What are the implications of antibiotic resistance in the treatment of gonorrhoea, and how should I adjust management accordingly?

The implications of antibiotic resistance in the treatment of gonorrhoea are significant, leading to changes in recommended management strategies ¹.

• Reduced Efficacy of Previous Regimens: Dual therapy with azithromycin 1g, previously advised, is no longer recommended due to an increase in the prevalence of azithromycin resistance in the UK and globally ¹. Studies have shown that gentamicin 240mg intramuscular (IM) with azithromycin 1g was insufficient to clear the infection in a significant proportion of participants ¹.
• High Ciprofloxacin Resistance: The prevalence of ciprofloxacin resistance in the UK is high (36.4% in 2017), meaning it is generally not recommended unless the *Neisseria gonorrhoeae* strain is known to be quinolone sensitive ¹. Systemic fluoroquinolones are now only prescribed when other commonly recommended antibiotics are inappropriate due to risks of disabling and potentially long-lasting or irreversible side effects ¹,².
• Monotherapy Concerns: Cefixime and gentamicin monotherapy have been associated with treatment failure, particularly for pharyngeal infections ¹.
• Risk of Accelerating Resistance: Avoiding azithromycin in gonorrhoea treatment also helps prevent accelerating the induction and spread of resistance in other sexually transmitted infections (STIs) like *Mycoplasma genitalium* and *Treponema pallidum* ¹.

Management should be adjusted accordingly to address these resistance concerns:

• First-Line Treatment: When antimicrobial susceptibility is not known prior to treatment, ceftriaxone 1g IM injection as a single dose is the recommended first-line choice ¹. Although ceftriaxone resistance is very low in England and Wales, the 1g dose is preferred as it is more effective against isolates with reduced susceptibility ¹.
• Alternative Regimens: For individuals with allergy, needle phobia, or other contraindications, alternative dual therapy regimens are recommended ¹. These include gentamicin 240mg IM as a single dose plus azithromycin 2g orally, or cefixime 400mg orally as a single dose plus azithromycin 2g orally (advisable only if an IM injection is contraindicated or refused) ¹. Resistance to cefixime is currently low in the UK ¹.
• Specific Populations: For pregnant or breastfeeding women, ceftriaxone 1g IM injection as a single dose is prescribed ¹. Azithromycin 2g as a single oral dose can be used if adequate alternatives are not available and the isolate is known to be susceptible; otherwise, specialist advice should be sought ¹. Ciprofloxacin should not be prescribed for pregnant or breastfeeding women ¹.
• Referral and Follow-up: All people with gonorrhoea should ideally be referred to a Genito-Urinary Medicine (GUM) clinic or other local specialist sexual health service for management ¹. If primary care undertakes management, it should be in line with local procedures and protocols, with appropriate expertise available ¹. A test of cure is recommended for all people treated for gonorrhoea ¹.
• Antimicrobial Stewardship: Regular review of local and national trends in gonococcal antimicrobial resistance is recommended when using alternative regimens without susceptibility data ¹. Promoting judicious use of antimicrobials is crucial to preserve their future effectiveness ³.