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

The British Association for Sexual Health and HIV (BASHH) UK gonorrhoea guideline has been updated in 2011. It offers advice on diagnosis, treatment and health promotion for anogenital and pharyngeal gonorrhoea. Nucleic acid amplification tests (NAATs) are now being used more for diagnosis and are increasing detection rates in the pharynx and rectum. First line treatment using ceftriaxone with azithromycin is now advised, along with routine test of cure (TOC). The aim is to slow the spread of resistant gonorrhoea now that fewer antibiotics remain effective. A patient information leaflet has been developed.

Summary-Cellmigration and replication associated with odontoblast replacement occurring soon after pulp exposure in primate teeth were studied. Class 5 cavity preparations resulting in pulp exposures were restored with a calcium hydroxide-containing capping agent and amalgam. Eighty-four and 96 h after this the animals were injected with 0.5 pCi/g body wt tritiated thymidine (sp. act. 6.7 Ci/mM). Teeth were extracted 6, 8, 10 and 12 days after treatment. The number of labelled cells as well as the number of grains per labelled cell were counted for odontoblast-like, fibroblast-like and perivascular cells in three 60 x 260 pm zones. These zones represented the odontoblast and cell-free (zone l), cell-rich (zone 2) and deep pulp (zone 3) areas of normal pulp tissue. Ten sections centred around the mid-point of the exposure were counted for each tooth. Matrix formation and labelled odontoblast-like cells were observed at the interface between the capping agent and the pulp as early as day 8. Other significant findings were: (1) an increase In labelled odontoblast-like cells in zone 1 over time, suggesting a continual influx of differentiating cells; (2) an increase in labelled cells in zone 1 over time with a concurrent decrease in zone 3, suggesting that the influx of cells in zone 1 was from the deeper pulp; and (3) differences in grain counts between zones, treatment times and cell types, indicating that at least two DNA replications had occurred between initial treatment and final odontoblast-like cell differentiation.

Four adult Rhesus monkeys provided 120 teeth for buccal Class V cavities. Twenty‐nine were non‐exposed controls and 91 were exposed for 3 intervals. All 120 teeth were capped with a hard set Ca(OH)2, medicament, restored with amalgam, 57 evaluated after 1 year and 63 after 2 years. Of the 91 exposed pulps, 45 showed complete healing, 25 showed pulpal inflammation varying from acute to chronic, 12 showed severe pulpal breakdown and abscess formation and 9 were necrotic. No difference was observed in the healing response between the 3 exposure times. New hard tissue formed at, or subjacent to, the medicament in 77 of 91 exposed pulps with a tunnel defect frequently present, running from the medicament interlace to the pulp. This study demonstrates that recurring pulp inflammation observed after 1 & 2 year direct pulp capping, is associated with bacterial contamination.

Cellular reorganization in the pulp following mechanical pulp exposure involves three steps: First, lysis and macrophage resolution of the clot form; second, there is an invasion of the clot area by fibroblasts and endothelial cells, i.e., formation of granulation tissue; third, an organization and differentiation of these cells into functional odontoblasts occurs as early as 9 days after exposure. Autoradiographic results showed an increased DNA synthesis in the fibroblast and endothelial cell populations which coincided with a histologically-observed increase in those populations. A relative increase in fibroblastic activity, as compared to endothelial cell activity, suggested that fibroblasts may be the cells that replace odontoblasts.