PERSPECTIVE n engl j med 366; 6 nejm. org february 9, 2012 486 ceptibility to cefixime; the cassette may have been acquired through horizontal transfer from oral commensal neisseria. Decreased susceptibility to cefixime was first reported in East Asia, and possible failure of treatment with cefixime was noted in Japan in 2003 and was later documented in Norway and the United Kingdom in 2010. The greatest worry is the strain isolated in Kyoto in 2009 from a patient with pharyngeal gonorrhea that was highly resistant to ceftriaxone (with MICs of 2.0 to 4.0 µg per milliliter). This strain is related to earlier clones with reduced cefixime susceptibility, but it carries a different version of the penA mosaic gene. 4 It has been almost 3 years since it was detected in Japan, so it may not be highly pathogenic. If history is any guide, however, such strains will continue to evolve. Indeed, we should anticipate the emergence of fit cephalosporin-resistant strains that can spread widely.