2018 UK national guideline for the management of infection with Neisseria gonorrhoeae

Abstract

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

Genomic evolution of Neisseria gonorrhoeae since the preantibiotic era (1928–2013): antimicrobial use/misuse selects for resistance and drives evolution

“…In the last 1-2 decade(s), there have been worrying reports from many continents of gonococcal strains with resistance to the ESCs, which are the last remaining alternatives for empiric first-line monotherapy of gonorrhoea [4,5,[7][8][9][10]. As a consequence, WHO global gonorrhoea treatment guidelines and guidelines in Europe, Australia, USA, and Canada currently recommend dual antimicrobial therapy, mostly ceftriaxone 250-500 mg single intramuscular dose plus azithromycin 1-2 g single oral dose, while some countries such as Japan and the UK since 2019 recommends only high-dose (1 g) ceftriaxone monotherapy [9,11]. Unfortunately, sporadic gonococcal isolates with ceftriaxone resistance have been described in many countries, and azithromycin resistance has been described in most settings worldwide [4,5,[7][8][9][10][11][12][13], and the first global failure with ceftriaxone plus azithromycin therapy was verified in the UK [12].…”

Diagnosis and management of gonorrhoea: a guide for GPs

“…• Cefixime 400mg orally plus azithromycin 2g orally or • Gentamicin 240mg IM plus azithromycin 2g orally or • Spectinomycin 2g IM plus azithromycin 2g orally or • Azithromycin 2g orally. 7 Ciprofloxacin should only be used if the organism is known to be susceptible. In 2017, 36.4% of gonococcal isolates that were referred to the Public Health England reference laboratory through the Sentinel reporting system were resistant to ciprofloxacin.…”

“…Following increasing reports of azithromycin resistance and concerns over antimicrobial stewardship, the 2019 guidelines have recommended that the first-line treatment returns to monotherapy with ceftriaxone, but at a higher dose of 1g, or ciprofloxacin where susceptibility is known. 7 The first reported case of gonorrhoea worldwide that was resistant to dual antibiotic therapy was described in the UK in 2015, in a heterosexual man who had sex with a female sexual partner in Japan. 8 He was eventually successfully treated with increased doses of both first-line drugs, after being given 1g ceftriaxone and 2g azithromycin.…”

Optimizing DNA extraction methods for Nanopore sequencing of Neisseria gonorrhoeae direct from urine samples

“…1,2 To reduce the spread of antimicrobial resistance, empirical dual therapy with single-dose azithromycin and ceftriaxone, the last two mainstream treatment options, is widely recommended. 2 However, increasing azithromycin resistance potentially undermines this approach leaving ceftriaxone empirical monotherapy as a last option, 3 but with ceftriaxone resistant cases recently reported in several countries worldwide. 4,5…”