CDC Sexually Transmitted Infections Treatment Guidelines, 2021

Serofast status in syphilis: Pathogenesis to therapeutics

Syphilis, a sexually transmitted infection caused by Treponema pallidum, has been experiencing a rise in prevalence in recent years. "Syphilis serofast" describes a unique serological reaction in patients with syphilis whose clinical symptoms have resolved following consistent anti-syphilitic therapy, but the non-Treponema pallidum antigen serologic test is still positive. Syphilis serofast is a risk factor for syphilis recurrence, neurosyphilis, and multisystem involvement. Considering the current lack of comprehensive knowledge about the epidemiological characteristics, pathogenesis, and therapies of syphilis serofast, we conducted an online search of research relating to syphilis serofast over the last twenty years. Previous research has shown that the pathogenesis of syphilis serofast is mainly related to clinical factors, immune factors, syphilis subtypes, and T.pallidum membrane protein repeat gene antigen. There are two distinct viewpoints on the treatment of serofast: no excessive treatment and active treatment. In addition, serofast patients also showed two clinical outcomes: syphilis recurrence and persistent serofast status. This article systematically reviews the related factors, treatment, and clinical outcomes of syphilis serofast, provides a theoretical basis for its research, diagnosis, and treatment, and helps clinicians develop a follow-up treatment management plan for syphilis serofast.

Individual and community level factors associated with sexually transmitted infections among men in Tanzania: insights from the Tanzania demographic and health survey of 2022

BACKGROUND

Sexually transmitted infections continue to be a significant public health issue on a global scale. Due to their effects on reproductive and child health as well as their role in facilitating the spread of HIV infection, sexually transmitted infections impose a heavy burden of morbidity and mortality in many developing countries. In addition, stigma, infertility, cancer, and an increased risk of HIV are the primary impacts of STIs on sexual and reproductive health. While numerous studies have been conducted in Tanzania to address this specific topic in various settings, the majority of them weren't representative. Therefore, the main objective of this study was to use data from the most recent Tanzania Demographic and Health Survey in order to evaluate the individual and community-level factors associated with sexually transmitted infections among Tanzanian men at the national level.

METHODS

The most recent datasets from the Tanzania demographic and health survey were used for secondary data analysis. A total of 5763 men participated in this study. The recent Tanzania demographic and health survey provides data for multilevel mixed effect analysis on the variables that contribute to sexually transmitted infections among men in Tanzania. Finally, the percentage and odd ratio were provided, together with their 95% confidence intervals.

RESULT

This study includes a total weighted sample of 5763 men from the Tanzania demographic and health survey. Of the total study participants, 7.5% of men had sexually transmitted infections in the last twelve months. Being married [AOR: 0.531, 95% CI (0.9014, 3.429)] was a factor that reduced the risk of sexually transmitted infections among men. On the other hand, being between the age range of 20 and 24 years [AOR: 6.310, 95% CI (3.514, 11.329)] and having more than one union [AOR: 1.861, 95% CI (1.406, 2.463)] were the factors that increased the risk of sexually transmitted infections among men.

CONCLUSIONS

Men's sexually transmitted infections have been associated with individual-level factors. So, the Tanzanian governments and the concerned stakeholders should provide special attention for men whose age range is 20-24 years old. Promoting marriages and limiting the number of sexual partners should be the main strategies to lower the risk of sexually transmitted infections among men in Tanzania.

Could ceftriaxone be a viable alternative to penicillin for the treatment of ocular syphilis?

This study was conducted to compare the effectiveness of ceftriaxone with that of aqueous crystalline penicillin G in treating ocular syphilis. We conducted a retrospective study from 2010 to 2021. Syphilis patients were administered either ceftriaxone (2 g intravenously daily for 14 days) or aqueous crystalline penicillin G [4 million units (MU) intravenously every 4 h for 14 days] as therapeutic interventions. Subsequently, we utilized these two groups to assess the serological results, cerebrospinal fluid analysis, and visual acuity at time intervals spanning 3 to 6 months post-treatment. A total of 205 patients were included, with 34 assigned to the ceftriaxone group and 171 to the penicillin group. The median age of patients was 56 years, with an interquartile range of 49-62 years, and 137 of them (66.8%) were male. Between 3 and 6 months after treatment, 13 patients (38.2%) in the ceftriaxone group and 82 patients (48.0%) in the penicillin group demonstrated effective treatment based on the clinical and laboratory parameters. The crude odds ratio (OR) was 0.672 (95% confidence interval [CI]: 0.316-1.428, P = 0.301), indicating no significant difference in effectiveness between the two groups. Thirty patients (17.5%) in the penicillin group and six patients (17.6%) in the ceftriaxone group did not experience successful outcomes. Notably, no serious adverse effects were reported in both the groups. There was no significant difference in the effectiveness of ceftriaxone and aqueous crystalline penicillin G in treating ocular syphilis. The administration of ceftriaxone without requiring hospitalization presents a convenient and safe alternative treatment option for ocular syphilis.

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.

Neurosyphilis is characterized by a compartmentalized and robust neuroimmune response but not by neuronal injury

BACKGROUND

Neurosyphilis is increasing in prevalence but its pathophysiology remains incompletely understood. This study assessed for CNS-specific immune responses during neurosyphilis compared to syphilis without neurosyphilis and compared these immune profiles to those observed in other neuroinflammatory diseases.

METHODS

Participants with syphilis were categorized as having neurosyphilis if their cerebrospinal fluid (CSF)-venereal disease research laboratory (VDRL) test was reactive and as having syphilis without neurosyphilis if they had a non-reactive CSF-VDRL test and a white blood cell count <5/μL. Neurosyphilis and syphilis without neurosyphilis participants were matched by rapid plasma reagin titer and HIV status. CSF and plasma were assayed for markers of neuronal injury and glial and immune cell activation. Bulk RNA sequencing was performed on CSF cells, with results stratified by the presence of neurological symptoms.

FINDINGS

CSF neopterin and five CSF chemokines had levels significantly higher in individuals with neurosyphilis compared to those with syphilis without neurosyphilis, but no markers of neuronal injury or astrocyte activation were significantly elevated. The CSF transcriptome in neurosyphilis was characterized by genes involved in microglial activation and lipid metabolism and did not differ in asymptomatic versus symptomatic neurosyphilis cases.

CONCLUSIONS

The CNS immune response observed in neurosyphilis was comparable to other neuroinflammatory diseases and was present in individuals with neurosyphilis regardless of neurological symptoms, yet there was minimal evidence for neuronal or astrocyte injury. These findings support the need for larger studies of the CSF inflammatory response in asymptomatic neurosyphilis.

FUNDING

This work was funded by the National Institutes of Health, grants K23MH118999 (S.F.F.) and R01NS082120 (C.M.M.).

Genotypic study of Chlamydia trachomatis for lymphogranuloma venereum diagnosis in rectal specimens from men who have sex with men: a cost-effectiveness analysis

PURPOSE

The significant proportion of asymptomatic patients and the scarcity of genotypic analysis of lymphogranuloma venereum (LGV), mainly among men who have sex with men (MSM), triggers a high incidence of underdiagnosed patients, highlighting the importance of determining the most appropriate strategy for LGV diagnosis, at both clinical and economical levels.

MATERIALS AND METHODS

We conducted L1-L3 serovar detection by molecular biology in stored Chlamydia trachomatis-positive samples from MSM patients with HIV, another STI or belonging to a Pre-exposure prophylaxis program, to make a cost effectiveness study of four diagnostic strategies with a clinical, molecular, or mixed approach.

RESULTS

A total of 85 exudates were analyzed: 35urethral (31 symptomatic/4 positive) and 50 rectal (22 symptomatic/25 positive), 70/85 belonging to MSM with associated risk factors. The average cost per patient was €77.09 and €159.55 for clinical (Strategy I) and molecular (Strategy IV) strategies respectively. For molecular diagnosis by genotyping of all rectal exudate samples previously positive for CT (Strategy II), the cost was €123.84. For molecular diagnosis by genotyping of rectal and/or urethral exudate samples from all symptomatic patients (proctitis or urethritis) with a previous positive result for CT (Strategy III), the cost was €129.39. The effectiveness ratios were 0.80, 0.95, 0.91, and 1.00 for each strategy respectively. The smallest ICER was €311.67 for Strategy II compared to Strategy I.

CONCLUSIONS

With 30% asymptomatic patients, the most cost-effective strategy was based on genotyping all rectal exudates. With less restrictive selection criteria, thus increasing the number of patients with negative results, the most sensitive strategies tend to be the most cost-effective, but with a high incremental cost-effectiveness ratio.

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.

Preferences for Rectal Sexually Transmitted Infection Sample Collection and Sexual Behaviors Among Adolescent and Young Adult Women Accessing Primary Care Services

BACKGROUND

High prevalence of asymptomatic rectal chlamydia and gonorrhea among women is increasingly recognized. Screening is controversial because of lack of natural history data. Barriers to screening may include reluctance to discuss anal sex and collect rectal samples. This study describes the prevalence of sexual contact exposing adolescent and young adult women to extragenital sexually transmitted infections and acceptability of self-collection and clinician collection of rectal samples, preference for self- versus clinician-collected rectal samples, and preference for home or doctor's office for sample collection.

METHODS

Participants were recruited from a primary care office and completed structured interviews assessing types of sexual contact and attitudes about rectal sampling. Differences were tested using χ2 and 2-sided Fisher exact test.

RESULTS

Of 110 cisgender women (aged 14-22 years) enrolled, the average age was 18.4 years (SD, 1.7 years), 83% reported a history of extragenital contact, 22% reported history of receptive anal intercourse. A majority of participants reported self- and clinician-collected rectal samples to be acceptable (86% and 73%, respectively), with preferences for self-collection (71%) over clinician collection (29%, P < 0.001) and collection at the doctor's office (85%) over home (15%, P < 0.001).

CONCLUSIONS

Adolescent and young adult (AYA) women engage in behaviors that increase the risk of rectal sexually transmitted infection (STI). Self- and clinician-collected rectal samples were acceptable. A majority of AYA women preferred to collect rectal samples in the doctor's office rather than at home. This may reduce adolescents' access to direct-to-consumer STI services. Offering in-clinic, self-collected rectal samples may improve uptake of rectal STI screening in adolescent girls.

Trichoscopic Features of Syphilitic Alopecia and Alopecia Areata: A Comparative Study

Background

Syphilitic alopecia (SA) and alopecia areata (AA) are two distinct conditions that frequently present diagnostic difficulties, especially when differentiating between them due to their similar clinical presentations. Trichoscopy may help in differential diagnosis, but a comparison between trichoscopic features of SA and AA is yet to be researched.

Objective

To compare trichoscopic features between SA and AA and determine their discriminative values.

Methods

Electronic medical records and trichoscopic images of patients diagnosed with SA or AA between January 2000 and February 2022 were retrieved. Trichoscopic features were statistically compared, and their discriminative values were demonstrated as sensitivity, specificity, predictive value, likelihood ratio, and area under the receiver operating characteristic curve (AUC).

Results

A total of 69 patients were included: 23 SA and 46 AA cases were matched with a 1:2 ratio. Black dots, broken hairs, pigtail hairs, exclamation mark hairs, tapered hairs, angulated hairs, and non-pigmented regrowing hairs were significantly more prevalent in AA than in SA (all P<0.05), whereas erythematous background was more prevalent in SA than in AA patients (P=0.008). Among the aforementioned trichoscopic features, exclamation mark hairs and non-pigmented regrowing hairs had a high positive likelihood ratio for AA (16.17 and 8.34, respectively); however, only exclamation mark hairs revealed high AUC (AUC=0.816).

Conclusion

Despite the presence of several similar trichoscopic features between SA and AA, trichoscopy can aid in distinguishing between the two diseases. Exclamation mark hairs are the only trichoscopic feature that can be used to differentiate patients with clinically suspicious SA from those with AA.

There are three major Neisseria gonorrhoeae β-lactamase plasmid variants which are associated with specific lineages and carry distinct TEM alleles

Neisseria gonorrhoeae is a significant threat to global health with an estimated incidence of over 80 million cases each year and high levels of antimicrobial resistance. The gonococcal β-lactamase plasmid, pbla, carries the TEM β-lactamase, which requires only one or two amino acid changes to become an extended-spectrum β-lactamase (ESBL); this would render last resort treatments for gonorrhoea ineffective. Although pbla is not mobile, it can be transferred by the conjugative plasmid, pConj, found in N. gonorrhoeae. Seven variants of pbla have been described previously, but little is known about their frequency or distribution in the gonococcal population. We characterised sequences of pbla variants and devised a typing scheme, Ng_pblaST that allows their identification from whole genome short-read sequences. We implemented Ng_pblaST to assess the distribution of pbla variants in 15 532 gonococcal isolates. This demonstrated that only three pbla variants commonly circulate in gonococci, which together account for >99 % of sequences. The pbla variants carry different TEM alleles and are prevalent in distinct gonococcal lineages. Analysis of 2758 pbla-containing isolates revealed the co-occurrence of pbla with certain pConj types, indicating co-operativity between pbla and pConj variants in the spread of plasmid-mediated AMR in N. gonorrhoeae. Understanding the variation and distribution of pbla is essential for monitoring and predicting the spread of plasmid-mediated β-lactam resistance in N. gonorrhoeae.

In Vitro Antifungal Activity of Azoles and Other Antifungal Agents Against Pathogenic Yeasts from Vulvovaginal Candidiasis in China

BACKGROUND

Vulvovaginal candidiasis (VVC) is a public health issue worldwide. Little is known of the optimal treatment of recurrent VVC (RVVC) has not been established.

OBJECTIVE

Through the in vitro antifungal susceptibility profiling of VVC isolates, we hope to foster significant improvements in the control and treatment of this disease.

METHODS

Candida isolates from VVC patients were collected from 12 hospitals in 10 cities across China. Species were identified by phenotype analysis and DNA sequencing. Species were identified by phenotype analysis and DNA sequencing. Susceptibilities to 11 drugs were determined by Clinical and Laboratory Standards Institute broth microdilution.

RESULTS

543 strains were isolated from those VVC patients enrolled in this study, of which, 15.7% were from RVVC. The most commonly identified species was C. albicans (460, 84.71%), and the most commonly non-albicans Candida spp. (NAC) was C. glabrata (47, 8.66%). NAC also included C. Krusei, Meyerozyma Guillermondii, Meyerozyma Caribbica, C. Tropicalis, C. Parapsilosis, and C. Nivariensis. Most C. albicans isolates were susceptible to caspofungin (99.8%), followed by fluconazole (92%) and voriconazole (82.6%). The proportion of C. albicans strains with wild type (WT) MICs that were susceptible to amphotericin B and caspofungin were 98%, followed by posaconazole at 95%, itraconazole at 86%, fluconazole at 74% and voriconazole at 54%. The fluconazole MICs for C. albicans were lower than those for NAC (P < 0.05), while the itraconazole MICs showing no significant difference (P > 0.05). The susceptible rate of uncomplicated VVC to fluconazole was 92%. The proportion of WT strains to fluconazole in RVVC was much lower than that in other types of VVC (67 vs. 77%, P < 0.05). However, the proportions of WT strains to itraconazole in RVVC was over 85%, which was much higher than that to fluconazole (87 vs. 67%, P < 0.05).

CONCLUSIONS

C. albicans was still the predominant pathogen for VVC in China, while C. glabrata was the main species in NAC. Fluconazole could still be used as an empirical treatment for uncomplicated VVC. However, fluconazole may not be the first choice for the therapy of RVVC. In such cases, itraconazole appears to be the more appropriate treatment. As for VVC caused by NAC, nonfluconazole drugs, such as itraconazole, may be a good choice.

Coexistence of condyloma acuminatum and extramammary Paget's disease on penis and scrotum: A rare case report

RATIONALE

Extramammary Paget's disease (EMPD) is a rare skin cancer that commonly occurs in sites rich in apocrine glands, such as perineum, vulva, axilla, scrotum, and penis. On the other hand, condyloma acuminatum (CA; also referred to as anogenital warts) is a common benign neoplasm caused by human papillomavirus. Few cases of coexistent EMPD and CA have been reported because of the rarity of the condition.

PATIENT CONCERNS AND DIAGNOSIS

A 72-year-old man with a genital mass, which appeared to be composed of multiple papillomatous masses, was referred for surgical resection. The lesion was first noticed 6 months previously and grew rapidly. CO2 ablative laser therapy was performed twice at a primary clinic, but the mass recurred.

INTERVENTION AND OUTCOMES

Excisional biopsy revealed the presence of coexistent EMPD and CA. Additional wide excision was performed, and postoperative biopsy confirmed no residual tumor. Two years after surgery, no recurrence had occurred.

LESSONS

CA can co-occur with several types of skin malignancies, and a skin malignancy coexisting with CA is difficult to diagnose visually. Therefore, even if a skin lesion in the genital region is considered to be CA, we recommend punch biopsy before treatment because it can benefit prognosiss.

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

Background

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

Methods

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

Results

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

Conclusions

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

Epidemiological, Clinical, and Trichoscopic Features of Syphilitic Alopecia: A Retrospective Analysis and Systematic Review

Background

Syphilitic alopecia (SA), which mimics other types of alopecia, is an uncommon manifestation of secondary syphilis. Trichoscopic features may facilitate its diagnosis. However, studies on SA and its trichoscopic characteristics remain limited.

Objective

To investigate the epidemiological, clinical, and trichoscopic findings and laboratory results, treatment, and outcomes of SA in Thai patients as well as to comprehensively summarize all trichoscopic features of SA through a systematic review.

Methods

Data on patients diagnosed with SA between December 2010 and December 2021 were obtained from their medical records and analyzed retrospectively. A systematic review of trichoscopic data, both from our institution and from studies registered in the PubMed, MEDLINE, and Embase databases, was conducted. A descriptive summarization was performed to comprehensively study the trichoscopic features of SA.

Results

Of the 205 patients with secondary syphilis, 23 patients with SA (symptomatic SA: 20, essential SA: 3) were included. The mean age was 27.6 ± 8.8 years, and male predominance was noted. The moth-eaten pattern was the most common SA presentation, and the parieto-occipital scalp was the most commonly affected area. All patients with SA achieved significant hair regrowth within 3 months of antibiotic therapy. Trichoscopic images were available for 20 patients with SA from our institute and were included in the systematic review. Fourteen articles provided information on 21 patients. Overall (N = 41), 26 (63.4%), 8 (19.5%), and 7 (17.1%) patients had moth-eaten alopecia, diffuse alopecia, and mixed alopecia, respectively. The most frequent trichoscopic finding was short regrowing hairs (78%), followed by decreased hair per follicular unit (75.6%), and empty follicles (51.2%). Unique features included flame hairs, bent tapering hairs, reddish-brown background, and brown rings around the perifollicular areas, each described in one case. However, the results were based only on case reports and small case series.

Conclusions

Given the progressively increasing frequency of SA, trichoscopic examination may be valuable when SA is suspected in patients with idiopathic alopecia; however, our findings are quite non-specific. The absence of exclamation mark hairs may help in the diagnosis of SA. Further comparative studies on other types of alopecia are required to determine the most useful diagnostic features.