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Molina JM, Bercot B, Assoumou L, Rubenstein E, Algarte-Genin M, Pialoux G, Katlama C, Surgers L, Bébéar C, Dupin N, Ouattara M, Slama L, Pavie J, Duvivier C, Loze B, Goldwirt L, Gibowski S, Ollivier M, Ghosn J, Costagliola D. Doxycycline prophylaxis and meningococcal group B vaccine to prevent bacterial sexually transmitted infections in France (ANRS 174 DOXYVAC): a multicentre, open-label, randomised trial with a 2 × 2 factorial design. THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00236-6. [PMID: 38797183 DOI: 10.1016/s1473-3099(24)00236-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 04/06/2024] [Accepted: 04/09/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Increased rates of sexually transmitted infections (STIs) are reported among men who have sex with men (MSM) and new interventions are needed. We aimed to assess whether post-exposure prophylaxis (PEP) with doxycycline could reduce the incidence of chlamydia or syphilis (or both) and whether the meningococcal group B vaccine (4CMenB) could reduce the incidence of gonorrhoea in this population. METHODS ANRS 174 DOXYVAC is a multicentre, open-label, randomised trial with a 2 × 2 factorial design conducted at ten hospital sites in Paris, France. Eligible participants were MSM aged 18 years or older, HIV negative, had a history of bacterial STIs within the 12 months before enrolment, and who were already included in the ANRS PREVENIR study (a cohort of MSM using pre-exposure prophylaxis with tenofovir and emtricitabine for HIV prevention). Participants were randomly assigned (2:1) to doxycycline PEP (two pills of 100 mg each orally within 72 h after condomless sex, with no more than three doses of 200 mg per week) or no PEP groups and were also randomly assigned (1:1) to the 4CMenB vaccine (GlaxoSmithKline, Paris, France; two intramuscular injections at enrolment and at 2 months) or no vaccine groups, using a computer-generated randomisation list with a permuted fixed block size of four. Follow-up occurred for at least 12 months (with visits every 3 months) up to 24 months. The coprimary outcomes were the risk of a first episode of chlamydia or syphilis (or both) after the enrolment visit at baseline for the doxycycline intervention and the risk of a first episode of gonorrhoea starting at month 3 (ie, 1 month after the second vaccine dose) for the vaccine intervention, analysed in the modified intention-to-treat population (defined as all randomly assigned participants who had at least one follow-up visit). This trial is registered with ClinicalTrials.gov, NCT04597424 (ongoing). FINDINGS Between Jan 19, 2021, and Sept 19, 2022, 556 participants were randomly assigned. 545 (98%) participants were included in the modified intention-to-treat analysis for the doxycycline PEP and no PEP groups and 544 (98%) were included for the 4CMenB vaccine and no vaccine groups. The median follow-up was 14 months (IQR 9-18). The median age was 40 years (34-48) and all 545 participants were male. There was no interaction between the two interventions (p≥0·1) for the primary outcome. The incidence of a first episode of chlamydia or syphilis (or both) was 8·8 per 100 person-years (35 events in 362 participants) in the doxycycline PEP group and 53·2 per 100 person-years (80 events in 183 participants) in the no PEP group (adjusted hazard ratio [aHR] 0·17 [95% CI 0·12-0·26]; p<0·0001). The incidence of a first episode of gonorrhoea, starting from month 3 was 58·3 per 100 person-years (103 events in 274 participants) in the 4CmenB vaccine group and 77·1 per 100 person-years (122 events in 270 participants) in the no vaccine group (aHR 0·78 [95% CI 0·60-1·01]; p=0·061). There were no deaths during the study. One drug-related serious adverse event (fixed-drug eruption) occurred in the doxycycline PEP group. Six (2%) participants in the doxycycline group discontinued doxycycline PEP because of gastrointestinal adverse events. INTERPRETATION Doxycycline PEP strongly reduced the incidence of chlamydia and syphilis in MSM, but we did not show efficacy of the 4CmenB vaccine for gonorrhoea. Doxycycline PEP should be assessed in other populations, such as heterosexual men and women, and its effect on antimicrobial resistance carefully monitored. FUNDING ANRS Maladies Infectieuses Emergentes. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Jean-Michel Molina
- Department of Infectious Diseases, Hospital Saint-Louis, Hospital Lariboisière, INSERM U944, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Paris, France.
| | - Beatrice Bercot
- Laboratory of Microbiology, Hospital Saint-Louis, Hospital Lariboisière, INSERM U944, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Paris, France; Department of Bacteriology, UMR CNRS 5234, French National Center for Bacterial Sexually Transmitted Infections, Bordeaux, France
| | - Lambert Assoumou
- Sorbonne University, INSERM, Institut Pierre Louis d'Epidemiology et de Santé Publique, Paris, France
| | - Emma Rubenstein
- Department of Infectious Diseases, Hospital Saint-Louis, Hospital Lariboisière, INSERM U944, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Paris, France
| | - Michele Algarte-Genin
- Sorbonne University, INSERM, Institut Pierre Louis d'Epidemiology et de Santé Publique, Paris, France
| | - Gilles Pialoux
- Department of Infectious Diseases, Hôpital Tenon, Paris, France
| | - Christine Katlama
- Sorbonne University, INSERM, Institut Pierre Louis d'Epidemiology et de Santé Publique, Paris, France; Department of Infectious Diseases, Hospital of la Pitié-Salpétrière, Paris, France
| | - Laure Surgers
- Sorbonne University, INSERM, Institut Pierre Louis d'Epidemiology et de Santé Publique, Paris, France; Department of Infectious Diseases, Hospital Saint-Antoine, Sorbonne Université, Paris, France
| | - Cécile Bébéar
- Department of Bacteriology, UMR CNRS 5234, French National Center for Bacterial Sexually Transmitted Infections, Bordeaux, France
| | - Nicolas Dupin
- Department of Dermatology, Hospital Cochin, Paris, France
| | - Moussa Ouattara
- Sorbonne University, INSERM, Institut Pierre Louis d'Epidemiology et de Santé Publique, Paris, France
| | - Laurence Slama
- Department of Immunology and Infectious Diseases, Hotel-Dieu, Paris, France
| | - Juliette Pavie
- Department of Clinical Immunology, Hotel-Dieu, Paris, France
| | - Claudine Duvivier
- Department of Infectious Diseases, INSERM U1016, Necker Pasteur Infectiology Center, Hospital Bichat, University of Paris Cité, Paris, France
| | - Benedicte Loze
- Department of Infectious Diseases, Hospital Saint-Louis, Hospital Lariboisière, INSERM U944, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Paris, France
| | - Lauriane Goldwirt
- Department of Pharmacology, Hospital Saint-Louis, Hospital Lariboisière, INSERM U944, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Paris, France
| | | | | | - Jade Ghosn
- Department of Infectious Diseases, IAME UMR1137, Hospital Bichat, University of Paris Cité, Paris, France
| | - Dominique Costagliola
- Sorbonne University, INSERM, Institut Pierre Louis d'Epidemiology et de Santé Publique, Paris, France
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Roster KIO, Mittelstaedt R, Reyes J, Aatresh AV, Grad YH. Molecular surveillance to monitor the prevalence of tetracycline resistance in Neisseria gonorrhoeae. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.07.24306823. [PMID: 38765970 PMCID: PMC11100842 DOI: 10.1101/2024.05.07.24306823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Doxycycline post-exposure prophylaxis (Doxy-PEP) reduces bacterial sexually transmitted infections (STIs) but may select for tetracycline resistance in Neisseria gonorrhoeae and co-resistance to other antibiotics, including ceftriaxone.. The implementation of doxy-PEP should be accompanied by monitoring doxycycline resistance, but the optimal strategy to detect changes in the prevalence of resistance has not been established. We used a deterministic compartmental model of gonorrhea transmission to evaluate the performance of two strategies in providing early warning signals for rising resistance: (1) phenotypic testing of cultured isolates and (2) PCR for tetM in remnants from positive Nucleic Acid Amplification Tests (NAATs) used for gonorrhea diagnosis. For each strategy, we calculated the resistance proportion with 90% simulation intervals as well as the time under each sampling strategy to achieve 95% confidence that the resistance proportion exceeded a resistance threshold ranging from 11-30%. Given the substantially larger available sample size, PCR for tetM in remnant NAATs detected increased high-level tetracycline resistance with high confidence faster than phenotypic testing of cultured specimens. Our results suggest that population surveillance using molecular testing for tetM can complement culturebased surveillance of tetracycline resistance in N. gonorrhoeae and inform policy considerations for doxy-PEP.
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Affiliation(s)
- Kirstin I Oliveira Roster
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Rachel Mittelstaedt
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
| | - Jordan Reyes
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Aishani V Aatresh
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, MA
- Harvard College, Cambridge, MA
| | - Yonatan H Grad
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, MA
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Manoharan-Basil SS, Gestels Z, Abdelatti S, De Baetselier I, Vanbaelen T, Hinterwirth A, Doan T, Lietman T, Kenyon C. Could the effect of antimicrobials on antimicrobial resistance be saturated at high-antimicrobial consumption? A comparison of the MORDOR and ResistAZM studies. Int J Infect Dis 2024; 145:107082. [PMID: 38703812 DOI: 10.1016/j.ijid.2024.107082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/12/2024] [Accepted: 04/29/2024] [Indexed: 05/06/2024] Open
Abstract
OBJECTIVES Antimicrobial resistance poses a considerable threat in high-antimicrobial-consumption populations, such as men who have sex with men (MSM) taking HIV pre-exposure prophylaxis. While the ResistAZM trial found no increase in macrolide resistance genes in MSM with gonorrhea after azithromycin treatment, the MORDOR trial observed an increase in these genes after mass azithromycin distribution. We hypothesized that this could be due to saturation of the resistome. To test this hypothesis, we compared the abundance of macrolide resistance determinants in anorectal samples between the baselines of the two trials. METHODS Shotgun metagenome reads from the anorectal baseline samples from the ResistAZM (n = 42) and MORDOR (n = 30) trials were analyzed using AMRPlusPlus. Nonhost reads were mapped to the MEGARes database to detect antibiotic resistance genes (ARG). Antimicrobial resistance (AMR) was normalized using cumulative sum scaling, and ARG abundance was estimated. RESULTS Macrolide, lincosamides, and streptogramins determinants were approximately 10-fold more abundant in the ResistAZM than the MORDOR samples (P ≤ 0.001). CONCLUSION The findings are compatible with our hypothesis. Thus, in populations with high-antimicrobial use, the relationship between antimicrobial consumption and AMR may be diminished due to saturation. These findings are vital for future studies investigating the resistogencity of novel interventions, such as doxycycline post-exposure prophylaxis, in populations with high preceding consumption of antimicrobials.
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Affiliation(s)
| | - Zina Gestels
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Saïd Abdelatti
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Irith De Baetselier
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Thibaut Vanbaelen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Armin Hinterwirth
- Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - Thuy Doan
- Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - Thomas Lietman
- Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - Chris Kenyon
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa
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Vanbaelen T, De Baetselier I, Manoharan-Basil SS, Kenyon C. Oral streptococcal susceptibility to azithromycin may be associated with doxycycline use: A post-hoc analysis with implications for doxycycline post exposure prophylaxis. Int J STD AIDS 2024:9564624241246301. [PMID: 38607607 DOI: 10.1177/09564624241246301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Tetracycline and macrolide resistance are frequently linked in streptococci and other species. We aimed to assess the association between doxycycline use and azithromycin MICs in oral streptococci. METHODS Linear regression was used to assess the association between doxycycline use in the prior year and the median MIC per participant of oral streptococcal colonies isolated at the baseline visit of the ResistAZM study. The analysis controlled for receipt of other antimicrobials as well as time since antimicrobial consumption. RESULTS Fifty-six individual colonies confirmed to be streptococci were isolated from 19 individuals at baseline. The azithromycin MICs of these isolates varied considerably between 0.25 mg/L and >256 mg/L (median 28 mg/L; IQR 1-192 mg/L). The consumption of doxycycline in the preceding 12 months was positively associated with median streptococcal azithromycin MIC (coef. 151.6 [95% CI 10.6-292.7]; p = .037). CONCLUSION This post-hoc analysis found that doxycycline use was associated with streptococcal azithromycin susceptibility. Numerous limitations of the study design mean that this study is best considered hypothesis generating. Prospective studies are required to assess if the use of doxycycline could select for macrolide resistance in oral streptococci.
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Affiliation(s)
- Thibaut Vanbaelen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Irith De Baetselier
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Chris Kenyon
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa
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Vanbaelen T, Manoharan-Basil SS, Kenyon C. Four recent insights suggest the need for more refined methods to assess the resistogenicity of doxycycline post exposure prophylaxis. CURRENT RESEARCH IN MICROBIAL SCIENCES 2024; 6:100234. [PMID: 38646593 PMCID: PMC11033152 DOI: 10.1016/j.crmicr.2024.100234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024] Open
Abstract
Two recently published randomized trials of doxycycline post exposure prophylaxis (PEP) have concluded that this intervention is highly effective at reducing the incidence of bacterial sexually transmitted infections (STIs) and has little or no risk of promoting the spread of antimicrobial resistance (AMR). In this perspective piece, we review four types of evidence that suggest that the risk of promoting AMR has been inadequately assessed in these studies. 1) The studies have all used proportion resistant as the outcome measure. This is a less sensitive measure of resistogenicity than MIC distribution. 2) These RCTs have not considered population-level pathways of AMR selection. 3) In populations with very high antimicrobial consumption such as PrEP cohorts, the relationship between antimicrobial consumption and resistance may be saturated. 4) Genetic linkage of AMR means that increased tetracycline use may select for AMR to not only tetracyclines but also other antimicrobials in STIs and other bacterial species. We recommend novel study designs to more adequately assess the AMR-inducing risk of doxycycline PEP.
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Affiliation(s)
- Thibaut Vanbaelen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, 2000, Belgium
| | | | - Chris Kenyon
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, 2000, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, 7700, South Africa
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Vanbaelen T, Manoharan-Basil SS, Kenyon C. 45 years of tetracycline post exposure prophylaxis for STIs and the risk of tetracycline resistance: a systematic review and meta-analysis. BMC Infect Dis 2024; 24:376. [PMID: 38575877 PMCID: PMC10996150 DOI: 10.1186/s12879-024-09275-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/31/2024] [Indexed: 04/06/2024] Open
Abstract
There is considerable interest in the use of doxycycline post exposure prophylaxis (PEP) to reduce the incidence of bacterial sexually transmitted infections (STIs). An important concern is that this could select for tetracycline resistance in these STIs and other species. We searched PubMed and Google Scholar, (1948-2023) for randomized controlled trials comparing tetracycline PEP with non-tetracycline controls. The primary outcome was antimicrobial resistance (AMR) to tetracyclines in all bacterial species with available data. Our search yielded 140 studies, of which three met the inclusion criteria. Tetracycline PEP was associated with an increasedprevalence of tetracycline resistance in Neisseria gonorrhoeae, but this effect was not statistically significant (Pooled OR 2.3, 95% CI 0.9-3.4). PEP had a marked effect on the N. gonorrhoeae tetracycline MIC distribution in the one study where this was assessed. Prophylactic efficacy was 100% at low MICs and 0% at high MICs. In the one study where this was assessed, PEP resulted in a significant increase in tetracycline resistance in commensal Neisseria species compared to the control group (OR 2.9, 95% CI 1.5-5.5) but no significant effect on the prevalence of tetracycline resistance in Staphylococcus aureus. The available evidence suggests that PEP with tetracyclines could be associated with selecting tetracycline resistance in N. gonorrhoeae and commensal Neisseria species.
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Affiliation(s)
- Thibaut Vanbaelen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, 2000, Antwerp, Belgium
| | | | - Chris Kenyon
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, 2000, Antwerp, Belgium.
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, 7700, South Africa.
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Unemo M, Cole MJ, Kodmon C, Day M, Jacobsson S. High tetracycline resistance percentages in Neisseria gonorrhoeae in Europe: is doxycycline post-exposure prophylaxis unlikely to reduce the incident gonorrhoea cases? THE LANCET REGIONAL HEALTH. EUROPE 2024; 38:100871. [PMID: 38476738 PMCID: PMC10928266 DOI: 10.1016/j.lanepe.2024.100871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 03/14/2024]
Affiliation(s)
- Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Institute for Global Health, University College London (UCL), London, UK
| | | | - Csaba Kodmon
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | | | - Susanne Jacobsson
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Vanbaelen T, Laumen J, Van Dijck C, De Block T, Manoharan-Basil SS, Kenyon C. Lack of Association between Antimicrobial Consumption and Antimicrobial Resistance in a HIV Preexposure Prophylaxis Population: A Cross-Sectional Study. Antibiotics (Basel) 2024; 13:188. [PMID: 38391574 PMCID: PMC10886153 DOI: 10.3390/antibiotics13020188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/01/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND In antibiotic naïve populations, there is a strong association between the use of an antimicrobial and resistance to this antimicrobial. Less evidence is available as to whether this relationship is weakened in populations highly exposed to antimicrobials. Individuals taking HIV preexposure prophylaxis (PrEP) have a high intake of antimicrobials. We previously found that there was no difference in the prevalence of pheno- and genotypic antimicrobial resistance between two groups of PrEP clients who had, and had not, taken antimicrobials in the prior 6 months. Both groups did, however, have a higher prevalence of resistance than a sample of the general population. METHODS In the current study, we used zero-inflated negative binomial regression models to evaluate if there was an individual level association between the consumption of antimicrobials and 1. the minimum inhibitory susceptibilities of oral Neisseria subflava and 2. the abundance of antimicrobial resistance genes in the oropharynges of these individuals. RESULTS We found no evidence of an association between the consumption of antimicrobials and the minimum inhibitory susceptibilities of oral Neisseria subflava or the abundance of antimicrobial resistance genes in these individuals. CONCLUSIONS We conclude that in high-antimicrobial-consumption populations, the association between antimicrobial consumption and resistance may be attenuated. This conclusion would not apply to lower-consumption populations.
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Affiliation(s)
- Thibaut Vanbaelen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, 2000 Antwerp, Belgium
| | - Jolein Laumen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, 2000 Antwerp, Belgium
| | - Christophe Van Dijck
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, 2000 Antwerp, Belgium
| | - Tessa De Block
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, 2000 Antwerp, Belgium
| | | | - Chris Kenyon
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, 2000 Antwerp, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town 7700, South Africa
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Xu A, Zuo Z, Yang C, Ye F, Wang M, Wu J, Tao C, Xun Y, Li Z, Liu S, Huang J. A long trend of sexually transmitted diseases before and after the COVID-19 pandemic in China (2010-21). Sex Health 2023; 20:497-505. [PMID: 37649382 DOI: 10.1071/sh22172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 08/04/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND The longer ongoing benefits of coronavirus disease 2019 (COVID-19) non-pharmaceutical interventions (NPIs) for sexually transmitted diseases (STDs) in China are still unclear. We aimed to explore the changes in five STDs (AIDS, hepatitis B, hepatitis C, gonorrhoea, and syphilis) before, during, and after the COVID-19 pandemic in mainland China, from 2010 to 2021. METHODS The number of the monthly reported cases of the five STDs were extracted from the website to construct the Joinpoint regression and autoregressive integrated moving average (ARIMA) models. Eight indicators reflecting NPIs were chosen from the COVID-19 Government Response Tracker system. The STDs and eight indicators were used to establish the Multivariable generalised linear model (GLM) to calculate the incidence rate ratios (IRRs). RESULTS With the exception of hepatitis B, the other four STDs (AIDS, hepatitis C, gonorrhoea, and syphilis) had a positive average annual percent change over the past 12years. All the ARIMA models had passed the Ljung-Box test, and the predicted data fit well with the data from 2010 to 2019. All five STDs were significantly reduced in 2020 compared with 2019, with significant estimated IRRs ranging from 0.88 to 0.92. In the GLM, using data for the years 2020 (February-December) and 2021, the IRRs were not significant after adjusting for the eight indicators in multivariate analysis. CONCLUSION Our study demonstrated that the incidence of the five STDs decreased rapidly during the COVID-19 pandemic in 2020. A recovery of STDs in 2021 was found to occur compared with that in 2020, but the rising trend disappeared after adjusting for the NPIs. Our study demonstrated that NPIs have an effect on STDs, but the relaxation of NPI usage might lead to a resurgence.
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Affiliation(s)
- Aifang Xu
- Department of Clinical Laboratory, Hangzhou Xixi Hospital, Hangzhou, Zhejiang 310023, China
| | - Zhongbao Zuo
- Department of Clinical Laboratory, Hangzhou Xixi Hospital, Hangzhou, Zhejiang 310023, China
| | - Chunli Yang
- Department of Clinical Laboratory, The 903rd Hospital of PLA, Hangzhou, Zhejiang 310013, China
| | - Fei Ye
- Health Examination Center, Hangzhou Xixi Hospital, Hangzhou, Zhejiang 310023, China
| | - Miaochan Wang
- Department of Clinical Laboratory, Hangzhou Xixi Hospital, Hangzhou, Zhejiang 310023, China
| | - Jing Wu
- Department of Clinical Laboratory, Hangzhou Xixi Hospital, Hangzhou, Zhejiang 310023, China
| | - Chengjing Tao
- Department of Obstetrics and Gynecology, Hangzhou Xixi Hospital, Hangzhou, Zhejiang 310023, China
| | - Yunhao Xun
- Department of Hepatology, Hangzhou Xixi Hospital, Hangzhou, Zhejiang 310023, China
| | - Zhaoyi Li
- Science and Education Department, Hangzhou Xixi Hospital, Hangzhou, Zhejiang 310023, China
| | - Shourong Liu
- Department of Hepatology, Hangzhou Xixi Hospital, Hangzhou, Zhejiang 310023, China
| | - Jinsong Huang
- Department of Hepatology, Hangzhou Xixi Hospital, Hangzhou, Zhejiang 310023, China
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Mårdh O, Plachouras D. Using doxycycline for prophylaxis of bacterial sexually transmitted infections: considerations for the European Union and European Economic Area. Euro Surveill 2023; 28:2300621. [PMID: 37971658 PMCID: PMC10655202 DOI: 10.2807/1560-7917.es.2023.28.46.2300621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/16/2023] [Indexed: 11/19/2023] Open
Affiliation(s)
- Otilia Mårdh
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
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Kenyon C, Gestels Z, Vanbaelen T, Abdellati S, Van Den Bossche D, De Baetselier I, Xavier BB, Manoharan-Basil SS. Doxycycline PEP can induce doxycycline resistance in Klebsiella pneumoniae in a Galleria mellonella model of PEP. Front Microbiol 2023; 14:1208014. [PMID: 37711686 PMCID: PMC10498386 DOI: 10.3389/fmicb.2023.1208014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/03/2023] [Indexed: 09/16/2023] Open
Abstract
Background Four randomized controlled trials have now established that doxycycline post exposure (sex) prophylaxis (PEP) can reduce the incidence of chlamydia and syphilis in men who have sex with men. These studies have concluded that the risk of selecting for antimicrobial resistance is low. We evaluated this risk in vitro and in vivo using a Galleria mellonella infection model. Methods We evaluated how long it took for doxycycline resistance to emerge during passage on doxycycline containing agar plates in 4 species - Escherichia coli, Klebsiella pneumoniae, Neisseria gonorrhoeae and Neisseria subflava. We then assessed if K. pneumoniae could acquire resistance to doxycycline (and cross resistance to other antimicrobials) during intermittent exposure to doxycycline in a Galleria mellonella model of doxycycline PEP. Results In our passage experiments, we found that resistance first emerged in K. pneumoniae. By day 7 the K. pneumoniae MIC had increased from 2 mg/L to a median of 96 mg/L (IQR 64-96). Under various simulations of doxycycline PEP in the G. mellonella model, the doxycycline MIC of K. pneumoniae increased from 2 mg/L to 48 mg/L (IQR 48-84). Ceftriaxone and ciprofloxacin MICs increased over ten-fold. Whole genome sequencing revealed acquired mutations in ramR which regulates the expression of the AcrAB-TolC efflux pump. Conclusion Doxycycline PEP can select for doxycycline, ceftriaxone and ciprofloxacin resistance in K. pneumoniae in a G. mellonella model. The emergent ramR mutations were similar to those seen in circulating strains of K. pneumoniae. These findings suggest that we need to assess the effect of doxycycline PEP on resistance induction on a broader range of bacterial species than has hitherto been the case.
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Affiliation(s)
- Chris Kenyon
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa
| | - Zina Gestels
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Thibaut Vanbaelen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Said Abdellati
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Dorien Van Den Bossche
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Irith De Baetselier
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Basil Britto Xavier
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Hospital Outbreak Support Team-HOST, Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
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12
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Kong FYS, Kenyon C, Unemo M. Important considerations regarding the widespread use of doxycycline chemoprophylaxis against sexually transmitted infections. J Antimicrob Chemother 2023; 78:1561-1568. [PMID: 37129293 PMCID: PMC10577522 DOI: 10.1093/jac/dkad129] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
Rates of sexually transmitted infections (STIs) continue to rise across the world and interventions are essential to reduce their incidence. Past and recent studies have indicated this may be achieved using doxycycline post-exposure prophylaxis (PEP) and this has sparked considerable interest in its use. However, many unanswered questions remain as to its long-term effects and particularly potentially negative impact on human microbiomes and antimicrobial resistance among STIs, other pathogens, and commensals. In this review, we discuss seven areas of concern pertaining to the widespread use of doxycycline PEP.
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Affiliation(s)
- Fabian Yuh Shiong Kong
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Chris Kenyon
- HIV/STI Unit, Institute of Tropical Medicine, Antwerp, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Örebro University, Örebro, Sweden
- Faculty of Population Health Sciences, Institute for Global Health, University College London, London, UK
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13
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Duan Q, Carmody C, Donovan B, Guy RJ, Hui BB, Kaldor JM, Lahra MM, Law MG, Lewis DA, Maley M, McGregor S, McNulty A, Selvey C, Templeton DJ, Whiley DM, Regan DG, Wood JG. Modelling response strategies for controlling gonorrhoea outbreaks in men who have sex with men in Australia. PLoS Comput Biol 2021; 17:e1009385. [PMID: 34735428 PMCID: PMC8594806 DOI: 10.1371/journal.pcbi.1009385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 11/16/2021] [Accepted: 08/26/2021] [Indexed: 11/19/2022] Open
Abstract
The ability to treat gonorrhoea with current first-line drugs is threatened by the global spread of extensively drug resistant (XDR) Neisseria gonorrhoeae (NG) strains. In Australia, urban transmission is high among men who have sex with men (MSM) and importation of an XDR NG strain in this population could result in an epidemic that would be difficult and costly to control. An individual-based, anatomical site-specific mathematical model of NG transmission among Australian MSM was developed and used to evaluate the potential for elimination of an imported NG strain under a range of case-based and population-based test-and-treat strategies. When initiated upon detection of the imported strain, these strategies enhance the probability of elimination and reduce the outbreak size compared with current practice (current testing levels and no contact tracing). The most effective strategies combine testing targeted at regular and casual partners with increased rates of population testing. However, even with the most effective strategies, outbreaks can persist for up to 2 years post-detection. Our simulations suggest that local elimination of imported NG strains can be achieved with high probability using combined case-based and population-based test-and-treat strategies. These strategies may be an effective means of preserving current treatments in the event of wider XDR NG emergence. In most high-income settings, gonorrhoea is endemic among men who have sex with men (MSM). While gonorrhoea remains readily treatable with antibiotics, there are major concerns about the threat of antimicrobial resistance arising from recent reports of treatment failure with first-line therapy and limited remaining treatment options. Here we investigated the potential for test-and-treat response strategies to eliminate such strains before their prevalence reaches a level requiring a shift to new first line therapies. Rather than directly consider resistance, we explore the mitigating effect of various test-and-treat measures on outbreaks of a generic imported strain which remains treatable. This is done within the framework of a realistic mathematical model of gonorrhoea spread in an MSM community that captures cases, anatomical sites of infection and sexual contacts at an individual level, calibrated to relevant Australian epidemiological data. The results indicate that strategies such as partner testing and treatment in combination with elevated asymptomatic community testing are highly effective in mitigating outbreaks but can take up to 2 years to achieve elimination. As there are currently no clear alternative drugs of proven efficacy and safety to replace ceftriaxone in first-line therapy, these promising results suggest potential for use of these outbreak response strategies to preserve current treatment recommendations.
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Affiliation(s)
- Qibin Duan
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Australia
- The Kirby Institute, UNSW Sydney, Sydney, Australia
| | - Chris Carmody
- Liverpool Sexual Health Clinic, South Western Sydney Local Health District, Sydney, Australia
- Western Sydney University, Sydney, Australia
| | - Basil Donovan
- The Kirby Institute, UNSW Sydney, Sydney, Australia
- Sydney Sexual Health Centre, South Eastern Sydney Local Health District, Sydney, Australia
| | | | - Ben B. Hui
- The Kirby Institute, UNSW Sydney, Sydney, Australia
| | | | - Monica M. Lahra
- Microbiology Department, New South Wales Health Pathology, The Prince of Wales Hospital, Sydney, Australia
- School of Medical Sciences, UNSW Sydney, Sydney, Australia
| | | | - David A. Lewis
- Western Sydney Sexual Health Centre, Western Sydney Local Health District, Sydney, Australia
- Westmead Clinical School, Faculty of Health and Medicine & Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
- Division of Medical Virology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Michael Maley
- Department of Microbiology and Infectious Diseases, Liverpool Hospital, Sydney, Australia
- South Western Clinical School, UNSW Sydney, Sydney, Australia
| | | | - Anna McNulty
- Sydney Sexual Health Centre, South Eastern Sydney Local Health District, Sydney, Australia
- School of Population Health, UNSW Sydney, Sydney, Australia
| | - Christine Selvey
- Communicable Diseases Branch, Health Protection NSW, Sydney, Australia
| | - David J. Templeton
- The Kirby Institute, UNSW Sydney, Sydney, Australia
- Department of Sexual Health Medicine, Sydney Local Health District and Discipline of Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - David M. Whiley
- Centre for Clinical Research, University of Queensland, Brisbane, Australia
| | | | - James G. Wood
- School of Population Health, UNSW Sydney, Sydney, Australia
- * E-mail:
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14
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Donovan LC, Fairley CK, Aung ET, Traeger MW, Wright EJ, Stoové MA, Chow EPF. The Presence or Absence of Symptoms Among Cases of Urethral Gonorrhoea Occurring in a Cohort of Men Taking Human Immunodeficiency Virus Pre-exposure Prophylaxis in the PrEPX Study. Open Forum Infect Dis 2021; 8:ofab263. [PMID: 34189177 PMCID: PMC8231363 DOI: 10.1093/ofid/ofab263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/20/2021] [Indexed: 12/02/2022] Open
Abstract
We aimed to estimate how often urethral gonorrhoea is symptomatic among men in the Pre-Exposure Prophylaxis Expanded Victoria study. Eighty-seven percent of 213 cases of urethral gonorrhoea were symptomatic. Ensuring men with urethral gonorrhoea both recognize and present early for treatment is critical to reduce transmission.
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Affiliation(s)
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ei T Aung
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Michael W Traeger
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Edwina J Wright
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Alfred Hospital, Monash Central Clinical School, Melbourne, Victoria, Australia.,Peter Doherty Institute, Melbourne, Victoria, Australia
| | - Mark A Stoové
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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15
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Comprehensive Bioinformatic Assessments of the Variability of Neisseria gonorrhoeae Vaccine Candidates. mSphere 2021; 6:6/1/e00977-20. [PMID: 33536323 PMCID: PMC7860988 DOI: 10.1128/msphere.00977-20] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
A protective vaccine is the only viable way to stop the spread of gonorrhea in the face of rising antibiotic resistance. However, the notorious phase and antigenic variation of Neisseria gonorrhoeae surface proteins remains one of the challenges in vaccine development. To facilitate vaccine advancement efforts, we carried out comprehensive bioinformatic analyses of sequence variation by comparing 34 gonorrhea antigen candidates among >5,000 clinical N. gonorrhoeae isolates deposited in the Neisseria PubMLST database. Eight protein antigens showed exceptional conservation by having a single allele variant distributed in >80% of isolates. An additional 18 vaccine candidates were represented by ≤3 alleles in >50% of N. gonorrhoeae isolates globally. Phylogenetic analyses highlighted closely related antigen variants and additionally showed that AniA and FetB were the closest between N. gonorrhoeae and N. meningitidis Up to 44% of N. meningitidis alleles for both antigens have premature stop codons, suggesting differential expression. Mapping polymorphisms to the available three-dimensional structures of 12 antigens revealed low-frequency surface polymorphisms. PorB and TbpB possessed numerous high-prevalence polymorphic sites. While TbpA was also highly variable, conserved loops were nonetheless identified. A high degree of sequence conservation, the distribution of a single antigen variant among N. gonorrhoeae strains globally, or low-frequency sequence polymorphisms in surface loops make ACP, AniA, BamA, BamE, MtrE, NspA, NGO0778, NGO1251, NGO1985, OpcA, PldA, Slam2, and ZnuD promising candidates for a gonorrhea vaccine. Finally, the commonly used N. gonorrhoeae FA1090 strain emerges as a vaccine prototype, as it carries antigen sequence types identical to the most broadly distributed antigen variants.IMPORTANCE Neisseria gonorrhoeae, the Gram-negative bacterium responsible for the sexually transmitted infection gonorrhea, is categorized as a high-priority pathogen for research and development efforts. N. gonorrhoeae's "superbug" status, its high morbidity, and the serious health impact associated with gonorrhea highlight the importance of vaccine development. One of the longstanding barriers to developing an effective vaccine against N. gonorrhoeae is the remarkable variability of surface-exposed antigens. In this report, we addressed this roadblock by applying extensive bioinformatic analyses to 34 gonorrhea antigen candidates among >5,000 clinical N. gonorrhoeae isolates. Our studies are important, as they reveal promising, conserved gonorrhea vaccine candidates and aid structural vaccinology. Moreover, these approaches are broadly applicable to other infectious diseases where surface antigen variability impedes successful vaccine design.
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16
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Could Intensive Screening for Gonorrhea/Chlamydia in Preexposure Prophylaxis Cohorts Select for Resistance? Historical Lessons From a Mass Treatment Campaign in Greenland. Sex Transm Dis 2020; 47:24-27. [PMID: 31856072 DOI: 10.1097/olq.0000000000001092] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Neisseria gonorrhoeae has developed resistance to all classes of antimicrobials used against it. Current strategies to prevent the emergence of pan-resistance include increased gonorrhea screening in high-prevalence populations such as men who have sex with men taking HIV preexposure prophylaxis. By increasing antimicrobial exposure, others have argued that intensive screening may inadvertently promote the emergence of antimicrobial resistance. AIM/METHODOLOGY To contribute to this discussion, we conducted a historical review of the effect of a mass gonorrhea treatment campaign in Greenland from 1965 to 1968 on the incidence of gonorrhea and antimicrobial resistance. We conducted a literature review using PubMed and Google Scholar to find relevant studies. Data on the incidence of gonorrhea, antimicrobial susceptibility, and antimicrobials dispensed were extracted and analyzed. RESULTS Eight articles were found with relevant information. The cornerstone of the campaign involved the repeated treatment for all persons with a diagnosis of gonorrhea in the past 6 months as well as all remaining unmarried persons between 15 and 30 years of age. There was a small and temporary decline in the incidence of gonorrhea during the campaign. The campaign was, however, associated with an increase in the proportion of gonococci that were not susceptible to penicillin. Gonococcal incidence continued to climb after the campaign ended but did decline dramatically after reductions in risk behavior after the global AIDS epidemic. DISCUSSIONS The mass gonorrhea treatment campaign in Greenland was associated with only a temporary decline in the incidence of gonorrhea. It was, however, followed by an increase in penicillin nonsusceptibility. Intense gonorrhea screening and treatment strategies should be aware of the risk of inducing antimicrobial resistance.
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17
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Martín-Sánchez M, Ong JJ, Fairley CK, Chen MY, Williamson DA, Maddaford K, Aung ET, Carter G, Bradshaw CS, Chow EPF. Clinical presentation of asymptomatic and symptomatic heterosexual men who tested positive for urethral gonorrhoea at a sexual health clinic in Melbourne, Australia. BMC Infect Dis 2020; 20:486. [PMID: 32641070 PMCID: PMC7346512 DOI: 10.1186/s12879-020-05197-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/24/2020] [Indexed: 11/24/2022] Open
Abstract
Background Asymptomatic screening for gonorrhoea in heterosexual men is currently not recommended in many countries including Australia, given the prevalence is relatively low in the heterosexual population. We aimed to determine the proportion of urethral gonorrhoea cases among heterosexual men attending a sexual health clinic that was asymptomatic and symptomatic, the time since last sexual contact to the onset of symptoms and the time to clinic presentation following the onset of symptoms. Methods This was a cross-sectional study that included heterosexual men aged 16 years or above attending the Melbourne Sexual Health Centre (MSHC) in Australia between August 2017 and August 2018. Gonorrhoea cases were diagnosed by nucleic acid amplification testing (NAAT) and/or culture. Descriptive analyses were conducted for all gonorrhoea cases including demographic characteristics, recent sexual practices, reported urethral symptoms and duration, sexual contact with a person diagnosed with gonorrhoea, investigations performed and laboratory results. Results There were 116 confirmed cases of urethral gonorrhoea in heterosexual men over the study period of which 6.0% (95% CI: 2.7–12.1%) were asymptomatic. Typical urethral discharge was present in 80.2% (95% CI: 71.9–86.5%) of men. The mean time between last sexual contact and the onset of symptoms was 7.0 days, and between the onset of symptoms to presentation to the clinic was 5.6 days. Conclusions A small proportion of heterosexual men with urethral gonorrhoea do not have any symptoms. Heterosexual men with urethral symptoms usually seek for healthcare within a week, prompting rapid healthcare-seeking behaviour.
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Affiliation(s)
- Mario Martín-Sánchez
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Melbourne, VIC, 3053, Australia. .,Preventive Medicine and Public Health Training Unit PSMar-UPF-ASPB, Barcelona, Spain. .,Public Health Agency of Barcelona, Plaça de Lesseps, 1, 08023, Barcelona, Spain.
| | - Jason J Ong
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Melbourne, VIC, 3053, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Melbourne, VIC, 3053, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Marcus Y Chen
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Melbourne, VIC, 3053, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Deborah A Williamson
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Kate Maddaford
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Melbourne, VIC, 3053, Australia
| | - Ei T Aung
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Melbourne, VIC, 3053, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Georgia Carter
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Melbourne, VIC, 3053, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Catriona S Bradshaw
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Melbourne, VIC, 3053, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Melbourne, VIC, 3053, Australia. .,Central Clinical School, Monash University, Melbourne, VIC, Australia. .,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia.
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18
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Cornelisse VJ, Bradshaw CS, Chow EPF, Williamson DA, Fairley CK. Oropharyngeal Gonorrhea in Absence of Urogenital Gonorrhea in Sexual Network of Male and Female Participants, Australia, 2018. Emerg Infect Dis 2019; 25:1373-1376. [PMID: 31211673 PMCID: PMC6590767 DOI: 10.3201/eid2507.181561] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We describe a sexual network consisting of 1 nonbinary-gendered participant and 2 male and 4 female participants in Australia, 2018. Six of 7 participants had oropharyngeal gonorrhea in the absence of urogenital gonorrhea. This observation supports a new paradigm of gonorrhea transmission in which oropharyngeal gonorrhea can be transmitted through tongue kissing.
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19
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Fairley CK, Cornelisse VJ, Hocking JS, Chow EPF. Models of gonorrhoea transmission from the mouth and saliva. THE LANCET. INFECTIOUS DISEASES 2019; 19:e360-e366. [PMID: 31324517 DOI: 10.1016/s1473-3099(19)30304-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/22/2019] [Accepted: 04/16/2019] [Indexed: 11/28/2022]
Abstract
This Personal View argues for a new framework of gonorrhoea transmission in men who have sex with men in which the oropharynx plays a major role in transmitting gonorrhoea to, or acquiring gonorrhoea from, their partner's oropharynx, penis, or anorectum through either direct contact or via saliva. To avoid preconceived notions of transmission dynamics, we ask readers to imagine that they are investigating a new sexually transmitted infection. On the basis of the existing clinical and epidemiological data for gonorrhoea at the penis, oropharynx, and anorectum site, we develop two models for transmission: the so-called penile model and the so-called oropharyngeal model. We argue that the existing epidemiological data and behavioural data best fit the oropharyngeal model. Our argument rests on the observation that, at the population level, the prevalence of urethral gonorrhoea is too rare to explain the high incidence of oropharynx and anorectum infection. We describe studies of gonorrhoea detection in saliva, saliva use during sex, epidemiological studies of kissing and oropharyngeal gonorrhoea, as well as studies aided by mathematical models. Finally, we argue that the correlation between sexual acts (eg, kissing, oral sex, anal sex, and saliva use) is so high that any epidemiological study that does not measure these factors will be prone to confounding.
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Affiliation(s)
- Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia; Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Vincent J Cornelisse
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia; Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Jane S Hocking
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia; University of Melbourne, Parkville, VIC, Australia
| | - Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia; Central Clinical School, Monash University, Melbourne, VIC, Australia
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20
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Whittles LK, White PJ, Didelot X. A dynamic power-law sexual network model of gonorrhoea outbreaks. PLoS Comput Biol 2019; 15:e1006748. [PMID: 30849080 PMCID: PMC6426262 DOI: 10.1371/journal.pcbi.1006748] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 03/20/2019] [Accepted: 01/04/2019] [Indexed: 11/26/2022] Open
Abstract
Human networks of sexual contacts are dynamic by nature, with partnerships forming and breaking continuously over time. Sexual behaviours are also highly heterogeneous, so that the number of partners reported by individuals over a given period of time is typically distributed as a power-law. Both the dynamism and heterogeneity of sexual partnerships are likely to have an effect in the patterns of spread of sexually transmitted diseases. To represent these two fundamental properties of sexual networks, we developed a stochastic process of dynamic partnership formation and dissolution, which results in power-law numbers of partners over time. Model parameters can be set to produce realistic conditions in terms of the exponent of the power-law distribution, of the number of individuals without relationships and of the average duration of relationships. Using an outbreak of antibiotic resistant gonorrhoea amongst men have sex with men as a case study, we show that our realistic dynamic network exhibits different properties compared to the frequently used static networks or homogeneous mixing models. We also consider an approximation to our dynamic network model in terms of a much simpler branching process. We estimate the parameters of the generation time distribution and offspring distribution which can be used for example in the context of outbreak reconstruction based on genomic data. Finally, we investigate the impact of a range of interventions against gonorrhoea, including increased condom use, more frequent screening and immunisation, concluding that the latter shows great promise to reduce the burden of gonorrhoea, even if the vaccine was only partially effective or applied to only a random subset of the population.
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Affiliation(s)
- Lilith K. Whittles
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
| | - Peter J. White
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- Modelling and Economics Unit, National Infection Service, Public Health England, London, United Kingdom
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- NIHR Health Protection Research Unit in Modelling Methodology, School of Public Health, Imperial College London, London, United Kingdom
| | - Xavier Didelot
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
- Department of Statistics, University of Warwick, Coventry, United Kingdom
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21
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Siguier M, Molina JM. Doxycycline Prophylaxis for Bacterial Sexually Transmitted Infections: Promises and Perils. ACS Infect Dis 2018; 4:660-663. [PMID: 29570279 DOI: 10.1021/acsinfecdis.8b00043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite their high global incidence, sexually transmitted infections (STIs) remain a neglected area of research. Increased rates of STIs have been reported in particular among men who have sex with men (MSM) probably because of the advances in the treatment and prophylaxis of human immunodeficiency virus (HIV) infection with a decrease in condom use. A recent report among MSM showed that the use of postexposure prophylaxis with doxycycline could dramatically reduce the incidence of chlamydia and syphilis but not of gonorrhea. The long-term consequences of this strategy are yet unknown, especially the risk of selection and dissemination of syphilis and chlamydia strains with doxycycline resistance, which has not been reported yet.
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Affiliation(s)
- Martin Siguier
- Department of Infectious Diseases, Saint-Louis Hospital, APHP, and University of Paris Diderot, Paris 75000, France
| | - Jean-Michel Molina
- Department of Infectious Diseases, Saint-Louis Hospital, APHP, and University of Paris Diderot, Paris 75000, France
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22
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Post-exposure prophylaxis with doxycycline to prevent sexually transmitted infections in men who have sex with men: an open-label randomised substudy of the ANRS IPERGAY trial. THE LANCET. INFECTIOUS DISEASES 2018; 18:308-317. [DOI: 10.1016/s1473-3099(17)30725-9] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/15/2017] [Accepted: 10/17/2017] [Indexed: 11/21/2022]
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23
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Whittles LK, White PJ, Didelot X. Estimating the fitness cost and benefit of cefixime resistance in Neisseria gonorrhoeae to inform prescription policy: A modelling study. PLoS Med 2017; 14:e1002416. [PMID: 29088226 PMCID: PMC5663337 DOI: 10.1371/journal.pmed.1002416] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 09/26/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Gonorrhoea is one of the most common bacterial sexually transmitted infections in England. Over 41,000 cases were recorded in 2015, more than half of which occurred in men who have sex with men (MSM). As the bacterium has developed resistance to each first-line antibiotic in turn, we need an improved understanding of fitness benefits and costs of antibiotic resistance to inform control policy and planning. Cefixime was recommended as a single-dose treatment for gonorrhoea from 2005 to 2010, during which time resistance increased, and subsequently declined. METHODS AND FINDINGS We developed a stochastic compartmental model representing the natural history and transmission of cefixime-sensitive and cefixime-resistant strains of Neisseria gonorrhoeae in MSM in England, which was applied to data on diagnoses and prescriptions between 2008 and 2015. We estimated that asymptomatic carriers play a crucial role in overall transmission dynamics, with 37% (95% credible interval CrI 24%-52%) of infections remaining asymptomatic and untreated, accounting for 89% (95% CrI 82%-93%) of onward transmission. The fitness cost of cefixime resistance in the absence of cefixime usage was estimated to be such that the number of secondary infections caused by resistant strains is only about half as much as for the susceptible strains, which is insufficient to maintain persistence. However, we estimated that treatment of cefixime-resistant strains with cefixime was unsuccessful in 83% (95% CrI 53%-99%) of cases, representing a fitness benefit of resistance. This benefit was large enough to counterbalance the fitness cost when 31% (95% CrI 26%-36%) of cases were treated with cefixime, and when more than 55% (95% CrI 44%-66%) of cases were treated with cefixime, the resistant strain had a net fitness advantage over the susceptible strain. Limitations include sparse data leading to large intervals on key model parameters and necessary assumptions in the modelling of a complex epidemiological process. CONCLUSIONS Our study provides, to our knowledge, the first estimates of the fitness cost and benefit associated with resistance of the gonococcus to a clinically relevant antibiotic. Our findings have important implications for antibiotic stewardship and public health policies and, in particular, suggest that a previously abandoned antibiotic could be used again to treat a minority of gonorrhoea cases without raising resistance levels.
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Affiliation(s)
- Lilith K Whittles
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
| | - Peter J White
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom.,MRC Centre for Outbreak Analysis and Modelling, School of Public Health, Imperial College London, London, United Kingdom.,NIHR Health Protection Research Unit in Modelling Methodology, School of Public Health, Imperial College London, London, United Kingdom.,Modelling and Economics Unit, National Infection Service, Public Health England, London, United Kingdom
| | - Xavier Didelot
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
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Alirol E, Wi TE, Bala M, Bazzo ML, Chen XS, Deal C, Dillon JAR, Kularatne R, Heim J, Hooft van Huijsduijnen R, Hook EW, Lahra MM, Lewis DA, Ndowa F, Shafer WM, Tayler L, Workowski K, Unemo M, Balasegaram M. Multidrug-resistant gonorrhea: A research and development roadmap to discover new medicines. PLoS Med 2017; 14:e1002366. [PMID: 28746372 PMCID: PMC5528252 DOI: 10.1371/journal.pmed.1002366] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Emilie Alirol and colleagues discuss the development of new treatments for gonorrhea.
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Affiliation(s)
- Emilie Alirol
- Global Antibiotics Research and Development Partnership (GARDP), Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
- * E-mail:
| | - Teodora E. Wi
- World Health Organization (WHO), Geneva, Switzerland
| | - Manju Bala
- Regional STD Teaching, Training & Research Centre, VMMC and Safdarjung Hospital, New Delhi, India
| | | | - Xiang-Sheng Chen
- National Center for STD Control, Chinese Academy of Medical Sciences & Peking Union Medical College Institute of Dermatology, Nanjing, China
| | - Carolyn Deal
- STD Branch, Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), Rockville, Maryland, United States of America
| | | | - Ranmini Kularatne
- Centre for HIV & Sexually Transmitted Infections, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Jutta Heim
- Global Antibiotics Research and Development Partnership (GARDP), Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Rob Hooft van Huijsduijnen
- Global Antibiotics Research and Development Partnership (GARDP), Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Edward W. Hook
- University of Alabama, Birmingham, Alabama, United States of America
| | - Monica M. Lahra
- World Health Organization Collaborating Centre for Sexually Transmitted Diseases, South Eastern Area Laboratory Services, The Prince of Wales Hospital, Sydney, Australia
| | - David A. Lewis
- Western Sydney Sexual Health Centre, Parramatta, NSW, Australia, and Marie Bashir Institute for Infectious Diseases and Biosecurity & Sydney Medical School-Westmead, University of Sydney, Westmead, Australia
| | | | - William M. Shafer
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia, United States of America, and Laboratories of Bacterial Pathogenesis, VA Medical Center, Decatur, Georgia, United States of America
| | - Liz Tayler
- World Health Organization (WHO), Geneva, Switzerland
| | - Kimberly Workowski
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, United States of America
| | - Magnus Unemo
- World Health Organization Collaborating Centre for Gonorrhoea and other STIs, Örebro University, Örebro, Sweden
| | - Manica Balasegaram
- Global Antibiotics Research and Development Partnership (GARDP), Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
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Ong JJ, Fethers K, Howden BP, Fairley CK, Chow EPF, Williamson DA, Petalotis I, Aung E, Kanhutu K, De Petra V, Chen MY. Asymptomatic and symptomatic urethral gonorrhoea in men who have sex with men attending a sexual health service. Clin Microbiol Infect 2017; 23:555-559. [PMID: 28257898 DOI: 10.1016/j.cmi.2017.02.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/16/2017] [Accepted: 02/18/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Guidelines regarding whether men who have sex with men (MSM) without symptoms of urethritis should be screened for urethral gonorrhoea differ between countries. We examined the rate of asymptomatic urethral gonorrhoea in MSM using sensitive nucleic acid amplification testing. METHODS This study was conducted on consecutive MSM attending the Melbourne Sexual Health Centre between July 2015 and May 2016 for sexually transmitted infections screening. Gonorrhoea testing with the Aptima Combo 2 (AC2) assay was performed on all urine specimens obtained from MSM, whether symptoms of urethritis were present or not. Men were classified as having: typical discharge if they reported symptoms suggesting purulent discharge; other symptoms if they reported other symptoms of urethritis; and no symptoms if they reported no urethral symptoms. RESULTS During the study period, there were 7941 clinic visits by 5947 individual MSM with 7090 urine specimens obtained from 5497 individual MSM tested with the AC2 assay. Urethral gonorrhoea was detected in 242 urine specimens from 228 individual MSM. The majority (189/242, 78%, 95% CI 73-83) reported typical discharge, 27/242 (11%, 95% CI 8-16) reported other urethral symptoms, and 26/242 (11%, 95% CI 7-15) reported no symptoms on the day of presentation and testing. Among men with urethral gonorrhoea, the proportions with concurrent pharyngeal or rectal gonorrhoea were 32% (134/210) and 64% (74/235), respectively. The mean interval between last reported sexual contact and onset of typical urethral discharge, where present, was 3.9 days. CONCLUSION The findings from our study lend support to guidelines that recommend screening asymptomatic MSM for urethral gonorrhoea.
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Affiliation(s)
- J J Ong
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic., Australia; Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia.
| | - K Fethers
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic., Australia
| | - B P Howden
- Microbiological Diagnostic Unit, Department of Microbiology and Immunology at the Peter Doherty Institution for Infection and Immunity, University of Melbourne, Melbourne, Vic., Australia
| | - C K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic., Australia; Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia
| | - E P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic., Australia; Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia
| | - D A Williamson
- Microbiological Diagnostic Unit, Department of Microbiology and Immunology at the Peter Doherty Institution for Infection and Immunity, University of Melbourne, Melbourne, Vic., Australia
| | - I Petalotis
- Microbiological Diagnostic Unit, Department of Microbiology and Immunology at the Peter Doherty Institution for Infection and Immunity, University of Melbourne, Melbourne, Vic., Australia
| | - E Aung
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic., Australia
| | - K Kanhutu
- University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences, Melbourne, Vic., Australia
| | - V De Petra
- Microbiological Diagnostic Unit, Department of Microbiology and Immunology at the Peter Doherty Institution for Infection and Immunity, University of Melbourne, Melbourne, Vic., Australia
| | - M Y Chen
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic., Australia; Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia.
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Whole-genome sequencing to determine transmission of Neisseria gonorrhoeae: an observational study. THE LANCET. INFECTIOUS DISEASES 2016; 16:1295-1303. [PMID: 27427203 DOI: 10.1016/s1473-3099(16)30157-8] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/13/2016] [Accepted: 05/31/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND New approaches are urgently required to address increasing rates of gonorrhoea and the emergence and global spread of antibiotic-resistant Neisseria gonorrhoeae. We used whole-genome sequencing to study transmission and track resistance in N gonorrhoeae isolates. METHODS We did whole-genome sequencing of isolates obtained from samples collected from patients attending sexual health services in Brighton, UK, between Jan 1, 2011, and March 9, 2015. We also included isolates from other UK locations, historical isolates from Brighton, and previous data from a US study. Samples from symptomatic patients and asymptomatic sexual health screening underwent nucleic acid amplification testing; positive samples and all samples from symptomatic patients were cultured for N gonorrhoeae, and resulting isolates were whole-genome sequenced. Cefixime susceptibility testing was done in selected isolates by agar incorporation, and we used sequence data to determine multi-antigen sequence types and penA genotypes. We derived a transmission nomogram to determine the plausibility of direct or indirect transmission between any two cases depending on the time between samples: estimated mutation rates, plus diversity noted within patients across anatomical sites and probable transmission pairs, were used to fit a coalescent model to determine the number of single nucleotide polymorphisms expected. FINDINGS 1407 (98%) of 1437 Brighton isolates between Jan 1, 2011, and March 9, 2015 were successfully sequenced. We identified 1061 infections from 907 patients. 281 (26%) of these infections were indistinguishable (ie, differed by zero single nucleotide polymorphisms) from one or more previous cases, and 786 (74%) had evidence of a sampled direct or indirect Brighton source. We observed multiple related samples across geographical locations. Of 1273 infections in Brighton (including historical data), 225 (18%) were linked to another case elsewhere in the UK, and 115 (9%) to a case in the USA. Four lineages initially identified in Brighton could be linked to 70 USA sequences, including 61 from a lineage carrying the mosaic penA XXXIV allele, which is associated with reduced cefixime susceptibility. INTERPRETATION We present a whole-genome-sequencing-based tool for genomic contact tracing of N gonorrhoeae and demonstrate local, national, and international transmission. Whole-genome sequencing can be applied across geographical boundaries to investigate gonorrhoea transmission and to track antimicrobial resistance. FUNDING Oxford National Institute for Health Research Health Protection Research Unit and Biomedical Research Centre.
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Hui BB, Wilson DP, Ward JS, Guy RJ, Kaldor JM, Law MG, Hocking JS, Regan DG. The potential impact of new generation molecular point-of-care tests on gonorrhoea and chlamydia in a setting of high endemic prevalence. Sex Health 2016; 10:348-56. [PMID: 23806149 DOI: 10.1071/sh13026] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 05/04/2013] [Indexed: 11/23/2022]
Abstract
UNLABELLED Background Despite the availability of testing and treatment, bacterial sexually transmissible infections (STIs) continue to occur at endemic levels in many remote Indigenous communities in Australia. New generation molecular point-of-care (POC) tests have high sensitivity, comparable with conventional diagnostic tests, and have the potential to increase the impact of STI screening. METHODS We developed mathematical models of gonorrhoea (Neisseria gonorrhoeae) and chlamydia (Chlamydia trachomatis) transmission in remote Indigenous communities in Australia to evaluate screening and treatment strategies that utilise POC tests. RESULTS The introduction of POC testing with 95% sensitivity could reduce the prevalence of gonorrhoea and chlamydia from 7.1% and 11.9% to 5.7% and 8.9%, respectively, under baseline screening coverage of 44% per year. If screening coverage is increased to 60% per year, prevalence is predicted to be reduced to 3.6% and 6.7%, respectively, under conventional testing, and further reduced to 1.8% and 3.1% with the introduction of POC testing. Increasing screening coverage to 80% per year will result in a reduction in the prevalence of gonorrhoea and chlamydia to 0.6% and 1.5%, respectively, and the virtual elimination of both STIs if POC testing is introduced. CONCLUSIONS Modelling suggests that molecular POC tests of high sensitivity have great promise as a public health strategy for controlling chlamydia and gonorrhoea. However, evaluation of the cost-effectiveness of POC testing needs to be made before widespread implementation of this technology can be considered.
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Affiliation(s)
- Ben B Hui
- The Kirby Institute, University of New South Wales, Sydney, NSW 2052, Australia
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Hui BB, Gray RT, Wilson DP, Ward JS, Smith AMA, Philip DJ, Law MG, Hocking JS, Regan DG. Population movement can sustain STI prevalence in remote Australian indigenous communities. BMC Infect Dis 2013; 13:188. [PMID: 23618061 PMCID: PMC3641953 DOI: 10.1186/1471-2334-13-188] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 04/14/2013] [Indexed: 11/25/2022] Open
Abstract
Background For almost two decades, chlamydia and gonorrhoea diagnosis rates in remote Indigenous communities have been up to 30 times higher than for non-Indigenous Australians. The high levels of population movement known to occur between remote communities may contribute to these high rates. Methods We developed an individual-based computer simulation model to study the relationship between population movement and the persistence of gonorrhoea and chlamydia transmission within hypothetical remote communities. Results Results from our model suggest that short-term population movement can facilitate gonorrhoea and chlamydia persistence in small populations. By fixing the number of short-term travellers in accordance with census data, we found that these STIs can persist if at least 20% of individuals in the population seek additional partners while away from home and if the time away from home is less than 21 days. Periodic variations in travel patterns can contribute to increased sustainable levels of infection. Expanding existing STI testing and treatment programs to cater for short-term travellers is shown to be ineffective due to their short duration of stay. Testing and treatment strategies tailored to movement patterns, such as encouraging travellers to seek testing and treatment upon return from travel, will likely be more effective. Conclusion High population mobility is likely to contribute to the high levels of STIs observed in remote Indigenous communities of Australia. More detailed data on mobility patterns and sexual behaviour of travellers will be invaluable for designing and assessing STI control programs in highly mobile communities.
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Affiliation(s)
- Ben B Hui
- The Kirby Institute, University of New South Wales, Sydney, NSW 2052, Australia.
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30
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Fairley CK, Hocking JS. Sexual health in Indigenous communities. Med J Aust 2012; 197:597-8. [DOI: 10.5694/mja12.11448] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 10/23/2012] [Indexed: 11/17/2022]
Affiliation(s)
| | - Jane S Hocking
- School of Population Health, University of Melbourne, Melbourne, VIC
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Freeman CD, Nightingale CH, Quintiliani R. Minocycline: old and new therapeutic uses. Int J Antimicrob Agents 2012; 4:325-35. [PMID: 18611625 DOI: 10.1016/0924-8579(94)90034-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/1994] [Indexed: 10/27/2022]
Abstract
Since the introduction of minocycline HCl in the late 1960's, it has been used for disease states that have ranged from typical community-acquired infectious diseases to others that are non-infectious, such as resistant rheumatoid arthritis. Owing to its high penetration characteristics throughout the body, minocycline can be used in the treatment of a wide variety of extracellular and intracellular pathogens. This review examines the known and potential therapeutic uses of minocycline in a clinical setting.
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Affiliation(s)
- C D Freeman
- Department of Pharmacy Practice, College of Pharmacy, Butler University, Indianapolis, IN 46208, USA; Department of Pharmacy, Community Hospital East, Indianapolis, IN, USA
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The Cost and Cost-Effectiveness of Expedited Partner Therapy Compared With Standard Partner Referral for the Treatment of Chlamydia or Gonorrhea. Sex Transm Dis 2011; 38:1067-73. [DOI: 10.1097/olq.0b013e31822e9192] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shim BS. Current concepts in bacterial sexually transmitted diseases. Korean J Urol 2011; 52:589-97. [PMID: 22025952 PMCID: PMC3198230 DOI: 10.4111/kju.2011.52.9.589] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 04/28/2011] [Indexed: 11/30/2022] Open
Abstract
Sexually transmitted diseases (STDs) are the most common infectious diseases worldwide, with over 350 million new cases occurring each year, and have far-reaching health, social, and economic consequences. Failure to diagnose and treat STDs at an early stage may result in serious complications and sequelae. STDs are passed from person to person primarily by sexual contact and are classified into varied groups. Some cause mild, acute symptoms and some are life-threatening. They are caused by many different infectious organisms and are treated in different ways. Syphilis and gonorrhea are ancient afflictions. Now, however, Chlamydia is prevalent and has become the most common bacterial STD. Antimicrobial resistance of several sexually transmitted pathogens is increasing, rendering some regimens ineffective, adding to therapeutic problems. A standardized treatment protocol for STDs is recommended to ensure that all patients receive adequate treatment. Appropriate treatment of STDs is an important public health measure.
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Affiliation(s)
- Bong Suk Shim
- Department of Urology, School of Medicine, Ewha Womans University, Seoul, Korea
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Harkins AL, Munson E. Molecular Diagnosis of Sexually Transmitted Chlamydia trachomatis in the United States. ISRN OBSTETRICS AND GYNECOLOGY 2011; 2011:279149. [PMID: 21822498 PMCID: PMC3148448 DOI: 10.5402/2011/279149] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Accepted: 04/27/2011] [Indexed: 12/03/2022]
Abstract
Chlamydia, with its Chlamydia trachomatis etiology, is the most common bacterial sexually transmitted infection in the United States and is often transmitted via asymptomatic individuals. This review summarizes traditional and molecular-based diagnostic modalities specific to C. trachomatis. Several commercially available, FDA-approved molecular methods to diagnose urogenital C. trachomatis infection include nucleic acid hybridization, signal amplification, polymerase chain reaction, strand displacement amplification, and transcription-mediated amplification. Molecular-based methods are rapid and reliable genital specimen screening measures, especially when applied to areas of high disease prevalence. However, clinical and analytical sensitivity for some commercial systems decreases dramatically when testing urine samples. In vitro experiments and clinical data suggest that transcription-mediated amplification has greater analytical sensitivity than the other molecular-based methods currently available. This difference may be further exhibited in testing of extragenital specimens from at-risk patient demographics. The development of future molecular testing could address conundrums associated with confirmatory testing, medicolegal testing, and test of cure.
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Affiliation(s)
- April L Harkins
- Department of Clinical Laboratory Science, Marquette University, Milwaukee, WI 53233, USA
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Wetmore CM, Manhart LE, Wasserheit JN. Randomized controlled trials of interventions to prevent sexually transmitted infections: learning from the past to plan for the future. Epidemiol Rev 2010; 32:121-36. [PMID: 20519264 DOI: 10.1093/epirev/mxq010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Globally, sexually transmitted infections (STIs) represent a significant source of morbidity and disproportionately impact the health of women and children. The number of randomized controlled trials testing interventions to prevent STIs has dramatically increased over time. To assess their impact, the authors conducted a systematic review of interventions to prevent sexual transmission or acquisition of STIs other than human immunodeficiency virus, published in the English-language, peer-reviewed literature through December 2009. Ninety-three papers reporting data from 74 randomized controlled trials evaluating 75 STI prevention interventions were identified. Eight intervention modalities were used: behavioral interventions (36% of interventions), vaginal microbicides (16%), vaccines (16%), treatment (11%), partner services (9%), physical barriers (5%), male circumcision (5%), and multicomponent (1%). Overall, 59% of interventions demonstrated efficacy in preventing infection with at least 1 STI. Treatment interventions and vaccines for viral STIs showed the most consistently positive effects. Male circumcision protected against viral STIs and possibly trichomoniasis. Almost two-thirds of behavioral interventions were effective, but the magnitude of effects ranged broadly. Partner services yielded similarly mixed results. In contrast, vaginal microbicides and physical barrier methods demonstrated few positive effects. Future STI prevention efforts should focus on enhancing adherence within interventions, integrating new technologies, ensuring sustainable behavior change, and conducting implementation research.
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Affiliation(s)
- Catherine M Wetmore
- Center for AIDS and STD and Department of Global Health, University of Washington, Box 358210, Suite 600, 2301 Fifth Avenue, Seattle, WA 98121, USA.
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Munson E, Firmani MA. Molecular diagnosis ofNeisseria gonorrhoeaeinfection in the United States. ACTA ACUST UNITED AC 2009; 3:327-43. [DOI: 10.1517/17530050902860229] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Turner KME, Garnett GP, Ghani AC, Sterne JAC, Low N. Investigating ethnic inequalities in the incidence of sexually transmitted infections: mathematical modelling study. Sex Transm Infect 2004; 80:379-85. [PMID: 15459406 PMCID: PMC1744908 DOI: 10.1136/sti.2003.007575] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To investigate ethnic differences in rates of gonorrhoea using empirical sexual behaviour data in a simple mathematical model. To explore the impact of different intervention strategies in this simulated population. METHODS The findings from cross sectional studies of gonorrhoea rates and sexual behaviour in three ethnic groups in south east London were used to determine the parameters for a deterministic, mathematical model of gonorrhoea transmission dynamics, in a population stratified by sex, sexual activity (rate of partner change), and ethnic group (white, black African, and black Caribbean). We compared predicted and observed rates of infection and simulated the effects of targeted and population-wide intervention strategies. RESULTS In model simulations the reported sexual behaviours and mixing patterns generated major differences in the rates of gonorrhoea experienced by each subpopulation. The fit of the model to observed data was sensitive to assumptions about the degree of mixing by level of sexual activity, the numbers of sexual partnerships reported by men and women, and the degree to which observed data underestimate female infection rates. Interventions to reduce duration of infection were most effective when targeted at black Caribbeans. CONCLUSIONS Average measures of sexual behaviour in large populations are inadequate descriptors for the epidemiology of gonorrhoea. The consistency between the model results and empirical data shows that profound differences in gonorrhoea rates between ethnic groups can be explained by modest differences in a limited number of sexual behaviours and mixing patterns. Targeting effective services to particular ethnic groups can have a disproportionate influence on disease reduction in the whole community.
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Affiliation(s)
- K M E Turner
- Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.
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Buvé A, Changalucha J, Mayaud P, Gavyole A, Mugeye K, Todd J, Clayton T, Mosha F, Grosskurth H, Mabey D, Laga M, Van Lerberghe W, Hayes RJ. How many patients with a sexually transmitted infection are cured by health services? A study from Mwanza region, Tanzania. Trop Med Int Health 2001; 6:971-9. [PMID: 11737832 DOI: 10.1046/j.1365-3156.2001.00809.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To estimate the proportion of symptomatic patients with a bacterial sexually transmitted infection (STI) cured by primary health care services in Mwanza Region, Tanzania, and to compare the cure rate achieved by health centres before and after the introduction of improved STI treatment services. METHODS A model was used that describes the different hurdles patients with an STI take before they can be considered cured by the health services. The values for the input parameters for the model were taken from different studies. Data from an intervention trial as well as from a population-based study on male urethritis were used to estimate the proportion of symptomatic patients with an STI who seek care from a health centre. An observational study in four health centres where improved STI treatment services had been introduced provided estimates of the proportions of patients with an STI correctly diagnosed and treated. Patients who returned to the health centres after 1 week were interviewed about compliance. An estimate of the efficacy of treatments prescribed for STIs in health centres before the introduction of improved STI services was obtained from a study on prescription patterns for genital discharge syndrome (GDS) and genital ulcer disease (GUD). RESULTS It was estimated that in the catchment area of health centres offering improved STI services, 51-72% of patients with STI symptoms sought care from those health centres. About 76-85% of cases were correctly diagnosed, and of these 69-80% received efficacious treatment. Compliance with full treatment was estimated at 84%. The estimated overall cure rate achieved by the health centres offering improved STI services ranged between 23 and 41%. The proportion of symptomatic STI patients who attended a health centre before improved STI services were introduced was estimated at 39%. The estimated efficacy of the treatments prescribed was 28%. The overall cure rate achieved by these health centres was less than 10%. CONCLUSIONS When assessing the performance of STI case detection and management all steps have to be taken into account that are taken by patients with an STI before they can be considered cured by the health services. The intervention to improve STI services in Mwanza Region has resulted in an improvement of the cure rate of STIs achieved by primary health care centres.
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Affiliation(s)
- A Buvé
- Institute of Tropical Medicine, Antwerp, Belgium.
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Garnett GP, Bowden FJ. Epidemiology and control and curable sexually transmitted diseases: opportunities and problems. Sex Transm Dis 2000; 27:588-99. [PMID: 11099074 DOI: 10.1097/00007435-200011000-00007] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the availability of safe and effective treatment, infection with bacterial sexually transmitted diseases persists at a high prevalence in many populations. GOAL To review the difficulties of parameter estimation when a cure is readily available and to explore the impact of different treatment and screening strategies that might maximize the benefits of using available treatments. STUDY DESIGN A standard deterministic model for the spread of a bacterial sexually transmitted disease that causes symptomatic and asymptomatic infections, in which the population is stratified according to sex and sexual activity, is further stratified into two host groups to enable the modeling of different treatment and screening strategies. RESULTS In the presence of a core group, if an infection has a high transmission probability, then screening for asymptomatic infections has a short-lived benefit. Repeated screening is slightly better if it is not restricted to a fraction of the at-risk population, but targeting of high-risk groups should be effective. Screening to treat asymptomatic infections in men could be beneficial if a substantial fraction of cases remain asymptomatic. CONCLUSIONS After the initial gains achieved through treating symptomatic infections, further reductions in the prevalence of infections can be achieved by finding asymptomatic infections. However, these gains are difficult to achieve, especially in the case of gonorrhea. Because men are likely to have an asymptomatic chlamydial infection, screening of men for chlamydia should be worthwhile.
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Affiliation(s)
- G P Garnett
- Wellcome Trust Centre for the Epidemiology of Infectious Disease, University of Oxford, United Kingdom
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Donovan B. The repertoire of human efforts to avoid sexually transmissible diseases: past and present. Part 2: Strategies used during or after sex. Sex Transm Infect 2000; 76:88-93. [PMID: 10858708 PMCID: PMC1758293 DOI: 10.1136/sti.76.2.88] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND/OBJECTIVE Despite the focus by public health programmes on condoms, chastity, or monogamy, people use a much wider variety of strategies to minimize their personal risk of sexually transmissible disease (STD). The objective of this study was to compile a comprehensive list of personal and societal STD avoidance strategies. METHODS Data from clinical and research observations, computer searches, and historical texts were pooled. RESULTS A variety of behaviours during or after sex, other than condoms, were identified that have been perceived to alter STD risk. STD avoidance strategies were often poorly documented and difficult to disentangle from other drives such as aesthetics, sexual variety, and contraception. They also varied in popularity in time and place. Some examples were douching; systemic and topical prophylactic antimicrobials; non-penetrative sexual practices, post-coital urination; and examining sexual partners' genitalia. Interest in some practices has been recently revived--for example, vaginal microbicides and post-exposure chemoprophylaxis, while others--for example, withdrawal and non-penetrative sexual practices, receive scant attention but may be much more widely used. CONCLUSION The full spectrum of STD avoidance strategies warrants further study because some are ubiquitous across cultures and because they have the potential to complement or undermine safer sex programmes. Because of their greater acceptability, some less efficacious strategies may have greater public health importance than less popular but more efficacious strategies such as condoms.
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Affiliation(s)
- B Donovan
- Sydney Sexual Health Centre, Sydney Hospital, NSW, Australia.
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Garnett GP, Mertz KJ, Finelli L, Levine WC, St Louis ME. The transmission dynamics of gonorrhoea: modelling the reported behaviour of infected patients from Newark, New Jersey. Philos Trans R Soc Lond B Biol Sci 1999; 354:787-97. [PMID: 10365404 PMCID: PMC1692556 DOI: 10.1098/rstb.1999.0431] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A survey of the sexual behaviour of gonorrhoea patients in Newark was undertaken to evaluate parameters within a model of gonorrhoea transmission. Modelling work aimed to explain observed epidemiological patterns and to explore the potential impact of interventions. Reported behaviours, along with values derived from the literature, were used within a standard deterministic model of gonorrhoea transmission, where the population was stratified according to sex and rates of sex-partner change. The behaviours reported, particularly among women, are insufficient by themselves to explain the continued existence of gonorrhoea within the population. The majority of symptomatic patients seek treatment within a few days, and report that they do not have unprotected sex while symptomatic. The proportion of patients with low numbers of sex partners suggests that sexual mixing between people categorized according to sexual behaviour is near random. To explain the persistence of gonorrhoea, there must be some patients who, when infected, do not seek care in public clinics. In addition, gonorrhoea incidence in the model is sensitive to change, such that very small reductions in risk behaviour could lead to its elimination. This does not accord with the observed failure of many interventions to eliminate infection, suggesting that the modelled infection is too sensitive to change. The model, which has been influential in gonorrhoea epidemiology, is not consistent with the observed epidemiology of gonorrhoea in populations. Alternative models need to explore the observed stability of gonorrhoea before robust modelling conclusions can be drawn on how best to control infection. However, the current results do highlight the potential importance of asymptomatic infections and infections in those who are diseased and do not attend public health services. Screening and contact-tracing to identify asymptomatic infections in both men and women will be more effective in reaching those who maintain the infection within the community rather than simply treating symptomatic cases.
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Affiliation(s)
- G P Garnett
- Wellcome Trust Centre for the Epidemiology of Infectious Disease, University of Oxford
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Abstract
AIM To review the features of gonococcal infection in men in the 1990s. METHODS A retrospective study of all men with gonorrhoea presenting to an inner city department of genitourinary medicine in the years 1990 to 1992. RESULTS 1749 cases of gonorrhoea were seen in 1382 men. A high incidence of gonorrhoea was found in attenders of African or Caribbean extraction. In 228 men with a known date of infection, the incubation period, a mean of 8.3 days, was longer than previously described. The mean infectious period was 12.0 days. By 14 days 86.2% of men had developed symptoms. Of 1615 men with urethral infection 81.9% complained of discharge, while dysuria occurred in 52.8%. Discharge with dysuria were present in only 48.1% of patients. In 10.2% episodes of urethral infection the patients had no symptoms referable to their gonorrhoea. Urethral gonorrhoea was diagnosed by microscopy in 94.4% of symptomatic men and in only 81.1% of asymptomatic men. Microscopy of rectal samples were positive in 46.4% of cases. In this population, a dose of 2 g of ampicillin with 1 g of probenecid gave a high cure rate of gonorrhoea as long as infection was not due to penicillinase-producing organisms. CONCLUSIONS These data suggest that the incubation and infectious period of urethral gonorrhoea has increased compared with previous studies and that symptoms have altered. Only 48.1% of men described the classical symptoms of discharge with dysuria. Microscopy of urethral smears remains useful in symptomatic men but is less sensitive in those without symptoms.
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Affiliation(s)
- J Sherrard
- Department of Genitourinary Medicine, Radcliffe Infirmary, UK
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Higgins SP. Painful swelling of the prepuce occurring during penile erection. Genitourin Med 1996; 72:426. [PMID: 9038639 PMCID: PMC1195731 DOI: 10.1136/sti.72.6.426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- S P Higgins
- Department of Genitourinary Medicine, Manchester Royal Infirmary
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Affiliation(s)
- P Teofoli
- Department of Dermatology, University of Florence, Italy
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Abstract
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)
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Affiliation(s)
- W R Bowie
- Division of Infectious Diseases, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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Fekete T. Antimicrobial susceptibility testing of Neisseria gonorrhoeae and implications for epidemiology and therapy. Clin Microbiol Rev 1993; 6:22-33. [PMID: 8457978 PMCID: PMC358264 DOI: 10.1128/cmr.6.1.22] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Antimicrobial susceptibility testing (AST) of Neisseria gonorrhoeae has been under development since the early days of antimicrobial agents. However, it is rarely applied to clinical isolates today. The history of the various in vitro tests to determine the susceptibility of N. gonorrhoeae to antibiotics is rich with evidence that these results predict response to therapy for almost all agents tested. Further, AST is a useful and important aspect of strain characterization and disease epidemiology in conjunction with the more specific but laborious techniques of auxotyping, serotyping, and plasmid analysis. Current technology has overcome many of the objections to AST for N. gonorrhoeae with standardization of test media and the development of an accurate disk diffusion AST method that is suited to most clinical laboratories regardless of volume or level of technical expertise. Ironically, the very low level of resistance to the current primary treatment strategy in the United States, ceftriaxone or another potent cephalosporin, makes the use of AST somewhat superfluous.
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Affiliation(s)
- T Fekete
- Section of Infectious Diseases, Temple University Health Sciences Center, Philadelphia, Pennsylvania 19140
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Clendennen TE, Hames CS, Kees ES, Price FC, Rueppel WJ, Andrada AB, Espinosa GE, Kabrerra G, Wignall FS. In vitro antibiotic susceptibilities of Neisseria gonorrhoeae isolates in the Philippines. Antimicrob Agents Chemother 1992; 36:277-82. [PMID: 1605592 PMCID: PMC188352 DOI: 10.1128/aac.36.2.277] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Antibiotic susceptibility surveillance testing was performed on clinical isolates of Neisseria gonorrhoeae collected in September 1989 in the Philippines. beta-Lactamase was produced by 77 (55%) of 140 isolates. In vitro MIC testing revealed significant resistance to penicillin (MIC for 90% of isolates [MIC90], greater than 64 micrograms/ml), tetracycline (MIC90, 4 micrograms/ml), and cefmetazole (MIC90, 8 micrograms/ml). Spectinomycin resistance was rare (10 of 117), but the MIC90 was 32 micrograms/ml. Isolates were susceptible to fluoroquinolones and cephalosporins at the time of this survey, as evidenced by the MIC90s of ciprofloxacin (0.25 microgram/ml), norfloxacin (2.0 micrograms/ml), ofloxacin (0.625 microgram/ml), cefpodoxime (2.0 micrograms/ml), cefotaxime (1.0 microgram/ml), ceftazidime (0.25 microgram/ml), ceftizoxime (0.25 microgram/ml), and ceftriaxone (0.06 microgram/ml). To date, ceftriaxone resistance has not emerged, despite the widespread use of this antibiotic in the Philippines.
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Affiliation(s)
- T E Clendennen
- Navy Environmental and Preventive Medicine Unit Six, Pearl Harbor, Hawaii 96860-5040
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