Sexual Health

Gonorrhoea

Neisseria gonorrhoeae is a sexually transmitted infection whose treatment is governed by antimicrobial resistance. The safe pathway is site-complete NAAT plus culture and susceptibility testing, ceftriaxone-led treatment, resistance-aware test of cure and urgent escalation for disseminated or ocular disease.

In a nutshell

Gonorrhoea is a potentially asymptomatic STI with a major antimicrobial-resistance problem. Take site-complete NAAT and culture, including pharyngeal sampling for all urogenital cases and contacts, treat confirmed uncomplicated infection with ceftriaxone, use risk-stratified test of cure and escalate ocular, disseminated, pelvic and testicular complications urgently.

Classic presentation

A short-incubation profuse purulent urethral discharge and dysuria, or an asymptomatic cervical, rectal or pharyngeal infection found through testing or contact tracing.

Key points

Take NAAT and culture from relevant sites. The current BASHH guideline recommends pharyngeal sampling for everyone with urogenital gonorrhoea and all contacts, regardless of reported travel or sexual behaviour.
Culture from each positive site before treatment is essential for antimicrobial susceptibility testing; NAAT alone cannot guide resistance management.
Treat confirmed uncomplicated anogenital or pharyngeal gonorrhoea with ceftriaxone 1 g intramuscularly as a single dose. See BNF and BASHH guidance for the current regimen.
Cefixime 400 mg followed by 400 mg 6–12 hours later plus azithromycin 2 g is an alternative only when injection is contraindicated and susceptibility is available. See BNF and specialist protocol.
Ciprofloxacin is not empirical first line. It may be used only when clinically appropriate and susceptibility is known, with MHRA fluoroquinolone safety restrictions respected.
Routine test of cure is not needed for ceftriaxone-susceptible anogenital infection, but remains required for pharyngeal infection, pregnancy, unknown susceptibility, non-ceftriaxone treatment or persistent symptoms. Use NAAT at least 2 weeks after treatment if asymptomatic.
Gonococcal conjunctivitis can rapidly threaten sight: take urgent swabs, give systemic and topical treatment and involve ophthalmology.
Fever, pustular rash, tenosynovitis or septic arthritis suggests disseminated infection and needs blood cultures, disseminated-site sampling, ceftriaxone and specialist care.
Notify partners, test all contacts at the pharynx and advise no sex until 7 days after both the patient and partners complete treatment.

First-line investigation

NAAT plus culture and susceptibility testing from every relevant site, including pharyngeal sampling for all urogenital cases and contacts.

Management

Identify dangerous complications

Assess urgently for sight-threatening conjunctivitis, disseminated infection, PID, epididymo-orchitis, torsion and pregnancy. Arrange ophthalmology, acute medical, surgical or obstetric input when indicated.^1,4,5

Sample all relevant sites

Take NAAT and culture before treatment where possible. Include pharyngeal testing for all urogenital cases and contacts, and add rectal or other samples according to the sexual history and symptoms.^1,6,3

Treat with ceftriaxone

For confirmed uncomplicated anogenital or pharyngeal infection, use ceftriaxone 1 g IM as a single dose. See BNF and BASHH guidance for allergy, pregnancy, alternatives and local administration requirements.^1,8

Treat ocular and disseminated disease urgently

Use systemic and topical treatment with urgent ophthalmology for ocular infection, and ceftriaxone plus specialist infection management for disseminated disease. Add the relevant PID or epididymo-orchitis regimen when those complications are present.^1,4,5,8

Confirm cure and stop transmission

Use BASHH test-of-cure criteria, notify partners, test contacts at the pharynx and advise no sex until 7 days after both patient and partners complete treatment. Refer suspected treatment failure or resistant isolates to specialist microbiology and UKHSA pathways.^1,3,2

Exam traps

NAAT is sensitive but culture is needed for susceptibility testing and treatment-failure investigation.
Pharyngeal testing is now recommended for all people with urogenital gonorrhoea and all contacts, not just people with reported oral exposure or travel.
Cefixime is no longer the old single 400 mg alternative: BASHH 2025 uses a second 400 mg dose 6–12 hours later plus azithromycin when injection is contraindicated and susceptibility is available. See BNF.
Ciprofloxacin is not empirical first-line treatment, even though it may be used if susceptibility is known and other options are inappropriate.
A negative or early test of cure does not automatically distinguish treatment failure from reinfection or residual nucleic acid; involve sexual-health and microbiology specialists.
Purulent red eye is an emergency because gonococcus can penetrate the cornea and cause rapid visual loss.

Illustrations

Gram stain of gonococcal dischargeMicroscopy image of Gram-negative intracellular diplococci within neutrophils from a urethral or endocervical smear.Graham Beards, Wikimedia Commons · CC-BY-SA-4.0

Antimicrobial resistance trendDiagram illustrating the progressive loss of effective antibiotic classes against Neisseria gonorrhoeae over time, underscoring the need for culture and susceptibility testing.PassFinals · original

Disseminated gonococcal infectionClinical photograph of the pustular skin lesions associated with bacteraemic spread and septic arthritis.Splintercellguy, Wikimedia Commons · Public domain

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.