Due to increasing antimicrobial resistance (AMR), ceftriaxone is the only remaining single-dose antibiotic effective against Neisseria gonorrhoeae.1 To preserve this treatment option, guidelines have recommended combination therapy with azithromycin since 2012.1 The rationale was that azithromycin would eradicate isolates with reduced ceftriaxone susceptibility and thereby prevent the emergence of ceftriaxone resistance.1 However, no randomised controlled trials (RCTs) have assessed if combination therapy is superior to monotherapy for the treatment of gonorrhoea in terms of efficacy or emergence of AMR. Meta-analyses have found no difference in efficacy between monotherapy and dual therapy.2 In fact, increasing macrolide exposure may promote AMR acquisition.3 These considerations have led some guidelines to change back to recommending ceftriaxone monotherapy for uncomplicated gonorrhoea, and the 2020 European guidelines now include monotherapy as an alternative.4–6

Dutch guidelines are unusual in that, unlike the rest of Europe, they never recommended dual therapy; a single 500 mg intramuscular dose of ceftriaxone has been the preferred treatment for gonorrhoea since 2011.7 This policy allowed us to test whether between 2012 and 2019, the use of ceftriaxone monotherapy in the Netherlands …