2018 UK national guideline for the management of infection ...

1 Guidelines2018 UK national guideline for themanagement of infection withNeisseria gonorrhoeaeHelen Fifer1, John Saunders2, Suneeta Soni3, S Tariq Sadiq4and Mark FitzGerald5 Changes since 2011 guideline First line empirical treatment is now monotherapywith ceftriaxone 1 g intramuscularly If antimicrobial susceptibility test results from allsites of infection are available prior to treatmentand the isolate is sensitive to ciprofloxacin, thenthis should be used for treatment in preference toceftriaxone Inclusion of testing recommendations in people fol-lowing genital reconstructive surgery Recommendations for extra-genital testing in thosewith suspected or confirmed antimicrobial resistance Epidemiological treatment is recommended onlyfor those presenting within 14 days of those presenting after 14 days of exposure werecommend treatment based on the results oftestingSCOPE AND PURPOSEThis guideline offers recommendations for the diagnos-tic tests, treatment regimens and health promotionprinciples needed for the effective management of gon-orrhoea in people aged 16 years and older.

2 For indi-viduals under the age of 16 years please see the BritishAssociation for Sexual Health and HIV (BASHH) guideline on STI and Related Conditions in Childrenand Young People. The guidelines are primarily aimedat level 3 sexual health services within the UnitedKingdom (UK) although the principles of the recom-mendations could be adopted at all INDEPENDENCEThis guideline was commissioned and edited by theClinical Effectiveness Group (CEG) of BASHH,which provided funding for the literature search. Noother funding was OF DEVELOPMENTThis guideline was produced according to specificationsset out in the CEG s 2015 document Framework forguideline development and assessment outlined and has been updated by reviewing theprevious gonorrhoea guideline (2011) and medical lit-erature since its publication. A MEDLINE search ofpublished articles in English language for the years2009 18 was done using the subject headings gonor-rhoea OR gonorrhea OR Neisseria gonorrhoeae AND therapy OR treatment OR therapeutics OR resistance OR anti-bacterial agents OR antibiotics OR failure OR toxicity.

3 All entries in the Englishlanguage or with abstracts in English were viewedbecause of the paucity of clinical trials or reviews .The Cochrane Database of Systematic Reviews,Database of Abstracts of Reviews of Effectivenessand Cochrane Controlled Trials Register were reviewedusing the textword gonorrhoea and all entries wereconsidered. Abstracts from meetings in the relevantperiod were hand-searched and considered. Prioritywas given to randomized controlled trials and1 Consultant Microbiologist, national infection Service, Public HealthEngland2 Consultant in Sexual Health, national infection Service, Public HealthEngland and Central and North West London NHS Foundation Trust3 Consultant in Sexual Health, Brighton & Sussex University HospitalsNHS Trust4 Professor of Molecular Medicine, Institute for infection and Immunity, StGeorge s, University of London5 Consultant in Sexual Health, Clinical Effectiveness Group, BASHHC orresponding author:Helen Fifer, Public Health England, 61 Colindale Avenue, London, NW95EQ, : Journal of STD & AIDS2020, Vol.

4 31(1) 4 15!The Author(s) 2019 Article reuse : review evidence. Recommendations weremade and graded on the basis of best available evi-dence. There is a scarcity of high quality evidence toguide treatment recommendations and therefore, ameeting was held in June 2018 to discuss and resolvedifferences in opinion surrounding treatment recom-mendations. This was attended by representativesfrom the guideline writing group, the CEG, theGonococcal Resistance to Antimicrobials SurveillanceProgramme (GRASP) Steering Group and the BASHHB acterial Special Interest Group. Final agreement wasachieved by a majority decision following an open votein this meeting. The draft guideline was appraised withthe AGREE instrument, posted on the BASHH web-site for a consultation period of two months andassessed by a Health AND PUBLIC INVOLVEMENTA patient representative was a member of the writinggroup, attended writing group meetings and wasinvolved in the development of the guideline .

5 In addi-tion, attendees for treatment of confirmed gonorrhoeaat a specialist sexual health service were consulted ontreatment options (including epidemiological treat-ment) and test of is caused by the Gram-negative diplococ-cusNeisseria gonorrhoeae. The primary sites of infec-tion are the columnar epithelium-lined mucousmembranes of the urethra, endocervix, rectum, phar-ynx and conjunctiva. Transmission is by direct inocu-lation of infected secretions from one mucousmembrane to another. Secondary infection to otheranatomical sites, through systemic or transluminalspread, can also FEATURES1 3 Symptoms and signs of infection with gonorrhoeadepend, in part, on the site of infection . Co-existinginfections and conditions such asChlamydia trachoma-tis, Trichomonas vaginalis, Mycoplasma genitalium,Candida albicans and bacterial vaginosis, are notuncommon and these should be considered as a possi-ble cause for an individual s urethral infectionSymptoms occur in over 90% of individuals, with dis-charge and/or dysuria appearing two to five days fol-lowing exposure.

6 A mucopurulent urethral discharge isoften present on examination. Rarely, individuals maycomplain of testicular and epididymal pain with ten-derness and swelling present on urethral infectionUrethral infection may present with dysuria withouturinary infectionThe most common symptom, occurring in about 50%of individuals, is an increased or altered vaginal dis-charge. In about a quarter of individuals, lowerabdominal pain is present. Gonorrhoea rarely causesintermenstrual bleeding and menorrhagia. On exami-nation, a mucopurulent endocervical discharge maybe seen and easily induced endocervical bleeding maybe present. However, pelvic and lower abdominal ten-derness is an uncommon examination finding in theabsence of coinfection withChlamydia infectionMost cases are asymptomatic but symptoms mayinclude anal discharge and perianal/anal pain or dis-comfort. Rectal infection in cisgender women is presentin up to a third of cases of urogenital infection , andindividuals may not report a history of anal evidence suggests that rectal infection in theabsence of urogenital infection is infectionThis is predominantly asymptomatic but is occasional-ly associated with a sore infectionTransluminal spread ofN.

7 Gonorrhoeaefrom the ure-thra or endocervix may occur and cause epididymo-orchitis, prostatitis or pelvic inflammatory disease(PID). Haematogenous dissemination may occurfrom infected mucous membranes to cause skin lesions,arthralgia, arthritis and tenosynovitis (disseminatedgonococcal infection ). In a study involving nearly4,000 cisgender women attending a sexual healthclinic in the UK, PID was reported in approximately14% of those with AND SPECIMENCOLLECTIONThis section should be read in conjunction with PublicHealth England s Guidance for the detection ofgonorrhoea in England 2014 .6 The diagnosis ofgonorrhoea is established by the detection ofN. gonorrhoeaeat an infected site, either by nucleicFifer et amplification tests (NAATs) or by culture. Theapproach and method used to test for gonorrhoeawill be influenced by the clinical setting, storage andtransport system to the laboratory, local prevalenceof infection and the range of tests available in the lab-oratory.

8 No test for gonorrhoea offers 100% sensitivityand 9 Microscopy Microscopy of Gram-stained genital specimensallows direct visualisation ofN. gonorrhoeaeasmonomorphic Gram-negative diplococci withinpolymorphonuclear leukocytes. Penile urethra Microscopy of urethral or meatal swab smearshas good sensitivity (90 95%) in people with dis-charge from the penile urethra and is recom-mended to facilitate immediate presumptivediagnosis in these individuals (Grade 1C).1 Microscopy of penile urethral smears in thosewithout symptoms is less sensitive (50 75%),therefore it is not recommended in asymptomaticindividuals (Grade 1C).1 Female urethra and endocervix Microscopy has only 37 50% and 20% sensitiv-ity compared with culture for detecting gonor-rhoea from endocervical and female urethralsmears, The sensitivity of cervical microscopy comparedto NAATs in a more recent study was only16%.10 Female urethral and cervical microscopy is there-fore not routinely recommended (Grade 1C).

9 Rectum and pharynx Ano-rectal smears and microscopy should beoffered if rectal symptoms are present (Grade1C).11 The sensitivity of microscopy for detectingasymptomatic rectal infection is low and is notrecommended (Grade 1C).12 Microscopy of pharyngeal specimens is not rec-ommended (Grade 1C).Nucleic acid amplification tests NAATs are more sensitive than culture, particularlyfor oropharyngeal and rectal 15 NAAT sshow high sensitivity (>95%) in both symptomaticand asymptomatic ,16,17 Therefore,although NAATs are not licensed for use at extra-genital sites, their use is Commercially available NAATs differ in their cross-reactivity to commensalNeisseriaspecies which maybe present at significant levels, particularly in is recommended that laboratories con-firm any reactive test with an alternative moleculartarget if the positive predictive value of the initialtest for the population tested is less than 90%(Grade 1B).

10 6,7,19 This is particularly important forextra-genital specimens. Pooling of self-collected or clinician-collected rectal,pharyngeal and urine samples from the same indi-vidual could provide cost savings. There is a smallevidence base with mixed results using different test-ing platforms, specimen collection and poolingmethods. The largest study to date has shown thatpooling of self-taken swabs has lower sensitivity fordetection ofN. gonorrhoeaefrom pharyngeal sites,when compared with single site ser-vice considering the implementation of poolingshould perform appropriate clinical evaluation. Penile urethra NAATs show equivalent sensitivity in urine andurethral swab specimens from cisgender menalthough a first-pass urine is the ,21 Female urethra and endocervix Self-collected or clinician-collected vulvovaginalswabs perform better than endocervical swabsand significantly better than urine for ,7,9,22 24 Vulvovaginal swabs are there-fore recommended as the optimal specimen(Grade 1A).