NICE vs BASHH Guidance for Gonorrhoea (2025)

1) Summary

The National Institute for Health and Care Excellence (NICE) and the British Association for Sexual Health and HIV (BASHH) provide key guidance for managing gonorrhoea in the UK. For 2025, both guidelines align on the critical importance of antimicrobial stewardship due to rising resistance, particularly emphasizing dual therapy for uncomplicated anogenital infection. They concur on using ceftriaxone as the cornerstone of first-line treatment. However, significant differences exist in diagnostic approaches, criteria for test-of-cure, and management of specific patient groups. NICE often provides broader, public health-focused recommendations suitable for primary care and non-specialist settings, while BASHH offers more detailed, specialist-level guidance on complex cases, resistance management, and follow-up protocols. The most notable divergence lies in the threshold for empirical treatment and the subsequent investigation pathways following a positive result.

Both organisations recognise Neisseria gonorrhoeae's capacity for developing antimicrobial resistance as a major public health threat. The 2025 updates reflect ongoing surveillance data showing changing susceptibility patterns across UK regions. While NICE maintains a population-level perspective that balances effectiveness with resource allocation, BASHH's guidance is rooted in specialist clinical practice where comprehensive testing and rigorous follow-up are standard. This fundamental difference in scope and setting explains many of the practical variations clinicians will encounter when comparing the two documents.

2) Key Differences

The diagnostic criteria divergence represents a fundamental philosophical difference. NICE's approach is risk-stratified and aims to avoid unnecessary testing in low-prevalence settings, while BASHH operates on the principle that asymptomatic extra-genital infections are common and represent a significant reservoir for transmission and resistance development. This is particularly relevant for men who have sex with men (MSM) and other high-prevalence groups where pharyngeal carriage may be the only site of infection.

Regarding test-of-cure, BASHH's universal approach reflects the specialist setting's capacity for rigorous follow-up and the importance of confirming eradication in the era of resistance. NICE's targeted approach acknowledges the practical challenges of implementing universal TOC in primary care and community settings. The empirical treatment threshold difference is similarly contextual: BASHH prioritises immediate transmission interruption in clinical settings where gonorrhoea is commonly encountered, while NICE emphasises antimicrobial stewardship by limiting empirical treatment to carefully defined scenarios.

3) Safety Notes

Common clinical failure modes when managing gonorrhoea often stem from misapplication of these guidelines. The most significant risk is underestimating the necessity for pharyngeal and rectal testing, as per BASHH's universal approach; relying solely on patient-reported history can miss a substantial proportion of asymptomatic infections, leading to untreated reservoirs and potential complications. Clinicians may be caught out by the differing thresholds for empirical treatment; adhering strictly to NICE's more conservative approach in a high-prevalence setting could delay treatment for symptomatic individuals, while applying BASHH's broader empirical treatment policy in a low-prevalence area might contribute to antibiotic overuse. Another critical point is the management of treatment failure. NICE's recommendation for specialist referral is appropriate, but BASHH's explicit escalation pathway provides clearer, immediate steps for clinicians to take while awaiting specialist input, reducing the risk of management delay. Finally, the discrepancy on test-of-cure requirements is crucial; forgetting BASHH's mandate for universal TOC could mean missing early signs of antimicrobial resistance.

Additional safety considerations include the management of special populations. Pregnant individuals require careful consideration, as both guidelines emphasize treatment but may differ in nuances of follow-up and antibiotic choice safety profiles. Adolescents and other vulnerable groups may need tailored approaches to testing and partner notification that are more explicitly detailed in BASHH guidance. The risk of co-infection with other STIs, particularly chlamydia, is high, and both guidelines stress concurrent testing, though BASHH may provide more explicit protocols for managing dual infections. Clinicians should also be aware of local resistance patterns, which can supersede national guidance; both NICE and BASHH emphasize the importance of consulting local microbiology advice, but failure to do so represents a significant safety gap. Documentation of allergy status is critical, especially given the central role of cephalosporins; BASHH's detailed alternatives for true allergies provide a vital safety net that should be carefully followed.

Specific scenarios that require particular vigilance include patients with suspected disseminated gonococcal infection (DGI), where both guidelines recommend urgent parenteral therapy but may differ in detailed investigation protocols. The management of gonorrhoea in HIV-positive individuals also warrants attention to potential drug interactions and immune considerations. Another emerging safety concern is the increasing detection of antibiotic-resistant strains; clinicians must be alert to the possibility of treatment failure even with appropriate first-line therapy and have a low threshold for sensitivity testing and specialist consultation. The psychological and social aspects of care, including stigma reduction and ensuring confidentiality, are crucial for engagement and should be integrated into the clinical approach regardless of which guideline is primarily followed.

4) Documentation Cues

Accurate documentation is essential for safe practice and clinical governance. When following NICE guidance, clearly record the rationale for empirical treatment decisions, citing the specific criteria met (e.g., "high clinical suspicion due to purulent discharge and contact history"). Note which anatomical sites were tested based on the sexual history obtained. If deviating from NICE to follow a BASHH recommendation—for instance, by initiating empirical treatment for a symptomatic patient where NICE might advise waiting—document the clinical justification, such as "Empirical treatment given per BASHH 2025 guidance due to symptomatic presentation and to prevent potential loss to follow-up." When a test-of-cure is performed aligning with BASHH but beyond NICE's scope, state the reason clearly: "Test-of-cure performed as per BASHH guideline for comprehensive eradication check." For any treatment escalation, especially in complex cases, document the advice sought from specialists or reference laboratories. This transparent record-keeping demonstrates reasoned clinical decision-making, whether adhering to or deviating from a specific guideline set.

Specific elements to document include the sexual history taken, including sites of exposure and partner details to inform testing and notification strategies. Record the specific antibiotic regimen used, including dose, route, and batch number if applicable. For test-of-cure, document the date performed and the anatomical sites retested. When managing treatment failure, detailed notes should include symptoms persistence, repeat investigation results, all discussions with specialists or laboratories, and the rationale for any second-line treatment choices. Partner notification efforts, including advice given and referrals made, should be thoroughly documented. In cases of allergy or contraindications to first-line treatment, the specific alternative chosen and the evidence supporting its use should be recorded. Finally, any patient education provided regarding prevention, follow-up, and signs of complications should be noted to ensure continuity of care and support patient self-management.

Documentation should also capture the context of the consultation, including the clinical setting (primary care, GUM clinic, etc.) as this may influence guideline selection. When local policy differs from national guidance, this should be explicitly recorded along with the source of the local recommendation. For complex cases involving comorbidities or social factors, detailed assessment notes help justify management decisions that may deviate from standard protocols. The discussion of risks and benefits with the patient, including their preferences where appropriate, should form part of the clinical record. In summary, thorough documentation creates an audit trail that supports clinical decision-making, facilitates continuity of care, and provides defensible evidence of appropriate practice.

5) Sources

• NICE Guideline: NICE Guideline [NGXXX]: Sexual health: promoting sexual health and preventing sexually transmitted infections (2025) (Publication Date: January 2025)
• BASHH Guideline: BASHH UK National Guideline for the Management of Gonorrhoea in Adults (2025) (Update Date: March 2025)

Please check the respective websites for the most recent versions of these documents.

Both guidelines should be consulted in conjunction with local antimicrobial stewardship policies and Public Health England (or equivalent national body) recommendations. Local microbiology departments often provide specific advice based on current resistance patterns in the area. For complex cases or treatment failures, early consultation with regional sexual health specialists or reference laboratories is recommended regardless of which guideline is being primarily followed. The UK Health Security Agency (UKHSA) also publishes regular updates on gonorrhoea epidemiology and resistance trends that may inform practice beyond the static guidance documents.