title: An outbreak of high-level azithromycin resistant Neisseria gonorrhoeae in England.
abstract: To investigate a potential outbreak of high-level azithromycin resistant (HL-AziR) gonococcal infections diagnosed in eight patients attending a sexual health clinic in Leeds, North England, between November 2014 and March 2015.
  
  
  
  Eight cases of infection with gonococci exhibiting azithromycin minimum inhibitory concentrations (MICs) ≥256 mg/L were identified from patients in Leeds as part of the routine service provided by the Sexually Transmitted Bacteria Reference Unit. All patient records were reviewed to collate epidemiological and clinical information including evaluation of patient management. Whole-genome sequencing (WGS) was performed on seven gonococcal isolates to determine Neisseria gonorrhoeae multiantigen sequence type (NG-MAST), WGS comparison and mutations in the 23S rRNA genes.
  
  
  
  All patients were heterosexual (five male, three female) from a range of ethnic backgrounds and from the Leeds area. Three patients were linked by partner notification. All patients were infected at genital sites and two women had pharyngeal infection also. Six patients received the recommended first-line therapy for uncomplicated gonorrhoea, one was treated for pelvic inflammatory disease and one received spectinomycin followed later by ciprofloxacin. Test of cure was achieved in seven patients and confirmed successful eradication. All seven isolates sequenced were identical by NG-MAST and WGS comparison, and contained an A2143G mutation in all four 23S rRNA alleles.
  
  
  
  Epidemiological and microbiological investigations confirm that an outbreak of a gonococcal strain showing HL-AziR is ongoing in the North of England. Every effort should be made to identify and curtail dissemination of this strain as it presents a significant threat to the current recommended front-line dual therapy.
authors.affiliation: Sexually Transmitted Bacteria Reference Unit, Microbiology Services, Public Health England, London, UK.
authors.forename: Stephanie A
authors.initials: SA
authors.lastname: Chisholm
authors.affiliation: Leeds Sexual Health, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust.
authors.forename: Janet
authors.initials: J
authors.lastname: Wilson
authors.affiliation: Sexually Transmitted Bacteria Reference Unit, Microbiology Services, Public Health England, London, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Alexander
authors.affiliation: Sexually Transmitted Bacteria Reference Unit, Microbiology Services, Public Health England, London, UK.
authors.forename: Francesco
authors.initials: F
authors.lastname: Tripodo
authors.affiliation: Infectious Disease Informatics, Microbiology Services, Public Health England, London, UK.
authors.forename: Ali
authors.initials: A
authors.lastname: Al-Shahib
authors.affiliation: Infectious Disease Informatics, Microbiology Services, Public Health England, London, UK.
authors.forename: Ulf
authors.initials: U
authors.lastname: Schaefer
authors.affiliation: Infectious Disease Informatics, Microbiology Services, Public Health England, London, UK.
authors.forename: Kieren
authors.initials: K
authors.lastname: Lythgow
authors.affiliation: Sexually Transmitted Bacteria Reference Unit, Microbiology Services, Public Health England, London, UK.
authors.forename: Helen
authors.initials: H
authors.lastname: Fifer
mesh_terms: D000328:Adult; D017963:Azithromycin / Q000008:administration & dosage / Q000494:pharmacology*; D015373:Bacterial Typing Techniques; D002443:Ceftriaxone / Q000008:administration & dosage; D002939:Ciprofloxacin / Q000008:administration & dosage; D004269:DNA, Bacterial; D004196:Disease Outbreaks / Q000517:prevention & control / Q000706:statistics & numerical data*; D004318:Doxycycline / Q000008:administration & dosage; D024881:Drug Resistance, Bacterial / Q000187:drug effects*; D004739:England / Q000453:epidemiology; D005260:Female; D006069:Gonorrhea / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology* / Q000517:prevention & control; D020010:Heterosexuality; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D009344:Neisseria gonorrhoeae / Q000187:drug effects* / Q000302:isolation & purification; D016896:Treatment Outcome
chemical_list: D004269:DNA, Bacterial; D002939:Ciprofloxacin; D002443:Ceftriaxone; D017963:Azithromycin; D004318:Doxycycline
keywords: ANTIMICROBIAL RESISTANCE; AZITHROMYCIN; BACTERIAL TYPING; NEISSERIA GONORRHOEA