Changes in the prevalence of self-reported sexually transmitted bacterial infections from 2010 and 2017 in two large European samples of men having sex with men-is it time to re-evaluate STI-screening as a control strategy?

BACKGROUND/OBJECTIVES

Many European countries reported increased numbers of syphilis, gonorrhoea and chlamydia diagnoses among men who have sex with men (MSM) in recent years. Behaviour changes and increased testing are thought to drive these increases.

METHODS

In 2010 and 2017, two large online surveys for MSM in Europe (EMIS-2010, EMIS-2017) collected self-reported data on STI diagnoses in the previous 12 months, diagnostic procedures, STI symptoms when testing, number of sexual partners, and sexual behaviours such as condom use during the last intercourse with a non-steady partner in 46 European countries. Multivariate regression models were used to analyse factors associated with diagnoses of syphilis, gonorrhoea/chlamydia, and respective diagnoses classified as symptomatic and asymptomatic. If applicable, they included country-level screening rates.

RESULTS

Questions on STI diagnoses and sexual behaviours were answered by 156,018 (2010) and 125,837 (2017) participants. Between 2010 and 2017, overall diagnoses with gonorrhoea/chlamydia and syphilis increased by 76% and 83% across countries. Increases were more pronounced for asymptomatic compared to symptomatic infections. The proportion of respondents screened and the frequency of screening grew considerably. Condomless anal intercourse with the last non-steady partner rose by 62%; self-reported partner numbers grew. Increased syphilis diagnoses were largely explained by behavioural changes (including more frequent screening). Gonorrhoea/chlamydia increases were mainly explained by more screening and a change in testing performance. A country variable representing the proportion of men screened for asymptomatic infection was positively associated with reporting symptomatic gonorrhoea/chlamydia, but not syphilis.

DISCUSSION/CONCLUSION

The positive association of country-level screening rates with the proportion of symptomatic infections with gonorrhoea/chlamydia may indicate a paradoxical effect of screening on incidence of symptomatic infections. Treatment of asymptomatic men might render them more susceptible to new infections, while spontaneous clearance may result in reduced susceptibility. Before expanding screening programmes, evidence of the effects of screening and treatment is warranted.

The Impact of Selected Bacterial Sexually Transmitted Diseases on Pregnancy and Female Fertility

Sexually transmitted infections (STIs) caused by Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium are a common cause of pelvic inflammatory disease (PID) which can lead to tubal factor infertility (TFI). TFI is one of the most common causes of infertility, accounting for 30% of female fertility problems. STIs can also have an impact on pregnancy, leading to adverse pregnancy outcomes. Escalating antibiotic resistance in Neisseria gonorrhoeae and Mycoplasma genitalium represents a significant problem and can be therapeutically challenging. We present a comprehensive review of the current treatment options, as well as the molecular approach to this subject. We have given special attention to molecular epidemiology, molecular diagnostics, current and new treatments, and drug resistance.

Symptoms, Sites, and Significance of Mycoplasma genitalium in Men Who Have Sex with Men

During 2016-2017, we tested asymptomatic men who have sex with men (MSM) in Melbourne, Australia, for Mycoplasma genitalium and macrolide resistance mutations in urine and anorectal swab specimens by using PCR. We compared M. genitalium detection rates for those asymptomatic men to those for MSM with proctitis and nongonococcal urethritis (NGU) over the same period. Of 1,001 asymptomatic MSM, 95 had M. genitalium; 84.2% were macrolide resistant, and 17% were co-infected with Neisseria gonorrhoeae or Chlamydia trachomatis. Rectal positivity for M. genitalium was 7.0% and urine positivity was 2.7%. M. genitalium was not more commonly detected in the rectums of MSM (n = 355, 5.6%) with symptoms of proctitis over the same period but was more commonly detected in MSM (n = 1,019, 8.1%) with NGU. M. genitalium is common and predominantly macrolide-resistant in asymptomatic MSM. M. genitalium is not associated with proctitis in this population.

Optimizing bacterial DNA extraction in urine

Urine is an acceptable, non-invasive sample for investigating the human urogenital microbiota and for the diagnosis of sexually transmitted infections. However, low quantities of bacterial DNA and PCR inhibitors in urine may prevent efficient PCR amplification for molecular detection of bacteria. Furthermore, cold temperatures used to preserve DNA and bacteria in urine can promote precipitation of crystals that interfere with DNA extraction. Saline, Dulbecco’s Phosphate Buffered Saline, or Tris-EDTA buffer were added to urine from adult men to determine if crystal precipitation could be reversed without heating samples beyond ambient temperature. Total bacterial DNA concentrations and PCR inhibition were measured using quantitative PCR assays to compare DNA yields with and without buffer addition. Dissolution of crystals with Tris-EDTA prior to urine centrifugation was most effective in increasing bacterial DNA recovery and reducing PCR inhibition. DNA recovery using Tris-EDTA was further tested by spiking urine with DNA from bacterial isolates and median concentrations of Lactobacillus jensenii and Escherichia coli 16S rRNA gene copies were found to be higher in urine processed with Tris-EDTA. Maximizing bacterial DNA yield from urine may facilitate more accurate assessment of bacterial populations and increase detection of specific bacteria in the genital tract.

[Sexually transmitted Mycoplasma genitalium infection is difficult to treat]

Mycoplasma genitalium infection is sexually transmitted, and it is almost as common as chlamydia in most European settings. Symptoms are indistinguishable from those of chlamydia, and late sequelae are believed to be similar. Treatment of M. genitalium infection is complicated due to widespread antimicrobial resistance not only to first-line azithromycin but now also increasingly to second-line moxifloxacin, leaving no other antibiotics registered in Denmark available for effective treatment. In the absence of available antimicrobials, screening of asymptomatic individuals should be avoided.

[Diagnosis of vaginal discharge]

Changes in vaginal discharge are often caused by imbalance in the vaginal microflora, and laboratory testing is usually of little use, as most microbes detected are commensals. In-office diagnosis in general practice using wet mount microscopy and Amsel criteria is helpful and often sufficient to ensure correct diagnosis and treatment. Laboratory testing of vaginal discharge should only be performed, if sexually transmitted disease is suspected, if there is treatment failure or inconclusive wet mount prior to gynaecological surgery, and in pregnant women with recurrent miscarriage or preterm birth.

Detection of Ureaplasma Species by a Semi-Quantitative PCR Test in Urine Samples: Can It Predict Clinical Significance?

BACKGROUND

Ureaplasma species (Usp) are the most prevalent genital Mycoplasma isolated from the urogenital tract of both men and women. Usp may be commensals in the genital tract but may also be contributors to a number of pathological conditions of the genital tract. Because they can also just colonize the genital tract of healthy people, their pathogenic role can be difficult to prove.

OBJECTIVES

The aim of the study was to evaluate the efficacy of a quantitative polymerase chain reaction (qPCR) method for the discrimination between infection and colonization by measuring prevalence of Usp in asymptomatic versus symptomatic patients.

METHODS

Urine samples were tested for U. parvum and U. urealyticum using a semi-quantitative multiplex PCR technique for sexually transmitted diseases (Anyplex™ STI-7 Detection Kit, Seegene, South Korea). A total of 250 symptomatic and 250 asymptomatic controls were included.

RESULTS

A strong positive result for U. parvum was significantly more prevalent in symptomatic compared to asymptomatic patients. This finding was observed especially in women and in the young group (15-35 years of age). No significant differences were observed between the prevalence in symptomatic and asymptomatic patients of U. parvum with low strength of positivity and for U. urealyticum in all groups by age, gender, and strength of positivity.

CONCLUSIONS

The significant difference between the symptomatic and asymptomatic group in the highest positivity group for U. parvum using the Anyplex™ STI-7 detection kit in urine may indicate a high probability of infection rather than colonization, especially in women and young patients.

Sexually Transmitted Infection Testing of HIV-Positive Medicare and Medicaid Enrollees Falls Short of Guidelines

BACKGROUND

Men who have sex with men with HIV have high sexually transmitted infection (STI) incidence. Thus, the Centers for Disease Control and Prevention (CDC) recommends at least yearly STI screening of HIV-infected individuals.

METHODS

We calculated testing rates for syphilis, chlamydia, and gonorrhea among HIV-positive Californians with Medicare or Medicaid insurance in 2010. Logistic regressions estimated how testing for each bacterial STI relates to demographic and provider factors.

RESULTS

Fewer than two-thirds of HIV-positive Medicare and fewer than three-quarters of Medicaid enrollees received a syphilis test in 2010. Screenings for chlamydia or gonorrhea were less frequent: approximately 30% of Medicare enrollees were tested for chlamydia or gonorrhea in 2010, but higher proportions of Medicaid enrollees were tested (45%-46%). Only 34% of HIV-positive Medicare enrollees who were tested for syphilis were also screened for chlamydia or gonorrhea on the same day. Nearly half of Medicaid enrollees were tested for all 3 STIs on the same day. Patients whose providers had more HIV experience had higher STI testing rates.

CONCLUSIONS

Testing rates for chlamydia and gonorrhea infection are low, despite the increase in these infections among people living with HIV and their close association with HIV transmission. Interventions to increase STI testing include the following: prompts in the medical record to routinely conduct syphilis testing on blood drawn for viral load monitoring, opt-out consent for STI testing, and provider education about the clinical importance of STIs among HIV-positive patients. Last, it is crucial to change financial incentives that discourage nucleic acid amplification testing for rectal chlamydia and gonorrhea infections.

Bacterial etiology of sexually transmitted infections at a STI clinic in Ghana; use of multiplex real time PCR

BACKGROUND

Most sexually transmitted infection (STI) management efforts focus on the syndromic approach to diagnose and treat patients. However, most women with STIs have been shown to be entirely asymptomatic, or if symptoms exist, are often missed when either clinical or conventional bacteriologic diagnostic tools are employed.

METHODS

We assessed the performance of a multiplex real time PCR assay to describe other potential pathogens that could be missed by conventional bacteriological techniques in 200 women attending a routine STI clinic in Kumasi, Ghana.

RESULTS

Although a total 78.00% of the women were asymptomatic, 77.1% of them tested positive for at least one bacterial STI pathogen. Mycoplasma genitalium was the most commonly detectable pathogen present in 67.5% of all women. Of those testing positive, 25.0% had single infections, while 38.0% and 19.5% had double and triple infections respectively. Altogether, 86.54% and 90.91% of the symptomatic and asymptomatic women respectively tested positive for at least one pathogen (p<0.05). There were no significant associations (p<0.05) between the clinical manifestations of the symptomatic women and the pathogens detected in their samples.

CONCLUSIONS

Our study confirmed the importance of complementing the syndromic approach to STI management with pathogen detection and most importantly recognise that STIs in women are asymptomatic and regular empirical testing even for both symptomatic and asymptomatic patients is critical for complete clinical treatment.

FUNDING

EOD (Ellis Owusu-Dabo Research working group, KCCR).

Management of sexually acquired reactive arthritis in 19 North Thames GUM clinics

Our objective was to describe how genitourinary medicine (GUM) clinics in the North Thames region manage sexually acquired reactive arthritis (SARA), and to compare management with national guidelines. A self-completed questionnaire survey and retrospective case note review was conducted between September and October 2001. Clinicians in 33 clinics were asked to describe their clinic's policy on the management of SARA, and to review the last five cases seen or the last cases seen in the preceding two years, if less than five.

Nineteen (58%) clinics took part. There were inter-clinic variations in the investigation and management of patients, with only 63% (12/19) of clinics offering non-steroidal anti-inflammatory drugs (NSAIDs) and 58% (11/19) giving doxycycline 1001mg. twice daily for two weeks for urethritis - the rest using any of three other antibiotic regimens. There was no consistent policy of referral between other specialties and GUM for genital screening and partner notification. A total of 36 male and female case notes were reviewed. Patients without arthritis or joint swelling (5/38, 13%), or with non-typical symptoms such as diarrhoea (5/38, 13%) were diagnosed inappropriately with SARA.

Only 33 (87%) had evidence of a sexually transmitted infection (STI) with at least two (5%) of patients being treated with antibiotics despite no apparent indication being present. Only 21 (55%) had documented NSAID therapy. Case identification was difficult due to the lack of a national disease code (KC60) for SARA.

The data suggest that a diagnosis of SARA is sometimes being made with no identifiable STI, or where symptoms are more suggestive that another route of infection is likely. A clear guideline within clinics to standardize prescribing of antibiotics is needed and collaborative policies with GUM are needed for other specialties to use when investigating and managing patients with seronegative arthritis. GUM should consider re-introducing a KC60 code for SARA for better case identification.

The uptake of HIV testing among patients with chlamydial or gonococcal infections attending a genitourinary medicine clinic

Bacterial sexually transmitted infections (STIs) may be markers of high-risk sexual activity. Counselling for these infections provides an opportunity for promoting HIV testing.

The aim of the present study was to compare the uptake of HIV testing between patients with gonorrhoea or chlamydial infections and those without a bacterial STI. A study on patients screened for chlamydial or gonococcal infections in the Department of Genitourinary (GU) Medicine, Edinburgh between 1 July 2002 and 30 June 2003. The overall uptake of HIV testing among patients screened for chlamydial and gonococcal infections was 2263 (37%) of 6184 and 2012 (44%) of 4583, respectively ( P < 0.0002). Uptake of HIV testing was significantly higher among uninfected patients: for chlamydial infection, 17% of 1857 infected patients versus 45% of 4327 uninfected patients ( P < 0.0002); and for gonococcal infection, 24% of 256 infected patients versus 45% of 4327 uninfected patients ( P < 0.0002).

The policy of pre-test counselling needs to be redesigned in order to improve the uptake of HIV testing among patients with high-risk sexual activity.

Chlamydial infection in women along the US–Mexico border

Few studies have reported on sexually transmitted infections at the US–Mexico border, so the prevalence of Chlamydia trachomatis in this population remains uncertain. This binational project investigated the prevalence of, and risk factors for, C. trachomatis among women along the Arizona, US–Sonora, Mexico border.

Women who self-referred for routine gynaecological care were invited to complete an interviewer-administered questionnaire and to undergo a Pap smear, C. trachomatis test, and HPV test. In 2270 women, C. trachomatis prevalence overall was 8.2% as measured by hybrid capture and 2.6% by enzyme immunoassay. Infection was associated with young age, a history of new sexual partner(s) in the previous three months, HPV infection, and proximity of clinic to the international border. Antibiotic use in the previous 30 days was associated with decreased odds of infection.

Women in Arizona–Sonora border communities are at increased risk for C. trachomatis infection compared to women attending clinics in non-border locations.

The three-year positivity rate of sexually transmitted infections among a group of HIV-infected men attending the Department of Genitourinary Medicine, Edinburgh, UK

The aim of this study was to investigate the prevalence of sexually transmitted infections (STI) among patients at the time of and subsequent to the diagnosis of HIV, and possible immunological or virological features of patients with STI. An observational study was carried out on the results of annual STI screenings conducted on consecutive HIV-infected men in the Department of Genitourinary Medicine, Edinburgh between 1 January 1999 and 1 January 2003. Patients were tested for syphilis, gonococcal, and chlamydial infections.

Among the 79 male patients in the study cohort, the frequencies of all STI rose within the study period. The three-year positivity rates of episodes of gonorrhoea, chlamydia, and syphilis were (42/131) 32%, (21/127) 16%, and (13/150) 9%, respectively. Patients with STI had significantly higher median CD4+ T-cells ( P<0.02) and lower median viral loads ( P<0.0001), and a higher proportion of them were on highly active anti-retroviral therapy (HAART) ( P<0.0002) compared with those without an STI. Routine screening for STI and counselling for safe sex should be part of care for all HIV-infected patients.

Prevalence of sexually transmitted infections among long-distance truck drivers in Tongling, China

Little is known about sexually transmitted infections (STIs), including HIV, among truck drivers in China. A cross-sectional study was conducted among truck drivers in Tongling of Anhui Province. A total of 550 truck drivers were interviewed with a structured questionnaire, and blood samples were collected and tested for HIV, syphilis, and herpes simplex virus 2 (HSV-2), and urine specimens for Neisseria gonorrhoeae and Chlamydia trachomatis. Prevalence was 10.6% for C. trachomatis and 8.1% for N. gonorrhoeae. Antibodies for syphilis were found in 0.7% and for HSV-2 in 4.4%, and none was positive for HIV. About 92 (17.4%) truck drivers had at least one STI. There was no statistically significant association between sociodemographic, occupation or behavioural variables and the presence of a positive test for any STI. Our study suggests a high prevalence of STIs, particularly bacterial infections, among the truck drivers, indicating the need for health education, behavioural change interventions and STI care services in this population.

Non-chlamydial non-gonococcal urethritis or undiagnosed chlamydial urethritis?

The aim of this study is to investigate the prevalence of sexually transmitted infections (STI) in the partners of men with non-chlamydial, non-gonococcal urethritis (NCNGU).

Observational study of the sexual partners of men with NCNGU diagnosed in the Department of Genitourinary Medicine, Edinburgh between 1 June 2002 and 31 December 2003. The diagnosis of chlamydial infection was based on ligase chain reaction (LCx) between June 2002 and March 2003, and on polymerase chain reaction (PCR) thereafter. Gonococcal infection was diagnosed with culture method.

Sexual partners of 99 (25%) of the 403 heterosexual men diagnosed with NCNGU were screened. Chlamydial infection was detected in 19 (19%) of the female sexual partners. Higher proportion of female partners of symptomatic men (15/51) had chlamydial infection compared with that of partners of asymptomatic men (4/48) ( P < 0.005).

NCNGU may be related to false-negative results of chlamydial diagnostic tests. Screening and treatment of sexual partners of men with NCNGU is therefore necessary.

Incidence of gonococcal and chlamydial infections and coverage of two laboratory surveillance networks, France, 2012

Surveillance of sexually transmitted diseases in France is based on voluntary networks of laboratories and clinicians. Despite the importance of incidence data in improving knowledge about the national context and in international comparisons, such data were not previously available. During nationwide quality control of laboratories, mandatory for all laboratories, we conducted a survey in June 2013 to estimate the incidence rates of gonococcal and chlamydial infections for 2012 and to estimate the proportion of diagnoses performed (coverage) by the country's two laboratory-based sentinel networks for these diseases. Estimated incidence rates for 2012 were 39 per 100,000 persons aged 15 to 59 years for gonorrhoea and 257 per 100,000 persons aged 15 to 49 years for chlamydia. These rates were consistent with the average levels for a group of other Western countries. However, different estimates between countries may reflect disparate sources of surveillance data and diverse screening strategies. Better comparability between countries requires harmonising data sources and the presentation of results. Estimated coverage rates of the gonococcal and chlamydial infection surveillance networks in France in 2012 were 23% and 18%, respectively, with substantial regional variations. These variations justify improving the representativeness of these networks by adding laboratories in insufficiently covered areas.

Chlamydia trachomatis, Neisseria gonorrhoeae and syphilis among men who have sex with men in Brazil

BACKGROUND

Sexually transmitted diseases (STD) are frequently asymptomatic and increase the likelihood of transmitting and acquiring HIV. In Brazil, the guidelines for STDs diagnosis and treatment are based on the syndromic approach. Nucleic acid amplification tests (NAAT) has been recommended as routine STDs screening in some countries, especially for men who have sex with men (MSM). Limited data are available about how to best define target groups for routine screening by NAATs within this population. We aimed to assess the prevalence of rectal and urethral Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections and syphilis, and the factors associated with having at least one STD among HIV-infected and uninfected MSM in Rio de Janeiro, Brazil.

METHODS

From August 2010 to June 2012, 391 MSM were enrolled into the Evandro Chagas National Institute of Infectious Diseases-INI-Fiocruz cohort, and 292 MSM (HIV-infected:211 and HIV-uninfected:81) were included in this study. NAATs were performed on the rectal swabs and urine for CT and NG. The rapid plasma reagin test and microhemagglutination assay for Treponema pallidum were performed for syphilis diagnosis.

RESULTS

The overall prevalence of STD was 20.0% (95%CI:15.7-25.1): 10% anorectal chlamydia; syphilis 9.9%; anorectal gonorrheae 2.5%; and urethral chlamydia 2.2%; no case of urethral gonorrheae was detected. The proportion of HIV-positive MSM who had at least one STD was nearly two times that of HIV-negative MSM (22.6% vs 13.2%; P = 0.09). The frequency of each STD, except for anorectal NG (1.5% vs.5.2%), was higher among HIV-positive than HIV-negative individuals. Among the 211 asymptomatic participants, 17.5% (n = 37) were identified as having at least one STD; 10.4% (n = 22/211) tested positive for anorectal chlamydia. Sixty five percent of HIV-positive MSM were asymptomatic at the time of the STD diagnosis, while 100.0% of the HIV-negative MSM. Age (APR = 0.78; 95%CI:0.60-1.00 for each additional ten years) and a positive-HIV serostatus (APR = 2.05; 95%CI:1.03-4.08) were significantly associated with STD diagnosis.

CONCLUSION

An overall high STD-prevalence rate was observed, especially among HIV-infected and in younger individuals, and the majority of STDs were asymptomatic. STD screening using NAATs among asymptomatic MSM is a potentially cost-effective intervention for the prevention of HIV infection among MSM.

Comparison of culture versus quantitative real-time polymerase chain reaction for the detection of Taylorella equigenitalis in field samples from naturally infected horses in Canada and Germany

A quantitative real-time polymerase chain reaction method (qPCR) was developed and tested for the detection of Taylorella equigenitalis. It was shown to have an analytical sensitivity of 5 colony-forming units (CFU) of T. equigenitalis when applied to the testing of culture swabs that mimicked field samples, and a high analytical specificity in not reacting to 8 other commensal bacterial species associated with horses. As designed, it could also differentiate specifically between T. equigenitalis and T. asinigenitalis. The qPCR was compared to standard culture in a study that included 45 swab samples from 6 horses (1 stallion, 5 mares) naturally infected with T. equigenitalis in Canada, 39 swab samples from 5 naturally infected stallions in Germany, and 311 swab samples from 87 culture negative horses in Canada. When the comparison was conducted on an individual sample swab basis, the qPCR had a statistical sensitivity and specificity of 100% and 96.4%, respectively, and 100% and 99.1% when the comparison was conducted on a sample set basis. A comparison was also made on 203 sample swabs from the 5 German stallions taken over a span of 4 to 9 mo following antibiotic treatment. The qPCR was found to be highly sensitive and at least as good as culture in detecting the presence of T. equigenitalis in post-treatment samples. The work demonstrates that the qPCR assay described here can potentially be used to detect the presence of T. equigenitalis directly from submitted sample swabs taken from infected horses and also for determining T. equigenitalis freedom following treatment.

Chlamydia trachomatis related knowledge and practices in medical practioners--a survey

INTRODUCTION

Chlamydia trachomatis is a frequently encountered condition by general physicians, urologists and infectious diseases specialists. It can affect both genders and causes significant morbidity if not treated properly and promptly. In addition, it can cause ophthalmia neonatorum, which manifests as neonatal conjunctivitis in the newborns.

METHODOLOGY

The data was collected from fourteen tertiary care hospitals in two provinces of Pakistan during the time period of four months (September-December 2013). Inclusion criteria included all medical practitioners working at those hospitals and there were no limitations of age and gender to participate. The participants were approached through email which included a self administered questionnaire. Written consent was obtained from the participants and the study was approved by the ethical committee of all selected hospital.

RESULTS

Overall 130 participants participated with a response rate of 65%. Females were 52.3% and males were 47.7%. In the study 17.7% of male and 29.4% of female participants proclaimed that they referred a patient to an infectious disease specialist in case the diagnosis of Chlamydia was dubious. 72.5% of the male and 55.8% of the female medical practitioners indicated that they yield detailed sexual history from the patients with Chlamydia. Regarding inquiring about the drugs history from the patient at risk of STDs, 22.6% male and 35.3% of female participants informed that they took a detailed drug history. Only 1.5% of the female medical practitioners notified Chlamydia to the partner of diseased patient themselves (provider referral). 24% male and 17.6% female participants had an understanding regarding the definite test of diagnosis for sexually transmitted Chlamydia.

CONCLUSION

More sexual health skills development is required in medical practitioners working in Pakistan. The major deficient areas are sexual and drug history taking, management of sexually transmitted diseases and partner notification.

[Chlamydia: from population screening to individual repeated screening]

Chlamydia trachomatis is a frequent sexually transmitted infection especially in young adults and adolescents. Its complications can impair a woman's reproductive potential. chlamydia control has several challenges. These include asymptomatic infections; a long duration of untreated infections; re-infections and partner treatments. Any person with infection is at high risk of re-infection. Repeated screening would decrease, at an individual level, the risk of complications. General practitioners, gynaecologists and centres for sexual health could participate in Chlamydia screening for asymptomatic infections, in Switzerland, the cost of the laboratory test is fixed by national tariff regulations. The cost is high and prohibitive for many, especially adolescents and young adults and needs to be lowered.

Screening for nonviral sexually transmitted infections in adolescents and young adults

Prevalence rates of many sexually transmitted infections (STIs) are highest among adolescents. If nonviral STIs are detected early, they can be treated, transmission to others can be eliminated, and sequelae can be averted. The US Preventive Services Task Force and the Centers for Disease Control and Prevention have published chlamydia, gonorrhea, and syphilis screening guidelines that recommend screening those at risk on the basis of epidemiologic and clinical outcomes data. This policy statement specifically focuses on these curable, nonviral STIs and reviews the evidence for nonviral STI screening in adolescents, communicates the value of screening, and outlines recommendations for routine nonviral STI screening of adolescents.

Performance and comparison of self-reported STI symptoms among high-risk populations - MSM, sex workers, persons living with HIV/AIDS - in El Salvador

Resource-limited countries have limited laboratory capability and rely on syndromic management to diagnose sexually transmitted infections (STIs). We aimed to estimate the sensitivity, specificity and positive predictive value (PPV) of STI syndromic management when used as a screening method within a study setting. Men who have sex with men (MSM), female sex workers (FSWs) and people living with HIV/AIDS (PLWHA) participated in a behavioural surveillance study. Data were obtained on demographics, sexual behaviours, STI history and service utilisation. Biological specimens were tested for genital inflammatory infections (Neisseria gonorrhoeae [GC], Chlamydia trachomatis [CT], Mycoplasma genitalium [MG], Trichomonas vaginalis [TV]) and genital ulcerative infection (syphilis and Herpes simplex virus-2). There was a high prevalence of Herpes simplex virus-2 (MSM 48.1%, FSW 82.0% and PLWHA 84.4%). Most participants reported no ulcerative symptoms and the majority of men reported no inflammatory symptoms. Sensitivity and PPV were poor for inflammatory infections among PLWHA and MSM. Sensitivity in FSWs for inflammatory infections was 75%. For ulcerative infections, sensitivity was poor, but specificity and PPV were high. Reliance on self-reported symptoms may not be an effective screening strategy for these populations. STI prevention studies should focus on symptom recognition and consider routine screening and referral for high-risk populations.

[Questionnaire survey on medical care for male urethritis in community clinics in Shiga prefecture]

Six regional medical associations in Shiga prefecture agreed to cooperate in an investigation of medical care for male gonococcal and chlamydial urethritis. In June 2011, we sent a questionnaire to 372 medical offices in Shiga prefecture, and analyzed replies of respondents. Ten urologists and 175 non-urologists responded to the survey (response rate 49.7%). Among 185 physicians, 52 (10 urologists and 42 nonurologists) have treated male patients with gonococcal and chlamydial urethritis. More than 20% (42/175) of non-urological clinics are involved in the medical management. At initial diagnosis for sexually transmitted male urethritis, all urologists select the nucleic acid amplification method (100%), whereas many non-urologists do not (35%). For the treatment of chlamydial urethritis, non-urologists select levofloxacin (LVFX, 52.8%) rather than azithromycin (AZM, 22.0%), whereas urologists use AZM (78.0%) mostly but do not use LVFX (0%) (p = 0.023). For the treatment of gonococcal urethritis, non-urologists prefer oral new quinolones (53.1%) compared to urologists (25.0%) (p = 0. 74). For cure judgment of gonoccocal and chlamydial urethritis, many non-urologists rely on the improvement of subjective symptoms (50 and 47%), but urologists do not (10 and 0%) (p = 0.022 and 0.026, respectively). As for recognition of the clinical guideline for sexually transmitted disease, most urologists (90%) know it, but few non-urologists (13%) do (p < 0.001). We found that non-urological clinics make a great contribution to the medical treatment for male gonococcal and chlamydial urethritis in Shiga prefecture. It is important to standardize the medical care for sexually transmitted male urethritis by familiarizing non-urological practitioners with the clinical guideline.

[Manifestations of sexually transmitted diseases on oral mucous membranes]

Many believe that oral sex is safe sex and does not pose a risk of getting sexually transmitted diseases. Despite the prevalence of oral sex, the number of diagnosed oral and pharyngeal sexually transmitted infection is lower than that of anal and vaginal sex. Oral contact with the genitals can cause tiny micro traumas through which pathological microorganisms that are present in body fluids can come into contact and be transmitted. This article reviews the literature on the role of oral sex in the transmission of sexually transmitted diseases and the corresponding clinical presentation or oral diseases.

Non-participation in chlamydia screening in The Netherlands: determinants associated with young people's intention to participate in chlamydia screening

BACKGROUND

In The Netherlands, a national chlamydia screening program started in 2008, but the participation was low and the screening was not cost-effective. This study aimed to explore unconscious and conscious associations with chlamydia screening (16-29 year-olds). In addition, we examined whether information presented in chlamydia screening invitation letters had an effect on the evaluation of these determinants compared to a no-letter group.

METHODS

An Internet survey was conducted that included self-report measures of attitude, susceptibility, severity, unrealistic optimism, subjective, moral, and descriptive norm, perceived behavioral control, outcome expectations, barriers, intention, and a response time measure to assess unconscious associations of chlamydia screening with annoyance, threat and reassurance.

RESULTS

On the unconscious level, participants (N = 713) who received no information letter associated testing for chlamydia with annoyance and threat, but also with reassurance (all p's < .001). On the self-report measures, participants showed a low intention towards chlamydia screening (M = 1.42, range 1-5). Subjective norm, moral norm, perceived susceptibility and attitude were the most important predictors of the intention to screen (R2 = .56). Participants who rated their susceptibility as high also reported more risky behaviors (p < .001).In the groups that received a letter (N = 735), a weaker unconscious association of chlamydia screening with annoyance was found compared with the no-letter group (p < .001), but no differences were found in reassurance or threat. Furthermore, the letters caused a higher intention (p < .001), but intention remained low (M = 1.74). On a conscious level, giving information caused a more positive attitude, higher susceptibility, a higher subjective and moral norm, and more positive outcome expectations (all p's < .001).

CONCLUSION

Subjective norm, moral norm, susceptibility, and attitude towards chlamydia might be crucial targets to increase chlamydia screening behavior among sexually active young people. This study shows that informational invitation letters increase the intention and the intention-predicting variables. More evidence is needed on whether screening behavior can be increased by the use of an alternative information letter adapted to the specific unconscious and conscious determinants revealed in this study, or that we need other, more interactive behavior change methods.

[Clinical, laboratory and uretroscopic evaluation of the effectiveness of Safocid in the complex treatment of urethritis associated with sexually transmitted infections by using endoscopic techniques]

The study included 110 men suffering from sexually transmitted infections. Clinical diagnosis was made using modern hardware and instrumental methods of examination. It is shown that the combined preparation "Safocid" is a high-effective drug for the etiotropic treatment of specific and non-specific urethritis, with elimination of causative microorganisms of sexually transmitted infections in 96.4% of cases.

Looking for an asymptomatic infection: usefulness of screening for Chlamydia trachomatis and genital herpes

Chlamydia trachomatis (CT) and Herpes simplex virus type 2 (HSV-2) genital infections are among the more frequent sexually transmissible infections with different prevalence by age, populations and geographical areas. Both are widespread, have an asymptomatic latent stage detectable only by laboratory and can have serious consequences such as tubal infertility and neonatal herpes. The direct isolation of CT in cervical or urethral discharge through Nucleic Acid Amplification Test (NAATs) allows to detect and to treat the infection with effective antibiotic medication. The screening of all women younger than 25 year old showed to be effective in reducing tubal complications but not in decreasing the incidence of the infection in the general population. Only a proactive screening of younger women, repeated yearly and associated with an effective partner notification could achieve a decrease of the incidence rate in the general population. The detection of type specific herpetic antibodies allows to identify persons with herpetic infection regardless of symptoms. While a population-based screening of general population cannot be proposed at the moment, a selective screening (attenders of STI clinic, HIV-positive patients, pregnant women) is a debated issue between those who consider it an effective means to detect persons with unrecognized symptoms who are infectious and those who think that preventive measures and antiviral medication are not effective enough to be proposed.

[Experimental evaluation of the Sysmex UF-1000i for ruling out non-gonococcal urethritis]

Acute nongonococcal urethritis (NGU) is one of the commonest sexually transmitted infections affecting men and women. The diagnosis of NGU has traditionally required microscopic evidence of urethritis. However, a significant proportion of patients with urethral symptoms do not have microscopic evidence of urethritis. The purpose of the present study was to evaluate the analytical performance of the UF1000i, a recently introduced fluorescence flow cytometer intended for urinalysis purposes which provides new analytical features that seem particularly suitable for microbiological diagnostics, for ruling out NGU or predicting the presence of infection. The Sysmex UF1000i is a flow cytometry analyzer capable of quantifying a lot of particles, including bacteria (BACT) and white blood cells (WBCs). To evaluate the analytical performance of the UF1000i as a method for ruling out NGU, we examined 200 urethral smear samples, collected in a new liquid transport medium (Copan), and compared the UF1000i results with standard culture/molecular and microscopic Gram stain results. With instrument cut-off values of 200 BACT x 10^6/L and 500 WBCs x 10^6/L, we obtained a sensitivity of 84%, a specificity of 82%, and a high negative predictive value (96%). Culture/molecular detection of pathogens remains the gold standard technique for the diagnosis of NGU. However, the Sysmex UF1000i is capable of improving the efficiency of NGU presumptive diagnosis, providing results in a few minutes, with a high negative predictive value and high values of sensitivity.

[Antibiotic resistance as a public health problem: the case of genital mycoplasmoses]

Antibiotic resistance is an emerging public health problem especially due to the continuous use of antibiotics that selects more aggressive and resistant species. In the present study the authors determined the antibiotic sensitivity of 128 Mycoplasma hominis strains obtained from urethral swabs of male patients (mean age 36 years). The Mycoplasma IST 2 strip was used to test antibiotic susceptibility: 88% of analysed strains were found to be resistant to erythromycin and azithromycin, 75% to clarithromycin, 50% to ofloxacin and ciprofloxacin, and 12% to tetracycline. All strains were susceptible to josamycin, doxycycline and pristinamycin. Results were comparable to those of a recent study by Savarino-Mattei which also showed high resistance of M hominis to macrolide antibiotics and to ciprofloxacin and susceptibility to tetracyclines. Doxycycline is currently the antibiotic of first choice for treating M hominis infections.

The overall agreement of proposed definitions of mucopurulent cervicitis in women at high risk of Chlamydia infection

The overall agreement between different criteria for cervicitis in women infected with Chlamydia trachomatis and/or Mycoplasma genitalium, and in women who tested negative was examined. Women attending a clinic for sexually transmitted diseases were enrolled because of sexual partners' suspected chlamydia infection. M. genitalium was tested in a sample of first-catch urine and an endocervical specimen, whereas specimens from four different sites were used for detection of C. trachomatis. Signs of friability and purulent endocervical discharge were documented at gynaecological examination. Specimens for microscopy were taken from the endocervix and urethra as well as the vaginal discharge, and bacterial vaginosis was examined for. The criteria being evaluated included cervical friability and/or pus; polymorphonuclear leukocytes (PMNL)/epithelium cell ratio in the vaginal discharge; and more than 30 PMNL per high-power field in the endocervical smear. The overall agreement of the indicators of cervicitis in women infected with C. trachomatis and/or M. genitalium was 40.5% (15/37), and for those women with negative tests 35.3% (12/34). The criteria for cervicitis require further evaluation, including study of a control group of women at low risk of having a sexually transmitted infection.

Guidelines for the laboratory diagnosis of mycoplasma genitalium infections in East European countries

The present guidelines aim to provide comprehensive information regarding laboratory diagnosis of Mycoplasma genitalium infections in East European countries. These guidelines are intended primarily for laboratory professionals testing specimens from patients at sexual health care clinics, but may also be useful for community-based screening programmes. Diagnosis of M. genitalium infection is performed exclusively using nucleic acid amplification tests (NAATs), owing to the poor and slow growth of the bacterium in culture. Because no internationally validated and approved commercial NAAT for M. genitalium detection is presently available, it is necessary that laboratories performing M. genitalium diagnostics not only carefully evaluate and validate their in-house PCRs before using them routinely, but also use comprehensive internal controls and take part in external quality assessment programmes. The guidelines were elaborated as a consensus document of the Eastern European Sexual and Reproductive Health (EE SRH) Network, and comprise one element of a series of guidelines aimed at optimizing, standardizing, and providing guidance on quality laboratory testing for reproductive tract infections.

[HBD-1 and hBD-2 are expressed in cervico-vaginal lavage in female genital tract due to microbial infections]

OBJECTIVES

The aim of this study was to evaluate and compare concentration of selected human beta-defensins (hBD-1, hBD-2) in cervico-vaginal lavage (CVL), obtained from women with candidiasis, chlamydiasis and other bacterial infections.

MATERIAL AND METHODS

beta-defensins were detected quantitatively by RT-PCR (7000 Taqman, Applied Biosystems) in cervico-vaginal lavage collected from 120 (79 women in the study group and 41 controls) non-pregnant women, aged 18-40 (mean age 28.5 +/- 6.29). The study group patients were divided into three subgroups on the basis of clinical and microbiological diagnosis: women with candidiasis (n=13); with chlamydiasis (n=13), and with other bacterial infections (n=12).

RESULTS

The highest count of hBD-1 RNA copies was found in women with bacterial infections and candidiasis (335.84 and 320.10 respectively), and hBD-2--with chlamydiasis. The difference between RNA copies of hBD-1/microg in candidiasis, chlamydiasis and bacterial pathogens was statistically significant; for hBD-2 only in case of chlamydiasis.

CONCLUSIONS

Chlamydia trachomatis infection activates the production of hBD-2. Candida albicans, Chlamydia trachomatis, and bacterial pathogens induced variable increases of hBD-1 concentration.

[Clinical application of azithromycin extended-release (ER) formulation to treat female sexually transmitted infection]

The prevalence of female sexually transmitted infection (STI) in Japan is in the decreasing tendency after 2002, however it still actualizes as a social problem. Azithromycin, which is 15-member macrolide antimicrobial agent, has indication to treat the chlamydia STI in a single dose of 1 g. In April 2009, a single dose of 2 g of azithromycin extended release (ER) formulation, which is improved formulation by the viewpoint of pharmacokinetics-pharmacodynamics, was approved and has indications to treat not only chlamydial STI but also gonococcal STI. We considered the clinical application of azithromycin ER to treat female STI, including our new our own experiences because the clinical studies of azithromycin ER for STI had not been conducted. In conclusion, azithromycin ER was suggested theoretically becoming one of the choices of new treatment STI caused by not only chlamydia but also gonococcus, more clinical consideration to treat STI will be necessary in the future.

Vulvovaginitis in childhood

Symptoms related to vulvitis and vulvovaginitis are a frequent complaint in the paediatric age. Knowledge of the risk factors and the pathogenetic mechanisms, combined with thorough clinical examination, helps to distinguish between dermatological diseases, non-specific vulvitis and vulvovaginitis proper. On the basis of microbiological data, the most common pathogens prove to be Streptococcus pyogenes, Haemophilus influenzae and Enterobius vermicularis; fungal and viral infections are less frequent. The possibility of isolating opportunistic pathogens should also be considered. In rare situations, the isolation of a micro-organism normally transmitted by sexual contact should prompt a careful evaluation of possible sexual abuse. Current treatments for specific and non-specific forms are outlined, together with pointers for the evaluation of recurrence.

Vulvar diseases of the tropics: a review

With the increasing immigrant population in the United States, it is imperative for clinicians in the United States to become versed in tropical vulvar conditions uncommon to indigenous members of developed nations that may present to their practice. Travelers to tropical areas may also contract diseases that occur in these areas, which may manifest as a vulvar condition and mimic a sexually transmitted disease. A brief review is presented.

Asymptomatic sexually transmitted infections in HIV-infected men who have sex with men: prevalence, incidence, predictors, and screening strategies

Sexually transmitted infections (STIs) have increased among men who have sex with men (MSM) and are associated with unsafe sex practices, intrinsic morbidity, and enhanced genital shedding and transmission of HIV. Screening for asymptomatic STIs is recommended as part of the HIV prevention efforts, however, optimal screening strategies among HIV-infected MSM have not been well defined. In this study, conducted from April 2004 to September 2006, 212 HIV-infected MSM from two urban HIV clinics were screened for asymptomatic STIs. Testing for Neisseria gonorrhea and Chlamydia trachomatis from pharynx, rectum, and urine, as well as serologic testing for syphilis were performed initially, and then after 6 and 12 months. A self-administered questionnaire was used to assess possible predictors of incident asymptomatic STIs. A cost analysis was performed to assess different screening strategies for detecting incident STIs. The baseline prevalence of STIs was 14% (n = 29; 95% confidence interval [CI] 9%-19%) and the incidence of new infections was 20.8 cases per 100 person years (95% CI 14.8-28.4 cases per 100 person years). Younger age, higher CD4 cell count, and marijuana use were associated with increased risk of acquiring an asymptomatic STI. The laboratory cost to detect one positive STI did not significantly differ between once- and twice-yearly screening. However, almost half of all incident STIs were detected at the 6-month screening visit, potentially resulting in an increased duration of infectivity if these cases remained undiagnosed. In conclusion, prevalent and incident asymptomatic STIs are common among HIV-infected MSM. Our data support current Center for Disease Control and Prevention STI guidelines that recommend routine screening at increased frequency for HIV-infected MSM.

Role of Mycoplasma genitalium and Ureaplasma urealyticum in non-gonococcal urethritis in Hong Kong

OBJECTIVE

To determine the association of Mycoplasma genitalium and Ureaplasma urealyticum in symptomatic male patients presenting with non-gonococcal urethritis in a sexually transmitted infection clinic in Hong Kong.

DESIGN

Cross-sectional study.

SETTING

A sexually transmitted infection clinic, Department of Health, Centre for Health Protection, Hong Kong.

PATIENTS

A cohort of consecutive new male patients attending the government sexually transmitted infection clinic.

MAIN OUTCOME MEASURES

Prevalence of Mycoplasma genitalium and Ureaplasma urealyticum among symptomatic male patients with non-gonococcal urethritis and asymptomatic patients without non-gonococcal urethritis.

RESULTS

Specimens of 22 and 10 patients tested positive by polymerase chain reaction for Ureaplasma urealyticum and Mycoplasma genitalium respectively, among the symptomatic non-gonococcal urethritis group (n=98). In the asymptomatic control group (n=236), corresponding patient numbers whose specimens tested positive were 47 and 5. There was no statistically significant difference between the two groups, in terms of the proportion of patients infected with Mycoplasma genitalium (P=0.799) or Ureaplasma urealyticum (P=0.535).

CONCLUSIONS

In our study, demonstration of Mycoplasma genitalium and Ureaplasma urealyticum by polymerase chain reaction was not associated with symptomatic non-gonococcal urethritis in male patients attending a Hong Kong government clinic for sexually transmitted infections.

[Chlamydia trachomatis infection in sexually active teenagers]

BACKGROUND

The prevalence of Chlamydia trachomatis infections among Polish teenagers remains unknown. Sexually active teenagers are exposed at sexually transmitted infections, including Chlamydia trachomatis (CT). Most infections are asymptomatic and, therefore, untreated. Early detection and treatment of cervical chlamydial infections may prevent pelvic inflammatory diseases and prevent later infertility.

AIM

to determine the prevalance and risk factors of Chlamydia trachomatis infections among sexually active female teenager.

MATERIALS AND METHODS

243 sexually active girls, 16-19 year-olds, attending the outpatient clinic were enrolled in this study between 2005-2007. The participants filled in a questionnaire containing such information as age, purpose of visit, level of education, age at the first intercourse, number of sexual partners, number of current partners (in the past 3 months), contraceptive methods, use of condoms, past history of STD and obstetric history at the first visit. Pelvic examination was performed to check the following: vaginal discharge, presence of abnormalites of the cervix (ectopy, erythema, tenderness of uterine and adnexal) and to take a Pap smear and a cervical swab for Chlamydia trachomatis. Cervical swabs for Chlamydia trachomatis were tested by polymerase chain reaction (PCR).

RESULTS

The prevalence of CT genital infection in the studied group was 2,9%. Adolescent females infected by CT less frequently admitted to the use of condom and more often did not use any contraception at all, in comparison with the girls without CT genital infections (29% and 57% vs. 37% and 19%). There were statistically significant differences in the results of the abnormal Pap smears (ASCUS, LGSIL) between the two groups.

Moraxella catarrhalis associated with acute urethritis imitating gonorrhoea acquired by oral-genital contact

A case of heterosexual transmission of Moraxella catarrhalis by fellatio, which resulted in acute purulent urethritis mimicking gonorrhoea in the male partner, is described. In male patients with urethritis due to M. catarrhalis, orogenital contact with a sexual partner carrying the organism in his/her oropharynx is the probable route of transmission.

Norwegian men diagnosed with genital Chlamydia trachomatis infection notified two-thirds of their sexual partners

Chlamydia trachomatis (CT) is a widespread, sexually transmitted disease with potential long-term effects on female reproductive health. The objective of this study was to investigate compliance to treatment, partner notification, and attendance for test-of-cure among Norwegian men diagnosed with CT. We conducted a longitudinal case-series study among 81 CT positive men identified in a cross-sectional study (n = 1032, April-December 2005). Participants were interviewed on partner notification intentions at the treatment visit and on partner notification actions at the test-of-cure visit. Of the 81 patients, 8 (10%) did not meet for treatment, 2 were treated elsewhere, and 6 were treated but not interviewed. At the treatment visit, the 65 interviewed men reported that they intended to notify 100 out of 165 partners (61%). 40 of 71 treated patients attended for test-of-cure (56%). Four men (10%) needed repeated treatment. The 35 men interviewed at test-of-cure visit reported that 63 out of 95 partners (68%) had been notified. In conclusion, men diagnosed with CT infection are relatively open on notifying sexual partners but have low compliance to meeting for test-of-cure.

[Chlamydia trachomatis infections--a time for action?]

Infection with Chlamydia trachomatis is the most common sexually transmitted disease in the world. In women it mainly occurs before the age of 25 years, while in men it can still be diagnosed till the age of 35 years. In Western Europe the prevalence of a Chlamydia trachomatis infection has been estimated, according to WHO data, as between 2.7% (Italy) and 8.0% (Island). A general screening strategy is now being discussed in Germany. A non-diagnosed and non-treated Chlamydia trachomatis infection and the resulting health problems have not only severe consequences for the individual but also results in major epidemiological and socio-economic public health problems. This issue is not only of extreme importance in health policy, but has also a major impact in family policy, especially in view of the declining birth rates and the demographic changes.