In the United States, reports of apparent failures of gonorrhea to respond to treatment with CDC-recommended therapies should be reported to Sancta St Cyr, MD, MPH (gispinfo@cdc.gov; 404-718-5447). Surveillance and Data Management Branch, Division of STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Mailstop E02, Atlanta, GA 30333.

CDC also recommends that isolates from certain infections be submitted to the Neisseria Reference Laboratory at CDC for confirmation: Cau Pham, PhD, whi4@cdc.gov, 404-718-5642, Neisseria Reference Laboratory, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Mailstop A12, Atlanta, GA 30333. These infections comprise those that do not respond to CDC-recommended therapy. See pg. 6, Recommended Testing and Confirmatory Testingpdf icon for a complete list.

Timeline of Antibiotic Resistance and Changing Treatment Recommendations

In 1993, ciprofloxacin, a fluoroquinolone, and two cephalosporins (ceftriaxone and cefixime) were the recommended treatments for gonorrhea. However, in the late 1990s and early 2000s, ciprofloxacin resistance was detected in Hawaii and the West Coast. By 2004, ciprofloxacin- resistant gonorrhea had significantly increased among men who have sex with men (MSM) leading to the discontinuation of the drug in this population. By 2006, nearly 14% of gonorrhea samples were resistant to ciprofloxacin. Ciprofloxacin resistance was present in all regions of the country and in the heterosexual population. On April 13, 2007, CDC stopped recommending fluoroquinolones as empiric treatment for gonorrhea altogether. The cephalosporins, either cefixime or ceftriaxone, were the only remaining recommended treatments.

Similar to trends observed elsewhere in the world, CDC observed worrisome trends of decreasing cephalosporin susceptibility. To preserve cephalosporins for as long as possible, CDC has updated its STD Treatment Guidelines frequently since 2010. Currently, just one regimen is recommended as first-line treatment for gonorrhea: the injectable cephalosporin, ceftriaxone, alongside oral azithromycin.

Gonorrhea’s susceptibility to azithromycin has declined in recent years; however, CDC continues to monitor antibiotic resistance to it, cephalosporins, and other drugs. An animated video with a historical timeline of drug-resistant gonorrhea in the U.S. is also available.

CDC has not received any reports of verified clinical treatment failures to any cephalosporin in the United States.

See Gonorrhea Statistics.

Laboratory Challenges

Culture testing is when bacteria is first grown on a nutrient plate and is then exposed to known amounts of an antibiotic to determine the bacteria’s susceptibility to the antibiotic. A major challenge to monitoring emerging resistant gonorrhea is the substantial decline in the use of gonorrhea culture testing by many clinicians, as well as the reduced capability of many laboratories to perform the gonorrhea culture techniques required for antibiotic susceptibility testing. The decline in culture testing results from an increased use of newer laboratory technology, such as a diagnostic test called the Nucleic Acid Amplification Test (NAAT). Currently, there is no well-studied, reliable technology that allows for antibiotic susceptibility testing from nonculture specimens. Increased laboratory culture capacity is needed.

CDC recommends that all state and local health department labs maintain or develop the capacity to perform gonorrhea culture, or form partnerships with experienced laboratories that can perform this type of testing.

See Laboratory Information.