This Scottish Health Protection Network (SHPN) guide should be used alongside the external guidance that it relates to.
This guide covers the UK Health Security Agency’s 'Managing incidents of ceftriaxone-resistant Neisseria gonorrhoeae in England’.
This external guidance has been approved for use in Scotland by the SHPN Guidance Group (SHPN-GG).
This guidance is for clinicians, microbiologists, epidemiologists and public health authorities.
Other people who require advice should contact their local health protection team.
What the guidance covers
The purpose of this document is to provide public health guidance to clinicians, microbiologists, epidemiologists and public health authorities in the management of ceftriaxone-resistant Neisseria gonorrhoeae.
Guide for use in Scotland
The following recommendations for using this guidance in Scotland were agreed by the SHPN through the agreed review and adoption process.
Antimicrobial resistant Neisseria gonorrhoeae in Scotland
Neisseria gonorrhoeae, the causative agent of gonorrhoea, has developed resistance to all previous antibiotics used in the treatment of infection in recent years and has become a global threat to public health.
Surveillance of antimicrobial sensitivity in Scotland is performed by the Scottish Bacterial Sexually Transmitted Infections Reference Laboratory (SBSTIRL) on all Neisseria gonorrhoeae isolates that it receives which represents approximately 50% of gonorrhoea episodes each year.
One episode is classified as positive samples taken from multiple specimen sites and taken on more than one occasion from the same individual within a 42-day period.
It is essential that samples for bacterial culture are taken for a high proportion of gonorrhoea cases.
Surveillance of antimicrobial resistant gonorrhoea in Scotland
Data on testing and diagnoses
As the guidance has been produced for England, there are several places in which the specific terminology is inappropriate for Scotland.
Some replacements or translations will be needed to avoid confusion in Scotland.
Main terminology differences
The relevant bodies in Scotland are:
- Public Health Scotland (PHS)
- NHS board health protection teams
- UKHSA antimicrobial resistant STIs national reference laboratory
The Scottish Bacterial Sexually Transmitted Infections Reference Laboratory (SBSTIRL) performs antibiotic resistance surveillance.
- Second-Generation Surveillance System (SGSS)
Electronic Communication of Surveillance in Scotland System (ECOSS).
- GUMCAD STI surveillance system
National Sexual Health (NaSH) IT system
- UKHSA consultant microbiologist
Consultant clinical scientist at SBSTIRL
- Chief Medical Advisor and Chief Scientific Officer
Director of Public Health Science and Head of Health Protection (Infection Services)
- Standard national incident
Consult the Management of public health incidents: guidance on the roles and responsibilities of NHS led incident management teams guidance to determine the level of response required
- CMO briefing and UKHSA briefing note
PHS Health Protection Alert
Surveillance and process differences
As this guidance has been produced for use in England there are some key differences to highlight.
Defining the risk
When defining risk, laboratory results should be interpreted carefully and in discussion with SBSTIRL.
Particularly as culture-negative and positive NAAT specimens taken two to three weeks after treatment (test of cure) are more commonly due to detection of persistent low-level DNA and not due to treatment failure.
Reporting an incident
Treatment failures or suspected cases of ceftriaxone-resistant Neisseria gonorrhoeae should be reported to the PHS BBV/STI team and SBSTIRL using the following email addresses
Please note that personal identifiable information should not be shared using the BBV/STI email address. The BBV/STI team will advise on how further information can be shared once alerted to a case or cluster.
If an isolate is available from an episode of treatment failure, this should be sent immediately to SBSTIRL.
SBSTIRL do not offer an assay that can detect mutations that confer resistance to ceftriaxone in the Neisseria gonorrhoeae penA gene from a nucleic acid amplification test (NAAT).
The PHS BBV/STI team will be responsible for coordinating a risk assessment of the threat to public health based on the information available from the:
- treating clinician
- antimicrobial resistance testing
- responsible health protection team (HPT)
An incident management team (IMT) should be convened if it is determined there is a risk of potential or actual further spread within Scotland.
The chair and arrangements of the IMT should be decided based on the guidance in Management of public health incidents: guidance on the roles and responsibilities of NHS led incident management teams.
The flow diagram details the steps in the risk assessment following the identification of a probable case.
Full text version
A probable case of ceftriaxone-resistant Neisseria gonorrhoeae was reported by SBSTIRL or sexual health clinicians.
Go to question 1.
Question 1: Is there a viable isolate available for antimicrobial-resistance testing?
If no, go straight to question 5.
If yes, send the isolate to SBSTIRL for confirmatory testing. There are two possible outcomes:
- If outcome 1 'confirmed by SBSTIRL as resistant (minimum inhibitory concentration (MIC) > 0.125 mg/L)', go to question 2.
- If outcome 2 'confirmed by SBSTIRL as susceptible', this is low risk and no further action is needed.
Question 2: Did the individual most likely get the infection in Scotland/UK or abroad?
If abroad, go to question 3.
If Scotland or UK, an IMT should be held. See notes 1 and 2 at the end of this process for more information about the IMT.
Question 3: Did the individual have sexual partners in the UK since getting the infection?
If no, go to question 4.
If yes, an IMT should be held. See notes 1 and 2 at the end of this process for more information about the IMT.
Question 4: What was the result of the test of cure (TOC)?
If positive, assess and report to PHS and SBSTIRL as a potential
treatment failure. This result should be interpreted carefully and in discussion with SBSTIRL. This is because positive tests of cure in the absence of culture are more commonly due to detection of persistent low-level DNA.
If negative, no further action is needed (unlikely further transmission).
Question 5: Has the individual recently (≤3 months) had unprotected sex in an Asia-Pacific country or had a sexual partner with recent travel to an Asia-Pacific country?
If no, go to question 4.
If yes, go to question 3.
Note 1. The following questions should be asked before the IMT if possible.
- Is the individual a sexual partner of a confirmed case with ceftriaxone resistance?
- Did the individual have a positive TOC at any site following treatment with ceftriaxone?
NB: An IMT should be held regardless of the answers.
Note 2. The chair and arrangements of the IMT should be decided based on the guidance in Management of public health incidents: guidance on the roles and responsibilities of NHS led incident management teams.
There is no Scottish equivalent of the Field Service portal and no standard questionnaire for ceftriaxone-resistant Neisseria gonorrhoeae cases.
Information should be obtained from sexual history consultations and questionnaires may be developed in response to an outbreak.
View the external guidance
This external guidance should be used together with the guide for use in Scotland provided on these pages.