The role of the L421P mutation in Penicillin-Binding Protein 1 (PBP1) in the evolution of chromosomally mediated penicillin resistance in Neisseria gonorrhoeae

ponAL421P encodes a mutated variant of penicillin-binding protein 1 (PBP1) and is a key resistance determinant that increases the penicillin MIC (MICPEN) above the clinical breakpoint in Neisseria gonorrhoeae. Despite the removal of penicillin from treatment guidelines for gonococcal infections in the 1980s, ponAL421P is present in nearly 50% of current N. gonorrhoeae isolates in the PubMLST database. Bioinformatic analysis indicates that ponAL421P is exclusive to N. gonorrhoeae isolates, whereas Leu-421 is 100% conserved in other Neisseria species. To understand the involvement of ponAL421P in antibiotic resistance, we introduced ponA variants encoding 16 different amino acids at position-421 into FA6140, a penicillin-resistant gonococcal isolate that naturally harbors ponAL421P. Proline-421 was the only mutation that increased the MICPEN to the same level as FA6140. We also assessed the fitness of strains with the 16 mutant ponA alleles over multiple serial passages, both with and without sub-MIC levels of penicillin. There was no fitness defect attributed to ponAL421P under these experimental conditions; instead, our analyses suggest that the widespread occurrence of ponAL421P is driven by its capacity to increase the MICpen above the clinical breakpoint. In FA6140 transformed with the mosaic penA allele from strain H041, a ceftriaxone-resistant isolate, ponAL421P increased the MIC of ceftriaxone, suggesting that ceftriaxone targets PBP1 in this strain. We conclude that the ponAL421P allele emerged in gonococcal isolates, increasing the MICPEN above the clinical breakpoint, and has remained in the population even after the removal of penicillin from treatment guidelines. ImportanceThe emergence of antibiotic-resistant Neisseria gonorrhoeae threatens effective treatment of gonorrhea, one of the most common sexually transmitted infections worldwide. Understanding the genetic changes that drive and maintain resistance is crucial for anticipating future resistance trends. Here, we investigated the impact of a key resistance mutation in PBP1 (encoded by ponAL421P). Although penicillin has not been used to treat gonorrhea for decades, this mutation remains widespread even in recent N. gonorrhoeae isolates. ponAL421P confers clinically relevant penicillin resistance without imposing an in vitro fitness cost. ponAL421P also increases resistance to ceftriaxone in strains with penA alleles that are associated with ceftriaxone resistance. This work highlights the role of the ponAL421P allele in shaping the current antibiotic resistance landscape and supports the need for ongoing surveillance and evolutionary studies of such mutations in the gonococcal population.