During 2023, 10 cases of locally acquired mosquito-transmitted (autochthonous) malaria were reported to CDC from four U.S. states after a 20-year period with no autochthonous cases. These cases highlight that although the United States eliminated malaria transmission in the early 1950s, the country remains susceptible to malaria reintroduction. This report provides operational guidance to local, state, tribal, territorial, and Federalpublic health responders on public health investigation and response to a suspected autochthonous malaria case in the United States. The guidance in this report updates the 2006 guidance (CDC. Locally acquired mosquito-transmitted malaria: a guide for investigations in the United States. Atlanta, GA: US Department of Health and Human Services, CDC; 2006) and is based on CDC subject-matter expertise, outbreak response experience from 2023, and targeted literature review. Investigations of suspected autochthonous malaria cases often raise public concern and can require substantial public health resources. Public health investigations of these cases should include epidemiologic, entomologic, and laboratory components and frequently require coordination among local, state, and Federal jurisdictions. This report provides an outline ofthe essential actions for such investigations conducted by describing the components ofthe investigation andproviding resources and tools to assist public health personnel at the local, state, and Federal level.

A 65-year-old resident of Westchester County, New York was diagnosed with Plasmodium falciparum infection on 2 October 2023. The case had no recent history of international travel to a malaria-endemic area. An extensive epidemiological investigation was initiated to identify the most likely source of the infection and assess the risk of continuing local transmission. Interviews with the case identified multiple potential exposure routes including domestic travel within the United States, hospitalizations overlapping that of individuals diagnosed with travel-associated malaria, residential proximity to imported malaria cases, and outdoor activity overlapping the potential dusk/dawn biting activity of Anopheles mosquitoes. The epidemiologic investigation included syndromic surveillance, healthcare facility investigations, and genetic analysis of specimens collected from the case patient and other malarious patients with epidemiologic links. Results of the genetic analysis and epidemiologic investigation implicated blood-borne transmission in a healthcare setting from a concurrently hospitalized traveler with confirmed malaria. The mechanism remains unknown, although it was likely due to a lapse in infection control. No mosquito-transmitted cases were identified in New York. No additional induced cases from a blood-borne/healthcare-associated exposure were identified. The identification and prompt investigation of potentially locally acquired malaria infections can aid in preventing additional cases by identifying the source and enacting appropriate control measures if necessary.

Background:Malaria is a mosquito borne disease caused by parasites of the genus Plasmodium. In 2023, the United States (US) experienced nine cases of autochthonous Plasmodium vivax malaria transmission; seven in Florida, one in Texas, and another in Arkansas. These were the first autochthonous cases since 2003 when a cluster was identified in Florida. The aim of this study was to genetically characterize the implicated P. vivax isolates in order to complement epidemiologic investigations of these cases. Methods:A custom Illumina AmpliSeq sequencing panel capturing 495 amplicons was designed. This panel was used to ascertain whether these 2023 cases were related, and assess if they were associated with a single or separate introduction events. Sequence data were hierarchically clustered and a Naïve Bayes classification approach was used to assign genotypes to a probable geographic origin based on 113 'geo-informative' SNPs captured by the panel. Genotypes associated with the 2023 Arkansas, Texas, and Florida cases were clustered alongside those sequenced from archived blood samples from the 2003 Florida case-patients, a set of reference strains, and other travel-associated specimens. Microsatellite analysis was performed on a subset of samples from these autochthonous cases to complement the AmpliSeq analysis. Findings:The 2023 autochthonous Florida cases were genetically linked as were the 2003 Florida cases. The 2023 and 2003 Florida clusters were genetically distinct, and the two Florida clusters were distinct from the 2023 Texas and Arkansas cases, which were also distinct from each other. These genotypes classified to the Central or South American region using the Naïve Bayes classifier, including those from the 2003 cluster. Interpretation:These data support that at least three distinct P. vivax introduction events in the US in 2023, involving parasites possessing genetic signatures consistent with Central or South America. Funding:This work was supported by the National Center for Emerging and Zoonotic Infectious Diseases at the US Centers for Disease Control and Prevention.

BACKGROUND:Disseminated gonococcal infection (DGI) is a rare complication of Neisseria gonorrhoeae (Ng) infection, historically affecting 0.5% to 3% of individuals. In 2019, a DGI genomic cluster associated with the ST-7822 strain was identified in southwest Michigan. This study retrospectively assessed the persistence of this strain. METHODS:Ninety Ng isolates from disseminated sites of infection from Michigan (2019-2023) were sequenced; antimicrobial susceptibility testing was performed. Phylogenetic analysis was performed to assess genetic relatedness. Data from 370 ST-7822 urogenital and extragenital gonococcal infection (UGI) isolates were included in the phylogenetic analysis. The porB1A allele, a marker associated with DGI, and antimicrobial resistance markers were also analyzed. RESULTS:Phylogenetic analysis identified 7 DGI clades, with clade 7 (n = 26) containing the 2019 cluster (n = 11). Clade 7 isolates (mean SNP difference, 32) formed 2 subclusters from a single ancestor between 2019 and 2023 and clustered with local UGI isolates. All clade 7 DGI isolates and 82.7% of ST-7822 UGI isolates carried the porB1A allele. Among DGI isolates with antimicrobial susceptibility testing data (n = 88), all were susceptible to ceftriaxone; no mosaic penA alleles were identified. CONCLUSIONS:The persistence of clade 7 associated with the 2019 Michigan DGI cluster suggests ongoing regional transmission of the ST-7822 strain type that has a high proportion with porB1A allele, which has been associated with invasive infection. The genetic similarity between DGI and UGI isolates suggests that DGI strains are not genetically distinct but derived from circulating strains causing mucosal infections. Continued genomic surveillance is essential to understand virulence factors contributing to disseminated infections.

In recent years, multiple reports have emerged describing real-time quantitative polymerase chain reaction (qPCR) detection of DNA derived from human parasite species in environmental soil samples. In one such report, sampling was focused in impoverished areas of the southeastern United States, and a link between poverty and the presence of parasite DNA in soil was proposed. Whether transmission of certain parasitic diseases persists in the United States in association with poverty remains an important question. However, we emphasize caution when reviewing interpretations drawn solely from qPCR detection of parasite-derived environmental DNA without further verification. We discuss here the limitations of using qPCR to test environmental DNA samples, the need for sampling strategies that are unbiased and repeatable, and the importance of selecting appropriate control areas and statistical tests to draw meaningful conclusions.

Importance:In 2023, the US reported 10 locally acquired mosquito-transmitted malaria cases of 4 genetic lineages in 4 states, the first such outbreaks detected in 20 years and the largest in 35 years. Objective:To present the investigations, interventions, and challenges in the public health response to the malaria outbreaks and provide recommendations for future outbreaks. Design, Setting, and Participants:This qualitative study was an interdisciplinary public health response to the locally acquired malaria outbreaks in May to December 2023 and included case investigations, enhanced case finding, polymerase chain reaction analysis of captured Anopheles spp mosquitoes for Plasmodium spp parasites, and novel targeted amplicon sequencing of Plasmodium spp in patient blood samples. Public health interventions included incident command activation, clinician outreach, community awareness, and vector control. Patient data were acquired through public health surveillance as part of National Notifiable Disease Surveillance. Exposure:Plasmodium vivax-infected and Plasmodium falciparum-infected Anopheles spp mosquitoes. Main Outcomes and Measures:Confirmed malaria infection via blood film microscopy and polymerase chain reaction, presence of Plasmodium spp in Anopheles spp mosquitoes, and genetic markers associated with an endemic region of origin and parasite strain relatedness via targeted amplicon sequencing. Results:The study included 10 patients (mean [SD] age of 39.5 [15.0] years; 7 male [70%]) from Florida, Texas, Maryland, and Arkansas with locally acquired mosquito-transmitted malaria and 783 Anopheles spp mosquitoes across 4 states. No patient had a recent history of international travel or blood-borne exposures. Outbreak cases had epidemiologic links within but not across state lines. P vivax was detected in 3 Anopheles crucians in Florida. Sequencing data showed that all Florida P vivax cases shared the same Plasmodium strain. The Texas and Arkansas P vivax cases were genetically distinct from each other and from Florida's cases. All 9 P vivax strains had genetic signatures that were consistent with Central and South American origin. Maryland's P falciparum parasites were consistent with African origin. The outbreaks were contained. Conclusions and Relevance:In this qualitative study of locally transmitted malaria, outbreaks remained contained to individual counties, with Florida's P vivax cases linked to a single strain distinct from those in other states. Sustained Plasmodium spp transmission is unlikely in the US, though increases in global travel and migration, population, temperatures, and persistence of Anopheles spp vectors may increase risk for locally acquired malaria. Clinicians should prescribe chemoprophylaxis for patients traveling to endemic regions, ensure timely diagnosis and treatment, and facilitate public health reporting. Researching US Anopheles spp ecology and control methods while accelerating efforts to reduce malaria globally could mitigate future risk.

A case of locally acquired (autochthonous) mosquito-transmitted Plasmodium vivax malaria was diagnosed in Arkansas in September 2023. This represents the 10th autochthonous case identified nationally in 2023, after 20 years without recorded local mosquitoborne malaria transmission in the United States. The public health response included case investigation, active case surveillance, mosquito surveillance and control, assessment of medical countermeasures, and clinical and public outreach. Prompt diagnosis and appropriate treatment of malaria can improve clinical outcomes and, in addition to vector control, minimize risk for local transmission. Clinicians should consider malaria among patients who have traveled to countries where malaria is endemic, or with unexplained fever regardless of travel history. Although the risk for autochthonous malaria in the United States remains very low, its reemergence highlights the importance of vectorborne disease preparedness and response. Examples of such efforts include improving awareness among clinicians, access to diagnostics and antimalarial medications, and capacity for mosquito surveillance and control. Collaboration and communication among CDC, health departments, local jurisdictions, clinicians, hospitals, laboratories, and the public can support rapid malaria diagnosis, prevention, and control. Before traveling internationally to areas where malaria is endemic, travelers should consult with their health care provider regarding recommended malaria prevention measures, including chemoprophylaxis and precautions to avoid mosquito bites, to reduce both personal and community risk.

Neisseria meningitidis (Nm) and Neisseria gonorrhoeae (Ng) are human pathogens that sometimes occupy the same anatomical niche. Ng, the causative agent of gonorrhea, infects 87 million individuals annually worldwide and is an urgent threat due to increasing drug resistance. Ng is a pathogen of the urogenital tract and may infect the oropharyngeal or rectal site, often asymptomatically. Conversely, Nm is an opportunistic pathogen. While often a commensal in the oropharyngeal tract, it is also the leading cause of bacterial meningitis with 1.2 million cases globally, causing significant morbidity and mortality. Horizontal gene transfer (HGT) is likely to occur between Ng and Nm due to their shared anatomical niches and genetic similarity, which poses challenges for accurate detection and treatment. Routine surveillance through the Gonococcal Isolate Surveillance Project and Strengthening the U.S. Response to Resistant Gonorrhea detected six concerning urogenital Neisseria isolates with contradicting species identification in Milwaukee (MIL). While all six isolates were positive for Ng using nucleic acid amplification testing (NAAT) and matrix-assisted laser desorption/ionization time of flight identified the isolates as Ng, two biochemical tests, Gonochek-II and API NH, classified them as Nm. To address this discrepancy, we performed whole-genome sequencing (WGS) using Illumina MiSeq on all isolates and employed various bioinformatics tools. Species detection analysis using BMScan, which uses WGS data, identified all isolates as Ng. Furthermore, Kraken revealed over 98% of WGS reads mapped to the Ng genome and <1% to Nm. Recombination analysis identified putative HGT in all MIL isolates within the γ-glutamyl transpeptidase (ggt) gene, a key component in the biochemical tests used to differentiate between Nm and Ng. Further analysis identified Nm as the source of HGT event. Specifically, the active Nm ggt gene replaced the Ng pseudogenes, ggt1 and ggt2. Together, this study demonstrates that closely related Neisseria species sharing a niche underwent HGT, which led to the misidentification of species following biochemical testing. Importantly, NAAT accurately detected Ng. The misidentification highlights the importance of using WGS to continually evaluate diagnostic or bacterial identification tests.

IntroductionNeisseria gonorrhoeae (Ng) has successively developed resistance to all previously recommended antimicrobial therapies, with ceftriaxone being the last option for monotherapy of gonorrhea. Global emergence and international spread of the FC428 clone derived mosaic penA-60 allele, associated with highlevel ceftriaxone minimum inhibitory concentrations (MICs) in non FC428 clone Ng lineages, has become an increasing concern. The penA-60 allele carrying Ng was first identified in the U.S. in Las Vegas, Nevada (2019; GCWGS-102723), with a multi-locus sequence type (MLST)-1901 strain, in a non FC428 clone Ng lineage, which is associated with a historically ceftriaxone susceptible core genogroup. Later in 2022, an allele genetically similar to penA-60, mosaic penA-237, was identified in the UK (H22-722) and France (F92) with high-level ceftriaxone MICs and both belonged to MLST-1901.MethodsIn this study, we assessed phylogenomic relatedness and antimicrobial resistance (AMR) determinant profiles of these three isolates with high-level ceftriaxone MICs among a global collection of 2,104 genomes belonging to the MLST-1901 core genome cluster group 31, which includes strains separated by a locus threshold of 200 or fewer differences (Ng_cgc_200). Recombination events in and around the penA coding region were catalogued and potential sources of inter species recombinant DNA were also inferred.ResultsThe global population structure of MLST-1901 core genogroup falls into 4 major lineages. Isolates GCWGS-10723, F92, and H22-722 clustered within Lineage 1, which was dominated by non-mosaic penA-5 alleles. These three isolates formed a clade within Lineage 1 that consisted of isolates from North America and southeast Asia. Neisseria subflava and Neisseria sicca were identified as likely progenitors of two independent recombination events that may have led to the generation of mosaic penA-60 and penA-237, within a possible non-mosaic penA-5 background.DiscussionsOur study suggests that there are multiple evolutionary pathways that could generate concerning mosaic penA alleles via homologous recombination of historically susceptible Ng lineages with Neisseria commensals. Enhanced surveillance of gonococcal strains and Neisseria commensals is crucial for understanding of the evolution of AMR, particularly in less-studied regions (e.g., Asia), where high-level ceftriaxone MICs and multi-drug resistance are more prevalent.

Eight cases of locally acquired, mosquito-transmitted (i.e., autochthonous) Plasmodium vivax malaria, which has not been reported in the United States since 2003, were reported to CDC from state health departments in Florida and Texas during May 18-July 17, 2023. As of August 4, 2023, case surveillance, mosquito surveillance and control activities, and public outreach and education activities continue in both states. U.S. clinicians need to consider a malaria diagnosis in patients with unexplained fever, especially in areas where autochthonous malaria has been recently reported, although the risk for autochthonous malaria in the United States remains very low. Prompt diagnosis and treatment of malaria can prevent severe disease or death and limit ongoing transmission to local Anopheles mosquitoes and other persons. Preventing mosquito bites and controlling mosquitoes at home can prevent mosquitoborne diseases, including malaria. Before traveling internationally to areas with endemic malaria, travelers should consult with a health care provider regarding recommended malaria prevention measures, including potentially taking malaria prophylaxis. Malaria is a nationally notifiable disease; continued reporting of malaria cases to jurisdictional health departments and CDC will also help ensure robust surveillance to detect and prevent autochthonous malaria in the United States.

COVID-19 has brought unprecedented challenges to clinical and public health laboratories. While U.S. laboratories have continued striving to provide quality test results during the pandemic, the uncertainty and lack of supplies became a significant hurdle, hindering day-to-day laboratory operations and the ability to increase testing capacity for both SARS-CoV-2 and non-COVID-19 testing. In addition, long-standing laboratory workforce shortages became apparent, hindering the ability of clinical and public health laboratories to rapidly increase testing. The American Society for Microbiology, the College of American Pathologists, the National Coalition of STD Directors, and the Emerging Infections Network independently conducted surveys in 2020 and early 2021 to assess the capacity of the nation's clinical laboratories to respond to the increase in demand for testing during the COVID-19 pandemic. The results of these surveys highlighted the shortages of crucial supplies for SARS-CoV-2 testing and supplies for other routine laboratory diagnostics, as well as a shortage of trained personnel to perform testing. The conclusions are based on communications, observations, and the survey results of the clinical laboratory, public health, and professional organizations represented here. While the results of each survey considered separately may not be representative of the entire community, when considered together they provide remarkably similar results, further validating the findings and highlighting the importance of laboratory supply chains and the personnel capable of performing these tests for any response to a large-scale public health emergency.

Background The only drugs approved by the US Food and Drug Administration for oral treatment of trichomoniasis belong to the 5-nitroimidazole group. Most individuals infected with Trichomonas vaginalis can be cured with a standard treatment of metronidazole or tinidazole, but it is estimated that more than 159,000 people fail treatment each year. Although a minimal lethal concentration (MLC) corresponding to treatment failure has been reported for metronidazole, the MLC for tinidazole associated with treatment failure has not been determined. We conducted a study using T. vaginalis isolates from women with reported treatment success or failure to determine these values. Methods We measured MLCs of 47 isolates obtained from women who had failed metronidazole treatment, 33 isolates from women who had failed tinidazole treatment, and 48 isolates from women successfully cured with metronidazole. The cutoff was calculated as the 95th percentile of MLCs of susceptible isolates for each drug. Results Our data confirmed that the MLC previously associated with metronidazole treatment failure is ≥50 μg/mL and identified the MLC associated with tinidazole treatment failure as ≥6.3 μg/mL. For metronidazole, the agreement between laboratory result and treatment outcome was 93.7%; for tinidazole, this agreement was 88.9%. Conclusions The T. vaginalis susceptibility assay is useful for determining whether 5-nitroimidazole treatment failure in persons with trichomoniasis can be attributed to drug resistance. These results are useful for establishing interpretive guidance of test results, and MLC levels can help guide appropriate patient treatment.

Background The Aptima Combo 2 (AC2) assay manufactured by Hologic, Inc., detects Neisseria gonorrhoeae and/or Chlamydia trachomatis (CT) in urogenital and extragenital specimens by targeting either a 16S rRNA (N. gonorrhoeae) or 23S rRNA (CT) region. In 2019, a mutation (C1515T) in the 23S rRNA region was reported to cause false-negative/equivocal results in specimens collected in Finland. Specimens containing this variant (Fl-nvCT) were also discovered internationally. Working with specimens submitted to a large commercial laboratory, we sought to determine if this variant was also present in the United States. Methods A subset (n = 401) of specimens tested with the AC2 assay collected during a 5-week period in late 2019/early 2020 were evaluated using an updated AC2 assay. Results Although the FI-nvCT variant was not detected within this specimen panel, 2 CT variants containing 23S rRNA mutations (A1518G, G1526A) were identified. The updated AC2 assay targeting an additional region of the 23S rRNA detected both of these variants. A retrospective study of >18 million AC2 results tested between 2018 and 2019 did not display a decrease in CT positivity. Conclusions Although we did not detect the Fl-nvCT variant among US specimens, we show evidence that the low occurrence of similar diagnostic-escape mutants can be detected with an updated AC2 assay using multiple 23S rRNA targets.

Disseminated gonococcal infection (DGI) is a rare complication caused by the systemic dissemination of Neisseria gonorrhoeae to normally sterile anatomical sites. Little is known about the genetic diversity of DGI gonococcal strains and how they relate to other gonococcal strains causing uncomplicated mucosal infections. We used whole genome sequencing to characterize DGI isolates (n = 30) collected from a surveillance system in Georgia, United States, during 2017-2020 to understand phylogenetic clustering among DGI as well as uncomplicated uro- and extragenital gonococcal infection (UGI) isolates (n = 110) collected in Fulton County, Georgia, during 2017-2019. We also investigated the presence or absence of genetic markers related to antimicrobial resistance (AMR) as well as surveyed the genomes for putative virulence genetic factors associated with normal human-serum (NHS) resistance that might facilitate DGI. We found that DGI strains demonstrated significant genetic variability similar to the population structure of isolates causing UGI, with sporadic incidences of geographically clustered DGI strains. DGI isolates contained various AMR markers and genetic mechanisms associated with NHS resistance. DGI isolates had a higher frequency of the porB1A allele compared with UGI (67% vs 9%, P < .0001); however, no single NHS resistance marker was found in all DGI isolates. Continued DGI surveillance with genome-based characterization of DGI isolates is necessary to better understand specific factors that promote systemic dissemination.

Neisseria gonorrhoeae multi-locus sequence type (ST) 9363 genogroup isolates have been associated with reduced azithromycin susceptibility (AZM rs ) and show evidence of clonal expansion in the U.S. Here we analyze a global collection of ST-9363 genogroup genomes to shed light on the emergence and dissemination of this strain. The global population structure of ST-9363 genogroup falls into three lineages: Basal, European, and North American; with 32 clades within all lineages. Although, ST-9363 genogroup is inferred to have originated from Asia in the mid-19 th century; we estimate the three modern lineages emerged from Europe in the late 1970s to early 1980s. The European lineage appears to have emerged and expanded from around 1986 to 1998, spreading into North America and Oceania in the mid-2000s with multiple introductions, along with multiple secondary reintroductions into Europe. Our results suggest two separate acquisition events of mosaic mtrR and mtrR promoter alleles: first during 2009-2011 and again during the 2012-2013 time, facilitating the clonal expansion of this genogroup with AZM rs in the U.S. By tracking phylodynamic evolutionary trajectories of clades that share distinct demography as well as population-based genomic statistics, we demonstrate how recombination and selective pressures in the mtrCDE efflux operon granted a fitness advantage to establish ST-9363 as a successful gonococcal lineage in the U.S. and elsewhere. Although it is difficult to pinpoint the exact timing and emergence of this young genogroup, it remains critically important to continue monitoring it, as it could acquire additional resistance markers.

Objectives Neisseria gonorrhoeae (gonococcus) infection is one of the most commonly reported nationally notifiable conditions in the United States. Gonococcus has developed antimicrobial resistance to each previously used antibiotic for gonorrhea therapy. However, some isolates may be still susceptible to no longer recommended, yet still effective antibiotics. This in turn suggests that targeted therapy could slow resistance development to currently recommended empirical treatments. We curated a gonococcal Ciprofloxacin Antibiotic Resistance Isolate Bank panel (Cipro-panel) as a tool for validating or developing new tests to determine ciprofloxacin susceptibility. Method The Cipro-panel was selected using whole genome sequencing, bioinformatic tools, and antimicrobial susceptibility testing (AST) data. Isolates were further selected based on nucleotide variations in gyrA and parC genes. Results We selected 14 unique N. gonorrhoeae isolates from the 2006–2012 Gonococcal Isolate Surveillance Project (GISP) collection. They represented a wide range of antimicrobial susceptibility to ciprofloxacin and commonly observed nucleotide variations of gyrA and parC genes. This Cipro-panel consists of 5 isolates with resistant phenotypes (MIC > = 1 μg/mL), 8 isolates with susceptible phenotypes (MIC < = 0.06 μg/mL), and 1 isolate falling in the Clinical and Laboratory Standards Institute defined intermediate range. Among the gyrA variations we observed a total of 18 SNPs. Four positions had nonsynonymous changes (nucleotide positions 272, 284, 1093, and 1783). The first two positions (272 and 284) have been linked previously with resistance to ciprofloxacin (i.e. amino acid positions 91 and 95). For the parC gene, we observed a total of 21 possible SNPs. Eight of those SNPs resulted in non-synonymous amino acid changes. One location (amino acid 87) has been previously reported to be associated with ciprofloxacin resistance. Conclusions This Cipro-Panel is useful for researchers interested in developing clinical tests related to ciprofloxacin. It could also provide additional choices for validation, quality assurance purposes and improve antibiotic usage.

During 2015-2019, 77 culture-confirmed disseminated gonococcal infection (DGI) cases were identified through active surveillance for a rate of 0.13 cases per 100 000 population. All available isolates were susceptible to ceftriaxone. Continued DGI surveillance can help inform treatment recommendations. Background Disseminated gonococcal infections (DGIs) are thought to be uncommon; surveillance is limited, and case reports are analyzed retrospectively or in case clusters. We describe the population-level burden of culture-confirmed DGIs through the Active Bacterial Core surveillance (ABCs) system. Methods During 2015-2016, retrospective surveillance was conducted among residents in 2 ABCs areas and prospectively in 3 ABCs areas during 2017-2019. A DGI case was defined as isolation of Neisseria gonorrhoeae from a normally sterile site. A case report form was completed for each case and antimicrobial susceptibility testing (AST) was performed on available isolates. Results During 2015-2019, 77 DGI cases were identified (a rate of 0.13 cases per 100 000 population) and accounted for 0.06% of all reported gonorrhea cases in the 3 surveillance areas. Most DGI cases were male (64%), non-Hispanic Black (68%), and ranged from 16 to 67 years of age; blood (55%) and joint (40%) were the most common sterile sites. Among 29 isolates with AST results during 2017-2019, all were susceptible to ceftriaxone. Conclusions DGI is an infrequent complication of N gonorrhoeae; because it can quickly develop antimicrobial resistance, continued DGI surveillance, including monitoring trends in antimicrobial susceptibility, could help inform DGI treatment recommendations.