Gonorrhoea, Antibiotic Prescribing

Comments from Expert Advisory Committee

1. Consideration should be given to referring patients with suspected gonorrhoea to a dedicated GUM clinic. Patients who are allergic to cephalosporins should be referred to a dedicated service and where not possible, discussed with a specialist in Genitourinary Medicine or Infectious Diseases.
2. The number of cases of gonorrhoea reported in Ireland has been increasing in the recent past and the increase appears to be occurring in young heterosexual men and women and men who have sex with men (MSM).
3. Infection can be asymptomatic in both males and females. Symptoms in males include dysuria and a urethral discharge. Symptoms in women include vaginal discharge, intermenstrual bleeding, post coital bleeding. Rectal infection can lead to proctitis.
4. Infection can lead to epididymo-orchitis in males.
5. Infection can lead to pelvic inflammatory disease (PID) in females. PID is associated with an increased risk of tubal factor infertility, ectopic pregnancy and chronic pelvic pain.
6. Diagnosis using NAAT (nucleic acid amplification technique, e.g. PCR, polymerase chain reaction) is the current diagnostic gold standard. This is frequently combined with a chlamydia NAAT in the same test.
7. Diagnosis can be made on first void urine in males and vulvovaginal or endocervical swab in females. Vulvovaginal swabs can be provider or self-taken.
8. In sexually active men who have sex with men (MSM), pharyngeal and rectal sites should be tested too.
9. A diagnosis of gonorrhoea in MSM should prompt a discussion about HIV prevention including PrEP.
10. Increasing resistance to antimicrobials is a major concern with gonorrhoea globally. Ciprofloxacin resistance was seen in 45% of isolates tested in the national Gonococcal Reference Laboratory in 2019.
11. Empiric treatment with oral cefixime or ciprofloxacin is inappropriate.
12. NAAT testing does not currently give information on gonorrhoea antimicrobial susceptibility and wherever possible culture and sensitivity testing needs to be done. Treatment can be initiated, as outlined in the table below, without sensitivity results.
13. Test of cure is recommended 2-3 weeks post completion of treatment and is particularly important where sensitivities are unknown and/or ceftriaxone treatment not given.
14. Individuals diagnosed with gonorrhoea should be offered testing for other STIs including HIV, Hepatitis B, syphilis and chlamydia.
15. Hepatitis C testing should be considered part of routine sexual health screening in the following circumstances: MSM, People living with HIV; Commercial sex workers; People who inject drugs (PWID). Partners of the above should also be considered for HCV testing.
16. Sexual partners in the preceding 6 months should be informed of the need for testing and patients should be encouraged to inform their sexual partners. Sexual partners in the two week window period after last sexual contact may have a false negative result and should be empirically treated for gonorrhoea.
17. Advise no sexual contact until negative on test of cure for gonorrhoea (2-3 weeks post treatment) but if no test of cure completed, then should abstain for 2 weeks.
18. Gonorrhoea is a notifiable disease. Notification process is usually initiated by the testing laboratory.

Treatment

Empiric treatment with oral cefixime is inappropriate.

Treatment of uncomplicated angogenital and pharyngeal gonorrhoea in adults including those with cephalosporin allergy.

* this should be managed in a specialist setting and if not feasible, only following specialist advice, especially where sensitivity of the isolate is not known and a symptomatic person is being treated empirically.