AKT · Sexual health/Bacterial STIs

Gonorrhoea

Neisseria gonorrhoeae — Gram-negative diplococcus

Overview

Second commonest bacterial STI; purulent urethritis/cervicitis, with rising antimicrobial resistance driving the ceftriaxone-only first line and mandatory test of cure.

Recognise

Men: purulent urethral discharge, dysuria (often symptomatic)
Women: often asymptomatic; discharge, dysuria, pelvic pain
Extragenital: rectal, pharyngeal; disseminated gonococcal infection (pustular rash, arthritis, tenosynovitis)
Neonatal: ophthalmia neonatorum (within 48h, purulent) — emergency

Red flags

Disseminated infection, neonatal conjunctivitis, or PID

Differentials & how to tell them apart

Chlamydiaco-exists; less purulent — distinguish by NAAT/culture

Non-gonococcal urethritisNAAT negative for GC; consider Mycoplasma

Reactive arthritissterile; follows infection rather than DGI septic joint

Investigations

NAAT first; ALSO culture before treatment for antimicrobial susceptibility (resistance). Microscopy of Gram-stained smear shows intracellular Gram-negative diplococci. Pharyngeal testing for all.

Management

Ceftriaxone 1 g IM single dose

1Refer to GUM. First-line: ceftriaxone 1 g IM single dose.Gate: Ciprofloxacin 500 mg PO single dose ONLY if antimicrobial susceptibility is known and the isolate is ciprofloxacin-sensitive
2IM/cephalosporin contraindicated: gentamicin 240 mg IM + azithromycin 2 g PO, OR cefixime 400 mg + azithromycin 2 g.
3Test of cure is MANDATORY for ALL gonorrhoea (resistance) — NAAT ~2 weeks (or culture).

Ceftriaxone — first-line, 1 g IM single dose (resistance-driven monotherapy)

Ciprofloxacin — ONLY if susceptibility known and sensitive (no longer empirical)

Gentamicin + azithromycin / cefixime + azithromycin — if IM contraindicated/allergy

Key points

Unlike chlamydia, gonorrhoea ALWAYS needs a test of cure. Ophthalmia neonatorum = single-dose ceftriaxone for the neonate + ophthalmology.

Monitor & prognosis

Mandatory TOC; symptom resolution; re-test at 3 months.

Good if treated; resistance is the live threat.

Source: BASHH 2025; NICE CKS Gonorrhoea