Asymptomatic and symptomatic urethral gonorrhoea in men who have sex with men attending a sexual health service

A Participatory Approach to Identifying Gaps in and Recommendations for Sexually Transmitted Infection and Preexposure Prophylaxis Clinical Services in Pierce County, Washington

BACKGROUND

Pierce County, Washington, has a high burden of sexually transmitted infections (STIs) relative to Washington State and the United States. We used a participatory approach to identify gaps in STI and preexposure prophylaxis (PrEP) service provision in Pierce County and generate recommendations to address these gaps.

METHODS

In collaboration with the Tacoma-Pierce County Health Department (TPCHD), we conducted 14 key informant interviews with local STI/PrEP providers from varied clinical settings. Using rapid qualitative analysis, we identified key gaps and strengths in service provision. Local, state, and national HIV/STI subject matter experts (SMEs) prioritized the gaps and recommendations to address them via an online survey.

RESULTS

The primary 6 gaps ranked by SMEs (N = 32) in order of importance included the following: (1) inadequate availability of STI and PrEP services, (2) lack of awareness of STI and PrEP services, (3) need for free/low cost STI and PrEP care, (4) need for stronger relationships among providers and TPCHD, (5) reduced accessibility related to geographically distributed population and centralized services, and (6) frequent referrals pose a service barrier. Subject matter experts prioritized recommendations for each gap as follows: (1) create an STI specialty clinic, (2) implement an STI/PrEP service availability outreach campaign, (3) strengthen referral relationships between TPCHD and free/low-cost providers, (4) develop a provider support network, (5) create a mobile STI clinic, and (6) develop an STI specialty clinic.

CONCLUSIONS

Sexually transmitted infection specialty clinics were prioritized by SMEs to improve access to STI and PrEP care in Pierce County, and to serve as a resource for local providers.

The Management of Gonorrhea in the Era of Emerging Antimicrobial Resistance: What Primary Care Clinicians Should Know

Gonorrhea rates continue to rise in the United States and Neisseria gonorrhoeae's propensity to develop resistance to all therapies used for treatment has complicated the management of gonorrhea. Ceftriaxone is the only remaining highly effective recommended regimen for gonococcal treatment and few new anti-gonococcal antimicrobials are being developed. The 2021 CDC STI Treatment Guidelines increased the dose of ceftriaxone to 500 mg (1 g if ≥ 150 kg) for uncomplicated infections. It is recommended that all clinicians should be aware of antimicrobial resistant gonorrhea and be able to appropriately manage any suspected gonorrhea treatment failure case.

Risk factors for sexually transmitted infections among men who have sex with men

BACKGROUND

Sexually transmitted infections (STIs) are a global public health concern and sub-Saharan Africa, has limited data on STIs in the men who have sex with men (MSM) population. Syndromic management has controversies for treating asymptomatic STIs (ASTIs).

AIM

The aim of this study was to describe the risk factors for STIs among MSM.

SETTING

This study was conducted in Tshwane North, Gauteng Province in South Africa.

METHODS

A cross-sectional quantitative design was employed using structured questionnaires, rapid plasma reagent test, from December 2021 to May 2022. Bivariate and multivariate analyses were used for statistical analysis.

RESULTS

A total of 200 MSM with the mean age of 27.6, standard deviations: 6.8 participated, and STIs prevalence was 66%, with 37% concurrent infections. Ureaplasma urealyticum was (24%), Mycoplasma hominis (23%), Chlamydia trachomatis (20%), Treponema pallidum (20%) and Neisseria gonorrhoeae (9%). The risk factors for acquisition of STI include having a new partner in the last month (OR = 1.68; CI: 0.98-3.13).

CONCLUSION

The prevalence of ASTIs is high. Serial and multiple sexual partners are the risk factors.Contribution: This study contributes to the body of knowledge of the burden of STIs among high-risk population.

A Systematic Review of Kissing as a Risk Factor for Oropharyngeal Gonorrhea or Chlamydia

BACKGROUND

Tongue kissing is a poorly studied risk factor for sexually transmitted infections (STIs). We undertook the first systematic review to assess whether kissing is a risk factor for gonorrhea or chlamydia of the oropharynx.

METHODS

Online databases (MEDLINE, EMBASE, CINAHL, Web of Science, Cochrane) and reference lists were searched until September 30, 2022. The eligibility criteria for studies included: any peer-reviewed study design in the English language; gonorrhea or chlamydia diagnosed by nucleic acid amplification test, or an infection self-reported by a patient; tongue kissing or its equivalent measured as an exposure. Studies were appraised using a quality scoring tool and qualitatively synthesized.

RESULTS

Of 8248 studies screened, 6 were eligible for review. All were conducted among men who have sex with men in Australia, including 3 prospective cohort studies, 2 cross-sectional studies, and 1 age-matched case-control study. In summary, all 5 studies examining gonorrhea found an unadjusted association between kissing and oropharyngeal gonorrhea. Two cross-sectional studies found that tongue kissing was an independent risk factor for oropharyngeal gonorrhea after adjusting for other confounders, such as participant demographic characteristics and other sexual practices. In contrast, a single eligible prospective cohort study found no association between kissing and oropharyngeal chlamydia.

CONCLUSIONS

This systematic review summarized the existing evidence that suggests that tongue kissing may be a risk factor for oropharyngeal gonorrhea but not chlamydia. Reinforcing the message that oropharyngeal gonorrhea could be transmitted through kissing may inform the development of novel approaches to prevent and treat gonorrhea.

Sex and Gender Differences in Bacterial Infections

There is a growing awareness of the importance of sex and gender in medicine and research. Women typically have stronger immune responses to self and foreign antigens than men, resulting in sex-based differences in autoimmunity and infectious diseases. In both animals and humans, males are generally more susceptible than females to bacterial infections. At the same time, gender differences in health-seeking behavior, quality of health care, and adherence to treatment recommendations have been reported. This review explores our current understanding of differences between males and females in bacterial diseases. We describe how genetic, immunological, hormonal, and anatomical factors interact to influence sex-based differences in pathophysiology, epidemiology, clinical presentation, disease severity, and prognosis, and how gender roles affect the behavior of patients and providers in the health care system.

Cervicovaginal Microbiota Predicts Neisseria gonorrhoeae Clinical Presentation

Neisseria gonorrhoeae infection of the female lower genital tract can present with a spectrum of phenotypes ranging from asymptomatic carriage to symptomatic cervical inflammation, or cervicitis. The factors that contribute to the development of asymptomatic or symptomatic infections are largely uncharacterized. We conducted a pilot study to assess differences in the cervicovaginal microbial community of patients presenting with symptomatic vs. asymptomatic N. gonorrhoeae infections to a sexually transmitted infections (STI) clinic. DNA was isolated from cervicovaginal swab specimens from women who tested positive for N. gonorrhoeae infection using a clinical diagnostic nucleic acid amplification test. We performed deep sequencing of 16S ribosomal RNA gene amplicons, followed by microbiome analyses with QIIME, and species-specific real-time PCR to assess the composition of microbial communities cohabitating the lower genital tract with the infecting N. gonorrhoeae. Specimens collected from asymptomatic individuals with N. gonorrhoeae infection and no co-infection with Chlamydia trachomatis and/or Trichomonas vaginalis carried Lactobacillus-dominant microbial communities more frequently than symptomatic patients without co-infection. When compared to asymptomatic individuals, symptomatic women had microbial communities characterized by more diverse and heterogenous bacterial taxa, typically associated with bacterial vaginosis (BV) [Prevotella, Sneathia, Mycoplasma hominis, and Bacterial Vaginosis-Associated Bacterium-1 (BVAB1)/"Candidatus Lachnocurva vaginae"]. Both symptomatic and asymptomatic N. gonorrhoeae patients with additional STI co-infection displayed a BV-like microbial community. These findings suggest that Lactobacillus-dominant vaginal microbial community may protect individuals from developing symptoms during lower genital tract infection with N. gonorrhoeae.

Community-Based Prevalence Estimates of Chlamydia trachomatis and Neisseria gonorrhoeae Infections Among Gay, Bisexual, and Other Men Who Have Sex With Men in Montréal, Canada

BACKGROUND

Reported cases of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections are increasing among Canadian men. Estimates of community-based CT/NG prevalence are lacking among gay, bisexual, and other men who have sex with men (GBM).

METHODS

Respondent driven sampling was used to recruit GBM in Montréal, Canada between February 2017 and June 2018. Specimens provided from urogenital, rectal, and pharyngeal sites were analyzed using nucleic acid amplification test to detect CT/NG. Prevalence estimates of CT/NG, overall and by anatomical site were calculated. All estimates are respondent-driven sampling-adjusted.

RESULTS

Among 1177 GBM, the prevalence of rectal, urogenital, pharyngeal and overall were respectively 2.4%, 0.4%, 0.4%, and 2.8% for CT infections, and 3.1%, 0.4%, 3.5%, and 5.6% for NG infections. If testing had been limited to the urogenital site, 80% and 94% of CT and NG infections, respectively, would have been missed.

CONCLUSIONS

This community-based study among GBM shows that the CT prevalence was about half of that observed for NG. A large part of CT/NG infections involves only the extragenital sites, highlighting the need for systematic multisite screening regardless of symptoms. In the mist of the COVID-19 pandemic and the limited CT/NG screening capacity due to test kits shortage, it might be considered to prioritize rectal and pharyngeal CT/NG testing over urogenital testing in asymptomatic GBM.

Impact of Anatomic Site, Specimen Collection Timing, and Patient Symptom Status on Neisseria gonorrhoeae Culture Recovery

BACKGROUND

Neisseria gonorrhoeae culture is required for antimicrobial susceptibility testing, but recovering isolates from clinical specimens is challenging. Although many variables influence culture recovery, studies evaluating the impact of culture specimen collection timing and patient symptom status are limited. This study analyzed urogenital and extragenital culture recovery data from Centers for Disease Control and Prevention's Strengthening the US Response to Resistant Gonorrhea (SURRG) program, a multisite project, which enhances local N. gonorrhoeae culture and antimicrobial susceptibility testing capacity.

METHODS

Eight SURRG jurisdictions collected gonococcal cultures from patients with N. gonorrhoeae-positive nucleic acid amplification test (NAAT) results attending sexually transmitted disease and community clinics. Matched NAAT and culture specimens from the same anatomic site were collected, and culture recovery was assessed. Time between NAAT and culture specimen collection was categorized as same day, 1 to 7 days, 8 to 14 days, or ≥15 days, and patient symptoms were matched to the anatomic site where culture specimens were collected.

RESULTS

From 2018 to 2019, among persons with N. gonorrhoeae-positive NAAT, urethral infections resulted in the highest culture recovery (5927 of 6515 [91.0%]), followed by endocervical (222 of 363 [61.2%]), vaginal (63 of 133 [47.4%]), rectal (1117 of 2805 [39.8%]), and pharyngeal (1019 of 3678 [27.7%]) infections. Culture recovery was highest when specimens were collected on the same day as NAAT specimens and significantly decreased after 7 days. Symptoms were significantly associated with culture recovery at urethral (P = <0.0001) and rectal (P = <0.0001) sites of infection but not endocervical, vaginal, or pharyngeal sites.

CONCLUSIONS

Culture specimen collection timing and patient symptomatic status can impact culture recovery. These findings can guide decisions about culture collection protocols to maximize culture recovery and strengthen detection of antimicrobial-resistant infections.

Gonorrhoea: a systematic review of prevalence reporting globally

BACKGROUND

The World Health Organization (WHO) recommends periodic gonorrhoea prevalence assessments in the general population or proxies thereof (including pregnant women, women attending family planning clinics, military recruits, and men undergoing employment physicals for example) and in population groups at increased risk, including men-who-have-sex-with-men (MSM) and sex workers.

METHOD

We evaluated reported prevalence data, including estimates from proxy general population samples to reflect the WHO recommendations. We describe the outcomes from the general population country-by-country and extend previous reviews to include MSM, sex workers, and extragenital infections.

RESULT AND CONCLUSION

In our systematic search, 2015 titles were reviewed (January 2010-April 2019) and 174 full-text publications were included. National, population-based prevalence data were identified in only four countries (the United States of America, the United Kingdom, Peru, New Caledonia) and local population-based estimates were reported in areas within five countries (China, South Africa, Brazil, Benin, and Malawi). The remaining studies identified only reported test positivity from non-probability, proxy general population samples. Due to the diversity of the reviewed studies, detailed comparison across studies was not possible. In MSM, data were identified from 64 studies in 25 countries. Rectal infection rates were generally higher than urogenital or pharyngeal infection rates, where extragenital testing was conducted. Data on sex workers were identified from 41 studies in 23 countries; rates in female sex workers were high. Current prevalence monitoring was shown to be highly suboptimal worldwide. Serial prevalence monitoring of critical epidemiological variables, and guidelines to optimize prevalence study conduct and reporting beyond antenatal settings are recommended.

Decreases in Reported Sexually Transmitted Infections During the Time of COVID-19 in King County, WA: Decreased Transmission or Screening?

BACKGROUND

In response to the COVID-19 pandemic, Washington State's Stay Home, Stay Healthy (SHSH) order was implemented on March 24, 2020. We hypothesized that pandemic mitigation measures might reduce sexually transmitted infection (STI) screening and/or transmission.

METHODS

We used King County, WA STI surveillance and sexual health clinic (SHC) data from January 1, 2019, to July 31, 2020. We calculated mean weekly case counts for gonorrhea, primary and secondary (P&S) syphilis, male urethral gonorrhea, and early latent (EL) syphilis for 3 periods in 2020: pre-SHSH (January 1-March 23), SHSH (March 24-June 5), and reopening (June 6-July 31). Primary and secondary syphilis and male urethral gonorrhea were used as proxies for sexual behavior, and EL syphilis was used as a proxy for STI screening. We compared SHC visits (2019 vs. 2020) and SHC gonorrhea treatment practices (across 2020 periods).

RESULTS

Compared with January to July 2019, from January to July 2020, reported cases of gonorrhea, male urethral gonorrhea, P&S syphilis, and EL syphilis decreased by 9%, 5%, 16%, and 22%, respectively. Mean weekly case counts of gonorrhea, male urethral gonorrhea, and EL syphilis decreased pre-SHSH to SHSH, but all returned to pre-SHSH levels during reopening. Sexual health clinic visits during SHSH were 55% lower in 2020 than in 2019. In the SHC during SHSH, ceftriaxone treatment of gonorrhea decreased, whereas cefixime/cefpodoxime treatment and gonorrhea treatment with no testing increased.

CONCLUSIONS

Decreases in reported STIs concurrent with COVID-19 SHSH may reflect a true decline in STI transmission. However, the larger decreases in asymptomatic infections indicate that much of the observed decrease was likely due to decreased screening.

Vaccine Candidates for the Control and Prevention of the Sexually Transmitted Disease Gonorrhea

The World Health Organization (WHO) has placed N. gonorrhoeae on the global priority list of antimicrobial resistant pathogens and is urgently seeking the development of new intervention strategies. N. gonorrhoeae causes 86.9 million cases globally per annum. The effects of gonococcal disease are seen predominantly in women and children and especially in the Australian Indigenous community. While economic modelling suggests that this infection alone may directly cost the USA health care system USD 11.0–20.6 billion, indirect costs associated with adverse disease and pregnancy outcomes, disease prevention, and productivity loss, mean that the overall effect of the disease is far greater still. In this review, we summate the current progress towards the development of a gonorrhea vaccine and describe the clinical trials being undertaken in Australia to assess the efficacy of the current formulation of Bexsero^® in controlling disease.

Prevalence of human papillomavirus in young men who have sex with men after the implementation of gender-neutral HPV vaccination: a repeated cross-sectional study

BACKGROUND

Anal infection with high-risk human papillomavirus (HPV) genotypes 16 and 18 and anal cancer are overrepresented in men who have sex with men (MSM). This study investigated HPV prevalence in young MSM before and after the implementation of a school-based quadrivalent HPV (genotypes 6, 11, 16, and 18) vaccination programme for boys in Australia in 2013.

METHODS

In this repeated cross-sectional study, MSM aged 16-20 years were recruited from two successive birth cohorts via sexual health clinics and the community in Melbourne, Australia. The first cohort was before the implementation of gender-neutral vaccination (HYPER1 study, done in 2010-12, NCT01422356), and the second was the post-vaccination cohort (HYPER2 study, done in 2017-18, NCT03000933). Men who self-identified as being same-sex attracted were enrolled, and those recruited via the HYPER2 study had to be resident in Australia since 2013 to ensure eligibility. Study procedures were done in the Melbourne Sexual Health Centre. A clinician-collected anal swab and self-collected penile swab and oral rinse were tested for 28 HPV genotypes, and data on demographics and sexual health practices were collected via questionnaires. Only assessable samples were included in the analyses. We compared anatomical site-specific prevalence of HPV genotypes between cohorts by calculating the prevalence ratio, adjusting for age, circumcision, and sex with women. Herd protection was also assessed, by calculating the adjusted prevalence ratios by vaccination status.

FINDINGS

400 MSM, 200 per cohort, were included in the study. In both cohorts, the median number of lifetime male partners was ten (IQR 5-25). The prevalence of any anal quadrivalent vaccine-preventable HPV genotype was higher in the pre-vaccination cohort (54 [28%] of 193) than in the post-vaccination cohort (14 [7%] of 193; adjusted prevalence ratio [PR] 0·24, 95% CI 0·14-0·42), largely driven by decreases in HPV6, followed by HPV11, 16, and 18. Nevertheless, there was also a significant reduction in anal HPV16 and 18 in the post-vaccination cohort from the pre-vaccination cohort (0·31, 0·14-0·68). The prevalence of any penile quadrivalent vaccine-preventable HPV genotype was also higher in the pre-vaccination cohort (21 [12%] of 177) than in the post-vaccination cohort (11 [6%] of 179; 0·48, 0·24-0·97), driven by decreases in HPV 6 and 11, but not by 16 and 18. The prevalence of any oral quadrivalent vaccine-preventable HPV genotype was higher in the pre-vaccination cohort (seven [4%] of 200) than in the post-vaccination cohort (one [1%] of 199; 0·10, 0·01-0·97); there were no cases of oral HPV6 or 11 detected in HYPER2. Comparing the pre-vaccinated cohort with the 149 confirmed vaccinated men from HYPER2 showed a reduction in any quadrivalent vaccine-preventable HPV genotype for anal (0·09, 0·03-0·25) and penile (0·18, 0·05-0·59) infection but not for oral infection (0·17, 0·03-1·08).

INTERPRETATION

A reduction in anal, penile, and oral quadrivalent vaccine-targeted genotypes occurred in young MSM following the implementation of a school-based gender-neutral HPV vaccination programme. The fall in anal HPV16 and 18 may lead to a reduction in the incidence of anal cancer.

FUNDING

Merck and the Australian Government Department of Health.

The Presence or Absence of Symptoms Among Cases of Urethral Gonorrhoea Occurring in a Cohort of Men Taking Human Immunodeficiency Virus Pre-exposure Prophylaxis in the PrEPX Study

We aimed to estimate how often urethral gonorrhoea is symptomatic among men in the Pre-Exposure Prophylaxis Expanded Victoria study. Eighty-seven percent of 213 cases of urethral gonorrhoea were symptomatic. Ensuring men with urethral gonorrhoea both recognize and present early for treatment is critical to reduce transmission.

HIV, Sexually Transmitted Infections and Sexual Practices Among Male Sex Workers Attending a Sexual Health Clinic in Melbourne, Australia: 2010 to 2018

BACKGROUND

There are limited data on HIV/sexually transmitted infection (STI) positivity and sexual practices among male sex workers (MSWs) both globally and particularly in Australia. This study aimed to explore demographic characteristics, sexual practices, and HIV/STI positivity among MSWs attending a sexual health clinic in Melbourne.

METHODS

We analyzed computerized medical records of all first-visit consultations with men 18 years or older who self-identified as current sex workers and attended the Melbourne Sexual Health Centre (MSHC) between 2010 and 2018. Demographic data, sexual behavior data, and laboratory results for HIV, syphilis, chlamydia, and gonorrhea were collected as part of routine clinical care at Melbourne Sexual Health Centre.

RESULTS

Of the 190 MSWs included in the analysis, the median age was 28 years (interquartile range, 23-30 years), 30.4% (52/171) reported having condomless penile-anal sex with their clients, and 59.6% (102/171) reported having condomless penile-oral sex with their clients since their last STI screening. Most (85.6%) MSWs had noncommercial sex partners, including 56.5% with male partners only, 30.6% with female partners only, and 12.9% with both. Approximately half of MSWs used condoms consistently with noncommercial sex partners (regardless of partner gender). The positivity for incident HIV was 1.7% (95% confidence interval [CI], 0.0%-5.0%), that for syphilis was 6.1% (95% CI, 2.6%-10.5%), that for chlamydia was 9.6% (95% CI, 5.6%-14.9%), and that for gonorrhea was 10.8% (95% CI, 4.4%-20.9%). Male sex workers who exclusively had sex with women had a lower any HIV/STI positivity (0%) compared with MSW who had sex with men (15.7%; P = 0.013).

CONCLUSIONS

Male sex workers fall into 2 groups: those who had male clients and/or noncommercial partners who have a relatively high HIV/STI positivity and those who only had female partners or clients whose HIV/STI positivity is low. Both have a high proportion of condomless sex with clients and noncommercial sex partners. Strategies to increase condom use during sex work are needed.

Culture obtained from urethral swab of asymptomatic men who screen positive for Neisseria gonorrhoeae by urine nucleic acid amplification testing

BACKGROUND

In a previous study of men attending Melbourne Sexual Health Centre who had Neisseria gonorrhoeae detected by urine Aptima Combo 2 (AC2) testing, 11% were asymptomatic. This study aimed to determine whether N. gonorrhoeae can be cultured from asymptomatic men screening positive for N. gonorrhoeae by nucleic acid amplification testing (NAAT) of urine.

METHODS

Between 1 July 2017 and 31 March 2019, all men attending Melbourne Sexual Health Centre were tested for N. gonorrhoeae by AC2 testing of urine whether urethral symptoms were reported or not. NAAT-positive men were recalled and a urethral swab performed for gonococcal culture using modified Thayer-Martin media with determination of minimum inhibitory concentrations (MICs) by agar dilution.

RESULTS

There were 1001 cases (860 individuals) positive for N. gonorrhoeae by urine AC2: 892 (89%) reported urethral symptoms; 109 (11%) did not. Twenty-five asymptomatic cases were excluded because of antibiotic use at or following screening. Of the remaining 84 asymptomatic men, 41 (49%) had a urethral swab performed a median of 5 days after screening. Twenty-one men had urethral discharge at the return visit, 11 of whom reported the discharge at the return visit. Of the 41 men who were swabbed, 31 (76%; 95% CI 60% to 88%) were culture positive for N. gonorrhoeae. Among the 21 men who subsequently developed discharge, 19 (90%; 95% CI 70% to 99%) were culture positive. Among the 20 men who remained asymptomatic, 12 (60%; 95% CI 36% to 81%) were culture positive. MIC profiles were obtained from all isolates.

CONCLUSIONS

Gonorrhoea was isolated in most but not all asymptomatic men screening positive for N. gonorrhoeae by urine NAAT. Clinicians should consider performing urethral culture in such men to ensure optimal surveillance for antimicrobial resistance. Isolation of N. gonorrhoeae by culture in men without discharge indicates these are true infections with viable organisms.

Clinical profile and co-infections of urethritis in males

BACKGROUND

Infectious urethritis are classified in N. gonorrhoeae (NG) urethritis and non-gonococcal urethritis, caused commonly by C. trachomatis (CT) or M. genitalium (MG) in Western Europe. The primary objective of the study is to evaluate the association between the clinical profile and the pathogens. Secondly, to assess the prevalence of co-infections.

METHODS

The clinical profile of urethritis in men caused by NG, CT and MG confirmed by nucleic acid amplification test (NAAT) on first void urine has been retrospectively collected. The clinical profiles comprised the assessment of dysuria and/or discharge and the clinical-dermoscopic examination of the genitalia. Serological tests for syphilis and HIV were also performed.

RESULTS

A total of 101 episodes of NAAT confirmed NG, CT or MG urethritis were identified. The prevalence for each pathogen was 50.60%, 33.73% and 15.66%, respectively. Co-infections were observed in few cases (four MG+CT, one NG+CT, one NG+MG), with M. hominis, U. urealitycum and U. parvum positivity found concomitantly in 7-8% cases. The median age of patients was 33 years. Dysuria was reported in 88% cases (95% NG, 79% CT, 78% MG urethritis). Urethral discharge was found in 86% of cases, including purulent discharge in 61% (98% NG, 70% MG) and transparent in 25% (64% CT). Dysuria and purulent discharge were observed in 95% NG, 54% MG and 29% CT cases, whereas dysuria and transparent discharge were observed in 50% CT, 23% MG and in none of NG cases (P<0.01). Balanitis/meatitis was observed in 24% of cases, genital warts in 12% and proctalgia in 4%.

CONCLUSIONS

NAAT is crucial for defining urethritis etiology. Dysuria is the most common symptom. Gonococcal urethritis present with purulent discharge, whereas transparent discharge is associated with non-gonococcal pathogens. Co-infections are rare. Clinical exam may detect other infectious diseases, in particular genital warts.

Optimizing Strategies for Chlamydia trachomatis and Neisseria gonorrhoeae Screening in Men Who Have Sex With Men: A Modeling Study

BACKGROUND

International guidelines recommend the systematic screening for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) infections in all men who have sex with men (MSM) who have engaged in unprotected sex. However, the optimal screening strategy remains unclear. We developed a modeling approach to optimize NG/CT screening strategy in MSM.

METHODS

A compartmental model of NG/CT screening and infection was implemented. NG/CT anal, pharyngeal, and urine (APU) samples from MSM attending the sexually transmitted infections clinic were used to estimate the screening rate, prevalence, and incidence in a base case scenario. Different screening strategies (scenarios; S) were then evaluated: APU samples every 12 months (S1); APU samples every 3 months (S2); APU samples every 6 months (S3); anal and pharyngeal (AP) samples every 6 months (S4); and AP samples every 3 months (S5).

RESULTS

We analyzed 2973 triplet APU samples from 1255 patients. We observed 485 NG and 379 CT diagnoses. NG/CT prevalence and incidence estimates were 12.0/11.1% and 40/29 per 100 person-years, respectively, in the base case scenario. As compared to S2, the reference strategy, the proportions of missed NG/CT diagnoses were 42.0/41.2% with S1, 21.8/22.5% with S3, 25.6/28.3% with S4, and 6.3/10.5% with S5, respectively. As compared to S2, S1 reduced the cost of the analysis by 74%, S3 by 50%, S4 by 66%, and S5 by 33%. The numbers needed to screen for catching up the missed NG/CT diagnoses were 49/67 with S1, 62/82 with S3, 71/87 with S4, and 143/118 with S5.

CONCLUSIONS

S5 appears to be the best strategy, missing only 6.3/10.5% of NG/CT diagnoses, for a cost reduction of 33%.

Trends and differences in sexual practices and sexually transmitted infections in men who have sex with men only (MSMO) and men who have sex with men and women (MSMW): a repeated cross-sectional study in Melbourne, Australia

OBJECTIVES

In the 2010s, there has been an increase in sexually transmitted infections (STI) in men who have sex with men (MSM) in Australia, and since 2015 also in urban heterosexuals. Men who have sex with both men and women (MSMW) have characteristics that may differ from both men who have sex with men only (MSMO) and heterosexual men. We aimed to compare the sexual practices and the trends in HIV/STI positivity between MSMO and MSMW.

DESIGN

Repeated cross-sectional study.

SETTING

A sexual health centre in Melbourne, Australia.

PARTICIPANTS

MSM aged 18 years and above who attended the Melbourne Sexual Health Centre for the first time between 2011 and 2018. This includes 12 795 MSMO and 1979 MSMW.

PRIMARY OUTCOME MEASURES

Demographic characterics, sexual practices and HIV/STI positivity.

RESULTS

Compared with MSMW, MSMO were more likely to practice anal sex and to have condomless receptive anal sex with casual male partners, and less likely to have a current regular relationship. Over the 8-year period, there was an increase in condomless receptive anal sex with casual male partners for both groups (MSMO: from 46.2% to 63.3%, ptrend <0.001; MSMW: from 41.3% to 57.9%, ptrend=0.011). Syphilis positivity increased in MSMO (from 5.5% to 7.9%, ptrend=0.012) and MSMW (from 0.9% to 6.4%, ptrend=0.004) and HIV remained stable. Gonorrhoea increased among MSMO from 2011 to 2014 (from 6.7% to 9.6%, ptrend=0.002), and remained stable from 2015 to 2018. MSMO had higher odds of testing positive for gonorrhoea (adjusted OR (aOR) 1.36, 95% CI 1.13 to 1.64), chlamydia (aOR 1.39, 95% CI 1.16 to 1.67), syphilis (aOR 1.74, 95% CI 1.37 to 2.22) and HIV (aOR 4.60, 95% CI 2.43 to 8.70) than MSMW.

CONCLUSIONS

MSMW have overall lower condomless sex and lower HIV/STI positivity. In the last years, changes in sexual practices in MSM have affected both MSMW and MSMO leading to an increased STI risk.

Risk factors for urethral gonorrhoea infection among heterosexual males in Melbourne, Australia: 2007-17

Background Since 2014 there has been an increase in gonorrhoea among heterosexuals in Australia. Sex with a partner from a country with high gonorrhoea prevalence has been identified as a risk factor for gonorrhoea in heterosexual females, but risk factors for heterosexual males remain unclear. This study determined risk factors for gonorrhoea among heterosexual males.

METHODS

Retrospective analysis was performed among heterosexual males attending Melbourne Sexual Health Centre (MSHC) between 1 January 2007 and 31 December 2017. Countries for overseas sexual partners were stratified as high-prevalence countries (HPC) or low-prevalence countries (LPC) based on the incidence of gonorrhoea.

RESULTS

The annual gonorrhoea positivity increased from 0.72% in 2007 to 1.33% in 2017 (Ptrend <0.001). Males attending MSHC as a contact of gonorrhoea had the highest odds of testing positive (adjusted odds ratio (aOR) 7.46; 95% confidence interval (CI) 4.46-12.49), followed by males identifying as Aboriginal and Torres Strait Islander (aOR 2.57; 95% CI 1.30-5.09), males who had injected drugs in the past 12 months (aOR 2.44; 95% CI 1.39-4.30) and males who had sex with a female from an HPC (aOR 2.18; 95% CI 1.77-2.68). Males aged ≥35 were at higher risk than those aged ≤24 years (aOR 1.44; 95% CI 1.14-1.82). Gonorrhoea positivity increased among males who had sex with females from an LPC (from 0.60% to 1.33%; Ptrend = 0.004) but remained the same over time among males who had sex with females from an HPC (2.14%; Ptrend = 0.143).

CONCLUSIONS

There was an 80% increase in urethral gonorrhoea among heterosexual males between 2007 and 2017. Having sex with a female from an HPC is a significant risk factor for gonorrhoea. Gonorrhoea positivity among men having sex with a female from an HPC did not change over time, suggesting this risk factor has become less important.

Mycoplasma genitalium coinfection in men with symptomatic gonococcal urethritis

OBJECTIVES

International guidelines recommend Mycoplasma genitalium testing, preferably using an assay to detect macrolide resistance-associated mutations, for men presenting with non-gonococcal urethritis, but there is no specific guidance on such testing for men with gonococcal urethritis.

METHODS

This study aimed to estimate the proportion of men with gonococcal urethritis who have coinfection with M. genitalium through a retrospective analysis of cases of symptomatic urethral gonorrhoea at Western Sydney Sexual Health Centre in 2017 and 2018.

RESULTS

Fourteen of 184 (7.6%, 95% CI 3.7 to 11.5) men with gonococcal urethritis had M. genitalium detected in the urine at the time of presentation. No demographic or behavioural factors predicted M. genitalium coinfection. Coinfection with urethral Chlamydia trachomatis was detected in 29 of 184 (15.8%, 95% CI 10.5 to 21.1). All five men with macrolide-resistant M. genitalium detected returned for treatment with moxifloxacin at a median of 8 days (range 5-16 days) after presentation and treatment of gonorrhoea; three of five were documented to remain symptomatic at this visit.

CONCLUSION

Although M. genitalium coinfection is less common than chlamydia among men with symptomatic gonococcal urethritis, M. genitalium testing, using an assay to detect macrolide resistance, will potentially reduce symptom duration particularly for men with macrolide-resistant infections, but may not be justifiable on cost-benefit analysis.

Oropharyngeal and Genital Gonorrhea Infections Among Women and Heterosexual Men Reporting Sexual Contact With Partners With Gonorrhea: Implication for Oropharyngeal Testing of Heterosexual Gonorrhea Contacts

BACKGROUND

There have been very limited studies of oropharyngeal gonorrhea in heterosexuals. Routine screening of oropharyngeal gonorrhea is not recommended in heterosexual contacts of gonorrhea. This study aimed to examine oropharyngeal gonorrhea positivity among heterosexuals reporting contact with a partner with gonorrhea.

METHODS

At the Melbourne Sexual Health Centre (MSHC), all heterosexual individuals reporting contact with sexual partners with gonorrhea are tested for genital gonorrhea. In May 2017, MSHC also included screening for oropharyngeal gonorrhea in heterosexual contacts of gonorrhea. All contacts of gonorrhea among women and heterosexual men between May 2017 and November 2018 were reviewed. Site-specific gonorrhea positivity was also calculated.

RESULTS

One hundred ninety-one gonorrhea contacts (102 heterosexual men and 89 women) were reviewed. The median age was 28 (interquartile range, 24-33) years. The gonorrhea positivity in males was significantly higher at the oropharynx compared with urethra (18%; 95% confidence interval [CI], 11% to 26% vs 2%; 95% CI, 0% to 7%; P < 0.001); and higher at the oropharynx compared with cervicovaginal site in women (46%; 95% CI, 35% to 57% vs 36%; 95% CI, 26% to 47%; P = 0.056). Of the 100 men who did not have genital gonorrhea, 17 (18%; 95% CI, 10% to 26%) tested positive at the oropharynx. Of the 55 women who did not have genital gonorrhea, 21 (24%; 95% CI, 15% to 34%) tested positive at the oropharynx. Infection at both the oropharynx and genital sites was not associated with sex worker status in women. Overall, 89% and 40% of gonorrhea in heterosexual men and women were only in the oropharynx, respectively.

CONCLUSIONS

Oropharyngeal gonorrhea testing among heterosexual contacts of gonorrhea may be indicated given a substantial proportion of gonorrhea contacts are only infected at this site.

Clinical presentation of asymptomatic and symptomatic heterosexual men who tested positive for urethral gonorrhoea at a sexual health clinic in Melbourne, Australia

Background

Asymptomatic screening for gonorrhoea in heterosexual men is currently not recommended in many countries including Australia, given the prevalence is relatively low in the heterosexual population. We aimed to determine the proportion of urethral gonorrhoea cases among heterosexual men attending a sexual health clinic that was asymptomatic and symptomatic, the time since last sexual contact to the onset of symptoms and the time to clinic presentation following the onset of symptoms.

Methods

This was a cross-sectional study that included heterosexual men aged 16 years or above attending the Melbourne Sexual Health Centre (MSHC) in Australia between August 2017 and August 2018. Gonorrhoea cases were diagnosed by nucleic acid amplification testing (NAAT) and/or culture. Descriptive analyses were conducted for all gonorrhoea cases including demographic characteristics, recent sexual practices, reported urethral symptoms and duration, sexual contact with a person diagnosed with gonorrhoea, investigations performed and laboratory results.

Results

There were 116 confirmed cases of urethral gonorrhoea in heterosexual men over the study period of which 6.0% (95% CI: 2.7–12.1%) were asymptomatic. Typical urethral discharge was present in 80.2% (95% CI: 71.9–86.5%) of men. The mean time between last sexual contact and the onset of symptoms was 7.0 days, and between the onset of symptoms to presentation to the clinic was 5.6 days.

Conclusions

A small proportion of heterosexual men with urethral gonorrhoea do not have any symptoms. Heterosexual men with urethral symptoms usually seek for healthcare within a week, prompting rapid healthcare-seeking behaviour.

Cross-sectional study of asymptomatic Neisseria gonorrhoeae and Chlamydia trachomatis infections in sexually transmitted disease related clinics in Shenzhen, China

The aims of this study were to investigate the prevalence and proportion of laboratory-confirmed urethral Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections that were asymptomatic among individuals presenting to clinics in Shenzhen and the risk factors related to asymptomatic CT infection. In a cross-sectional study, eligible individuals were invited to participate in the questionnaire, and urine specimens were collected to identify CT and NG infections using a nucleic acid amplification test (NAAT). Considering the differences in the presentation of symptoms between men and women, this study was stratified by gender. Corresponding outcomes were analyzed by Chi-square test and multivariate logistic regression. A total of 2,871 participants were asymptomatic and included in our analyses: 1120 (39.0%) men and 1751 (61.0%) women. The prevalence of asymptomatic NG and CT infections was 0.9% and 6.2% in men, and 0.4% and 7.9% in women, respectively. The proportion of asymptomatic urethral CT among men with urethral CT was 28.3%; for women, it was 34.2%. For asymptomatic men with CT, 3 independent risk factors were identified: (1) men under the age of 30 (aOR, 1.83; 95% CI, 1.11-3.03); (2) being employed in the commercial service work (2.82; 1.36-5.84); and (3) being recruited through the urological department (2.12; 1.19-3.79). For asymptomatic women with urethral CT, age less than 30 years was a risk factor. In conclusion, a substantial prevalence of asymptomatic CT infections was found among men and women presenting to clinics in Shenzhen. The significant correlation between asymptomatic CT infection and these risk factors could help identify high-risk populations and guide screening.

Genomic epidemiology and population structure of Neisseria gonorrhoeae in Norway, 2016-2017

This study presents the nationwide epidemiology of Neisseria gonorrhoeae, using whole-genome sequencing of all culture-positive cases, which comprise roughly 40 % of all cases of gonorrhea reported in Norway from 2016 to 2017. Isolates were assigned to sequence types and Bayesian analysis clusters and variation in genes coding for antibiotic resistance was linked to phenotypic resistance data. The study also included isolates taken from the same patients from different anatomical sites at one or more time points. Comparing these isolates allows for observation of patterns of infections, i.e. multiple reinfections of genetically related clones vs. reinfections of genetically distant clones, and quantification of the genomic variation of closely related isolates from samples taken from a patient within the same day. Demographically, the patients in the study could be split into two groups; one group of patients from the capital with a high proportion of men who have sex with men (MSM), and another consisting of young adults with transmission primarily between males and females from outside the capital. Some clusters of N. gonorrhoeae were restricted to one of these two demographic groups. Pairwise comparison of multiple isolates from the same patients revealed that most were reinfected with different clones. Observations of frequent reinfections in patients is a concern and should be taken into account in the development of improved information and treatment guidelines.

Oropharyngeal Gonorrhea in Absence of Urogenital Gonorrhea in Sexual Network of Male and Female Participants, Australia, 2018

We describe a sexual network consisting of 1 nonbinary-gendered participant and 2 male and 4 female participants in Australia, 2018. Six of 7 participants had oropharyngeal gonorrhea in the absence of urogenital gonorrhea. This observation supports a new paradigm of gonorrhea transmission in which oropharyngeal gonorrhea can be transmitted through tongue kissing.

Men at risk of gonococcal urethritis: a case-control study in a Darwin sexual health clinic

BACKGROUND

Male urethritis is primary sexually transmitted. Northern Territory (NT) has the highest rates of gonococcal infection in Australia and local guidelines recommend empiric treatment with azithromycin and ceftriaxone for all men presenting with urethritis. As gonococcal drug resistance is a growing concern, this study aims to improve empiric use of ceftriaxone through examining local patterns of male urethritis, comparing cases of gonococcal urethritis (GU) to controls with non-gonococcal urethritis (NGU).

METHODS

A retrospective study was undertaken of all men with symptomatic urethritis presenting to Darwin sexual health clinic from July 2015 to July 2016 and aetiology of urethritis in this population was described. Demographic, risk profile, and clinical features of GU cases were compared to NGU controls.

RESULTS

Among n = 145 men, the most common organisms identified were Chlamydia trachomatis (23.4%, SE 3.5%) and Neisseria gonorrhoeae (17.2%, SE 3.1%). The main predictors of GU were any abnormalities on genital examination (aOR 10.4, 95% CI 2.1 to 50.8) and a history of urethral discharge (aOR 5.7, 95% CI 1.4 to 22.6). Aboriginal patients (aOR 3.0, 95% CI 0.9 to 9.6) and those over 30 years of age (aOR 1.4, 95% CI 0.3 to 7.0) were more likely to have GU in the unadjusted analysis, but not in the adjusted model.

CONCLUSION

This is the first study looking at patterns of male urethritis in urban NT and the results support a move towards adopting national guidelines to use ceftriaxone for empiric management of syndromic urethritis only in high-risk patients. In addition to traditional demographic risk factors, clinical features remain an important component of risk stratification.

Only recent sexual partners contribute to oropharyngeal gonorrhoea positivity: the number of sexual partners over different time periods as an indicator of gonorrhoea and chlamydia infection duration among men who have sex with men

Background Mathematical models have demonstrated that the majority of gonococcal transmission is from oropharynx to oropharynx (i.e. kissing) among men who have sex with men (MSM). The aim of this study is to investigate the association between the number of partners within specific time periods and gonorrhoea and chlamydia positivity.

METHODS

This was a retrospective data analysis of MSM attending the Melbourne Sexual Health Centre between 2007 and 2016. Univariable and multivariable logistic regression analyses, with generalised estimating equations (GEE), were performed to determine if the number of partners within specified time periods was associated with site-specific gonorrhoea and chlamydia positivity.

RESULTS

There were 45933 consultations which included 15197 MSM. Oropharyngeal gonorrhoea positivity was associated with the number of partners in the past 3 months, but not the number of partners 4-12 months ago; men who had ≥6 partners in the past 3 months had significantly higher odds of acquiring oropharyngeal gonorrhoea (aOR 1.93; 95% CI 1.61-2.31), but this was not the case for men who had ≥6 partners 4-12 months ago. Anorectal gonorrhoea and chlamydia and urethral chlamydia were associated with the number of partners in both time periods after adjusting for age and condom use.

CONCLUSIONS

The association of oropharyngeal gonorrhoea with the number of recent partners, but not partners from an earlier period, unlike anorectal gonorrhoea and anorectal and urethral chlamydia, could be explained by a shorter duration of oropharyngeal gonococcal infection. Annual screening for gonorrhoea may be insufficient to materially reduce oropharyngeal prevalence.

The role of saliva in gonorrhoea and chlamydia transmission to extragenital sites among men who have sex with men: new insights into transmission

INTRODUCTION

Gonorrhoea and chlamydia cases have been rising among gay, bisexual and other men who have sex with men (MSM) over the last decade. The majority of cases are extragenital and occur at the oropharynx and anorectum. The aim of this narrative review was to review the risk factors and mode of transmission for gonorrhoea and chlamydia at the oropharynx and anorectum among MSM.

RESULTS AND DISCUSSION

New evidence suggests that oropharyngeal gonorrhoea can be transmitted by kissing in addition to through the established route of condomless oral sex; and anorectal gonorrhoea can be acquired when saliva is used as a lubricant for anal sex and rimming in addition to the established route of condomless penile-anal sex in MSM. In contrast, condomless penile-anal sex remains the major route for chlamydia transmission.

CONCLUSIONS

Substantial transmission of gonorrhoea may occur with practices other than the established routes of condomless oral and/or anal sex and hence condoms may not be effective in preventing gonorrhoea transmission to extragenital sites. In contrast, condoms are effective for chlamydia control because it is mainly transmitted through condomless penile-anal sex. Novel interventions for gonorrhoea that reduce the risk of transmission at extragenital site are required.

New thinking on gonorrhoea control in MSM: are antiseptic mouthwashes the answer?

PURPOSE OF REVIEW

The rate of gonorrhoea is rising and is much higher in men who have sex with men (MSM) than heterosexuals. The purpose of this review was to describe research supporting a new paradigm of transmission of gonorrhoea in MSM and interventions that may result from this.

RECENT FINDINGS

Evidence is accumulating that gonorrhoea in MSM is transmitted differently than previously thought and that asymptomatic sites of infection may play a major role in the persistent of gonorrhoea at a population level. Saliva commonly contains gonorrhoea, and saliva is commonly used during sexual acts. Both in-vitro, in-vivo studies have suggested that antibacterial mouthwash may reduce gonorrhoea at the oropharynx. A recently published mathematical model also suggests that if mouthwash were effective, it would result in considerable declines in the community prevalence in MSM.

SUMMARY

A newly suggested paradigm for the transmission of gonorrhoea in MSM could potentially offer a simple condom-free control strategy. But considerable more research is required before it could be recommended even if it were shown to be effective in a clinical trial.

Models of gonorrhoea transmission from the mouth and saliva

This Personal View argues for a new framework of gonorrhoea transmission in men who have sex with men in which the oropharynx plays a major role in transmitting gonorrhoea to, or acquiring gonorrhoea from, their partner's oropharynx, penis, or anorectum through either direct contact or via saliva. To avoid preconceived notions of transmission dynamics, we ask readers to imagine that they are investigating a new sexually transmitted infection. On the basis of the existing clinical and epidemiological data for gonorrhoea at the penis, oropharynx, and anorectum site, we develop two models for transmission: the so-called penile model and the so-called oropharyngeal model. We argue that the existing epidemiological data and behavioural data best fit the oropharyngeal model. Our argument rests on the observation that, at the population level, the prevalence of urethral gonorrhoea is too rare to explain the high incidence of oropharynx and anorectum infection. We describe studies of gonorrhoea detection in saliva, saliva use during sex, epidemiological studies of kissing and oropharyngeal gonorrhoea, as well as studies aided by mathematical models. Finally, we argue that the correlation between sexual acts (eg, kissing, oral sex, anal sex, and saliva use) is so high that any epidemiological study that does not measure these factors will be prone to confounding.

Estimate of male urethritis incidences in France between 2007 and 2017 with a specific focus on Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis infections

BACKGROUND

In a context of increasing use of Nucleic Acid Amplification Test, diagnoses of Neisseria gonorrhoeae and Chlamydia trachomatis infections among men increased in Europe and USA since 2007. We aimed to describe trends in the incidence of male urethritis in France between 2007 and 2017.

METHODS

We analysed male urethritis clinical cases reported by the French GPs' Sentinelles network.

RESULTS

GPs reported 1944 cases of male urethritis during the study period. The estimated annual incidence rates in men aged 15 years and older remained stable between 226 cases per 100,000 seen in 2007 and 196 in 2017 (P value = 0.9). A third-generation cephalosporin with macrolide or tetracycline was prescribed in 17.5% of cases in 2009 (27/154) and 32.4% in 2017 (47/145) (P value = 0.0327).

CONCLUSIONS

The incidence rates for adult male urethritis diagnosed in primary care have remained stable since 2007 in France in contrast with the increasing trend of Neisseria gonorrhoeae and Chlamydia trachomatis infections based on microbiological surveillance. Using stable clinical definition for male urethritis seems essential to follow correctly epidemiological dynamic.

Evidence for a new paradigm of gonorrhoea transmission: cross-sectional analysis of Neisseria gonorrhoeae infections by anatomical site in both partners in 60 male couples

OBJECTIVE

Gonorrhoea transmission between men is currently thought to occur primarily to and from the urethra. Transmission without urethral involvement, from throat-to-throat and throat-to-anus, is considered to be uncommon. Using gonorrhoea results from male couples, we aimed to investigate the transmission dynamics of gonorrhoea. If current medical consensus is correct, then most throat and anal infections should be explained by the partner's urethral infection.

METHODS

This is a cross-sectional analysis of gonorrhoea diagnosed by nucleic acid amplification tests in both partners in male couples who attended Melbourne Sexual Health Centre together between March 2015 and June 2017. Isolates obtained from culture-positive infections underwent whole genome sequencing to assess phylogenetic relatedness between partners.

RESULTS

In all 60 couples (120 men) at least one partner had gonorrhoea, and isolates had very high phylogenetic relatedness between partners. After excluding men with urethral gonorrhoea, among 32 men with anal gonorrhoea, 34% (95% CI 19% to 53 %) had a partner with throat gonorrhoea. After excluding couples where either man had urethral gonorrhoea, among 48 couples in which at least one man had throat gonorrhoea, in 23% (95% CI 12% to 37 %) of couples both men had throat gonorrhoea.

CONCLUSIONS

The observed gonorrhoea positivity when urethral infection is absent supports a new paradigm of gonorrhoea transmission, where the throat is a major source of gonorrhoea transmission between men, through tongue kissing, oroanal sex and saliva use as anal lubricant. Public health messages may need to address the risk of saliva exposure during sex.

Concordance of gonorrhoea of the rectum, pharynx and urethra in same-sex male partnerships attending a sexual health service in Melbourne, Australia

BACKGROUND

We aimed to describe anatomic site-specific concordance of gonococcal infections in partnerships of men who have sex with men (MSM).

METHODS

We conducted a cross-sectional analysis of data from MSM partnerships attending Melbourne Sexual Health Centre between March 2011 and February 2015. Logistic regression models (random effect) were used to examine the association between gonococcal infections of the urethra, rectum and pharynx. Gonococci were detected by culture at all anatomic sites.

RESULTS

The analysis included 495 partnerships. Of the men with urethral gonorrhoea, 33% (95% CI 18-52) had partners with pharyngeal gonorrhoea and 67% (95% CI 48-82) had partners with rectal gonorrhoea. The adjusted odds of having urethral gonorrhoea was 4.6 (95% CI 1.2-17.1) for a man whose partner had pharyngeal gonorrhoea, and 48.1 (95% CI 18.3-126.7) for a man whose partner had rectal gonorrhoea. Of the men with rectal gonorrhoea, 46% (95% CI 31-61) had a partner with urethral gonorrhoea and 23% (95% CI 12-37) had a partner with pharyngeal gonorrhoea. The adjusted odds of having rectal gonorrhoea was 63.9 (95% CI 24.7-165.6) for a man whose partner had urethral gonorrhoea. Of the men with pharyngeal gonorrhoea, 42% (95% CI 23-63) had a partner with rectal gonorrhoea and 23% (95% CI 9-44) had a partner with had a partner with pharyngeal gonorrhoea. The adjusted odds of having pharyngeal gonorrhoea was 8.9 (95% CI 3.2-24.6) for a man whose partner had rectal gonorrhoea. The crude odds of having pharyngeal gonorrhoea was 14.2 (95% CI 5.1-39.0) for a man whose partner had pharyngeal gonorrhoea.

CONCLUSIONS

These data provide the first estimates of concordance of anatomic site-specific gonococcal infections in MSM partnerships, and confirm that urethral gonorrhoea is contracted from both rectal and pharyngeal sites, and suggest that gonococci transmit between the rectum and pharynx. However, due to use of culture rather than NAAT, our analysis was not adequately powered to assess pharynx-to-pharynx transmission of gonococci.

Risk factors for oropharyngeal gonorrhoea in men who have sex with men: an age-matched case-control study

OBJECTIVES

Oropharyngeal gonorrhoea is common among men who have sex with men (MSM). We aimed to clarify which oral sex practices were independent risk factors for oropharyngeal gonorrhoea: tongue kissing, receptive oro-penile sex (fellatio) or insertive oro-anal sex (rimming), and whether daily use of mouthwash and recent antibiotic use was protective.

METHODS

In 2015, we conducted an age-matched case-control study of MSM who attended the Melbourne Sexual Health Centre. Cases had tested positive for oropharyngeal gonorrhoea by nucleic acid amplification testing, and controls had tested negative. Questionnaire items included tongue kissing, oral sex practices, condom use, recent antibiotic use, mouthwash use and alcohol consumption.

RESULTS

We identified 177 cases, age matched to 354 controls. In univariable analyses, cases were 1.90 times (95% CI 1.13 to 3.20) more likely than controls to have had casual sexual partners (CSP) in the preceding 3 months, were 2.17 times (95% CI 1.31 to 3.59) more likely to have kissed CSP and were 2.04 times (95% CI 1.26 to 3.30) more likely to have had receptive oro-penile sex with CSP. Oropharyngeal gonorrhoea was not associated with insertive oro-anal sex or mouthwash use. The number of CSP for tongue kissing and receptive oral sex and total CSP were highly correlated, and in multivariable analysis neither kissing nor receptive oro-penile sex was significantly associated with having oropharyngeal gonorrhoea, after adjusting for total number of CSP.

CONCLUSIONS

The finding that oropharyngeal gonorrhoea was associated with a higher number of sexual partners but not specific sexual practices highlights the need for further research in the area of gonorrhoea transmission to define the probability of transmission from specific sex acts.

A multicentre double-blind randomised controlled trial evaluating the efficacy of daily use of antibacterial mouthwash against oropharyngeal gonorrhoea among men who have sex with men: the OMEGA (Oral Mouthwash use to Eradicate GonorrhoeA) study protocol

BACKGROUND

Gonorrhoea is one of the most common sexually transmissible infections in men who have sex with men (MSM). Gonorrhoea rates have increased substantially in recent years. There is concern that increasing gonorrhoea prevalence will increase the likelihood of worsening antibiotic resistance in Neisseria gonorrhoeae. A recent randomised controlled trial (RCT) demonstrated that a single-dose of mouthwash has an inhibitory effect against oropharyngeal gonorrhoea. We are conducting the first RCT to evaluate whether daily use of mouthwash could reduce the risk of acquiring oropharyngeal gonorrhoea.

METHODS/DESIGN

The OMEGA (Oral Mouthwash use to Eradicate GonorrhoeA) study is a double-blind RCT and will be conducted at several sexual health clinics and high caseload General Practice (GP) clinics in Melbourne and Sydney, Australia. A total of 504 MSM attending the participating sites will be recruited. Participants will be randomised to either using 'Study mouthwash A' or 'Study mouthwash B' for 12 weeks. Study mouthwash A was inhibitory against N. gonorrhoeae in vitro, whereas study mouthwash B was not. Participants will be instructed to rinse and gargle the study mouthwash for 60 seconds every day. The primary outcome is the proportion of participants with oropharyngeal gonorrhoea detected by nucleic acid amplification test by 12 weeks.

DISCUSSION

The results from this trial may provide a novel way to reduce gonorrhoea prevalence and transmission without the use of antibiotics that may be associated with development of resistance. If shown to be effective, the widespread use of mouthwash will reduce the prevalence of oropharyngeal gonorrhoea, which plays key role in driving the emergence of gonococcal antimicrobial resistance through DNA exchange with oral commensal bacteria. The anticipated net effect will be interruption of onward transmission of N. gonorrhoeae within high density sexual networks within MSM populations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616000247471 , registered on 23rd February 2016.