Gonorrhoea

Overview

** 2024 Update** Please be aware that Gonorrhoea (GC) cases have resurged in England, including a rise in cases in Bristol, so it is vital to be testing and treating appropriately.

Symptoms

The following symptoms should be investigated appropriately but it should be noted that many patients will be asymptomatic:

Unity Sexual Health

Referrals for treatment and contact tracing of gonorrhoea can be made to Unity.

Patients can also self refer - see Unity - services currently available page.

See referral section below for details on referral from primary care.

Investigations

If gonorrhoea is suspected then NAATs should be sent from all sites used for sex, for example pharynx, vagina, anus or urine (in male bodied patients)

If positive for gonorrhoea on NAATs or contact with another person who has confirmed gonorrhoea then in addition to NAATs, swabs for GC culture (purple M,C&S swab) should be taken from all sites used for sex before commencement of treatment. 

• Endocervical cultures for patients who have had vaginal intercourse
• Urethral culture in male bodied patients.

This can be undertaken in primary care or by referral to Unity.

Treatment

Treatment in Unity

Unity will undertake treatment of patients with gonorrhoea and patients can be referred or can self refer (see referral section below) - please provide patients with evidence of positive test(s).

Treatment in Primary Care

If GP wants to treat themselves, please see the BNSSG Infections Guidelines  - Genital tract infections - Gonorrhoea which summarises treatment recommendations. These guidelines are due to be reviewed in October 2024. Unity currently recommend the following:

• Recommended regimen (should be used first line)-
  • Ceftriaxone 1g (with 3.5mls 1% lidocaine) IM Stat
  • Symptomatic rectal infection requires Doxycycline 100mg BD for 21 days in addition to above.
• If no antimicrobial sensitivities known and IM injection is contraindicated or refused by the patient-
  • Cefixime 400mg PO stat plus azithromycin 2g PO Stat
• Penicillin Allergy
  • Gentamycin 240mg IM plus Azithromycin 2g PO Stat

Advise the patient to abstain from sexual intercourse (SI) and until 7 days after they and their partner(s) have completed treatment.

Test of cure

The patient should perform repeat GC NAATs testing from all previously positive sites no sooner than 2 weeks after treatment.

Partner /Contact notification

Partner notification can be carried out by Unity or in primary care:

Partner Notification

The following partners should be notified (this can be patient led):

• All partners within the preceding 2 weeks (or the last partner if longer than two weeks ago) for male patients with symptomatic urethral infection
• All partners within the preceding 3 months for all other patients

All patients referred to Unity for treatment will have partner notification discussed with a health adviser. If patients require support with partner notification in the community, they are able to contact the health advising team on 0117 342 6944.

Management of Asymptomatic Contacts of Gonorrhoea

• For those presenting 14 days or more after potential exposure: GC NAATs testing is recommended (and abstinence from sex with index partner until results known)
• For those presenting within 14 days of potential exposure: Consider epidemiological treatment (with 1g IM ceftriaxone stat) based on clinical risk assessment and following a discussion with the patient. It may be appropriate to not give epidemiological treatment and repeat testing 2 weeks after exposure.

Referral

Self Referral

See Unity - services currently available page.

Referral

See Clinical services (unitysexualhealth.co.uk) page

If unable to administer IM medications (as this is first line treatment), or if any concerns regarding a resistant case then call the Unity professional line on 0117 342 6913.

Out of Hours Referrals: 

• If uncomplicated GC infection (i.e. no signs or symptoms of PID or epididymo-orchitis) referrals can be made via email (unityreferrals@uhbw.nhs.uk) and the patient will be contacted the next working day to make arrangements for treatment. Whilst there is no risk to the patient to leave treatment for a couple of days (e.g. over the weekend), the GP should advise the patient to abstain from sexual intercourse.
• If the patient refuses referral, give second line oral treatment as above.
• If complicated infection is suspected (e.g. PID, epididymo-orchitis) GP can commence the oral part of the antibiotic regime for PID or epididymo-orchitis (i.e. Doxycycline +/- Metronidazole) whilst awaiting Unity review for IM Ceftriaxone.
• If patient is systemically unwell, please refer to relevant specialty for urgent care.

Treatment Failure

Cases of possible ceftriaxone treatment failure should be discussed with the Unity Professional Line on 0117 342 6913 and reported to UKHSA.

Red flags

If any concerns about Pelvic Inflammatory Disease, please see separate guideline.

Resources

Patient Information/ Leaflets- E.g. BASHH patient leaflet: Gonorrhoea | BASHH

Unity patient information on STIs- Types of Sexually Transmitted Infections (unitysexualhealth.co.uk)

Evidence: BASHH guidelines- BASHH Guidelines

Unity Clinical Services and How to Refer- Clinical services (unitysexualhealth.co.uk)

UKHSA guidelines - Gonorrhoea: guidance, data and analysis

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.