Executive summary
- Antibiotic resistance has fundamentally changed gonorrhoea treatment. The previous dual therapy (ceftriaxone + azithromycin) is now abandoned — azithromycin is no longer recommended. Ceftriaxone 1 g IM as a single agent is current first-line treatment.
- Many infections are asymptomatic — particularly pharyngeal and rectal infections, and a significant proportion of genital infections in women. Opportunistic testing is important.
- Test of cure (TOC) is mandatory after gonorrhoea treatment due to resistance risk. Arrange at 2 weeks post-treatment via GUM.
- Most cases should be managed via GUM for treatment administration, partner notification, and TOC. Primary care's role is recognition and NAAT testing.
Presentations by site
- Urethral (men): Urethral discharge (classically yellow/green, profuse), dysuria. ~10% are asymptomatic.
- Cervical/vaginal (women): Often asymptomatic. May present with increased vaginal discharge, dysuria, intermenstrual or post-coital bleeding. Consider gonorrhoea in any woman with purulent cervical discharge or cervicitis.
- Pharyngeal: Usually asymptomatic or mild sore throat. Easily missed if not specifically tested. Important reservoir for transmission.
- Rectal: Often asymptomatic. May cause proctitis — discharge, discomfort, bleeding. Requires rectal NAAT specifically.
- Disseminated gonococcal infection (DGI): Rare — septic arthritis, tenosynovitis, or skin pustules in sexually active adults. Send joint aspirate for gonococcal culture; hospital admission required.
Testing
- Nucleic acid amplification test (NAAT) is the standard diagnostic method. It is more sensitive than culture for most sites.
- Swab sites should match patient risk: Urethral (men), vulvovaginal or cervical (women), plus pharyngeal and rectal swabs for MSM and based on sexual history in others.
- Self-taken vulvovaginal swabs (VVS) are acceptable and non-inferior to clinician-collected samples — this facilitates community testing.
- Culture is required in addition to NAAT if gonorrhoea is confirmed on NAAT, to enable antibiotic sensitivity testing. Arrange via GUM — they will take the culture swab at treatment attendance.
Treatment
- First-line (current BASHH guidance): Ceftriaxone 1 g IM single dose. This should be administered in GUM. Do not prescribe empirically in primary care if at all possible — gonorrhoea treatment should follow culture-guided or GUM-directed pathways.
- If ceftriaxone is unavailable or patient is unable to attend GUM urgently and clinical need is high, seek telephone advice from GUM before prescribing any alternative, as resistance patterns require microbiological input.
- Cephalosporin allergy: Specialist management required — discuss with GUM or microbiology. There are very limited alternatives with established efficacy.
- Concurrent chlamydia treatment: If chlamydia has not been excluded, add doxycycline 100 mg twice daily for 7 days at the same time as gonorrhoea treatment.
Frequently asked questions
Why is azithromycin no longer used for gonorrhoea?
Azithromycin resistance in Neisseria gonorrhoeae has risen to levels where it is no longer reliably effective. BASHH updated its guidelines to remove azithromycin from the gonorrhoea treatment regimen. Using it unnecessarily would also accelerate resistance. Ceftriaxone 1 g IM alone is the current recommendation.
My patient has a positive NAAT — can I treat in primary care?
Ideally refer to GUM — they need to administer the IM injection, take cultures for sensitivity testing, arrange test of cure, and conduct partner notification. If the patient cannot attend GUM in a timely manner, telephone GUM for advice. Do not prescribe oral alternatives without microbiological guidance.
What is the window period for gonorrhoea NAAT?
NAAT can detect Neisseria gonorrhoeae within 2 weeks of exposure, and often sooner. If a patient presents within 2 weeks of a potential exposure with no symptoms, testing may be appropriate but repeat testing at 2 weeks is advisable to exclude very early infection.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.