Key points

Gonorrhoea is a highly prevalent STI
Approximately 78 million people are infected globally each year. Main symptoms include discharge in the affected area and pain or difficulty when urinating.
A single oral tablet can be used instead of painful injections
Ciprofloxacin remains a viable treatment option for greater than 70% of gonorrhoea infections in Australia.
Rapid and effective diagnostics can support the use of ciprofloxacin oral therapy
New UK guidelines (draft, out for consultation) recommend screening for the infection and its resistance status and then determining the treatment options in management of gonorrhoea.

What is gonorrhoea?

Gonorrhoea is a sexually transmitted infection (STI) caused by bacteria called Neisseria gonorrhoeae. It is one of the most prevalent STIs, according to the World Health Organization (WHO) an estimated 78 million people are infected with gonorrhoea globally each year.

Gonorrhoea is transmitted by direct sexual contact with the infectious area. Primary infection sites are the mucosal membranes of urethra, cervix, rectum, throat (pharynx) and eye.

Symptoms of gonorrhoea include the following:

In men
▪ Pus and discharge from urethra
▪ Pain and/or difficulty when urinating
▪ Pain in affected area
▪ Swelling and tenderness in testicles and epididymis (rare)

In women
▪ Pain and/or difficulty in urinating
▪ Increased or altered vaginal discharge
▪ Lower abdominal pain
▪ Intermenstrual bleeding and abnormally heavy menstruation (rare)

In rectal infections following symptoms may be found in the affected area

▪ Discharge
▪ Pain
▪ Discomfort

Pharynx infections are mostly asymptomatic but sometimes may involve sore throat

Gonorrhoea and resistance

Gonorrhoea is highly resistant to many antibiotics and has become more resistant over time. Prof. David Lewis (Western Sydney Sexual Health Centre and University of Sydney) explains during the 80’s there were 3 antimicrobial drug classes that were successful in treating gonorrhoea, but as of 2018, resistance has developed to all known classes.

“The bacteria that cause gonorrhoea are particularly smart. Every time we use a new class of antibiotics to treat the infection, the bacteria evolve to resist them.”
Dr Teodora Wi, Medical Officer, Human Reproduction, WHO

Continued use of ineffective antibiotics is highly problematic. Unnecessary exposure to antibiotics will promote development of resistance. For gonorrhoea, empirical treatment based on symptoms, without any prior knowledge of resistance, would accelerate development of resistance, resulting in more difficult to treat infections. Untreatable, super resistant strains of gonorrhoea have been reported in Australia and the UK in 2018. This is an alarming warning that gonorrhoea may quickly overcome the current in-use antibiotics if no intervention is made.

Treatment options – tablet vs injection

Standard treatment of gonorrhoea without knowledge of resistance (empirical treatment) follows the international recommendation of intramuscularly injected ceftriaxone. This is an uncomfortable treatment for the patient, requiring a mandatory local anaesthetic to reduce the associated pain. Furthermore, there are global calls to conserve the use of ceftriaxone and minimise unnecessary prescriptions, because there are limited alternatives available once resistance develops.

The alternative is ciprofloxacin, a single dose tablet taken orally. Patients are expected to prefer this treatment experience compared to ceftriaxone injection. It is estimated that greater than 70% of gonorrhoea infections in Australia are susceptible to ciprofloxacin. Ciprofloxacin remains a viable treatment option for gonorrhoea in many regions including the UK, Europe, and the US, if the information about resistance status can be known.

Using resistance guided therapy

Summary of the provisional BASHH guideline for treatment of gonorrhoea. Refer to the full guideline for details.

The new 2018 UK national guideline (draft, out for consultation) includes strong recommendations for resistance guided therapy in management of gonorrhoea infections (Grade 1A recommendation).

Use of rapid and effective diagnostics is a critical step in the management, as it provides information not only on the presence of infection but also the resistance status to ciprofloxacin in a timely fashion without delaying the treatment. Clinicians can use the information to determine whether single dose oral ciprofloxacin therapy is suitable for the patient. In cases where ciprofloxacin is not suitable, ceftriaxone injection would be used as an alternative.

Resistance Guided Therapy is beneficial for the patient as it provides a more convenient and preferable treatment option. It is also highly beneficial for the community because it is an effective strategy to delay development of antimicrobial resistance. Resistance Guided Therapy enables currently available antibiotics to remain effective for longer periods of time (antibiotic stewardship).