Clinical presentation of asymptomatic and symptomatic women who tested positive for genital gonorrhoea at a sexual health service in Melbourne, Australia

Zap the clap with DNA: a novel microbicide for preventing Neisseria gonorrhoeae infection

Each year, Neisseria gonorrhoeae (Ngo) causes over 1.5 million new infections in the United States, and >87 million worldwide. The absence of a vaccine for preventing gonorrhea, the rapid emergence of multidrug-resistant and extremely drug-resistant Ngo strains, and the limited number of antibiotics available for treating gonorrhea underscore the importance of developing new modalities for addressing Ngo infection. Here, we describe DNA-based microbicides that kill Ngo but not commensals. Previously, we showed that Ngo is killed when it takes up differentially methylated DNA with homology to its genome. We exploited this Achilles heel to develop a new class of microbicides for preventing Ngo infection. These microbicides consist of DNA molecules with specific sequences and a methylation pattern different from Ngo DNA. These DNAs kill low-passage and antibiotic-resistant clinical isolates with high efficiency but leave commensals unharmed. Equally important, the DNAs are equally effective against Ngo whether they are in buffered media or personal lubricants. These findings illustrate the potential of this new class of practical, low-cost, self-administered DNA-based microbicides for preventing Ngo transmission during sexual intercourse.

Computational prediction of crucial genes involved in gonorrhea infection and neoplastic cell transformation: A multiomics approach

Neisseria gonorrheae, the causative agent of genitourinary infections, has been associated with asymptomatic or recurrent infections and has the potential to form biofilms and induce inflammation and cell transformation. Herein, we aimed to use computational analysis to predict novel associations between chronic inflammation caused by gonorrhea infection and neoplastic transformation. Prioritization and gene enrichment strategies based on virulence and resistance genes utilizing essential genes from the DEG and PANTHER databases, respectively, were performed. Using the STRING database, protein‒protein interaction networks were constructed with 55 nodes of bacterial proteins and 72 nodes of proteins involved in the host immune response. MCODE and cytoHubba were used to identify 12 bacterial hub proteins (murA, murB, murC, murD, murE, purN, purL, thyA, uvrB, kdsB, lpxC, and ftsH) and 19 human hub proteins, of which TNF, STAT3 and AKT1 had high significance. The PPI networks are based on the connectivity degree (K), betweenness centrality (BC), and closeness centrality (CC) values. Hub genes are vital for cell survival and growth, and their significance as potential drug targets is discussed. This computational study provides a comprehensive understanding of inflammation and carcinogenesis pathways that are activated during gonorrhea infection.

Review of mathematical models of Neisseria gonorrhoeae vaccine impact: Implications for vaccine development

An effective prophylactic vaccine for prevention of Neisseria gonorrhoeae infection would have a major impact on sexual and reproductive health worldwide. Interest in developing gonorrhoea vaccines is growing due to the reported high rates of N. gonorrhoeae infections globally, and the threat of antimicrobial resistance. Several gonorrhoea vaccine candidates are currently under evaluation and various mathematical models have been used to assess the potential population-level impact a gonorrhoea vaccine may have once available. Here we review key aspects of gonorrhoea vaccine mathematical modelling studies, including model structures, populations considered, and assumptions used as well as vaccine characteristics and implementation scenarios investigated. The predicted vaccine impact varied between studies, ranging from as little as ∼17 % reduction in N. gonorrhoeae prevalence after 30 years up to 100 % reduction after 5 years. However, all studies predicted that even a partially effective gonorrhoea vaccine could have a substantial impact in reducing N. gonorrhoeae prevalence or incidence, particularly when high coverage is achieved within either important risk groups or the overall sexually active population. As expected, higher vaccine efficacy against acquisition of N. gonorrhoeae and longer duration of protection were linked to greater reductions in infections. A vaccine that alters onward transmission could also substantially reduce infections. Several gaps and research needs have been identified by researchers in the field and via this narrative literature review. For example, future modelling to inform gonorrhoea vaccine development and implementation should consider additional populations that are at high risk of N. gonorrhoeae infection, especially in low- and middle-income settings, as well as the impact of vaccination on the potential adverse sexual and reproductive health outcomes of infection. In addition, more detailed and robust epidemiological, biological, and behavioural data is needed to enable more accurate and robust modelling of gonorrhoea vaccine impact to inform future scientific and public health decision-making.

Alcohol Misuse and Sexually Transmitted Infections: Using the CAGE Questionnaire as a Screening Tool

Background: While the connection between alcohol and risky behavior is well known, a clear correlation between alcohol misuse and contracting sexually transmitted infections (STIs) has not been determined. The 4-question CAGE questionnaire-the acronym stands for attitudes and activities related to alcohol use-is often administered at primary care annual visits to screen patients for alcohol abuse. This study assessed the relationship between CAGE scores and STI results to determine if the CAGE questionnaire could help determine the need for STI screening at annual visits. Methods: All patients who received a CAGE screening from 2015 to 2022 at a Gulf South health system were included in the analysis. The primary outcome of the study was the relationship between a positive CAGE score (a score ≥2) and a positive STI result. STIs included in the primary analysis were human immunodeficiency virus (HIV), hepatitis B, syphilis, chlamydia, gonorrhea, and trichomoniasis. The correlation between a positive CAGE score and hepatitis C was examined as a secondary outcome. Results: A total of 40,022 patients received a CAGE screening during the study period, and 757 (1.9%) scored ≥2 on the CAGE questionnaire. Significant associations were found between a positive CAGE score and hepatitis B (odds ratio [OR]=2.69, 95% CI 1.91, 3.80; P<0.001), gonorrhea (OR=5.43, 95% CI 1.80, 16.39; P=0.003), and hepatitis C (OR=2.10, 95% CI 1.57, 2.80; P<0.001). No associations were found between a positive CAGE score and HIV, chlamydia, or trichomoniasis. No patients with a CAGE score ≥2 had a syphilis diagnosis; therefore, no syphilis analysis was possible. Conclusion: Based on the results of this study, patients with a CAGE score ≥2 may benefit from screening for hepatitis B, hepatitis C, and gonorrhea at their primary care annual visit. Early STI detection could lead to prompt treatment and prevent further transmission and complications.

Microevolution and Its Impact on Hypervirulence, Antimicrobial Resistance, and Vaccine Escape in Neisseria meningitidis

Neisseria meningitidis is commensal of the human pharynx and occasionally invades the host, causing the life-threatening illness invasive meningococcal disease. The meningococcus is a highly diverse and adaptable organism thanks to natural competence, a propensity for recombination, and a highly repetitive genome. These mechanisms together result in a high level of antigenic variation to invade diverse human hosts and evade their innate and adaptive immune responses. This review explores the ways in which this diversity contributes to the evolutionary history and population structure of the meningococcus, with a particular focus on microevolution. It examines studies on meningococcal microevolution in the context of within-host evolution and persistent carriage; microevolution in the context of meningococcal outbreaks and epidemics; and the potential of microevolution to contribute to antimicrobial resistance and vaccine escape. A persistent theme is the idea that the process of microevolution contributes to the development of new hyperinvasive meningococcal variants. As such, microevolution in this species has significant potential to drive future public health threats in the form of hypervirulent, antibiotic-resistant, vaccine-escape variants. The implications of this on current vaccination strategies are explored.

Disseminated Gonococcal Infection Due to a Mediport Catheter Infection

Gonorrhea is a sexually transmitted disease caused by Neisseria gonorrhoeae and has a wide clinical spectrum that can range from asymptomatic to disseminated disease. Most women with gonorrhea are asymptomatic and if left untreated, it can lead to serious complications like pelvic inflammatory disease (PID) and infertility. Disseminated gonococcal infection (DGI) is usually characterized by dermatitis, tenosynovitis, and septic arthritis but rarely can also cause bacteremia, endovascular infections, osteomyelitis, and meningitis. Gonococcal bacteremia is regarded as a disseminated disease and is typically associated with infection of the mucosal surfaces such as the urethra, endocervix, and pharynx. This report, to the best of our knowledge, presents a case of DGI associated with a mediport catheter in a patient with breast cancer without any history of gonococcal symptoms. She was monogamous and denied any history of sexually transmitted infections. The patient presented with fever and chills associated with pain and purulent discharge from the mediport catheter site. The mediport catheter was removed, and antibiotics were initiated. Both blood and wound cultures grew N. gonorrhoeae. She completed a 10-day course of ceftriaxone and improved clinically with complete remission of her symptoms. A review of the literature on the reported cases of DGI associated with bacteremia and endovascular infections is also presented.

Trans-inclusive Sexual Health Questionnaire to Improve Human Immunodeficiency Virus/Sexually Transmitted Infection (STI) Care for Transgender Patients: Anatomic Site-Specific STI Prevalence and Screening

BACKGROUND

In 2018, the municipal Sexual Health Clinic in Seattle, implemented trans-inclusive questions about sexual behavior, anatomy, gender-affirming surgeries, and sexually transmitted infection (STI) symptoms in the clinic's computer-assisted self-interview (CASI) to improve care for transgender and nonbinary (TNB) patients.

METHODS

We calculated test positivity, the proportion of TNB patient visits that received testing for human immunodeficiency virus (HIV); syphilis; pharyngeal, rectal, and urogenital gonorrhea (GC); and chlamydia (CT) before (5/2016-12/2018) and after (12/2018-2/2020) implementation of new CASI questions, and the proportion of asymptomatic patients who received anatomic site-specific screening based on reported exposures.

RESULTS

There were 434 TNB patients with 489 and 337 clinic visits during each period, respectively. Nonbinary patients assigned male at birth (AMAB) had the highest prevalence of GC (10% pharyngeal, 14% rectal, 12% urogenital). Transgender women, transgender men, and nonbinary people AMAB had a high prevalence of rectal CT (10%, 9%, and 13%, respectively) and syphilis (9%, 5%, and 8%). Asymptomatic transgender women, transgender men, and nonbinary patients AMAB were more likely to receive extragenital GC/CT screening compared with nonbinary patients assigned female at birth. After implementation of trans-inclusive questions, there was a 33% increase in the number of annual TNB patient visits but no statistically significant increase in HIV/STI testing among TNB patients.

CONCLUSIONS

TNB people had a high prevalence of extragenital STIs and syphilis. Implementation of trans-inclusive medical history questions at a clinic that serves cisgender and transgender patients was feasible and important for improving the quality of affirming and inclusive sexual healthcare.

The potential public health impact of adolescent 4CMenB vaccination on Neisseria gonorrhoeae infection in England: a modelling study

INTRODUCTION

Diagnoses of gonorrhoea in England rose by 26% between 2018 and 2019. Recent evidence that a vaccine against meningococcal B disease currently offered to infants in the UK (4CMenB) could additionally protect (with 31% efficacy) against gonorrhoea has led to renewed hope for a vaccine. A Phase 2 proof-of-concept trial of 4CMenB vaccination against gonorrhoea in adults is currently underway.

OBJECTIVES

To investigate the potential public health impact of adolescent gonorrhoea vaccination in England, considering different implementation strategies.

METHODS

We developed a deterministic transmission-dynamic model of gonorrhoea infection among heterosexual 13-64-year-olds stratified by age, sex and sexual activity. We explored the impact of a National Immunisation Programme (NIP) among 14-year-olds for a vaccine with 31% efficacy, 6 years' duration of protection, and 85% uptake. We also explored how impact might change for varying efficacy (20-50%) and uptake (75-95%), the addition of a catch-up programme, the use of boosters, and varying duration of protection.

RESULTS

An NIP against gonorrhoea could lead to 50,000 (95% credible interval, CrI 31,000-80,000) and 849,000 (95%CrI 476,000-1,568,000) gonorrhoea infections being averted over 10 and 70 years, respectively, in England, for a vaccine with 31% efficacy and 85% uptake. This is equivalent to 25% (95%CrI 17-33%) of heterosexual infections being averted over 70 years. Vaccine impact is predicted to increase over time and be greatest among 13-18-year-olds (39% of infections 95%CrI 31-49% averted) over 70 years. Varying vaccine efficacy and duration of protection had a noticeable effect on impact. Catch-up and booster vaccination increased the short- and long-term impact, respectively.

CONCLUSIONS

A partially-effective vaccine against gonorrhoea infection, delivered to 14-year-olds alongside the MenACWY vaccine, could have an important population impact on gonorrhoea. Catch-up and booster vaccination could be considered alongside cohort vaccination to increase impact.

Patterns of Sexual Practices, Sexually Transmitted Infections and Other Genital Infections in Women Who Have Sex with Women Only (WSWO), Women Who Have Sex with Men Only (WSMO) and Women Who Have Sex with Men and Women (WSMW): Findings from a Sexual Health Clinic in Melbourne, Australia, 2011-2019

Despite rises in sexually transmitted infection (STI) notifications among Australian women in the last decade, limited STI surveillance data exist specifically for women who have sex with women. This study aimed to compare differences in sexual practices and positivity for STIs and other genital infections among women who have sex with men only (WSMO), women who have sex with women only (WSWO), and women who have sex with men and women (WSMW), and whether these changed over time. In this retrospective repeated cross-sectional study, women attending the Melbourne Sexual Health Centre for the first time between 2011 and 2019 were categorized as "WSMW," "WSWO," or "WSMO" according to self-reported sexual practices in the previous 12 months. Demographic information, sexual practices, and positivity for STIs and other genital infections were compared between the three groups and over time. A total of 36,147 women (2618 WSMW, 534 WSWO, and 32,995 WSMO) were included. WSMW reported more sexual partners (median = 6; IQR = 4-10) than WSMO (median = 3; IQR = 2-5) and WSWO (median = 2; IQR = 1-4) (p < .001). A higher proportion of WSMW always used condoms with casual male partners compared to WSMO (20.4% vs 15.9%; p < .001). The proportion of women who always used condoms with casual male partners decreased over time in WSMO, (19.9% in 2011 to 15.2% in 2019, p_trend < .001) but not in WSMW. Bacterial vaginosis was more common in WSWO (14.8%) than in WSMW (11.8%) and WSMO (7.7%) (p < .001). Chlamydia was more common in WSMO (9.3%) than in WSMW (6.6%) and WSWO (1.2%) (p < .001). Syphilis was more common in WSMO (1.0%) than in WSMW (0.3%) and WSWO (0.0%) (p = .004). Over time, chlamydia positivity in WSWO increased (from 0.0% to 2.7%, p_trend = .014), and syphilis positivity in WSMW increased (from 0.0% to 0.7%, p_trend = .028); however, positivity of these STIs did not change in other groups. Sexual practices and positivity for STIs and other genital infections differed according to the sex of women's partners in the previous 12 months. Knowledge of these differences is important to account for future changes in STI trends that may occur in these subpopulations.

Neisseria gonorrhoeae physiology and pathogenesis

Neisseria gonorrhoeae is an obligate human pathogen that is the cause of the sexually transmitted disease gonorrhoea. Recently, there has been a surge in gonorrhoea cases that has been exacerbated by the rapid rise in gonococcal multidrug resistance to all useful antimicrobials resulting in this organism becoming a significant public health burden. Therefore, there is a clear and present need to understand the organism's biology through its physiology and pathogenesis to help develop new intervention strategies. The gonococcus initially colonises and adheres to host mucosal surfaces utilising a type IV pilus that helps with microcolony formation. Other adhesion strategies include the porin, PorB, and the phase variable outer membrane protein Opa. The gonococcus is able to subvert complement mediated killing and opsonisation by sialylation of its lipooligosaccharide and deploys a series of anti-phagocytic mechanisms. N. gonorrhoeae is a fastidious organism that is able to grow on a limited number of primary carbon sources such as glucose and lactate. The utilization of lactate by the gonococcus has been implicated in a number of pathogenicity mechanisms. The bacterium lives mainly in microaerobic environments and can grow both aerobically and anaerobically with the aid of nitrite. The gonococcus does not produce siderophores for scavenging iron but can utilize some produced by other bacteria, and it is able to successful chelate iron from host haem, transferrin and lactoferrin. The gonococcus is an incredibly versatile human pathogen; in the following chapter, we detail the intricate mechanisms used by the bacterium to invade and survive within the host.

Oropharyngeal gonorrhoea infections among heterosexual women and heterosexual men with urogenital gonorrhoea attending a sexual health clinic in Melbourne, Australia

OBJECTIVES

There is limited evidence about the transmission and prevalence of oropharyngeal gonorrhoea in heterosexuals. From August 2017, Melbourne Sexual Health Centre (MSHC) began testing for oropharyngeal gonorrhoea among heterosexuals with untreated urogenital gonorrhoea. This study aims to determine the positivity of oropharyngeal gonorrhoea among heterosexuals diagnosed with urogenital gonorrhoea at MSHC between August 2017 and May 2020.

METHODS

We included individuals who had oropharyngeal gonorrhoea testing within 30 days of initial testing. We reported the number and proportion of oropharyngeal gonorrhoea positivity, stratified by gender and contact of gonorrhoea. The χ² test was performed to compare the oropharyngeal gonorrhoea positivity between groups.

RESULTS

Of 617 individuals with untreated urogenital gonorrhoea, 424 (68.7%) were tested for oropharyngeal gonorrhoea. Oropharyngeal gonorrhoea positivity was 38.9% (95%CI 34.2-43.7%, 165/424), and was higher in women than in men (115/252, 45.6% versus 50/172, 29.1%, p = 0.001). Furthermore, oropharyngeal gonorrhoea positivity was higher among individuals who were contacts of gonorrhoea cases compared to those who were not (29/44, 65.9% versus 136/380, 35.8%, p < 0.001). There was also no significant difference between women who were sex workers and those who were not (30/78, 38.5% versus 85/174, 48.9%, p = 0.126).

CONCLUSIONS

Our data suggest that oropharyngeal gonorrhoea infection is common among heterosexual women and heterosexual men with untreated urogenital gonorrhoea. Testing heterosexual women and heterosexual men for oropharyngeal gonorrhoea will identify a significant proportion with unrecognized oropharyngeal infections whose recommended treatment is different in some countries.

Incidence and duration of incident oropharyngeal gonorrhoea and chlamydia infections among men who have sex with men: prospective cohort study

Objectives

This prospective cohort study aimed to determine the natural history and incidence of oropharyngeal gonorrhoea and chlamydia among a cohort of men who have sex with men (MSM) over a 12-week period, and to examine risk factors associated with incident oropharyngeal infections.

Methods

MSM either aged ≥18 years and had a diagnosis of oropharyngeal gonorrhoea by nucleic acid amplification test (NAAT) in the past 3 months or aged 18–35 years who were HIV-negative taking pre-exposure prophylaxis (PrEP) were eligible for this study. Enrolled men were followed up for 12 weeks. Oropharyngeal swabs were collected at week 0 (baseline) and week 12 (end of study). Between these time points, weekly saliva specimens and the number of tongue kissing, penile–oral and insertive rimming partners were collected by post. Oropharyngeal swabs and saliva specimens were tested by NAAT for Neisseria gonorrhoeae and Chlamydia trachomatis. Poisson regression was performed to examine the risk factors (weekly number of partners) associated with incident oropharyngeal gonorrhoea.

Results

A total of 100 MSM were recruited. The incidence of oropharyngeal gonorrhoea and chlamydia was 62 (95% CI 37 to 105) and 9 (95% CI 2 to 35)/100 person-years, respectively. The median duration of incident oropharyngeal infection with gonorrhoea was 28 days (IQR=21–36, n=7). The incidence rate ratio (IRR) for oropharyngeal gonorrhoea increased with an increased number of kissing partners (IRR=1.08; 95% CI 1.03 to 1.12) an increased number of penile-oral sex partners (IRR=1.07, 95% CI 1.01 to 1.14) but not with an increased number of insertive rimming partners (IRR=1.11, 95% CI 0.96 to 1.29) or other demographic factors. The IRR and duration of incident oropharyngeal chlamydia were not calculated due to the small number of cases (n=2).

Conclusions

MSM have a high incidence of oropharyngeal gonorrhoea and the median duration of infection was less than 3 months.