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Contents lists available at ScienceDirect

International Journal of Antimicrobial Agents

journal homepage: www.elsevier.com/locate/ijantimicag

In vitro evaluation of antimicrobial resistance selection in Neisseria

gonorrhoeae
George P. Allen∗, Kristina M. Deao, Stephanie A. Hill, Sandra M. Schipelliti, Thomas Tran
School of Pharmacy, Westbrook College of Health Professions, University of New England, 716 Stevens Avenue, Portland, ME 04103, USA

a r t i c l e i n f o a b s t r a c t

Article history: Gonococcal infections represent an urgent public-health threat as >50% of cases caused by Neisseria
Received 1 February 2021 gonorrhoeae strains display reduced susceptibility to at least one antimicrobial agent. We evaluated the
Accepted 6 August 2021
pharmacodynamics of a number of antimicrobials against N. gonorrhoeae in order to assess the likeli-
Available online xxx
hood of mutant selection by these agents. The mutant prevention concentration (MPC) and mutant selec-
Editor: Dr. Po-Ren Hsueh tion window (MSW) were determined for azithromycin, ceftriaxone, doxycycline, ertapenem, gentamicin,
ciprofloxacin, levofloxacin and moxifloxacin against a wild-type strain of N. gonorrhoeae (ATCC 49226) and
Keywords:
Neisseria gonorrhoeae a gyrA mutant of ATCC 49226. Pharmacokinetic parameters, including peak concentration (Cmax ), half-life
Mutant prevention concentration (t1/2 ) and area under the plasma concentration–time curve over 24 h (AUC), associated with each agent
Mutant selection window were used to calculate the time within the MSW (TMSW , percentage of the dosing interval that antimicro-
bial concentrations fall within the MSW), Cmax /MPC ratio and AUC/MPC ratio for each antimicrobial agent.
Concentrations of ceftriaxone (500 mg), ertapenem, ciprofloxacin, levofloxacin and moxifloxacin surpass
the MPC for both strains. Results of pharmacodynamic analyses suggest that ertapenem, ciprofloxacin,
levofloxacin and moxifloxacin may be most likely to prevent mutant selection in N. gonorrhoeae. Use of
ceftriaxone, azithromycin, doxycycline or gentamicin for gonorrhoea is expected to lead to the ongoing
emergence of resistance to these agents. There is a clear need to develop novel treatment regimens for
gonococcal infections in order to limit the dissemination of resistance in N. gonorrhoeae.
© 2021 Elsevier Ltd and International Society of Antimicrobial Chemotherapy. All rights reserved.

1. Introduction
Gonorrhoea is currently the second most commonly reported
sexually transmitted infection worldwide and rates of reported in-
fections continue to increase. In 2018, a total of 583 405 cases
were reported by the US Centers for Disease Control and Preven-
tion (CDC), reflecting an increase by 5% in 2017–2018, and rates
of reported cases have increased by 82.6% since a historically low
rate in 2009 [1]. The development of significant antimicrobial re-
sistance in Neisseria gonorrhoeae has further impacted the treat-
ment of gonorrhoea and has led to the removal of many previ-
ously recommended antimicrobials from current clinical practice
guidelines. Current treatment guidelines from the CDC for uncom-
plicated gonococcal infections recommend ceftriaxone as the pre-
ferred first-line agent, whereas guidelines published by the World
Health Organization (WHO) recommend the combination of cef-
triaxone or cefixime with azithromycin [2,3]. However, N. gonor-
rhoeae displays reduced susceptibility to all recommended first-
line agents included in these treatment guidelines. For example,
∗
Corresponding author. Tel.: +1 207 221 4075; fax: +1 207 523 1927.
E-mail address: gallen3@une.edu (G.P. Allen).
recent surveillance studies in the USA, Europe and Australia have
reported reduced susceptibility to azithromycin, and reduced sus-
ceptibility to ceftriaxone was reported in the USA and Australia
[4]. Thus, novel treatment approaches for gonorrhoea are clearly
needed.
The standard measure of antimicrobial susceptibility is the min-
imum inhibitory concentration (MIC). The mutant prevention con-
centration (MPC) is the lowest antimicrobial concentration that in-
hibits the growth of mutants contained within a heterogeneous
population of bacteria with varied levels of susceptibility and may
provide an alternative to the MIC that measures the potential for
resistance selection by antimicrobials more accurately [5]. The mu-
tant selection window (MSW) represents the range of antimicro-
bial concentrations that falls between the MIC and the MPC; ev-
idence from in vitro and animal models suggests that antimicro-
bial concentrations that fall within the MSW promote the selection
of mutants [5]. We used MPC and MSW testing, along with phar-
macodynamic analyses, to assess the likelihood of resistance selec-
tion in two strains of N. gonorrhoeae by azithromycin, ceftriaxone,
doxycycline, ertapenem, gentamicin, ciprofloxacin, levofloxacin and
moxifloxacin.

https://doi.org/10.1016/j.ijantimicag.2021.106417
0924-8579/© 2021 Elsevier Ltd and International Society of Antimicrobial Chemotherapy. All rights reserved.

Please cite this article as: G.P. Allen, K.M. Deao, S.A. Hill et al., In vitro evaluation of antimicrobial resistance selection in Neisseria
gonorrhoeae, International Journal of Antimicrobial Agents, https://doi.org/10.1016/j.ijantimicag.2021.106417
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2. Materials and methods Table 1

Minimum inhibitory concentration (MIC) and mutant prevention
concentration (MPC) values to various antimicrobial agents for two
2.1. Bacterial strains Neisseria gonorrhoeae strains

Antimicrobial ATCC 49226 m-49226

Neisseria gonorrhoeae ATCC 49226 was obtained from Microbio-
logics, Inc. (St. Cloud, MN, USA). A gyrA mutant (Ser91Phe) of ATCC MIC MPC MIC MPC
49226 (m-49226) was obtained by culturing 1010 CFU of ATCC Azithromycin 0.5 32 0.5 32
49226 on agar medium containing 0.0625 mg/L levofloxacin [6]. Ceftriaxone 0.03125 1 0.03125 1
Doxycycline 1 16 1 16
Ertapenem 0.015625 0.125 0.015625 0.125
2.2. Antimicrobial agents
Gentamicin 4 64 4 64
Ciprofloxacin 0.0078125 0.03125 0.125 0.5
All antimicrobials were obtained from Sigma Chemical Co. (St Levofloxacin 0.0078125 0.125 0.125 0.5
Louis, MO, USA). Moxifloxacin 0.015625 0.0625 0.125 0.5

2.3. Medium
Gonococcal agar (Difco Laboratories, Detroit, MI, USA) supple-
mented with 1% IsoVitaleXTM (Becton, Dickinson & Co., Franklin
Lakes, NJ, USA) was used for antimicrobial susceptibility testing.
Bacterial inocula used in MPC testing were prepared using gono-
coccal broth supplemented with 1% IsoVitaleXTM [7].
2.4. Antimicrobial susceptibility testing
MIC testing was performed by Etest (bioMérieux, AB Biodisk,
Solna, Sweden) with an inoculum of 1 × 105 CFU/mL. MICs were
determined following incubation for 18–24 h at 35°C in 5% CO2 .
Clinical and Laboratory Standards Institute (CLSI) guidelines were
used to interpret susceptibility testing results [8].
2.5. Mutant prevention concentration (MPC) determination
AUC/MPC ratio for each antimicrobial agent. For agents admin-
istered as single-dose therapy, a 24-h period was used in these
analyses. Pharmacokinetic parameters attained by azithromycin 2
g orally × 1 (ƒCmax , 0.51 mg/L; t1/2 , 68 h; AUC, 5.59 mg•h/L), cef-
triaxone 250 mg intramuscularly × 1 (ƒCmax , 0.95 mg/L; t1/2 , 8
h; AUC, 16.75 mg•h/L), ceftriaxone 500 mg intramuscularly × 1
(ƒCmax , 1.9 mg/L; t1/2 , 8 h; AUC, 33.5 mg•h/L), doxycycline 100 mg
orally every 12 h (ƒCmax , 1.3 mg/L; t1/2 , 19.5 h; AUC, 7.24 mg•h/L),
ertapenem 1 g intramuscularly × 1 (ƒCmax , 3.53 mg/L; t1/2 , 4
h; AUC, 26.25 mg•h/L), gentamicin 240 mg intramuscularly × 1
(ƒCmax , 10.79 mg/L; t1/2 , 2.5 h; AUC, 47.34 mg•h/L), ciprofloxacin
500 mg orally × 1 (ƒCmax , 1.68 mg/L; t1/2 , 4 h; AUC, 8.12 mg•h/L),
levofloxacin 500 mg orally × 1 (ƒCmax , 3.52 mg/L; t1/2 , 7 h; AUC,
33.05 mg•h/L) and moxifloxacin 400 mg orally × 1 (ƒCmax , 2.15
mg/L; t1/2 , 12 h; AUC, 19.56 mg•h/L) were used in all pharmacody-
namic analyses.

MPC determination was performed using a previously pub-

lished adaptation of a methodology originally described by Blon-
deau et al. [6]. For each isolate, a suspension of the organism in
sterile 0.9% sodium chloride was prepared and 10 agar plates were
inoculated with a sterile swab in order to form a confluent lawn
of growth on each plate. Following incubation for 24 h at 35°C in
5% CO2 , all resulting bacterial growth was collected and transferred
to 500 mL of broth medium and then incubated for an additional
24 h. The resulting suspension was centrifuged (50 0 0 × g for 15
min), the supernatant was discarded and bacterial cells were re-
suspended in broth medium to yield a final inoculum with a con-
centration of 1010 CFU/mL. Finally, 100 μL of this suspension was
applied to each of 10 agar plates containing known antimicrobial
concentrations (2-fold increasing stepwise dilutions above the MIC
of each antimicrobial). Inoculated plates were incubated for 72 h
and screened for growth. The lowest antimicrobial concentration
that inhibited all visible growth was deemed the MPC. MIC test-
ing of recovered colonies was performed to ensure the presence of
resistance.
2.6. Pharmacodynamic analyses
Pharmacokinetic parameters, including peak concentration
(Cmax ), half-life (t1/2 ) and area under the plasma concentration–
time curve over 24-h (AUC), achieved after dosing in adult pa-
tients were used to perform pharmacodynamic analyses [9–16].
Free (unbound; f) Cmax and AUC values were calculated using pro-
tein binding values of 29% for azithromycin, 95% for ceftriaxone,
90% for doxycycline, 95% for ertapenem, 7% for gentamicin, 30% for
ciprofloxacin, 31% for levofloxacin and 50% for moxifloxacin. These
pharmacokinetic parameters were used to calculate the %T>MPC
(percentage of the dosing interval during which concentrations ex-
ceed the MPC), %TMSW (percentage of the dosing interval during
which concentrations fall within the MSW), Cmax /MPC ratio and
3. Results
3.1. Antimicrobial susceptibility testing and mutant prevention
concentration (MPC) determination
MIC and MPC values are shown in Table 1. According to CLSI in-
terpretive standards, both isolates are susceptible to azithromycin,
ceftriaxone and ciprofloxacin but non-susceptible to doxycycline.
Susceptibility breakpoints for ertapenem, gentamicin, levofloxacin
and moxifloxacin for N. gonorrhoeae have not been established.
3.2. Pharmacodynamic analyses
Results of pharmacodynamic analyses (%T>MPC , %TMSW ,
Cmax /MPC and AUC/MPC) are shown in Table 2. Azithromycin
is the only tested antimicrobial that fails to achieve concentrations
above the MIC for either strain and thus concentrations fall below
the MSW for both strains. Concentrations of ceftriaxone following
administration of a 250 mg dose fall within the MSW for 100%
of the dosing interval for both isolates, whereas concentrations
achieved after the administration of a 500 mg dose fall within the
MSW for 69.13% of the dosing interval. The only antimicrobials
to attain concentrations above the MPC are ceftriaxone (only at
a dose of 500 mg), ertapenem, ciprofloxacin, levofloxacin and
moxifloxacin.
4. Discussion
The ongoing dissemination of antimicrobial resistance in N. gon-
orrhoeae has resulted in limited treatment options for gonococcal
infections. Gonorrhoea may become an untreatable disease if cur-
rent resistance trends persist, and novel antimicrobial therapies for
this infection that display a minimal propensity to select resistant

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Table 2
Pharmacodynamic analyses for various antimicrobial agents for two Neisseria gonorrhoeae strains

Antimicrobial ATCC 49226 m-49226

%T>MPC %TMSW Cmax /MPC AUC/MPC %T>MPC %TMSW Cmax /MPC AUC/MPC

Azithromycin 0 0 0.02 0.17 0 0 0.02 0.17

Ceftriaxone (250 mg) 0 100 0.95 16.75 0 100 0.95 16.75
Ceftriaxone (500 mg) 30.87 69.13 1.9 33.5 30.87 69.13 1.9 33.5
Doxycycline 0 61.25 0.08 0.45 0 61.25 0.08 0.45
Ertapenem 80.34 19.66 28.24 210 80.34 19.66 28.24 210
Gentamicin 0 14.9 0.17 0.74 0 14.9 0.17 0.74
Ciprofloxacin 95.83 4.17 53.76 259.84 29.15 70.85 3.36 16.24
Levofloxacin 100 0 28.16 264.4 82.14 17.86 7.04 66.1
Moxifloxacin 100 0 137.6 312.96 100 0 4.3 39.12

%T>MPC , percentage of the dosing interval during which concentrations exceed the MPC; MPC, mutant prevention concen-
tration; %TMSW , percentage of the dosing interval during which concentrations fall within the mutant section window;
Cmax , peak concentration; AUC, area under the plasma concentration–time curve over 24 h.

mutants are needed. We evaluated the risk of resistance induction
in N. gonorrhoeae by a number of antimicrobial agents.
Reduced susceptibility to azithromycin in N. gonorrhoeae has
been increasingly reported. The first N. gonorrhoeae isolate in the
USA with high-level azithromycin resistance was identified in 2011,
and dissemination of strains with high-level azithromycin resis-
tance has been reported [17,18]. In the USA, the percentage of iso-
lates with reduced azithromycin susceptibility increased from 0.6%
in 2013 to 4.6% in 2018, and reduced susceptibility has been asso-
ciated with azithromycin exposure [1].
The AUC/MIC ratio is the pharmacokinetic/pharmacodynamic
parameter that correlates with the antibacterial activity of
azithromycin. The pharmacodynamics of azithromycin relative to
the MPC and/or MSW has not been thoroughly studied and
it is unknown whether a target AUC/MPC threshold that pre-
vents the growth of mutants exists. In Streptococcus pneumoniae,
azithromycin exposures that achieved AUC/MIC values of 23 and
45 resulted in the enrichment of mutants and it was hypothe-
sised that azithromycin-resistant S. pneumoniae mutants were se-
lected because azithromycin concentrations never exceeded the
MPC90 [19]. The low AUC/MIC and AUC/MPC values attained by
azithromycin against N. gonorrhoeae ATCC 49226 and m-49226
(and the failure of azithromycin to exceed the MPC for either
strain) suggest that resistance to azithromycin in N. gonorrhoeae
will continue to emerge with continued use.
Reduced susceptibility in N. gonorrhoeae to extended-spectrum
cephalosporins (ESCs) has been increasingly reported. From 2009–
2015, the WHO Global Gonococcal Antimicrobial Surveillance Pro-
gramme found that 66% of countries that monitored susceptibility
to ESCs reported isolates with reduced susceptibility or resistance
[20]. In 2011, the first N. gonorrhoeae isolate with high-level ceftri-
axone resistance was reported [21].
Ertapenem is not included in CDC or WHO guidelines for the
management of gonococcal infections. In a susceptibility study of
112 N. gonorrhoeae isolates, ertapenem MIC50 and MIC90 values
were 2-fold higher than corresponding values for cefixime and cef-
triaxone [22]. Another susceptibility study that included 257 iso-
lates (including 2 extensively drug-resistant strains) found that er-
tapenem MIC values (MIC50 , 0.032 mg/L; MIC90 , 0.064 mg/L) and
ceftriaxone MIC values (MIC50 , 0.032 mg/L; MIC90 , 0.125 mg/L)
were similar and that four ceftriaxone-resistant isolates (with MICs
of 0.5–4 mg/L) displayed ertapenem MICs of 0.016–0.064 mg/L
[23].
In vitro studies have shown that the parameters T>MIC (time
that the concentration exceeds the MIC) and minimum concentra-
tion (Cmin )/MIC ratio are associated with suppression of resistance
by β -lactams in Gram-negative bacteria. Cephalosporin dosage reg-
imens that achieved %T>MIC values of 80–100% or Cmin /MIC val-
ues of 2–7.7 suppressed the emergence of resistance [24]. In a
mouse model of gonococcal infection, bacterial clearance of a
cephalosporin-susceptible strain was achieved by cefixime or cef-
triaxone doses that achieved a T>MIC of 20–24 h [25]. In ani-
mal model studies of the cephalosporin cefquinome, doses that
achieved a %T>MPC that was less than 50% of the dosing interval
were associated with mutant enrichment in Escherichia coli [26].
We predict increased resistance selection with the continued use
of ceftriaxone to treat N. gonorrhoeae. The higher dose (500 mg)
that is now recommended by the CDC results in more favourable
pharmacodynamics and may limit the selection of resistance, al-
though ceftriaxone doses as high as 1 g may achieve suboptimal
pharmacodynamics against isolates with MICs of ≥0.125 mg/L [27].
Meropenem dosage regimens that achieved T>MIC values of
≥85% or Cmin /MIC values of ≥3.8 prevented the emergence of re-
sistance in Pseudomonas aeruginosa and Klebsiella pneumoniae, re-
spectively [24]. The relationship between carbapenem concentra-
tions, the MPC and/or MSW, and the emergence of resistance has
not been studied. Nonetheless, the fact that ertapenem achieves a
%T>MPC that is greater than 80% of the dosing interval is potentially
a promising finding. Ertapenem was used to successfully treat a
patient infected with N. gonorrhoeae with high-level resistance to
azithromycin and resistance to ceftriaxone who experienced treat-
ment failure after the administration of the combination of ceftri-
axone and azithromycin, later followed by a single dose of specti-
nomycin [28].
Current WHO treatment guidelines include azithromycin, rather
than doxycycline, as a preferred component of the first-line
regimen for gonorrhoea because of the higher prevalence of
tetracycline-resistant N. gonorrhoeae strains [3]. Tetracycline resis-
tance in N. gonorrhoeae has been noted for decades and resistance
rates have continued to increase. The most recent surveillance re-
port from the CDC found that 25.6% of isolates were resistant to
tetracycline [1]. Studies specifically measuring doxycycline suscep-
tibility (using susceptibility breakpoints for tetracycline) have re-
ported doxycycline resistance rates greater than 50% [29].
In Staphylococcus aureus, MIC elevations were observed when a
doxycycline regimen that achieved a %T>MSW of greater than 80
(AUC/MIC of 60) was simulated in vitro [30]. Mutants of Enterococ-
cus faecium were selected by a doxycycline regimen that achieved
an AUC/MIC of 230 and resulted in concentrations falling within
the MSW throughout the entire 24-h dosing interval [31]. Our
analysis of doxycycline’s pharmacodynamics against N. gonorrhoeae
ATCC 49226 and m-49226 leads us to predict that doxycycline will
continue to select resistant mutants of N. gonorrhoeae due to the
%TMSW , AUC/MPC and AUC/MIC values attained.
Susceptibility breakpoints for gentamicin for N. gonorrhoeae
have not been established, but suggested MIC breakpoints for sus-
ceptibility and resistance are ≤4 mg/L and ≥32 mg/L, respec-
tively. A surveillance study that included 10 403 urethral isolates

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G.P. Allen, K.M. Deao, S.A. Hill et al.
in 2015–2016 found that gentamicin MICs ranged from 1–16 mg/L,
with 26.9% of isolates demonstrating an MIC of ≤4 mg/L and
73.1% of isolates exhibiting intermediate susceptibility (MIC, 8–16
mg/L); the percentage of isolates with intermediate susceptibil-
ity increased from 68% in 2015 to 78% in 2016 [32]. In 202 pa-
tients with urogenital gonococcal infections, 100% of participants
who received a regimen consisting of gentamicin 240 mg and
azithromycin 2 g achieved clinical cure [33]. In this study, suscepti-
bility testing of pre-treatment strains revealed a gentamicin MIC50
of 4 mg/L and an MIC90 of 8 mg/L, with no isolates demonstrating
MICs at or above the proposed resistance breakpoint of ≥32 mg/L
[33]. A regimen that included gentamicin 240 mg and azithromycin
1 g resulted in clearance of uncomplicated genital, pharyngeal or
rectal gonococcal infection in 91% of participants, and three indi-
viduals infected with isolates with a gentamicin MIC > 4 mg/L ex-
perienced clearance of their infection [34].
The Cmax /MIC and AUC/MIC ratios have been linked to resis-
tance suppression by aminoglycosides, and a Cmax /MIC ratio of 15–
32 or an AUC/MIC ratio of 110 have been shown to prevent the
emergence of resistance [24]. In S. aureus exposed to gentamicin
in an in vitro pharmacodynamic model, gentamicin-resistant mu-
tants were enriched by a dose that achieved a %T>MPC of 0% but
not by a dose that achieved a %T>MPC of 11% [35]. Our results sug-
gest that the use of gentamicin for gonococcal infections may lead
to the emergence of resistance, although we did not assess the
effect of combination therapy with other agents. Gentamicin has
been shown to display synergy in vitro with ertapenem and ce-
fixime against N. gonorrhoeae [36].
Fluoroquinolone-resistant strains of N. gonorrhoeae were iden-
tified in the USA in 1991 and the continuing emergence of flu-
oroquinolone resistance led the CDC to remove fluoroquinolones
from the list of recommended treatment options for gonorrhoea in
2007 [37]. Recent surveillance surveys in the USA, Europe and Aus-
tralia reported ciprofloxacin resistance rates in N. gonorrhoeae to be
31.2%, 46.5% and 27.5%, respectively [4]. The combination of gemi-
floxacin 320 mg and azithromycin 2 g achieved microbiological
cure in 99.5% of 199 evaluable participants in a randomised, mul-
tisite, open-label, non-comparative trial, although elevated gemi-
floxacin MICs were found during pre-treatment susceptibility anal-
yses [33].
The AUC/MPC ratio is associated with the suppression of
fluoroquinolone resistance. In vitro, ciprofloxacin exposures that
achieved an AUC/MPC ratio of 22 or 35 prevented the emer-
gence of resistance in fluoroquinolone-susceptible strains, while
an AUC/MPC ratio of 11 or 14 prevented further resistance in
gyrA mutants [38,39]. Other in vitro evaluations have shown that
an AUC/MPC of 59, 60, 69 or 89 prevented the recovery of
fluoroquinolone-resistant mutants of S. aureus [5]. In N. gonor-
rhoeae ATCC 49226, all tested fluoroquinolones achieve concen-
trations above the MPC for the majority of the dosing interval
and display AUC/MPC values that suggest a low likelihood of mu-
tant selection. In m-49226, concentrations of ciprofloxacin and lev-
ofloxacin fall within the MSW for a greater proportion of the dos-
ing interval, but AUC/MPC ratios achieved by ciprofloxacin, lev-
ofloxacin and moxifloxacin are of sufficient magnitude to suggest
that these agents may prevent further resistance.
Our work has several limitations. We studied only two strains
of N. gonorrhoeae and further evaluation of additional strains with
varied susceptibility profiles is needed. We used the Etest method-
ology to test antimicrobial susceptibility rather than a reference
method (broth microdilution or agar dilution). Etest has shown
high correlation with agar dilution susceptibility testing for cef-
triaxone, cefixime and cefpodoxime, although Etest resulted in
slightly lower MICs [40]. Our pharmacodynamic analyses were
based on plasma concentrations of all antimicrobials, whereas an-
timicrobial concentrations at the site of infection may vary. In-
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International Journal of Antimicrobial Agents xxx (xxxx) xxx
terpretations of our pharmacodynamic analyses were developed
based on documented findings from studies of bacteria other than
N. gonorrhoeae, as there are limited data to support a particular an-
timicrobial exposure (and resulting %T>MPC , %TMSW , Cmax /MPC or
AUC/MPC) that is associated with mutant selection in N. gonor-
rhoeae. Furthermore, the relationship between antimicrobial con-
centrations, the MPC/MSW and the restriction of mutant growth
has not been evaluated for all of the tested agents. Finally, time–
kill analyses or in vitro pharmacodynamic modelling experiments
are necessary to confirm our predictions regarding mutant selec-
tion by the tested agents.
Our study suggests that ertapenem and the tested fluoro-
quinolones may display the lowest propensity to select resistant
strains. However, the dissemination of fluoroquinolone-resistant N.
gonorrhoeae has previously limited the use of fluoroquinolones for
gonococcal infections, and evidence of the clinical efficacy of er-
tapenem for gonorrhoea is limited. Strategies to address gono-
coccal resistance, including the development of new therapeutic
agents or the use of revised dosage regimens and combinations of
existing agents, are needed.
Declaration of Competing Interest
None declared.
Funding
None.
Ethical approval
Not required.
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