20 2 Oxfordshire Sexual Health Service, Oxford University Hospitals NHS Foundation Trust, 21 Oxford, UK g 22 Brighton and Hove sexual health and contraception service, Royal Sussex County Hospital, 23 Brighton, UK h 24 25 26 Running title: Nanopore sequencing N. gonorrhoeae direct from urine 27 Address correspondence to teresa.street@ndm.ox.ac.uk and david.eyre@bdi.ox.ac.uk. 28 3 Abstract 29Background. Empirical gonorrhoea treatment at initial diagnosis reduces onward 30 transmission. However, increasing resistance to multiple antibiotics may necessitate waiting 31 for culture-based diagnostics to select an effective treatment. There is a need for same-day 32 culture-free diagnostics that identify infection and detect antimicrobial resistance. 33 Methods. We investigated if Nanopore sequencing can detect sufficient N. gonorrhoeae 34 DNA to reconstruct whole genomes directly from urine samples. We used N. gonorrhoeae 35 spiked urine samples and samples from gonorrhoea infections to determine optimal DNA 36 extraction methods that maximize the amount of N. gonorrhoeae DNA sequenced whilst 37 minimizing contaminating host DNA. 38 Results. In simulated infections the Qiagen UCP Pathogen Mini kit provided the highest ratio 39 N. gonorrhoeae to human DNA and the most consistent results. Depletion of human DNA 40 with saponin increased N. gonorrhoeae yields in simulated infections, but decreased yields 41 in clinical samples. In ten urine samples from men with symptomatic urethral gonorrhoea, 42 ≥87% coverage of an N. gonorrhoeae reference genome was achieved in all samples, with 43 ≥92% coverage breath at ≥10-fold depth in 7 (70%) samples. In simulated infections if ≥10 4 44 CFU/ml of N. gonorrhoeae was present, sequencing of the large majority of the genome was 45 frequently achieved. N. gonorrhoeae could also be detected from urine in cobas PCR Media 46 tubes and from urethral swabs, and in the presence of simulated Chlamydia co-infection. 47 Conclusion. Using Nanopore sequencing of urine samples from men with urethral 48 gonorrhoea sufficient data can be obtained to reconstruct whole genomes in the majority of 49 samples without the need for culture. 50 51 4 52