A Randomized Controlled Trial of Ceftriaxone and Doxycycline, With or Without Metronidazole, for the Treatment of Acute Pelvic Inflammatory Disease

Comparative clinical and incremental cost-effectiveness analysis of treatments for pelvic inflammatory disease in southern Brazil

OBJECTIVE

This paper evaluates the accuracy of C-reactive protein (CRP), leukocyte count, and neutrophil-to-lymphocyte ratio (NLR) for diagnosing tubo-ovarian abscess (TOA) and assessing the cost-effectiveness of different treatment regimens for pelvic inflammatory disease (PID), with and without TOA.

METHOD

A retrospective cohort study was conducted between January 1, 2003, and December 30, 2021, including women aged 13-80 years diagnosed with PID. The analysis focused on the incremental cost-effectiveness ratio of different treatment regimens.

RESULTS

C-reactive protein, leukocyte count, and NLR were found to be statistically significant markers for diagnosing TOA. Out of 907 PID cases, 705 achieved clinical cure with initial treatment. The most cost-effective treatment for mild PID without TOA was ceftriaxone combined with azithromycin, which was considered less costly and more effective in the cost-effectiveness analysis. For severe PID with TOA, ampicillin combined with gentamicin and clindamycin was more cost-effective compared to ampicillin with sulbactam plus doxycycline, given a willingness-to-pay threshold of US$213.57 for a 4.2% increase in cure rate.

CONCLUSION

The study's findings support the use of CRP, leukocyte count, and NLR as diagnostic tools for TOA. Ceftriaxone combined with azithromycin is recommended as the first-line treatment for mild PID at our institution due to its cost-effectiveness. For TOA, ampicillin combined with gentamicin and clindamycin is a cost-effective option if the healthcare system's willingness to pay exceeds US$213.57 for a 4.2% increase in cure rate, contributing valuable insights for PID treatment strategies from a hospital's perspective. The average time of hospital admission for TOA was 3 days. After discharge, patients received oral doxycycline until completing 14 days of treatment.

High prevalence of chronic endometritis in women with nonstructural abnormal uterine bleeding and benefits of antimicrobial treatment on blood loss pattern: A prospective, observational study

OBJECTIVE

The causal link between chronic endometritis (CE) and nonstructural abnormal uterine bleeding (AUB) has been poorly investigated and requires further clarification. This study aimed to evaluate the prevalence of CE in women with nonstructural AUB and to assess the effect of CE cure on the menstrual blood loss pattern.

METHODS

This prospective study was conducted between 2022 and 2024 at the Department of Obstetrics and Gynecology, University of Bari, Italy. Women aged 20-45 undergoing hysteroscopy for AUB with confirmation of nonstructural causes were evaluated for CE and considered affected when both hysteroscopic and histologic/immunohistochemical (HIS/IHC) criteria were met. Women with CE were treated with specific culture-guided therapy. Cure ascertainment was confirmed by triple negativity at hysteroscopy-HIS/IHC-culture (Group A). In cases of a positive test, a second course of therapy, up to three courses, was repeated before declaring a persistent condition (Group B). At enrollment and at end-of-treatment evaluation, all participants completed a questionnaire to describe the bleeding characteristics and the Pictorial Blood Assessment Chart (PBAC). Serum hemoglobin and ferritin were also assessed.

RESULTS

Chronic endometritis was diagnosed in 102 of 145 (70.3%) women with nonstructural AUB enrolled in the study. Out of 102 CE patients, 81 (79.4%) patients showed CE resolution after therapy (group A), while in 21 patients (20.6%) CE was persistent (group B). The duration of heavy bleeding before treatment (baseline) was similar in both groups (P = ns). In contrast, at the end of treatment, days of heavy bleeding, days of spotting, and PBAC scores decreased significantly in group A compared with both same-group baseline assessment and group B. Serum hemoglobin and ferritin levels in cured women (A) were significantly higher than in those with persistent CE (B). PBAC scores in group A at 3 and 6 months after the end of treatment showed persistence of cure benefits on AUB. Finally, among patients with CE diagnosis, both univariate and multivariate regressions showed a significant association between cure of CE and reduced bleeding.

CONCLUSION

Chronic endometritis was highly prevalent in women with nonstructural AUB in our cohort. Cure of CE by targeted antimicrobial therapy led to significant improvements in bleeding patterns.

Therapeutic potential of botanical drugs and their metabolites in the treatment of pelvic inflammatory disease

The application of botanical drugs and their metabolites in the treatment of pelvic inflammatory disease (PID) has garnered significant attention. Owing to their broad-spectrum activity, global accessibility, and structural diversity, botanical drugs have emerged as promising candidates for adjunctive or alternative therapies. This review systematically summarizes botanical drugs and their metabolites, focusing on their antimicrobial potential against endogenous and exogenous pathogens associated with PID. Specifically, it addresses various underlying antibacterial mechanisms, including interference with bacterial cell membranes and cell walls, inhibition of pathogen-specific efflux pumps, modulation of pathogen-related gene expression, and synergistic effects when combined with conventional antibiotics. This review highlights the therapeutic promise of botanical drugs and their metabolites, emphasizing critical findings regarding their inhibitory effects on PID-associated pathogens. Such insights provide valuable guidance for future therapeutic strategies and may support ongoing antibiotic discovery and development.

Comprehensive Assessment of Genital Infections and Reproductive Health in Women Visiting a Fertility Clinic in Warangal, India-A Case-Control Study

Background

Female infertility is a global health issue however, its link with genital infections is often overlooked due to asymptomatic nature of infections. Delayed diagnosis and treatment due to absence of reliable point-of-care (POC) tools result in long-term pathological consequences and infertility. This pilot-scale study aims to identify the most noteworthy prognostic symptoms of genital infections that exhibit a significant correlation with reproductive tract disorders and infertility.

Methods

We designed a detailed questionnaire and conducted a case-control, observational study with 100 female patients, categorized into infertile (n1 = 62) and healthy groups (n2 = 38) followed by statistical analysis.

Results

This study highlights an early onset of infertility (18-25 years). Approximately 27% of the infertile female patients are symptomatic for genital infections, and ~42% exhibit menstrual irregularities. Polycystic ovarian syndrome/disease (PCOS/PCOD, ~30%) appears to be the most predominant disorder, followed by endometrial disorders (~10%) and tubal damage (~8%) in infertile patients. A multivariate correlation analysis revealed a highly significant (p ≤ 0.05) and strong association (0.15 < Φ ≤ 1.0) between menstrual disorders, endometrial disorders, uterine/tubal blockage, and hormonal disruption with infection-associated symptoms, e.g. vaginitis, cervicitis, pelvic inflammatory disorder (PID), dyspareunia or infections like tuberculosis (TB) & urinary tract infection (UTI).

Conclusions

Our study shows a significant contribution of genital infections to female infertility. Nevertheless, a substantial 73% of infertile patients are ineligible for confirmatory diagnosis due to the absence of classical infection symptoms. This underscores the pressing requirement for comprehensive screening strategies for timely management of reproductive health and fertility.

Patient or Public Contribution

This study was performed in line with the principles of the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines (Supporting Information 1) [1]. The study was performed following an ethical approval of the Institutional Human Ethics Committee. All individuals who participated in the study were fully informed about various aspects, including the study's objectives, methodologies, sources of funding, potential conflicts of interest, institutional affiliations of the researcher, anticipated benefits, potential risks, and the discomfort they might experience. Their participation was contingent on obtaining their informed consent (See Supporting Information 2 for patient consent form). Furthermore, to safeguard patient confidentiality, we took measures to de-identify patient information. This included the removal of exact ages, which were replaced with age ranges, and the omission of exact dates or photographs during presentation of the data.

Enhanced inflammatory and oxidative response mitigation by acetyl-L-carnitine in a rat model of pelvic inflammatory disease

Acetyl-L-carnitine (ALC) is known for its potent antioxidant and anti-inflammatory properties. This research aimed to investigate the properties of ALC in combating pelvic inflammatory disease (PID) in a rat model. PID, a consequence of sexually transmitted infections in females, can impact the fallopian tubes and uterus, leading to complications. This study is a randomized control preclinical experiment. A total of 24 reproductively mature Sprague Dawley female rats were randomly and equally assigned (n = 4 per group) to six cohorts: control, PID, low-dose prophylactic, high-dose prophylactic, and low-dose therapeutic and high-dose therapeutic groups. PID was induced by injecting the rat cervix with a multi-pathogen solution. Acetyl-L-carnitine, 100 mg/kg (once a day), was orally administered to rats in the low-dose prophylactic group, while 200 mg/kg (once a day) to the high-dose prophylactic group, starting 1 day prior to induction of PID. The therapeutic groups were given similar doses of ALC 1 day after the PID model was confirmed. Samples from the right upper genital tract were collected for ELISA and antioxidant assays, while the left upper genital tract samples underwent histopathological analysis. According to the results, the ALC-treated groups showed a decreased level of cytokines (IL-1β, TNF-α) and oxidative stress markers (catalase, lipid peroxidation) when compared to the PID group. Histopathological examinations revealed that ALC treatment reduced the infiltration of neutrophils and lymphocytes in the uterus compared to the PID group. It was concluded that ALC showed potential antioxidant and anti-inflammatory effects in PID and, therefore, could be used as a possible option for the treatment of PID.

Trends in infections detected in women with cervicitis over a decade

Objectives

There is a growing body of evidence that in the absence of Chlamydia trachomatis and/or Neisseria gonorrhoeae, Mycoplasma genitalium and bacterial vaginosis (BV) are associated with cervicitis. We aimed to describe infections detected among cervicitis cases over a decade and establish how commonly M. genitalium and BV were detected among non-chlamydial/non-gonococcal cases to inform testing and treatment practices.

Methods

We conducted a retrospective case-series to determine the number of cervicitis cases diagnosed with genital infections (C. trachomatis, N. gonorrhoeae, M. genitalium and BV) among women attending the largest public sexual health service in Australia from 2011 to 2021. We determined the proportion of cervicitis cases with one or more genital infections detected, and trends in testing and detection of each infection over time.

Results

Over a decade 813 cervicitis cases were diagnosed; 421 (52%, 95%CI: 48%-55%) had no infection detected; 226/729 (31%, 95%CI: 28%-35%) had BV, 163/809 (20%, 95%CI: 17%-23%) C. trachomatis, 48/747 (6%, 95%CI: 5%-8%) M. genitalium, and 13/793 (2%, 95%CI: 1%-3%) N. gonorrhoeae. Of the 665 (82%) cases tested for all four infections, 268 (40%) had one infection and 73 (11%) had >1 infection detected. Of the 517/665 (78%) non-chlamydial/non-gonococcal cases, 164 (32%) had BV and 16 (3%) had M. genitalium as the sole infections detected; a further 13 cases (3%) were co-infected with BV and M. genitalium. The proportion of cases tested for BV (90%) did not change overtime, but detection increased from 32% to 45% (Ptrend < 0.001). The proportion of cases tested for M. genitalium increased from 84% in 2011 to 96% in 2019 (Ptrend = 0.006), with M. genitalium-detection in cervicitis increasing from 3% to 7% (Ptrend = 0.046).

Conclusions

In our study population, chlamydia or gonorrhoea were not detected in ∼75% of cervicitis cases; 1 in 3 of these cases had BV and/or M. genitalium, and both increased in prevalence over time. These data highlight the need for clinicians to consider BV and M. genitalium when assessing and managing cervicitis.

Successful Treatment of Mycoplasma genitalium Urethritis With High-Dose Tinidazole

ABSTRACT

A 30-year-old male patient with symptomatic Mycoplasma genitalium urethritis failed treatment with oral azithromycin, 2-stage doxycycline-moxifloxacin, and minocycline. Molecular testing confirmed the presence of macrolide resistance mutations. Treatment with oral tinidazole 2 g daily for 7 days resulted in clinical and microbiologic cure.

Understanding Quorum-Sensing and Biofilm Forming in Anaerobic Bacterial Communities

Biofilms are complex, highly organized structures formed by microorganisms, with functional cell arrangements that allow for intricate communication. Severe clinical challenges occur when anaerobic bacterial species establish long-lasting infections, especially those involving biofilms. These infections can occur in device-related settings (e.g., implants) as well as in non-device-related conditions (e.g., inflammatory bowel disease). Within biofilms, bacterial cells communicate by producing and detecting extracellular signals, particularly through specific small signaling molecules known as autoinducers. These quorum-sensing signals are crucial in all steps of biofilm formation: initial adhesion, maturation, and dispersion, triggering gene expression that coordinates bacterial virulence factors, stimulates immune responses in host tissues, and contributes to antibiotic resistance development. Within anaerobic biofilms, bacteria communicate via quorum-sensing molecules such as N-Acyl homoserine lactones (AHLs), autoinducer-2 (AI-2), and antimicrobial molecules (autoinducing peptides, AIPs). To effectively combat pathogenic biofilms, understanding biofilm formation mechanisms and bacterial interactions is essential. The strategy to disrupt quorum sensing, termed quorum quenching, involves methods like inactivating or enzymatically degrading signaling molecules, competing with signaling molecules for binding sites, or noncompetitively binding to receptors, and blocking signal transduction pathways. In this review, we comprehensively analyzed the fundamental molecular mechanisms of quorum sensing in biofilms formed by anaerobic bacteria. We also highlight quorum quenching as a promising strategy to manage bacterial infections associated with anaerobic bacterial biofilms.

Antimicrobial treatment and resistance in sexually transmitted bacterial infections

Sexually transmitted infections (STIs) have been part of human life since ancient times, and their symptoms affect quality of life, and sequelae are common. Socioeconomic and behavioural trends affect the prevalence of STIs, but the discovery of antimicrobials gave hope for treatment, control of the spread of infection and lower rates of sequelae. This has to some extent been achieved, but increasing antimicrobial resistance and increasing transmission in high-risk sexual networks threaten this progress. For Neisseria gonorrhoeae, the only remaining first-line treatment (with ceftriaxone) is at risk of becoming ineffective, and for Mycoplasma genitalium, for which fewer alternative antimicrobial classes are available, incurable infections have already been reported. For Chlamydia trachomatis, in vitro resistance to first-line tetracyclines and macrolides has never been confirmed despite decades of treatment of this highly prevalent STI. Similarly, Treponema pallidum, the cause of syphilis, has remained susceptible to first-line penicillin.

Clinical Updates in Sexually Transmitted Infections, 2024

Sexually transmitted infections (STIs) continue to increase in the United States with more than 2.5 million cases of gonorrhea, chlamydia, and syphilis reported to the Centers for Disease Control and Prevention in 2022. Untreated STIs in women can lead to adverse outcomes, including pelvic inflammatory disease, infertility, chronic pelvic pain, and pregnancy complications such as ectopic pregnancy, early pregnancy loss, stillbirth, and neonatal transmission. STI-related guidelines can be complex and are frequently updated, making it challenging to stay informed on current guidance. This article provides high-yield updates to support clinicians managing STIs by highlighting changes in screening, diagnosis, and treatment. One important topic includes new guidance on syphilis screening, including a clarified description of high community rates of syphilis based on Healthy People 2030 goals, defined as a case rate of primary or secondary syphilis > 4.6 per 100,000. Reproductive aged persons living in counties above this threshold should be offered syphilis screening. Additionally, American College of Obstetricians & Gynecologists now recommends syphilis screening three times during pregnancy regardless of risk-at the first prenatal visit, during the third trimester, and at delivery. In addition, new guidance to support consideration for extragenital screening for gonorrhea and chlamydia in women at sites such as the anus and pharynx is discussed. Other topics include the most recent chlamydia, gonorrhea, trichomoniasis, and pelvic inflammatory disease treatment recommendations; screening and treatment guidance for Mycoplasma genitalium; genital herpes screening indications and current diagnostic challenges; and the diagnosis and management of mpox in women and during pregnancy.

A Rare Case of Lymphocytic Ascites

Ascites can manifest as a result of many conditions, with cirrhosis being the most common cause in the United States. Here, we present a case of lymphocytic ascites, a less common variant that occurred due to infection with Chlamydia trachomatis. This was a 37-year-old female with a history of substance and sexual abuse who presented with the chief complaints of abdominal pain, abdominal distension, and weight gain. She was febrile on admission with a distended, tender abdomen. The more common cardiac, renal, and hepatic causes were ruled out with extensive workup. Diagnosis and therapeutic paracentesis were done with fluid analysis significant for lymphocyte predominance and absence of malignant cells. Multi-modal imaging had ruled out suspicious malignant masses but CT abdomen/pelvis did show complex large volume ascites. Urine chlamydia and gonorrhea polymerase chain reaction (PCR) had resulted positive for chlamydia, leading us to start Doxycycline. Other infectious workups were negative, but ascitic fluid chlamydia NAAT was positive. Though initially worsening, the patient started showing significant clinical improvement after starting doxycycline, with the resolution of ascites and associated symptoms. This case report intends to bring to attention the importance of testing for chlamydia infection in cases of lymphocytic ascites, especially in sexually active females.

The Role of Prevotella Species in Female Genital Tract Infections

Female genital tract infections (FGTIs) include vaginal infections (e.g., bacterial vaginosis [BV]), endometritis, pelvic inflammatory disease [PID], and chorioamnionitis [amniotic fluid infection]. They commonly occur in women of reproductive age and are strongly associated with multiple adverse health outcomes including increased risk of HIV/sexually transmitted infection acquisition and transmission, infertility, and adverse birth outcomes such as preterm birth. These FGTIs are characterized by a disruption of the cervicovaginal microbiota which largely affects host immunity through the loss of protective, lactic acid-producing Lactobacillus spp. and the overgrowth of facultative and strict anaerobic bacteria. Prevotella species (spp.), anaerobic Gram-negative rods, are implicated in the pathogenesis of multiple bacterial FGTIs. Specifically, P. bivia, P. amnii, and P. timonensis have unique virulence factors in this setting, including resistance to antibiotics commonly used in treatment. Additionally, evidence suggests that the presence of Prevotella spp. in untreated BV cases can lead to infections of the upper female genital tract by ascension into the uterus. This narrative review aims to explore the most common Prevotella spp. in FGTIs, highlight their important role in the pathogenesis of FGTIs, and propose future research in this area.

A randomized, double-blind, positive-controlled, Phase-II clinical trial to evaluate efficacy and safety of Fuke Qianjin capsule in Pakistani patients with pelvic inflammatory disease

Ethnopharmacological relevance: Pelvic inflammatory disease (PID) is a frequently occurring gynecological disorder mainly caused by the inflammation of a woman's upper genital tract. Generally, antibiotics are used for treating PID, but prolonged use poses potential risks of gut bacterial imbalance, bacterial resistance, super bacteria production, and associated adverse reactions. Traditional Chinese medicine (TCM) has shown unique advantages in various ailments and has received widespread clinical research attention. Fuke Qianjin (FUKE) capsule is an approved National Medical Products Administration (NMPA License No. Z20020024) Chinese herbal prescription that has been widely used individually or in combination with other Western medicines for the treatment of various gynecological inflammatory diseases, including chronic cervicitis, endometritis, and chronic PID. Aim: This clinical trial was designed to assess the safety and efficacy of FUKE capsule in mild-to-moderate symptomatic PID patients. Materials and methods: This phase 2, randomized, double-blind, positive controlled clinical trial was conducted in mild-to-moderate symptomatic PID patients at a single center in Pakistan from 21 September 2021 to 11 March 2022. Eligible female participants were randomly assigned to a test and a control group with a ratio of 1:1. The test group subjects received two metronidazole (METRO) tablets and one doxycycline hyclate (DOXY) simulant at a time, twice daily for 14 days, and two Fuke Qianjin (FUKE) capsules, three times a day after a meal for 28 days. Subjects in the control group received two METRO tablets and one DOXY tablet at a time, twice daily for 14 days, and two FUKE simulant capsules, three times a day after meal for 28 days. The primary efficacy outcome was an improvement in pelvic pain symptoms assessed through a visual analog scale (VAS). The secondary outcomes were the improvement in secondary efficacy symptoms like local physical signs, clinical assessment of leucorrhea and cervical secretions through laboratory examination, and improvement in the maximum area of pelvic effusion assessed through gynecological ultrasound after the treatment. The safety outcomes were assessed through vital signs, laboratory tests, electrocardiogram findings, and adverse events/serious adverse events. Results: A total of 198 subjects with active PID were randomly assigned to a test group (n = 99) and a control group (n = 99). The baseline characteristics of the subjects in the two groups were similar. In the intention-to-treat analysis, the primary efficacy was 84.9% for the test group and 71.6% for the control group, with a statistically significant difference (p = 0.0370; 95% CI -0.2568 to -0.0088). The secondary clinical efficacy was 88.4% for the test group and 82.7% for the control group, with no significant difference (p = 0.2977; 95% CI -0.1632 to 0.0501). The improvement in local physical signs was 95.8% for the test group and 76.9% for the control group, with no significant difference (p = 0.0542; 95% CI -0.3697 to -0.0085). The inter-group non-inferiority comparison showed that the upper limit of the 95% CI was less than 0.15 and thus met the non-inferiority requirements of the test group to the control group. The results of clinical signs of leucorrhea and cervical secretions showed that there was no difference in the rate of improvement between the test and control groups, indicating that FUKE was non-inferior to DOXY. A total of 14 adverse events in eight subjects were observed in the trial, with an incidence rate of 4.7%. Four subjects in each group experienced seven adverse events with 4.5% and 4.8% incidence rates of adverse reactions in the test and control groups, with no statistically significant differences (p = 0.2001). No serious adverse events occurred in the trial. Conclusion: The results of this trial indicate that the test drug (Fuke Qianjin capsule) is non-inferior to the control drug (doxycycline hyclate tablet) in treating mild-to-moderate PID patients with comparable efficacy, safety, and tolerability to the control drug. Clinical Trial Registration: www.clinicaltrials.gov, identifier NCT04723069.

Clinical Presentations and Treatment Outcomes of Mycoplasma genitalium Infections at a Large New York City Health Care System

BACKGROUND

Mycoplasma genitalium (MG) is an emerging sexually transmitted infection. Treatment of MG is complicated by increasing resistance to primary treatment regimens, including macrolides and fluoroquinolones. Understanding the various clinical presentations and relative effectiveness of treatments for MG is crucial to optimizing care.

METHODS

Patients with a positive MG nucleic acid amplification test between July 1, 2019, and June 30, 2021, at a large health system in New York City were included in a retrospective cohort. Demographics, clinical presentations, coinfections, treatment, and follow-up microbiologic tests were obtained from the electronic medical record. Associations with microbiologic cure were evaluated in bivariate and multivariable logistic regression models.

RESULTS

Five hundred two unique patients had a positive MG nucleic acid amplification test result during the study period. Male individuals presented predominantly with urethritis (117 of 187 [63%]) and female individuals with vaginal symptoms (142 of 315 [45%]). Among patients with follow-up testing who received a single antibiotic at the time of treatment, 43% (90 of 210) had persistent infection and 57% (120 of 210) had microbiologic cure. Eighty-two percent of patients treated with moxifloxacin had microbiologic cure compared with 41% of patients receiving azithromycin regimens ( P < 0.001). In multivariable analysis, treatment with moxifloxacin was associated with 4 times the odds of microbiologic cure relative to low-dose azithromycin (adjusted odds ratio [aOR], 4.18; 95% confidence interval, 1.73-10.13; P < 0.01).

CONCLUSIONS

Clinical presentations of MG vary, with urethritis or vaginal symptoms in most cases. Among patients who received a single antibiotic, only treatment with moxifloxacin was significantly associated with microbiologic cure relative to low-dose azithromycin.

Ribosome-targeting antibiotic control NLRP3-mediated inflammation by inhibiting mitochondrial DNA synthesis

While antibiotics are designed to target bacteria specifically, most are known to affect host cell physiology. Certain classes of antibiotics have been reported to have immunosuppressive effects, but the underlying mechanisms remain elusive. Here, we show that doxycycline, a ribosomal-targeting antibiotic, effectively inhibited both mitochondrial translation and nucleotide-binding domain and leucine-rich repeat-containing protein 3 (NLRP3) inflammasome-mediated caspase-1 activation and interleukin-1β (IL-1β) production in bone-marrow-derived macrophages (BMDMs). In addition, knockdown of mitochondrial methionyl-tRNA formyltransferase (Mtfmt), which is rate limiting for mitochondrial translation, also resulted in the inhibition of NLRP3 inflammasome-mediated caspase-1 activation and IL-1β secretion. Furthermore, both doxycycline treatment and Mtfmt knockdown blocked the synthesis of mitochondrial DNA (mtDNA) and the generation of oxidized mtDNA (Ox-mtDNA), which serves as a ligand for NLRP3 inflammasome activation. In addition, in vivo results indicated that doxycycline mitigated NLRP3 inflammasome-dependent inflammation, including lipopolysaccharide-induced systemic inflammation and endometritis. Taken together, the results unveil the antibiotics targeting the mitoribosome have the ability to mitigate NLRP3 inflammasome activation by inhibiting mitochondrial translation and mtDNA synthesis thus opening up new possibilities for the treatment of NLRP3-related diseases.

A prospective preconception cohort study of the association between Mycoplasma genitalium and fecundability in Kenyan women trying to conceive

STUDY QUESTION

Is Mycoplasma genitalium-infection associated with reduced fecundability?

SUMMARY ANSWER

Preconception M. genitalium-infection was associated with 27% lower fecundability though confidence intervals were wide, and the association between M. genitalium and fecundability may be dependent on concurrent bacterial vaginosis (BV).

WHAT IS KNOWN ALREADY

M. genitalium has been associated with cervicitis, pelvic inflammatory disease, infertility, and preterm birth, but the extent to which M. genitalium is causally related to adverse reproductive sequelae in women is debated.

STUDY DESIGN, SIZE, DURATION

Kenyan women enrolled in a prospective preconception cohort provided vaginal fluid specimens and underwent monthly pregnancy testing. Stored samples from 407 women who had been trying to conceive for ≤6 months were tested for M. genitalium using a nucleic acid amplification test.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data on first day of last menstrual period, sexual behavior, pregnancy status, and vaginal specimens were collected at monthly preconception visits. The association between M. genitalium detected at the visit prior to each pregnancy test and fecundability was estimated using discrete time proportional probabilities models. Secondary analyses explored the influence of concurrent BV on the association between M. genitalium and fecundability.

MAIN RESULTS AND THE ROLE OF CHANCE

The 407 participants experienced 1220 menstrual cycles and 213 pregnancies. The prevalence of M. genitalium at enrollment was 7.7%. After adjustment for age, frequency of condomless sex in the last 4 weeks, and study site, M. genitalium was associated with a 27% lower fecundability, but confidence intervals were wide (adjusted fecundability ratio (aFR) 0.73, 95% CI 0.44, 1.23). In secondary analyses, when compared to cycles without M. genitalium or BV at the visit prior, women with both M. genitalium and BV at the visit prior had a 51% lower fecundability (aFR = 0.49, 95% CI 0.22, 1.09) whereas there was no association of M. genitalium alone (aFR = 0.98 (95% CI 0.54, 1.76)), and a smaller reduction in fecundability for women with BV only (aFR = 0.80 (95% CI 0.60, 1.07)).

LIMITATIONS, REASONS FOR CAUTION

Results should be interpreted cautiously given the relatively low prevalence of M. genitalium and wide confidence intervals.

WIDER IMPLICATIONS OF THE FINDINGS

In this cohort of Kenyan women trying to conceive, the association between M. genitalium and fecundability was influenced by concurrent BV status, suggesting there may be a synergistic effect of M. genitalium and BV on fecundability.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a National Institutes of Health grant (NICHD R01 HD087346-RSM). R.S.M. received additional support for mentoring (NICHD K24 HD88229). E.M.L. was supported by pre- and post-doctoral fellowships (NIAID T32 AI07140, NICHD F32 HD100202). Data collection and management were completed using REDCap electronic data capture tools hosted at the University of Washington's Institute of Translational Health Science supported by grants from NCATS/NIH (UL1 TR002319). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. R.S.M. receives research funding, paid to the University of Washington, from Hologic Corporation and consulting fees from Lupin Pharmaceuticals. L.E.M. receives research funding and material for research studies, paid to the University of Washington, from Hologic Corporation and Nabriva Therapeutics, travel support from Hologic, and consulting fees from Health Advances. E.M.L.'s contributions to this study primarily occurred while affiliated with the University of Washington; at the time of submission, E.M.L. was an employee of and holds stock or stock grants for AbbVie, Inc. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Global burden of pelvic inflammatory disease and ectopic pregnancy from 1990 to 2019

BACKGROUND

Pelvic inflammatory disease (PID) is a widespread female public problem worldwide. And it could lead to infertility, preterm labor, chronic pelvic pain, and ectopic pregnancy (EP) among reproductive-aged women. This study aimed to assess the global burden and trends as well as the chaning correlation between PID and EP in reproductive-aged women from 1990 to 2019.

METHODS

The data of PID and EP among reproductive-aged women (15 to 49 years old) were extracted from the Global Burden of Disease study 2019. The disease burden was assessed by calculating the case numbers and age-standardized rates (ASR). The changing trends and correlation were evaluated by calculating the estimated annual percentage changes (EAPC) and Pearson's correlation coefficient.

RESULTS

In 2019, the ASR of PID prevalence was 53.19 per 100,000 population with a decreasing trend from 1990 (EAPC: - 0.50), while the ASR of EP incidence was 342.44 per 100,000 population with a decreasing trend from 1990 (EAPC: - 1.15). Globally, PID and EP burdens changed with a strong positive correlation (Cor = 0.89) globally from 1990 to 2019. In 2019, Western Sub-Saharan Africa, Australasia, and Central Sub-Saharan Africa had the highest ASR of PID prevalence, and Oceania, Eastern Europe, and Southern Latin America had the highest ASR of EP incidence. Only Western Europe saw significant increasing PID trends, while Eastern Europe and Western Europe saw increasing EP trends. The highest correlations between PID and EP burden were observed in Burkina Faso, Laos, and Bhutan. General negative correlations between the socio-demographic index and the ASR of PID prevalence and the ASR of EP incidence were observed at the national levels.

CONCLUSION

PID and EP continue to be public health burdens with a strong correlation despite slightly decreasing trends detected in ASRs globally. Effective interventions and strategies should be established according to the local situation by policymakers.

Update in Epidemiology and Management of Mycoplasma genitalium Infections

Mycoplasma genitalium is a frequent cause of urogenital syndromes in men and women and is associated with adverse sequelae in women. M genitalium also infects the rectum, and may cause proctitis, but rarely infects the pharynx. Diagnosis requires nucleic acid amplification testing. Antibiotic resistance is widespread: more than half of infections are resistant to macrolides and fluoroquinolone resistance is increasing. Resistance-guided therapy is recommended for symptomatic patients, involving initial treatment with doxycycline to reduce organism load followed by azithromycin for macrolide-sensitive infections or moxifloxacin for macrolide-resistant infections. Neither screening nor tests of cure are recommended in asymptomatic persons.

Chlamydia trachomatis-An Emerging Old Entity?

Chlamydia trachomatis is an evasive pathogen that can prompt severe clinical manifestations in humans such as vaginitis, epididymitis, lymphogranuloma venereum, trachoma, conjunctivitis and pneumonia. If left untreated, chronic infections with C. trachomatis can give rise to long-lasting and even permanent sequelae. To shed some light on its widespread nature, data from original research, systematic reviews and meta-analyses from three databases was collected and analyzed in the context of chlamydial infection, related symptoms and appropriate treatment modalities. This review describes the bacterium's pervasiveness on a global scale, especially in developing countries, and suggests ways to halt its transmission and spread. Infections with C. trachomatis often go unnoticed, as many individuals are asymptomatic and unaware of their diagnosis, contributing to a delay in diagnosis and treatment. The high prevalence of chlamydial infection highlights the need for a universal screening and detection method enabling immediate treatment at its onset. Prognosis is favorable with antibiotic therapy and education for high-risk groups and their sexual partners. In the future, a quick, easily accessible, and inexpensive test should be developed to diagnose and treat infected individuals early on. Along with a vaccine against C. trachomatis, it would halt the transmission and spread of the pathogen worldwide.

In Vitro Susceptibility and Resistance of Mycoplasma genitalium to Nitroimidazoles

Mycoplasma genitalium is a sexually transmitted reproductive tract pathogen of men and women. M. genitalium infections are increasingly difficult to treat due to poor efficacy of doxycycline and acquired resistance to azithromycin and moxifloxacin. A recent clinical trial suggested that metronidazole may improve cure rates for women with pelvic inflammatory disease and reduced the detection of M. genitalium when included with standard doxycycline plus ceftriaxone treatment. As data regarding susceptibility of mycoplasmas to nitroimidazoles are lacking in the scientific literature, we determined the in vitro susceptibility of 10 M. genitalium strains to metronidazole, secnidazole, and tinidazole. MICs ranged from 1.6 to 12.5 μg/mL for metronidazole, 3.1 to 12.5 μg/mL for secnidazole, and 0.8 to 6.3 μg/mL for tinidazole. None of these agents was synergistic with doxycycline in checkerboard broth microdilution assays. Tinidazole was superior to metronidazole and secnidazole in terms of MIC and time-kill kinetics and was bactericidal (>99.9% killing) at concentrations below reported serum concentrations. Mutations associated with nitroimidazole resistance were identified by whole-genome sequencing of spontaneous resistant mutants, suggesting a mechanism for reductive activation of the nitroimidazole prodrug by a predicted NAD(P)H-dependent flavin mononucleotide (FMN) oxidoreductase. The presence of oxygen did not affect MICs of wild-type M. genitalium, but a nitroimidazole-resistant mutant was defective for growth under anaerobic conditions, suggesting that resistant mutants may have a fitness disadvantage in anaerobic genital sites. Clinical studies are needed to determine if nitroimidazoles, especially tinidazole, are effective for eradicating M. genitalium infections in men and women.

Chronic Pelvic Pain: A Comprehensive Review

Chronic pelvic pain (CPP) is explained as a complaint of cyclic or non-cyclic pelvic pain lasting for at least six months with or without dysmenorrhea, dyspareunia, dysuria, and dyschezia. The etiology of symptoms can be categorized according to organ system involvement. Gynecological causes typically involve endometriosis-related pain, pelvic congestion syndrome, pelvic inflammatory disease, adenomyosis, hydrosalpinx, etc. Endometriosis-related pain is seldom non-cyclic and may present due to recurrent bleeding in endometriotic implants. Engorgement of veins leads to inadequate venous washout and presents chronic pelvic pain in pelvic congestion syndrome. The pressure effect of benign lesions of the uterus and cervix may lead to cyclic pain, as in uterine fibroids. Often presentation of diseases like hydrosalpinx may not present until it has overdistended or may at times present as acute pelvic pain if it undergoes torsion. Long-standing untreated pelvic inflammatory diseases in sexually active females is another cause of pelvic pain. The complaint of CPP is also shared due to the involvement of the gastrointestinal system in conditions like irritable bowel syndrome, inflammatory bowel diseases, long-standing abdominal hernias, colorectal cancer, etc. Alteration of the gut biome and dysregulated brain-gut associations lead to typical manifestations of chronic lower back pain and pelvic pain in irritable bowel syndrome. Colorectal tumors, when in the advanced stage, may spread to nearby tissues creating fistulas and affecting nearby nerves, causing pelvic, perineal, and sacral pain. Abdominal hernias with small bowel prolapse are always related to pelvic pain symptoms. Infections in the urinary tract like urethral syndrome, chronic prostatitis, and chronic recurrent cystitis present with CPP and voiding problems. Musculoskeletal etiologies, though varying in degrees, are responsible for isolated complaints of CPP. Examples include pelvic girdle pain, levator syndrome, coccygodynia, and pelvic floor prolapse.

Genetic susceptibility loci for Chlamydia trachomatis endometrial infection influence expression of genes involved in T cell function, tryptophan metabolism and epithelial integrity

Objectives

Identify genetic loci of enhanced susceptibility to Chlamydial trachomatis (Ct) upper genital tract infection in women.

Methods

We performed an integrated analysis of DNA genotypes and blood-derived mRNA profiles from 200 Ct-exposed women to identify expression quantitative trait loci (eQTL) and determine their association with endometrial chlamydial infection using a mediation test. We further evaluated the effect of a lead eQTL on the expression of CD151 by immune cells from women with genotypes associated with low and high whole blood expression of CD151, respectively.

Results

We identified cis-eQTLs modulating mRNA expression of 81 genes (eGenes) associated with altered risk of ascending infection. In women with endometrial infection, eGenes involved in proinflammatory signaling were upregulated. Downregulated eGenes included genes involved in T cell functions pivotal for chlamydial control. eGenes encoding molecules linked to metabolism of tryptophan, an essential chlamydial nutrient, and formation of epithelial tight junctions were also downregulated in women with endometrial infection. A lead eSNP rs10902226 was identified regulating CD151, a tetrospanin molecule important for immune cell adhesion and migration and T cell proliferation. Further in vitro experiments showed that women with a CC genotype at rs10902226 had reduced rates of endometrial infection with increased CD151 expression in whole blood and T cells when compared to women with a GG genotype.

Conclusions

We discovered genetic variants associated with altered risk for Ct ascension. A lead eSNP for CD151 is a candidate genetic marker for enhanced CD4 T cell function and reduced susceptibility.

Shipi Shugan Decoction Protected against Sequela of Pelvic Inflammatory Disease via Inhibiting SIRT1/NLRP3 Signaling Pathway in Pelvic Inflammatory Disease Rats

Sequela of pelvic inflammatory disease (SPID) is a common and frequently occurring disease clinically. Traditional Chinese medicine (TCM) provided unique advantages in the treatment of SPID. In this study, we aimed to investigate the protective mechanism of Shipi Shugan Decoction (SSD), a Chinese herbal formula, on SPID using a SPID rat model. Mixed bacterial infection and mechanical injury were used for modeling. The chemical composition of SSD was analyzed by ultra-performance liquid chromatography-mass spectrometry (UPLC-MS). The inflammatory factors were detected by enzyme-linked immunosorbent assay (ELISA) and western blot techniques. We found that SSD dose-dependently inhibited the content of IL-18, IL-1β, TNF-α, and IL-6 in serum samples of SPID rats. The results from the hematoxylin and eosin (H&E) stain showed that SSD improved pathological injury of the uterus and fallopian tubes induced by a pathogen. In addition, SSD dose-dependently inhibited mitochondrial dysfunction and oxidative stress of SPID rats. The expression of SIRT1 was promoted, and NLRP3 inflammasome was deactivated by SSD gavage compared with the SPID group. Specifically, SIRT1 inhibitor EX-527 cotreatment significantly reversed the improvement effect of SSD on pelvic inflammatory disease in rats. Taken together, the results of this study suggest that Shipi Shugan Decoction may be an effective TCM for the treatment of SPID.

Identification and Treatment of Acute Pelvic Inflammatory Disease and Associated Sequelae

Pelvic inflammatory disease (PID) is an ascending polymicrobial infection of the upper female genital tract. The presentation of PID varies from asymptomatic cases to severe sepsis. The diagnosis of PID is often one of exclusion. Primary treatment for PID includes broad-spectrum antibiotics with coverage against gonorrhea, chlamydia, and common anaerobic and aerobic bacteria. If not clinically improved by antibiotics, percutaneous drain placement can promote efficient source control, as is often the case with large tubo-ovarian abscesses. Ultimately, even with treatment, PID can result in long-term morbidity, including chronic pelvic pain, infertility, and ectopic pregnancy.

Effectiveness and safety of morinidazole in the treatment of pelvic inflammatory disease: A multicenter, prospective, open-label phase IV trial

Background

Antimicrobial resistance to metronidazole has emerged after several decades of worldwide use of the drug. The purpose of this study was to evaluate the effectiveness, safety and population pharmacokinetics of morinidazole plus levofloxacin in adult women with pelvic inflammatory disease (PID).

Methods

Patients in 30 hospitals received a 14-day course of 500 mg intravenous morinidazole twice daily plus 500 mg of levofloxacin daily. A total of 474 patients were included in the safety analysis set (SS); 398 patients were included in the full analysis set (FAS); 377 patients were included in the per protocol set (PPS); 16 patients were included in the microbiologically valid (MBV) population.

Results

The clinical resolution rates in the FAS and PPS populations at the test of cure (TOC, primary effectiveness end point, 7–30 days post-therapy) visit were 81.91 and 82.49% (311/377), respectively. There were 332 patients who did not receive antibiotics before treatment, and the clinical cure rate was 82.83%. Among 66 patients who received antibiotics before treatment, 51 patients were clinically cured 7–30 days after treatment, with a clinical cure rate of 77.27%. The bacteriological success rate in the MBV population at the TOC visit was 87.5%. The minimum inhibitory concentration (MIC) values of morinidazole for use against these anaerobes ranged from 1 to 8 μg/mL. The rate of drug-related adverse events (AEs) was 27.43%, and no serious AEs or deaths occurred during the study.

Conclusions

The study showed that treatment with a 14-day course of intravenous morinidazole, 500 mg twice daily, plus levofloxacin 500 mg daily, was effective and safe. The results of this study were consistent with the results of a phase III clinical trial, which verified the effectiveness and safety of morinidazole.

Weighing Potential Benefits and Harms of Mycoplasma genitalium Testing and Treatment Approaches

This systematic review demonstrates increasing antimicrobial resistance and incomplete understanding of the bacterium’s natural history.

Since Mycoplasma genitalium was identified 40 years ago, much of the epidemiology has been described, diagnostic tests have been developed and approved, and recommended treatment approaches have been identified. However, the natural history remains incompletely understood, and antimicrobial resistance has rapidly increased. This review summarizes evidence published since the US Centers for Disease Control and Prevention 2015 Sexually Transmitted Diseases Treatment Guidelines. Data on sequelae remain insufficient, macrolide resistance is common, and fluoroquinolone resistance is increasing. Potential benefits of testing and treatment include resolving symptoms, interrupting transmission, and preventing sequelae. Potential harms include cost, patient anxiety, and increasing antimicrobial resistance.

Sexually Transmitted Infection Treatment Guidelines for Adolescent Health Providers: What's New in 2021?

The Centers for Disease Control and Prevention's Sexually Transmitted Infections Treatment Guidelines, 2021 contain new recommendations for the treatment of gonococcal, chlamydial, and trichomonas infections, as well as pelvic inflammatory disease. Providers are encouraged to broaden their screening practices by considering incorporating rectal and pharyngeal testing when indicated, as well as opt-out testing for adolescent females. The discussion of testing and counseling for genital herpes infections has been expanded.

Cerebral abscess with Streptococcus intermedius as a complication of pelvic inflammatory disease in the setting of intrauterine device use

A 43-year-old healthy female with no significant medical problems except for recently diagnosed pelvic inflammatory disease presented to our hospital with acute onset, severe head and neck pain. Brain imaging revealed a rim-enhancing lesion consistent with an abscess. The patient underwent successful surgical removal of the abscess and its capsule. Intraoperative cultures grew Streptococcus intermedius and she was discharged with a plan for four weeks of intravenous ceftriaxone.

The Combination of Clindamycin and Gentamicin Is Adequate for Pelvic Inflammatory Disease: A Retrospective Cohort Study

Pelvic inflammatory disease (PID) affects 4.4% of women aged 18-44 in the United States, and may cause infertility if it is ineffectively treated. A combination of clindamycin and gentamicin is generally used for the treatment of PID. The benefit of adding metronidazole into the treatment combination still remains unclear, and this study was designed to evaluate its effectiveness. We retrospectively included 107 women who were diagnosed with PID from May 2013 to September 2020 in a single hospital. Based on their used antibiotic regimens, the patients were divided into three groups-those who were treated with clindamycin + gentamicin (group 1, n = 46), those who took regular antibiotics plus metronidazole (group 2, n = 27), and others (group 3, n = 34). Primary outcomes included the rates of taking surgery after failed antibiotics, occurrence/rupture of tubo-ovarian abscesses, and readmission within the following 6 months of first treatment. Secondary outcomes to assess were the length of stay (LOS) and expenditure for PID. There were no significant differences in the surgical rates, readmission rates, LOS and expenditure noted between the three groups. Subgroup analysis showed that visual analogue pain scores being 5 or more would increase the LOS by 3.83 days (p < 0.001), and body temperature > 38.3 °C or more would increase the treatment total expenditure (p < 0.001). Our study results suggest that the combination of clindamycin + gentamicin is a convincible treatment protocol for PID.

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

A Review of the Challenges and Complexities in the Diagnosis, Etiology, Epidemiology, and Pathogenesis of Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is a syndrome that causes substantial morbidity, including chronic pelvic pain, to women globally. While limited data are available from low- and middle-income countries, national databases from the United States and Europe suggest that PID incidence may be decreasing but the rate of decrease may differ by the etiologic cause. Recent studies of women with PID have reported that fewer than half of women receiving a diagnosis of PID have gonococcal or chlamydial infection, while Mycoplasma genitalium, respiratory pathogens, and the constellation of bacteria associated with bacterial vaginosis may account for a substantial fraction of PID cases. The clinical diagnosis of PID is nonspecific, creating an urgent need to develop noninvasive tests to diagnose PID. Advances in serologic testing for Chlamydia trachomatis and Neisseria gonorrhoeae could advance epidemiologic studies, while the development of vaccines against these sexually transmitted pathogens could affect incident PID and associated morbidity.

Gonococcal Pelvic Inflammatory Disease: Placing Mechanistic Insights Into the Context of Clinical and Epidemiological Observations

While infection by Neisseria gonorrhoeae is often asymptomatic in women, undetected infections can ascend into the upper genital tract to elicit an inflammatory response that manifests as pelvic inflammatory disease, with the outcomes depending on the intensity and duration of inflammation and whether it is localized to the endometrial, fallopian tube, ovarian, and/or other tissues. This review examines the contribution of N. gonorrhoeae versus other potential causes of pelvic inflammatory disease by considering new insights gained through molecular, immunological, and microbiome-based analyses, and the current epidemiological burden of infection, with an aim to highlighting key areas for future study.

Host Genetic Risk Factors for Chlamydia trachomatis-Related Infertility in Women

BACKGROUND

Chlamydia trachomatis (Ct) infection ascending to the upper genital tract can cause infertility. Direct association of genetic variants as contributors is challenging because infertility may not be diagnosed until years after infection. Investigating the intermediate trait of ascension bridges this gap.

METHODS

We identified infertility genome-wide association study (GWAS) loci using deoxyribonucleic acid from Ct-seropositive cisgender women in a tubal factor infertility study and Ct-infected cisgender women from a longitudinal pelvic inflammatory disease cohort with known fertility status. Deoxyribonucleic acid and blood messenger ribonucleic acid from 2 additional female cohorts with active Ct infection and known endometrial infection status were used to investigate the impact of infertility single-nucleotide polymorphisms (SNPs) on Ct ascension. A statistical mediation test examined whether multiple infertility SNPs jointly influenced ascension risk by modulating expression of mediator genes.

RESULTS

We identified 112 candidate infertility GWAS loci, and 31 associated with Ct ascension. The SNPs altered chlamydial ascension by modulating expression of 40 mediator genes. Mediator genes identified are involved in innate immune responses including type I interferon production, T-cell function, fibrosis, female reproductive tract health, and protein synthesis and degradation.

CONCLUSIONS

We identified Ct-related infertility loci and their potential functional effects on Ct ascension.

The Continued Challenges in the Diagnosis of Acute Pelvic Inflammatory Disease: Focus on Clinically Mild Disease

Many women with lower genital tract infections associated with sexually transmitted pathogens have evidence of upper genital tract inflammation despite the absence of symptoms and signs traditionally associated with pelvic inflammatory disease (PID). New biomarkers are needed to identify these women with clinically mild PID or subclinical PID (silent salpingitis) to facilitate initiation of early treatment and ameliorate the sequelae associated with upper genital tract infection and inflammation.

Pelvic Inflammatory Disease Due to Neisseria gonorrhoeae and Chlamydia trachomatis: Immune Evasion Mechanisms and Pathogenic Disease Pathways

Pelvic inflammatory disease (PID) results from ascension of sexually transmitted pathogens from the lower genital tract to the uterus and/or fallopian tubes in women, with potential spread to neighboring pelvic organs. Patients may present acutely with lower abdominal or pelvic pain and pelvic organ tenderness. Many have subtle symptoms or are asymptomatic and present later with tubal factor infertility, ectopic pregnancy, or chronic pelvic pain. Neisseria gonorrhoeae and Chlamydia trachomatis are the 2 most commonly recognized PID pathogens. Their ability to survive within host epithelial cells and neutrophils highlights a need for T-cell-mediated production of interferon γ in protection. Data indicate that for both pathogens, antibody can accelerate clearance by enhancing opsonophagocytosis and bacterial killing when interferon γ is present. A study of women with N. gonorrhoeae- and/or C. trachomatis-induced PID with histologic endometritis revealed activation of myeloid cell, cell death, and innate inflammatory pathways in conjunction with dampening of T-cell activation pathways. These findings are supported by multiple studies in mouse models of monoinfection with N. gonorrhoeae or Chlamydia spp. Both pathogens exert multiple mechanisms of immune evasion that benefit themselves and each other at the expense of the host. However, similarities in host immune mechanisms that defend against these 2 bacterial pathogens instill optimism for the prospects of a combined vaccine for prevention of PID and infections in both women and men.

Etiology and Diagnosis of Pelvic Inflammatory Disease: Looking Beyond Gonorrhea and Chlamydia

Pelvic inflammatory disease (PID) is a clinical syndrome that has been associated with a wide range of potential causal pathogens. Three broad groups of organisms have been isolated from the genital tract of people with PID: sexually transmitted organisms such as Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis; bacterial vaginosis (BV)-associated species and genera such as Atopobium vaginae, Sneathia, and Megasphaera; and genera and species usually associated with the gastrointestinal or respiratory tracts such as Bacteroides, Escherichia coli, Streptococcus, or Haemophilus influenza. Although PID is often considered to be synonymous with gonorrhea or chlamydia, these pathogens are found in only one quarter to one third of people with PID, suggesting that broader screening and diagnostic and treatment strategies need to be considered to reduce the burden of PID and its associated sequelae.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

High Pgp3 Chlamydia trachomatis seropositivity, pelvic inflammatory disease and infertility among women, National Health and Nutrition Examination Survey, United States, 2013-2016

BACKGROUND

Chlamydia trachomatis causes pelvic inflammatory disease (PID) and tubal infertility. Pgp3 antibody (Pgp3Ab) detects prior chlamydial infections. We evaluated for an association of high chlamydial seropositivity with sequelae using a Pgp3Ab multiplex bead array (Pgp3AbMBA).

METHODS

We performed chlamydia Pgp3AbMBA on sera from women 18-39 years old participating in the 2013-2016 National Health and Nutrition Examination Survey (NHANES) with urine chlamydia nucleic acid amplification test results. High chlamydial seropositivity was defined as a median fluorescence intensity (MFI ≥ 50,000; low-positive was MFI > 551-<50,000. Weighted US population high-positive, low-positive, and negative Pgp3Ab chlamydia seroprevalence and 95% confidence intervals (95% CI) were compared for women with chlamydial infection, self-reported PID, and infertility.

RESULTS

Of 2,339 women aged 18-39 years, 1,725 (73.7%) had sera and 1,425 were sexually experienced. Overall, 104 women had high positive Pgp3Ab (5.4% [95% CI 4.0-7.0] of US women); 407 had low positive Pgp3Ab (25.1% [95% CI 21.5-29.0]), and 914 had negative Pgp3Ab (69.5% [95% CI 65.5-73.4]).Among women with high Pgp3Ab, infertility prevalence was 2.0 (95% CI 1.1-3.7) times higher than among Pgp3Ab-negative women (19.6% [95% CI 10.5-31.7] versus 9.9% [95% CI 7.7-12.4]). For women with low Pgp3Ab, PID prevalence was 7.9% (95% CI 4.6-12.6) compared to 2.3% (95% CI 1.4-3.6) in negative Pgp3Ab.

CONCLUSIONS

High chlamydial Pgp3Ab seropositivity was associated with infertility although small sample size limited evaluation of an association of high seropositivity with PID. In infertile women, Pgp3Ab may be a marker of prior chlamydial infection.

Bacterial vaginosis and its association with infertility, endometritis, and pelvic inflammatory disease

Bacterial vaginosis, pelvic inflammatory disease, and endometritis are infections of the genital tract that can lead to many adverse health outcomes, including infertility. Bacterial vaginosis is characterized by a lower prevalence of lactobacilli and a higher prevalence of anaerobic bacteria, including Gardnerella vaginalis, Megasphaera spp., and Atopobium vaginae. Endometritis and pelvic inflammatory disease are caused by the ascension of pathogenic bacteria to the uterus, although the mechanisms by which they do so are unclear. Bacterial vaginosis, chronic endometritis, and pelvic inflammatory disease have been linked to infertility in retrospective and prospective trials. Similarly, the causes of bacterial vaginosis and endometritis-related infertility are likely multifactorial and stem from inflammation, immune targeting of sperm antigens, the presence of bacterial toxins, and increased risk of sexually transmitted infections. Diagnosis and treatment of bacterial vaginosis, chronic endometritis, and pelvic inflammatory disease before attempting conception may be important components of preconceptional care for symptomatic women to improve outcomes of natural and assisted reproduction.

Megasphaera lornae sp. nov., Megasphaera hutchinsoni sp. nov., and Megasphaera vaginalis sp. nov.: novel bacteria isolated from the female genital tract

Six strictly anaerobic Gram-negative bacteria representing three novel species were isolated from the female reproductive tract. The proposed type strains for each species were designated UPII 199-6^T, KA00182^T and BV3C16-1^T. Phylogenetic analyses based on 16S rRNA gene sequencing indicated that the bacterial isolates were members of the genus Megasphaera. UPII 199-6^T and KA00182^T had 16S rRNA gene sequence identities of 99.9 % with 16S rRNA clone sequences previously amplified from the human vagina designated as Megasphaera type 1 and Megasphaera type 2, members of the human vaginal microbiota associated with bacterial vaginosis, preterm birth and HIV acquisition. UPII 199-6^T exhibited sequence identities ranging from 92.9 to 93.6 % with validly named Megasphaera isolates and KA00182^T had 16S rRNA gene sequence identities ranging from 92.6-94.2 %. BV3C16-1^T was most closely related to Megasphaera cerevisiae with a 16S rRNA gene sequence identity of 95.4 %. Cells were coccoid or diplococcoid, non-motile and did not form spores. Genital tract isolates metabolized organic acids but were asaccharolytic. The isolates also metabolized amino acids. The DNA G+C content for the genome sequences of UPII 199-6^T, KA00182^T and BV3C16-1^T were 46.4, 38.9 and 49.8 mol%, respectively. Digital DNA-DNA hybridization and average nucleotide identity between the genital tract isolates and other validly named Megasphaera species suggest that each isolate type represents a new species. The major fatty acid methyl esters include the following: C_12 : 0, C_16 : 0, C_16 : 0 dimethyl acetal (DMA) and summed feature 5 (C_15 : 0 DMA and/or C_14 : 0 3-OH) in UPII 199-6^T; C_16 : 0 and C_16 : 1 cis 9 in KA00182^T; C_12 : 0; C_14 : 0 3-OH; and summed feature 5 in BV3C16-1^T. The isolates produced butyrate, isobutyrate, and isovalerate but there were specific differences including production of formate and propionate. Together, these data indicate that UPII 199-6^T, KA00182^T and BV3C16-1^T represent novel species within the genus Megasphaera. We propose the following names: Megasphaera lornae sp. nov. for UPII 199-6^T representing the type strain of this species (=DSM 111201^T=ATCC TSD-205^T), Megasphaera hutchinsoni sp. nov. for KA00182^T representing the type strain of this species (=DSM 111202^T=ATCC TSD-206^T) and Megasphaera vaginalis sp. nov. for BV3C16-1^T representing the type strain of this species (=DSM 111203^T=ATCC TSD-207^T).

[Pelvic Inflammatory Disease - Synergies between Family Practices and Gynaecological Specialised Assessment]

Pelvic Inflammatory Disease - Synergies between Family Practices and Gynaecological Specialised Assessment Abstract. The 'pelvic inflammatory disease' (PID) describes an ascending inflammation of the upper female genital tract, beginning with a local cervicitis and proceeding to endometritis and adnexitis. It is a common clinical picture with rising numbers in recent years, and it occurs both in gynaecological and general practice. The symptoms are often unspecific, discrete or althogehter lacking. In order to reduce long-term risks of chronic pelvic pain, sterility and/or ectopic pregnancies, rapid diagnosis followed by immediate therapy and a good interdisciplinary cooperation are necessary. Screening programs for chlamydia and gonococcus as the most common pathogens of PID have not yet been implemented in Switzerland so far.