2020 European guideline for the diagnosis and treatment of gonorrhoea in adults

Abstract

Gonorrhoea is a major public health concern globally. Increasing incidence and sporadic ceftriaxone-resistant cases, including treatment failures, are growing concerns. The 2020 European gonorrhoea guideline provides up-to-date evidence-based guidance regarding the diagnosis and treatment of gonorrhoea. The updates and recommendations emphasize significantly increasing gonorrhoea incidence; broad indications for increased testing with validated and quality-assured nucleic acid amplification tests and culture; dual antimicrobial therapy including high-dose ceftriaxone and azithromycin (ceftriaxone 1 g plus azithromycin 2 g) OR ceftriaxone 1 g monotherapy (ONLY in well-controlled settings, see guideline for details) for uncomplicated gonorrhoea when the antimicrobial susceptibility is unknown; recommendation of test of cure (TOC) in all gonorrhoea cases to ensure eradication of infection and identify resistance; and enhanced surveillance of treatment failures when recommended treatment regimens have been used. Improvements in access to appropriate testing, test performance, diagnostics, antimicrobial susceptibility surveillance and treatment, and follow-up of gonorrhoea patients are essential in controlling gonorrhoea and to mitigate the emergence and/or spread of ceftriaxone resistance and multidrug-resistant and extensively drug-resistant gonorrhoea. For detailed background, evidence base and discussions, see the background review for the present 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults (Unemo M, et al. Int J STD AIDS. 2020).

Associations between antimicrobial susceptibility/resistance of Neisseria gonorrhoeae isolates in European Union/European Economic Area and patients’ gender, sexual orientation and anatomical site of infection, 2009–2016

“…to limit the spread of infection as well as to detect gonococcal AMR. This 3-site testing should ideally use molecular diagnostics for the extragenital samples and be routine in MSM, considered in women particularly if sexual contacts of gonorrhoea patients, and be guided based on sexual history, risk, travel history and symptoms or signs in all other patients [ 8 , 12 , 52 – 54 ].…”

“…The susceptibility to the last remaining effective options for empiric first-line monotherapy, i.e. the extended-spectrum cephalosporin (ESC) ceftriaxone given in combination therapy together with azithromycin or as monotherapy [8][9][10][11][12][13][14][15][16], is also decreasing and since 2015 an international spread of at least one ceftriaxone-resistant gonococcal strain has been documented [4][5][6][7][8][17][18][19][20][21][22][23][24][25][26]. Regular and quality-assured antimicrobial susceptibility surveillance for N. gonorrhoeae is imperative, to monitor current and emerging trends in AMR and to ensure effective patient management on an individual level as well as by timely revisions of treatment guidelines.…”

Antimicrobial resistance in Neisseria gonorrhoeae isolates and gonorrhoea treatment in the Republic of Belarus, Eastern Europe, 2009–2019

“…Alarmingly, the level of antimicrobial resistance (AMR) in Neisseria gonorrhoeae to a wide range of drugs has increased dramatically worldwide over the past decades, including first-line treatment [ 3 , 5 , 8 – 11 ]. Ceftriaxone, an extended-spectrum cephalosporin (ESC), is the last option for first-line empiric monotherapy internationally.…”

“…Ceftriaxone, an extended-spectrum cephalosporin (ESC), is the last option for first-line empiric monotherapy internationally. It is a concern that in vitro and clinically decreased susceptibility or resistance to ceftriaxone has been reported from many countries [ 3 , 5 , 8 – 28 ]. This has resulted in that the WHO global gonorrhoea treatment guidelines and international and national guidelines in Europe, Australia, and Canada recommend antimicrobial combination therapies, mostly ceftriaxone 250–1000 mg × 1 intramuscularly (IM) combined with azithromycin 1–2 g × 1 orally [ 8 , 11 , 29 , 30 ].…”

“…It is a concern that in vitro and clinically decreased susceptibility or resistance to ceftriaxone has been reported from many countries [ 3 , 5 , 8 – 28 ]. This has resulted in that the WHO global gonorrhoea treatment guidelines and international and national guidelines in Europe, Australia, and Canada recommend antimicrobial combination therapies, mostly ceftriaxone 250–1000 mg × 1 intramuscularly (IM) combined with azithromycin 1–2 g × 1 orally [ 8 , 11 , 29 , 30 ]. However, some countries, such as Japan, Ukraine and, since 2019 and 2020, the United Kingdom and USA, respectively, recommend high-dose (1 g except in the USA where 500 mg is recommended) ceftriaxone monotherapy, i.e., when chlamydial infection has been excluded [ 31 – 34 ].…”