We describe a gonorrhoea case with combined high-level azithromycin resistance and ceftriaxone resistance. In February 2018, a heterosexual male was diagnosed with gonorrhoea in the United Kingdom following sexual intercourse with a locally resident female in Thailand and failed treatment with ceftriaxone plus doxycycline and subsequently spectinomycin. Resistance arose from two mechanisms combining for the first time in a genetic background similar to a commonly circulating strain. Urgent action is essential to prevent further spread.

Changes since 2011 guideline • First line empirical treatment is now monotherapy with ceftriaxone 1 g intramuscularly • If antimicrobial susceptibility test results from all sites of infection are available prior to treatment and the isolate is sensitive to ciprofloxacin, then this should be used for treatment in preference to ceftriaxone • Inclusion of testing recommendations in people following genital reconstructive surgery • Recommendations for extra-genital testing in those with suspected or confirmed antimicrobial resistance • Epidemiological treatment is recommended only for those presenting within 14 days of exposure. For those presenting after 14 days of exposure we recommend treatment based on the results of testing SCOPE AND PURPOSE This guideline offers recommendations for the diagnostic tests, treatment regimens and health promotion principles needed for the effective management of gonorrhoea in people aged 16 years and older. For individuals under the age of 16 years please see the British Association for Sexual Health and HIV (BASHH) guideline on STI and Related Conditions in Children and Young People. The guidelines are primarily aimed at level 3 sexual health services within the United Kingdom (UK) although the principles of the recommendations could be adopted at all levels. EDITORIAL INDEPENDENCE This guideline was commissioned and edited by the Clinical Effectiveness Group (CEG) of BASHH, which provided funding for the literature search. No other funding was obtained. RIGOUR OF DEVELOPMENT This guideline was produced according to specifications set out in the CEG's 2015 document 'Framework for guideline development and assessment' outlined at https://www.bashh.org/bashh-groups/clinical-effective ness-group/ and has been updated by reviewing the previous gonorrhoea guideline (2011) and medical literature since its publication. A MEDLINE search of published articles in English language for the years 2009-18 was done using the subject headings 'gonorrhoea' OR 'gonorrhea' OR 'Neisseria gonorrhoeae' AND 'therapy' OR 'treatment' OR 'therapeutics' OR 'resistance' OR 'anti-bacterial agents' OR 'antibiotics' OR 'failure' OR 'toxicity'. All entries in the English language or with abstracts in English were viewed because of the paucity of 'clinical trials' or 'reviews'. The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness and Cochrane Controlled Trials Register were reviewed using the textword 'gonorrhoea' and all entries were considered. Abstracts from meetings in the relevant period were hand-searched and considered. Priority was given to randomized controlled trials and

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This is the first British Association for Sexual Health and HIV (BASHH) guideline for the diagnosis and management of Mycoplasma genitalium in people aged 16 years and older. The guideline is primarily aimed at level 3 sexually transmitted infection (STI) management services within the UK, although it could also serve as a reference guide for STI services at other levels.

We describe detection in the United Kingdom (UK) of the drug-resistant Neisseria gonorrhoeae FC428 clone, with ceftriaxone resistance and intermediate azithromycin resistance. Two female patients developed infection following contact with UK-resident men from the same sexual network linked to travel to Ibiza, Spain. One case failed treatment with ceftriaxone, and azithromycin and gentamicin, before successful treatment with ertapenem. Both isolates had indistinguishable whole-genome sequences. Urgent action is essential to contain this drug-resistant strain.