Antibiotic-resistant gonorrhea — often called "super gonorrhea" — is infection with Neisseria gonorrhoeae strains that no longer respond to drugs once used to cure it. In the US, gonorrhea is still curable: a single ceftriaxone injection works, and no verified US ceftriaxone treatment failures have been reported to date CDC STI Guidelines. But the margin is narrowing.
test all exposed sites
500 mg IM, single shot
| Item | Value |
|---|---|
| Test method | NAAT — test all exposed sites |
| Treatment | ceftriaxone — 500 mg IM, single shot |
| Throat infection | harder to cure |
| Retest | 3 mo |
Gonorrhea has burned through almost every antibiotic thrown at it. Over the decades it developed resistance to sulfonamides, penicillin, tetracyclines, fluoroquinolones, and the oral cephalosporin cefixime CDC. Cephalosporin susceptibility is now slowly declining, which is why injectable ceftriaxone is described as "one last" reliably effective class. The bug adapts fast, and the toolbox keeps shrinking.
Why gonorrhea becomes resistant
N. gonorrhoeae is unusually good at acquiring resistance because it readily swaps DNA with other bacteria. The pharynx — the throat — is a particular breeding ground. Gonorrhea sitting in the throat can pick up resistance genes from harmless Neisseria species that normally live there, then export those mutations to genital infections. Throat infections are usually symptomless and can persist for up to 16 weeks, which widens the window for both transmission and resistance to develop.
Ceftriaxone-resistant gonorrhea is no longer hypothetical. The resistant FC428 strain emerged in Japan in 2015 and has since spread internationally. The WHO estimated 82 million new gonorrhea infections worldwide in 2020 WHO, so even rare resistant strains have an enormous pool to circulate in.
How antibiotic-resistant gonorrhea is treated
For uncomplicated infection, the CDC recommends a single intramuscular dose of ceftriaxone 500 mg for people under 150 kg, or 1 g for those who weigh 150 kg or more, and that one injection covers genital, rectal, and throat sites MMWR 2020. If chlamydia hasn't been ruled out, doxycycline 100 mg by mouth twice daily for 7 days is added. For the full picture of doses and how the injection is given, see our gonorrhea treatment guide.
This is a recent change. Until 2020, the standard was dual therapy — ceftriaxone plus azithromycin. Azithromycin was dropped because resistance climbed quickly: isolates with elevated azithromycin MICs (a lab measure of how much drug it takes to stop the bug) rose more than seven-fold, from 0.6% in 2013 to 4.6% in 2018. At the same time the ceftriaxone dose was raised from 250 mg to 500 mg. That left a single ceftriaxone injection as the lone first-line regimen.
What to do if you can't take ceftriaxone
If you have a true cephalosporin allergy, the alternative is gentamicin 240 mg IM plus azithromycin 2 g by mouth, both as single doses. If ceftriaxone simply isn't available, cefixime 800 mg by mouth as a single dose is an option, but cefixime treats genital and rectal infection only and does not reliably cure the throat, so a test-of-cure is needed afterward. These fallbacks, and what newer resistance scenarios call for, are covered in our gonorrhea treatment page.
The new oral antibiotics: zoliflodacin and gepotidacin
In December 2025 the FDA approved two oral pills for uncomplicated urogenital gonorrhea — the first completely new antibiotic classes for this infection in over 30 years. Neither replaces ceftriaxone as first-line yet; both are options for resistance situations.
| Drug | How it's taken | Who it's for | How it works |
|---|---|---|---|
| Zoliflodacin (Nuzolvence) | Single oral dose | Age 12+, ≥35 kg (≥77 lb), uncomplicated urogenital infection | First-in-class spiropyrimidinetrione targeting bacterial DNA gyrase (GyrB) — a mechanism distinct from fluoroquinolones |
| Gepotidacin (Blujepa) | Oral tablets | Age 12+, ≥45 kg (≥99 lb); reserved for when few or no other options exist | Novel oral agent; limited safety data keep it a reserve, not first-line |
In its Phase 3 trial, zoliflodacin achieved roughly 91% microbiological cure and was non-inferior to the standard ceftriaxone-plus-azithromycin regimen FDA, 2025. Gepotidacin was previously approved for urinary tract infections in March 2025 FDA, 2025. Because both target gonorrhea in new ways, they're expected to keep working longer if used sparingly, so guidance reserves them rather than throwing them at every case.
What treatment is actually like
Treatment is a single ceftriaxone shot given in the clinic, not take-home pills. Oral antibiotics for gonorrhea are no longer reliable, so don't expect a prescription you fill at the pharmacy. The injection goes into a large muscle, often the buttock or thigh. It stings briefly, and you're done. At a public STI clinic this is often free or low-cost, and the shot is given on-site the same visit. You'll be told to abstain from sex for 7 days afterward.
Partner treatment
Anyone you had sex with in the prior 60 days should be notified and treated, even if they feel fine. They should also abstain from sex for 7 days after their own treatment. Where in-person evaluation isn't possible and it's legally permitted, expedited partner therapy (EPT) — cefixime 800 mg by mouth handed to a heterosexual partner — is an option. Skip partner treatment and you'll pass the same infection back and forth.
Follow-up, retesting, and test-of-cure
A routine test-of-cure isn't needed for genital or rectal infection after standard ceftriaxone. The throat is different. Even fully susceptible pharyngeal infections fail ceftriaxone about 4.6% of the time, so for throat gonorrhea — and after any cefixime treatment — return 7 to 14 days later for a test-of-cure, ideally a culture where available. Separately, everyone treated for gonorrhea should retest about 3 months later, because reinfection is common. Not sure how soon a test will pick anything up? See when to test after exposure.
What happens if gonorrhea goes untreated
Untreated gonorrhea causes real, sometimes permanent damage. In women it can ascend to cause pelvic inflammatory disease (PID, infection of the uterus and tubes), which can scar the fallopian tubes and lead to ectopic pregnancy (a pregnancy implanting outside the uterus, which can be life-threatening), infertility, and chronic pelvic pain. In men it can cause epididymitis — inflammation of the coiled tube behind the testicle — which can affect fertility. A swollen, painful testicle needs prompt care, not wait-and-see. Early warning signs are covered in our guide to gonorrhea symptoms in men.
In either sex the bacteria can spread to the bloodstream and joints — disseminated gonococcal infection (DGI), which causes fever, joint pain, and skin lesions and can be life-threatening. DGI is treated differently from uncomplicated gonorrhea, usually with hospitalization and ceftriaxone 1 g IM or IV every 24 hours. A newborn can also acquire infection at delivery. Treatment cures the infection, but medicine can't reverse damage that's already been done.
Prevention going forward
The practical moves that actually lower your risk:
- Use condoms correctly every time you have vaginal, anal, or oral sex.
- Get screened regularly, and ask for swabs of every exposed site — throat and rectum included — since a urine-only test misses infections there.
- Make sure partners are treated, and abstain from sex for 7 days after your shot so you don't bounce the infection back and forth.
- Mutual monogamy with a tested partner lowers risk; abstinence is the only certain method.
About DoxyPEP — taking doxycycline 200 mg within 72 hours after sex: it cuts chlamydia and syphilis by more than 70%, but it's far less effective against gonorrhea (around 50% in one trial, and inconsistent across studies). The CDC does not recommend DoxyPEP specifically for gonorrhea prevention, partly out of concern it could drive tetracycline resistance in N. gonorrhoeae CDC DoxyPEP 2024. Resistance is tracked nationally through CDC programs (GISP, eGISP, and SURRG, with GISP and eGISP folded into CARGOS in 2024).
When to see a clinician
See a clinician if you have discharge, burning with urination, a sore throat after oral sex, rectal pain, or a swollen testicle — or if a partner tells you they tested positive. Testing is straightforward: a first-catch urine sample plus a quick throat or rectal swab if you've had oral or anal sex. You can get tested at a clinic or order a home kit, and you can compare testing providers before you decide. Even with falling national numbers — about 601,000 reported US cases in 2023 CDC AtlasPlus 2023 — rates vary enormously by place, so local risk can run far higher than the national figure.