Antibiotic resistant gonorrhea

Antibiotic-resistant gonorrhea is Neisseria gonorrhoeae infection that fails to respond to one or more recommended antibiotics, and current CDC gonorrhea treatment guidelines recommend a single intramuscular 500 mg dose of ceftriaxone for uncomplicated urogenital, rectal, and pharyngeal infections in most persons (1 g is recommended for persons weighing ≥150 kg). Detection relies on timely testing, with nucleic acid amplification tests (NAATs) as the preferred screening method and gonorrhea culture testing required when antimicrobial susceptibility testing is needed to detect reduced susceptibility to cephalosporins or azithromycin. Public-health surveillance monitors trends in drug-resistant gonorrhea nationally and internationally. Partner notification and local public-health reporting are key elements of the public-health response.

Resistance arises through genetic changes—such as mosaic penA alleles and plasmid-mediated genes—and spreads via sexual networks; laboratory detection combines molecular diagnostics and phenotypic testing. NAAT detects organism presence rapidly and is the backbone of screening, but it does not return minimum inhibitory concentration (MIC) data, so gonorrhea culture testing with methods like agar dilution or Etest and follow-up antimicrobial susceptibility testing (AST) are required to measure MICs against ceftriaxone and other agents. Whole-genome sequencing and CDC’s Gonococcal Isolate Surveillance Project (GISP) provide population-level surveillance of Neisseria gonorrhoeae antimicrobial resistance, informing clinical recommendations for drug-resistant gonorrhea and updates to treatment algorithms. Rapid molecular assays for resistance (e.g., PCR assays targeting gyrA) are emerging but are not yet available for clinical use.

A common and consequential misconception is to treat a positive NAAT as sufficient for both diagnosis and resistance assessment; nucleic acid amplification tests are highly sensitive for detection but cannot provide susceptibility data, so clinicians managing suspected treatment failure or outbreaks should obtain gonorrhea culture testing for MIC determination and public-health reporting. Another frequent error is citing outdated regimens—single-dose azithromycin monotherapy and dual therapy with azithromycin were removed from CDC guidance after rising azithromycin resistance. Pharyngeal infections often have lower cure rates and are the reservoir where cephalosporin-resistant gonorrhea has most often emerged; although high-level ceftriaxone resistance remains rare, sporadic international cases underscore the need for targeted testing, timely retesting, and linkage to local drug-resistant gonorrhea surveillance.

Clinicians should use NAAT for routine screening, collect culture specimens when treatment failure, persistent symptoms, or outbreak investigation is suspected, and follow CDC gonorrhea treatment guidelines (ceftriaxone 500 mg IM single dose for most uncomplicated infections; 1 g if ≥150 kg). Local public-health departments should be notified of suspected drug-resistant cases to enable contact tracing and isolate submission to surveillance programs, including partner services. Test-of-cure by culture or NAAT is advised for persistent symptoms and for pharyngeal infections 7–14 days after treatment. This article presents a structured, step-by-step framework for testing, treatment, and public-health follow-up.