Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
The implications of antibiotic resistance in the treatment of gonorrhoea are significant, leading to changes in recommended management strategies NICE CKS.
- Reduced Efficacy of Previous Regimens: Dual therapy with azithromycin 1g, previously advised, is no longer recommended due to an increase in the prevalence of azithromycin resistance in the UK and globally NICE CKS. Studies have shown that gentamicin 240mg intramuscular (IM) with azithromycin 1g was insufficient to clear the infection in a significant proportion of participants NICE CKS.
- High Ciprofloxacin Resistance: The prevalence of ciprofloxacin resistance in the UK is high (36.4% in 2017), meaning it is generally not recommended unless the *Neisseria gonorrhoeae* strain is known to be quinolone sensitive NICE CKS. Systemic fluoroquinolones are now only prescribed when other commonly recommended antibiotics are inappropriate due to risks of disabling and potentially long-lasting or irreversible side effects NICE CKS,NICE CKS.
- Monotherapy Concerns: Cefixime and gentamicin monotherapy have been associated with treatment failure, particularly for pharyngeal infections NICE CKS.
- Risk of Accelerating Resistance: Avoiding azithromycin in gonorrhoea treatment also helps prevent accelerating the induction and spread of resistance in other sexually transmitted infections (STIs) like *Mycoplasma genitalium* and *Treponema pallidum* NICE CKS.
Management should be adjusted accordingly to address these resistance concerns:
- First-Line Treatment: When antimicrobial susceptibility is not known prior to treatment, ceftriaxone 1g IM injection as a single dose is the recommended first-line choice NICE CKS. Although ceftriaxone resistance is very low in England and Wales, the 1g dose is preferred as it is more effective against isolates with reduced susceptibility NICE CKS.
- Alternative Regimens: For individuals with allergy, needle phobia, or other contraindications, alternative dual therapy regimens are recommended NICE CKS. These include gentamicin 240mg IM as a single dose plus azithromycin 2g orally, or cefixime 400mg orally as a single dose plus azithromycin 2g orally (advisable only if an IM injection is contraindicated or refused) NICE CKS. Resistance to cefixime is currently low in the UK NICE CKS.
- Specific Populations: For pregnant or breastfeeding women, ceftriaxone 1g IM injection as a single dose is prescribed NICE CKS. Azithromycin 2g as a single oral dose can be used if adequate alternatives are not available and the isolate is known to be susceptible; otherwise, specialist advice should be sought NICE CKS. Ciprofloxacin should not be prescribed for pregnant or breastfeeding women NICE CKS.
- Referral and Follow-up: All people with gonorrhoea should ideally be referred to a Genito-Urinary Medicine (GUM) clinic or other local specialist sexual health service for management NICE CKS. If primary care undertakes management, it should be in line with local procedures and protocols, with appropriate expertise available NICE CKS. A test of cure is recommended for all people treated for gonorrhoea NICE CKS.
- Antimicrobial Stewardship: Regular review of local and national trends in gonococcal antimicrobial resistance is recommended when using alternative regimens without susceptibility data NICE CKS. Promoting judicious use of antimicrobials is crucial to preserve their future effectiveness NICE NG63.