Objectives: Describe the clinical, phenotypic, and genomic characteristics of ceftriaxone-resistance Neisseria gonorrhoeae from Scotland Methods: Cases were identified in routine care. Minimum inhibitory concentrations were determined for seven antimicrobial agents. Whole genome sequencing was performed with Illumina and Oxford Nanopore Technology instruments. A phylogeny containing global ceftriaxone-resistant genomes was generated with Parsnp. A collection of ST8780 genomes was also analysed to give further context using reference based mapping with Snippy. Results: There were five cases of ceftriaxone-resistant N. gonorrhoeae detected. One case (MLST ST1903) clustered within the FC428 lineage in a returning traveller from an Asia-Pacific country. Two cases belonged to the recently described extensively drug resistant MLST ST16406, a returning traveller from an Asia-Pacific country and a sexual contact within Scotland. The final two cases were a resident of an Asia-Pacific country and a sexual contact within Scotland, both belonged to MLST ST8780. These were distinct from other publicly available ST8780 genomes suggesting a novel introduction of the mosaic penA 60.001 allele. All cases were initially treated with ceftriaxone-based regimes, four returned for test of cure and showed clearance of infection. Conclusions: As ceftriaxone resistance is increasingly identified, multiple public health interventions are required to reduce the impact of resistance on gonorrhoea treatment globally.

The authors have declared no competing interest.

This work was funded by NHS National Services Scotland via the Scottish Bacterial Sexually Transmitted Infections Reference Laboratory

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