1
|
Braz Junior RP, Cesar GA, Amianti C, Bandeira LM, Da Silva ASP, Motta-Castro ARC. Behind Prep Decisions: Understanding User Patterns and Discontinuation Factors in Real-World. AIDS Behav 2024; 28:2979-2989. [PMID: 38825651 DOI: 10.1007/s10461-024-04383-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/04/2024]
Abstract
This study aimed to characterize the epidemiological aspects of PrEP use and barriers to accessing this prophylaxis. This cross-sectional study was conducted between January 2021 and April 2022, encompassing 140 PrEP users treated at the Testing and Counseling Center (CTA) in Campo Grande, Mato Grosso do Sul. Data on sociodemographic characteristics and factors associated with PrEP discontinuation were obtained using a standardized questionnaire. Most PrEP users were cisgender men (92.00%), predominantly white (51.00%), over 30 years of age (56.50%), homosexual-oriented (76.50%), and had a minimum of 12 years of education (77.50%). Approximately 60.00% admitted to inconsistent condom use in recent sexual encounters, primarily involving anal intercourse. Approximately 88.00% perceived themselves as at risk of contracting STIs in the upcoming year. Regarding new presentation forms, 54.00% indicated a willingness to use "on-demand PrEP," and 92.00% expressed interest in using "injectable PrEP." After 6 months of follow-up, 43.60% (95.00% CI: 35.50-52.00) discontinued PrEP use, primarily due to changes in sexual behavior (38.30%) and difficulties accessing healthcare services (21.28%). This study underscores the need to involve diverse key populations and highlights the significance of PrEP as an ongoing monitoring strategy for HIV/STI prevention in addition to the importance of incorporating new formulations such as daily oral PrEP into the Brazilian National Health System (SUS).
Collapse
Affiliation(s)
- R P Braz Junior
- Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brasil
- Secretaria Municipal de Saúde Municipal de Campo Grande (SESAU), Campo Grande, MS, Brasil
| | - G A Cesar
- Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brasil
- Secretaria Municipal de Saúde Municipal de Campo Grande (SESAU), Campo Grande, MS, Brasil
| | - C Amianti
- Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brasil.
| | - L M Bandeira
- Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brasil.
| | - A S P Da Silva
- Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brasil
- Secretaria Municipal de Saúde Municipal de Campo Grande (SESAU), Campo Grande, MS, Brasil
| | - A R C Motta-Castro
- Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brasil
- Fiocruz Mato Grosso do Sul, Fundação Oswaldo Cruz/Ministério da Saúde/Brasil, Campo Grande, MS, Brasil
| |
Collapse
|
2
|
Tran J, Fairley CK, Ong JJ, Aung ET, Chow EPF. Association between saliva use for masturbation and urethral gonorrhoea in men who have sex with men: A cross-sectional study. Int J Infect Dis 2024; 148:107219. [PMID: 39181439 DOI: 10.1016/j.ijid.2024.107219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 08/18/2024] [Accepted: 08/19/2024] [Indexed: 08/27/2024] Open
Abstract
OBJECTIVES The saliva of individuals with oropharyngeal gonorrhoea can contain viable Neisseria gonorrhoeae. This study examined if using saliva as a lubricant for masturbation is a risk factor for urethral gonorrhoea among men who have sex with men (MSM). METHODS In this cross-sectional study, MSM aged ≥18 years attending the Melbourne Sexual Health Centre between February 2021 and December 2023 were surveyed. Data were collected on sexual activities in the past 7 days, including receiving fellatio, condomless insertive anal sex, docking, and using saliva for masturbation. Multivariable logistic regression examined associations between these exposures and urethral gonorrhoea. RESULTS The median age of the 3114 men was 32 (IQR: 27-40), with 4.7% (n = 145) testing positive for urethral gonorrhoea. Urethral gonorrhoea was independently associated with an increasing number of partners for condomless insertive anal sex (P < 0.001). It was not significantly associated with receiving fellatio (P = 0.613), docking (P = 0.207), or using saliva for masturbation (P = 0.117). However, of the 110 men who only used saliva for masturbation, two (1.8%) had urethral gonorrhoea, and one (0.9%) had both urethral and oropharyngeal gonorrhoea. CONCLUSION Condomless insertive anal sex is the leading risk factor for urethral gonorrhoea and not using saliva as a lubricant for masturbation.
Collapse
Affiliation(s)
- Julien Tran
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jason J Ong
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ei T Aung
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
3
|
Hu Y, Zhao R, Li G, Liu Y, Lu F, She B, Zhao M, Zhang L. Associations between antibacterial mouthwash use with sexual behaviours and sexually transmitted infections among Chinese men who have sex with men: a cross-sectional study. Sex Health 2024; 21:SH24083. [PMID: 39159291 DOI: 10.1071/sh24083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 07/30/2024] [Indexed: 08/21/2024]
Abstract
Background Mouthwash is a commonly used product with the potential to prevent STIs. This study aimed to determine the association between mouthwash use frequency with sexual behaviours and STIs among Chinese men who have sex with men (MSM). Methods A cross-sectional study was conducted among MSM in Xi'an, China, from January to September 2022. Participants were categorised into non-mouthwash users, occasional (used it less than once every week) and frequent (used it more than once every week) mouthwash users. Multinomial logistic regression was performed to identify the association between mouthwash use frequency with sexual behaviours. Results Of 838 MSM included in the analysis, 621 (74.11%) reported never using mouthwash, whereas 47 (5.60%) used it occasionally and 170 (20.29%) used it frequently. Frequent mouthwash users had a lower prevalence of chlamydia compared with occasional users (8.33% vs 23.93%, P Conclusion MSM with more sexual partners or lower condom use frequency were more likely to be frequent mouthwash users. However, frequent mouthwash users had a lower chlamydia prevalence.
Collapse
Affiliation(s)
- Yawu Hu
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, 76 Yanta West Road, Xi'an 710061, Shaanxi, China
| | - Rui Zhao
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, 76 Yanta West Road, Xi'an 710061, Shaanxi, China
| | - Gaixia Li
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, 76 Yanta West Road, Xi'an 710061, Shaanxi, China
| | - Yi Liu
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, 76 Yanta West Road, Xi'an 710061, Shaanxi, China
| | - Fang Lu
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, 76 Yanta West Road, Xi'an 710061, Shaanxi, China
| | - Bingyang She
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, 76 Yanta West Road, Xi'an 710061, Shaanxi, China
| | - Min Zhao
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, 76 Yanta West Road, Xi'an 710061, Shaanxi, China; and Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, 157 Xiwu Av, Xi'an 710004, Shaanxi, China
| | - Lei Zhang
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, 76 Yanta West Road, Xi'an 710061, Shaanxi, China; and Artificial Intelligence and Modelling in Epidemiology Program, Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic, Australia; and School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia
| |
Collapse
|
4
|
Laumen JGE, Van Dijck C, Manoharan-Basil SS, de Block T, Abdellati S, Xavier BB, Malhotra-Kumar S, Kenyon C. The effect of daily usage of Listerine Cool Mint mouthwash on the oropharyngeal microbiome: a substudy of the PReGo trial. J Med Microbiol 2024; 73. [PMID: 38833520 DOI: 10.1099/jmm.0.001830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
Introduction. ListerineÒ is a bactericidal mouthwash widely used to prevent oral health problems such as dental plaque and gingivitis. However, whether it promotes or undermines a healthy oral microbiome is unclear.Hypothesis/Gap Statement. We hypothesized that the daily use of Listerine Cool Mint would have a significant impact on the oropharyngeal microbiome.Aim. We aimed to assess if daily usage of Listerine Cool Mint influenced the composition of the pharyngeal microbiome.Methodology. The current microbiome substudy is part of the Preventing Resistance in Gonorrhoea trial. This was a double-blind single-centre, crossover, randomized controlled trial of antibacterial versus placebo mouthwash to reduce the incidence of gonorrhoea/chlamydia/syphilis in men who have sex with men (MSM) taking HIV pre-exposure prophylaxis (PrEP). Fifty-nine MSM taking HIV PrEP were enrolled. In this crossover trial, participants received 3 months of daily Listerine followed by 3 months of placebo mouthwash or vice versa. Oropharyngeal swabs were taken at baseline and after 3 months use of each mouthwash. DNA was extracted for shotgun metagenomic sequencing (Illumina Inc.). Non-host reads were taxonomically classified with MiniKraken and Bracken. The alpha and beta diversity indices were compared between baseline and after each mouthwash use. Differentially abundant bacterial taxa were identified using ANOVA-like differential expression analysis.Results. Streptococcus was the most abundant genus in most samples (n = 103, 61.7 %) with a median relative abundance of 31.5% (IQR 20.6-44.8), followed by Prevotella [13.5% (IQR 4.8-22.6)] and Veillonella [10.0% (IQR 4.0-16.8)]. Compared to baseline, the composition of the oral microbiome at the genus level (beta diversity) was significantly different after 3 months of Listerine (P = 0.006, pseudo-F = 2.29) or placebo (P = 0.003, pseudo-F = 2.49, permutational multivariate analysis of variance) use. Fusobacterium nucleatum and Streptococcus anginosus were significantly more abundant after Listerine use compared to baseline.Conclusion. Listerine use was associated with an increased abundance of common oral opportunistic bacteria previously reported to be enriched in periodontal diseases, oesophageal and colorectal cancer, and systemic diseases. These findings suggest that the regular use of Listerine mouthwash should be carefully considered.
Collapse
Affiliation(s)
- J G E Laumen
- Department of Clinical Sciences, Institute of Tropical Medicine, STI Unit, Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - C Van Dijck
- Department of Clinical Sciences, Institute of Tropical Medicine, STI Unit, Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - S S Manoharan-Basil
- Department of Clinical Sciences, Institute of Tropical Medicine, STI Unit, Antwerp, Belgium
| | - T de Block
- Department of Clinical Sciences, Clinical Reference Laboratory, Institute of Tropical Medicine, Antwerp, Belgium
| | - S Abdellati
- Department of Clinical Sciences, Clinical Reference Laboratory, Institute of Tropical Medicine, Antwerp, Belgium
| | - B B Xavier
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - S Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - C Kenyon
- Department of Clinical Sciences, Institute of Tropical Medicine, STI Unit, Antwerp, Belgium
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
5
|
Phillips TR, Fairley CK, Maddaford K, McNulty A, Donovan B, Guy R, McIver R, Wigan R, Varma R, Ong JJ, Callander D, Skelsey G, Pony M, O'Hara D, Bilardi JE, Chow EP. Understanding Risk Factors for Oropharyngeal Gonorrhea Among Sex Workers Attending Sexual Health Clinics in 2 Australian Cities: Mixed Methods Study. JMIR Public Health Surveill 2024; 10:e46845. [PMID: 38767954 PMCID: PMC11148521 DOI: 10.2196/46845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 01/07/2024] [Accepted: 04/05/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND The risk factors for oropharyngeal gonorrhea have not been examined in sex workers despite the increasing prevalence of gonorrhea infection. OBJECTIVE This study aims to determine the risk factors for oropharyngeal gonorrhea in female and gender-diverse sex workers (including cisgender and transgender women, nonbinary and gender fluid sex workers, and those with a different identity) and examine kissing, oral sex, and mouthwash practices with clients. METHODS This mixed methods case-control study was conducted from 2018 to 2020 at 2 sexual health clinics in Melbourne, Victoria, and Sydney, New South Wales, Australia. We recruited 83 sex workers diagnosed with oropharyngeal gonorrhea (cases) and 581 sex workers without (controls). Semistructured interviews with 19 sex workers from Melbourne were conducted. RESULTS In the case-control study, the median age of 664 sex workers was 30 (IQR 25-36) years. Almost 30% of sex workers (192/664, 28.9%) reported performing condomless fellatio on clients. Performing condomless fellatio with clients was the only behavior associated with oropharyngeal gonorrhea (adjusted odds ratio 3.6, 95% CI 1.7-7.6; P=.001). Most participants (521/664, 78.5%) used mouthwash frequently. In the qualitative study, almost all sex workers reported kissing clients due to demand and generally reported following clients' lead with regard to kissing style and duration. However, they used condoms for fellatio because they considered it a risky practice for contracting sexually transmitted infections, unlike cunnilingus without a dental dam. CONCLUSIONS Our study shows that condomless fellatio is a risk factor for oropharyngeal gonorrhea among sex workers despite most sex workers using condoms with their clients for fellatio. Novel interventions, particularly targeting the oropharynx, will be required for oropharyngeal gonorrhea prevention.
Collapse
Affiliation(s)
- Tiffany R Phillips
- Monash University, Clayton, Australia
- Alfred Health, Melbourne Sexual Health Centre, Carlton, Australia
| | - Christopher K Fairley
- Monash University, Clayton, Australia
- Alfred Health, Melbourne Sexual Health Centre, Carlton, Australia
| | - Kate Maddaford
- Alfred Health, Melbourne Sexual Health Centre, Carlton, Australia
| | | | - Basil Donovan
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Rebecca Guy
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | | | - Rebecca Wigan
- Alfred Health, Melbourne Sexual Health Centre, Carlton, Australia
| | - Rick Varma
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Jason J Ong
- Monash University, Clayton, Australia
- Alfred Health, Melbourne Sexual Health Centre, Carlton, Australia
| | - Denton Callander
- The Kirby Institute, University of New South Wales, Sydney, Australia
- Operational Centre Geneva, Medecins Sans Frontiers, Mombasa, Kenya
- SexTech Lab, The New School, New York, NY, United States
| | | | - Mish Pony
- Scarlet Alliance, Australian Sex Workers Association, Sydney, Australia
| | - Dylan O'Hara
- Vixen, Victoria's Peer Sex Worker Organisation, Melbourne, Australia
| | - Jade E Bilardi
- Monash University, Clayton, Australia
- Alfred Health, Melbourne Sexual Health Centre, Carlton, Australia
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Eric Pf Chow
- Monash University, Clayton, Australia
- Alfred Health, Melbourne Sexual Health Centre, Carlton, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| |
Collapse
|
6
|
The Discovery of Oropharyngeal Microbiota with Inhibitory Activity against Pathogenic Neisseria gonorrhoeae and Neisseria meningitidis: An In Vitro Study of Clinical Isolates. Microorganisms 2022; 10:microorganisms10122497. [PMID: 36557750 PMCID: PMC9787740 DOI: 10.3390/microorganisms10122497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/02/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
With increasing incidence of pathogenic Neisseria infections coupled with emerging resistance to antimicrobials, alternative approaches to limit the spread are sought. We investigated the inhibitory effect of oropharyngeal microbiota on the growth of N. gonorrhoeae and N. meningitidis and the impact of the essential oil-based mouthwash Listerine Cool Mint® (Listerine). Oropharyngeal swabs from 64 men who have sex with men (n = 118) from a previous study (PReGo study) were analysed (ClinicalTrials.gov, NCT03881007). These included 64 baseline and 54 samples following three months of daily use of Listerine. Inhibition was confirmed by agar overlay assay, and inhibitory bacteria isolated using replica plating and identified using MALDI-TOF. The number of inhibitory isolates were compared before and after Listerine use. Thirty-one pharyngeal samples (26%) showed inhibitory activity against N. gonorrhoeae and/or N. meningitidis, and 62 inhibitory isolates were characterised. Fourteen species belonging to the genera Streptococci and Rothia were identified. More inhibitory isolates were observed following Listerine use compared to baseline, although this effect was not statistically significant (p = 0.073). This study isolated and identified inhibitory bacteria against pathogenic Neisseria spp. and established that daily Listerine use did not decrease their prevalence. These findings could provide a new approach for the prevention and treatment of pharyngeal Neisseria infections.
Collapse
|
7
|
Tran J, Fairley CK, Bowesman H, Aung ET, Ong JJ, Chow EPF. Non-conventional interventions to prevent gonorrhea or syphilis among men who have sex with men: A scoping review. Front Med (Lausanne) 2022; 9:952476. [PMID: 36203757 PMCID: PMC9530550 DOI: 10.3389/fmed.2022.952476] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesWe assessed nonconventional interventions that did not traditionally focus on increasing condom use and/or testing among men who have sex with men (MSM) and the evidence for these interventions.MethodsGuided by the Participants, Concept and Context (PCC) framework, we searched five online databases from inception to 9 August 2021 for original research on interventions that do not focus on increasing condom use and/or testing to prevent gonorrhea and/or syphilis in MSM. Two researchers screened titles and abstracts to assess eligibility, reviewed articles' full text and resolved discrepancies through discussion. We charted relevant study information, and the included studies were critically appraised.ResultsOf 373 articles retrieved, 13 studies were included. These studies were conducted in Australia (n = 3), Belgium (n = 2), China (n = 3), the Netherlands (n = 1) and the US (n = 4). Two randomized controlled trials (RCTs) of doxycycline as pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) reduced any STI incidence (gonorrhea, syphilis, or chlamydia), but only doxycycline PEP significantly reduced syphilis incidence. Six studies of interventions that facilitated self-collection, self-examination, and self-testing, found varied evidence for gonorrhea and/or syphilis prevention. Four RCTs and one single-arm trial examined the efficacy of mouthwash, but the evidence remains inconclusive on whether mouthwash use can prevent transmission between men.ConclusionWe found evidence for doxycycline PEP in reducing syphilis incidence, evidence on the use of mouthwash to prevent gonorrhea transmission between men remains inconclusive. More evidence is needed for interventions that do not focus on increasing condom use and/or testing to prevent gonorrhea and/or syphilis.
Collapse
Affiliation(s)
- Julien Tran
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- *Correspondence: Julien Tran
| | - Christopher K. Fairley
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Henry Bowesman
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Ei T. Aung
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Jason J. Ong
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Eric P. F. Chow
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
8
|
Saud Z, Tyrrell VJ, Zaragkoulias A, Protty MB, Statkute E, Rubina A, Bentley K, White DA, Rodrigues PDS, Murphy RC, Köfeler H, Griffiths WJ, Alvarez-Jarreta J, Brown RW, Newcombe RG, Heyman J, Pritchard M, Mcleod RW, Arya A, Lynch CA, Owens D, Jenkins PV, Buurma NJ, O'Donnell VB, Thomas DW, Stanton RJ. The SARS-CoV2 envelope differs from host cells, exposes procoagulant lipids, and is disrupted in vivo by oral rinses. J Lipid Res 2022; 63:100208. [PMID: 35436499 PMCID: PMC9010312 DOI: 10.1016/j.jlr.2022.100208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/23/2022] [Accepted: 04/04/2022] [Indexed: 12/14/2022] Open
Abstract
The lipid envelope of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an essential component of the virus; however, its molecular composition is undetermined. Addressing this knowledge gap could support the design of antiviral agents as well as further our understanding of viral-host protein interactions, infectivity, pathogenicity, and innate immune system clearance. Lipidomics revealed that the virus envelope comprised mainly phospholipids (PLs), with some cholesterol and sphingolipids, and with cholesterol/phospholipid ratio similar to lysosomes. Unlike cellular membranes, procoagulant amino-PLs were present on the external side of the viral envelope at levels exceeding those on activated platelets. Accordingly, virions directly promoted blood coagulation. To investigate whether these differences could enable selective targeting of the viral envelope in vivo, we tested whether oral rinses containing lipid-disrupting chemicals could reduce infectivity. Products containing PL-disrupting surfactants (such as cetylpyridinium chloride) met European virucidal standards in vitro; however, components that altered the critical micelle concentration reduced efficacy, and products containing essential oils, povidone-iodine, or chlorhexidine were ineffective. This result was recapitulated in vivo, where a 30-s oral rinse with cetylpyridinium chloride mouthwash eliminated live virus in the oral cavity of patients with coronavirus disease 19 for at least 1 h, whereas povidone-iodine and saline mouthwashes were ineffective. We conclude that the SARS-CoV-2 lipid envelope i) is distinct from the host plasma membrane, which may enable design of selective antiviral approaches; ii) contains exposed phosphatidylethanolamine and phosphatidylserine, which may influence thrombosis, pathogenicity, and inflammation; and iii) can be selectively targeted in vivo by specific oral rinses.
Collapse
Affiliation(s)
- Zack Saud
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Victoria J Tyrrell
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Andreas Zaragkoulias
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Majd B Protty
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Evelina Statkute
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Anzelika Rubina
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Kirsten Bentley
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Daniel A White
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | | | - Robert C Murphy
- Department of Pharmacology, University of Colorado Denver, Aurora, CO, USA
| | - Harald Köfeler
- Core Facility Mass Spectrometry, Medical University of Graz, Graz, Austria
| | | | - Jorge Alvarez-Jarreta
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Richard William Brown
- ENT Department, Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham, United Kingdom
| | - Robert G Newcombe
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - James Heyman
- Division of Surgery, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Manon Pritchard
- Advanced Therapies Group, School of Dentistry, Cardiff University, Cardiff, United Kingdom
| | - Robert Wj Mcleod
- Division of Surgery, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Arvind Arya
- ENT Department, Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham, United Kingdom
| | - Ceri-Ann Lynch
- Anaesthetics and Critical Care Directorate, Cwm Taf University Health Board, Royal Glamorgan Hospital, Llantrisant, United Kingdom
| | - David Owens
- Division of Surgery, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - P Vince Jenkins
- Haemostasis Diagnosis and Research, University Hospital Wales, Cardiff, United Kingdom
| | - Niklaas J Buurma
- Physical Organic Chemistry Centre, School of Chemistry, Cardiff University, Cardiff, United Kingdom
| | - Valerie B O'Donnell
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom.
| | - David W Thomas
- Advanced Therapies Group, School of Dentistry, Cardiff University, Cardiff, United Kingdom.
| | - Richard J Stanton
- Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom.
| |
Collapse
|
9
|
Inhibitory Activity of Antibacterial Mouthwashes and Antiseptic Substances against Neisseria gonorrhoeae. Antimicrob Agents Chemother 2022; 66:e0004222. [PMID: 35579459 PMCID: PMC9211398 DOI: 10.1128/aac.00042-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Improved treatment and prevention strategies, such as antimicrobial mouthwashes, may be important for addressing the public health threat of antimicrobial-resistant Neisseria gonorrhoeae. Here, we describe the activity of seven common antibacterial mouthwashes and antiseptics against N. gonorrhoeae isolates, incorporating the use of a human saliva test matrix. Our data demonstrate that antibacterial mouthwashes and antiseptics vary in their ability to inhibit the in vitro growth of N. gonorrhoeae and saliva may impact this inhibitory activity.
Collapse
|
10
|
Chow EPF, Phillips TR, Tran J, Aung ET, Maddaford K, Fairley CK. A cross-sectional study of male and female kissing partners among men who have sex with men. Sex Health 2022; 19:27-32. [PMID: 35241217 DOI: 10.1071/sh21184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/30/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Kissing may be a risk factor for gonorrhoea. Past studies have focused on male kissing partners among men who have sex with men (MSM). This study aimed to examine the kissing practices of MSM who kiss male and female partners. METHODS We conducted a cross-sectional survey at the Melbourne Sexual Health Centre (MSHC) between March and April 2019. Men attending the MSHC, aged ≥16years who reported any sexual contact with another man in the previous 12months were invited to participate in the survey. Data about the number of kissing-only (kissing without sex), kissing-with-sex, and sex-only (having sex without kissing) partners in the previous 3months were collected. Men were asked to report the number of male and female partners separately. RESULTS There were 357 MSM included in the survey. Most men (97.2%, n=347) had kissed or had sex with another man, whereas 16.0% (n=57) had kissed or had sex with a female partner in the previous 3months. Of the 57 men, 26.3% (n=15) had only kissed a female partner without having sex. The mean number of male partners for kissing-only was 5.5 (s.d.=6.6), kissing-with-sex was 5.0 (s.d.=6.6) and sex-only was 3.9 (s.d.=4.3). The mean number of female partners for kissing-only was 4.2 (s.d.=6.9), kissing-with-sex was 3.8 (s.d.=4.9) and sex-only was 3.2 (s.d.=3.4). CONCLUSION MSM not only kiss men in the absence of sex, but also kiss women in the absence of sex. Gonorrhoea could be transmitted between MSM and women via kissing in the absence of sex.
Collapse
Affiliation(s)
- Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic. 3053, Australia; and Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic. 3004, Australia; and Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic. 3053, Australia
| | - Tiffany R Phillips
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic. 3053, Australia; and Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic. 3004, Australia
| | - Julien Tran
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic. 3053, Australia; and Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic. 3004, Australia
| | - Ei T Aung
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic. 3053, Australia; and Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic. 3004, Australia
| | - Kate Maddaford
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic. 3053, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic. 3053, Australia; and Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic. 3004, Australia
| |
Collapse
|
11
|
Neisseria mucosa Does Not Inhibit the Growth of Neisseria gonorrhoeae. SCI 2022. [DOI: 10.3390/sci4010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Antibiotic-sparing treatments are required to prevent the further emergence of antimicrobial resistance in Neisseria gonorrhoeae. Commensal Neisseria species have previously been found to inhibit the growth of pathogenic Neisseria species. For example, a previous study found that three out of five historical isolates of Neisseria mucosa could inhibit the growth of N. gonorrhoeae. In this study, we used agar overlay assays to assess if 24 circulating and historical isolates of Neisseria mucosa could inhibit the growth of 28 circulating and historical isolates of N. gonorrhoeae. Although pitting around each colony of N. mucosa created an optical illusion of decreased growth of N. gonorrhoeae, we found no evidence of inhibition (n = 24). In contrast, positive controls of Streptococcus pneumoniae and Escherichia coli demonstrated a strong inhibitory effect against the growth of N. gonorrhoeae.
Collapse
|
12
|
Van Dijck C, Tsoumanis A, De Hondt A, Cuylaerts V, Laumen J, Van Herrewege Y, Florence E, De Baetselier I, Kenyon C. Chlorhexidine Mouthwash Fails to Eradicate Oropharyngeal Gonorrhea in a Clinical Pilot Trial (MoNg). Sex Transm Dis 2022; 49:e38-e41. [PMID: 34282741 DOI: 10.1097/olq.0000000000001515] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT This single-arm open-label pilot trial in Antwerp, Belgium, was ended early in accordance with the protocol because twice-daily gargling with chlorhexidine 0.2% for 6 days failed to eradicate Neisseria gonorrhoeae from the oropharynx of asymptomatic men who have sex with men (n = 3; efficacy of 0%; 95% confidence interval, 0%-56.1%).
Collapse
Affiliation(s)
| | - Achilleas Tsoumanis
- From the Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp
| | - Annelies De Hondt
- From the Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp
| | - Vicky Cuylaerts
- From the Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp
| | | | - Yven Van Herrewege
- From the Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp
| | - Eric Florence
- From the Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp
| | - Irith De Baetselier
- From the Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp
| | | |
Collapse
|
13
|
The Impact of Mouthwash on the Oropharyngeal Microbiota of Men Who Have Sex with Men: a Substudy of the OMEGA Trial. Microbiol Spectr 2022; 10:e0175721. [PMID: 35019769 PMCID: PMC8754113 DOI: 10.1128/spectrum.01757-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Mouthwash is a commonly used product and has been proposed as an alternative intervention to prevent gonorrhea transmission. However, the long-term effects of mouthwash on the oral microbiota are largely unknown. We investigated the impact of 12 weeks of daily mouthwash use on the oropharyngeal microbiota in a subset of men who have sex with men who participated in a randomized trial comparing the efficacy of two alcohol-free mouthwashes for the prevention of gonorrhea. We characterized the oropharyngeal microbiota using 16S rRNA gene sequencing of tonsillar fossae samples collected before and after 12 weeks of daily use of Listerine mouthwash or Biotène dry mouth oral rinse. Permutational multivariate analysis of variance (PERMANOVA) was used to assess differences in oropharyngeal microbiota composition following mouthwash use. Differential abundance testing was performed using ALDEx2, with false-discovery rate correction. A total of 306 samples from 153 men were analyzed (Listerine, n = 78 and Biotène, n = 75). There was no difference in the overall structure of the oropharyngeal microbiota following Listerine or Biotène use (PERMANOVA P = 0.413 and P = 0.331, respectively). Although no bacterial taxa were significantly differentially abundant following Listerine use, we observed a small but significant decrease in the abundance of both Streptococcus and Leptotrichia following Biotène use. Overall, our findings suggest that daily use of antiseptic mouthwash has minimal long-term effects on the composition of the oropharyngeal microbiota. IMPORTANCE Given the role of the oral microbiota in human health, it is important to understand if and how external factors influence its composition. Mouthwash use is common in some populations, and the use of antiseptic mouthwash has been proposed as an alternative intervention to prevent gonorrhea transmission. However, the long-term effect of mouthwash use on the oral microbiota composition is largely unknown. We found that daily use of two different commercially available mouthwashes had limited long-term effects on the composition of the oropharyngeal microbiota over a 12-week period. The results from our study and prior studies highlight that different mouthwashes may differentially affect the oral microbiome composition and that further studies are needed to determine if mouthwash use induces short-term changes to the oral microbiota that may have detrimental effects.
Collapse
|
14
|
Xu X, Chow EPF, Ong JJ, Shen M, Wang C, Hocking JS, Fairley CK, Zhang L. Modelling the potential role of saliva use during masturbation in the transmission of Neisseria gonorrhoeae at multiple anatomical sites. Sex Health 2021; 18:466-474. [PMID: 34914887 DOI: 10.1071/sh21138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/05/2021] [Indexed: 11/23/2022]
Abstract
Background Neisseria gonorrhoeae can be cultured from saliva in men with pharyngeal gonorrhoea and could theoretically be transmitted from the pharynx to the urethra when saliva is used as a lubricant for masturbation. In this work, we proposed that saliva use during masturbation may be a potential transmission route of gonorrhoea. Methods We analysed the transmission of Neisseria gonorrhoeae at the oropharynx, urethra and anorectum with mathematical models among men who have sex with men using data from six different studies. Model 1 included transmission routes (oral sex, anal sex, rimming, kissing, and three sequential sex practices). In Model 2, we added saliva use during solo masturbation and mutual masturbation to model 1. Results Model 2 could replicate single site infection at the oropharynx, urethra and anorectum and multi-site infection across six different datasets. However, the calibration of Model 2 was not significantly different from Model 1 across four datasets. Model 2 generated an incidence of gonorrhoea from masturbation of between 5.2% (95% CI: 3.2-10.1) to 10.6% (95% CI: 5.8-17.3) across six data sets. Model 2 also estimated that about one in four cases of urethral gonorrhoea might arise from solo masturbation and mutual masturbation. Conclusions Our models raise the possibility that saliva use during masturbation may play a role in transmitting gonorrhoea. This is an important area to explore because it contributes to the knowledge base about gonorrhoea transmission.
Collapse
Affiliation(s)
- Xianglong Xu
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Vic. 3053, Australia; and Faculty of Medicine, Central Clinical School, Nursing and Health Sciences, Monash University, 99 Commercial Road, Melbourne, Vic. 3004, Australia; and China Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi 710061, PR China
| | - Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Vic. 3053, Australia; and Faculty of Medicine, Central Clinical School, Nursing and Health Sciences, Monash University, 99 Commercial Road, Melbourne, Vic. 3004, Australia; and Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie Street, Carlton, Vic. 3053, Australia
| | - Jason J Ong
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Vic. 3053, Australia; and Faculty of Medicine, Central Clinical School, Nursing and Health Sciences, Monash University, 99 Commercial Road, Melbourne, Vic. 3004, Australia; and China Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi 710061, PR China
| | - Mingwang Shen
- China Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi 710061, PR China
| | - Chongjian Wang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan, China
| | - Jane S Hocking
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie Street, Carlton, Vic. 3053, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Vic. 3053, Australia; and Faculty of Medicine, Central Clinical School, Nursing and Health Sciences, Monash University, 99 Commercial Road, Melbourne, Vic. 3004, Australia; and China Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi 710061, PR China
| | - Lei Zhang
- Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, Vic. 3053, Australia; and Faculty of Medicine, Central Clinical School, Nursing and Health Sciences, Monash University, 99 Commercial Road, Melbourne, Vic. 3004, Australia; and China Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi 710061, PR China; and Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan, China
| |
Collapse
|
15
|
Laumen JGE, Van Dijck C, Manoharan-Basil SS, Abdellati S, De Baetselier I, Cuylaerts V, De Block T, Van den Bossche D, Xavier BB, Malhotra-Kumar S, Kenyon C. Sub-Inhibitory Concentrations of Chlorhexidine Induce Resistance to Chlorhexidine and Decrease Antibiotic Susceptibility in Neisseria gonorrhoeae. Front Microbiol 2021; 12:776909. [PMID: 34899659 PMCID: PMC8660576 DOI: 10.3389/fmicb.2021.776909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/25/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives: Chlorhexidine digluconate (chlorhexidine) and Listerine® mouthwashes are being promoted as alternative treatment options to prevent the emergence of antimicrobial resistance in Neisseria gonorrhoeae. We performed in vitro challenge experiments to assess induction and evolution of resistance to these two mouthwashes and potential cross-resistance to other antimicrobials. Methods: A customized morbidostat was used to subject N. gonorrhoeae reference strain WHO-F to dynamically sustained Listerine® or chlorhexidine pressure for 18 days and 40 days, respectively. Cultures were sampled twice a week and minimal inhibitory concentrations (MICs) of Listerine®, chlorhexidine, ceftriaxone, ciprofloxacin, cefixime and azithromycin were determined using the agar dilution method. Isolates with an increased MIC for Listerine® or chlorhexidine were subjected to whole genome sequencing to track the evolution of resistance. Results: We were unable to increase MICs for Listerine®. Three out of five cultures developed a 10-fold increase in chlorhexidine MIC within 40 days compared to baseline (from 2 to 20 mg/L). Increases in chlorhexidine MIC were positively associated with increases in the MICs of azithromycin and ciprofloxacin. Low-to-higher-level chlorhexidine resistance (2–20 mg/L) was associated with mutations in NorM. Higher-level resistance (20 mg/L) was temporally associated with mutations upstream of the MtrCDE efflux pump repressor (mtrR) and the mlaA gene, part of the maintenance of lipid asymmetry (Mla) system. Conclusion: Exposure to sub-lethal chlorhexidine concentrations may not only enhance resistance to chlorhexidine itself but also cross-resistance to other antibiotics in N. gonorrhoeae. This raises concern regarding the widespread use of chlorhexidine as an oral antiseptic, for example in the field of dentistry.
Collapse
Affiliation(s)
- Jolein G E Laumen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.,Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Christophe Van Dijck
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.,Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | | | - Saïd Abdellati
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Irith De Baetselier
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Vicky Cuylaerts
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Tessa De Block
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Dorien Van den Bossche
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Basil B Xavier
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Surbhi Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Chris Kenyon
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
16
|
Novel strategies for prevention and treatment of antimicrobial resistance in sexually-transmitted infections. Curr Opin Infect Dis 2021; 34:591-598. [PMID: 34545855 DOI: 10.1097/qco.0000000000000793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Antimicrobial resistance in sexually acquired infection (STI) pathogens is an important global public health threat. There is an urgent need for novel STI treatment and prevention strategies to tackle the rising incidence of STIs in high-income settings and the static progress in low- and middle-income settings over the past decade. The purpose of this review was to describe the research outlining the emergence of resistance in common STI pathogens and new strategies for their treatment and prevention. RECENT FINDINGS Rates of STIs have dramatically increased over the past decade. Further, antimicrobial resistance to first-line agents among key STI pathogens continues to emerge globally. Recent findings demonstrate promising results regarding the efficacy of novel antimicrobial treatment strategies for these pathogens, including several new, repurposed and unique combinations of antimicrobials. In addition, a number of new biomedical prevention strategies, such as antibacterial mouthwash and doxycycline chemoprophylaxis, are being investigated as novel prevention strategies for bacterial STIs. SUMMARY Significant progress has been made in the development of novel antimicrobials for the treatment of antimicrobial-resistant sexually acquired pathogens. However, due to the rapid development of resistance to antimicrobials demonstrated by these pathogens in the past, further research and development of effective prevention strategies should be prioritized.
Collapse
|
17
|
Xu X, Chow EPF, Shen M, Zou Z, Wang C, Ong JJ, Fairley CK, Zhang L. Potential effect of antiseptic mouthwash on the incidence of Neisseria gonorrhoeae among men who have sex with men: a mathematical modelling study. BMJ Open 2021; 11:e052823. [PMID: 34620667 PMCID: PMC8499270 DOI: 10.1136/bmjopen-2021-052823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES The incidence of Neisseria gonorrhoeae and its antimicrobial resistance is increasing in many countries. Antibacterial mouthwash may reduce gonorrhoea transmission without using antibiotics. We modelled the effect that antiseptic mouthwash may have on the incidence of gonorrhoea. DESIGN We developed a mathematical model of the transmission of gonorrhoea between each anatomical site (oropharynx, urethra and anorectum) in men who have sex with men (MSM). We constructed four scenarios: (1) mouthwash had no effect; (2) mouthwash increased the susceptibility of the oropharynx; (3) mouthwash reduced the transmissibility from the oropharynx; (4) the combined effect of mouthwash from scenarios 2 and 3. SETTING We used data at three anatomical sites from 4873 MSM attending Melbourne Sexual Health Centre in 2018 and 2019 to calibrate our models and data from the USA, Netherlands and Thailand for sensitivity analyses. PARTICIPANTS Published available data on MSM with multisite infections of gonorrhoea. PRIMARY AND SECONDARY OUTCOME MEASURES Incidence of gonorrhoea. RESULTS The overall incidence of gonorrhoea was 44 (95% CI 37 to 50)/100 person-years (PY) in scenario 1. Under scenario 2 (20%-80% mouthwash coverage), the total incidence increased (47-60/100 PY) and at all three anatomical sites by between 7.4% (5.9%-60.8%) and 136.6% (108.1%-177.5%). Under scenario 3, with the same coverage, the total incidence decreased (20-39/100 PY) and at all anatomical sites by between 11.6% (10.2%-13.5%) and 99.8% (99.2%-100%). Under scenario 4, changes in the incidence depended on the efficacy of mouthwash on the susceptibility or transmissibility. The effect on the total incidence varied (22-55/100 PY), and at all anatomical sites, there were increases of nearly 130% and large declines of almost 100%. CONCLUSIONS The effect of mouthwash on gonorrhoea incidence is largely predictable depending on whether it increases susceptibility to or reduces the transmissibility of gonorrhoea.
Collapse
Affiliation(s)
- Xianglong Xu
- China-Australia Joint Research Center for Infectious Diseases,School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi an, Shanxi, People's Republic of China
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Mingwang Shen
- China-Australia Joint Research Center for Infectious Diseases,School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi an, Shanxi, People's Republic of China
| | - Zhuoru Zou
- China-Australia Joint Research Center for Infectious Diseases,School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi an, Shanxi, People's Republic of China
| | - Chongjian Wang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
| | - Jason J Ong
- China-Australia Joint Research Center for Infectious Diseases,School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi an, Shanxi, People's Republic of China
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Christopher K Fairley
- China-Australia Joint Research Center for Infectious Diseases,School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi an, Shanxi, People's Republic of China
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Lei Zhang
- China-Australia Joint Research Center for Infectious Diseases,School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi an, Shanxi, People's Republic of China
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
| |
Collapse
|
18
|
Rotsaert A, Reyniers T, Van Dijck C, Vuylsteke B, Kenyon C. Proposing an antibacterial mouthwash to prevent gonorrhoea is not sexy. THE LANCET. INFECTIOUS DISEASES 2021; 21:909. [PMID: 34174229 DOI: 10.1016/s1473-3099(21)00322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Anke Rotsaert
- Sexual and Reproductive Health Research Group, Institute of Tropical Medicine, 2000 Antwerp, Belgium.
| | - Thijs Reyniers
- Sexual and Reproductive Health Research Group, Institute of Tropical Medicine, 2000 Antwerp, Belgium
| | - Christophe Van Dijck
- Sexual and Reproductive Health Research Group, Institute of Tropical Medicine, 2000 Antwerp, Belgium
| | - Bea Vuylsteke
- Sexual and Reproductive Health Research Group, Institute of Tropical Medicine, 2000 Antwerp, Belgium
| | - Chris Kenyon
- Sexual and Reproductive Health Research Group, Institute of Tropical Medicine, 2000 Antwerp, Belgium
| |
Collapse
|
19
|
Ceccherini-Silberstein F, Desai M, Thomson-Glover R. Research news in clinical context. Sex Transm Infect 2021; 97:321-322. [PMID: 34282044 DOI: 10.1136/sextrans-2020-054857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Monica Desai
- Blood Safety, Hepatitis, STI & HIV Division, National Infection Service, Public Health England, London, UK
| | - Rebecca Thomson-Glover
- Sexual Health Department, St Helens and Knowsley NHS Trusts, St Helens Hospital, St Helens, UK
| |
Collapse
|
20
|
Is it the end of mouthwash as an intervention for gonorrhoea? THE LANCET. INFECTIOUS DISEASES 2021; 21:763-764. [PMID: 34051184 DOI: 10.1016/s1473-3099(21)00195-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/15/2021] [Indexed: 11/22/2022]
|
21
|
Van Dijck C, Tsoumanis A, Rotsaert A, Vuylsteke B, Van den Bossche D, Paeleman E, De Baetselier I, Brosius I, Laumen J, Buyze J, Wouters K, Lynen L, Van Esbroeck M, Herssens N, Abdellati S, Declercq S, Reyniers T, Van Herrewege Y, Florence E, Kenyon C. Antibacterial mouthwash to prevent sexually transmitted infections in men who have sex with men taking HIV pre-exposure prophylaxis (PReGo): a randomised, placebo-controlled, crossover trial. THE LANCET. INFECTIOUS DISEASES 2021; 21:657-667. [PMID: 33676596 DOI: 10.1016/s1473-3099(20)30778-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/09/2020] [Accepted: 09/24/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bacterial sexually transmitted infections (STIs) are highly prevalent among men who have sex with men who use HIV pre-exposure prophylaxis (PrEP), which leads to antimicrobial consumption linked to the emergence of antimicrobial resistance. We aimed to assess use of an antiseptic mouthwash as an antibiotic sparing approach to prevent STIs. METHODS We invited people using PrEP who had an STI in the past 24 months to participate in this single-centre, randomised, double-blind, placebo-controlled, AB/BA crossover superiority trial at the Institute of Tropical Medicine in Antwerp, Belgium. Using block randomisation (block size eight), participants were assigned (1:1) to first receive Listerine Cool Mint or a placebo mouthwash. They were required to use the study mouthwashes daily and before and after sex for 3 months each and to ask their sexual partners to use the mouthwash before and after sex. Participants were screened every 3 months for syphilis, chlamydia, and gonorrhoea at the oropharynx, anorectum, and urethra. The primary outcome was combined incidence of these STIs during each 3-month period, assessed in the intention-to-treat population, which included all participants who completed at least the first 3-month period. Safety was assessed as a secondary outcome. This trial is registered with Clinicaltrials.gov, NCT03881007. FINDINGS Between April 2, 2019, and March 13, 2020, 343 participants were enrolled: 172 in the Listerine followed by placebo (Listerine-placebo) group and 171 in the placebo followed by Listerine (placebo-Listerine) group. The trial was terminated prematurely because of the COVID-19 pandemic. 151 participants completed the entire study, and 89 completed only the first 3-month period. 31 participants withdrew consent, ten were lost to follow-up, and one acquired HIV. In the Listerine-placebo group, the STI incidence rate was 140·4 per 100 person-years during the Listerine period, and 102·6 per 100 person-years during the placebo period. In the placebo-Listerine arm, the STI incidence rate was 133·9 per 100 person-years during the placebo period, and 147·5 per 100 person-years during the Listerine period. We did not find that Listerine significantly reduced STI incidence (IRR 1·17, 95% CI 0·84-1·64). Numbers of adverse events were not significantly higher than at baseline and were similar while using Listerine and placebo. Four serious adverse events (one HIV-infection, one severe depression, one Ludwig's angina, and one testicular carcinoma) were not considered to be related to use of mouthwash. INTERPRETATION Our findings do not support the use of Listerine Cool Mint as a way to prevent STI acquisition among high-risk populations. FUNDING Belgian Research Foundation - Flanders (FWO 121·00).
Collapse
Affiliation(s)
- Christophe Van Dijck
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Medical Microbiology, University of Antwerp, Belgium
| | - Achilleas Tsoumanis
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Medical Sciences, University of Antwerp, Belgium
| | - Anke Rotsaert
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bea Vuylsteke
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Elke Paeleman
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Irith De Baetselier
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Isabel Brosius
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jolein Laumen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jozefien Buyze
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kristien Wouters
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Lutgarde Lynen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Marjan Van Esbroeck
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Natacha Herssens
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Said Abdellati
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Steven Declercq
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Thijs Reyniers
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Yven Van Herrewege
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Eric Florence
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Chris Kenyon
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa.
| |
Collapse
|
22
|
de Vries HJC, van der Loeff MFS. Antiseptic mouthwashes against sexually transmitted infections. THE LANCET. INFECTIOUS DISEASES 2021; 21:583-584. [PMID: 33676594 DOI: 10.1016/s1473-3099(20)30839-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/08/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Henry J C de Vries
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands; Department of Dermatology, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, Amsterdam 1100DD, Netherlands.
| | - Maarten F Schim van der Loeff
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands; Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, Amsterdam 1100DD, Netherlands
| |
Collapse
|
23
|
Lim KYL, Mullally CA, Haese EC, Kibble EA, McCluskey NR, Mikucki EC, Thai VC, Stubbs KA, Sarkar-Tyson M, Kahler CM. Anti-Virulence Therapeutic Approaches for Neisseria gonorrhoeae. Antibiotics (Basel) 2021; 10:antibiotics10020103. [PMID: 33494538 PMCID: PMC7911339 DOI: 10.3390/antibiotics10020103] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 01/15/2023] Open
Abstract
While antimicrobial resistance (AMR) is seen in both Neisseria gonorrhoeae and Neisseria meningitidis, the former has become resistant to commonly available over-the-counter antibiotic treatments. It is imperative then to develop new therapies that combat current AMR isolates whilst also circumventing the pathways leading to the development of AMR. This review highlights the growing research interest in developing anti-virulence therapies (AVTs) which are directed towards inhibiting virulence factors to prevent infection. By targeting virulence factors that are not essential for gonococcal survival, it is hypothesized that this will impart a smaller selective pressure for the emergence of resistance in the pathogen and in the microbiome, thus avoiding AMR development to the anti-infective. This review summates the current basis of numerous anti-virulence strategies being explored for N. gonorrhoeae.
Collapse
Affiliation(s)
- Katherine Y. L. Lim
- Marshall Centre for Infectious Disease Research and Training, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia; (K.Y.L.L.); (C.A.M.); (E.C.H.); (E.A.K.); (N.R.M.); (E.C.M.); (V.C.T.); (M.S.-T.)
| | - Christopher A. Mullally
- Marshall Centre for Infectious Disease Research and Training, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia; (K.Y.L.L.); (C.A.M.); (E.C.H.); (E.A.K.); (N.R.M.); (E.C.M.); (V.C.T.); (M.S.-T.)
| | - Ethan C. Haese
- Marshall Centre for Infectious Disease Research and Training, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia; (K.Y.L.L.); (C.A.M.); (E.C.H.); (E.A.K.); (N.R.M.); (E.C.M.); (V.C.T.); (M.S.-T.)
| | - Emily A. Kibble
- Marshall Centre for Infectious Disease Research and Training, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia; (K.Y.L.L.); (C.A.M.); (E.C.H.); (E.A.K.); (N.R.M.); (E.C.M.); (V.C.T.); (M.S.-T.)
- School of Veterinary and Life Sciences, Murdoch University, Murdoch, WA 6150, Australia
| | - Nicolie R. McCluskey
- Marshall Centre for Infectious Disease Research and Training, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia; (K.Y.L.L.); (C.A.M.); (E.C.H.); (E.A.K.); (N.R.M.); (E.C.M.); (V.C.T.); (M.S.-T.)
- School of Veterinary and Life Sciences, Murdoch University, Murdoch, WA 6150, Australia
| | - Edward C. Mikucki
- Marshall Centre for Infectious Disease Research and Training, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia; (K.Y.L.L.); (C.A.M.); (E.C.H.); (E.A.K.); (N.R.M.); (E.C.M.); (V.C.T.); (M.S.-T.)
| | - Van C. Thai
- Marshall Centre for Infectious Disease Research and Training, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia; (K.Y.L.L.); (C.A.M.); (E.C.H.); (E.A.K.); (N.R.M.); (E.C.M.); (V.C.T.); (M.S.-T.)
| | - Keith A. Stubbs
- School of Molecular Sciences, University of Western Australia, Crawley, WA 6009, Australia;
| | - Mitali Sarkar-Tyson
- Marshall Centre for Infectious Disease Research and Training, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia; (K.Y.L.L.); (C.A.M.); (E.C.H.); (E.A.K.); (N.R.M.); (E.C.M.); (V.C.T.); (M.S.-T.)
| | - Charlene M. Kahler
- Marshall Centre for Infectious Disease Research and Training, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia; (K.Y.L.L.); (C.A.M.); (E.C.H.); (E.A.K.); (N.R.M.); (E.C.M.); (V.C.T.); (M.S.-T.)
- Correspondence:
| |
Collapse
|
24
|
Role of saliva use during masturbation in the transmission of Chlamydia trachomatis in men who have sex with men. Epidemiol Infect 2021. [PMCID: PMC8506448 DOI: 10.1017/s0950268821001941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abstract
Masturbation is a common sexual practice in men, and saliva is often used as a lubricant during masturbation by men who have sex with men. However, the role of saliva use during masturbation in the transmission of chlamydia is still unclear. We developed population-level, susceptible-infected-susceptible compartmental models to explore the role of saliva use during masturbation on the transmission of chlamydia at multiple anatomical sites. In this study, we simulated both solo masturbation and mutual masturbation. Our baseline model did not include masturbation but included transmission routes (anal sex, oral-penile sex, rimming, kissing and sequential sexual practices) we have previously validated (model 1). We added masturbation to model 1 to develop the second model (model 2). We calibrated the model to five clinical datasets separately to assess the effects of masturbation on the prevalence of site-specific infection. The inclusion of masturbation (model 2) significantly worsened the ability of the models to replicate the prevalence of C. trachomatis. Using model 2 and the five data sets, we estimated that saliva use during masturbation was responsible for between 3.9% [95% confidence interval (CI) 2.0–6.8] and 6.2% (95% CI 3.8–10.5) of incident chlamydia cases at all sites. Our models suggest that saliva use during masturbation is unlikely to play a major role in chlamydia transmission between men, and even if it does have a role, about one in seven cases of urethral chlamydia might arise from masturbation.
Collapse
|