HAS updates its recommendations

With the increase in cases and the increase in antibiotic resistance, the High Authority for Health (HAS) published in April 2025 new recommendations on the management of infections to infections Neisseria gonorrhoeae. An expected updating, which echoes growing concerns in sexual health, especially among the most exposed populations.

Gonorrhea, or Blennorrhagia, is one of the IS Sexually transmitted infections. most frequent bacterial. Transmitted by sexual means, often asymptomatic, it primarily affects young adults and men with sex with men (HSH). In addition to genital complications (salpingitis, infertility, prostatitis, etc.), it increases the risk of transmission of HIV Human immunodeficiency virus. In English: HIV (Human Immunodeficist Virus). Isolated in 1983 at the Institut Pasteur de Paris; Recently discovered (2008) awarded by the Nobel Prize in Medicine awarded to Luc Montagnier and Françoise Barré-Sinoussi. A quick, suitable and rigorous management is therefore essential.

Faced with the circulation of resistant strains, the HAS updated its 2016 recommendations to align the treatments on the latest sensitivity data, strengthen prevention, and refine the management of contact cases.

Main news for recommendations 2025

Clarified first line treatment

The main novelty concerns the dosage of ceftriaxone, which becomes the reference treatment for uncomplicated gonococcal infections. The dosage is 1 g of ceftriaxone in single dose, intramuscular (IM) or intravenous (IV).

This monotherapy is recommended without waiting for the antibiogram, especially in the event of evocative symptoms.

This scheme replaces old dosages at 500 mg (see US recommendations), deemed insufficient in the context of a progressive decrease in the sensitivity of the bacteria. Single dose administration facilitates observance, reduces the risk of transmission and limits the risks of evolution to resistant strains.

In the event of an allergy confirmed to ceftriaxone or impossibility of IM administration, alternatives are planned.

Alternatives in case of allergy to ceftriaxone

In patients with an allergy documented at Ceftriaxone, the management of uncomplicated forms is based on Gentamicin 240 mg by single dose, with clinical control at 72 hours.

This is an appeal option, requiring closer surveillance (renal and auditory toxicity), and not recommended for complicated infections without specialized advice.

The other alternative is ciprofloxacin 500 mg in single dose per bone if the antibiogram confirms the sensitivity of gonococcus to this antibiotic.

Azithromycin 2 g per os (1 g then 1 g at 6 h interval) in third intent only, due to the need to save macrolides.

Alternative in case of reluctance to IM injection or anticoagulant treatment

In case of reluctance to intramuscular injection or in patients with coagulation disorders contraindicating this mode of administration, alternatives are ciprofloxacin 500 mg per bone of or céfixime 400 mg per bone of, subject to an antibiogram with a sensitivity kept to these antibiotics.

Ceftriaxone 1 g IV is also possible; On the other hand, the subcutaneous route is contraindicated.

Special cases: specific management depending on the situation

➤ Return of Asia-Pacific (area with high resistance):

• HAS recommends a probabilistic treatment associating Ceftriaxone 1 G IM + Azithromycin 2 G PO (excluding AMM).
• In the event of a minimum inhibitory concentration (CMI)> 0.125 mg/L, a specialized opinion is required and the strain must be sent to the National Reference Center (CNR).

➤ Complicated infections:

• In case of invasive, joint or meningeal gonococcies, the recommended treatment is CEFTRIAXONE IV 1 g/day (meningitis: 2 g/day) for 7 to 14 days, or even 4 weeks for endocarditis.
• Infant ophthalmia must be treated by Céfotaxime 100 mg/kg/d (replacing the ceftriaxone).

➤ Pregnant or breastfeeding woman: same indications

➤ People living with HIV: no dose adjustment, no interaction reported with antiretrovirals.

Support and notification of sexual partners

Any diagnosis of gonorrhea implies active management of sexual partners, even asymptomatic. The HAS recommends an empirical treatment identical to that of the index case without delay the results of the tests, in order to avoid cross -reinfection.

Ensure the regression of symptoms

A clinical control at D7 is recommended to ensure the regression of symptoms for symptomatic forms.

A microbiological control test (TAAN) is indicated 3 weeks after treatment in symptomatic patients who have received another antibiotic therapy than ceftriaxone, or in the event of suspicion of failure.

In the event of failure, stump isolation and an antibiogram are essential.

Summary table of recommended treatments

Towards global and preventive management

Beyond antibiotic treatment, the HAS recalls the importance of global management:

• Prevention information (condoms, PrEP Pre-exhibition prophylaxis. PREP is a strategy that allows a seronegative person exposed to HIV to eliminate the risk of infection, taking, continuously or “on demand”, anti-retroviral treatment based on Truvada®. PEP, hepatitis B vaccination);
• Associated IST screening (Syphilis, Chlamydia, HIV);
• Psychosocial support, especially in the event of sexual violence, vulnerability or unwanted pregnancy;
• Notification of partners, with extension to 6 months except in the event of symptomatic male uretritis (time reduced to 2 weeks).

In the absence of guaranteed follow -up, accelerated partner treatment (TAP) is encouraged.

HAS 2025 recommendations mark a turning point in the fight against infections Neisseria gonorrhoeaewith a finer approach and adapted to current issues: rise in resistance, inclusive management and anchoring in an extended vision of sexual health.

For professionals as for patients, the message is clear: treat better, prevent more, follow closely.