High burden of untreated syphilis, drug resistant Neisseria gonorrhoeae, and other sexually transmitted infections in men with urethral discharge syndrome in Kampala, Uganda

Self-collected penile-meatal swabs are suitable for the detection of STIs in Ugandan men with high rates of STI coinfections

BACKGROUND

Sexually transmitted infections (STIs) are a global health challenge. Testing is not routinely performed in low- and middle-income countries (LMICs), which bear a disproportionate burden of STIs. Self-collected penile-meatal swabs (SCPMS) are an alternative to urine for STI testing, but data from LMICs are limited.

METHODS

Between October 2019 and September 2020, recruited participants with urethral discharge syndrome at government health facilities in Kampala, Uganda, provided urine and SCPMS. Samples were retrospectively analysed for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV) using Aptima assays. Paired SCPMS and urine samples with discordant STI results were analysed using real-time PCR assays.

RESULTS

Of the 250 participants, 66.8% (n=167), 22.8% (n=57), 12.8% (n=32) and 2.4% (n=6) tested positive for NG, CT, MG and TV, respectively, on testing of their SCPMS and urine samples. The overall agreement between urine and SCPMS for all STIs using the Aptima assays was 98.7% (987/1000). After adjudication with PCR assays, the agreement between urine and SCPMS for NG, CT, MG and TV was 100% (250/250), 97.6% (244/250), 99.6% (249/250), and 99.6% (249/250), respectively. There was no significant difference between SCPMS and urine (p=0.9996). For paired samples with one STI (n=164) or ≥2 STIs (n=39), concordance was 100% (656/656) and 97.2% (175/180), respectively. There was no association between number of STIs and agreement between sample types (p=0.8606).

CONCLUSIONS

This study revealed a high level of agreement between SCPMS and urine for detection of STIs in symptomatic Ugandan men, even in the presence of multiple concurrent STIs. SCPMS may be a suitable alternative to urine, with ease of collection, transporting, and processing of samples.

Association between city-level sociodemographic and health factors and the prevalence of antimicrobial-resistant gonorrhea in the US, 2000-2019: a spatial-temporal modeling study

Background

Evidence from the surveillance systems of antimicrobial-resistant (AMR) gonorrhea suggests substantial variation in the prevalence of AMR gonorrhea across populations. However, little is known about the extent to which the population-level demographic, socioeconomic, and health factors (e.g., population density, poverty level, or the prevalence of other sexually-transmitted diseases) are associated with the burden of AMR gonorrhea. We developed a hierarchical Bayesian spatial-temporal logistic regression model to investigate the association between multiple spatially- and temporally-varying predictors and the proportion of isolates with resistance to each one of ciprofloxacin, penicillin, and tetracycline between 2000 and 2019 in the United States (US).

Methods

The model was informed by data from the Gonococcal Isolate Surveillance Project (GISP), a sentinel surveillance system to monitor trends in the AMR gonorrhea in the US. During our study period, GISP included 112,487 isolates from the first 25 symptomatic men who have been diagnosed with urethral gonorrhea each month after attending participating sexually-transmitted disease clinics in one of about 30 select cities.

Findings

Among 112,487 isolates collected between 2000 and 2019, 16.5%, 13.7%, and 22.2% were resistance to ciprofloxacin, penicillin, and tetracycline. Denser populations were associated with higher prevalence of ciprofloxacin and penicillin resistance (odd ratio (OR): 1.5, 95% with credible interval: [1.29, 1.74] and 1.36 [1.22, 1.52], respectively); West was associated with higher prevalence of ciprofloxacin resistance (OR with respect to Midwest: 14.42 [2.02, 59.27]) and Southeast was associated with higher prevalence of ciprofloxacin and penicillin resistance (OR with respect to Midwest: 6.66 [1.59, 18.20] and 7.59 [2.3, 22.94]); higher prevalence of HIV was associated with higher prevalence of ciprofloxacin and tetracycline resistance (OR: 1.18 [1.01, 1.37] and 1.14 [1.02, 1.28]); and higher incidence of gonorrhea was associated with higher prevalence of tetracycline resistance (OR: 1.08 [1.05, 1.11]).

Interpretation

Geographic location and certain population-level characteristics including population density and HIV prevalence could provide insight about the population-level risk of AMR gonorrhea at a county-level. These results could guide the expansion of AMR surveillance systems or access to drug susceptibility testing in areas with characteristics associated with increased prevalence of AMR gonorrhea.

Funding

US National Institutes of Health.

A systematic review and guide for using multi-response statistical models in co-infection research

The simultaneous infection of organisms with two or more co-occurring pathogens, otherwise known as co-infections, concomitant infections or multiple infections, plays a significant role in the dynamics and consequences of infectious diseases in both humans and animals. To understand co-infections, ecologists and epidemiologists rely on models capable of accommodating multiple response variables. However, given the diversity of available approaches, choosing a model that is suitable for drawing meaningful conclusions from observational data is not a straightforward task. To provide clearer guidance for statistical model use in co-infection research, we conducted a systematic review to (i) understand the breadth of study goals and host-pathogen systems being pursued with multi-response models and (ii) determine the degree of crossover of knowledge among disciplines. In total, we identified 69 peer-reviewed primary studies that jointly measured infection patterns with two or more pathogens of humans or animals in natural environments. We found stark divisions in research objectives and methods among different disciplines, suggesting that cross-disciplinary insights into co-infection patterns and processes for different human and animal contexts are currently limited. Citation network analysis also revealed limited knowledge exchange between ecology and epidemiology. These findings collectively highlight the need for greater interdisciplinary collaboration for improving disease management.

Aetiological molecular identification of sexually transmitted infections that cause urethral discharge syndrome and genital ulcer disease in Brazilian men: a nationwide study

BACKGROUND

Little is known about the aetiology of urethral discharge syndrome (UDS) and genital ulcer disease (GUD) in Brazil due to limited access to laboratory tests and treatment based mainly on the syndromic approach.

OBJECTIVES

To update Brazilian treatment guidelines according to the current scenario, the first nationwide aetiological study for UDS and GUD was performed.

METHODS

Male participants with urethral discharge (UD) and/or genital ulcer (GU) reports were enrolled. Sample collection was performed by 12 sentinel sites located in the five Brazilian regions. Between 2018 and 2020, 1141 UD and 208 GU samples were collected in a Universal Transport Medium-RT (Copan). A multiplex quantitative PCR kit (Seegene) was used to detect UD: Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), M. hominis (MH), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV), Ureaplasma parvum (UP), U. urealyticum (UU) and another kit to detect GU: cytomegalovirus (CMV), Haemophilus ducreyi (HD), herpes simplex virus type 1 (HSV1), herpes simplex virus type 2 (HSV2), lymphogranuloma venereum (LGV), Treponema pallidum (TP) and varicella-zoster virus (VZV).

RESULTS

In UD samples, the frequency of pathogen detection was NG: 78.38%, CT: 25.6%, MG: 8.3%, UU: 10.4%, UP: 3.5%, MH: 3.5% and TV: 0.9%. Coinfection was assessed in 30.9% of samples, with 14.3% of NG/CT coinfection. The most frequent pathogen identified in GU was HSV2, present in 40.8% of the samples, followed by TP at 24.8%, LGV and CMV at 1%, and HSV1 at 0.4%. Coinfection of TP/HSV2 was detected in 4.4% of samples. VZV and HD were not detected. In 27.7% of the GU samples, no pathogen was detected.

CONCLUSION

This study provided the acquisition of unprecedented data on the aetiology of UDS and GUD in Brazil, demonstrated the presence of a variety of pathogens in both sample types and reaffirmed the aetiologies known to be most prevalent globally.

Antibiotic overuse, poor antimicrobial stewardship, and low specificity of syndromic case management in a cross section of men with urethral discharge syndrome in Kampala, Uganda

OBJECTIVE

High prevalence of sexually transmitted infections (STIs) combined with poor antimicrobial stewardship are drivers of STI antimicrobial resistance (AMR) especially in resource-limited settings where syndromic case management (SCM) is the norm. We characterized patterns of antibiotic use prior to clinic attendance and study enrollment in Ugandan men with urethral discharge syndrome (UDS), evaluated in-clinic prescribing, and the performance characteristics of SCM.

METHODS

Participants were recruited from government clinics participating in an existing gonococcal surveillance program in Kampala, Uganda. Questionnaires including antimicrobial use prior to attendance, prior episodes of UDS, penile swabs, and blood samples were collected. Bivariable and multivariable logistic regression models were used to estimate odds ratios (OR) for preselected factors likely to be associated with antibiotic use. In-clinic antibiotic treatment data were extracted from clinical notes, and the performance of SCM against laboratory-based STI diagnoses was evaluated.

FINDINGS

Between October 2019 and November 2020, 100(40%) of 250 men with UDS reported taking antibiotics in the 14days prior to attending the clinic. Of these 210(84%) had at least one curable STI and 20% had a reactive point-of-care HIV test. Multivariable analysis demonstrated significant associations between recent antimicrobial use and duration of UDS symptoms <6 days (OR 2.98(95%CI 1.07,8.36), p = 0.038), and sex with women only (OR 0.08(95%CI 0.01,0.82),p = 0.038). The sensitivity of SCM ranged from 80.0% to 94.4%; specificity was low between 5.6% and 33.1%. The positive predictive value of SCM ranged from 2.4(95%CI 0.7,6.0) for trichomoniasis to 63.4(95%CI 56.5,69.9) for gonorrhea.

CONCLUSION

Pre-enrollment antibiotic use was common in this population at high risk of STI and HIV. Combined with the poor specificity of SCM for male UDS, extensive antibiotic use is a likely driver of STI-AMR in Ugandan men. Interventions to improve antimicrobial stewardship and deliver affordable diagnostics to augment SCM and decrease overtreatment of STI syndromes are required.

High level of HIV viral suppression in a cross-sectional study of Ugandan men with urethritis and bacterial STI

BACKGROUND

Urethritis associated with non-viral sexually transmitted infections (STI) increases the risk of HIV acquisition and transmission in those living with HIV (LWH) without viral load suppression (VLS). Compared to women, men typically have lower rates of HIV VLS. We assessed the prevalence of VLS and drug resistance mutations in men LWH and urethral discharge syndrome (UDS) in Kampala, Uganda.

METHODS

Men with UDS were recruited in Kampala October 2019-November 2020. Medical, demographic, and behavioural data were collected with biological samples. All reactive HIV results (rapid, sequential algorithm) underwent confirmatory HIV antibody- and HIV incidence-testing, and viral load (VL) measurement. The pol and gp41 regions were sequenced on samples with VLs >1000 cpm, phylogenetic trees were generated, and resistance mutations were investigated.

RESULTS

50 of 250 participants (20%) had reactive HIV rapid tests and 48/50 (96%) were aware of their HIV status and using antiretroviral therapy (ART). The median age was 38 years (IQR 32-45), 27/50 (54%) had engaged in transactional sex, and 30/50 (60%) reported alcohol before sex. VLS was present in 46/50 (92%). There were no major resistance mutations present in any samples analyzed.

CONCLUSIONS

The prevalence of HIV and VLS was greater in these men than in the general Ugandan adult population. Most men LWH were on ART and thus less likely to transmit HIV despite demonstrating sexual behaviours associated with high-risk of STIs. These data emphasize that high levels of ART coverage and VLS are achievable among men with UDS in urban Kampala.

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.

Cluster analysis for symptomatic management of Neisseria gonorrhoea and Chlamydia trachomatis in sexually transmitted infections related clinics in China

OBJECTIVE

This study aimed to perform a cluster analysis of symptoms linked with Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) and to identify which cluster of symptoms was associated with a higher risk of NG and CT.

STUDY DESIGN

From 15 April to 16 May 2018, a cross-sectional study was conducted, and patients attending sexually transmitted infections (STI) related clinics were recruited from 22 medical institutions in six districts of Shenzhen city.

METHODS

A structured questionnaire was used to collect social-demographic information as well as STI symptoms, and urine samples were collected for nucleic acid detection. Cluster analysis and logistic regression were applied.

RESULTS

Among 8,207 participants, the prevalence of CT and NG infection was 9.04% (742/8,207) and 2.36% (194/8,207), respectively. Among male outpatients, four clusters with distinct symptomatic patterns were identified. Unmarried, having casual sexual partners in the past 6 months, cluster 2 (OR = 6.70, 95% CI = 3.36-13.35) and cluster 4 (OR = 24.53, 95% CI = 12.96-46.44) were risk factors associated with NG infection. Unmarried, cluster 2 (OR = 2.54, 95% CI = 1.83-3.53) and cluster 4 (OR = 3.31, 95% CI = 2.37-4.61) were risk factors associated with CT infection. Among female outpatients, five clusters with distinct symptomatic patterns were identified. Aged 24 years or below and cluster 3 (OR = 3.68, 95% CI = 1.61-8.39) were risk factors associated with NG infection. Aged 24 years or below, unmarried, having a high school/secondary technical school education, and having junior high school or below education were risk factors associated with CT infection.

CONCLUSION

The cluster of symptoms integrated into risk assessment for CT and NG infections suggests a new strategy of symptomatic management. Healthcare providers in STI clinics and resource-limited places may use this strategy to identify more potential patients and deliver adequate, acceptable, and equitable STI care for outpatients with a high risk of STI.