Differential response of chlamydial and ureaplasma-associated urethritis to sulphafurazole (sulfisoxazole) and aminocyclitols

Management of Mycoplasma genitalium infections - can we hit a moving target?

Mycoplasma genitalium is an etiological agent of sexually transmitted infections, but due to its fastidious growth requirements, only a few M. genitalium strains are available for determination of the activity of currently used and new antimicrobial agents.

Recent clinical trials have demonstrated that treatment with azithromycin has decreasing efficacy due to an increasing prevalence of macrolide resistance, which is likely to be attributed to the widespread use of 1 g single dose azithromycin. Second line treatment with moxifloxacin is similarly under pressure from emerging resistance. The era of single dose monotherapy for uncomplicated STIs such as M. genitalium and N. gonorrhoeae, while convenient for patients and physicians, has been associated with escalating resistance and treatment failure and is now drawing to a close. There is a critical need for trials of combinations of existing registered drugs and new antimicrobial compounds, implementation of diagnostic testing combined with molecular detection of resistance, and antimicrobial surveillance.

Microbiology of the prostate

Prostatitis is a common genitourinary disease in men. The National Institutes of Health has defined four types of prostatitis. The bacteriology of acute and chronic bacterial prostatitis is well understood. Causative organisms can be isolated by four-glass urine cultures. Chronic pelvic pain syndrome (CPPS; chronic abacterial prostatitis) is an enigma; whether there is a microbiologic cause for this condition is unknown. Researchers have postulated that CPPS may be an infectious disease of the prostate. This article reviews current literature regarding the microbiology of the prostate in CPPS.

Etiology of nongonococcal nonchlamydial urethritis

The majority of cases of acute nongonococcal urethritis (NGU) are due to causes other than infection with Chlamydia trachomatis. Pathogens implicated as causes of nonchlamydial nongonococcal urethritis (NCNGU) include Mycoplasma genitalium, Ureaplasma urealyticum, Trichomonas vaginalis, and primary infection with herpes simplex virus. In a majority of cases of acute NCNGU, no pathogen can be isolated. The etiology of chronic NCNGU is unknown.

An association between non-gonococcal urethritis and bacterial vaginosis and the implications for patients and their sexual partners

OBJECTIVES

The aetiology of non-gonococcal urethritis (NGU) in a considerable proportion of men remains unaccounted for. We wished to investigate the possible aetiological role of bacterial vaginosis (BV), the commonest cause of abnormal discharge in women, in this condition.

METHODS

We carried out two studies. In the first, case-control, study, we recruited men with and without NGU and examined their female partners for evidence of BV. The second, cohort design, study which ran concurrently with the first study involved recruiting women with and without BV and examining their male partners for evidence of NGU. The diagnoses of both NGU and BV were made microscopically to include symptomatic and asymptomatic individuals in both disease categories.

RESULTS

In the case-control study 51 couples were recruited. Of these 39 men had NGU and 12 (31%) of their female contacts had BV. In contrast, of 12 men without NGU, only one (8%) of the female partners had BV (odds ratio 4.89, 95% CI: 0.51-42.27). When only Chlamydia trachomatis negative patients were considered, the odds ratio for an association between BV and NGU was increased to 6.77, 95% CI: 0.73-62.68). Thirty eight couples were recruited to the cohort design study. Of 17 women with BV, 12 (71%) of their male partners had NGU. In contrast, of 21 women without BV, seven (33%) of their male partners had NGU (p = 0.049, odds ratio 4.8). When only C trachomatis negative patients were considered, the significance of the association was increased (p = 0.037; odds ratio 5.42).

CONCLUSIONS

An association exists between NGU and BV, and vice versa. If BV arises de novo the findings could help to explain the development of urethritis in stable sexual relationships.

Risk factors for urethritis in heterosexual men. The role of fellatio and other sexual practices

BACKGROUND

Nonchlamydial nongonococcal urethritis (NGU) is a common sexually transmitted disease (STD) in heterosexual men. Prior studies have suggested that NGU may be acquired by insertive oral sex.

GOAL

To assess the association of oral sex and other sexual practices with nonchlamydial NGU in heterosexual men in order to better understand this syndrome and to guide its prevention and treatment. Risk factors for urethral gonorrhea and chlamydial infection were explored to contrast with NGU.

STUDY DESIGN

A retrospective case-control study was conducted among heterosexual men attending as STD clinic during 1993 and 1994. The study included 4,848 men who were sexually active within the prior 2 months and had urethral specimens obtained for Gram's stain, culture for Neisseria gonorrhoeae, and culture for Chlamydia trachomatis.

RESULTS

Insertive oral sex was not shown to be an independent risk factor for NGU. Independent predictors of nonchlamydial NGU by multivariate analysis included African-American race (odds ratio [OR] 3.71, 95% confidence interval [95% CI] 3.06 to 4.50) and having > or = two sex partners in the prior 2 months (OR 1.45, 95% CI 1.20 to 1.75). History of using condoms "always" was negatively associated with NGU (OR 0.59, 95% CI 0.43 to 0.79), gonorrhea (OR 0.31, 95% CI 0.17 to 0.56), and chlamydial infection (OR 0.67, 95% CI 0.44 to 1.03).

CONCLUSIONS

This study supports the sexually transmitted nature of nonchlamydial NGU but did not confirm an association with oral sex. However, the analysis was compromised by the rarity of insertive oral sex as patients' only sexual exposure. Consistent condom use protects against all causes of sexually acquired urethritis.

Drug therapies for sexually transmitted diseases. Clinical and economic considerations

Sexually transmitted diseases (STDs) are common, and result in immense social and economic costs. In some countries they have a major demographic impact. Because many STDs facilitate the transmission of HIV, the consequences of STDs are further increasing. At the same time, this association between STDs and HIV provides one of the ways in which drug therapy should be very cost effective. The perspective taken in this article is a societal one, and broader issues than those directly related to drug costs and benefits are discussed. However, it is the availability of drugs that has the potential to most quickly and most reliably make a major difference to overall health sector and societal costs as they relate to STDs. For those STDs for which curative therapy is available (particularly Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, and Trichomonas vaginalis) there have been large decreases in prevalence in many parts of the world. In contrast, those STDs for which curative therapy is not available (particularly HIV, genital herpes and genital human papillomavirus infection) have had stable or increasing prevalence. For these latter infections, each new case increases the overall prevalence. Numerous features of STDs make clinical and economic evaluation difficult. These include the sensitive nature of the topic, the changing epidemiology and drug susceptibility of individual STDs, the fact that a large proportion of those infected are asymptomatic, difficulties in making specific diagnoses, the fact that often consequences are recognised late, sexual re-exposure and reinfection, and inadequate data on which to do clinical and economic evaluations. Furthermore, risk of acquiring an STD roughly correlates inversely with socioeconomic status, and countries or places with the highest rates of STDs may have the least ability to deal effectively with their diagnosis and management. Most of the direct and indirect costs are incurred by women, since they experience the vast majority of the complications of STDs. Many of these only become apparent years later, which makes it very hard to attribute costs and benefits to a specific episode of infection, and to its treatment. The late and indirect costs, plus the costs of prevention, are hard to quantify. That the major burden of STDs is in adolescents and young adults, socioeconomically disadvantaged groups and women has important implications, including for pharmacoeconomic studies.(ABSTRACT TRUNCATED AT 400 WORDS)

The office approach to the sexually transmitted diseases: Part I

Sexually transmitted diseases (STDs) are diagnosed in 10 million patients per year in the United States. The infected individuals come from all walks of life and all age groups. They may present with either genital or nongenital signs and symptoms. Most individuals are treated as outpatients, but more than a quarter of a million hospital admissions for STDs are necessary each year. These numbers will rise precipitously as the number of AIDS cases increases. More than 10,000 deaths per year are caused by STDs, primarily because of AIDS, cervical carcinoma, and hepatitis B induced cirrhosis and hepatoma. Physicians must become highly skilled in the diagnosis and treatment of the common STDs caused by herpes simplex virus, Neisseria gonorrhoeae, and Chlamydia trachomatis. Simple office microscopic skills are needed for the diagnosis of vaginitis, cervicitis, and urethritis, and all physicians should be encouraged to develop these skills. Physicians will need to keep abreast of the rapidly evolving changes in the diagnosis and treatment of STDs.

Microflora of the urethra in adolescent boys: relationships to sexual activity and nongonococcal urethritis

Urethral cultures were obtained from 90 adolescent youth, 16 of whom denied previous sexual activity. Among the sexually active boys was a group of 32 with clinically significant pyuria, consistent with the diagnosis of urethritis, on a first-part urinalysis (FPU) specimen. To relate differences in urethral microflora to sexual activity, 42 sexually active patients with a negative FPU were compared with the never sexually active group. The profile of anaerobic, but not aerobic, bacteria isolated from the urethra was related to the presence or absence of previous sexual activity. Mycoplasma species and Ureaplasma urealyticum were isolated from sexually active patients only, and may be markers of sexual activity in adolescent boys. Of the 32 patients with FPU evidence of urethritis, 22 (69%) had cultures positive for Chlamydia trachomatis, and an additional three (9%) had cultures positive for Neisseria gonorrhoeae. The findings in sexually active patients with a positive FPU were otherwise similar to those of sexually active patients without evidence of urethritis. C. trachomatis appears to be the most important agent of urethritis among adolescent boys with a positive FPU.

Pathogenesis and significance of urogenital mycoplasmal infections

U. urealyticum and M. hominis can no longer be considered as harmless commensals of the lower genitourinary tract. Both can produce disease in humans. Diagnosis and management of infections due to these organisms must be based upon isolation of the organisms from the affected site and preferably the number of organisms present. Due to the frequent resistance of both organisms to tetracycline, treatment must be based upon appropriate antibiotic sensitivities. For a more detailed description of the basic biology of these organisms and isolation and identification and treatment, the reader is referred to several recent reviews.

Clinical approach to urethritis, mucocutaneous lesions, and inguinal lymphadenopathy in homosexual men

The spectrum of sexually transmitted diseases observed among homosexual men is diverse, but in general includes the same infections observed among heterosexuals. A systematic approach to the diagnosis of these diseases, incorporating sexual history, predominant symptoms, findings from physical examination, and office laboratory evaluation will frequently yield a specific diagnosis. Prompt diagnosis and treatment of patients, and when appropriate, of contacts are of critical importance to the prevention of unnecessary morbidity and further transmission of disease.

Mycoplasma infections of the human urogenital tract with particular reference to non-gonococcal urethritis

The criteria which need to be fulfilled before regarding a microorganism as a cause of non-gonococcal urethritis (NGU) are considered in relation to Mycoplasma hominis, Ureaplasma urealyticum and M. genitalium. There is no evidence to support an aetiological role for M. hominis, but few appropriate investigations have been undertaken. The criteria have been met, for the most part, in the case of U. urealyticum, but further quantitative studies are required. The role of M. genitalium is unknown, but its biological and morphological features and ability to cause genital disease in animals suggest that it may be pathogenic for man. It is emphasized that the criteria for regarding a microorganism as a cause of NGU should also be used where feasible when investigating the infectious aetiology of other genito-urinary conditions.

Serological characterisation of Ureaplasma urealyticum strains by enzyme-linked immunosorbent assay (ELISA)

A modification of enzyme-linked immunosorbent assay (ELISA) was developed for the serological characterisation and identification of strains of Ureaplasma urealyticum. The eight recognised human serotypes of U urealyticum and antisera produced against them were used as reference for the evaluation and standardisation of the method. The serological profile illustrating reactions of antigen with homologous and heterologous antisera was specific and reproducible for each serotype. The homologous reaction was always very prominent but some cross-reactivity was seen, most clearly between serotypes 2 and 5. The method was found to be suitable for serological typing of clinical isolates of U urealyticum because of rapid and simple technical procedure, good reproducibility of the results and economical consumption of antisera and other reagents.

Lack of in vitro activity of cefoxitin, cefamandole, cefuroxime, and piperacillin against Chlamydia trachomatis

Newer penicillins and cephalosporins are being evaluated in many infections. One of these infections, acute pelvic inflammatory disease, can be caused by Chlamydia trachomatis. This study demonstrated that cefoxitin, cefamandole, cefuroxime, and piperacillin had no effective in vitro activity against C. trachomatis.

Efficacy of treatment regimens for lower urogenital Chlamydia trachomatis infection in women

One hundred thirteen women had Chlamydia trachomatis isolated from the cervix, or urethra, or both, were treated, and followed until failure occurred or for at least 40 days after initiation of treatment. On regimens given four times daily for 7 days, failure occurred in three (8%) of 38 on tetracycline, 500 mg, in none of five on erythromycin, 500 mg, and in three (8%) of 37 on erythromycin, 250 mg. On regimens of 500 mg given four times daily for 10 days, failure occurred in none of nine on tetracycline and in one (4%) of 24 on sulfisoxazole. Erythromycin, 500 mg, was stopped because of severe side effects. Another 10 women were given a loading dose of ampicillin plus additional ampicillin for 3 to 21 days and were followed for 4 to 76 days after treatment was stopped. Only two women remained culture positive after therapy. This study demonstrates that antimicrobial regimens that are frequently given to women in North America have significant activity against C. trachomatis.

In vitro and in vivo efficacy of antimicrobials against Chlamydia trachomatis

With the exception of lymphogranuloma venereum, the treatment of Chlamydia trachomatis infections in the genital tract or acquired from the genital tract is relatively easy. In general, in vivo activity of antimicrobials against C. trachomatis correlates well with in vitro activity if sufficient antimicrobial is given for a long enough duration. Tetracycline and erythromycin and their derivatives remain the treatments of choice because of combined activity against C. trachomatis, in addition to most isolates of Neisseria gonorrhoeae and Ureaplasma urealyticum. Rifampin, sulfonamides, or trimethoprim-sulfamethoxazole can only be used if C. trachomatis alone is being treated. Although multiple dose penicillins may be significant activity in vivo, their use is not encouraged. Other antimicrobials like aminocyclitols, cephalosporins, and metronidazole have no activity. Seven day regimens of either a tetracycline or erythromycin are generally preferred for uncomplicated infections, but ten days of a tetracycline is preferred for complications like acute pelvic inflammatory disease or epididymitis. For ocular or pulmonary infection in infants, a two to three week regimen of oral sulfonamide or erythromycin is preferred. for the treatment of concurrent N. gonorrhoeae and C. trachomatis, a tetracycline should be administered for at least five days.

Genitourinary infection with Ureaplasma urealyticum in women attending a sexually transmitted diseases clinic

Ureaplasma urealyticum was detected in the cervix of 49·9% and in the urine of 47·7% of women attending a department of genitourinary medicine. Isolation of U urealyticum was not related to diagnosis, nor was there any association between the presence of the organism and any symptoms or signs of genital tract disease. Fewer organisms were detected in the cervix of women who had a concurrent infection with Chlamydia trachomatis than in women who had not. A pathological role for U urealyticum has not been established.

Chlamydia trachomatis and Ureaplasma urealyticum in men attending a sexually transmitted diseases clinic

Urethral specimens from 480 heterosexual patients were examined for Chlamydia trachomatis. Chlamydia were isolated from 32.7% of men with non-specific urethritis (NSU), from 16.1% of men with gonorrhoea, and from 4.1% of men without urethritis. Chlamydial isolation was not related to duration of symptoms, presence of discharge, or past history of attendance at the clinic. Urine from 176 heterosexual patients was examined for Ureaplasma urealyticum. Ureaplasmas were present in 53.8% of men with NSU, in 28% of men with gonorrhoea, and in 32.9% of men with no urethritis. Detection rates for ureaplasmas in patients with chlamydia-negative and chlamydia-positive NSU were similar, but ureaplasmas were present in significantly greater numbers in patients with chlamydia-negative NSU than in those with chlamydia-positive NSU.

Antimicrobial susceptibility of Ureaplasma urealyticum

An antimicrobial susceptibility test, a tow-tube broth dilution and disk elution method for Ureaplasma urealyticum, was modified to incorporate some of the standard procedures followed in traditional antimicrobial testing. The susceptibility pattern of the species was reevaluated by determining the effect of various antimicrobial agents on 21 vaginal isolates. All isolates were inhibited by tetracycline congeners (1 to 6 micrograms/ml) and killed by methenamine mandelate (0.6 mg/ml). All but one isolates were inhibited by erythromycin (0.4 to 3 micrograms/ml). Only eight isolates were inhibited by nalidixic acid (1 to 6 micrograms/ml), and seven were inhibited by nitrofurantoin (20 to 60 micrograms/ml), whereas all isolates were resistant to rifampin (1 microgram/ml) and trimethoprim-sulfamethoxazole (5 micrograms/ml). The in vitro technique described can readily be performed on individual patient isolates before the initiation of antimicrobial therapy.

Tetracycline in nongonococcal urethritis. Comparison of 2 g and 1 g daily for seven days

In a previous study treatment with minocycline 100 mg orally every day for seven days was as effective for nongonococcal urethritis (NGU) as 200 mg for seven days or 100 or 200 mg for 21 days. In this prospective, randomised study men with NGU received tetracycline either 500 mg or 250 mg four times daily for seven days. of 200 men initially enrolled, Chlamydia trachomatis was isolated from 40% and Ureaplasma urealyticum from 48%. Eight of 10 homosexual men compared with 39 (21%) of 190 bisexual or heterosexual men had negative culture results for both C trachomatis and U urealyticum (x2 = 15.5, P < 0.0005). U urealyticum was isolated more frequently from chlamydia-negative men and from men with 10 or fewer sex partners during their lifetime. Both regimens were equally effective in their in-vivo activity against C trachomatis and U urealyticum. Failure rates were similar with the two regimens. More obvious failure with purulent or profuse mucoid discharge and pyuria occurred more frequently with the 250-mg regimen (20% of 76 men on the 250-mg regimen compared with 7% of 67 men on the 500-mg regimen; x2 = 4.45, P < 0.05). Failure occurred more frequently in men who were initially chlamydia-negative and in men in whom U urealyticum persisted after medication. Thus, the 250-mg regimen appeared to be as effective as the 500-mg regimen in the initial treatment of NGU. However, one-third of men had persistent or recurrent urethritis with these regimens, and there is a need for antimicrobial agents with greater in-vivo activity, especially against chlamydia-negative NGU.

The rôle of Chlamydia trachomatis in genital-tract and associated diseases

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Nongonococcal urethritis

The nongonococcal urethritis (NGU) syndrome is a group of sexually transmitted infections that together exceed the frequency of gonorrhea in men in most urban areas of Europe and the United States, and probably in much of the remainder of the world. "Nongonococcal" is preferred to the term "non-specific" urethritis because the latter is less precise and carries the inaccurate implication that the causes are unknown and perhaps unknowable.

Non-specific (non-gonococcal) urethritis

A report is made of a small study of ureaplasmas and chlamydias in 32 cases of non-specific urethritis. Erythromycin was used as a therapeutic agent and found to be reasonably effective.

Comparison of erythromycin stearate and oxytetracycline in the treatment of non-gonococcal urethritis: their efficacy against Chlamydia trachomatis

The effectiveness of Oxytetracycline 250 mg. 6 hourly for 2 weeks and erythromycin stearate 500 mg. 12 hourly for 2 weeks in the treatment of non-gonococcal urethritis (NGU) have been compared; cell culture for Chlamydia trachomatis was performed before and after treatment. There was no significant difference between the results obtained with the two antimicrobials. Both were clinically effective in the treatment of Chlamydia-positive NGU. Response to therapy was rapid; 2 weeks after treatment began, only 5 (14%) of 35 men treated with Oxytetracycline and 4 (13%) of 30 men treated with erythromycin stearate still had urethritis. Clinical improvement was accompanied in the majority of cases by failure to re-isolate C. trachomatis, but a small number of men who had not been exposed to the risk of reinfection yielded chlamydiae after therapy with Oxytetracycline or erythromycin stearate.

The results of treatment of men with NGU from whom C. trachomatis had not been isolated were similar to those obtained in isolation-positive patients; again, there was no significant difference in the efficacy of the two antimicrobials. It is concluded that erythromycin stearate is a useful alternative to tetracyclines in the treatment of NGU.

Bacteriology of the urethra in normal men and men with nongonococcal urethritis

Sixty-nine Caucasian males without a previous history of urethritis and who developed nongonococcal urethritis (NGU) and 39 similar men without urethritis (NU) were cultured from the urethra for Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, aerobes, and anaerobes. C. trachomatis infection was proven by culture of serology in 26 (38%) of the NGU group and 1 (3%) of the NU group; the C. trachomatis-negative NGU group had significantly more U. urealyticum (81%) than the C. trachomatis-positive NGU group (42%) or the NU group (59%). Aerobes were isolated from significantly more NU men (91%) than from men with NGU (66%). The aerobic and anaerobic flora of the two NGU groups were similar. The NU group had significantly more aerobic lactobacilli. Haemophilus vaginalis, alpha-hemolytic streptococci (not Streptococcus faecalis), and anaerobes, predominantly Bacteroides species. This study has provided information about the prevalence and the variety of the aerobic and anaerobic microbiological flora of the anterior urethra of sexually active males. It does not implicate any bacteria other than C. trachomatis and U. urealyticum as potential causes of NGU.

Spectinomycin versus tetracycline for the treatment of gonorrhea

Spectinomycin and tetracycline are alternative drugs to penicillin in the treatment of gonorrhea. To compare the efficacy of these agents and their propensity to select resistant gonococci, we treated 4043 patients randomly with either 2 or 4 g of spectinomycin once or 9 g of oral tetracycline for four days. Minimum cure rate for anogenital gonorrhea was 94 per cent with either drug. Oropharyngeal infection responded poorly to spectinomycin in men, with failure of therapy in six of 11. Postgonococcal urethritis in men was less common after tetracycline than after spectinomycin (P less than 0.005). Spectinomycin failure was not related to drug resistance. Tetracycline failure correlated with resistance (P less than 0.0002); one fifth of the isolates resistant to 1.0 mug per milliter of tetracycline were not eradicated. For several reasons, including the appearance of beta-lactamase-producing gonococci, it is no longer clear that penicillin G is the "drug of choice" for gonorrhea. Spectinomycin and tetracycline are equally acceptable alternatives, each with distinct advantages and disadvantages.

Aetiology of acute epididymitis

24 patients with acute epididymitis were examined and underwent urethral and urine cultures for Neisseria gonorrhoeae, Ureaplasma urealyticum, herpes-simplex virus, Chlamydia trachomatis, cytomegalovirus, and gram-negative aerobic bacteria. The results suggest that in young men the sexually transmitted organisms which cause urethritis (N. gonorrhoeae, C. trachomatis, and possibly U. urealyticum) may also lead to acute epididymitis, whereas in older men coliforms and Pseudomonas are the predominant causes of epididymitis.