High-frequency switching between ON and OFF states in the phase variable modB methylase impacts gonococcal azithromycin susceptibility

The gonococcal adenine methylases modA and modB, belonging to separate Type III restriction modification systems, are phase variable and could thus enable rapid adaptation to changing environments. However, the frequency of phase variation across transmission chains and the phenotypic impact of phase variation are largely unknown. Here we show that the repeat tracts enabling phase variation expand and contract at high rates in both modA and modB. For modB, multiple ON/OFF transition events were identified over the course of a single outbreak. A mixed effects model using population samples from Norway and a global meta-analysis collection indicates that modB in the OFF state is predictive of moderately decreased ceftriaxone susceptibility. Our findings suggest that modB orchestration of genome-wide 6-methyladenine modification controls the expression of genes modulating ceftriaxone susceptibility. ImportanceDespite significant progress, our current understanding of the genetic basis of antibiotic susceptibility remains incomplete. The gonococcal methylase modB is phase variable, meaning that it can be switched ON or OFF via contraction or expansion of a repeat tract in the gene during replication. We find that transitions between the ON and OFF state occur at high frequency. Furthermore, isolates harbouring modB in a configuration predicted to be inactive had decreased susceptibility to ceftriaxone, an antibiotic used to treat gonorrhea. This finding improves understanding of the genetic underpinnings of antibiotic resistance, but further work is needed to elucidate the mechanics and broader phenotypic effects of epigenetic modifications and transcription.