Magnus Unemo

Extensively drug-resistant (XDR) Neisseria gonorrhoeae strains threaten the current empirical gonorrhoea treatment. We designed and analytically validated SensiTyper, a rule-based framework that predicts antimicrobial susceptibility from whole-genome sequencing data and generates susceptibility-guided individualized treatment recommendations. SensiTyper was applied to 13,701 gonococcal genomes from 68 countries in 1928-2024, including cultured isolates and clinical molecular samples, and benchmarked predictions against previous genomic and phenotypic data. Susceptibility predictions for ceftriaxone, ciprofloxacin, spectinomycin, and zoliflodacin had 98.9-100% sensitivity and specificity. Azithromycin susceptibility predictions had 92.5% sensitivity and 97.1% specificity, and gepotidacin susceptibility prediction 100% sensitivity, but 0% specificity, illustrating that low-level phenotypic gepotidacin resistance is not caused by the only known resistance determinants (GyrA A92T plus ParC D86N). The SensiTreat module integrates antimicrobial susceptibility profiles into sequential treatment logic, providing susceptibility-guided individualized treatment recommendations while also enabling alternative stewardship strategies prioritizing, e.g., ciprofloxacin. SensiTyper flags XDR isolates for expert follow-up, test-of-cure and comprehensive contact tracing. In conclusion, SensiTyper is a robust and adaptable approach for gonococcal antimicrobial susceptibility prediction, individualized gonorrhoea treatment and antimicrobial stewardship.

Background: Gonococcal antimicrobial resistance (AMR) surveillance depends on phenotypic susceptibility testing of viable Neisseria gonorrhoeae isolates. However, diagnosis increasingly relies on nucleic acid amplification tests (NAATs), which detect gonococcal nucleic acid but do not yield viable isolates. We quantified culture recovery among NAAT-positive N gonorrhoeae infections and identified clinical and laboratory factors associated with recovery.Methods: We searched PubMed, Embase, Scopus, and Dimensions for studies and conference abstracts published between Jan 1, 2000, and May 7, 2026. Eligible studies reported data to calculate culture recovery among NAAT-positive N gonorrhoeae infections. Pooled recovery was estimated using random-effects meta-analysis and associated factors were assessed using random-effects meta-regression.Findings: We included 99 studies, contributing 251 study estimates. Overall pooled recovery was 54% (95% CI 50–59), ranging from 81% (76–85) for male urethral to 27% (23–30) for pharyngeal specimens. Recovery was 60% (47–72) among symptomatic infections and 40% (31–50) among asymptomatic infections. In multivariable meta-regression, compared with cervical specimens, recovery was lower for anorectal (β -0·10, 95% CI -0·17 to -0·02; p=0·014), pharyngeal (-0·36, -0·43 to -0·28; p<0·001), and vaginal specimens (-0·21, -0·34 to -0·08; p=0·001), and higher for male urethral specimens (0·17, 0·10 to 0·25; p6 h after specimen collection) was independently associated with lower recovery than immediate or ≤6 h plating (β -0·12, -0·23 to -0·01; p=0·038).Interpretation: Only about half of NAAT-positive infections yielded isolates, and recovery was strongly associated with anatomical site and the culture-specimen pathway. These findings show that culture recovery is not simply a laboratory outcome, but a selective infection-to-isolate pathway that determines which diagnosed infections become available for phenotypic antimicrobial resistance surveillance, which can limit the representativeness and bias the surveillance. Surveillance systems should optimise culture pathways, report transparent diagnostic-to-susceptibility denominators, and integrate molecular tools that complement culture. Funding : Australian National Health and Medical Research Council and the Australian Research Council Industrial Transformation Research Hub.

Objectives: Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a global public health concern, particularly due to increasing resistance to the last remaining monotherapy, ceftriaxone, in several Asian countries. We examined the AMR of gonococcal isolates obtained at the Bangrak STIs Center, Bangkok, Thailand in 2018–23, and used WGS on isolates resistant to ceftriaxone, cefixime and/or azithromycin. Methods: Genital and extragenital swabs from males, females and transgender women were cultured. Etest (five antimicrobials) and EUCAST breakpoints (v16.0), or disc diffusion method (ciprofloxacin) were used to determine AMR. WGS was performed using Illumina NextSeq 550. Results: In 2018–23, 765 gonococcal isolates from 739 patients were cultured. Resistance to ceftriaxone, cefixime, azithromycin, tetracycline and ciprofloxacin was 0.5%, 0.8%, 1.7%, 83.7% and 95.7%, respectively. Ceftriaxone-resistant isolates, all resistant also to cefixime, were first detected in 2023 (n = 3, 1.2%). Additional cefixime-resistant isolates were found in 2022 (n = 2, 1.4%). Azithromycin-resistant isolates first emerged in 2020 (n = 1, 0.9%) and increased to nine (3.7%) isolates in 2023. All ceftriaxone-resistant isolates contained penA-60.001, but cefixime resistance was additionally caused by penA-34.019 and penA-10.001. All azithromycin-resistant isolates had 23S rRNA mutations and/or mosaic/semi-mosaic MtrD (subunit of the MtrCDE efflux pump). Conclusions: Resistance to ceftriaxone, cefixime and azithromycin has emerged in gonococcal strains circulating in Bangkok, Thailand, and resistance appears to be increasing. Resistance to these last options for monotherapy or dual therapy emphasize the need for strengthened national culture-based and genomic surveillance to prevent the spread of MDR and XDR strains in Thailand and globally, and implementation of the novel oral treatments, i.e. zoliflodacin and gepotidacin.

Gonorrhoea, a sexually transmitted infection caused by Neisseria gonorrhoeae (NG), represents a significant public health concern, with at least 82 million new cases among adolescents and adults an...

We report the complete reference genome sequences of three Haemophilus ducreyi isolates (ITG3105, CIP76118, and TMA3542), generated using Oxford Nanopore and Illumina sequencing, and hybrid assemblies. Each genome has a closed circular chromosome; ITG3105 and TMA3542 also have plasmids. These reference genomes support genomic, epidemiological, and antimicrobial resistance surveillance of H. ducreyi .

In early 2026 in Croatia, a male heterosexual patient of Croatian origin was diagnosed with extensively drug-resistant (XDR) gonorrhoea after unprotected vaginal intercourse with a Croatian female. The Neisseria gonorrhoeae HR027 isolate (genomic lineage B, MLST sequence type (ST)9903) exhibited high-level azithromycin, ceftriaxone, cefixime, benzylpenicillin, ciprofloxacin and tetracycline resistance. It had the mosaic penA -60.001 allele, and A2045G mutations in 23S rRNA. A single dose of ceftriaxone 2 g administered intravenously cured the infection. HR027 showed zoliflodacin and gepotidacin wild-type minimum inhibitory concentrations.

Introduction: Syphilis is a leading cause of adverse pregnancy outcomes, excessively affecting sub-Saharan Africa. Early diagnosis and treatment are crucial to prevent mother-to-child transmission. The aims of the present study were to assess prevalence and epidemiological and clinical correlates of active syphilis diagnosed using serological [treponemal and non-treponemal (lipoidal)] assays and the research-use-only (RUO) Aptima Treponema pallidum assay [Hologic; transcription-mediated amplification (TMA) assay] among pregnant women attending four antenatal care facilities in Nchelenge, Zambia in 2023. Methods: Syphilis serology was performed using rapid diagnostic test [RDT; Core tests ^® ONE STEP Syphilis Test Kit (Core Technology, Atlanta, USA)]; positive samples were further evaluated by rapid plasma reagin [RPR; RPR Carbon Antigen Reagent (Eurocarb Products Ltd., Bristol, United Kingdom)] test. Active syphilis was defined as a positive RDT plus a positive RPR test, or a positive RUO Aptima T. pallidum assay. T. pallidum and other non-viral STIs ( Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium , and Trichomonas vaginalis ) were detected in clinician-collected vaginal swab samples using Aptima assays on the Panther system (Hologic). HIV testing was performed with the Determine HIV Test Kit, and bacterial vaginosis (BV) was diagnosed using Nugent's score. Active syphilis correlates were identified using univariable and multivariable logistic regression. Results: In total, 996 pregnant women were included in the analysis, of whom 136 women (13.7%) had an active syphilis infection. Of these women with active syphilis, 117 (86.0%) were positive in serology only, 15 (11.0%) in serology plus RUO Aptima T. pallidum assay, and four (2.9%) in RUO Aptima T. pallidum assay only. Rates of other current STIs and reproductive tract infections included: BV (23.3%), T. vaginalis (22.7%), M. genitalium (12.7%), HIV (8.7%), N. gonorrhoeae (8.4%), and C. trachomatis (7.4%). Secundigravidity, history of stillbirth, current concomitant M. genitalium, N. gonorrhoeae, T. vaginalis , and HIV infections were significant risk factors of active syphilis. Advanced gestational age (from 28 to 39 weeks) at enrolment was associated with significantly lower risk of syphilis positivity. Discussion: A remarkably high burden of syphilis and high co-infection rates with HIV and other non-viral STIs in pregnant women in Zambia underscore the urgent need for integrating syphilis and HIV universal screening programs, as well as to consider concurrent testing for selected other non-viral STIs. Where feasible due to the increased cost, supplementing serological screening with a highly sensitive and specific molecular test such as the RUO Aptima T. pallidum assay for suspected early syphilis can ensure timely detection of both seroconverted and seronegative early syphilis cases, early treatment and effective prevention of mother-to-child transmission.