Genetic Background Modulates Zoliflodacin and Gepotidacin Cross-Resistance and Fitness in Neisseria gonorrhoeae

The emergence of multidrug-resistant Neisseria gonorrhoeae has created an urgent need for new therapeutic options. Zoliflodacin and gepotidacin, 2 first-in-class topoisomerase inhibitors, are oral antibiotics recently approved by the FDA for gonorrhea treatment. Resistance to zoliflodacin can occur through gyrBD429N, but this mutation's impact on fitness and on resistance to other topoisomerase-targeting drugs have been unclear. The aim of this study was to investigate the in vitro fitness and antibiotic resistance implications of gyrBD429N in ciprofloxacin-resistant N. gonorrhoeae strains.

We introduced the gyrBD429N substitution into 9 clinical strains via transformation. Antimicrobial susceptibility testing was performed for zoliflodacin, gepotidacin, and ciprofloxacin using standard MIC assays. In vitro relative fitness of parent and resistant mutant strains was assessed by pairwise competition experiments.

gyrB D429N conferred cross-resistance to gepotidacin in 3 clinical strains, and its fitness effect varied by strain background. In particular, parCD86N appeared to potentiate gyrBD429N cross-resistance to gepotidacin, a drug for which resistance has previously only been seen in the presence of both parCD86N and gyrAA92T mutations.

Genetic background modulated the phenotypic effects of a zoliflodacin-resistance determinant on fitness and cross-resistance to gepotidacin. These findings inform strategies for introducing the new topoisomerase inhibitors into clinical use and for surveillance of resistance.