Mycoplasma genitalium infection and female reproductive tract disease: a meta-analysis

Association between polycystic ovary syndrome and the vaginal microbiome: A case-control study

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of reproductive age. Some evidence suggests that dysbiosis of the gut microbiota could be associated with PCOS clinical parameters, but little is known for the association between vaginal microbiome and PCOS.

OBJECTIVE

To determine differences in the vaginal microbiome between women with PCOS and healthy control women.

RESEARCH DESIGN AND METHODS

In this case-control study, the women with newly diagnosed PCOS (n = 39) and healthy controls (n = 40) were included from the hospital and maternal and child health centre, respectively. The vaginal swabs were collected, and microbiome structures were identified by 16S rRNA gene sequencing. The screening values for potential bacteria biomarker for PCOS were assessed by receiver operating characteristic (ROC) curve method.

RESULTS

There was significant difference in vaginal bacterial structures between PCOS and healthy control women. The vaginal bacterial species in the PCOS group were more diverse than the control group (Simpson index for PCOS group vs. control group: median 0.49 vs. 0.80, P = .008; Shannon index: median 1.07 vs. 0.44, P = .003; Chao1 index: median 85.12 vs. 66.13, P < .001). The relative abundance of Lactobacillus crispatus in the PCOS group was significantly lower than controls (P = .001), and the relative abundance of Mycoplasma and Prevotella was higher than controls (P < .001, P = .002, respectively). The Mycoplasma genus could be a potential biomarker for PCOS screening, as ROC analysis showed that the area under the curve (AUC) for the relative abundance of Mycoplasma was 0.958 (95% CI: 0.901-0.999). Subgroup analyses also showed these associations would not change among the women with the same BMI level and vagina cleanliness grading.

CONCLUSIONS

In the vaginal microbiome, the Mycoplasma genus was associated with PCOS. Further research is required to explore causal correlations between PCOS and the vaginal microbiome.

Characteristics of Mycoplasma genitalium Urogenital Infections in a Diverse Patient Sample from the United States: Results from the Aptima Mycoplasma genitalium Evaluation Study (AMES)

Data from a large prospective multicenter clinical validation study of a nucleic acid amplification in vitro diagnostic test for Mycoplasma genitalium were analyzed to describe the prevalence of M. genitalium infection, risk factors, and disease associations in female and male patients seeking care in diverse geographic regions of the United States. Among 1,737 female and 1,563 male participants, the overall prevalence of M. genitalium infection was 10.3% and was significantly higher in persons ages 15 to 24 years than in persons ages 35 to 39 years (for females, 19.8% versus 4.7% [odds ratio {OR} = 5.05; 95% confidence interval {CI} = 3.01 to 8.46]; for males, 16.5% versus 9.4% [OR = 1.91; 95% CI = 1.20 to 3.02]). The risk for M. genitalium infection was higher in black than in white participants (for females, 12.0% versus 6.8% [OR = 1.88; 95% CI = 1.30 to 2.72]; for males, 12.9% versus 6.9% [OR = 2.02; 95% CI = 1.38 to 2.96]) and higher in non-Hispanic than in Hispanic participants (for females, 11.2% versus 6.0% [OR = 1.97; 95% CI = 1.25 to 3.10]; for males, 11.6% versus 6.8% [OR = 1.80; 95% CI = 1.14 to 2.85]). Participants reporting urogenital symptoms had a significantly elevated risk of M. genitalium infection compared to that for asymptomatic individuals (for females, OR = 1.53 [95% CI = 1.09 to 2.14]; for males, OR = 1.42 [95% CI = 1.02 to 1.99]). Women diagnosed with vaginitis and cervicitis had a higher prevalence of M. genitalium infection than women without those diagnoses, although this was statistically significant only for vaginitis (for vaginitis, OR = 1.88 [95% CI = 1.37 to 2.58]; for cervicitis, OR = 1.42 [95% CI = 0.61 to 2.96]). A diagnosis of urethritis in men was also significantly associated with M. genitalium infection (OR = 2.97; 95% CI = 2.14 to 4.13). Few characteristics distinguished asymptomatic from symptomatic M. genitalium infections. These results from persons seeking care in the United States suggest that M. genitalium infection should be considered in young persons presenting with urogenital symptoms.

Prevalence, Macrolide Resistance, and Fluoroquinolone Resistance in Mycoplasma genitalium in Men Who Have Sex With Men Attending an Sexually Transmitted Disease Clinic in Dublin, Ireland in 2017-2018

This is the first prevalence study of Mycoplasma genitalium and antimicrobial resistance study in Ireland. In urine samples from men who have sex with men (n = 400) attending a sexually transmitted disease clinic in Dublin, the prevalence of M. genitalium was 3% (12 of 400 specimens; 95% confidence interval, 1.3-4.7%), and the prevalences of macrolide resistance (75%), fluoroquinolone resistance (33.3%), and multidrug resistance (33.3%) were very high.

High rates of treatment failure for Mycoplasma genitalium among men and women attending a sexual health clinic

BACKGROUND

Mycoplasma genitalium (Mgen) causes non-gonococcal urethritis (NGU) and is believed to cause pelvic inflammatory disease (PID). High rates of macrolide resistance are well documented globally for Mgen. In Brighton, patients with NGU and PID are tested for Mgen and test of cure (TOC) offered post-treatment.

METHODS

Demographic, clinical and treatment history data were collected over a 12-month period for all Mgen-positive patients in a Brighton-based genitourinary clinic.

RESULTS

There were 114 patients with Mgen. 18% (61/339) of men with NGU and 9% (15/160) of women with PID had Mgen. 62/114 (54%) returned for first test TOC 4 weeks after treatment. 27/62 (44%) had a positive TOC; 25/27 (92.6%) had received azithromycin first line (500 mg stat then 250 mg OD for 4 days), 1/27 (3.7%) had received moxifloxacin first line (400 mg OD for 14 days) and 1/27 (3.7%) had received doxycycline first line (100 mg BD for 7 days). 20/27 (74%) returned for a second TOC 4 weeks later. 5/20 (25%) patients were positive on second TOC; 3/5 (60%) had received azithromycin second line and 2/5 (40%) had received moxifloxacin second line. Patients were more likely to have a positive TOC if they were at risk of reinfection (9/27 positive TOC vs 3/35 negative TOC; p=0.02). Patients given moxifloxacin were more likely to have a negative TOC (1/27 positive TOC vs 9/35 negative TOC; p=0.03) than those who received other antibiotic regimens.

CONCLUSIONS

Treatment failure rates for Mgen following azithromycin use are substantial, raising concerns regarding resistance. However, reinfection risk may contribute, suggesting a requirement for improved public awareness and clinician knowledge.

Prevalence of Mycoplasma genitalium infection in women with bacterial vaginosis

Background

Bacterial vaginosis (BV) is a common condition in reproductive-age women and is known to be positively associated with risk of acquisition of sexually transmitted infections (STI) such as chlamydia and gonorrhea. Mycoplasma genitalium is an emerging STI that has been linked to increased risk of pelvic inflammatory disease, adverse pregnancy outcomes and infertility. In the present study we sought to examine whether women diagnosed with symptomatic BV were at increased risk of having concurrent infection with Mycoplasma genitalium.

Methods

We used a novel PCR-based assay (ResistancePlus MG; SpeeDx Pty. Ltd., Sydney, Australia) to determine the prevalence of Mycoplasma genitalium infection and 23S rRNA macrolide-resistance mediating mutations (MRMM) in a cohort of 1532 women presenting with symptoms of vaginitis.

Results

M. genitalium was detected in 4.0% (62/1532) of samples with 37.1% (23/62) harboring MRMMs. The prevalence of M. genitalium infection in subjects with BV was significantly higher than in subjects with non-BV vaginitis (7.0% v 3.6%; OR = 1.97 (95% CI: 1.14–3.39).

Conclusions

Prevalence of M. genitalium infection is associated with BV in women with symptomatic vaginitis. Improved management of BV is needed as a component of STI prevention strategies.

Technologies, strategies and approaches for testing populations at risk of sexually transmitted infections: a systematic review protocol to inform prevention and control in EU/EEA countries

OBJECTIVES

This protocol outlines a systematic review methodology, aiming to assess the recent evidence-base for the impact of testing strategies and approaches on access to testing, testing coverage, and linkage to care for populations at risk for specific curable sexually transmitted infections (STIs) (chlamydia, gonorrhoea, syphilis, trichomoniasis, and Mycoplasma genitalium infections).

DATA SOURCES

These include MEDLINE, Embase, PsycINFO, Global Health, Cochrane Database, Epistemonikos, CINAHL Plus, and Web of Science Core Collection.

REVIEW METHODS

Papers reporting primary data from 1 January 2012 onwards will be included. Titles, abstracts, and full texts will be reviewed for inclusion, and data will be extracted using a pre-specified and piloted data extraction form, by two independent reviewers. Experts in the field will be contacted and interviewed for further information about ongoing or unpublished studies. A narrative synthesis of the findings will be conducted.

DISCUSSION

Outcomes of this study will inform policy makers, national and international programme coordinators, public health and clinical experts, and civil society organisations involved in STI prevention and control in EU/EEA countries and elsewhere. The review will provide a direction for future researchers and programmers seeking to improve STI testing services among key populations at high risk for STIs.

SYSTEMATIC REVIEW REGISTRATION

In accordance with guidelines outlined in the PRISMA-P methodology, this protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 30 January 2019: CRD42019118261.

Outcomes of Resistance-guided Sequential Treatment of Mycoplasma genitalium Infections: A Prospective Evaluation

Background

Rising macrolide and quinolone resistance in Mycoplasma genitalium necessitate new treatment approaches. We evaluated outcomes of sequential antimicrobial therapy for M. genitalium guided by a macrolide-resistance assay.

Methods

In mid-2016, Melbourne Sexual Health Centre switched from azithromycin to doxycycline (100 mg twice daily for 7 days) for nongonococcal urethritis, cervicitis, and proctitis. Cases were tested for M. genitalium and macrolide-resistance mutations (MRMs) by polymerase chain reaction. Directly after doxycycline, MRM-negative infections received 2.5 g azithromycin (1 g, then 500 mg daily for 3 days), and MRM-positive infections received sitafloxacin (100 mg twice daily for 7 days). Assessment of test of cure and reinfection risk occurred 14-90 days after the second antibiotic.

Results

Of 244 evaluable M. genitalium infections (52 women, 68 heterosexual men, 124 men who have sex with men) diagnosed from 20 June 2016 to 15 May 2017, MRMs were detected in 167 (68.4% [95% confidence interval {CI}, 62.2%-74.2%]). Treatment with doxycycline decreased bacterial load by a mean 2.60 log10 (n = 56; P < .0001). Microbiologic cure occurred in 73 of 77 MRM-negative infections (94.8% [95% CI, 87.2%-98.6%]) and in 154 of 167 MRM-positive infections (92.2% [95% CI, 87.1%-95.8%]). Selection of macrolide resistance occurred in only 2 of 76 (2.6% [95% CI, .3%-9.2%]) macrolide-susceptible infections.

Conclusions

In the context of high levels of antimicrobial resistance, switching from azithromycin to doxycycline for presumptive treatment of M. genitalium, followed by resistance-guided therapy, cured ≥92% of infections, with infrequent selection of macrolide resistance.

Implementing Mycoplasma genitalium testing across a London-based sexual health service: A quality improvement project

Recent national guidelines recommended testing for Mycoplasma genitalium (MG) in clinically-indicated conditions (CIC) including non-gonococcal urethritis (NGU), pelvic inflammatory disease (PID) and epididymo-orchitis. Over five months in 2018 a quality improvement project (QIP) was carried out across three London sexual health clinics with the aim of increasing MG testing rates in CICs. Three Plan-Do-Study-Act (PDSA) cycles were completed: improving IT access, an education event and reminder emails for clinicians who did not test in CIC. To measure testing rates ten patients from each CIC were randomly selected each week and MG testing outcomes were collected. As a balancing measure, we identified the rate of inappropriate MG testing. MG testing rates in patients with NGU increased to 90% following QIP initiation (baseline rate 60%) and this increase was sustained. No increase in MG testing was seen in PID and epididymo-orchitis. Inappropriate MG test rates were high (median of 11%) but remained constant throughout the QIP period. As MG testing is expanding across the UK, we outline a QIP integrating MG testing into a busy multi-site, sexual health service improving testing uptake while not increasing inappropriate testing.

A case of Mycoplasma genitalium possible resistance in a woman

Mycoplasma genitalium (MG) is an increasingly recognized sexually transmitted infection. In women, MG is particularly associated with endometritis, cervicitis, pelvic inflammatory disease, HIV, and long-term negative reproductive health and obstetric outcomes. In addition, MG has the potential to show resistance to antibiotics. We present here a case of possibly resistant MG in Lebanon, where MG prevalence and MG antibiotic resistance status are unknown.

The association of Chlamydia trachomatis and Mycoplasma genitalium infection with the vaginal metabolome

Chlamydia trachomatis (CT) and Mycoplasma genitalium (MG) are two highly prevalent bacterial sexually transmitted infections (STIs) with a significant rate of co-infection in some populations. Vaginal metabolites are influenced by resident vaginal microbiota, affect susceptibility to sexually transmitted infections (STIs), and may impact local inflammation and patient symptoms. Examining the vaginal metabolome in the context of CT mono (CT+) and CT/MG co-infection (CT+/MG+) may identify biomarkers for infection or provide new insights into disease etiology and pathogenesis. Yet, the vaginal metabolome in the setting of CT infection is understudied and the composition of the vaginal metabolome in CT/MG co-infected women is unknown. Therefore, in this analysis, we used an untargeted metabolomic approach combined with 16S rRNA gene amplicon sequencing to characterize the vaginal microbiota and metabolomes of CT+, CT+/MG+, and uninfected women. We found that CT+ and CT+/MG+ women had distinct vaginal metabolomic profiles as compared to uninfected women both before and after adjustment for the vaginal microbiota. This study provides important foundational data documenting differences in the vaginal metabolome between CT+, CT+/MG+ and uninfected women. These data may guide future mechanistic studies that seek to provide insight into the pathogenesis of CT and CT/MG infections.

Mycoplasma genitalium Infections With Macrolide and Fluoroquinolone Resistance-Associated Mutations in Heterosexual African American Couples in Alabama

BACKGROUND

Mycoplasma genitalium (MG) is a sexually transmitted pathogen associated with inflammatory syndromes in men and women. Macrolides and fluoroquinolones are recommended MG treatments. The frequency of MG strains with macrolide resistance-associated mutations (MRMs) and quinolone resistance-associated mutations (qRMs) is increasing worldwide, however these data are sparse in populations in the United States.

METHODS

We investigated the prevalence of MG infections with MRMs and qRMs and MG infection concordance within African American couples in Birmingham, AL. We used a real-time polymerase chain reaction to detect MG and identify MRMs. quinolone resistance-associated mutations were detected using traditional polymerase chain reactions amplifying regions in gyrA, gyrB, parC, and parE. The MG concordance in couples was evaluated by MG positivity and MG genotypes.

RESULTS

Oral, anal, urine, and/or vaginal specimens were tested from 116 couples. Twenty-eight (12.1%) participants comprising 22 couples tested MG-positive (11.2% in men and 12.9% in women). Macrolide resistance-associated mutations were detected in 17 (60.7%) MG-positive participants, with gender-specific resistance rates of 69.2% for men and 53.3% for women. quinolone resistance-associated mutations were detected in 3 (11.1%) MG-positive participants, all of whom also had MRMs. By MG positivity status, 27.3% of couples were concordant. If MG strain genotypes are also considered, then concordance was 20.0%.

CONCLUSIONS

Among heterosexual African Americans with MG infection, about 60% had strains with MRMs and 11% had strains with both MRMs and qRMs, highlighting the potential for MG treatment failure to not only macrolides, but also quinolones. These findings may help to guide clinicians in MG testing and treatment decisions in the United States.

Evaluation of the ResistancePlus MG FleXible Assay for Detection of Wild-Type and 23S rRNA-Mutated Mycoplasma genitalium Strains

Antibiotic resistance in Mycoplasma genitalium is rising globally, and resistance-guided diagnostics can facilitate targeted and timely treatment. The ResistancePlus MG FleXible (RPMG Flex) assay for the detection of M. genitalium and macrolide resistance-mediating mutations (MRMM) was evaluated for analytical sensitivity, specificity, reproducibility, and inhibition in the presence of interfering substances by simulating M. genitalium-negative pooled urine and swab matrices with M. genitalium cultures. Furthermore, the clinical sensitivity of the assay was evaluated and compared with a reference real-time PCR assay. The analytical sensitivity of the RPMG Flex assay was 157 genomes/ml for wild-type (WT) and 387 genomes/ml for MRMM strains in both matrices. For clinical specimens, the RPMG assay had an overall sensitivity of 96.1% (95% urine: 10/10 WT, 9/10 MRMM; 96.5% swab: 25/26 WT, 26/29 MRMM) compared to 85.7% for the MgPa/MagNAPure24 assay (95% urine: 19/20; 87% swab: 48/57). Clinical specificity was 100% for urine and 98.5% for swab specimens, respectively. No inhibition due to the presence of any of the tested interfering substances was observed. The RPMG Flex assay was more sensitive than the reference MgPa assay, in particular, for swab specimens. The implementation of this assay may increase ease of use and considerably decrease hands-on time for sample preparation compared to a standard block-based assay. The RPMG Flex assay for the GeneXpert Dx system provides a much-needed platform for the simultaneous detection of MG and MRMM and may thereby facilitate resistance-guided therapy for M. genitalium infections.

Bacterial sexually transmitted infections

Worldwide, the incidence of bacterial sexually transmitted infections (STIs) has shown a significant increase in recent years. In Germany, this circumstance is reflected by a rise in the number of reported syphilis cases. There has also been an uptick in the incidence of non-notifiable STIs such as gonorrhea and infections caused by Chlamydia trachomatis and Mycoplasma genitalium. A key factor in the spread of these infections is their varied clinical presentation, which includes urogenital, pharyngeal and rectal involvement as well as a large number of asymptomatic cases. New real-time multiplex PCR methods allow for rapid and targeted detection of STI pathogens. The most common bacterial STI is urogenital chlamydial infection caused by serovars D-K, which affects young adults in particular. Lymphogranuloma venereum (LGV) caused by L serovars often presents as chlamydial proctitis. In recent years, Neisseria (N.) gonorrhoeae has shown a significant development of resistance, with high-level monoresistance and multiresistance to antibiotics commonly used for treatment. It is therefore imperative that sensitivity testing of N. gonorrhoeae be performed in addition to nucleic acid amplification tests (NAATs). Increased drug resistance has also been observed for Mycoplasma genitalium, a fact that complicates treatment.

Mycoplasma genitalium in Symptomatic Male Urethritis: Macrolide Use Is Associated With Increased Resistance

BACKGROUND

Mycoplasma genitalium (MG) causes symptomatic urethritis in men, and can infect alone or together with other sexually transmitted infection (STI) agents.

METHODS

The prevalence of MG and other STIs was determined in 1816 men with symptomatic urethritis. Resistance of MG to macrolides and fluoroquinolones was determined by sequencing; the impact of recent antimicrobial usage on the distribution of MG single or mixed infections was determined.

RESULTS

Overall, prevalence of MG infection was 19.7% (358/1816). Fifty-four percent (166/307) of MG infections occurred alone in the absence of other STI agents. Men with single MG infection self-administered or were prescribed antibiotics more often in the 30 days prior to enrollment than subjects with urethritis caused by MG coinfection (P < .0001). Higher rates (96.7%) of infection with macrolide resistance in MG were identified in men who had taken macrolides prior to enrollment (P < .03). Overall, 88.9% (303/341) of 23S ribosomal RNA (rRNA) genes contained mutations responsible for macrolide resistance; 89.5% (308/344) of parC and 12.4% (42/339) of gyrA genes had mutations responsible for fluoroquinolone resistance. Approximately 88% (270/308) of MG had combined mutations in 23S rRNA and parC genes; 10.4% (32/308) had mutations in all 3 genes.

CONCLUSIONS

MG was the single pathogen identified in 11% of men with symptomatic urethritis. Overall, nearly 90% of MG infections were resistant to macrolides and fluoroquinolones. Men who took macrolides in the 30 days prior to enrollment had higher rates (97%) of macrolide-resistant MG. Resistance was associated with numerous mutations in 23SrRNA, parC, and gyrA genes.

[Recurrent Urogynecological Infections]

Recurrent Urogynecological Infections Abstract. Changes in the urogenital microbiome of the bladder, urethra, vagina and cervix can cause recurrent infections. We distinguish between obligate and facultative pathogens. In the case of facultative pathogens, treatment with antibiotic, antiviral or antifungal drugs should only be considered in cases with attributable symptoms. Sexually transmitted diseases (STD) manifest either urogenitally alone or in association with an ascending infection of the adnexa as a pelvic inflammatory disease. STD may be asymptomatic, as in cases of chlamydia, or may cause a high burden of symptoms, impairment of quality of life or infertility. The aim of this minireview is to give an overview of the pathogenicity of the different germs and their treatment.

Prevalence and antibiotic resistance of rectal Mollicutes in HIV-infected men who have sex with men at the University Hospital of Dresden, Germany

BACKGROUND

Rectal sexually transmitted infections (STI) are common in men having sex with men (MSM). Mycoplasma genitalium is increasingly being reported in this localization, but due to frequent lack of symptoms at this site, clinical significance is still unclear. Rectal prevalence of Mycoplasma hominis and Ureaplasma species is not well studied so far. We aimed to investigate the prevalence and antibiotic sensitivity of rectal Mollicutes in our HIV-cohort.

METHODS

In 227 MSM presenting for annual STI-screening, 317 anorectal swabs were collected from January 2017 to December 2018. PCR was performed for detection of Chlamydia trachomatis, Neisseria gonorrhoeae, M. genitalium and also culture for M. hominis and Ureaplasma spec.

RESULTS

Prevalence for M. genitalium, M. hominis, Ureaplasma spec., C. trachomatis and N. gonorrhoeae was 8.2%, 7.3%, 12.0%, 5.1% and 1.9%, respectively. Patients were asymptomatic with few exceptions. Seroprevalence of syphilis in 227 MSM was 41.9%. In 20 strains of M. genitalium, resistance-associated mutations to macrolides and quinolones were found in 60% and 30%, respectively; in five strains (25%) to both. M. hominis and Ureaplasma spec. frequently occurred combined, mostly in significant quantity consistent with infection. M. hominis and Ureaplasma spec. regularly showed sensitivity to tetracycline.

CONCLUSION

At screening, rectal colonization with Mollicutes was common in our patients, but rarely caused symptoms. Due to rising antibiotic resistance of M. genitalium against quinolones, therapeutic options are increasingly limited. Treatment should be guided by antibiotic resistance testing including quinolones. In persisting anorectal symptoms, M. hominis and Ureaplasma spec. should also be taken into account.

Clinical Evaluation of Three Commercial PCR Assays for the Detection of Macrolide Resistance in Mycoplasma genitalium

As macrolide resistance in Mycoplasma genitalium is increasing worldwide, macrolide resistance-associated mutations should be assessed in M. genitalium-positive specimens. New commercial kits are available for detection of macrolide resistance concurrently with M. genitalium We prospectively evaluated the handling and clinical performances of three commercial kits for detection of macrolide resistance in M. genitalium Between August and December 2018, remnants of all urogenital specimens determined to be M. genitalium positive using an in-house real-time PCR assay were prospectively collected at the French National Reference Center for Bacterial Sexually Transmitted Infections, Bordeaux University Hospital, Bordeaux, France. The internal control of each kit was added to the primary specimen before DNA extraction, and the absence of amplification inhibition associated with the addition of the three internal controls was assessed. Specimens were evaluated with four assays: the ResistancePlus MG assay (SpeeDx), the S-DiaMGRes assay (Diagenode), the RealAccurate TVMGres assay (PathoFinder), and amplification and sequencing of the 23S rRNA gene (the reference assay). Overall, 195 M. genitalium-positive specimens were assessed. The positive agreement of M. genitalium detection for each kit ranged between 94.8% and 96.4%. Among 154 specimens with M. genitalium positivity as detected by the three commercial kits and 23S rRNA sequencing data, the clinical sensitivity and specificity ranges of the three commercial kits for detecting macrolide resistance-associated mutations were 95 to 100% and 94.6 to 97.3%, respectively. The sensitivity and specificity values were similar among the kits. The launch of three easy-to-use sensitive and specific commercial kits for simultaneous detection of M. genitalium and macrolide resistance will be useful for resistance-guided therapy.

Time to re-evaluate the guidance on sexual infections in fertility services

Current guidance in the UK for fertility services on the screening for sexually transmitted infections (STI) is solely directed towards Chlamydia trachomatis. Evidence used to formulate the guidance is based on research undertaken before more sensitive diagnostic methods were available and before testing of some organisms was even possible. This commentary outlines current STI trends, evidence available for STI effect on fertility and new diagnostic methods of screening. It aims to demonstrate that UK guidance should be updated and directed towards areas where further research is required.

Prevalence and incidence of Mycoplasma genitalium in a cohort of HIV-infected and HIV-uninfected pregnant women in Cape Town, South Africa

OBJECTIVE

Mycoplasma genitalium (MG) is a sexually transmitted organism associated with cervicitis and pelvic inflammatory disease in women and has been shown to increase the risk of HIV acquisition and transmission. Little is known about the prevalence and incidence of MG in pregnant women. Our study sought to evaluate the prevalence and incidence of MG infection in HIV-infected and HIV-uninfected pregnant women.

METHODS

We conducted a cohort study of 197 women ≥18 years receiving antenatal care in South Africa from November 2017 to February 2019. We over-recruited HIV-infected pregnant women to compare MG by HIV infection status. Self-collected vaginal swabs, performed at the first antenatal visit, third trimester and within 1 week post partum, were tested for MG using the Aptima assay (Hologic, USA). We report on the prevalence and incidence of MG and used multivariable logistic regression to describe correlates of MG and adverse pregnancy and birth outcomes (preterm delivery, miscarriage and vertical HIV transmission), adjusting for maternal age and HIV infection status.

RESULTS

At first antenatal visit, the median age was 29 years (IQR=24-34) and the gestational age was 19 weeks (IQR=14-23); 47% of women enrolled in the study were HIV-infected. MG prevalence was 24% (95% CI 16% to 34%, n=22) in HIV-infected and 12% (95% CI 6.8% to 20%, n=13) in HIV-uninfected pregnant women. MG incidence during pregnancy and early post partum was 4.7 infections per 100 woman-years (95% CI 1.2 to 12.9) or 3.9 per 1000 woman-months (95% CI 1.0 to 10.7). Adjusting for maternal age, HIV-infected women had over three times the odds of being infected with MG (adjusted OR=3.09, 95% CI 1.36 to 7.06).

CONCLUSION

We found a high prevalence and incidence of MG in pregnant women. Younger maternal age and HIV infection were associated with MG infection in pregnancy. Further research into birth outcomes of women infected with MG, including vertical transmission of HIV infection, is needed.

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.

Mycoplasma genitalium prevalence in Welsh sexual health patients: Low antimicrobial resistance markers and no association of symptoms to bacterial load

OBJECTIVES

Mycoplasma genitalium (MG) is a common cause of sexually transmitted infection, however no prevalence data is available for Wales. MG was detected by qPCR (quantitative) as well as two separate SpeeDx commercial assays, and related to clinical symptoms, age, gender and sample type.

METHODS

Cervical swabs, urethral swabs and/or urine were collected from 1000 patients at walk-in sexual health clinics at 3 Welsh health centres from October 2017-October 2018. Extracted DNA was investigated to determine concordance between an in-house quantitative PCR, SpeeDx ResistancePlus® MG and the SpeeDx MG + parC (beta 2) assays; mutations in parC were substantiated by Sanger sequencing.

RESULTS

MG was detected in 17/600 female patients (2.7%) and 13/400 (3.5%) male patients, with a 100% concordance between in-house qPCR and both SpeeDx assays. Macrolide resistance was low (relative to other studies), but more common in males (4/13; 30.8%) than females (2/17; 11.8%) and the only fluoroquinolone resistant sample (3.4% overall) was also macrolide resistant and detected from an MSM. Vaginitis was clinically apparent in 12/17 MG-positive females (2 with additional cervicitis, 1 with additional pelvic inflammatory disease), while 7 MG-positive males were asymptomatic. MG bacterial load did not correlate to clinical symptoms and females (4559 ± 1646/ml) had significantly lower MG load than males (84,714 ± 41,813/ml; p = 0.0429).

CONCLUSIONS

MG prevalence and antibiotic resistance in Welsh sexual health clinics is low. MG bacterial load did not correlate to clinical presentation, men have higher MG load/ml in urine than women, genders have different age bias for MG prevalence and urine and swabs are equivalent for detecting MG.

Molecular Testing for Mycoplasma genitalium in the United States: Results from the AMES Prospective Multicenter Clinical Study

A prospective multicenter clinical study involving subjects from 21 sites across the United States was conducted to validate the performance of a new in vitro diagnostic nucleic acid amplification test (NAAT) for the detection of Mycoplasma genitalium.

A prospective multicenter clinical study involving subjects from 21 sites across the United States was conducted to validate the performance of a new in vitro diagnostic nucleic acid amplification test (NAAT) for the detection of Mycoplasma genitalium. Seven urogenital specimen types (n = 11,556) obtained from 1,778 females, aged 15 to 74 years, and 1,583 males, aged 16 to 82 years, were tested with the Aptima Mycoplasma genitalium assay, an investigational transcription-mediated amplification (TMA) NAAT for the detection of M. genitalium 16S rRNA. Infected status for enrolled subjects was established using results obtained from testing either self-collected vaginal swab or clinician-collected male urethral swab specimens with a composite reference method consisting of three transcription-mediated amplification NAATs targeting unique regions of M. genitalium 16S or 23S rRNA. M. genitalium prevalence was 10.2% in females and 10.6% in males; prevalence was high in both symptomatic and asymptomatic subjects for both sexes. Compared to the subject infected status standard, the investigational test had sensitivity and specificity estimates, respectively, of 98.9% and 98.5% for subject-collected vaginal swabs, 92.0% and 98.0% for clinician-collected vaginal swabs, 81.5% and 98.3% for endocervical swabs, 77.8% and 99.0% for female urine, and 98.2% and 99.6% for male urethral swabs, 88.4% and 97.8% for self-collected penile meatal swabs, and 90.9% and 99.4% for male urine specimens. For all seven specimen types, within-specimen positive and negative agreements between the investigational test and the composite reference standard ranged from 94.2% to 98.3% and from 98.5 to 99.9%, respectively. These results provide clinical efficacy evidence for the first FDA-cleared NAAT for M. genitalium detection in the United States.

Multicenter Clinical Evaluation of a Novel Multiplex Real-Time PCR (qPCR) Assay for Detection of Fluoroquinolone Resistance in Mycoplasma genitalium

Mycoplasma genitalium causes a common sexually transmitted infection with a marked propensity to develop antimicrobial resistance. As few treatment options exist, this poses significant challenges to clinicians. Recent diagnostic advances have resulted in tests that report the simultaneous detection of M. genitalium and any resistance to macrolides, the first-line treatment. This allows for therapy to be tailored to the individual, thereby optimizing treatment outcomes.

Mycoplasma genitalium causes a common sexually transmitted infection with a marked propensity to develop antimicrobial resistance. As few treatment options exist, this poses significant challenges to clinicians. Recent diagnostic advances have resulted in tests that report the simultaneous detection of M. genitalium and any resistance to macrolides, the first-line treatment. This allows for therapy to be tailored to the individual, thereby optimizing treatment outcomes. However, resistance to fluoroquinolones, the second-line treatment, is increasing in M. genitalium. In this study, we describe a new assay, MG+parC (beta), which simultaneously reports the detection of M. genitalium and five parC mutations that have been associated with resistance to fluoroquinolones. These mutations affect the amino acid sequence of ParC at residues S83R (A247C), S83I (G248T), D87N (G259A), D87Y (G259T), and D87H (G259C). The study tested the MG+parC (beta) assay with 202 M. genitalium-positive clinical samples from Australia (n = 141) and Spain (n = 61). Compared to Sanger sequencing, the assay performed with a kappa value of 0.985 (95% confidence interval [CI], 0.955 to 1.000), with a mutation detection sensitivity of 97.6% (95% CI, 87.4 to 99.9), and specificity of 100.0% (95% CI, 97.7 to 100.0). Fluoroquinolone resistance-associated mutations in parC targeted by the assay were more prevalent among the Australian cohort (23.4% [95% CI,16.3 to 31.8]) compared to the Spanish population (8.8% [95% CI, 2.9% to 19.3%]) (P = 0.019). The MG+parC (beta) kit is a simple and reliable method for simultaneous detection of M. genitalium and fluoroquinolone resistance-associated mutations in clinical settings. This novel diagnostic tool may extend the utility of the second line of antimicrobial therapies in M. genitalium infection.

Risk of Pelvic Inflammatory Disease in Relation to Chlamydia and Gonorrhea Testing, Repeat Testing, and Positivity: A Population-Based Cohort Study

Background

There is uncertainty around whether the risks of pelvic inflammatory disease (PID) differ following Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhea) infection. We quantified the risk of PID associated with chlamydia and gonorrhea infection and subsequent repeat infections in a whole-population cohort.

Methods

A cohort of 315123 Western Australian women, born during 1974-1995, was probabilistically linked to chlamydia and gonorrhea testing records and to hospitalizations and emergency department presentations for PID from 2002 to 2013. Time-updated survival analysis was used to investigate the association between chlamydia and gonorrhea testing, and positivity, and risk of PID.

Results

Over 3199135 person-years, 120748 women had pathology test records for both chlamydia and gonorrhea, 10745 chlamydia only, and 653 gonorrhea only. Among those tested, 16778 (12.8%) had ≥1 positive chlamydia test, 3195 (2.6%) ≥1 positive gonorrhea test, and 1874 (1.6%) were positive for both. There were 4819 PID presentations (2222 hospitalizations, 2597 emergency presentations). Adjusting for age, Aboriginality, year of follow-up, health area, and socioeconomic status, compared to women negative for chlamydia and gonorrhea, the relative risk (adjusted incidence rate ratio) of PID was 4.29 (95% confidence interval [CI], 3.66-5.03) in women who were both chlamydia and gonorrhea positive; 4.54 (95% CI, 3.87-5.33) in those only gonorrhea positive; and 1.77 (95% CI, 1.61-1.94) in those only chlamydia positive.

Conclusions

Gonorrhea infection conferred a substantially higher risk than chlamydia of hospitalization or emergency department presentation for PID. The emergence of gonorrhea antimicrobial resistance may have a serious impact on rates of PID and its associated reproductive health sequelae.

Barriers to testing and management of Mycoplasma genitalium infections in primary care

Testing and treatment for Mycoplasma genitalium (MG) infections has recently been facilitated by the increasing availability of molecular tests, but the role of testing in community-based populations is not established. Between 15 May 2017 and 22 November 2017, we tested 561 samples from 547 individuals presenting to primary care in Auckland, New Zealand, requesting investigation for sexually transmitted infections, with concurrent sterile pyuria, using the Aptima MG assay (Hologic, San Diego, CA, USA) in order to establish the prevalence of MG in this group, rates of macrolide resistance and audit primary care’s capacity to manage infections in line with international guidelines. MG was detected in 55 (10%) samples, and co-pathogens were detected in 24 (44%) MG-positive samples. Macrolide resistance mutations were detected in 22/36 (61%) samples subsequently tested using PlexPCR M. genitalium ResistancePlus (Speedx Pvt Ltd., Sydney, Australia). Empiric azithromycin treatment was given to 18 (33%) patients, and test of cure was performed in 15 (27%) patients. Our pilot study demonstrates that sterile pyuria can be a useful marker to direct testing resources in community settings, but highlights important barriers to management of MG in primary care, including clinician knowledge, high prevalence of macrolide resistance and poor completion rates for test of cure.

Parenchymal-sparing versus extended hepatectomy for colorectal liver metastases: A systematic review and meta-analysis

AIMS

To assess the safety and efficacy of parenchymal-sparing hepatectomy (PSH) as a treatment of colorectal liver metastases (CLM).

METHODS

A comprehensive medical literature search was performed. Perioperative and long-term survival outcomes were pooled. Subgroup analysis and meta-regression analysis were performed to identify potential sources of heterogeneity.

RESULTS

A total of 18 studies comprising 7081 CLM patients were eligible for this study. The PSH was performed on 3974 (56.1%) patients. We found that the OS (overall survival; hazard ratio [HR] = 1.01, 95% confidence interval [CI]: 0.94-1.08) and RFS (recurrence-free survival; HR = 1.00, 95% CI: 0.94-1.07) were comparable between non-PSH and PSH group. The perioperative outcomes were better in PSH than in non-PSH group. Non-PSH group was significantly associated with longer operative time (standard mean difference [SMD] = 1.17, 95% CI: 0.33-2.00), increased estimated blood loss (SMD = 1.36, 95% CI: 0.64-2.07), higher intraoperative transfusion rate (risk ratio [RR] = 2.27, 95% CI: 1.60-3.23), and more postoperative complications (RR = 1.39, 95% CI: 1.16-1.66). Meta-regression analyses revealed that no variable influenced the association between surgical types and the survival outcomes.

CONCLUSIONS

This study shows that PSH is associated with better perioperative outcomes without compromising oncological outcomes. Given the increasing incidence of hepatic parenchyma, the PSH treatment offers a greater opportunity of repeat resection for intrahepatic recurrent tumors. It should be considered as an effective surgical approach for CLM.

Prevalence of Mycoplasma genitalium and Azithromycin-resistant Infections Among Remnant Clinical Specimens, Los Angeles

BACKGROUND

Mycoplasma genitalium is an important cause of bacterial sexually transmitted diseases. Diagnosis and susceptibility testing of M. genitalium are limited by the fastidious nature of the organism. Therefore, the prevalence of infection and azithromycin resistance are poorly studied.

METHODS

We conducted an exploratory study on remnant clinical specimens. We collected remnant DNA from consecutive urine samples and clinical swabs (cervical/vaginal, rectal, and pharyngeal) previously tested for Neisseria gonorrhoeae and Chlamydia trachomatis using the Cobas 4800 CT/NG assay (Roche Molecular Systems, Pleasanton, CA) between March-April 2017 from across the University of California, Los Angeles Health System. We then retrospectively tested all specimens with the ResistancePlus MG (550) kit, a molecular assay for the detection of M. genitalium and genetic mutations associated with azithromycin resistance.

RESULTS

Among 500 specimens, the prevalence of M. genitalium was 1.1% (95% confidence interval [CI], 0.04%-3.0%) in urine samples (n = 362), 17.4% (95% CI, 5.7%-39.6%) in rectal swabs (n = 23), and 1.9% (95% CI, 0.3%-7.3%) in cervical/vaginal swabs (n = 106). The prevalence of N. gonorrhoeae was 0.6% in urine samples and 4.3% in rectal swabs, whereas the prevalence of C. trachomatis was 2.2% in urine samples, 4.3% in rectal swabs and 3.8% in cervical/vaginal swabs. Of the 10 M. genitalium positive specimens, 8 (80.0%) had a mutation associated with azithromycin resistance.

CONCLUSIONS

The prevalence of M. genitalium infection in our population varied by anatomic site of infection. Most M. genitalium infections had at least 1 mutation associated with azithromycin resistance.

Clinical Characteristics of Anorectal Mycoplasma genitalium Infection and Microbial Cure in Men Who Have Sex With Men

BACKGROUND

We report clinical characteristics of proctitis caused solely by Mycoplasma genitalium (MG) compared with chlamydia and gonococcus. We determined the proportions cured with first-line (azithromycin) and second-line antimicrobials (moxifloxacin, pristinamycin).

METHODS

A total of 166 patients attending Melbourne Sexual Health Centre from 2012 to 2016 with symptoms of proctitis were tested for MG, Chlamydia trachomatis, and Neisseria gonorrhoeae. Demographic characteristics, sexual behaviors, clinical symptoms, and signs were recorded. Multinomial multivariable logistic regression was used to test for significant differences in symptoms and signs for the pathogens detected.

RESULTS

Seventeen percent of men had MG (95% confidence interval, 12-24), 21% had chlamydia (15-27), and 40% had gonococcal monoinfection (32-48), whereas 22% had MG coinfection (16-29). Relative to men with MG monoinfection, those with chlamydial monoinfection reported more anal pain (adjusted prevalence odds ratio (aPOR), 4.68 [1.41-14.19]), whereas men with gonococcal monoinfection reported more anal pain (aPOR, 6.75 [2.21-20.55]) and tenesmus (aPOR, 15.44 [1.62-146.90]), but less anal itch (aPOR, 0.32 [0.11-0.93]). The microbiological cure for MG using azithromycin was low at 35% (22-50), whereas moxifloxacin subsequently cured 92% (64-100) and pristinamycin cured 79% (54-94) of infections.

CONCLUSIONS

M. genitalium was almost as common as chlamydia in men presenting to a sexual health center with symptoms of proctitis. Men with anorectal MG monoinfection were less likely to have symptoms and signs compared with those with chlamydia or gonococcus monoinfection. Cure for men with symptomatic anorectal MG by azithromycin was low. We suggest routine testing for MG in cases of proctitis, with test of cure after treatment being essential.

Diagnosis of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and Mycoplasma genitalium: an observational study of testing patterns, prevalence and co-infection rates in northern New Zealand

Background This study sought to determine community prevalence, epidemiology and testing patterns for sexually transmissible infections (STI) in northern New Zealand.

METHODS

A total of 2643 samples submitted for STI testing between 26 November 2015 and 7 December 2015 underwent analysis by Aptima Combo 2 (Hologic, San Diego, CA, USA), Trichomonas vaginalis (TV), and Mycoplasma genitalium (MG) assays. Results were analysed by patient demographics.

RESULTS

Four hundred and eleven pathogens were detected from 359 patients, with Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), TV, and MG detected in 178 (6.7%), 19 (0.7%), 80 (3%) and 134 (5.1%) samples respectively. With the exception of TV, STI prevalence was highest in people <25 years of age. Infection was more common in men for NG (odds ratio (OR) 5.05, P<0.001) and CT (OR 2.72, P<0.001). Māori and Pacific ethnicity were associated with increased risk of MG (OR 1.82, P=0.006,) TV (OR 6.1, P<0.001) and CT (OR 3.31, P<0.001) infection, and TV and NG infections were more prevalent as social deprivation increased. A mismatch between testing rates and prevalence of infection was seen, with fewer tests performed for males (OR 0.2, P<0.001) than females and no difference in testing of Māori and Pacific men (3064/100000) compared with men of European background (3181/100000, OR 0.96, P=0.76), despite an increased risk of disease.

CONCLUSIONS

There are disparately low testing rates for STIs in certain high-risk groups in northern New Zealand.

Mycoplasma genitalium, a stealth female reproductive tract

Mycoplasma genitalium was first isolated from the urethral swabs of two symptomatic men with urethritis in 1980. It is a sexually transmitted bacterium associated with a number of urogenital conditions in women like cervicitis, endometritis, pelvic inflammatory disease, infertility, and susceptibility to human immunodeficiency virus (HIV). However, M. genitalium may also act like a stealth pathogen at female reproductive tract, giving no symptoms. Its prevalence varies between different groups, with the average being 0.5-10% in the general population and 20-40% in women with sexually transmitted infections. The recommended treatment of this infection is azithromycin as a single 1-g dose. However, in recent years, macrolide resistance has increased which is significantly lowering the cure rate, being less than 50% in some studies. New treatment regimens need to be investigated due to increasing drug resistance. The discussion and suggestion of an algorithm for management of this infection is the highlight of this paper.

Analysis of Infection Loads in Mycoplasma genitalium Clinical Specimens by Use of a Commercial Diagnostic Test

Mycoplasma genitalium is a common sexually transmitted infection with a propensity to acquire resistance to commonly used antimicrobial therapies. Bacterial load has been linked to patient symptoms and the success of treatment. In this study, we demonstrate methodology to estimate load from routine diagnostic assays using the ResistancePlus MG test (SpeeDx Pty Ltd., Australia). The method gave comparable quantitation to an M. genitalium-specific 16S rRNA quantitative PCR (qPCR; Spearman r = 0.94) for the samples analyzed (n = 499, including urine and swab types as detailed below) and was, therefore, employed to analyze typical load levels for samples in a diagnostic laboratory (total of 1,012 tests). When stratified by sample type, female urine (median, 826 genomes/ml) had the lowest load. This was significantly lower than median loads for all other sample types (male urine [6.91 × 10³ genomes/ml], anal swabs [5.50 × 10³], cervical swabs [8.15 × 10³], endocervical swabs [3.97 × 10³], and vaginal swabs [6.95 × 10³]) (P < 0.0001). There were no significant differences in load estimates between the other sample types. Reproducibility of load estimates conducted on the same samples was high (r > 0.85). In conclusion, this methodology to provide load estimates for M. genitalium can be easily integrated into routine diagnostic laboratory workflow. Given the association between organism load, symptoms, and treatment success, load assessment has future diagnostic potential.

Prevalence of Mycoplasma genitalium and macrolide resistance among asymptomatic people visiting a point of care service for rapid STI screening: a cross-sectional study

Objectives

Although rapid screening and treatment programmes have been recently implemented to tackle STIs, testing Mycoplasma genitalium (MG) among asymptomatic populations is not currently recommended due to the lack of scientific evidence and the emergence of antibiotic resistance. The main objective of this study was to estimate the prevalence of MG and macrolide resistance among asymptomatic people visiting a point of care service for rapid STI screening and to identify risk factors associated with the acquisition of this infection.

Methods

Between October 2017 and January 2018, a total of 890 asymptomatic individuals attending to the STI screening service Drassanes Exprés in Barcelona, Spain, were tested for MG and macrolide resistance using the molecular ResistancePlus MG assay (SpeeDx, Australia). Asymptomatically infected individuals were invited to attend the STI Unit for resistance-guided antimicrobial therapy.

Results

Overall, the prevalence of MG was 7.4% (66/890; 95% CI 5.8% to 9.3%), being higher among men who have sex with men (MSM) (46/489) compared with heterosexual men and women (20/401; p=0.012). Macrolide resistance was found in 32/46 (69.6%; 95% CI 54.2% to 82.3%) MSM, while only 2/20 (10.0%; 95% CI 1.2% to 31.7%) infections among heterosexuals presented macrolide resistance-mediated mutations (p<0.001). MSM behaviour, receptive anal intercourse, HIV positive status, syphilis history and high-risk sexual activity (more than five sexual partners in the last 3 months) were significantly associated with MG infection. Furthermore, the resistance-guided therapy approach was implemented in 36/66 (54.6%) individuals.

Conclusions

The research provides further data regarding the prevalence of MG and macrolide resistance among asymptomatic individuals. It also identifies higher risk subpopulations which might be targets for MG screening. Nevertheless, there is insufficient data to justify MG testing among asymptomatic individuals and current STI guidelines should be followed until evidence shows the cost and effectiveness of screening.

Design and Validation of Transcription-Mediated-Amplification Nucleic Acid Amplification Tests for Mycoplasma genitalium

Mycoplasma genitalium is a sexually transmitted bacterium linked to adverse sexual and reproductive health outcomes in women and men. M. genitalium is difficult to culture, and in the absence of validated amplified molecular methods for diagnosis of infection, there is no reference standard available for use as a comparator for the validation of new M. genitalium diagnostic tests. We evaluated the analytical and clinical performance of three transcription-mediated amplification (TMA) tests for M. genitalium, each targeting unique rRNA sequences, for use as a composite comparator for clinical validation of the Aptima Mycoplasma genitalium (AMG) assay, an in vitro diagnostic (IVD) TMA test that targets 16 s rRNA of M. genitalium Analytical sensitivity, specificity, and strain inclusivity of all four TMA tests were determined using nine laboratory strains of M. genitalium and 56 nontarget bacteria, protozoa, and viruses. Analytical sensitivity of the tests for M. genitalium ranged from 0.017 to 0.040 genome equivalents/ml. None of the nontarget organisms evaluated cross-reacted with any test. A composite comparator reference standard consisting of the 3 alternate (Alt) TMA tests was used to evaluate the clinical performance of the AMG assay by testing residual vaginal swab, female urine, and male urine specimens obtained from 1,400 adult subjects from three U.S. clinical sites. Using this reference standard to establish infected specimen status, the sensitivity, specificity, and overall agreement of the AMG IVD assay were 100%, 99.9%, and 99.9%, respectively. These results demonstrate the utility of molecular composite reference standard methodology for the clinical validation of future IVD tests for this organism.

British Association for Sexual Health and HIV national guideline for the management of infection with Mycoplasma genitalium (2018)

This is the first British Association for Sexual Health and HIV (BASHH) guideline for the diagnosis and management of Mycoplasma genitalium in people aged 16 years and older. The guideline is primarily aimed at level 3 sexually transmitted infection (STI) management services within the UK, although it could also serve as a reference guide for STI services at other levels.

The impact of sample storage on molecular-based detection of Mycoplasma genitalium

AIMS

Mycoplasma genitalium causes a common, sexually transmitted bacterial infection. This study assessed the detection of M. genitalium in stored urine samples to understand the impact of sample storage on M. genitalium detection.

METHODS

Aliquots of M. genitalium-positive urine (n = 20 patients) were stored at either room temperature (22°C) or 4°C, without a preservative. At weekly intervals, samples were tested using the commercial test ResistancePlus MG^® (SpeeDx^® , Australia). We report the analysis at 1 week, an acceptable collection-to-test turnaround time, with further analysis over 5 weeks to illustrate degradation trends.

RESULTS

After storing at 4°C, the proportion of specimens that remained positive for M. genitalium was 100% after 1 week and 95% after 4 weeks. Storage at 22°C led to more rapid decline in detection in the first 4 weeks, with 95% detected after 1 week and 85% at 2 weeks onwards. At 5 weeks, samples stored at both temperatures had an 85% M. genitalium detection rate, with increase in crossing points (Cq) of 0·72 (95% confidence interval (CI) 0·01-1·43; P-trend = 0·027) at 4°C, and 1·75 ((95% CI 0·79-2·71), P-trend <0·001) at 22°C.

CONCLUSIONS

Urine samples stored without preservative, and unfrozen, retained high M. genitalium detection levels over the short term (up to 5 weeks). To minimize degradation, storing at 4°C is recommended.

SIGNIFICANCE AND IMPACT OF THE STUDY

There is little known about the stability of clinical samples for M. genitalium detection. This study found that a high proportion (85-100%) of samples are still suitable for M. genitalium detection after storage for up to 5 weeks.

Liver hanging maneuver versus conventional approach for open hepatectomy: a meta-analysis

BACKGROUND

This study aimed to compare the safety and efficacy of the liver hanging maneuver (LHM) versus conventional approach for open hepatectomy.

METHODS

A comprehensive medical literature search was performed. Perioperative outcomes and long-term survival outcomes were reported. Subgroup analyses were conducted according to surgical approaches, modification of LHM, geographical region and indications for liver resection.

RESULTS

A total of 16 studies including 1109 patients were enrolled. The LHM was performed on 471 (37%) patients. The pooled outcomes showed hepatectomy with the LHM was associated with less estimated blood loss [standard mean difference (SMD): -0.77, P < 0.001], lower intraoperative transfusion rate [odds ratio (OR): 0.28, P = 0.003], less transection time (SMD: -0.68, P = 0.01), shorter duration of hospitalization (SMD:-0.19, P = 0.004), lower total complication rate (OR: 0.63, P = 0.008) and longer overall survival [hazard ration (HR): 0.70, P = 0.002] compared to conventional open hepatectomy. Subgroup analyses showed similar outcomes to overall analyses.

CONCLUSIONS

The present meta-analysis suggested that the LHM was a safe and feasible alternative to conventional open hepatectomy with better perioperative and long-term outcomes. It was unnecessary to combine the LHM with anterior approach (AA) in consideration of perioperative outcomes.

In vitro activity of zoliflodacin (ETX0914) against macrolide-resistant, fluoroquinolone-resistant and antimicrobial-susceptible Mycoplasma genitalium strains

Background

Mycoplasma genitalium is estimated to be the second most common cause of bacterial sexually transmitted infection in Europe. It is of increasing public health concern due to the rapid development of resistance to different antimicrobial classes, including the preferred first- and second-line treatments azithromycin and moxifloxacin. Thus, new antimicrobial agents are urgently needed, especially for the treatment of MDR strains.

Methods

The in vitro activity of the new spiropyrimidinetrione zoliflodacin against 47 M. genitalium strains was assessed by growing M. genitalium in Vero cell culture and measuring growth by quantitative PCR. The collection included 34 moxifloxacin-susceptible (MIC <1 mg/L) and 13 moxifloxacin-resistant (MIC ≥1 mg/L) strains. Twenty-three of the strains were azithromycin resistant (MIC ≥16 mg/L) and 12 of these strains were MDR.

Results

Only one (2.1%) strain with substantially increased MIC (4 mg/L) and potential resistance to zoliflodacin was found. Zoliflodacin was overall more potent than moxifloxacin (P = 0.009) and no cross-resistance was observed between the two drug classes of topoisomerase II inhibitors. Differences in the MICs of zoliflodacin and azithromycin were not statistically significant; however, 23 (48.9%) compared with potentially 1 (2.1%) of the strains were resistant to azithromycin and zoliflodacin, respectively.

Conclusions

Zoliflodacin is a promising candidate for the treatment of M. genitalium and it is important to further develop and evaluate this drug.

Prevalence of macrolide- and fluoroquinolone-resistant Mycoplasma genitalium strains in clinical specimens from men who have sex with men of two sexually transmitted infection practices in Berlin, Germany

OBJECTIVES

The cell-wall-less Mollicutes species Mycoplasma genitalium is a sexually transmitted micro-organism that causes different male and female genital tract infections. In recent years, resistance of the pathogen to macrolides and fluoroquinolones has been increasingly reported worldwide and is more frequent in risk groups.

METHODS

To determine the rates of antimicrobial resistance, M. genitalium strains in 195 specimens from 154 outpatients (154 first and 41 follow-up samples) treated in two specialised practices between September 2017 and December 2018 in Berlin, Germany, were analysed.

RESULTS

The included patients were predominantly men who have sex with men (MSM) (91.6%) and were HIV-positive in many cases (49.4%). Only 27.3% of M. genitalium-positive patients reported symptoms. Among the first samples (mainly rectal swabs) (57.8%), mutations associated with macrolide (23S rRNA) and quinolone (parC gene) resistance were detected in 79.9% and 13.0% of strains, respectively. Resistance to both classes of antibiotics was found in 11.7% of specimens. Changes of A→G at position 2072 of 23S rRNA and of serine at position 83 of ParC were the most frequent alterations.

CONCLUSION

Although azithromycin is recommended as a first-line antibiotic to treat infections with M. genitalium in MSM, according to these data its use must be highly limited in Berlin. Besides the need for resistance studies regarding strains circulating in other locations and among different patient groups in Germany, the results emphasise the importance of intensified antibiotic resistance testing of M. genitalium to avoid a further increase in treatment failures in infections with this emerging human pathogen.

Long Duration of Asymptomatic Mycoplasma genitalium Infection After Syndromic Treatment for Nongonococcal Urethritis

BACKGROUND

Although Mycoplasma genitalium (MG) is an acknowledged cause of nongonococcal urethritis (NGU), access to diagnostic testing is limited. Syndromic management is common, yet little is known about natural history.

METHODS

Between August 2014 and April 2016, 13 heterosexual men aged ≥16 years with MG were identified within a cohort study of men with and without NGU attending an urban sexually transmitted diseases clinic. Men had 6-7 monthly visits. NGU was defined as ≥5 polymorphonuclear leukocytes per high-power field on urethral Gram stain plus either visible urethral discharge or urethral symptoms. Men with NGU received 1 g of azithromycin. Men with persistent NGU received moxifloxacin 400 mg for 14 days. First-void urine was retrospectively tested for MG using transcription-mediated amplification. Resistance-associated mutations were detected by polymerase chain reaction (PCR) and sequencing. Organism load was determined by quantitative PCR.

RESULTS

Sixty-two percent of MG-positive men had macrolide resistance-mediating mutations (MRMM) at enrollment; 31% had parC mutations (all outside the quinolone resistance-determining region). MG persisted after azithromycin in 7 men, 6 of whom had MRMM. The median duration of persistence in the absence of curative therapy was 143 days (range, 21-228). Five men experienced symptom resolution after azithromycin, but MG persisted for another 89-186 days before moxifloxacin. Organism load was somewhat lower in MRMM than wild-type infections (P = .16).

CONCLUSIONS

The high prevalence of macrolide resistance and long duration of infection after symptom resolution highlights the need for diagnostic MG testing of men with NGU to direct therapy.

Mycoplasma genitalium incidence, treatment failure, and resistance: a retrospective survey of men of infertile couples from a hospital in China

BACKGROUND

Mycoplasma genitalium infection is significantly associated with an increased risk of male infertility. To date, few large M. genitalium studies have been conducted in China.

OBJECTIVE

This study aimed to estimate the M. genitalium incidence and treatment failure and to provide information regarding the resistance of M. genitalium to macrolide and tetracycline antibiotics among men of infertile couples in China.

MATERIALS AND METHODS

This study was performed as a retrospective survey of seminal and meatus urinarius secreta specimens of 30,094 men of infertile couples collected and used for microbiological tests for the evaluation of genital tract infections (Mycoplasma genitalium, Chlamydia trachomatis, and Neisseria gonorrhoeae) between October 2016 and December 2017. Mycoplasma genitalium RNA was detected using novel simultaneous amplification testing. Macrolide and tetracycline resistance screening was introduced using polymerase chain reaction (PCR) and Sanger sequencing.

RESULTS

The incidence of M. genitalium was 2.49% (749 of 30,094; 95% confidence interval (CI), 2.31-2.66%). After antibiotic treatment, the mean values of semen parameters increased from those measured before treatment. The overall incidence of treatment failure was 17.56% (82/467; 95% CI, 14.10%-21.02%) (112-26-4 = 82), irrespective of the drug used. Resistance to macrolide and tetracycline antibiotics was detected in 58 samples (58/60, 96.67%; 95% CI, 91.99-101.34%) and 27 samples (27/60, 45.00%; 95% CI, 32.04-57.96%), respectively.

CONCLUSIONS

Although the M. genitalium incidence was relatively low, the detection of macrolide antibiotic resistance in >96.67% of the treatment failure samples most likely explained the high azithromycin treatment failure rate (73/195, 37.44%) in our study. These findings indicate the need to provide resistance testing and to reappraise the recommended antimicrobial options in China.

Alternate Nucleic Acid Targets Can Be Used To Create a Composite Standard To Evaluate Clinical Performance of Nucleic Acid Amplification Tests

Evaluating the clinical performance of a new nucleic acid amplification test (NAAT) for Mycoplasma genitalium, B. Kirkconnell, B. Weinbaum, K. Santos, T. Le Nguyen, et al. (J Clin Microbiol 57:e00264-19, 2019, https://doi.org/10.1128/JCM.00264-19) created 3 alternate NAATs that detected other unique M. genitalium gene targets. Lacking a reference standard, they used the consensus of results with those 3 NAATs as the comparator. This approach could be a new paradigm to evaluate new NAATs when there is no previously defined reference standard.

Prospective Evaluation of Cervicovaginal Self- and Cervical Physician Collection for the Detection of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium Infections

BACKGROUND

This study aimed to examine the agreement between sexually transmitted infection (STI) screening using self-collected specimens and physician-collected specimens, and to investigate the acceptability of self-collection for screening in an 18-month study of female sex workers in a high-risk, low-resource setting.

METHODS

A total of 350 female sex workers in Nairobi, Kenya, participated in a prospective study from 2009 to 2011. Women self-collected a cervicovaginal specimen. Next, a physician conducted a pelvic examination to obtain a cervical specimen. Physician- and self-collected specimens were tested for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium (MG) using Aptima nucleic acid amplification assays (Hologic). Specimens were collected at 3-month intervals over 18-month follow-up. κ Statistics measured agreement of positivity between self-collection and physician collection.

RESULTS

Baseline STI prevalence was 2.9% for N. gonorrhoeae, 5.2% for C. trachomatis, 9.2% for T. vaginalis, and 20.1% for MG in self-collected samples, and 2.3%, 3.7%, 7.2%, and 12.9%, respectively, in physician-collected samples. κ Agreement was consistently strong (range, 0.66-1.00) for all STIs over the 18-month study period, except for MG, which had moderate agreement (range, 0.50-0.75). Most participants found self-collection easy (94%) and comfortable (89%) at baseline, with responses becoming modestly more favorable over time.

CONCLUSIONS

Self-collected specimen screening results showed strong agreement to clinical-collected specimens, except for MG, which was consistently detected more commonly in self-collected than in physician-collected specimens. Acceptability of the self-collection procedure was high at baseline and increased modestly over time. In high-risk, low-resource settings, STI screening with self-collected specimens provides a reliable and acceptable alternative to screening with physician-collected specimens.

Trichomonas vaginalis and Mycoplasma infections among women with vaginal discharge at Fann teaching hospital in Senegal

Background:

Trichomonas vaginalis and genital Mycoplasmas are two synergistic pathogens, but in many settings, limited data on the co-infection by Trichomonas and Mycoplasma are available.

Objective:

This study aimed at assessing Mycoplasma prevalence and its association with Trichomonas vaginalis among women with vaginal discharge.

Materials and Methods:

A retrospective analysis of laboratory records (2012 and 2013) from patients referred at the Fann teaching hospital in Dakar Senegal for vaginal discharge was carried out. Detection of genital mycoplasmas was based on the commercial Kit Mycoplasma Duo Bio-Rad™ using endo-cervical swabs. Vaginal swabs were collected and examined using optic microscopy with 40x magnification to detect T. vaginalis.

Results:

Overall, data from 1257 women were analysed. Prevalence of Mycoplasma hominis represented 57.4%, 95%CI(54.6-60.1), versus 54.9%, 95%CI(52.1-57.5) for Ureaplasma urealyticum. Trichomonas vaginalis infection was observed with a frequency of 3%. Out of the 50 patients with trichomoniasis, 76% of them were co-infected by Mycoplasma hominis and patients with Trichomonas vaginalis had an increased risk of acquiring Mycoplasma infection (adjusted OR:2.5, 95%CI(1.2-5.2);p=0.02)).

Conclusion:

Trichomonas vaginalis and Mycoplasmas are two closely associated pathogens in the urogenital tract of women. This clinically significant symbiotic action may require systematic screening of Mycoplasma among patients with trichomoniasis for optimal management of sexually transmitted infections.

Mycoplasma genitalium incidence, persistence, concordance between partners and progression: systematic review and meta-analysis

Background

Mycoplasma genitalium is increasingly seen as an emerging sexually transmitted pathogen, and has been likened to Chlamydia trachomatis, but its natural history is poorly understood. The objectives of this systematic review were to determine M. genitalium incidence, persistence, concordance between sexual partners and the risk of pelvic inflammatory disease (PID).

Methods

We searched Medline, EMBASE, LILACS, IndMed and African Index Medicus from 1 January 1981 until 17 March 2018. Two independent researchers screened studies for inclusion and extracted data. We examined results in forest plots, assessed heterogeneity and conducted meta-analysis where appropriate. Risk of bias was assessed for all studies.

Results

We screened 4634 records and included 18 studies; six (4201 women) reported on incidence, five (636 women) on persistence, 10 (1346 women and men) on concordance and three (5139 women) on PID. Incidence in women in two very highly developed countries was 1.07 per 100 person-years (95% CI 0.61 to 1.53, I² 0%). Median persistence of M. genitalium was estimated from one to three months in four studies but 15 months in one study. In 10 studies measuring M. genitalium infection status in couples, 39%–50% of male or female sexual partners of infected participants also had M. genitalium detected. In prospective studies, PID incidence was higher in women with M. genitalium than those without (risk ratio 1.73, 95% CI 0.92 to 3.28, I² 0%, two studies).

Discussion

Incidence of M. genitalium in very highly developed countries is similar to that for C. trachomatis, but concordance might be lower. Taken together with other evidence about age distribution and antimicrobial resistance in the two infections, M. genitalium is not the new chlamydia. Synthesised data about prevalence, incidence and persistence of M. genitalium infection are inconsistent. These findings can be used for mathematical modelling to investigate the dynamics of M. genitalium.

Registration numbers

CRD42015020420, CRD42015020405