# Epidemiology of gonococcal arthritis in Brittany - France (EpGAr study)

Valentin Lemoine, Simon Rolland, Sophie Reissier, David Luque Paz, Marion Souffez, Mathilde Favalelli, Victor Scavazzin, Julie Brousseau, Claudie Lamoureux, Caroline Piau-Couapel, et al.

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Valentin Lemoine, Simon Rolland, Sophie Reissier, David Luque Paz, Marion Souffez, et al. Epidemiology of gonococcal arthritis in Brittany - France (EpGAr study). International Journal of Medical Microbiology, 2025, 322, pp.151692. 10.1016/j.ijmm.2025.151692. hal-05425713

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# Epidemiology of gonococcal arthritis in Brittany - France (EpGAr study)

Valentin Lemoine<sup>a,1,* ID</sup>, Simon Rolland<sup>b</sup>, Sophie Reissier<sup>c,d</sup>, David Luque Paz<sup>d,e</sup>, Marion Souffez<sup>c</sup>, Mathilde Favalelli<sup>c</sup>, Victor Scavazzin<sup>a,f</sup>, Julie Brousseau<sup>g,h,i</sup>, Claudie Lamoureux<sup>a</sup>, Caroline Piau<sup>c</sup>, Vincent Cattoir<sup>c,d</sup>, François Caméléna<sup>g,h,i</sup>, Béatrice Berçot<sup>g,h,i</sup>, Geneviève Héry-Arnaud<sup>a,f,** ID</sup>

## ARTICLE INFO

### Keywords:

- Gonococci

- Septic arthritis

- Gonococcal arthritis

- Neisseria gonorrhoeae

- Disseminated gonococcal infection

- Sexually transmitted infections

## ABSTRACT

**Background:** Gonococcal infections are sexually-transmitted infections (STIs), which in 0.5–3 % of cases, can progress to disseminated infections (DGI). This study aimed to characterize the epidemiology of septic arthritis and tenosynovitis caused by *Neisseria gonorrhoeae*, the two most common clinical manifestations of DGI (30–90 %).

**Methods:** A retrospective observational study was conducted in two French referral hospitals from June 2014 to June 2024. Adult patients treated for septic arthritis due to *N. gonorrhoeae* with a positive culture of joint fluid were included.

**Results:** We identified ten cases (eight males and two females) with a mean age of 44 years. The infected joints were the wrist, knee, thumb, elbow, ankle, and hip. On average, it took 13 days from the onset of symptoms to the administration of appropriate antibiotic treatment. Among the ten cases, seven strains were available. Of these, five were resistant to fluoroquinolones and six to tetracyclines. All strains were susceptible to third-generation cephalosporins. All patients received ceftriaxone as first-line therapy and achieved complete recovery in 70 % (7/10) of cases at the one-year follow-up. Whole genome sequencing identified virulence-associated alleles, such as *porB1a*, but no clustering of hypervirulent clones was observed.

**Conclusions:** Our findings highlight the variety of joints affected by septic arthritis caused by *N. gonorrhoeae*, as well as high level of resistance to both fluoroquinolones and tetracyclines. These results emphasize the importance of vigilance when diagnosing and managing gonococcal infections, particularly in high-risk populations, and highlight the need for further research into alternative treatments to address emerging resistance.

## 1. Background

Gonococcal infections are sexually-transmitted infections (STIs) that remain a major public health problem, with an estimated 82.4 million [47.7 million-130.4 million] new cases in 2020 among adolescents and

adults aged 15–49 (WHO, 2024). Antibiotic resistance in *Neisseria gonorrhoeae* has steadily increased over recent decades, through horizontal gene transfer and mutations of key antibiotic target genes (Quillin and Seifert, 2018). Several antimicrobials used in the past are no longer recommended, such as sulfonamides, penicillins, and tetracyclines.

<footnote><sup>a</sup> Infectious Agents Department, Bacteriology Laboratory, Brest University Hospital, Brest, France</footnote>

<footnote><sup>b</sup> Department of Infectious and Tropical Diseases, Brest University Hospital, Brest, France</footnote>

<footnote><sup>c</sup> Bacteriology and Hospital Hygiene Laboratory, CHU de Rennes, Rennes, France</footnote>

<footnote><sup>d</sup> INSERM, UMR_S1230 BRM, University of Rennes, Rennes, France</footnote>

<footnote><sup>e</sup> Department of Infectious and Tropical Diseases, Rennes University Hospital, Rennes, France</footnote>

<footnote><sup>f</sup> Univ Brest, INSERM, EFS, UMR 1078, GGB, Faculty of Medicine and Health Sciences, Brest F-29200, France</footnote>

<footnote><sup>g</sup> Assistance-Publique Hôpitaux de Paris, Laboratory of Bacteriology, Hospital Saint-Louis and Lariboisière, Paris, France</footnote>

<footnote><sup>h</sup> Associated Laboratory of the French National Center for Bacterial Sexually Transmitted Infections, Saint Louis Hospital, Paris, France</footnote>

<footnote><sup>i</sup> Paris Cité University, IAME UMR1137, PreVIST Team, Paris, France</footnote>

<footnote>* Corresponding author.</footnote>

<footnote>** Correspondence to: Laboratoire de Bactériologie, Département des Agents Infectieux, CHU de Brest, Bd Tanguy Prigent, Brest 29200, France.
E-mail addresses: valentin.lemoine@chu-rennes.fr (V. Lemoine), hery@univ-brest.fr (G. Héry-Arnaud).</footnote>

<footnote n="1">¹ Present address: Laboratoire de bactériologie et hygiène hospitalière, CHU de Rennes, 2 Rue Henri le Guilloux, 35000 Rennes, France</footnote>
Currently, the prevalence of ceftriaxone-resistant *N. gonorrhoeae* remains low in Europe, despite the occurrence of imported cases. However, a concerning increase in cases has been observed in China and South-East Asia (Adamson et al., 2024; Ouk et al., 2023; Xiu et al., 2025). Furthermore, there has been a marked increase in azithromycin resistance over the past 5–10 years worldwide (Jacobsson et al., 2025).

Historically, disseminated gonococcal infections (DGI) have been estimated to account for 0.5–3 % of gonococcal infections; however, recent data are lacking (Eisenstein and Masi, 1981; Holmes, 1971). These include tenosynovitis, arthritis and infective endocarditis. According to several case series, arthritis and tenosynovitis represent the two most frequent presentations (30–90 %) (Belkacem et al., 2013; Birrell et al., 2019; Moussiegt et al., 2022; Nossent et al., 2022; Tuttle et al., 2015; Wise, 1994). Although these infections are now rare, they can lead to severe complications including functional sequelae, particularly if diagnosis and treatment are delayed (Bardin, 2003).

In the 1980s, the wrist was the most affected joint, closely followed by the knees and metacarpophalangeal joints (Eisenstein and Masi, 1981). Other joints such as the ankle, elbow, hip, shoulder, foot and clavicle were less involved.

Despite being well-documented historically, there are only few recent publications about this infection, and the virulence factors associated with these clinical manifestations remain poorly understood. In addition, DGI has recently become a cause for concern in the United States and the CDC now defines DGI as an infection involving the isolation or detection of *N. gonorrhoeae* in normally sterile body fluids, such as joint fluid, blood, or cerebrospinal fluid (CDC, 2025).

Our study aims to describe clinical and microbiological characteristics of recent cases of osteoarticular infections caused by *N. gonorrhoeae* in patients living in Western France, combining clinical data with strain descriptions.

## 2. Methods

### 2.1. Study population and data collection

We conducted a retrospective observational study, including all adult patients with joint samples (enrichment vial or native swab) positive for *N. gonorrhoeae* between June 2014 and June 2024, from two French referral hospitals located in the Brittany region (Brest University Hospital and Rennes University Hospital). We excluded patients who had expressed opposition for the participation to the study, as well as those under legal protection.

We collected clinical and biological data using laboratory information systems and medical files from the two referral hospitals. Demographic data included: age, sex, and if known, sexual orientation. Clinical and microbiological data encompassed the date of sampling, sample nature, cytology, presence of associated STIs, comorbidities, clinical features of infection, imaging results, blood cultures positive or not, time to diagnosis, empirical and adapted treatments, antibiotic susceptibility profile, surgical interventions, and clinical outcomes.

Phenotypic and genomic characterization was carried out by the French National Reference Center (NRC) for STI for gonococcal expertise localized at the Saint-Louis hospital (AP-HP) in Paris. Antimicrobial susceptibility testing (AST) was performed and minimum inhibitory concentrations (MICs) of cefixime, ceftriaxone, azithromycin, gentamicin, ciprofloxacin and tetracycline were determined using Etest® strips on PolyViteX® agar (bioMérieux, Marcy-l'Étoile, France) incubated for 24 h at + 36 ± 1°C, in a humid, 5 % CO₂-enriched atmosphere. Resistance was defined according to the criteria of the European Committee on Antimicrobial Susceptibility Testing, EUCAST (EUCAST, 2025). Whole genome sequencing (WGS) was performed using the Illumina MiSeq approach instrument. Quality control, assembly, molecular typing and characterization of antimicrobial resistance determinants were performed as previously described (Caméléna et al., 2024). Genomes were aligned with ceftriaxone-resistant strains

previously isolated in France (F90–93) and reference strains (WHOF, WHOX and WHOY). We used ParSNP v.1.2 (https://github.com/marlparsnp) to correct the alignments for recombination. We then constructed a maximum-likelihood phylogeny for core-genome comparisons and visualized the comparisons by using iTol (https://itol.embl.de), as previously described (Caméléna et al., 2024).

### 2.2. Data analysis

Data were presented as counts and percentages or as the median with the 25th-75th quartiles in a univariate analysis.

## 3. Results

We included 10 patients with a diagnosis of arthritis or tenosynovitis due to *N. gonorrhoeae* over the study period: 8 males and 2 females, with a mean age of 44 years (Table 1). Of them, 40 % (4/10) reported risky sexual behaviors, such as multiple partnerships or unprotected sex. Among the men, two declared having sex with men (MSM). Ninety percent (9/10) of patients had a check-up for STIs, which yielded a positive result in 3 of the 9 patients: one was HIV-positive with an undetectable viral load, and carried a pharyngeal *N. gonorrhoeae*; one was an anal gonococcal carrier; one was infected with urinary *Chlamydia trachomatis* and pharyngeal *N. gonorrhoeae*. Seven of the ten documented cases were reported since 2020.

Sixty percent (6/10) of patients had infections in multiple joints. The wrist was the most affected joint (4/10), followed by the knee (2/10). Other locations included the thumb, elbow, ankle and hip. None of the patients exhibited genital signs of infection.

A biological inflammatory syndrome was observed in all patients, with a median C-reactive protein of 93.5 mg/L (interquartile range [IQR]: 54.6–145.5 mg/L). Joint fluids were inflammatory, with leukocyte counts showing a median of 48,000/mm³ (IQR: 16,500–126,750/mm³), predominantly composed of neutrophils. Gram staining of joint fluid was performed in seven patients and was negative in all cases. All blood cultures performed were negative (0/5). Of the 10 patients, 9 had a positive joint fluid culture. In one case (patient no. 8), the diagnosis was established using PCR. In another case (patient no. 3), joint fluid was found to be culture-negative but PCR-positive following analysis of a single sample; a second puncture was required to perform the culture and obtain the antibiogram of the strain.

The median time from symptom onset to the initiation of bacteria-specific antibiotic therapy was 10 days. Only three out of ten patients received an empiric antibiotic therapy: one with cloxacillin, one with amoxicillin-clavulanic acid, and one with a combination of ceftriaxone and gentamicin.

After identification and antibiotic susceptibility testing, all patients were treated according to current national guidelines, with intravenous ceftriaxone for a minimum of five days and up to 14 days (median seven days). Two patients required surgery, which included surgical drainage and lavage. Seventy percent (7/10) of patients achieved full recovery following treatment. One patient (no. 3) developed polyarthritis two years after the initial episode, with gonococcal PCR positive in urine, prompting additional treatment with ceftriaxone for seven days. Another patient (no. 5) described chronic finger pain two years after the infectious episode. Finally, a third patient (no. 6) required lavage six months after diagnosis due to persistent pain from de Quervain's tenosynovitis, recognized as post-septic sequelae of gonococcal infection.

Of the 10 patients, 7 strains were available for analysis and sent to the French NRC of STI for molecular typing by WGS. The isolates belonged to ST7822 (n = 3), ST8135 (n = 1), ST11422 (n = 1), ST1588 (n = 1), and ST9362 (n = 1). Molecular typing results for each patient are shown in Table 2. Fig. 1 illustrates the phylogenetic tree based on 14,942 SNPs of the core genome with some international reference strains (WHOF, WHOX, WHOY) and French MDR-NG reference strains (F90, F91, F92, F93). These findings indicate substantial genetic
<table><caption>**Table 1**
Cases description.</caption><thead><tr><th>Patient number</th><th>Age</th><th>Gender</th><th>Year of diagnosis</th><th>Medical history</th><th>Risky sexual behavior</th><th>STI history</th><th>Articulation *</th><th>Bacteriology of joint culture</th><th>Days to antibiotics</th><th>Empiric antibiotic therapy</th><th>Documented antibiotic therapy</th><th>Surgery</th><th>Outcome</th></tr></thead><tbody><tr><td>1</td><td>46</td><td>M</td><td>2015</td><td>Fractured wrist</td><td>Yes</td><td>None</td><td>Wrist</td><td>Positive</td><td>4</td><td>Ceftriaxone and gentamicin</td><td>Ceftriaxone</td><td>No</td><td>Full recovery</td></tr><tr><td>2</td><td>19</td><td>F</td><td>2019</td><td>Lymphoma Systemic lupus</td><td>No</td><td>None</td><td>Elbow</td><td>Positive</td><td>9</td><td>No</td><td>Ceftriaxone</td><td>No</td><td>Full recovery</td></tr><tr><td>3</td><td>54</td><td>F</td><td>2019</td><td>Active smoking Alcohol addiction</td><td>No</td><td>None</td><td>Knee</td><td>Negative but positive PCR on joint puncture</td><td>10</td><td>No</td><td>Ceftriaxone and azithromycin</td><td>No</td><td>Secondary polyarthritis</td></tr><tr><td>4</td><td>50</td><td>M</td><td>2020</td><td>Cutaneous and lymph node Kaposi's sarcoma Anal condylomas</td><td>Unk</td><td>Treated HIV infection Pharyngeal N. gonorrhoeae</td><td>Thumb</td><td>Positive</td><td>Unk</td><td>No</td><td>Ceftriaxone</td><td>No</td><td>Full recovery</td></tr><tr><td>5</td><td>38</td><td>M</td><td>2022</td><td>None</td><td>No</td><td>None</td><td>Wrist</td><td>Positive</td><td>45</td><td>Amoxicillin - clavulanate</td><td>Ceftriaxone</td><td>Yes</td><td>Chronic sequelae pain</td></tr><tr><td>6</td><td>25</td><td>M</td><td>2022</td><td>None</td><td>Unk</td><td>None</td><td>Wrist</td><td>Positive</td><td>12</td><td>No</td><td>Ceftriaxone</td><td>No</td><td>Chronic sequelae pain</td></tr><tr><td>7</td><td>44</td><td>M</td><td>2023</td><td>ENT cancer</td><td>NC</td><td>Rectal N. gonorrhoeae</td><td>Knee</td><td>Positive</td><td>5</td><td>No</td><td>Ceftriaxone</td><td>No</td><td>Full recovery</td></tr><tr><td>8</td><td>65</td><td>M</td><td>2023</td><td>Alcohol addiction</td><td>Yes</td><td>None</td><td>Ankle</td><td>Negative but positive PCR on joint puncture</td><td>9</td><td>No</td><td>Ceftriaxone</td><td>No</td><td>Full recovery</td></tr><tr><td>9</td><td>21</td><td>M</td><td>2021</td><td>None</td><td>Yes</td><td>Urine C. trachomatis Pharyngeal N. gonorrhoeae</td><td>Hip</td><td>Positive</td><td>12</td><td>Cloxacillin</td><td>Ceftriaxone</td><td>No</td><td>Full recovery</td></tr><tr><td>10</td><td>73</td><td>M</td><td>2024</td><td>Diabetes High blood pressure Dyslipidemia</td><td>Yes</td><td>None</td><td>Wrist</td><td>Positive</td><td>11</td><td>No</td><td>Ceftriaxone</td><td>Yes</td><td>Full recovery</td></tr></tbody></table>

<footnote>* main location sampled; Unk, unknown; ENT, ear, nose, throat</footnote>
<table><caption>**Table 2**
Phenotype (MIC determination) and genotype profiles (molecular typing by whole genome sequencing).</caption><thead><tr><th rowspan="2">Patient number</th><th rowspan="2">Reference</th><th colspan="2">MIC (mg/L)</th><th colspan="10">Molecular determinants</th></tr><tr><th>Ceftriaxone</th><th>Cefixime</th><th>Ciprofloxacin</th><th>Gentamicin</th><th>Azithromycin</th><th>Tetracycline</th><th>NG-MLST</th><th>PorB</th><th>PenA</th><th>TEM-1B</th><th>GyrA mutation</th><th>ParC mutation</th><th>RpsJ mutation</th><th>TetM</th></tr></thead><tbody><tr><td>2</td><td>Ng0044</td><td>&lt; 0.002 (S)</td><td>&lt; 0.016 (S)</td><td>0.002 (S)</td><td>8</td><td>0.032 (S)</td><td>0.25 (S)</td><td>8135</td><td>PorB1b</td><td>15.001</td><td>Absent</td><td>WT</td><td>WT</td><td>WT</td><td>Absent</td></tr><tr><td>3</td><td>Ng0045</td><td>0.002 (S)</td><td>&lt; 0.016 (S)</td><td>4 (R)</td><td>8</td><td>0.125 (S)</td><td>2 (R)</td><td>7822</td><td>PorB1a</td><td>5.002</td><td>Absent</td><td>S91F, D95A</td><td>S87R</td><td>V57M</td><td>Absent</td></tr><tr><td>4</td><td>Ng0047</td><td>&lt; 0.002 (S)</td><td>&lt; 0.016 (S)</td><td>8 (R)</td><td>8</td><td>2 (R)</td><td>2 (R)</td><td>7822</td><td>PorB1a</td><td>3.001</td><td>Absent</td><td>S91F, D95A</td><td>S87R</td><td>V57M</td><td>Absent</td></tr><tr><td>5</td><td>Ng0046</td><td>0.004 (S)</td><td>&lt; 0.016 (S)</td><td>0.032 (S)</td><td>8</td><td>1 (S)</td><td>4 (R)</td><td>11422</td><td>PorB1b</td><td>2.001</td><td>Absent</td><td>WT</td><td>WT</td><td>Absent</td><td>Absent</td></tr><tr><td>6</td><td>Ng0049</td><td>0.004 (S)</td><td>&lt; 0.016 (S)</td><td>4 (R)</td><td>8</td><td>0.5 (S)</td><td>1 (R)</td><td>7822</td><td>PorB1a</td><td>5.002</td><td>Absent</td><td>S91F, D95A</td><td>S87R</td><td>V57M</td><td>Absent</td></tr><tr><td>7</td><td>Ng0048</td><td>0.008 (S)</td><td>0.032 (S)</td><td>4 (R)</td><td>4</td><td>0.125 (S)</td><td>1 (R)</td><td>1588</td><td>PorB1a</td><td>19.001</td><td>Present</td><td>S91F, D95A</td><td>S87R</td><td>V57M</td><td>Absent</td></tr><tr><td>10</td><td>Ng0043</td><td>0.002 (S)</td><td>&lt; 0.016 (S)</td><td>4 (R)</td><td>4</td><td>1 (S)</td><td>1 (R)</td><td>9362</td><td>PorB1b</td><td>2.001</td><td>Absent</td><td>S91F, D95A</td><td>S87R</td><td>V57M</td><td>Absent</td></tr></tbody><tfoot><tr><td colspan="17">MIC: minimal inhibitory concentration; S: susceptible; R: resistant (EUCAST)</td></tr></tfoot></table>

diversity among the seven isolates, with a median pairwise SNP distance of 6134. Notably, within the three ST7822 isolates, pairwise SNP distances ranged from 430 to 1240.

Among the seven isolates sequenced, 71 % (5/7) were resistant to fluoroquinolones through mutations in the *gyrA* and *parC* genes located in the quinolone-resistance determining region (QRDR), and 86 % (6/7) were resistant to tetracycline through mutation in *rpsJ* gene. No *tet(M)* gene was detected in any of the isolates. Only one strain was penicillinase-producing (TEM-1), and one out of seven strains was resistant to azithromycin (MIC > 1). All strains were susceptible to third-generation cephalosporins (MIC ≤ 0.008). In terms of virulence, 57 % (4/7) of strains carried the *porB1a* allele, which is associated with greater virulence (cell invasion, serum resistance) compared to the more common *porB1b* allele (Ram et al., 2001).

## 4. Discussion

Our case series shows that DGI can affect a wide range of patients, not limited to young adults, with ages ranging from 19 to 73 years, suggesting that clinicians should maintain a broad diagnostic suspicion regardless of age. The literature often suggests that sexually active women were mainly affected (Bardin, 2003). However, this was not the case with our patient cohort (sex ratio largely dominated by men), nor with a previous French study, which showed that men appeared to be more at risk than women (Belkacem et al., 2013). Notably, two male patients were identified as MSM, a population consistently shown to be at higher risk for gonococcal and other STIs (Kounta et al., 2024). Although the knee is a commonly affected joint in DGI, it is noteworthy that multiple locations can be involved, including the wrist. Furthermore, none of the cases in our cohort reported a skin rash, whereas dermatitis is often associated with arthritis (Barr and Danielsson, 1971; Bleich et al., 2012). As expected, risky sexual behavior, particularly multiple partners and inconsistent condom use, was common (40 %) among patients. Only one case occurred in a patient with HIV-positive status, who had an undetectable viral load. Complement deficiencies, a known risk factor for disseminated infections (Ellison et al., 1987; Figueroa and Densen, 1991; McWhinney et al., 1991), were not identified in our cohort, but only one patient underwent an immunological workup, which was normal (C3, C4 and CH50 were within the normal range). The recent use of HIV pre-exposure prophylaxis (PrEP) could contribute to a rise in gonococcal infections in the coming years, as reduced condom use may increase the risk of STIs other than HIV (Marcus et al., 2019). In addition, the French public health agency has noted an increase in positivity rates among men and women since 2021, with approximately 23,000 people diagnosed and treated in 2023 (70 % of whom were men) in private medical testing laboratories (Santé Publique France, 2023).

From a therapeutic perspective, our isolates remain susceptible to third-generation cephalosporins. This treatment is simple and generally well-tolerated, although its long-term effectiveness is threatened by the global rise of antimicrobial resistance. By contrast, the high rate of fluoroquinolone resistance observed in our cohort mirrors previously reported national and international trends (Anwar et al., 2020; Unemo et al., 2016; Vidaurrazaga and Perlman, 2020), confirming that this antibiotic no longer has a role in the management of DGI. Given reports of third-generation cephalosporins resistant strains worldwide, particularly in China, and with several cases reported in France (Caméléna et al., 2024; Qin et al., 2025), AST remains essential for each case.

Accurate diagnosis is crucial, especially since fluoroquinolones are still often prescribed in cases of acute arthritis. Synovial fluid culture can be negative because of the fragility of the bacteria in the environment, making it essential for the differential diagnosis of microcrystalline arthritis, for which colchicine is commonly prescribed. In our series, the use of blood culture bottles to enrich synovial fluid samples improved diagnostic yield. Molecular biology, such as specific PCR or rapid multiplex assays, could further enhance detection and help avoid
<figure><img src="image_4.png" /><figcaption>**Fig. 1.** Phylogenetic tree based on 14,942 SNPs of the core genome with international reference strains (WHOX) and French reference strains (FXX). FQ: fluoroquinolones. NG-MLST: *Neisseria gonorrhoeae* sequence type based on MLST scheme. GyrA-D95*: D95A mutation except for F93 (D95G), WHOX (D95N) and WHOY (D95G). Antibiotic susceptibility and resistance are indicated by green and red colors, respectively. The presence and absence of resistance gene/mutation are indicated by black and white squares, respectively.</figcaption></figure>

unnecessary or inappropriate treatments.

Finally, the rise observed in Brittany with 7 of the 10 documented cases occurring since 2020, echoes recent studies from Spain and the United States (Maldonado-Barrueco et al., 2024; Tang et al., 2023) and raises the question of a possible resurgence of DGI. Molecular typing revealed no evidence of hypervirulent or clonal expansion within this cohort. The STs found are common in France: ST7822 is the 3rd most common ST in France, ST 11422 the 7th, ST 1588 the 9th and ST8135 is in the top 15 (data from the French National Reference Center for STI) (CNR des IST bactériennes, 2023). While the *porB1a* allele, known to be more prevalent in DGI in general (Welch et al., 2024), was found in over half the strains, its presence was inconsistent. All these factors call for further exploration of a larger number of strains. While no definitive virulence signature emerged, genomic surveillance remains crucial for epidemiological tracking and international comparisons.

## 5. Conclusion

The resurgence of gonococcal osteoarticular infections in Western France echoes global trends and underlines the need for renewed clinical awareness. Although rare, these infections are painful, potentially disabling, and demand prompt antibiotic therapy, sometimes with surgical intervention. Our findings confirm associations with high-risk sexual behavior and MSM status, and highlight alarming resistance levels to fluoroquinolones and tetracyclines, despite maintained efficacy of ceftriaxone. The genomic diversity observed, including inconsistent *porB1a* detection, reinforces the importance of continued molecular surveillance. Future work should prioritize early diagnosis and the development of new therapeutic strategies to counter rising resistance.

## Ethics approval and consent to participate

This study is registered under number NCT06897943 and was approved by the Brest University Hospital Ethics Committee on March 6, 2025. All the study participants gave their informed consent to participation, in line with French ethical guidelines.

## Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

## CRediT authorship contribution statement

**Valentin Lemoine:** Writing – original draft, Methodology, Investigation, Formal analysis, Data curation. **Simon Rolland:** Writing – original draft, Methodology, Investigation, Formal analysis, Data curation.

**Sophie Reissier:** Writing – original draft, Methodology, Investigation. **David Luque-Paz:** Writing – original draft, Methodology, Investigation, Formal analysis. **Marion Souffez:** Data curation. **Mathilde Favalelli:** Data curation. **Victor Scavazzin:** Data curation. **Julie Brousseau:** Writing – original draft. **Claudie Lamoureux:** Data curation. **Caroline Piau:** Data curation. **Vincent Cattoir:** Writing – original draft, Visualization, Investigation. **François Caméléna:** Writing – original draft, Methodology, Investigation, Formal analysis, Data curation. **Béatrice Berçot:** Supervision, Resources, Funding acquisition. **Geneviève Héry-Arnaud:** Writing – original draft, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis.

## Declaration of Competing Interest

The authors declare that they have no competing interests.

## Acknowledgements

This work was the subject of a poster presented at the 44th Interdisciplinary Meeting on Anti-Infective Chemotherapy (RICAI) in Paris on December 16–17, 2024. We would like to thank the biologists, technicians, and engineers at the bacteriology laboratories of the Brest and Rennes University Hospitals, as well as the French National Reference Center for STIs in Paris.

## Data availability

Data will be made available on request.

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