Gonorrhoea

Gonorrhoea, gonococcal infection, Neisseria gonorrhoeae infection, "the clap".

Sexually transmitted infection caused by the gram-negative diplococcus Neisseria gonorrhoeae.

Approximately 1,000 new cases annually in Switzerland, with 600–800 occurring in men who have sex with men (MSM). Pharyngeal and rectal infections are often asymptomatic, acting as important reservoirs of transmission.

• Urogenital gonorrhoea
• Pharyngeal gonorrhoea
• Rectal gonorrhoea
• Disseminated gonorrhoea (e.g., arthritis-dermatitis syndrome, sepsis)

Transmission occurs via unprotected vaginal, oral, or anal sexual contact. Vertical transmission to neonates is possible during delivery. Risk factors include multiple sexual partners, MSM, and unprotected intercourse.

Incubation period: 1–7 days (typically 2–4).
♂: Urethritis with purulent discharge or asymptomatic (~10%).
♀: Often asymptomatic; occasionally cervicitis, dysuria, or lower abdominal pain.

Extragenital manifestations: Pharyngitis and proctitis are usually asymptomatic. Disseminated disease may present with arthritis, dermatitis, or endocarditis in rare cases

PCR (NAAT) from urethral, vaginal, pharyngeal, rectal swabs, or urine.
Culture is recommended if PCR is positive to enable antimicrobial susceptibility testing. Concurrent screening for Chlamydia, HIV, and syphilis is advised. Pharyngeal and rectal swabs are particularly important in MSM.

Primarily genitourinary tract, pharynx, rectum; in disseminated cases also joints, skin, heart, or central nervous system.

Unprotected sexual contact, frequent partner changes, history of MSM. Women are often asymptomatic despite infection.

Relevant only in disseminated gonorrhoea: cutaneous manifestations may include pustules or vasculitic lesions.

♂: Epididymitis, prostatitis, urethral stricture
♀: Salpingitis, pelvic inflammatory disease (PID), ectopic pregnancy, infertility
Both: Arthritis-dermatitis syndrome, septic arthritis, rare cases of endocarditis or meningitis

Timely treatment generally leads to full recovery in uncomplicated cases. Delayed diagnosis can result in severe complications. Multidrug-resistant strains are increasingly reported.

Safer sex practices (e.g. condoms, barrier methods), partner notification and treatment, routine screening in high-risk groups. Culture and resistance testing recommended. No licensed vaccine available in Switzerland.

First-line treatment for uncomplicated urogenital, rectal, or pharyngeal gonorrhoea:

• Ceftriaxone 1 g intramuscularly (ventrogluteal) or intravenously as a single dose
• Azithromycin is no longer routinely recommended in combination therapy to avoid promoting resistance.

Alternative treatment (in case of penicillin/cephalosporin allergy or resistance):

• Consultation with an infectious disease specialist is required.
• Ertapenem 1 g i.m. has demonstrated non-inferiority to 500 mg ceftriaxone in clinical trials and may be considered in selected cases.

Test-of-cure and Partner Management
Abstinence from sexual activity is recommended for at least 7 days after completing treatment.
A test-of-cure is advised in persistent symptoms, pharyngeal infection, or suspected treatment failure.

1. Ross JDC, Wilson J, Workowski KA, Taylor SN, et al. Oral gepotidacin for uncomplicated urogenital gonorrhoea (EAGLE-1): a phase 3 non-inferiority trial. Lancet. 2025;405:1608-1620 
2. Luckey A, Broadhurst H, et al. Oral zoliflodacin non-inferior to ceftriaxone + azithromycin: global phase 3 RCT, 2025 
3. Reimche JL, Pham CD, Joseph SJ, et al. Emergence of a multidrug-resistant Neisseria gonorrhoeae strain in the USA. Lancet Infect Dis. 2024;24:e149-e151 
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8. Barbee LA, Soge OO, et al. Time-to-clearance of N. gonorrhoeae RNA at the pharynx after treatment. J Clin Microbiol. 2022;60:e0039922 
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10. de Vries HJC et al. European guideline on management of proctitis, proctocolitis and enteritis due to STIs. J Eur Acad Dermatol Venereol. 2021;35:1434-1443