Gonorrhoea

Comments from Expert Advisory Group

1. Referral to a dedicated GUM clinic for treatment is recommended for all patients where first line treatment with ceftriaxone cannot be administered.
2. The number of cases of gonorrhoea reported in Ireland has been increasing in recent years and the increase appears to be occurring in young heterosexual men and women and gay, bisexual and other men who have sex with men (gbMSM).
3. Genitourinary tract infection can be asymptomatic in both males (less than 10%) and females (approximately 50%). Symptoms in males include dysuria and a urethral discharge. Symptoms in women include  vaginal discharge, intermenstrual bleeding, post-coital bleeding, and/or lower abdominal pain. Urethral infection may present with dysuria without urinary frequency. Rectal infection can lead to proctitis.
4. Infection can lead to epididymo-orchitis, prostatitis and infertility 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. In sexually active gbMSM, pharyngeal and rectal sites should also be tested. Pharyngeal and rectal site testing can be considered in women who are sexual contacts of a person with gonorrhoea and should be guided by assessment of risk and symptoms in all others.
8. Increasing resistance to antimicrobials is a major concern with gonorrhoea. For example, ciprofloxacin resistance was seen in 60% of isolates tested in the National Gonococcal Reference Laboratory in 2022.
9. NAAT testing does not currently give information on gonorrhoea antimicrobial susceptibility. Wherever possible, culture should be taken in all gonorrhoea cases diagnosed by NAAT prior to antibiotics being given so that susceptibility testing can be performed and resistant strains identified. This is ideally carried out with gonorrhoea specific culture plates (in GUM clinics) but can be performed in general practice with a charcoal swab of the positive site, sent without delay, and with clear information that gonorrhoea culture and sensitivity is requested. Ceftriaxone treatment can be initiated, as outlined in the table below, without waiting for sensitivity results.
10. Empiric treatment with oral cefixime, ciprofloxacin or azithromycin is inappropriate.
11. Test of cure is recommended 2-3 weeks post completion of treatment and is particularly important where sensitivities are unknown and/or ceftriaxone treatment is not given.
12. Individuals diagnosed with gonorrhoea should be offered testing for other STIs including HIV, Hepatitis B, syphilis and chlamydia.
13. Hepatitis C (HCV) testing should be considered part of routine sexual health screening in the following circumstances: gbMSM; People living with HIV; Commercial sex workers; People who inject drugs (PWID). Partners of the above should also be considered for HCV testing.
14. A diagnosis of gonorrhoea in gbMSM should prompt a discussion about HIV prevention including pre-exposure prophylaxis PrEP.
15. Sexual partners of the following should be informed of the need for testing:
    • Men with symptomatic urethral infection: all partners within the preceding 2 weeks (or the last partner if longer than two weeks ago).
    • All others with infection at other sites or asymptomatic infection: all partners within the preceding 3 months.
16. 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. Seek specialist (GUM/ Infectious Diseases/ Obstetrics/ Microbiology) advice in cases of gonorrhoea in pregnant or breastfeeding patients.
19. Gonorrhoea is a notifiable disease. Notification process is usually initiated by the testing laboratory.

Treatment

Seek specialist (GUM Clinician / Infectious Diseases / Obstetrics / Microbiology) advice in cases of gonorrhoea in pregnant or breastfeeding patients.

Useful Resources

• National guidelines for the prevention and control of gonorrhoea and for minimising the impact of antimicrobial resistance in Neisseria gonorrhoea

Patient Information