al, 2007; NTIS, 2008d].
• Macrolides are considered to be suitable treatment options in pregnancy where indicated [NTIS, 2008c].
• Erythromycin is generally preferred because there is more experience with it than with other macrolides [NTIS, 2008b]. However, it is probably not as effective as azithromycin in the treatment of chlamydia [Brocklehurst and Rooney, 1998].
• Animal studies and limited observational data have not indicated an increased risk of congenital malformations with the use of azithromycin in pregnancy [NTIS, 2008a]. The manufacturer advises that azithromycin tablets should only be used in pregnancy if definitely indicated, and that breastfeeding should be discontinued during treatment with azithromycin and for 2 days after stopping treatment (breast milk should be discarded during this period) [ABPI Medicines Compendium, 2011].
• Fluoroquinolones are not recommended in pregnancy or breastfeeding except 'for the treatment of serious or life-threatening conditions unresponsive to standard antibiotic therapy', because there is a theoretical risk of arthropathy in the child [Schaefer et al, 2007; NTIS, 2008c].

What information and advice should I give someone with gonorrhoea?

• Advise the person to attend a genito-urinary medicine clinic or other local specialist sexual health service if possible.
• Inform the person that these services have the resources to ensure effective management and partner notification, and that they are confidential and non-judgemental.
• Discuss the long-term implications if gonorrhoea is left untreated for the health of the person and their partners.
• Reinforce this information with clear and accurate written material where available (see the patient information from the Family Planning Association onGonorrhoea (fpa)).
• Advise the person to abstain from sex until they and any partners have completed treatment; if azithromycin is used, this will be 7 days after treatment is given.
• Advise the person regarding safe sexual practice in the future.

Basis for recommendation

Recommendations for providing information and advice are based on expert opinion from the National guideline on the diagnosis and treatment of gonorrhoea in adults, published by the British Association for Sexual Health and HIV [BASHH, 2011b].

When and how should sexual partners be notified?

• Partner notification is essential for all people with newly diagnosed gonorrhoea. Ideally this should be done by a trained health adviser in genito-urinary medicine (GUM).
• For people with symptomatic anogenital gonorrhoea, all partners within the preceding 2 weeks should be notified, or their most recent partner, if this was longer than 2 weeks ago.
• For people with asymptomatic gonorrhoea, or gonorrhoea at other sites, all partners within the preceding 3 months should be notified.
• Three methods of partner notification are used. For each method, the healthcare professional should document all actions and outcomes.
• Patient referral: the person with gonorrhoea is encouraged to notify their past and present partners. This is the usual method used in primary care and the only practical option if provider referral is not available.
• Provider referral: the healthcare professional notifies the person's partners on their behalf. This option is recommended, but is often not available in primary care. Ideally, provider referral should be facilitated by a trained health adviser in a GUM clinic (see Admission and referral). If referral to a GUM clinic is not possible, a primary healthcare professional who has undergone appropriate training and has support from healthcare advisers in GUM is the next best option.
• Contract referral: the person with gonorrhoea is encouraged to notify their partners, with the understanding that a healthcare professional will later notify those partners who do not visit the health service within an allotted time. This option is not usually suitable in a primary care setting.
• Notified partners should be screened for sexually transmitted infections (prior to giving antibiotics if possible) and treated empiricallywhilst waiting for results.

Basis for recommendation

Recommendations for partner notification are based on expert opinion from the National guideline on the diagnosis and treatment of gonorrhoea in adults, published by the British Association for Sexual Health and HIV [BASHH, 2011b].

Partner notification in primary care

• There is expert consensus that if referral to a GUM clinic (or to a general practice providing an enhanced sexual health service) is not possible, contact tracing should be undertaken in primary care, and this should be documented [Fitzgerald et al, 1996].

Period of partner notification

• The recommended periods for notification are consistent with what is known about the natural course of symptomatic infection with gonorrhoea[Marrazzo et al, 2010]. However, there is less certainty about the natural course of asymptomatic infection or infection at sites other than the genitals and rectum, and a period of 3 months is therefore advised as a precautionary measure [BASHH, 2011b].

Method of partner notification

• A Cochrane systematic review (search date: around 2001) found evidence that both provider and contract referral methods result in more partners presenting for medical evaluation compared with patient referral [Mathews et al, 2001]. However, in practice, provider referral can be difficult to organize, and most GUM clinics in the UK use patient referral as the contact method of first choice [Stokes and Schober, 1999].

How should I follow up someone with gonorrhoea?

• Follow up all people with gonorrhoea about 1 week after treatment.
• Confirm that the person has adhered to treatment and symptoms have resolved.
• Confirm that partner notification has been carried out (if patient or contract referral was used).
• Ask about recent sexual history (and the possibility of re-infection), and reinforce advice about safe sexual practice.
• A test of cure (TOC) is recommended for all people who have been treated for gonorrhoea.
• If signs or symptoms persist, test with culture, performed at least 3 days after completion of treatment.
• If the person is asymptomatic, test with nucleic acid amplification testing (NAAT) where available (followed by culture if positive), at least 2 weeks after completion of treatment.
• If it is not possible or practical to perform a test of cure in all people treated for gonorrhoea, the following groups of people should be prioritized for a TOC:
• People with persistent signs or symptoms.
• People with pharyngeal infection.
• People who have been treated with anything other than the first-line recommendation.

Basis for recommendation

Recommendations on follow up are based on the National guideline on the diagnosis and treatment of gonorrhoea in adults, published by the British Association for Sexual Health and HIV [BASHH, 2011b].

• A test of cure (TOC) is now recommended in all people treated for gonorrhoea to identify patterns of emerging resistance.
• The recommendations for the method and timing of TOC are based on expert opinion and pragmatic considerations.

Prescriptions

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).

Anogenital gonorrhoea: cephalosporin + azithromycin

Age from 13 years onwards

Multi-therapy: First choice: IM ceftriaxone plus azithromycin

Ceftriaxone injection: 500mg single dose

Ceftriaxone 250mg powder for solution for injection vials

Reconstitute the contents of two vials and give a single dose of 500mg by intramuscular injection.

Supply 2 250mg vial.

Age: from 13 years onwards

NHS cost: £4.80

Licensed use: no - off-label dose

Azithromycin capsules: 1 gram single dose

Azithromycin 250mg capsules

Take four capsules as a single dose.

Supply 4 capsules.

Age: from 13 years onwards

NHS cost: £9.64

Licensed use: no - off-label indication

Multi-therapy: If IM injection not suitable: oral cefixime plus azithromycin

Cefixime tablets: 400mg single dose

Cefixime 200mg tablets

Take two tablets as a single dose.

Supply 2 tablets.

Age: from 13 years onwards

NHS cost: £3.78

Licensed use: no - off-label indication

Azithromycin capsules: 1 gram single dose

Azithromycin 250mg capsules

Take four capsules as a single dose.

Supply 4 capsules.

Age: from 13 years onwards

NHS cost: £9.64

Licensed use: no - off-label indication

Anogenital gonorrhoea: alternative in penicillin allergy

Age from 18 years onwards

Multi-therapy: Ciprofloxacin + azithromycin: ONLY if sensitive (NOT if pregnant)

Ciprofloxacin tablets: 500mg single dose

Ciprofloxacin 500mg tablets

Take one tablet as a single dose.

Supply 1 tablet.

Age: from 18 years onwards

NHS cost: £0.12

Licensed use: yes

Azithromycin capsules: 1 gram single dose

Azithromycin 250mg capsules

Take four capsules as a single dose.

Supply 4 capsules.

Age: from 18 years onwards

NHS cost: £9.64

Licensed use: no - off-label indication

Multi-therapy: Ofloxacin + azithromycin: ONLY if sensitive (NOT if pregnant)

Ofloxacin tablets: 400mg single dose

Ofloxacin 400mg tablets

Take one tablet as a single dose.

Supply 1 tablet.

Age: from 18 years onwards

NHS cost: £0.62

Licensed use: yes

Azithromycin capsules: 1 gram single dose

Azithromycin 250mg capsules

Take four capsules as a single dose.

Supply 4 capsules.

Age: from 18 years onwards

NHS cost: £9.64

Licensed use: no - off-label indication

Pharyngeal gonorrhoea: cephalosporin + azithromycin

Age from 13 years onwards

Multi-therapy: First choice: IM ceftriaxone plus azithromycin

Ceftriaxone injection: 500mg single dose

Ceftriaxone 250mg powder for solution for injection vials

Reconstitute the contents of two vials and give a single dose of 500mg by intramuscular injection.

Supply 2 250mg vial.

Age: from 13 years onwards

NHS cost: £4.80

Licensed use: no - off-label dose

Azithromycin capsules: 1 gram single dose

Azithromycin 250mg capsules

Take four capsules as a single dose.

Supply 4 capsules.

Age: from 13 years onwards

NHS cost: £9.64

Licensed use: no - off-label indication

Multi-therapy: If IM injection not suitable: oral cefixime plus azithromycin

Cefixime tablets: 400mg single dose, then 200mg twice a day

Cefixime 200mg tablets

Take two tablets as a single dose, then take one tablet twice a day for 3 days.

Supply 8 tablets.

Age: from 13 years onwards

NHS cost: £15.12

Licensed use: no - off-label indication

Azithromycin capsules: 1 gram single dose

Azithromycin 250mg capsules

Take four capsules as a single dose.

Supply 4 capsules.

Age: from 13 years onwards

NHS cost: £9.64

Licensed use: no - off-label indication

Pharyngeal gonorrhoea: alternative in penicillin allergy

Age from 18 years onwards

Ciprofloxacin tablets: ONLY if sensitive (NOT if pregnant)

Ciprofloxacin 500mg tablets

Take one tablet as a single dose.

Supply 1 tablet.

Age: from 18 years onwards

NHS cost: £0.12

Licensed use: yes

Ofloxacin tablets: ONLY if sensitive (NOT if pregnant)

Ofloxacin 400mg tablets

Take one tablet as a single dose.

Supply 1 tablet.

Age: from 18 years onwards

NHS cost: £0.62

Licensed use: yes

Prescribing information

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this PRODIGY topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).

What issues should I consider before prescribing a cephalosporin?

• Intramuscular (IM) cefotaxime is the cephalosporin of choice for treating gonorrhoea. If an IM injection is contraindicated or refused, oral cefixime is recommended. Both cefotaxime and cefixime are third generation cephalosporins.

Contraindications and precautions

• Cephalosporins should not be taken by people who have a true penicillin allergy. Note that gastrointestinal adverse effects alone (e.g. nausea, vomiting, or diarrhoea) do not constitute an allergy to penicillin.

Adverse effects

• Gastrointestinal effects such as diarrhoea, nausea and vomiting are common with cephalosporins.
• Rarely, cephalosporins can cause antibiotic-associated colitis — consider the possibility of this in anyone who presents with diarrhoea after treatment with ceftriaxone or cefixime.

Drug interactions

• Oral hormonal contraception — additional contraceptive precautions are not required during or after a course of ceftriaxone or cefixime.
• However, women should be advised about the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the section on Antibiotics in the PRODIGY topic on Contraception - assessment.

Basis for recommendation

Contraindications and precautions

• Between 0.5% and 6.5% of people with a true penicillin allergy will also be allergic to cephalosporins [BNF 61, 2011]. Although this cross-sensitivity is thought to be negligible with third generation cephalosporins, it is recommended that all people with a history of true penicillin allergy should avoid taking any cephalosporin [ABPI Medicines Compendium, 2009b; BASHH, 2011b; BNF 61, 2011].

Adverse effects

• Gastrointestinal effects including diarrhoea, nausea, and vomiting are reported to occur in 1–10% of people taking ceftriaxone [ABPI Medicines Compendium, 2009b]. Pseudomembranous colitis (caused by infection with Clostridium difficile) is reported to be very rare (less than 0.01%), however, the manufacturers recommend that this should be considered in people who develop diarrhoea after a course of ceftriaxone or cefixime[ABPI Medicines Compendium, 2009b; ABPI Medicines Compendium, 2010b].

Drug interactions

• Although the UKMEC criteria advise additional precautions with antibiotics that do not induce enzymes [FSRH, 2009], this was an interim measure until the evidence could be reviewed in detail by the FSRH clinical effectiveness unit.
• Having reviewed the available evidence, the FSRH no longer advises that additional precautions are required to maintain contraceptive efficacy when using antibiotics that are not enzyme inducers with combined hormonal methods for durations of 3 weeks or less, unless the antibiotics (or the illness) cause vomiting or diarrhoea.

What issues should I consider before prescribing azithromycin?

Cautions and precautions

• Use azithromycin with caution in people who may be predisposed to prolongation of the QT interval. This includes people:
• With congenital or documented acquired QT prolongation.
• Currently receiving treatment with other active substances known to prolong the QT interval such as antiarrhythmics of classes IA and III.
• With electrolyte disturbance, particularly in cases of hypokalaemia and hypomagnesaemia.
• With clinically relevant bradycardia, cardiac arrhythmia, or severe cardiac insufficiency.

Adverse effects

• Nausea, vomiting, diarrhoea, and abdominal discomfort are the most common adverse effects of all the macrolides, but are milder and less frequent with azithromycin than with erythromycin.

Drug interactions

• Warfarin — rarely, azithromycin can produce a marked increase in the anticoagulant effects of warfarin.
• Advise people taking warfarin to seek immediate medical advice if they experience spontaneous bleeding, and the bleeding does not stop or recurs. This includes bruising, bleeding gums, nosebleeds, prolonged bleeding from cuts, and blood in the urine or stools.

Basis for recommendation

Cautions and precautions

• Prolonged QT interval or cardiac repolarization have been reported with other macrolides and a similar effect with azithromycin has not been ruled out [ABPI Medicines Compendium, 2011].

Adverse effects

• Information regarding the nature and frequency of adverse effects is taken from the British National formulary [BNF 61, 2011].

Drug interactions

• Macrolides are generally considered to be inhibitors of the enzyme CYP3A4, however they vary in the strength of their effect and azithromycin only inhibits CYP3A4 to a small, usually clinically insignificant degree [Baxter, 2010].
• A marked increase in the effects of warfarin has been noted in a small number of people concomitantly taking azithromycin. Although a causal mechanism has not been established, the manufacturer recommends that prescribers give consideration to the frequency of INR monitoring for people who are already taking warfarin [ABPI Medicines Compendium, 2011]. However, it is unclear how this might be affected by single-dose azithromycin.

What issues should I consider before prescribing a quinolone?

• Ciprofloxacin or ofloxacin are the quinolones of choice for treating gonorrhoea. However, a quinolone should only be prescribed when an infection is known to be quinolone sensitive before treatment is started.

Contraindications and precautions

• Avoid quinolones in:
• Children and adolescents younger than 18 years old.
• People with epilepsy or conditions that predispose to seizures, and in people taking other medication that may predispose to seizures.
• People with a history of tendonitis.

Adverse effects

• Musculoskeletal pain is occasionally experienced by people taking quinolones (0.1–1.0%); tendinitis is a very rare adverse effect (less than 0.01%).
• Advise the person that if they experience pain or inflammation of a tendon they should urgently consult a healthcare professional.
• If tendonitis is suspected (if pain or inflammation of a tendon occurs), treatment should be stopped.
• Rarely, quinolones can cause antibiotic-associated colitis — consider the possibility of this in anyone who presents with diarrhoea after treatment with ciprofloxacin or ofloxacin.

Drug interactions

• Theophylline — concurrent administration of ciprofloxacin can cause an increase in serum theophylline levels; advise the person to be aware of the signs of increased levels of theophylline, such as nausea, vomiting, tremor, and palpitations.
• Phenytoin — concurrent administration of ciprofloxacin can cause an increase or decrease in serum phenytoin levels.
• Warfarin — increased anticoagulation has occasionally been reported with concurrent administration of quinolones.
• Advise people taking warfarin to seek immediate medical advice if they experience spontaneous bleeding, and the bleeding does not stop or recurs. This includes bruising, bleeding gums, nosebleeds, prolonged bleeding from cuts, and blood in the urine or stools.

Basis for recommendation

Contraindications and precautions

• The manufacturers of ciprofloxacin (Ciproxin^®) and ofloxacin (Taravid^®) state that fluoroquinolones should be avoided in people with tendinitis or epilepsy [ABPI Medicines Compendium, 2009a; ABPI Medicines Compendium, 2010a]. However, the adverse effects of fluoroquinolones are not likely to be significant, as they are given as a single dose for the treatment of gonorrhoea.
• Quinolones can lower the seizure threshold and should therefore be avoided in people at increased risk of seizure. Seizures have rarely occurred in people without a previous history of seizures; concurrent use of nonsteroidal anti-inflammatory drugs or theophylline may also increase the risk [CSM, 1991].
• Quinolones can very rarely cause tendon damage; the risk of tendon rupture is increased by co-administration of corticosteroids [CSM, 2002].

Adverse effects

• Gastrointestinal effects including diarrhoea and nausea are reported to occur in 1–10% of people taking ciprofloxacin [ABPI Medicines Compendium, 2010a], and are slightly less common with ofloxacin [ABPI Medicines Compendium, 2009a]. Pseudomembranous colitis (caused by infection withClostridium difficile) is reported to be very rare (less than 0.01%), however, the manufacturers recommend that this should be considered in people who develop diarrhoea after a course of ciprofloxacin or ofloxacin ABPI Medicines Compendium, 2009a; ABPI Medicines Compendium, 2010a.

Interactions

• Information on drug interactions is taken from the Summary of Characteristics for ciprofloxacin (Ciproxin^®) and ofloxacin (Taravid^®) [ABPI Medicines Compendium, 2009a; ABPI Medicines Compendium, 2010a; ABPI Medicines Compendium, 2009a] and from the reference text Stockley's Drug Interactions [Baxter, 2010].[ABPI Medicines Compendium, 2010a; ABPI Medicines Compendium, 2009a].

Evidence

Supporting evidence

Evidence on effectiveness of antibiotics for gonorrhoea in men and women who are not pregnant

Randomized controlled trials (RCTs) have found single-dose antibiotics to be effective in the treatment of uncomplicated genital gonorrhoea, although they are less effective in the treatment of pharyngeal gonorrhoea. Cephalosporins, fluoroquinolones, and macrolides have historically all produced microbiological cure rates in excess of 95%, but recent issues with bacterial resistance have meant that third-generation cephalosporins (cefixime or ceftriaxone) are recommended first line.

Overall effectiveness of antibiotics

• A systematic review (search date: 1981 to 1993) investigated the effectiveness of single-dose antibiotics in men and women with confirmed gonorrhoea infection [Moran and Levine, 1995]. In total, 24,383 trial participants receiving 30 different antibiotic regimens (21 antibiotic drugs) were analysed. The main outcome reported was microbiological cure.
• Most of the antibiotics were highly effective, with an overall cure rate of 96.7%.
• Antibiotics that were effective included cephalosporins, fluoroquinolones, and macrolides (penicillin drugs were not studied, or these trials predated the literature search).
• Antibiotics were at least 95% effective for the treatment of gonorrhoea of the male and female urethra, male and female rectum, and cervix. For example, the cure rate for male urethritis was 96.4% (95% CI 96.0 to 96.7).
• Antibiotics were less effective in the treatment of pharyngeal gonorrhoea, with a 79.2% cure rate in men (95% CI 73.3 to 85.2) and 83.6% in women (95% CI 78.9 to 88.4).
• The investigators found a good correlation between the cure rate and the minimum inhibitory concentration required to inhibit the growth of 90% of organisms (MIC₉₀, calculated from studies in vitro). The authors commented that, ideally, a drug should achieve a plasma concentration of four times its MIC₉₀ for a minimum of 10 hours to be considered fully effective.
• The authors concluded that ceftriaxone, cefixime, ciprofloxacin, or ofloxacin was the preferred treatment for people with uncomplicated gonorrhoea. Fluoroquinolones are no longer suitable for empirical treatment because of problems with resistance. See Resistance to antibiotics for more information.

Effectiveness of ceftriaxone and cefixime

• PRODIGY identified three comparative RCTs that investigated the effectiveness of intramuscular ceftriaxone and oral cefixime (third-generation cephalosporin antibiotics recommended by UK national guidelines [BASHH, 2011b]).
• One study randomized 128 men with confirmed gonococcal urethritis to receive either ceftriaxone 250 mg or cefoxitin 2 g (both delivered intramuscularly) [Zajdowicz et al, 1983]. Both drugs were highly effective at curing the infection, with ceftriaxone having a 100% success rate and cefoxitin having a 99% success rate (one person with penicillin-resistant gonorrhoea relapsed).
• One study in 393 people with uncomplicated and/or pharyngeal gonorrhoea randomized them to receive a single 250 mg dose of ceftriaxone or pivampicillin (1.2 grams with probenecid, unavailable in the UK) [Christophersen et al, 1989]. Ceftriaxone was found to have a 100% cure rate for both sites of infection (70 people had pharyngeal infection).
• One study randomized 209 men and 124 women with uncomplicated gonorrhoea to receive one of three interventions: oral cefixime 400 mg or 800 mg, or intramuscular ceftriaxone 250 mg [Handsfield, 1991].
• The overall microbiological cure rates were similar in men and women: 96% (95% CI 94 to 98) for cefixime 400 mg, 98% (95% CI 95 to 100) for cefixime 800 mg, and 98% (95% CI 95 to 100) for ceftriaxone.
• However, only 91% of people presenting with pharyngeal gonorrhoea were successfully treated, and about 50% of people who presented with coexisting chlamydia had persistent chlamydial infection.

Evidence on effectiveness of antibiotics for gonorrhoea in pregnant women

Evidence from two comparative randomized controlled trials (RCTs) indicates that amoxicillin (combined with probenecid), ceftriaxone, and cefixime are effective in the treatment of gonorrhoea in pregnant women. However, amoxicillin is no longer recommended for empirical treatment because of the emergence of gonococcal resistance to penicillins.

• A Cochrane systematic review (search date: January 2007) identified two comparative RCTs with 346 participants that investigated the effectiveness of antibiotics in pregnant women with microbiologically confirmed gonorrhoea [Brocklehurst, 2002].
• All the antibiotics were considered effective, with microbiological cure rates between 89% and 97%. Failure to achieve microbiological cure was similar for each regimen.
• Amoxicillin (plus probenecid) compared with spectinomycin — favoured spectinomycin, but this was not significant (odds ratio [OR] of treatment failure 2.29, 95% CI 0.74 to 7.08).
• Amoxicillin (plus probenecid) compared with ceftriaxone — favoured ceftriaxone, but this was not significant (OR 2.29, 95% CI 0.74 to 7.08).
• Ceftriaxone was of similar effectiveness to cefixime (OR 1.22, 95% CI 0.16 to 9.01).
• The author commented that the small number of participants limited their ability to detect modest but important differences between the regimens.
• Amoxicillin is no longer recommended for the empirical treatment of gonorrhoea because of the emergence of bacterial resistance (see Resistance to antibiotics for more information).

Evidence on gonococcal resistance to antibiotics

Historical evidence has shown that the organism that causes gonorrhoea has become increasingly resistant to antibiotics, including sulphonylureas, penicillins, tetracyclines, macrolides, and quinolones. Currently, cephalosporins are the only commonly prescribed drug class that does not have significant resistance issues, although some evidence indicates that resistance is emerging.

• Gonorrhoea is caused by the Gram-negative diplococcus bacterium Neisseria gonorrhoeae, which is capable of chromosomal and plasmid-mediated genetic change through selection pressure. Consequently, gonorrhoea has become increasingly resistant to modern antibiotics.
• Gonorrhoea was first treated successfully with the discovery of sulphonamides in the 1930s, but their efficacy was short-lived because of the development of resistance in the mid-1940s [Workowski et al, 2008].
• Penicillin was introduced in the 1940s and remained an effective treatment for gonorrhoea for several decades. However, resistance became increasingly prevalent in the 1980s, and its use as a first-line antibiotic was no longer recommended by the 1990s [Tyson, 2005]. Resistance to tetracyclines also precluded these as an effective option by this time [Bignell et al, 2006].
• The fluoroquinolone ciprofloxacin was first patented in 1983, and initially the fluoroquinolones were a highly effective treatment for gonorrhoea. However, case reports of resistance rapidly emerged from the Far East and Pacific regions, and by the mid-2000s, fluoroquinolones were no longer regarded as a suitable option for the empirical treatment of gonorrhoea [CDC, 2007].
• The Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) was established in June 2000 with the remit of monitoring gonococcal resistance to antibiotics in the UK. In 2010 GRASP collected 1425 isolates and performed antimicrobial susceptibility testing on those which proved positive to N. gonorrhoeae. The following is a summary of their findings [HPA, 2011]:
• Penicillin resistance in genito-urinary medicine (GUM) clinics remained relatively stable at 20%.
• Tetracycline resistance in GUM clinics remained relatively stable at 69%.
• Ciprofloxacin resistance remained endemic in GUM clinics at 36%.
• Azithromycin resistance decreased from 1.2% in 2009 to 0.5% in 2010 in GUM clinic isolates.
• Cefixime resistance rose from 1.2% of gonococcal isolates in 2009 to 6.3% in 2010. Worryingly, there is also evidence of a drift towards higher minimum inhibitory concentrations for ceftriaxone and cefixime in recent years. However, confirmed therapeutic failure to cefixime is rare, and is undocumented for ceftriaxone in England and Wales.
• No isolates showed resistance to ceftriaxone in 2010.
• Current recommendations for the management of gonorrhoea reflect the fact that cephalosporins (ceftriaxone and cefixime) have less resistance associated with them compared with other antibiotics [BASHH, 2011b]. However, surveillance of antibiotic resistance is an ongoing process and is likely to affect the appropriate antibiotic selection for gonorrhoea in the future.

References

All references with links to [Free Full-text] are freely available online to users in the UK. Links to PubMed abstracts are also provided where available. Clarity is not responsible for the content of external sites.

Free Full-text links are to dynamic documents that may have been updated since they were originally cited in the PRODIGY topic. All links are checked regularly by Information Specialists and updated to the latest version. Changes in the content of updated documents will not be reflected in the PRODIGY topic text until the next revision.

The following references were cited in September 2009. References dated after this reflect new evidence incorporated since original publication of this topic.

1. ABPI Medicines Compendium (2009a) Summary of product characteristics for Tarivid 200mg & 400mg tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. www.emc.medicines.org.uk [Free Full-text]
2. ABPI Medicines Compendium (2009b) Summary of product characteristics for Rocephin 250mg, 1g and 2g vials. Electronic Medicines Compendium. Datapharm Communications Ltd. www.emc.medicines.org.uk [Free Full-text]
3. ABPI Medicines Compendium (2010a) Summary of product characteristics for Ciproxin tablets 500mg. Electronic Medicines Compendium. Datapharm Communications Ltd. www.emc.medicines.org.uk [Free Full-text]
4. ABPI Medicines Compendium (2010b) Summary of product characteristics for Suprax tablets 200mg. Electronic Medicines Compendium. Datapharm Communications Ltd. www.emc.medicines.org.uk [Free Full-text]
5. ABPI Medicines Compendium (2011) Summary of product characteristics for Zithromax capsules, suspension. Electronic Medicines Compendium. Datapharm Communications Ltd. www.emc.medicines.org.uk [Free Full-text]
6. Adler, M. (2004) ABC of sexually transmitted infections. London: BMJ Publishing.
7. BASHH (2011a) UK national guideline on the management of pelvic inflammatory disease 2011. British Association for Sexual Health and HIV.www.bashh.org [Free Full-text]
8. BASHH (2011b) UK national guideline on the management of gonorrhoea in adults 2011. British Association for Sexual Health and HIV.www.bashh.org [Free Full-text]
9. BASHH and HPA (2010) Guidance for gonorrhoea testing in England and Wales. Health Protection Agency. www.bashh.org [Free Full-text]
10. Baxter, K. (Ed.) (2010) Stockley's drug interactions 2010: pocket companion. London: Pharmaceutical Pres.
11. Bignell, C. (1996) Antibiotic treatment of gonorrhoea: clinical evidence for choice. Genitourinary Medicine 72(5), 315-320. [Free Full-text]
12. Bignell, C. (2009) 2009 European (IUSTi/WHO) guideline on the diagnosis and treatment of gonorrhoea in adults. International Journal of STD & AIDS 20(7), 453-457. [Free Full-text]
13. Bignell, C., Ison, C.A. and Jungmann, E. (2006) Gonorrhoea. Sexually Transmitted Infections 82(Suppl 4), iv6-iv9.
14. BNF 61 (2011) British National Formulary. 61st edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.
15. Brocklehurst, P. (2002) Antibiotics for gonorrhoea in pregnancy (Cochrane Review). The Cochrane Library. Issue 2. John Wiley & Sons, Ltd.www.thecochranelibrary.com [Free Full-text]
16. Brocklehurst, P. and Rooney, G. (1998) Interventions for treating genital Chlamydia trachomatis infection in pregnancy (Cochrane Review).The Cochrane Library. Issue 4. John Wiley & Sons Ltd. www.thecochranelibrary.com [Free Full-text]
17. CDC (2007) Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. Morbidity & Mortality Weekly Report 56(14), 332-336. [Abstract] [Free Full-text]
18. Chisholm, S.A., Neal, T.J., Alawattegama, A.B. et al. (2009) Emergence of high-level azithromycin resistance in Neisseria gonorrhoeae in England and Wales. Journal of Antimicrobial Chemotherapy 64(2), 353-8.
19. Christophersen, J., Bollerup, A.C., From, E. et al. (1989) Treating genitourinary and pharyngeal gonorrhoea with single dose ceftriaxone.Genitourinary Medicine 65(1), 14-17. [Abstract] [Free Full-text]
20. CSM (1991) Convulsions due to quinolone antimicrobial agents. Current Problems in Pharmacovigilance 32(Oct), 2. [Free Full-text]
21. CSM (2002) Reminder: fluoroquinolone antibiotics and tendon disorders. Current Problems in Pharmacovigilance 28(Apr), 3-4. [Free Full-text]
22. Fitzgerald, M., Thirlby, D., Bell, G. and Bedford, C. (1996) National standards for contact tracing in gonorrhoea. Royal College of Physicians, National Audit Development Programme in Sexual Health. International Journal of STD and AIDS 7(4), 301.
23. FSRH (2009) UK medical eligibility criteria for contraceptive use. Faculty of Sexual and Reproductive Healthcare. www.fsrh.org [Free Full-text]
24. Handsfield, H.H. (1991) A comparison of single-dose cefixime with ceftriaxone as treatment for uncomplicated gonorrhea. The Gonorrhea Treatment Study Group. New England Journal of Medicine 325(19), 1337-1341. [Abstract]
25. Handsfield, H..H.., Dalu, Z..A.., Martin, D..H.. et al. (1994) Multicenter trial of single-dose azithromycin vs ceftriaxone in the treatment of uncomplicated gonorrhea. 21(2).
26. Horner, P. (2009) Personal communication. Consultant Senior Lecturer, Department of Social Medicine, University of Bristol: Bristol.
27. HPA (2008) Diagnosis of chlamydia: quick reference guide for general practices for consultation and local adaptation. Health Protection Agency. www.hpa.org.uk [Free Full-text]
28. HPA (2010) Rise in new diagnoses of sexually transmitted infections in the United Kingdom in 2009. Health Protection Agency. www.hpa.org.uk[Free Full-text]
29. HPA (2011) GRASP 2010 report. The gonococcal resistance to antimicrobials surveillance programme. Health Protection Agency.www.hpa.org.uk [Free Full-text]
30. Marrazzo, J.M., Handsfield, H.H. and Sparling, P.F. (2010) Neisseria gonorrhoeae. In: Mandell, G.L., Bennett, J.E. and Dolin, R. (Eds.) Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 7th edn. Philadelphia: Chuchill Livingstone. 2753-2770.
31. Mathews, C., Coetzee, N., Zwarenstein, M. et al. (2001) Strategies for partner notification for sexually transmitted diseases (Cochrane Review). The Cochrane Library. Issue 4. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
32. Moran, J.S. and Levine, W.C. (1995) Drugs of choice for the treatment of uncomplicated gonococcal infections. Clinical Infectious Diseases20(Suppl 1), S47-S65. [Abstract]
33. NICE (2009) When to suspect child maltreatment (NICE guideline). National Institute for Health and Clinical Excellence. www.nice.org.uk [Free Full-text]
34. NPC (2011) Key therapeutic topics 2010/11 - Medicines management options for local implementation. National Prescribing Centre.www.npc.nhs.uk [Free Full-text]
35. NTIS (2008a) Use of azithromycin in pregnancy. TOXBASE. National Teratology Information Service. www.toxbase.org
36. NTIS (2008b) Use of erythromycin in pregnancy. TOXBASE. National Poisons Information Service. www.toxbase.org
37. NTIS (2008c) The treatment of infections in pregnancy. TOXBASE. National Poisons Information Service. www.toxbase.org
38. NTIS (2008d) Use of cephalosporins in pregnancy. TOXBASE. National Teratology Information Service. www.toxbase.org
39. RCGP and BASHH (2006) Sexually transmitted infections in primary care. Royal College of General Practitioners. www.bashh.org [Free Full-text]
40. RCOG (2009) Management of acute pelvic inflammatory disease (minor revisions made to this document in March 2009). Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk [Free Full-text]
41. Schaefer, C., Peters, P. and Miller, R.K. (Eds.) (2007) Drugs during pregnancy and lactation: treatment options and risk assessment. 2nd edn. Oxford: Academic Press.
42. Stokes, T. and Schober, P. (1999) A survey of contact tracing practice for sexually transmitted diseases in GUM clinics in England and Wales.International Journal of STD & AIDS 10(1), 17-21. [Abstract]
43. Tyson, M. (2005) Guidance for first-line treatment of anogenital gonorrhoea infection. British Journal of Nursing 14(12), 646-648. [Abstract]
44. Workowski, K.A., Berman, S.M. and Douglas, J.M. (2008) Emerging antimicrobial resistance in Neisseria gonorrhoeae: urgent need to strengthen prevention strategies. Annals of Internal Medicine 148(8), 606-613. [Abstract] [Free Full-text]
45. Zajdowicz, T.R., Sanches, P.L., Berg, S.W. et al. (1983) Comparison of ceftriaxone with cefoxitin in the treatment of penicillin-resistant gonococcal urethritis. British Journal of Venereal Disease 59(3), 176-178. [Abstract] [Free Full-text]

Search strategy

Further information on the PRODIGY literature searching policy is available in the 'About' section of the PRODIGY website.

Scope of search

A literature search was conducted for guidelines, systematic reviews, and background reviews on the primary care management of gonorrhoea.

Search dates

Guidelines, Medline, EMBASE: January 2005 – June 2009

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.

• gonorrhea/, gonorrhea.tw, gonorrhoea.tw, gonococcal.tw, neisseria gonorrhoeae/, neisseria gonorrhoeae.tw

Table 1. Key to search terms.

Search commands	Explanation
/	indicates a MeSH subject heading with all subheadings selected
.tw	indicates a search for a term in the title or abstract
exp	indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$	indicates that the search term was truncated (e.g. wart$ searches for wart and warts)

Topic specific literature search sources

• British Association for Sexual Health and HIV
• International Union against Sexually Transmitted Infections
• Centers for Disease Control and Prevention

Sources of guidelines

• National Institute for Health and Clinical Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• National Guidelines Clearinghouse
• New Zealand Guidelines Group
• Canadian Medical Association
• Institute for Clinical Systems Improvement
• Guidelines International Network
• NHS Evidence - National Library of Guidelines
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• Royal College of Nursing
• Health Protection Agency
• National Resource for Infection Control
• CREST
• World Health Organization
• NHS Scotland National Patient Pathways
• Agency for Healthcare Research and Quality
• TRIP database
• Patient UK Guideline links
• UK Ambulance Service Clinical Practice Guidelines
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Alberta Medical Association
• British Columbia Medical Association
• University of Michigan Medical School
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
• Systematic reviews
• Protocols
• Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
• NHS Economic Evaluations
• Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
• Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug & Therapeutics Bulletin
• MeReC
• NPCi
• DynaMed
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Drugs in this topic

Scenario: Management

Amoxicillin 500mg capsules

Age from 13 years onwards

Amoxicillin 500mg capsules: Take one capsule three times a day for 7 days.

Amoxicillin 500mg capsules

Take one capsule three times a day for 7 days.

Supply 21 capsules.

Age: from 13 years onwards

NHS cost: £1.46

Licensed use: yes

Azithromycin 250mg capsules

Age from 13 years onwards

Azithromycin 250mg capsules: Take four capsules as a single dose. (a)

Azithromycin 250mg capsules

Take four capsules as a single dose.

Supply 4 capsules.

Age: from 13 years onwards

NHS cost: £8.83

Licensed use: yes

Age from 13 years onwards

Azithromycin 250mg capsules: Take four capsules as a single dose.

Azithromycin 250mg capsules

Take four capsules as a single dose.

Supply 4 capsules.

Age: from 13 years onwards

NHS cost: £8.83

Licensed use: no - off-label indication

Cefixime 200mg tablets

Age from 13 years onwards

Cefixime 200mg tablets: Take two tablets as a single dose, then take one tablet twice a day.

Cefixime 200mg tablets

Take two tablets as a single dose, then take one tablet twice a day for 3 days.

Supply 8 tablets.

Age: from 13 years onwards

NHS cost: £15.12

Licensed use: no - off-label indication

Age from 13 years onwards

Cefixime 200mg tablets: Take two tablets as a single dose.

Cefixime 200mg tablets

Take two tablets as a single dose.

Supply 2 tablets.

Age: from 13 years onwards

NHS cost: £3.78

Licensed use: no - off-label indication

Ceftriaxone 250mg powder for solution for injection vials

Age from 13 years onwards

Ceftriaxone 250mg powder for solution for injection vials: Reconstitute and give a single dose of 250mg by intramuscular injection. (a)

Ceftriaxone 250mg powder for solution for injection vials

Reconstitute and give a single dose of 250mg by intramuscular injection.

Supply 1 250mg vial.

Age: from 13 years onwards

NHS cost: £2.40

Licensed use: yes

Ceftriaxone 250mg powder for solution for injection vials: Reconstitute and give a single dose of 250mg by intramuscular injection. (a)

Ceftriaxone 250mg powder for solution for injection vials

Reconstitute and give a single dose of 250mg by intramuscular injection.

Supply 1 250mg vial.

Age: from 13 years onwards

NHS cost: £2.40

Licensed use: yes

Age from 13 years onwards

Ceftriaxone 250mg powder for solution for injection vials: Reconstitute and give a single dose of 250mg by intramuscular injection. (a)

Ceftriaxone 250mg powder for solution for injection vials

Reconstitute and give a single dose of 250mg by intramuscular injection.

Supply 1 250mg vial.

Age: from 13 years onwards

NHS cost: £2.40

Licensed use: yes

Ceftriaxone 250mg powder for solution for injection vials: Reconstitute and give a single dose of 250mg by intramuscular injection. (a)

Ceftriaxone 250mg powder for solution for injection vials

Reconstitute and give a single dose of 250mg by intramuscular injection.

Supply 1 250mg vial.

Age: from 13 years onwards

NHS cost: £2.40

Licensed use: yes

Ciprofloxacin 500mg tablets

Age from 18 years onwards

Ciprofloxacin 500mg tablets: Take one tablet as a single dose.

Ciprofloxacin 500mg tablets

Take one tablet as a single dose.

Supply 1 tablet.

Age: from 18 years onwards

NHS cost: £0.12

Licensed use: yes

Doxycycline 100mg capsules

Age from 13 years onwards

Doxycycline 100mg capsules: Take one capsule twice a day for 7 days.

Doxycycline 100mg capsules

Take one capsule twice a day for 7 days.

Supply 14 capsules.

Age: from 13 years onwards

NHS cost: £0.97

Licensed use: yes

Patient information: Swallow the capsules whole, with a glass of water, with or after some food. Sit upright or stand while swallowing the medicine.

Erythromycin 250mg gastro-resistant tablets

Age from 13 years onwards

Erythromycin 250mg gastro-resistant tablets: Take two tablets four times a day for 7 days.

Erythromycin 250mg gastro-resistant tablets

Take two tablets four times a day for 7 days.

Supply 56 tablets.

Age: from 13 years onwards

NHS cost: £3.70

Licensed use: yes

Ofloxacin 400mg tablets

Age from 18 years onwards

Ofloxacin 400mg tablets: Take one tablet as a single dose.

Ofloxacin 400mg tablets

Take one tablet as a single dose.

Supply 1 tablet.

Age: from 18 years onwards

NHS cost: £0.62

Licensed use: yes

Leaflets for patients

• Gonorrhoea (fpa)

Gonorrhoea (fpa)

This information is from the Family Planning Association (fpa). For more information, see the fpa website at www.fpa.org.uk.

View as a leaflet

Gonorrhoea is a common bacterial sexually transmitted infection (STI). It can be painful and can cause serious health problems such as infertility in both men and women.

This information can tell you what you can do if you are worried that you might have gonorrhoea and advice on how to protect yourself.

What causes gonorrhoea?

Gonorrhoea is caused by a bacteria which is found mainly in the semen and vaginal fluids of men and women who have the infection. Gonorrhoea is easily passed from one person to another through sexual contact. Anyone who is sexually active can get it and pass it on. You don't need to have lots of sexual partners.

How is gonorrhoea passed on?

Gonorrhoea is usually passed from one person to another during sex. The bacteria can live inside the cells of the cervix (entrance to the womb), the urethra (tube where urine comes out), the rectum, the throat and occasionally the eyes. You can become infected with gonorrhoea if you come into contact with infected semen or infected discharge from the vagina, throat or rectum.

The infection is most commonly spread through:

• unprotected vaginal, anal or oral sex
• sharing sex toys if you don't wash them or cover them with a new condom each time they're used.

Gonorrhoea can also be passed from a pregnant woman to her baby (see What happens if I get gonorrhoea when I'm pregnant?)

In women it is possible for the bacteria to spread in the vaginal secretions, to the rectum. You don't need to have anal sex for this to happen.

Gonorrhoea bacteria that come into contact with the eye can cause conjunctivitis. This is uncommon in adults.

It is not clear if gonorrhoea can be spread by transferring the bacteria to another person's genitals on the fingers or through rubbing vulvas (female genitals) together.

You cannot catch gonorrhoea from kissing, hugging, sharing baths or towels, swimming pools, toilet seats or from sharing cups, plates or cutlery.

What are the signs and symptoms?

About ten per cent of infected men and 50 per cent of infected women will not have any obvious signs or symptoms. Signs and symptoms can show up 1—14 days after coming into contact with gonorrhoea, many months later, or not until the infection spreads to other parts of your body. You might notice:

Women

• an unusual vaginal discharge which may be thin or watery, yellow or green
• pain when passing urine
• lower abdominal pain or tenderness (this is rare)
• rarely, bleeding between periods or heavier periods (including women who are using hormonal contraception).

Men

• an unusual discharge from the tip of the penis — the discharge may be white, yellow or green
• pain when passing urine
• rarely, pain or tenderness in the testicles
• inflammation of the foreskin (less common).

Men and women

• Infection in the rectum. This does not usually have any signs and symptoms but may cause anal pain, discomfort or discharge.
• Infection in the throat. This usually has no symptoms.
• Infection in the eyes. This can cause pain, swelling, irritation and discharge (conjunctivitis).

How will I know if I have the infection?

You can only be certain you have gonorrhoea if you have a test. If you think you may have gonorrhoea it is important that you don't delay getting a test.

You may wish to have a test if:

• you or your partner have or think you might have symptoms
• you have recently had unprotected sex with a new partner
• you or your partner have had unprotected sex with other partners
• during a vaginal examination your doctor or nurse says that the cells of the cervix are inflamed and/or there is an unusual discharge
• a sexual partner tells you they have a sexually transmitted infection
• you have another sexually transmitted infection
• you are pregnant or planning a pregnancy.

You could still have gonorrhoea even if your partner has tested negative — you should not rely on a partner's negative test result.

If you have had gonorrhoea and it has been treated, you will not be immune to the infection — you can get it again.

If you have gonorrhoea you may wish to be tested for other sexually transmitted infections as you can have more than one sexually transmitted infection at the same time. Having an infection such as gonorrhoea can mean you are more at risk of becoming infected with HIV or of passing HIV on if you already have HIV.

How soon after sex can I have a test?

It is important not to delay getting a test if you think you might have gonorrhoea. It is possible to do a gonorrhoea test within a few days of having sex but sometimes you may be advised to wait up to a week after having sex. You can test for gonorrhoea even if there are no symptoms.

What does the test involve?

There are different ways of testing for gonorrhoea.

Women

• A doctor or nurse may use a swab to collect a sample of cells from the cervix during an internal examination, or from the vagina.
• You may be asked to use a swab or a tampon yourself to collect cells from inside the vagina.

Men

• You may be asked to provide a urine sample. Before having this test you may be advised not to pass urine (pee) for one to two hours.

Men and women

• A doctor or nurse may use a swab to collect a sample of cells from the entrance of the urethra.
• If you have had anal or oral sex the doctor or nurse may use swabs to collect cells from your rectum and throat. These swabs are not done routinely on everybody.
• If you have symptoms of conjunctivitis – discharge from the eye(s) – swabs will also be used to collect a sample of discharge from your eye(s).

A swab looks a bit like a cotton bud, but is smaller and rounded. It sometimes has a small plastic loop on the end rather than a cotton tip. It is wiped over the parts of the body that could be infected and easily picks up samples of discharge and cells. This only takes a few seconds and is not painful, though it may be uncomfortable for a moment.

Sometimes it is possible for a specimen to be looked at under the microscope immediately and for you to get the test result straight away. Otherwise you will have to wait up to two weeks to get your results.

Cervical smear tests and routine blood tests do not detect gonorrhoea. If you are not sure whether you have been tested for gonorrhoea, just ask.

How accurate are the tests?

The accuracy of a gonorrhoea test depends on the kind of test used and which part of your body the sample is collected from.

The accuracy of a single test from the genital area is between 75—95 per cent. Tests from the throat are less sensitive.

As no test is 100 per cent accurate there is a small chance that the test will give a negative result when you do have the infection. This is known as a false negative result. This can sometimes explain why you might get a different result when you go to a different clinic to have another test or why you and your partner might get a different test result.

It is possible for some gonorrhoea tests to be positive if you haven't got gonorrhoea, but this is uncommon. If there are doubts about the result you may be offered a second test to confirm the presence of gonorrhoea.

Where can I get a test?

There are a number of services you can go to. Choose the service you feel most comfortable with.

A gonorrhoea test can be done at:

• a genitourinary medicine (GUM) or sexual health clinic
• some general practices (as your doctor or practice nurse)
• some contraceptive and young people's clinics.

For information on how to find a service see Where can I get more information and advice?

It is possible to buy a gonorrhoea test to do at home. The accuracy of these tests varies so it is recommended that you go to a sexual health service to have a test. You can also choose to pay for a gonorrhoea test at a private clinic.

Will I have to pay for tests and treatment?

All tests are free through NHS services. Treatment is also free unless you go to your general practice when you may have to pay a prescription charge for the treatment.

What is the treatment for gonorrhoea?

The treatment for gonorrhoea is antibiotics. The treatment is at least 95 per cent effective.

• Early treatment of gonorrhoea involves taking a single dose of antibiotic tablet(s) or having one antibiotic injection.
• If there is a high chance you have the infection, treatment may be started before the results of the test are back. You will always be given treatment if your partner is found to have gonorrhoea.
• You may also need other treatment if complications have occurred.
• The antibiotics that are used to treat gonorrhoea interact with methods of contraception that contain estrogen and progestogen (for example, the combined contraceptive pill and contraceptive patch). Tell the doctor or nurse if you are using these methods so they can advise you on how to ensure you are protected from pregnancy.
• There is no evidence that complementary therapies can cure gonorrhoea.

When will the signs and symptoms go away?

You should notice an improvement in the signs and symptoms quite quickly.

• Discharge or pain when you urinate should improve within two to three days.
• Discharge and discomfort in the rectum should improve within two to three days.
• Bleeding between periods or heavier periods that have been caused by gonorrhoea should have improved by your next period.
• Pelvic pain and pain in the testicles should start to improve quickly but may take up to two weeks to go away.

If you have pelvic pain or painful sex that does not improve see your doctor or nurse as it may be necessary to have some further treatment or to investigate other possible causes of the pain.

Do I need to have a test to check that the gonorrhoea has gone?

You will not normally need a follow-up test. You should however go back to the clinic if:

• you think you may have come into contact with gonorrhoea again
• you had unprotected sex with your partner in the week following the treatment (see How soon can I have sex again?)
• the signs and symptoms don't go away (see When will the signs and symptoms go away?)
• you had gonorrhoea of the throat
• your test was negative but you develop signs or symptoms of gonorrhoea (see What are the signs and symptoms?).

In these situations you may need a repeat test. How quickly the test can be repeated will depend on which test is being used. This can vary from three days to two weeks. The clinic or general practice will advise you.

If you were treated for gonorrhoea in early pregnancy you may be advised to have another test later in the pregnancy.

You can always go back to the doctor, nurse or clinic if you have any questions or need any advice on how to protect yourself from infection in the future.

What happens if gonorrhoea isn't treated?

If gonorrhoea is treated early it is unlikely to cause any long term problems. Not everyone who has gonorrhoea has complications. However, without effective treatment the infection can spread to other parts of the body. The more times you have gonorrhoea the more likely you are to get complications.

• In women, gonorrhoea can spread to other reproductive organs causing pelvic inflammatory disease (PID). This can lead to long-term pelvic pain, blocked fallopian tubes, infertility and ectopic pregnancy (when the pregnancy develops outside the womb).
• In men, gonorrhoea can lead to a painful infection in the testicles and prostate gland and possibly reduced fertility.
• Less commonly, gonorrhoea can cause inflammation of the joints and tendons, and skin lesions.
• Rarely, gonorrhoea can also cause inflammation of the membranes of the brain and spinal cord (meningitis) and the heart.

Can gonorrhoea go away without treatment?

It can but it is unlikely. The infection may be there for many months before it goes away and without treatment you cannot be sure when or if it will go away. If you delay seeking treatment you risk the infection causing long-term damage and you may pass the infection on to someone else.

How soon can I have sex again?

It is strongly advised that you do not have any sexual intercourse, including vaginal, anal or oral sex until you and your partner have both finished the treatment and any follow-up treatment. This is to help prevent you being reinfected or passing the infection on to someone else. If it is not possible to avoid sex, make sure you use a condom. This might reduce the risk of infection, but won't eliminate it.

Will I know how long I've had the infection?

The gonorrhoea test cannot tell you how long the infection has been there. If you have had more than one sexual partner it can be difficult to know which partner you got gonorrhoea from. If you feel upset or angry about having gonorrhoea and find it difficult to talk to your partner or friends, don't be afraid to discuss how you feel with the staff at the clinic or general practice.

Should I tell my partner?

If the test shows that you have gonorrhoea then it is very important that your current sexual partner and any other recent partners are also tested and treated. The staff at the clinic or general practice can discuss with you which of your sexual partners may need to be tested.

You may be given a 'contact slip' to send or give to your partner(s) or, with your permission, the clinic can do this for you. The slip explains that they may have been exposed to a sexually transmitted infection and suggests that they go for a check-up. It may or may not say what the infection is. It will not have your name on it, so your confidentiality is protected. This is called partner notification. You are strongly advised to tell your partner(s), but it isn't compulsory.

How will I know if the gonorrhoea has affected my fertility?

Gonorrhoea is just one of many factors that can affect fertility in mean and women. Many men and women who have had gonorrhoea will not become infertile and many women will not have an ectopic pregnancy (see What happens if gonorrhoea isn't treated?). If you have had gonorrhoea it is still important to use contraception if you want to avoid pregnancy. You should not assume you are infertile. You will not normally be offered any routine tests to see if you are fertile unless you or your partner are having difficulty in getting pregnant. If you are concerned, talk to your doctor or practice nurse.

What happens if I get gonorrhoea when I'm pregnant?

Gonorrhoea can be passed to the baby during childbirth. This can cause inflammation and discharge in the baby's eyes (conjunctivitis). Gonorrhoea can be treated with antibiotics when you are pregnant or when you are breastfeeding — the antibiotics won't harm the baby.

Does gonorrhoea cause cervical cancer?

There is no evidence that gonorrhoea causes cervical cancer.

How can I protect myself from gonorrhoea?

It is possible to get gonorrhoea and other sexually transmitted infections by having sex with someone who has the infection but has no symptoms. The following measures will help protect you from gonorrhoea and most other sexually transmitted infections including HIV and chlamydia. If you have a sexually transmitted infection without knowing it they will also help prevent you from passing it on to your partner.

• Use condoms (male or female) every time you have vaginal or anal sex.
• If you have oral sex, cover the penis with a condom or the female genitals and male or female anus with a latex or polyurethane (soft plastic) square.
• If you are a woman and rub your vulva against your female partner's vulva one of you should cover the genitals with a latex or polyurethane (soft plastic) square.
• If you are not sure how to use condoms correctly see our information on condoms, or call fpa's helpline. See Where can I get more information and advice?
• Avoid sharing sex toys. If you do share them, wash them or cover them with a new condom before anyone else uses them.

Where can I get more information and advice?

Find out where to get more information and advice.

Using a service

• Wherever you go, you shouldn't be judged because of your sexual behaviour.
• All advice, information and tests are free. All services are confidential.
• All test are optional and should only be done with your permission.
• Ask as many questions as you need to – and make sure you get answers you understand.