Randomized Multicenter Trial for the Validation of an Easy-to-Administer Algorithm to Define Penicillin Allergy Status in Sexually Transmitted Infection Clinic Outpatients

BACKGROUND

Approximately 15% of patients in sexually transmitted infection (STI) clinics report penicillin allergies, complicating treatment for syphilis and gonorrhea. Nonetheless, >90% do not have a penicillin allergy when evaluated. We developed and validated an algorithm to define which patients reporting penicillin allergy can be safely treated at STI clinics with these drugs.

METHODS

Randomized controlled trial to assess feasibility and safety of penicillin allergy evaluations in STI clinics. Participants with reported penicillin allergy answered an expert-developed questionnaire to stratify risk. Low-risk participants underwent penicillin skin testing (PST) followed by amoxicillin 250 mg challenge or a graded oral challenge (GOC)-amoxicillin 25 mg followed by 250 mg. Reactions were recorded, and participant/provider surveys were conducted.

RESULTS

Of 284 participants, 72 (25.3%) were deemed high risk and were excluded. Of 206 low-risk participants, 102 (49.5%) underwent PST without reactions and 3 (3%) had mild reactions during the oral challenge. Of 104 (50.5%) participants in the GOC, 95 (91.3%) completed challenges without reaction, 4 (4.2%) had mild symptoms after 25 mg, and 4 (4.2%) after 250-mg doses. Overall, 195 participants (94.7%) successfully completed the study and 11 (5.3%) experienced mild symptoms. Of 14 providers, 12 (85.7%) completed surveys and 11 (93%) agreed on the safety/effectiveness of penicillin allergy assessment in STI clinics.

CONCLUSIONS

An easy-to-administer risk-assessment questionnaire can safely identify patients for penicillin allergy evaluation in STI clinics by PST or GOC, with GOC showing operational feasibility. Using this approach, 67% of participants with reported penicillin allergy could safely receive first-line treatments for gonorrhea or syphilis. Clinical Trials Registration. Clinicaltrials.gov (NCT04620746).

Spanish Academy of Dermatology and Venereology (AEDV) expert recommendations for the management of sexual transmitted parasitosis. Scabies, and pediculosis pubis

Sexually transmitted infections are communicable diseases where the pathogen is transmitted through sexual contact. The Sexually Transmitted Infections Working Group of the Spanish Academy of Dermatology and Venereology (AEDV) is engaged in the drafting of documents to guide dermatologists and health care personnel who treat Spanish patients with these infections. This document analyzes the epidemiological, clinical, therapeutic, and control characteristics of 2 sexually transmitted parasitosis: scabies due to Sarcoptes scabiei var. hominis, and pubic pediculosis due to Phthirus pubis. Both parasitoses share a sort of mixed spread through sexual and community transmission regardless of the route through which the infection was initially acquired. This specific feature creates particularities in the management and control of the infestation.

[Translated article] Spanish Academy of Dermatology and Venereology (AEDV) expert recommendations for the management of sexual transmitted parasitosis. Scabies, and pediculosis pubis

Sexually transmitted infections are communicable diseases where the pathogen is transmitted through sexual contact. The Sexually Transmitted Infections Working Group of the Spanish Academy of Dermatology and Venereology (AEDV) is engaged in the drafting of documents to guide dermatologists and health care personnel who treat Spanish patients with these infections. This document analyzes the epidemiological, clinical, therapeutic, and control characteristics of 2 sexually transmitted parasitosis: scabies due to Sarcoptes scabiei var. hominis, and pubic pediculosis due to Phthirus pubis. Both parasitoses share a sort of mixed spread through sexual and community transmission regardless of the route through which the infection was initially acquired. This specific feature creates particularities in the management and control of the infestation.

Reducing Barriers for Expedited Partner Treatment in Adolescents and Young Adults: A Quality Improvement Initiative

BACKGROUND

Adolescents and young adults (AYAs) face significant barriers to screening, testing, and treatment of sexually transmitted infections (STIs). Expedited partner therapy (EPT) streamlines partner treatment of STIs, but use among adolescents is low. We aimed to increase EPT offering and provision at 2 adolescent medicine clinics (AMCs) and the emergency department (ED) in an urban children's hospital. We addressed barriers at provider, pharmacy, and patient levels. We compared EPT offering and provision for chlamydia ( Chlamydia trachomatis [CT]) and trichomonas ( Trichomonas vaginalis [TV]) infection at baseline and across 2 intervention cycles.

METHODS

Baseline data were collected from July 2019 to March 2020 and our intervention time frame spanned from April 2020 to October 2021. Laboratory codes identified patients with CT or TV infections. Cycle 1 allowed providers to order EPT within a patient's chart. The second cycle targeted education and standardization for STI/EPT notification and counseling. During this cycle, notification of ED patients was centralized to the AMC nurses.

RESULTS

A total of 747 CT and TV cases were identified. In the AMC, EPT offering increased from 77.3% to 87.7% ( P = 0.01). Expedited partner therapy provision increased from 32.3% to 69.9% ( P < 0.001). Expedited partner therapy offering for ED patients increased by 82.3%. Retesting rates remained consistent, with a significant drop in reinfection rates ( P = 0.003) within patients seen in the AMC.

CONCLUSIONS

This quality improvement initiative successfully increased EPT offering and provision among the cases identified. Future cycles may include longer-term follow-up to confirm partner treatment and testing per guidelines.

Use of Expedited Partner Therapy for Pregnant Women Treated for Sexually Transmitted Infections in Gaborone, Botswana

BACKGROUND

Partner notification and treatment for sexually transmitted infections are critical to prevent reinfection and reduce transmission. However, partner treatment rates are low globally. Expedited partner therapy (EPT), in which the patient delivers treatment directly to their partner, may result in more partners treated. We assessed partner notification and treatment outcomes among pregnant women in Gaborone, Botswana, including EPT intent, uptake, and effectiveness.

METHODS

The Maduo study was a cluster-controlled trial evaluating the effect of antenatal Chlamydia trachomatis and Neisseria gonorrhoeae infection screening in pregnant women. The intervention arm received screening at first antenatal care (ANC), third-trimester, and postnatal care visits. The standard-of-care arm received screening postnatally. Participants screening positive were given options for partner treatment: contact slips, in-clinic treatment, or EPT. Self-reported partner notification and treatment outcomes were assessed at test-of-cure visit.

RESULTS

Of 51 women who screened positive for C. trachomatis / N. gonorrhoeae at first ANC and returned for test of cure, 100% reported notifying their partner and 48 (94.1%) reported their partner received treatment. At third trimester 100% (n = 5), reported partners were treated. Before testing, EPT intent was lower than EPT uptake at all time points (first ANC: 17.9% vs. 80.4%; third-trimester: 57.1% vs. 71.4%; postnatal care: 0% vs. 80.0%). Partner treatment success was 100% among EPT users compared with 70% among nonusers ( P = 0.006).

CONCLUSIONS

Partner notification and treatment success was high in this population. Despite low pretest intent to use EPT, uptake was high and associated with greater partner treatment success. Our findings suggest that EPT may be a successful partner treatment strategy to pursue in low- and middle-income countries.

Expanding expedited partner therapy and HIV prophylaxis in the emergency department

PURPOSE

Sexually transmitted infections (STIs) continue to have a disproportionate impact on individuals belonging to sexual, gender, and racial minorities. Across the nation, many emergency medicine pharmacists (EMPs) possess the skills and knowledge to expand the provision of expedited partner therapy (EPT) for STIs and provide HIV prophylaxis within existing practice frameworks. This report serves as a call to action for expanded provision of EPT and HIV prophylaxis by EMPs and highlights current barriers and solutions to increase pharmacist involvement in these practice areas.

SUMMARY

Emergency medicine pharmacy practice continues to expand to allow for limited prescribing authority through collaborative practice agreements (CPAs). In recent years, CPA restrictions have been changed to facilitate treatment of more patients with less bureaucracy. This report addresses the unique challenges and opportunities for expanding EPT and HIV pre- and postexposure prophylaxis provision by pharmacists in emergency departments (EDs). Furthermore, current strategies and treatments for EPT, such as patient-delivered partner therapy and HIV prophylaxis, are discussed. Pharmacist involvement in STI treatment and HIV prevention is a key strategy to increase access to high-risk populations with high ED utilization and help close current gaps in care.

CONCLUSION

Expanding EMP provision of EPT and HIV prophylaxis may be beneficial to reducing the incidence of STIs and HIV infection in the community. CPAs offer a feasible solution to increase pharmacist involvement in the provision of these treatments. Legislative efforts to expand pharmacist scope of practice can also contribute to increasing access to EPT and HIV prophylaxis. With these efforts, EMPs can play an essential role in the fight against STIs and HIV.

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.

Moving Toward Online-Based Sexually Transmitted Infection Testing and Treatment Services for Young People: Who Will Use It and What Do They Want?

BACKGROUND

The market for online sexually transmitted infection (STI) services is rapidly expanding. Online health services often have unequal uptake among different demographics of the population. There is a need to understand how different online delivery options for STI testing may appeal to different groups of young people, particularly young people who have higher rates of STI diagnoses.

METHODS

An online survey of young Australians aged 16 to 29 years was conducted to understand service preferences regarding consultation (telehealth, fully automated questionnaire), testing (electronic pathology form, at-home self-sampling), and treatment (e-prescriptions, mailed oral tablets). Multivariable multinomial logistic regression examined associations between user characteristics and service preferences, and adjusted relative risk ratios (aRRRs) and 95% confidence intervals (CIs) are presented.

RESULTS

Among 905 respondents, rural youth were more likely to prefer fully automated questionnaires (aRRR, 1.9; 95% CI, 1.0-3.5) over telehealth consultations, whereas culturally and linguistically diverse (CALD) youth were less likely (aRRR, 0.4; 95% CI, 0.2-0.7). Rural youth preferred at-home self-sampling kits (aRRR, 1.9; 95% CI, 1.3-2.7) over electronic forms for on-site collection at pathology centers, with the opposite for CALD youth (aRRR, 0.7; 95% CI, 0.5-1.0). Receiving oral antibiotics by mail was preferred by rural youth (aRRR, 2.3; 95% CI, 1.1-4.6) over for in-clinic treatment, but not for CALD youth (aRRR, 0.5; 95% CI, 0.4-0.8).

CONCLUSIONS

Our findings suggest that rural youth tend to prefer self-navigated and automated options, whereas CALD prefer options with greater provider engagement. Online STI service providers should consider how different service options may affect equitable uptake across the population and implications for addressing disparities in testing and treatment.

Pharmacokinetics of single dose doxycycline in the rectum, vagina, and urethra: implications for prevention of bacterial sexually transmitted infections

BACKGROUND

Clinical trials showed a single oral dose of doxycycline taken after sex protects against STIs among men who have sex with men (MSM) but not women. Pharmacokinetic data at vaginal, rectal and penile sites of STI exposure are lacking. We examined vaginal, rectal and urethral doxycycline concentrations in men and women to better inform STI prevention.

METHODS

Doxycycline pharmacokinetics in male and female participants 18-59 years of age were evaluated in blood and urine and on rectal and vaginal swabs collected at 1, 2, 4, 8, 24, 48, 72, 96 and 168 h after receiving a 200 mg oral doxycycline dose in a non-randomised single dose open label single centre study in Atlanta, Georgia. Rectal, vaginal, and cervical biopsies and male urethral swabs were collected 24 h after dosing (Trial registration: NCT04860505). Doxycycline was measured by liquid chromatography-mass spectrometry.

FINDINGS

Eleven male and nine female participants participated in the study. Doxycycline concentrations on rectal and vaginal swabs collected up to 96 h after dosing were approximately twice those of plasma and remained above minimum inhibitory concentrations (MICs) for at least four, three, and two days for Chlamydia trachomatis, Treponema pallidum, and tetracycline-sensitive Neisseria gonorrhoeae, respectively. Geometric mean doxycycline concentrations in male urethral secretions (1.166 μg/mL; 95% CI 0.568-2.394 μg/mL), male rectal (0.596 μg/g; 0.442-0.803 μg/g), vaginal (0.261 μg/g; 0.098-0.696 μg/g) and cervical tissue (0.410 μg/g; 0.193-0.870 μg/g) in biopsies collected 24 h after dosing exceeded MICs. Plasma and urine doxycycline levels defined adherence markers up to four and seven days postdosing, respectively. No adverse events were reported in this study.

INTERPRETATION

Doxycycline efficiently distributes to the rectum, vagina and urethra. Findings can help explain efficacy of STI prevention by doxycycline.

FUNDING

Funded by CDC intramural funds, CDC contract HCVJCG-2020-45044 (to CFK).

Stellungnahme der Deutschen STI-Gesellschaft zur antibiotischen STI-Prophylaxe mit Doxycyclin (Doxy-PEP, Doxy-PrEP): Position Statement of the German STI Society on the Prophylactic Use of Doxycycline to Prevent STIs (Doxy-PEP, Doxy-PrEP)

Seit etwa zwei Jahrzehnten ist eine Zunahme der Syphilisinzidenz zu beobachten, insbesondere unter Männern, die Sex mit Männern haben (MSM). Diese Entwicklung hat zu einem wachsenden Interesse an Studien zur prophylaktischen Anwendung des Antibiotikums Doxycyclin zur Vermeidung von Syphilisinfektionen und anderen sexuell übertragbaren Infektionen (STI), international meist als Doxycyclin‐Prä‐ beziehungsweise Post‐Expositionsprophylaxe (Doxy‐PrEP, Doxy‐PEP) bezeichnet, geführt. Zugleich steigt die Nachfrage seitens potenzieller Nutzer nach dieser präventiven Maßnahme.

Mehrere randomisierte kontrollierte Studien haben gezeigt, dass die prophylaktische Anwendung von Doxycyclin bei MSM und Trans‐Frauen mit HIV‐PrEP‐Gebrauch oder bekannter HIV‐Infektion das Risiko einer Syphilis‐ und Chlamydien‐Infektion wirksam reduziert. Zum gegenwärtigen Zeitpunkt bestehen jedoch noch offene Fragen, insbesondere hinsichtlich der möglichen Auswirkungen einer breiten Anwendung der antibiotischen STI‐Prophylaxe mit Doxycyclin auf Tetrazyklin‐ und andere antimikrobielle Resistenzen bei bakteriellen STI, anderen bakteriellen Pathogenen und Bakterien des Mikrobioms.

Angesichts der steigenden Nachfrage und der Herausforderung, eine Abwägung zwischen Wirksamkeit, Sicherheit und dem Risiko der Förderung von Antibiotikaresistenzen vorzunehmen, hat die Deutsche STI‐Gesellschaft (DSTIG) die vorliegende Stellungnahme erarbeitet. Diese enthält spezifische Empfehlungen zu potenziellen Indikationen, Kriterien und Anlässen für den Einsatz von Doxycyclin zur Prävention von STI. Die Empfehlungen basieren auf aktuellen Studienergebnissen und der Meinung von Fachpersonen.

Identifying the Need for and Availability of Evidence-Based Care for Sexually Transmitted Infections in Rural Primary Care Clinics

BACKGROUND

Increasing rates of bacterial sexually transmitted infections (STIs) may lead to increased HIV rates, as the STI and HIV epidemics are syndemic. Centers for Disease Control and Prevention guidelines recommend including extragenital (i.e., rectal and/or pharyngeal) STI screenings for certain populations at increased risk of STIs and concurrent infections with HIV.

METHODS

A descriptive study was conducted by interviewing staff members from 4 rural primary care clinics in areas of high need for STI and HIV services in South Carolina. Qualitative data about their clinical practices in 2021 were obtained. The primary outcome was to determine the awareness and availability of health care services associated with STI and HIV care in these locations.

RESULTS

Clinics in target counties provided limited STI and HIV testing and treatment services, especially for populations at risk of infection, indicating the need for additional clinical training and professional development for all clinic staff. Specifically, only 1 of 4 clinics provided extragenital STI testing, and no clinics reported prescribing preexposure prophylaxis.

CONCLUSIONS

Rural primary care clinics can fill important gaps in the availability of STI and HIV services with appropriate support and incentives. Findings from this study may aid in facilitating policy (state Medicaid agency) and program (state health department) decisions related to STI and HIV testing and treatment.

Anal Monkeypox Disease: Description of 65 Cases

BACKGROUND

Monkeypox is a zoonosis endemic in Africa caused by 3 orthopoxvirus clades. Knowledge of the disease is limited, but a worldwide outbreak involving a new route of transmission was declared in April 2022.

OBJECTIVE

This study aimed to describe anal symptoms and outcomes in patients infected with Monkeypox virus presenting to an emergency proctology unit in Paris.

DESIGN

This was an observational study.

SETTING

We reported anal symptoms of all consecutive patients with monkeypox anal infection in a single proctology center between June 16, 2022, and July 26, 2022. Association with sexually transmitted infections and outcomes were also recorded.

PATIENTS

Sixty-five men with a mean age of 39.6 (19.9-64.6) years with confirmed monkeypox anal infection were included in the study.

MAIN OUTCOME MEASURES

Anal symptoms and their severity were clinically assessed. A favorable outcome consisted of a complete resolution of clinical manifestation.

RESULTS

Sexual transmission was reported in 51 patients (78.4%), among whom 63 (97%) were men who have sex with men. Twenty-eight (43%) were living with HIV, and 24 (36.9%) were taking tenofovir/emtricitabine for HIV preexposure prophylaxis. Anal symptoms appeared first in 36 patients (55.4%) and skin rash or other general symptoms in 22 patients (33.8%). Incubation time was 6.9 (1-26) days. Symptoms included painful perianal (n = 42 patients; 64.6%), anal (n = 28, 43%), and rectal (n = 25; 38.4%) ulcerations and perianal vesicles (n = 24; 36.9%). Proctitis was observed in 49 patients (75.4%). It was mild in 20 (40.8%) and intense in 29 (59.2%), and severe proctitis mimicking high intersphincteric suppuration was found in 4 (8.2%). Fifteen patients (23.1%) had concurrent sexually transmitted infection and 3 were hospitalized. Complete symptom resolution occurred within 12 days.

LIMITATIONS

We performed a single-center study during a short period of time.

CONCLUSIONS

Proctological symptoms are frequent in the current outbreak of monkeypox disease, probably linked to the route of transmission. Rectal ulcerations mimicking high intersphincteric suppuration should be recognized to avoid unnecessary surgery. See Video Abstract .

ENFERMEDAD ANAL DE LA VIRUELA DEL MONO DESCRIPCIN DE CASOS

ANTECEDENTES:La viruela del simio mono es una zoonosis endémica en África causada por tres clados de orthopoxvirus. El conocimiento de la enfermedad es limitado, pero en abril de 2022 se declaró un brote mundial que implica una nueva vía de transmisión.OBJETIVO:Describir los síntomas anales y los resultados en pacientes que sufren de infección por Monkeypox que asistieron a una unidad de proctología de emergencia en París.DISEÑO:Un estudio observacional.ESCENARIO:Informamos los síntomas anales de todos los pacientes consecutivos con infección anal por viruela del mono en un solo centro de proctología entre el 16/6/2022 y el 26/7/2022. También se registró la asociación con infecciones de transmisión sexual (ITS) y el resultado.PACIENTES:Sesenta y cinco hombres de 39,6 [19,9-64,6] años con infección anal confirmada.PRINCIPALES MEDIDAS DE RESULTADO:Los síntomas anales y su gravedad se evaluaron clínicamente. Un resultado favorable consistió en una resolución completa de la manifestación clínica.RESULTADOS:La transmisión sexual se informó en 51 (78,4%) pacientes, de los cuales 63 (97%) eran hombres que tuvieron sexo con hombres. Veintiocho (43%) vivían con el VIH y 24 (36,9%) tomaban Emtricitabina/Tenofovir para profilaxis previa por exposición al VIH. Los síntomas anales aparecieron primero en 36 (55,4%) pacientes y la erupción cutánea u otros síntomas generales en 22 (33,8%). El tiempo de incubación fue de 6,9 [1-26] días. Los síntomas incluyeron ulceraciones perianales dolorosas (n = 42 pacientes, 64,6%), anales (n = 28, 43%), rectales (n = 25, 38,4%) y vesículas perianales (n = 24, 36,9%). Se observó proctitis en 49 (75,4%) pacientes. Fue leve en 20 (40,8%) e intensa en 29 (59,2%) y proctitis severa simulando supuración interesfinteriana alta en 4 (8,2%). Quince (23,1%) pacientes presentaban ITS concurrentes y 3 fueron hospitalizados. La resolución completa de los síntomas ocurrió dentro de los 12 días.LIMITACIONES:Estudio de un solo centro y durante corto período de tiempo.CONCLUSIÓN:Los síntomas proctológicos son frecuentes en el brote actual de la enfermedad de la viruela del mono, probablemente relacionados con la vía de transmisión. Las ulceraciones rectales que simulan una supuración interesfinteriana alta deben reconocerse para evitar una cirugía innecesaria. (Traducción-Dr. Fidel Ruiz Healy ).

Analysis of Patient Adherence to Filling Emergency Department Discharge Prescriptions for Empiric Treatment of Chlamydia

PURPOSE

Sexually transmitted infections (STIs) represent an enormous public health burden in the United States. Emergency departments (EDs) are a significant source of medical care, particularly for vulnerable patient populations. Guidelines for the treatment of Chlamydia trachomatis have evolved and now recommend doxycycline 100 mg orally twice daily for 7 days as the primary regimen for adults. However, the single-dose azithromycin regimen can be given during the ED visit, while the new regimen has nonadherence hurdles. The purpose of this study will be determining the rate of ED discharge prescription pick ups of doxycycline for Chlamydia trachomatis infection at two discharge pharmacies.

METHODS

This is a retrospective chart review of information contained in the electronic medical record (EMR) from August 1st, 2021 - July 31st, 2022. Adult patients who present to the two EDs in the healthcare system and those who received empiric antibiotic treatment for Chlamydia trachomatis infection prior to, or at, ED discharge will be included. Patients who are pregnant, less than 18 years old, those without a Chlamydia trachomatis nucleic acid amplification test during their ED visit, or patients whose antibiotic treatment prescription was sent to a pharmacy other than the two primary discharge pharmacies at the respective medical centers will be excluded. The primary outcome of this study will be determining the rate of emergency department (ED) discharge prescription pick ups of doxycycline for empiric treatment of Chlamydia trachomatis infection at two discharge pharmacies. The secondary outcomes will include the incidence of repeat positive tests between four weeks and 90 days, risk of repeat positive tests in those who do not fill doxycycline, number of positive and negative test results, rate of prescribing adherence to 2021 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infections Treatment Guidelines regimens for empiric treatment, and insurance status at the time of discharge fill.

RESULTS

Seven hundred and thirty patients were pulled from the EMR. One hundred of the patients were excluded from the study as they did not receive empiric antibiotic treatment for Chlamydia trachomatis infection prior to, or at, ED discharge leaving 630 participants. Among this group, 369 patients were excluded as their discharge prescription was not sent to the discharge pharmacies within the medical system, leaving 261 individuals in the study. Per chart review, 215 of the patients picked up their doxycycline prescription (82.4%) and 46 (17.6%) patients failed to pick up their prescription. Additionally, 43 (16.5) of the patients who were prescribed empiric therapy had a positive chlamydia trachomatis test, while 209 (83.5%) of those had a negative test. This study also showed 188 (72%) patients received treatment according to the current CDC recommendations.

CONCLUSION

Majority of patients who received prescriptions from the in-hospital discharge pharmacy picked up their prescriptions.

A pharmacist-driven deprescribing protocol for negative urine and sexually transmitted infection cultures in the emergency department increases antibiotic-free days

PURPOSE

Emergency department (ED) pharmacists commonly perform positive culture follow-ups that result in optimized antibiotic prescribing. The purpose of this study was to evaluate the potential positive impact on the outcome of antibiotic-free days through an ED pharmacist-driven protocol to contact patients with negative urine cultures and sexually transmitted infection (STI) test results who were discharged with antibiotics.

METHODS

This was a single-center, prospective, observational, pre-post intervention study to determine antibiotic use in patients with negative urine cultures who were discharged from the Loyola Medical University Center ED with antibiotics prescribed. Patients were identified through daily positive culture reports. The primary outcome was days free of antibiotics, defined as the number of calendar days within 28 days after urine culture or STI test collection on which the patient did not receive any antibiotic treatments.

RESULTS

One hundred ninety-two patients were screened. Sixty-three and twenty-six patients met the inclusion criteria in the pre- and postintervention groups, respectively. The study identified 163/465 (35.1%) antibiotic free days for the preintervention group, compared to 150.5/187 (80.5%) antibiotic-free days for the postintervention group. A majority of the patients did not have urinary tract infection as the chief complaint. The most common urinary and STI symptoms upon ED admission in the pre- and postintervention groups were dysuria (19.2% vs 28.1%) and unusual discharge (30.8% vs 28.6%), respectively.

CONCLUSION

This study showed that a pharmacist-driven protocol increased the number of antibiotic-free days for patients prescribed empiric antibiotic therapy and discharged from the ED with subsequent negative urine cultures and STI results. We propose taking a novel approach in discontinuation of antibiotics by implementing an expansion of ED culture programs to include negative cultures that promote antimicrobial stewardship.

Implementation preferences for the management of sexually transmitted infections in the South African health system: a discrete choice experiment

OBJECTIVES

Despite strengthening HIV prevention with the introduction of pre-exposure prophylaxis (PrEP), STI services have remained relatively unchanged and the standard of care remains syndromic management. We used a discrete choice experiment to investigate service users' preferences for the diagnosis and treatment of STIs in South Africa.

METHODS

Between 1 March 2021 and 20 April 2021, a cross-sectional online questionnaire hosted on REDCap was administered through access links sent to WhatsApp support groups for HIV PrEP users and attendees of two primary healthcare clinics and two mobile facilities in the Eastern Cape and Gauteng provinces aged between 18 and 49 years. Participants either self-completed the questionnaire or received support from a research assistant. We used a conditional logit model for the initial analysis and latent class model (LCM) to establish class memberships, with results displayed as ORs and probabilities.

RESULTS

We enrolled 496 individuals; the majority were female (69%) and <30 years (74%). The LCM showed two distinct groups. The first group, comprising 68% of the participants, showed a strong preference for self-sampling compared with no sampling (OR 2.16, 95% CI 1.62 to 2.88). A clinic follow-up appointment for treatment was less preferable to same-day treatment (OR 0.78, 95% CI 0.63 to 0.95). Contact slip from index patient (OR 0.86, 95% CI 0.76 to 0.96) and healthcare professional (HCP)-initiated partner notification (OR 0.63, 95% CI 0.55 to 0.73) were both less preferable than expedited partner treatment (EPT). The second group included 32% of participants with a lower preference for self-sampling compared with no sampling (OR 0.65, 95% CI 0.41 to 1.04). There was no treatment option that was significantly different from the others; however, there was a strong preference for HCP-initiated partner notification to EPT (OR 1.53, 95% CI 1.10 to 2.12).

CONCLUSIONS

Our results suggest that service users preferred STI testing prior to treatment, with the majority preferring self-taken samples and receiving aetiology-based treatment on the same day.

Pharmacy-based sexually transmitted infection service implementation considerations: A scoping review

BACKGROUND

Rates of sexually transmitted infections (STIs) are rising despite significant management efforts in traditional healthcare settings. The growing number of individuals affected by STIs demonstrates a gap in care. Pharmacy-based STI clinical services are a potential solution to improve care.

OBJECTIVE

To identify and summarize research about the implementation of pharmacy-based STI services, focusing on program characteristics, barriers, facilitators, and pharmacist and patient experiences.

METHODS

A search of PubMed, Embase, and Cochrane Database of Systematic Reviews was conducted for papers evaluating STI expanded-scope clinical services performed by regulated pharmacists in an outpatient/community pharmacy setting. Study setting, design, data collection method, outcomes, target infection, services offered, patient population, and barriers and facilitators are reported.

RESULTS

Twelve studies, 11 cross-sectional and 1 randomized control trial, were identified in this review. All studies focused on chlamydia, and two included gonorrhea and trichomoniasis or syphilis. Eleven services investigated STI screening, with four also offering treatment, and two offering partner treatment. Overall, patients reported positive experiences, found the services accessible, and trusted pharmacists. Pharmacists recognized the importance of STI services, were keen, and felt comfortable performing clinical tasks. Patients described convenience as a key facilitator, and concerns about privacy, particularly at the pharmacy counter, and the stigma and fear of judgement associated with STIs as primary barriers. For facilitators, pharmacists reported increased job satisfaction and a sense of relieving the burden on traditional STI services; for barriers, pharmacists highlighted patient recruitment, communication challenges, and lack of remuneration.

CONCLUSION

Research on pharmacy-based STI services includes predominately small-scale, cross-sectional studies, and focuses on chlamydia screening. Both patients and pharmacists perceive these services to be acceptable and feasible, though strategies addressing patient privacy and recruitment, pharmacist competency, training, and remuneration must be considered to support the success of pharmacy-based STI services.

2023 Korean sexually transmitted infections treatment guidelines for Mycoplasma genitalium by KAUTII

The Korean Association of Urogenital Tract Infection and Inflammation and the Korea Disease Control and Prevention Agency updated the Korean sexually transmitted infections (STIs) guidelines to respond to the changing epidemiologic trends, evolving scientific evidence, and advances in laboratory diagnostics and research. The main recommendations in the Mycoplasma genitalium infection parts of the Korean STIs guidelines 2023 revision are as follows: 1) For initial treatment: azithromycin 500 mg orally in a single dose, then 250 mg once daily for 4 days. 2) In case of treatment failure or recurrence, a macrolide susceptibility/resistance test is required, when susceptibility/resistance test is not feasible, doxycycline or minocycline 100 mg orally twice daily for 7 days, followed by azithromycin 1 g orally on the first day, then azithromycin 500 mg orally once daily for 3 days and then a test-of-cure should be considered 3 weeks after completion of therapy. 3) In case of macrolide sensitivity, doxycycline or minocycline 100 mg orally twice daily for 7 days, followed by azithromycin 1 g orally initial dose, then azithromycin 500 mg orally once daily for 3 days. 4) In case of macrolide resistance, doxycycline or minocycline 100 mg orally twice daily for 7 days, followed by moxifloxacin 400 mg orally once daily for 7 days. In the Korean STIs guideline 2023, macrolide resistance-guided antimicrobial therapy was emphasized due to the increased prevalence of macrolide resistance worldwide. Therefore, in case of treatment failure or recurrence, a macrolide susceptibility/resistance test is required.

A National Study of Expedited Partner Therapy Use in Emergency Departments: A Survey of Medical Director Knowledge, Attitudes, and Practices

BACKGROUND

Emergency departments (EDs) are the primary source of health care for many patients diagnosed with sexually transmitted infections (STIs). Expedited partner therapy (EPT), treating the partner of patients with STIs, is an evidence-based practice for patients who might not otherwise seek care. Little is known about the use of EPT in the ED. In a national survey, we describe ED medical directors' knowledge, attitudes, and practices of EPT.

METHODS

A cross-sectional survey of medical directors from academic EDs was conducted from July to September 2020 using the Academy of Academic Administrators of Emergency Medicine Benchmarking Group. Primary outcomes were EPT awareness, support, and use. The survey also examined barriers and facilitators.

RESULTS

Forty-eight of 70 medical directors (69%) responded. Seventy-three percent were aware of EPT, but fewer knew how to prescribe it (38%), and only 19% of EDs had implemented EPT. Seventy-nine percent supported EPT and were more likely to if they were aware of EPT (89% vs. 54%; P = 0.01). Of nonimplementers, 41% thought EPT was feasible, and 56% thought departmental support would be likely. Emergency department directors were most concerned about legal liability, but a large proportion (44%) viewed preventing sequelae of untreated STIs as "extremely important."

CONCLUSIONS

Emergency department medical directors expressed strong support for EPT and reasonable levels of feasibility for implementation but low utilization. Our findings highlight the need to identify mechanisms for EPT implementation in EDs.

Korean sexually transmitted infection guidelines 2023 revision, guideline update of viral infections: Genital herpes and anogenital warts

The Korean Association of Urogenital Tract Infection and Inflammation and the Korea Disease Control and Prevention Agency regularly update, revise, and develop new content for the Korean sexually transmitted infection (STI) guidelines. These professional bodies respond to changing epidemiological trends and evolving scientific evidence, and consider advances in laboratory diagnostics and research. The principal recommendations of the 2023 Korean STI guidelines in terms of viral infection follow: 1) If genital herpes recurs more than 4-6 times annually, suppressive therapy with acyclovir 400 mg orally 2 times/day or famciclovir 250 mg orally 2 times/day or valacyclovir 500 mg orally once a day (for patients with <10 episodes/year) or valacyclovir 1 g orally once daily (for patients with ≥10 episodes/year) is recommended to prevent recurrence; 2) molecular human papillomavirus (HPV) testing is not recommended as a routine test for STI status, nor for determination of HPV vaccination status; and 3) patients should inform their current sexual partners about anogenital warts because the types of HPV that cause such warts can be passed to partners. These guidelines will be updated every 5 years and will be revised when new knowledge on STIs becomes available and there is a reasonable need to improve the guidelines. Physicians and other healthcare providers can use the guidelines to assist in the prevention and treatment of STIs.

[Tropical sexually transmitted infections Summary of the SFMTSI Scientific Day of November 9, 2023]

Sexually transmitted infections (STIs) deserve more attention today than ever in the tropics. Indeed, the emergence of monkeypox in 2022 in Western countries reminds the risk of exporting STIs from the tropics as it was already known for decades with the worldwide spread of HIV/AIDS infection from tropical Africa. Some hazards are already well identified. According to WHO 2023 report STIs are increasing in the world. Antibiotic resistance is increasing for Neisseria gonorrhoeae, and already well established for Mycoplasma genitalium, whereas Treponema pallidum has become resistant to macrolides within the last twenty years. Some neglected tropical diseases (Zika, Ebola, monkeypox) can also be sexually transmitted, sometimes months after cure (Ebola). In this setting, the use of PrEP in migrants, and in Africa, is worth to be discussed beyond traditional circles.

Antimicrobial use of patients with sexually transmitted infection symptoms prior to presentation at five health facilities in Southern Ghana

BACKGROUND

Unregulated and inappropriate antimicrobial use are major contributors to the evolution of antimicrobial resistance worldwide. It is important to monitor and collect data on the use of antibiotics at health facilities and in the general population in order to support antimicrobial stewardship programs.

METHODS

As part of a gonorrhea surveillance study that was conducted from June 2012 to Jan 2018, we administered a questionnaire to elicit information on the types of antimicrobials used by individuals to treat symptoms of a gonorrhea infection prior to presenting at five health facilities in Southern Ghana.

RESULTS

Almost one-third (383/1,349; 28%) of study participants admitted taking one or more antimicrobial types before hospital presentation, while 138/383 (36%) of those who took antimicrobials could not remember what they ingested. A greater percentage of individuals who reported prior antimicrobial use before presentation at a health facility tested positive for gonorrhea by NAAT (30%), in contrast to 24% for those without prior treatment (p = 0.004). Penicillin and its derivatives, as well as ciprofloxacin and doxycycline, were the most used, while a few individuals reported taking drugs such as kanamycin and rifampin. Males were more likely than females to take an antimicrobial prior to attending a health center.

CONCLUSION

In order to curb excessive and inappropriate antimicrobial use, antibiotics used by patients before presenting at hospitals ought to be investigated by healthcare providers. It is recommended that health professionals receive continuing education on the consequences of unregulated antimicrobial use.

Potential delayed and/or missed STI diagnoses among outpatients presenting with lower genitourinary tract symptoms: a real-world database study

OBJECTIVES

Sexually transmitted infection (STI) diagnosis is complicated as these infections can present with lower genitourinary tract symptoms (LGUTS) that overlap with other disorders, i.e. urinary tract infections (UTIs). The study's objective was to determine potential missed STI diagnoses from patients presenting with LGUTS in the US between January 2010 and December 2019.

METHODS

The de-identified insurance claims data from the IBM® MarketScan® Research Databases were collected from patients (14-64 years old) who presented with LGUTS, which could be caused by an STI. A 'GAP' cohort was created, consisting of episodes with potentially delayed STI (Chlamydia trachomatis [CT]/Neisseria gonorrhoeae [NG]) treatment. The intention was to capture episodes where an STI was not initially suspected. Four subgroups were defined depending on the treatment received (fluoroquinolone; azithromycin and/or doxycycline; cephalosporins; gentamicin and azithromycin).

RESULTS

The GAP cohort consisted of 833,574 LGUTS episodes from the original cohort (23,537,812 episodes). Post-index CT/NG testing was carried out for 4.6% and 5.4% of the episodes from men and women, respectively. There were ≥2 return visits for 16.1% and 15.8% of the episodes from men and women, respectively. A substantial percentage of episodes from men (52.1%) and women (68.3%) were diagnosed with a UTI and/or acute cystitis at the index prior to receiving post-index STI treatment. Other top conditions diagnosed at index for men were dysuria (25.8% of the episodes), orchitis/epididymitis (14.3% of the episodes), and acute prostatitis (10.1% of the episodes), and for women were dysuria (24.2% of the episodes), vaginitis/vulvitis/vulvovaginitis (11.7% of the episodes), and cervicitis (3.3% of the episodes).

CONCLUSION

These findings highlight delayed STI antibiotic treatment and low rates of CT/NG testing, suggesting late STI consideration and suboptimal diagnosis. Additionally, our study illustrates the importance of accurately diagnosing and treating STIs in patients with LGUTS and associated conditions, to avoid antibiotic misuse and complications from delayed administration of appropriate treatment.

Economic evaluation of antimicrobial resistance in curable sexually transmitted infections; a systematic review and a case study

OBJECTIVE

To provide a summary of the economic and methodological evidence on capturing antimicrobial resistance (AMR) associated costs for curable sexually transmitted infections (STIs). To explore approaches for incorporating the cost of AMR within an economic model evaluating different treatment strategies for gonorrhoea, as a case study.

METHODS

A systematic review protocol was registered on PROSPERO (CRD42022298232). MEDLINE, EMBASE, CINAHL, Cochrane Library, International Health Technology Assessment Database, National Health Service Economic Evaluation Database, and EconLit databases were searched up to August 2022. Included studies were analysed, quality assessed and findings synthesised narratively. Additionally, an economic evaluation which incorporated AMR was undertaken using a decision tree model and primary data from a randomised clinical trial comparing gentamicin therapy with standard treatment (ceftriaxone). AMR was incorporated into the evaluation using three approaches-integrating the additional costs of treating resistant infections, conducting a threshold analysis, and accounting for the societal cost of resistance for the antibiotic consumed.

RESULTS

Twelve studies were included in the systematic review with the majority focussed on AMR in gonorrhoea. The cost of ceftriaxone resistant gonorrhoea and the cost of ceftriaxone sparing strategies were significant and related to the direct medical costs from persistent gonorrhoea infections, sequelae of untreated infections, gonorrhoea attributable-HIV transmission and AMR testing. However, AMR definition, the collection and incorporation of AMR associated costs, and the perspectives adopted were inconsistent or limited. Using the review findings, different approaches were explored for incorporating AMR into an economic evaluation comparing gentamicin to ceftriaxone for gonorrhoea treatment. Although the initial analysis showed that ceftriaxone was the cheaper treatment, gentamicin became cost-neutral if the clinical efficacy of ceftriaxone reduced from 98% to 92%. By incorporating societal costs of antibiotic use, gentamicin became cost-neutral if the cost of ceftriaxone treatment increased from £4.60 to £8.44 per patient.

CONCLUSIONS

Inclusion of AMR into economic evaluations may substantially influence estimates of cost-effectiveness and affect subsequent treatment recommendations for gonorrhoea and other STIs. However, robust data on the cost of AMR and a standardised approach for conducting economic evaluations for STI treatment which incorporate AMR are lacking, and requires further developmental research.

Predictors of PrEP retention in at risk patients seen at a HIV primary care clinic in San Diego

BACKGROUND

Adherence to medication and retention in care are key contributors to the efficacy of pre-exposure prophylaxis (PrEP) for prevention of HIV. Therefore, it is important to understand factors that may impact retention in various settings that prescribe PrEP.

METHODS

We evaluated factors associated with retention in care 3 and 12 months after PrEP initiation at a primary care HIV clinic in San Diego. Retention was defined as having an office/virtual visit within 1 month from the 3- or 12-months time point or interacting with the clinic leading to medication being refilled.

RESULTS

A total of 199 patients were included. Retention rates were 74.4% and 52.8% at 3 and 12 months respectively. In the multivariate analysis, reporting depression or anxiety was associated with being retained in care (p = 0.004) and identifying as cisgender female was associated with lack of retention (p = 0.04) at 3 months. Testing positive for a sexually transmitted infection was associated with 12-months retention (p = 0.004); however, this was likely influenced by difference in the frequency of testing in those retained versus not retained.

CONCLUSION

Ongoing efforts to determine the optimal method for provision of PrEP care that supports retention for different populations at risk for HIV, are needed.

Sexually transmitted infections in Spain: Current status

Sexually Transmitted Infections (STI) are a major public health problem. The problems inherent to their diagnosis, treatment and prevention have to do not only with their nature, but also with organizational issues and overlapping competencies of the different health authorities in Spain. The real situation of STI in Spain, at present, is poorly known. For this reason, the Scientific Committee on COVID and Emerging Pathogens of the Illustrious Official College of Physicians of Madrid (ICOMEM) has formulated a series of questions on this subject which were distributed, not only among the members of the Committee, but also among experts outside it. The central health authorities provide very high and increasing figures for gonococcal infection, syphilis, Chlamydia trachomatis infection and lymphogranuloma venereum (LGV). Both HIV infection and Monkeypox are two important STI caused by viruses in our environment, to which it should be added, mainly, Herpes simplex virus (HSV) and Human papillomavirus (HPV) infections. Emerging microorganisms such as Mycoplasma genitalium pose not only pathogenic challenges but also therapeutic problems, as in the case of N. gonohrroeae. The pathways that patients with suspected STI follow until they are adequately diagnosed and treated are not well known in Spain. Experts understand that this problem is fundamentally managed in public health institutions, and that Primary Care and Hospital Emergency Services, together with some institutions that deal monographically with this problem, are the recipients of most of these patients. One of the most serious difficulties of STI lies in the availability of the microbiological tests necessary for their diagnosis, particularly in this era of outsourcing of microbiology services. Added to this is the increased cost of implementing the latest generation of molecular techniques and the difficulties of transporting samples. It is clear that STI are not diseases to which the entire population is equally exposed and it is necessary to have a better knowledge of the risk groups where to focus the necessary interventions adapted to their characteristics. It should not be forgotten that STI are also a problem in the pediatric age group and that their presence can be a marker of sexual abuse with all that this implies in terms of health care and medicolegal activity. Finally, STI are infections that are associated with a high cost of care for which we have very little information. The possibility of expanding the automatic performance of laboratory tests for STI surveillance through laboratory routines is encountering ethical and legal problems that are not always easy to solve. Spain has created a ministerial area of specific attention to STI and there are plans to improve the diagnosis, treatment and prevention of these problems, but we still lack the necessary evidence on their impact. We cannot forget that these are diseases that transcend the individual and constitute a Public Health problem.

Self-start HIV postexposure prophylaxis (PEPSE), to reduce time to first dose and increase efficacy

BACKGROUND

Effectiveness of HIV postexposure prophylaxis (PEPSE) correlates with speed of uptake following HIV exposure. Time to first dose has not improved in the UK for over 10 years. On-demand pre-exposure prophylaxis (PrEP) has shown that people can self-start medication for HIV prevention.We hypothesised that advanced provision of PEPSE (HOME PEPSE) for men who have sex with men (MSM) to self- initiate would reduce time to first dose following HIV exposure.

METHODS

Phase IV, randomised, prospective, 48-week, open-label study was carried out. MSM at medium risk of acquiring HIV were randomised (1:1) to immediate or deferred standard of care (SOC) HOME PEPSE. Every 12 weeks, participants self-completed mental health/risk behaviour surveys and had HIV/sexually transmitted infection (STI) testing.HOME PEPSE comprised a 5-day pack of emtricitabine/tenofovir disoproxil fumarate/maraviroc 600 mg once daily initiated following potential exposure to HIV. If taken, participants completed a risk survey; PEPSE continuation was physician directed. Primary outcome was time from potential exposure to HIV to first PEPSE dose.

FINDINGS

139 participants randomised 1:1; 69 to immediate HOME PEPSE and 70 to deferred HOME PEPSE. Median age 30 years (IQR 26-39), 75% white, 55% UK born and 72% university educated. 31 in HOME PEPSE and 15 in SOC arm initiated PEPSE. Uptake of HOME PEPSE was appropriate in 27/31 cases (87%, 95% CI: 71% to 95%). Median time from exposure to first dose was 7.3 hours (3.0, 20.9) for HOME PEPSE and 28.5 hours (17.3, 34.0) for SOC (p<0.01). HOME PEPSE was well tolerated with no discontinuations.No significant differences in missed opportunities for PEPSE uptake, sexual behaviour or bacterial STI infections between treatment arms.

INTERPRETATION

HOME PEPSE reduced the time from exposure to first-dose PEPSE by 21+ hours, with no impact on safety. This significantly improves the efficacy of PEPSE and provides an option for people declining PrEP.

Important considerations regarding the widespread use of doxycycline chemoprophylaxis against sexually transmitted infections

Rates of sexually transmitted infections (STIs) continue to rise across the world and interventions are essential to reduce their incidence. Past and recent studies have indicated this may be achieved using doxycycline post-exposure prophylaxis (PEP) and this has sparked considerable interest in its use. However, many unanswered questions remain as to its long-term effects and particularly potentially negative impact on human microbiomes and antimicrobial resistance among STIs, other pathogens, and commensals. In this review, we discuss seven areas of concern pertaining to the widespread use of doxycycline PEP.

Multidrug-Resistant Trichomoniasis: Successful Treatment With 3 Months of Twice-Daily Intravaginal Boric Acid

ABSTRACT

Trichomoniasis is the most common nonviral sexually transmitted infection. 1 For patients with resistance to standard treatment with 5-nitroimidazoles, alternative therapies are limited. We present a case of a 34-year-old woman with multidrug-resistant trichomoniasis who was successfully treated with 600 mg intravaginal boric acid twice daily for 3 months.

Sexually Transmitted Trichophyton mentagrophytes Genotype VII Infection among Men Who Have Sex with Men

Transmission of dermatophytes, especially Trichophyton mentagrophytes genotype VII, during sexual intercourse has been recently reported. We report 13 such cases in France. All patients were male; 12 were men who have sex with men. Our findings suggest sexual transmission of this pathogen within a specific population, men who have sex with men.

Effect of tenofovir-based HIV pre-exposure prophylaxis against HBV infection in men who have sex with men

BACKGROUND AND AIMS

Men who have sex with men (MSM) are vulnerable to contracting HBV as a sexually transmitted infection. We evaluated the incidence of HBV infection (HBI) and the prophylactic effect of tenofovir-based pre-exposure prophylaxis (PrEP) on HBI in an MSM cohort.

METHODS AND RESULTS

MSM who were older than 16 years were enrolled from January 2018 and followed up until June 2021 and tested for HIV, bacterial sexually transmitted infections, and HBsAg/ HBsAb and HBcAb every 3 months based on inclusion criteria, including HBsAg, HBcAb, HBsAb, and HIV negativity at enrollment. HBI was defined as seroconversion of HBsAg or HBcAb status. The log-rank test was used to evaluate the prophylactic effect of PrEP against HBI. As a substudy, individuals excluded from the main study due to HBs Ab positivity were evaluated for HBI incidence. Among 1577 MSM, 786 participants (546 PrEP nonusers, 131 daily PrEP users, and 109 event-driven PrEP users) met the criteria and were included. The annual incidence of HBV among PrEP nonusers (3.8%, 21 infections, with 559.5 person-years) was significantly higher ( p = 0.018, log-rank test) than that among daily PrEP users [0.77%, 1 infection (admitted nonadherence), with 129.3 person-years] and event-driven PrEP users (no infection with 93.8 person-years). Although the incidence of HBI and HIV infection decreased with PrEP use, the incidence of other sexually transmitted infections was higher in both daily and event-driven PrEP users. The annual incidence of HBV among HBsAb-positive and HBcAb-negative PrEP nonusers was 1.8% (3 infections, with 167.5 person-years).

CONCLUSIONS

Tenofovir-based PrEP prevented HBI among MSM in a real-world setting.

Predominance of High-Level Tetracycline-Resistant Neisseria gonorrhoeae in Kenya: Implications for Global Implementation of Doxycycline Postexposure Prophylaxis for Prevention of Sexually Transmitted Infections

ABSTRACT

Using archived Neisseria gonorrhoeae samples from 2008 to 2012, the prevalence of tet (M) genemediating high-level tetracycline resistance in N. gonorrhoeae was 96% among 50 Kenyan women. Determining the local and national prevalence of gonococcal tetracycline resistance and surveillance of gonococcal antimicrobial resistance can inform the implementation of doxycycline postexposure prophylaxis for STI prevention.

Impact of Point-of-Care Testing on the Management of Sexually Transmitted Infections in South Africa: Evidence from the HVTN702 Human Immunodeficiency Virus Vaccine Trial

BACKGROUND

Alternative approaches to syndromic management are needed to reduce rates of sexually transmitted infections (STIs) in resource-limited settings. We investigated the impact of point-of-care (POC) versus central laboratory-based testing on STI treatment initiation and STI adverse event (STI-AE) reporting.

METHODS

We used Kaplan-Meier and Cox regression models to compare times to treatment initiation and STI-AE reporting among HVTN702 trial participants in South Africa. Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) were diagnosed POC at eThekwini clinic and in a central laboratory at Verulam/Isipingo clinics. All clinics used POC assays for Trichomonas vaginalis (TV) testing.

RESULTS

Among 959 women (median age, 23 [interquartile range, 21-26] years), median days (95% confidence interval [95%CI]) to NG/CT treatment initiation and NG/CT-AE reporting were 0.20 (.16-.25) and 0.24 (.19-.27) at eThekwini versus 14.22 (14.12-15.09) and 15.12 (13.22-21.24) at Verulam/Isipingo (all P < .001). Median days (95%CI) to TV treatment initiation and TV-AE reporting were 0.17 (.12-.27) and 0.25 (.20-.99) at eThekwini versus 0.18 (.15-.2) and 0.24 (.15-.99) at Verulam/Isipingo (all P > .05). Cox regression analysis revealed that NG/CT treatment initiation (adjusted hazard ratio [aHR], 39.62 [95%CI, 15.13-103.74]) and NG/CT-AE reporting (aHR, 3.38 [95%CI, 2.23-5.13]) occurred faster at eThekwini versus Verulam/Isipingo, while times to TV treatment initiation (aHR, 0.93 [95%CI, .59-1.48]) and TV-AE reporting (aHR, 1.38 [95%CI, .86-2.21]) were similar.

CONCLUSIONS

POC testing led to prompt STI management with potential therapeutic and prevention benefits, highlighting its utility as a diagnostic tool in resource-limited settings.

Prevalence of HIV seropositive status and associated factors among family members of index cases of antiretroviral clinical attendants in Sodo Town, Southern Ethiopia

BACKGROUND

Human immunodeficiency virus is primarily transmitted through sexual contact with an infected partner and babies born to mothers infected with the virus. Partners of people living with HIV and children whose parents have HIV are at higher risk of contracting HIV unless they take preventive measures. This study aimed at identifying prevalence and determinants of HIV infection among family members of index cases on antiretroviral treatment (ART).

METHODS

A community-based cross-sectional study was conducted among 623 randomly selected family members of HIV index cases in Sodo Town from February to June 2021. A pre-tested structural questionnaire was used to collect data. Binary logistic regression was used to identify variables independently associated with the outcome variable. The adjusted odds ratio (AOR) with 95% confidence interval (CI) was used to show the strength of association, and a P-value 0.05 was used as a cut-off point to determine the level of statistical significance of point estimate.

RESULTS

This study revealed that 31.5% (95%CI: 27.6-35.2%) of family members of index cases were HIV seropositive. In subgroup analysis, this study also revealed that 11.1% (95%CI 8.4-14.5%) of biological children and 69.6% (95%CI 63.1-75.6%) of spousal partners of index cases were HIV seropositive. Immediate ART initiation of index cases (AOR = 0.148, 95%CI: 0.067-0.325), being bedridden or ambulatory functional status at enrollment (AOR = 7.71, 95%CI: 3.5-17), and baseline CD4 level of 350 cells/ml (AOR = 8.06, 95%CI: 1.8-36) were statistically significant with the outcome variable among biological children. Among spousal partners, STI history or symptoms (AOR = 5.7, 95%CI: 1.86-17.5), early disclosure (AOR = 0.062, 95%CI: 0.024-0.159), immediate ART initiation (AOR = 0.172, 95%CI: 0.044-0.675), and duration of infection (AOR = 5.09, 95%CI: 1.8-14.4) were statistically associated with the outcome variable.

CONCLUSION

As evidenced by our data, the risk of HIV among family members of index cases is high. Interventions like immediate ART initiation, early disclosure, screening, and early treatment of STIs for minimizing HIV transmission might be given.

Presumptive and Follow-Up Treatment Associated With Gonorrhea and Chlamydia Testing Episodes in Sexually Transmitted Disease Clinics: Impact of Changing Treatment Guidelines for Gonorrhea, Sexually Transmitted Disease Surveillance Network, 2015-2018

Background:

CDC recommendation for treatment of uncomplicated gonorrhea (NG) were revised in December 2020 and include ceftriaxone monotherapy when chlamydial infection was excluded. We evaluated the impact of these revised treatment recommendations using data from a network of STD clinics prior to the change in guidelines.

Methods:

We performed a cross-sectional analysis from 8 STD clinics participating in the STD Surveillance Network from Jan 2015-June 2018 assessing gonorrhea/chlamydia (CT) testing episodes, NAAT results, CT only and NG/CT treatment records, and timing of treatment. We describe the frequency of NG and CT treatment practices and what proportion of patients treated would not have had to receive an anti-chlamydial agent.

Results:

Of 190,589 episodes that occurred during the study period, 67,895 (35.6%) episodes were associated with a treatment record consistent with gonorrhea and/or chlamydia (CT only (n=37,530) or NG/CT (n=30,365)), most (~86%) were prescribed on the same-day as initial testing. Of the 67,895 episodes with corresponding treatment record(s), 42.1% were positive for either NG or CT compared to 3.7% were positive for NG or CT for those not associated with treatment records (n=122,694 episodes). Among 30,365 episodes associated with NG/CT treatment records, monotherapy would only have been indicated for 10.1% (3,081/30,365) of the episodes as they were treated on follow-up and were NG positive and CT negative.

Conclusions:

Treatment was prescribed in one third of NG/CT testing episodes, with the majority provided same day. Despite changes in NG treatment guidelines to ceftriaxone monotherapy, majority of patients would continue to receive an anti-chlamydia agent when treated for gonorrhea in these settings.

Provision of same-day treatment is common in STD clinic patients being treated for gonorrhea and chlamydia, likely resulting in patients continuing to get dual therapy despite recent treatment guideline changes.

Etiological Surveillance of Male Urethritis Syndrome in South Africa: 2019 to 2020

BACKGROUND

In South Africa, male urethritis syndrome (MUS) is the most common sexually transmitted infection (STI) syndrome in men. We determined the distribution of STI etiologies and the susceptibility profiles of Neisseria gonorrhoeae isolates from men presenting with MUS to 3 sentinel surveillance health care facilities. Secondary objectives were to determine the seroprevalence of coinfections (HIV, syphilis, herpes simplex virus 2).

METHODS

Consecutive, consenting men with symptomatic urethral discharge were enrolled between January 1, 2019, and December 31, 2020. Genital discharge swab and blood specimens were collected and transported to a central STI reference laboratory in Johannesburg, South Africa.

RESULTS

Among 769 men enrolled, N. gonorrhoeae was the commonest cause of MUS (674 [87.8%]; 95% confidence interval [CI], 85.2%-89.9%), followed by Chlamydia trachomatis (161 [21.0%]; 95% CI, 18.2%-24.0%). Of 542 cultivable N. gonorrhoeae isolates, all were susceptible to ceftriaxone (modal minimum inhibitory concentration, 0.004 mg/L) and azithromycin (modal minimum inhibitory concentration, 0.128 mg/L). Seroprevalence rates of HIV, syphilis, and HSV-2 were 21.4% (95% CI, 18.5%-24.5%), 2.3%, and 50.1%, respectively. Condom use at last sexual encounter was reported by only 7%, less than 50% had been medically circumcised, and only 66.7% (58 of 87) who self-reported an HIV-positive status were adherent on antiretroviral drugs.

CONCLUSIONS

Neisseria gonorrhoeae and C. trachomatis were the predominant causes of MUS. Currently recommended dual ceftriaxone and azithromycin therapy are appropriate for MUS syndromic management; however, surveillance must be maintained to timeously detect emerging and increasing gonococcal resistance. Clinic-based interventions must be intensified in men seeing sexual health care to reduce the community transmission and burden of STI and HIV.

Updates in the treatment of gonococcal infections

ABSTRACT

This article highlights important changes in treatment of gonococcal infections secondary to rising infection rates, as well as increased drug-resistance to previous therapy recommendations. The article is intended to assist clinicians in both the ambulatory as well as inpatient setting when treating patients with sexually transmitted infections.

Sexually Transmitted Infections: Updates From the 2021 CDC Guidelines

Sexually transmitted infection (STI) rates are increasing for most nationally notifiable disease categories in the United States. The 2021 Centers for Disease Control and Prevention STI guidelines provide several updated, evidence-based testing and treatment recommendations. The recommended treatment for gonorrhea is ceftriaxone monotherapy given intramuscularly, with dosing based on the patient's body weight. For chlamydia, doxycycline is the preferred treatment. A test-of-cure is recommended for all cases of pharyngeal gonorrhea and for rectal chlamydia if treated with azithromycin. Vaginal trichomoniasis should be treated with a seven-day regimen of metronidazole. Treatment of pelvic inflammatory disease routinely includes metronidazole with doxycycline and an increased dosage of ceftriaxone. Syphilis of less than one year's duration should be treated with a single dose of intramuscular penicillin G benzathine, 2.4 million units. Syphilis of more than one year's or unknown duration should be treated with three consecutive weekly doses of intramuscular penicillin G benzathine, 2.4 million units each. A thorough evaluation for otic, ophthalmic, and neurologic symptoms is essential for anyone with syphilis because these complications can occur at any stage and require 10 to 14 days of treatment with intravenous aqueous crystalline penicillin G. Family physicians can reduce STI rates by taking a thorough sexual history, especially in teens and young adults, ordering screening tests and treatment based on the updated Centers for Disease Control and Prevention STI guidelines, and collaborating with public health departments for disease reporting and partner services.

Retrospective Analysis of Ugandan Men with Urethritis Reveals Mycoplasma genitalium and Associated Macrolide Resistance

The rising rates of antimicrobial resistance (AMR) in Mycoplasma genitalium globally and the association of this sexually transmitted infection (STI) with cervicitis, urethritis, and HIV are potentially of great public health concern. Data on the epidemiology of M. genitalium in men in sub-Saharan Africa are limited. We sought to determine the prevalence of M. genitalium and macrolide resistance in men with urethritis in Kampala, Uganda. Self-collected penile-meatal swabs and/or urine samples from men with symptomatic urethritis (n = 250) were retrospectively analyzed for the presence of M. genitalium and macrolide resistance markers with the Aptima M. genitalium and ResistancePlus M. genitalium assays. Additionally, demographic and STI coinfection data were used to investigate associations with M. genitalium infection. M. genitalium was detected in 12.8% (32/250) of individuals; 40.6% (n = 13) had M. genitalium monoinfection. Mutations associated with macrolide resistance were detected in 10.7% (3/28) of participants. Coinfection with Neisseria gonorrhoeae was common (41.0%), but M. genitalium was more prevalent in participants without N. gonorrhoeae coinfection (P = 0.001). M. genitalium is common in Ugandan men with urethritis both as a monoinfection and as a coinfection with other curable STIs. Macrolide resistance was present and warrants further research on treatment outcomes and the association between untreated M. genitalium and subsequent morbidity. IMPORTANCE Mycoplasma genitalium is a common sexually transmitted infection associated with urethritis in men. Little is known about M. genitalium infection in men with urethritis in Uganda. We report that 12% of participants in this study were positive for M. genitalium and that resistance to azithromycin, a macrolide antibiotic, is present. Furthermore, we show that either self-collected penile-meatal swabs or urine can be used for detection of M. genitalium.

Diagnosis and Management of Trichomonas vaginalis: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines

Trichomonas vaginalis is likely the most prevalent nonviral sexually transmitted infection, affecting an estimated 3.7 million women and men in the United States. Health disparities are prominent in the epidemiology of trichomoniasis, as African Americans are >4 times more likely to be infected than persons of other races. Since publication of the 2015 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines, additional data have bolstered the importance of T. vaginalis infection sequelae in women, including increased risk of human immunodeficiency virus (HIV) acquisition, cervical cancer, preterm birth, and other adverse pregnancy outcomes. Less is known about the clinical significance of infection in men. Newly available diagnostic methods, including point-of-care assays and multiple nucleic acid amplification tests, can be performed on a variety of genital specimens in women and men, including urine, allowing more accurate and convenient testing and screening of those at risk for infection. Repeat and persistent infections are common in women; thus, rescreening at 3 months after treatment is recommended. In vitro antibiotic resistance to 5-nitroimidazole in T. vaginalis remains low (4.3%) but should be monitored. High rates of T. vaginalis among sexual partners of infected persons suggest a role for expedited partner treatment. A randomized controlled trial in HIV-uninfected women demonstrated that multidose metronidazole 500 mg twice daily for 7 days reduced the proportion of women with Trichomonas infection at 1 month test of cure compared with women receiving single-dose therapy (2 g). The 2-g single-dose oral metronidazole regimen remains the preferred treatment in men.

CROI 2022: epidemiologic trends and prevention for HIV and SARS-CoV-2

At the 2022 Conference on Retroviruses and Opportunistic Infections, several speakers discussed disparities in HIV and COVID-19 infections and outcomes. Although the lifetime risk of HIV infection in the United States is higher overall in males than females, Black females have higher risk than White males. In 12 countries in sub-Saharan Africa, women aged 15 to 34 years accounted for more than half of all infections. Because knowledge of HIV serostatus is important for treatment and for prevention, several novel strategies were evaluated in the distribution of HIV self-test kits to undertested populations in the United States and sub-Saharan Africa. Data were presented on new products in the pre-exposure prophylaxis (PrEP) pipeline, including long-acting injectable cabotegravir, islatravir, vaginal rings, and in-situ forming implants. Challenges remain in the rollout of oral PrEP, and a number of innovative strategies to address barriers were discussed. Models suggest that the greatest impact of novel PrEP agents would be to increase the pool of persons using PrEP, rather than through improved efficacy. COVID-19 caused substantial declines in HIV and sexually transmitted infection prevention and treatment services, which have started to rebound, but are not yet at prepandemic levels in several settings.

Clinical Integration of a Highly Accurate Polymerase Chain Reaction Point-of-Care Test Can Inform Immediate Treatment Decisions for Chlamydia, Gonorrhea, and Trichomonas

BACKGROUND

Accurate same-day sexually transmitted infection (STI) diagnostic testing is generally unavailable, leading to syndromic management with high rates of overtreatment and undertreatment. We analyzed the ease of integration of the Visby STI Panel into clinical practice, studied acceptance by patients and clinic personnel, and assessed the potential to inform accurate treatment decisions.

METHODS

In a cross-sectional single-visit study of 55 women aged 18 to 56 years, women self-collected vaginal swab samples that were analyzed using the Visby STI Panel for Chlamydia trachomatis, Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV). Results were compared with standard-of-care clinic results from send-out laboratory polymerase chain reaction tests. Surveys assessed patient and device operator experiences with the Visby STI Panel and clinicians' perceived need for and acceptance of the device. Time parameters were measured to evaluate the impact on clinical workflow, and syndromic treatment decisions were compared with anticipated treatment based on the Visby STI Panel results.

RESULTS

Patients strongly agreed that sample self-collection was easy, and operators reported the device easy to use. Clinicians valued the rapid return of results, and patients were comfortable waiting up to 30 minutes to receive them. In 13 of 15 cases, the Visby STI Panel correctly identified undertreated patients as infected and correctly identified all 33 incidences of overtreatment.

CONCLUSIONS

Clinical adoption of the Visby STI Panel into primary care clinics and doctors' offices could reduce overtreatment and undertreatment of STIs. If integrated efficiently into the clinical workflow, the test would have minimal impact on staff time and visit duration for patients.

Single gene targeted nanopore sequencing enables simultaneous identification and antimicrobial resistance detection of sexually transmitted infections

OBJECTIVES

To develop a simple DNA sequencing test for simultaneous identification and antimicrobial resistance (AMR) detection of multiple sexually transmitted infections (STIs).

METHODS

Real-time PCR (qPCR) was initially performed to identify Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV) infections among a total of 200 vulvo-vaginal swab samples from female sex workers in Ecuador. qPCR positive samples plus qPCR negative controls for these STIs were subjected to single gene targeted PCR MinION-nanopore sequencing using the smartphone operated MinIT.

RESULTS

Among 200 vulvo-vaginal swab samples 43 were qPCR positive for at least one of the STIs. Single gene targeted nanopore sequencing generally yielded higher pathogen specific read counts in qPCR positive samples than qPCR negative controls. Of the 26 CT, NG or MG infections identified by qPCR, 25 were clearly distinguishable from qPCR negative controls by read count. Discrimination of TV qPCR positives from qPCR negative controls was poorer as many had low pathogen loads (qPCR cycle threshold >35) which produced few specific reads. Real-time AMR profiling revealed that 3/3 NG samples identified had gyrA mutations associated with fluoroquinolone resistance, 2/10 of TV had mutations related to metronidazole resistance, while none of the MG samples possessed 23S rRNA gene mutations contributing to macrolide resistance.

CONCLUSIONS

Single gene targeted nanopore sequencing for diagnosing and simultaneously identifying key antimicrobial resistance markers for four common genital STIs shows promise. Further work to optimise accuracy, reduce costs and improve speed may allow sustainable approaches for managing STIs and emerging AMR in resource poor and laboratory limited settings.