The Duration of Pharyngeal Gonorrhea: A Natural History Study

Pharyngeal gonococcal infection and the sensitivity of oral gargle samples in comparison to self-collected throat swabs for the detection of N. gonorrhoeae in persons in Tyrol, Austria

PURPOSE

Asymptomatic pharyngeal gonorrhoea could play an important role in transmission and should be screened for in persons at risk. We investigated the sensitivity of oral gargle samples to detect N. gonorrhoea and describe the frequency of infection by anatomical site.

METHODS

From June 2021 to July 2022 persons diagnosed with gonorrhoea in the STI/HIV department were asked to provide self-collected specimens for single-site testing by NAAT from throat (by gargling and swabbing), anorectum, and first-void urine.

RESULTS

104 episodes of gonorrhoea were analysed in 88 individuals. The median age was 33 years, 85 persons (96.5%) were male. The pharynx was the most common site of infection (71 cases, 68.2%); in 26 persons (25.0%) it was the only site of infection. Anorectal infection was detected in 65 cases (62.5%) and urogenital infection in 25 cases (24.0%). In 46 cases (44.2%) infection was detected in more than one anatomical site. Gargling was less sensitive than throat swabbing to detect pharyngeal infection (85.9% versus 97.2%, p = .038), but was preferred by patients. Only 4 of 71 pharyngeal infections (5.6%) were symptomatic; anorectal and urogenital infections were symptomatic in 12.3% and 76.0% of cases, respectively. Culture recovery of N.gonorrhoeae was only possible in 15.8% of throat swabs, but was successful in 61.9% of anorectal and 84.2% of urogenital samples.

CONCLUSIONS

Asymptomatic pharyngeal gonorrhoea is common. Gargle samples should be used only as alternative specimens with inferior sensitivity compared to throat swab samples.

Managing treatment failure in Neisseria gonorrhoeae infection: current guidelines and future directions

Due to the continued emergence of resistance to extended-spectrum cephalosporin antibiotics, clinicians are increasingly more likely to encounter cases of Neisseria gonorrhoeae treatment failure. The current international treatment guidelines offer few regimens for cases of N gonorrhoeae infection that do not respond to first-line therapy, and there are many complexities that should be considered with such regimens; these include regional variations in resistance to alternative agents, access to different antibiotics, and penetration of those antibiotics within different tissues. Further, such regimens do not account for the challenges of treating pharyngeal infections; many patients who have not responded to treatment with extended-spectrum cephalosporin antibiotics to date have had pharyngeal involvement. In addition, pharyngeal infections play a pivotal role in the emergence and spread of antimicrobial resistance in N gonorrhoeae and are more difficult to treat than urogenital infections because of the unfavourable pharmacokinetics of cephalosporins in pharyngeal tissues. Here, we summarise the current guidelines, provide additional approaches and considerations for clinicians, and highlight knowledge gaps that should be addressed to ensure appropriate therapy in cases of treatment failure.

Unveiling the immune dynamics of Neisseria persistent oral colonization

Commensal bacteria are crucial in maintaining host physiological homeostasis, immune system development, and protection against pathogens. Despite their significance, the factors influencing persistent bacterial colonization and their impact on the host still need to be fully understood. Animal models have served as valuable tools to investigate these interactions, but most have limitations. The bacterial genus Neisseria, which includes both commensal and pathogenic species, has been studied from a pathogenicity to humans perspective but lacks models that study immune responses in the context of long-term persistence. Neisseria musculi, a recently described natural commensal of mice, offers a unique opportunity to study long-term host-commensal interactions. In this study, for the first time, we have used this model to study the transcriptional, phenotypic, and functional dynamics of immune cell signatures in the mucosal and systemic tissue of mice in response to N. musculi colonization. We found key genes and pathways vital for immune homeostasis in palate tissue, validated by flow cytometry of immune cells from the lung, blood, and spleen. This study offers a novel avenue for advancing our understanding of host-bacteria dynamics and may provide a platform for developing efficacious interventions against mucosal persistence by pathogenic Neisseria.

HIV-Negative MSM Infected with Two Different Isolates of Drug-Resistant Neisseria gonorrhoeae-Case Report

The antimicrobial resistance of Neisseria gonorrhoeae (NG) is an increasing public health concern, highlighted by the fact that gonococcus is considered as a 'high'-priority pathogen by the WHO for research and development of new therapeutic options. According to the data of the European Centre for Disease Prevention and Control (ECDC) in 2022, the rate of NG infections is the highest recorded since European surveillance of sexually transmitted infections began in 2009. We report a brief description of a patient infected with two different isolates of drug-resistant N. gonorrhoeae. N. gonorrhoeae cultures were positive from oropharyngeal and urethral swabs and isolates had different antimicrobial susceptibility. We investigated the antimicrobial susceptibility of these isolates to six antimicrobials (ceftriaxone, cefixime, azithromycin, ciprofloxacin, tetracycline, and benzylpenicillin), and minimum inhibitory concentrations (MICs; mg/L) were determined using Etest on gonococcal isolates. Oropharyngeal isolate was resistant to azithromycin while urethral was resistant to penicillin, ciprofloxacin, and tetracycline. Two different and phylogenetically distinct sequence types of NG isolates were identified. Understanding the dynamics and drivers of resistance spread can provide an improved rationale for antibiotic management, and the level of NG resistance should be monitored closely.

Estimating Partnership Duration among MSM in Belgium-A Modeling Study

Mathematical modeling is widely used for describing infection transmission and evaluating interventions. The lack of reliable social parameters in the literature has been mentioned by many modeling studies, leading to limitations in the validity and interpretation of the results. Using data from the European MSM Internet survey 2017, we developed a network model to describe sex acts among MSM in Belgium. The model simulates daily sex acts among steady, persistent casual and one-off partners in a population of 10,000 MSM, grouped as low- or high-activity by using three different definitions. Model calibration was used to estimate partnership duration and homophily rates to match the distribution of cumulative sex partners over 12 months. We estimated an average duration between 1065 and 1409 days for steady partnerships, 4-6 and 251-299 days for assortative high- and low-activity individuals and 8-13 days for disassortative persistent casual partnerships, respectively, varying across the three definitions. High-quality data on social network and behavioral parameters are scarce in the literature. Our study addresses this lack of information by providing a method to estimate crucial parameters for network specification.

Changes in Inflammatory Cytokine Levels in Rectal Mucosa Associated With Neisseria gonorrheae and/or Chlamydia trachomatis Infection and Treatment Among Men Who Have Sex With Men in Lima, Peru

BACKGROUND

Neisseria gonorrheae and Chlamydia trachomatis are associated with mucosal inflammation and human immunodeficiency virus 1 (HIV-1) transmission. We assessed levels of inflammatory cytokines in men who have sex with men (MSM) with and without rectal gonorrhea and/or chlamydia in Lima, Peru.

METHODS

We screened 605 MSM reporting condomless receptive anal intercourse for rectal N. gonorrheae/C. trachomatis using nucleic acid testing. We identified 101 cases of gonorrhea and/or chlamydia and randomly selected 50 N. gonorrheae/C. trachomatis positive cases and matched 52 negative controls. We measured levels of IL-1β, IL-6, IL-8, and TNF-α in rectal secretions. Tests for HIV-1, rectal N. gonorrheae/C. trachomatis, and mucosal cytokines were repeated after 3 and 6 months. Cytokine levels in cases and uninfected controls were compared using Wilcoxon rank-sum tests and linear regression.

RESULTS

MSM with gonorrhea/chlamydia had elevated levels of all cytokines in rectal mucosa compared with matched controls (all P values <.001). Following antibiotic treatment there were no significant differences in cytokine levels at 3- or 6-month follow-up evaluations (all P values >.05).

DISCUSSION

Rectal gonorrhea/chlamydia infection is associated with transient mucosal inflammation and cytokine recruitment. Our data provide proof of concept for rectal sexually transmitted infection screening as an HIV prevention strategy for MSM. Clinical Trials Registration. NCT03010020.

STI pathogens in the oropharynx: update on screening and treatment

PURPOSE OF REVIEW

The rise in antimicrobial resistance in several STI pathogens such as Neisseria gonorrhoeae has become a public health threat as only one first-line treatment remains. Reducing screening interval for gonorrhoea and chlamydia in high-prevalence populations has been proposed to address antimicrobial stewardship, but this remains controversial. This review aimed to revisit the epidemiology of infections at the oropharynx and review the current screening recommendations and treatment guidelines in different populations.

RECENT FINDINGS

Emerging evidence suggests that the oropharynx is the primary anatomical site for gonorrhoea transmission but maybe not for chlamydia transmission. Most international guidelines recommend 3-monthly oropharyngeal gonorrhoea and chlamydia screening for high-prevalence populations (e.g. men who have sex with men) but not low-prevalence populations (e.g. heterosexuals) given the clinical and public health benefits of screening in low-prevalence populations are still unclear. Doxycycline remains the first-line treatment for oropharyngeal chlamydia in most guidelines. However, some countries have moved from dual therapy (ceftriaxone and azithromycin) to monotherapy (ceftriaxone) for oropharyngeal gonorrhoea treatment to address antimicrobial stewardship.

SUMMARY

The transmission of gonorrhoea and chlamydia is still not fully understood. Further work will be required to evaluate the benefits and harms of reducing screening in high-prevalence populations.

Frequent screening for asymptomatic chlamydia and gonorrhoea infections in men who have sex with men: time to re-evaluate?

There is increasing debate regarding the harms and benefits of frequent asymptomatic screening for Chlamydia trachomatis and Neisseria gonorrhoeae in men who have sex with men (MSM). One concern is that frequent asymptomatic screening could result in increased antimicrobial resistance in an array of sexually acquired infections and other pathogens, due to selection pressure exerted by frequent broad-spectrum antimicrobial usage within some sexual networks. Here, we outline the harms and benefits of frequent C trachomatis and N gonorrhoeae screening in MSM in high-income settings and propose that screening frequency be reduced. We describe the evidence gaps that should be further explored to better understand the implications of reducing the frequency of asymptomatic C trachomatis and N gonorrhoeae screening in MSM and the surveillance systems that should be in place to prepare for such changes.

Management of asymptomatic sexually transmitted infections in Europe: towards a differentiated, evidence-based approach

Most sexually transmitted infections (STIs) can be accurately diagnosed and treated during asymptomatic carriage. Widespread screening for these STIs is therefore assumed to be an effective way to reduce their prevalence and associated disease. In this review, we provide evidence that this is the case for HIV and syphilis. However, for other STIs such as Neisseria gonorrhoeae and Chlamydia trachomatis, our review reveals that the evidence that screening reduces infection prevalence and associated disease is weak. There is also growing evidence of harms from screening that might outweigh any benefits. The harms include the increased consumption of antimicrobials that follows frequent screening and increased detection of asymptomatic STIs in key populations, such as men who have sex with men taking HIV pre-exposure prophylaxis, and associated risk of antimicrobial resistance in target and non-target organisms. There may also be psycho-social harm associated with an STI diagnosis. We conclude that in the absence of symptoms, in high STI prevalence populations frequent STI screening should be limited to HIV and syphilis.

Inadequate performance of a risk score to predict asymptomatic Neisseria gonorrhoeae and Chlamydia trachomatis infection among cisgender men who have sex with men

OBJECTIVES

Epidemiological treatment of persons who are sexual contacts to partners with Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) often results in treatment of uninfected persons, which may increase the risk of antibiotic-resistant infections. We sought to identify the predictors of NG and/or CT infections to develop a risk score that could be used to limit epidemiological treatment to persons most likely to have these infections.

METHODS

We included visits to the Public Health - Seattle & King County Sexual Health Clinic by asymptomatic cisgender men who have sex with men (MSM) aged ≥18 who presented as a sexual contact to partner(s) with CT or NG infection between 2011 and 2019. We used logistic regression to estimate the odds of CT and/or NG infections associated with demographic and clinical predictors, selecting the final set of predictors using the Akaike information criteria and obtaining score weights from model coefficients. We used a cross-validation approach to obtain average model discrimination from each of 10 models, leaving out 10% of the data, and evaluated sensitivity and specificity at various score cut-offs.

RESULTS

The final model for predicting NG or CT infection included seven predictors (age <35 years, HIV status, receptive oral sex in the prior 2 months, CT diagnosis, condomless receptive anal intercourse, condomless insertive anal intercourse and methamphetamine use in the prior 12 months). Model discrimination, as measured by the receiver operating curve, was 0.60 (95% CI 0.54 to 0.66). Sensitivity for detection of infection was ≥90% for scores ≥3, ≥5 and ≥7; specificity for these cut-offs was <16%. At scores ≥9, ≥12 and ≥14, specificity increased but sensitivity decreased to ≤76%.

CONCLUSIONS

Our risk score did not sufficiently discriminate between asymptomatic MSM with and without NG/CT infection. Additional studies evaluating epidemiological treatment as a standard of care in diverse populations are needed to guide best practices in the management of contacts to NG/CT infection.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

HIV pre-exposure prophylaxis and diagnoses of sexually transmitted infections - observational data from German checkpoints, 01/2019-08/2021

BACKGROUND

The impact of starting HIV pre-exposure prophylaxis (PrEP) on diagnoses of sexually transmitted infections (STI) remains unclear. We used data from German HIV/STI Checkpoints collected from 01/2019 to 08/2021 to determine the impact of PrEP use on syphilis, gonorrhoea and chlamydia diagnoses.

METHODS

We used self-reported data on demographics, sexual behaviour, testing and PrEP use, as well as lab-confirmed diagnoses from visits to HIV/STI Checkpoints in Germany. PrEP use was categorized as (1) never used; (2) intention to use; (3) former use; (4) current on-demand use; (5) daily use. In multivariate regression analyses (MRA) with gonorrhoea, chlamydia, and syphilis diagnoses as outcomes, we controlled for age, number of sexual partners, number of condomless anal intercourse (CAI) partners in the last six months, and testing recency.

RESULTS

For the analysis, we included 9,219 visits for gonorrhoea and chlamydia testing and 11,199 visits for syphilis testing conducted at checkpoints from 01/2019 to 08/2021. MRA identified age (aOR 0.98; 95%CI 0.97-0.99), number of sexual partners in the past six months (aOR 4.90; 95%CI 2.53-9.52 for 11 + partners), and use of chemsex substances (aOR 1.62; 95%CI 1.32-2.00) as risk factors for gonorrhoea, while age (aOR 0.99; 95%CI 0.98-1.00), number of CAI partners (aOR 3.19; 95%CI 2.32-4.41 for 5 + partners), partner sorting (aOR 1.30; 95%CI 1.09-1.54), and use of chemsex substances (aOR 1.29; 95%CI 1.05-1.59) were risk factors for chlamydia infections. For syphilis, the number of CAI partners (aOR 3.19; 95%CI 1.60-6.34 for 5 + partners) was found to be the only significant risk factor. There was a strong association between PrEP use and the number of sexual partners (≤ 5 vs.>5: aOR 3.58; 95%CI 2.15-5.97 for daily PrEP use), the number of CAI partners in the past six months (≤ 1 vs.>1: aOR 3.70; 95%CI 2.15-6.37 for daily PrEP use), and the number of STI tests performed (suggesting higher testing frequency). Both outcomes were also related to partner sorting, chemsex, and selling sex.

CONCLUSIONS

Checkpoint visits reporting current PrEP use or intention to start PrEP correlated with eligibility criteria for PrEP, i.e. high partner numbers, inconsistent condom use during anal intercourse, and use of chemsex drugs. Use of HIV-specific prevention methods such as HIV serosorting, PrEP sorting, and viral load sorting was reported more frequently. (Daily) PrEP use was an independent risk factor for a chlamydia diagnosis only.

Prior Exposure to Azithromycin and Azithromycin Resistance Among Persons Diagnosed With Neisseria gonorrhoeae Infection at a Sexual Health Clinic: 2012-2019

BACKGROUND

There is conflicting evidence on whether prior azithromycin (AZM) exposure is associated with reduced susceptibility to AZM (AZMRS) among persons infected with Neisseria gonorrhoeae (NG).

METHODS

The study population included Public Health-Seattle and King County Sexual Health Clinic (SHC) patients with culture-positive NG infection at ≥1 anatomic site whose isolates were tested for AZM susceptibility in 2012-2019. We used multivariate logistic regression to examine the association of time since last AZM prescription from the SHC in ≤12 months with subsequent diagnosis with AZMRS NG (minimum inhibitory concentration [MIC], ≥2.0 µg/mL) and used linear regression to assess the association between the number of AZM prescriptions in ≤12 months and AZM MIC level, controlling for demographic, behavioral, and clinical characteristics.

RESULTS

A total of 2155 unique patients had 2828 incident NG infections, 156 (6%) of which were caused by AZMRS NG. AZMRS NG was strongly associated with receipt of AZM from the SHC in the prior 29 days (adjusted odds ratio, 6.76; 95% confidence interval [CI], 1.76 to 25.90) but not with receipt of AZM in the prior 30-365 days. Log AZM MIC level was not associated with the number of AZM prescriptions within ≤12 months (adjusted correlation, 0.0004; 95% CI, -.04 to .037) but was associated with number of prescriptions within <30 days (adjusted coefficient, 0.56; 95% CI, .13 to .98).

CONCLUSIONS

Recent individual-level AZM treatment is associated with subsequent AZMRS gonococcal infections. The long half-life and persistence of subtherapeutic levels of AZM may result in selection of resistant NG strains in persons with recent AZM use.

Incidence and Duration of Pharyngeal Chlamydia Among a Cohort of Men Who Have Sex With Men

BACKGROUND

The prevalence of pharyngeal chlamydia is low, but its incidence and duration are unknown. A high incidence or duration may support the role of pharyngeal chlamydia in sustaining chlamydia transmission.

METHODS

From March 2016 to December 2018, we enrolled men who have sex with men (MSM) in a 48-week cohort study in Seattle, Washington. Participants self-collected pharyngeal specimens weekly. We tested specimens using nucleic acid amplification testing at the conclusion of the study. In primary analyses, we defined incident pharyngeal chlamydia as >2 consecutive weeks of a positive pharyngeal specimen. In sensitivity analyses, we defined incident chlamydia as >1 week of a positive specimen. We estimated duration of pharyngeal chlamydia, censoring at loss to follow-up, receipt of antibiotics, or end of study.

RESULTS

A total of 140 participants contributed 70.5 person-years (PY); 1.4% had pharyngeal chlamydia at enrollment. In primary analyses, there were 8 pharyngeal chlamydia cases among 6 MSM (incidence = 11.4 per 100 PY; 95% confidence interval [CI]: 6.0-21.9). In sensitivity analysis, there were 19 cases among 16 MSM (incidence = 27.1 per 100 PY; 95% CI: 18.5-39.8). The median duration was 6.0 weeks (95% CI: 2.0-undefined) in primary analysis and 2.0 weeks (95% CI: 1.1-6.0) in sensitivity analysis. Duration was shorter for those with a history of chlamydia compared with those without (3.6 vs 8.7 weeks; P = .02).

CONCLUSIONS

Pharyngeal chlamydia has a low incidence and duration relative to other extragenital sexually transmitted infections. Its contribution to population-level transmission remains unclear.

Kissing, fellatio, and analingus as risk factors for oropharyngeal gonorrhoea in men who have sex with men: A cross-sectional study

BACKGROUND

Our aim was to determine whether exposure to the anatomical sites (oropharynx, penis, or anus) of male partners of men who have sex with men (MSM) were independent risk factors for oropharyngeal gonorrhoea after adjusting for exposures to these sites.

METHODS

In this cross-sectional study, we invited MSM who attended the Melbourne Sexual Health Centre (MSHC) in Victoria, Australia between 26-November 2018 and 31-December 2020 to complete a survey of their sexual practices in the past three months. We collected data on the number of male partners with whom men engaged in sexual activities that exposed their oropharynx to their partners' oropharynx (kissing), penis (fellatio), and anus (rimming or analingus). Only men who were aged ≥16 years, tested for oropharyngeal gonorrhoea and did not have indeterminate or invalid results were included in the final analysis. We conducted univariable and multivariable logistic regression analyses to investigate associations between oropharyngeal gonorrhoea and the three exposures to the oropharynx.

FINDINGS

The median age of the 2,322 men who completed the survey was 31 years (IQR: 26-40), and 5·2% (n = 120) were diagnosed with oropharyngeal gonorrhoea. Our univariate analysis showed that oropharyngeal gonorrhoea was significantly associated with increasing number of kissing (p _trend<0·0001), rimming (p _trend<0·0001) and fellatio (p _trend<0·0001) partners. After adjusting for all three exposures, oropharyngeal gonorrhoea was associated with increasing number of kissing (p _{trend =}0·014) and rimming partners (p _trend = 0·037) but not fellatio (p _trend = 0·61).

INTERPRETATION

Our data suggest kissing and rimming are important practices in oropharyngeal gonorrhoea transmission in MSM Novel interventions which target the oropharynx are required for gonorrohoea prevention.

FUNDING

Australian National Health and Medical Research Council.

Spontaneous clearance of asymptomatic anogenital and pharyngeal Neisseria gonorrhoeae: a secondary analysis from the NABOGO trial

INTRODUCTION

Spontaneous clearance of asymptomatic Neisseria gonorrhoeae (NG) does occur, but data are scarce. We aimed to assess spontaneous clearance among patients with asymptomatic anal, pharyngeal, vaginal and urethral NG infections who participated in the New AntiBiotic treatment Options for uncomplicated GOnorrhoea (NABOGO) trial. In addition, we assessed the determinants associated with spontaneous clearance.

METHODS

The NABOGO trial (Trial registration number: NCT03294395) was a randomised controlled, double-blind, single-centre trial assessing non-inferiority of ertapenem, gentamicin and fosfomycin to ceftriaxone for treatment of uncomplicated gonorrhoea. For asymptomatic NABOGO participants, we collected pre-enrolment and enrolment visit samples before trial medication was given. Spontaneous clearance was defined as a positive pre-enrolment nucleic acid amplification test (NAAT) result, followed by a negative NAAT at enrolment. We compared the median time between pre-enrolment and enrolment visits for patients who cleared spontaneously and for those who did not. Determinants of spontaneous clearance were assessed using logistic regression.

RESULTS

Thirty-two of 221 (14.5%) anal NG infections cleared spontaneously, 17 of 91 (18.7%) pharyngeal, 3 of 13 (23.1%) vaginal and 9 of 28 (32.1%) urethral NG infections. The median time between the pre-enrolment and enrolment visit was longer for patients who cleared their pharyngeal infection spontaneously compared with those who did not (median 8 days (IQR=7-11) vs 6 days (IQR=4-8), p=0.012); no determinants of clearance at other sites were identified. Overall, patients with more days between the pre-enrolment and enrolment visit were more likely to clear spontaneously (adjusted OR=1.06 per additional day, 95% CI 1.01 to 1.12). No association between location of NG infection and spontaneous clearance was found.

CONCLUSIONS

A significant proportion of asymptomatic patients cleared their NG infections spontaneously. Given these results, treatment of all NG infections after a one-time NAAT may be excessive, and more research on the natural history of NG is needed to improve antibiotic stewardship.

Time to Clearance of Neisseria gonorrhoeae RNA at the Pharynx following Treatment

The number of days until pharyngeal Neisseria gonorrhoeae nucleic acid amplification test (NAAT) results become negative after treatment remains unknown. Between March 2019 and April 2021, we enrolled men who have sex with men (MSM) who had a clinical positive pharyngeal N. gonorrhoeae Aptima Combo 2 test result but had not yet been treated in a prospective longitudinal cohort study. MSM were enrolled on their day of treatment and self-collected daily pharyngeal specimens for 21 days at home. We used Kaplan-Meier estimates to determine the median time to clearance and the >95% time to clearance and the log rank test for equality to evaluate factors associated with time to clearance. Sixty-four men were enrolled in the study. Analyses excluded 8 men (12.5%) who were N. gonorrhoeae negative by NAAT at enrollment and 11 (17%) who failed to return any home-collected specimens. Among the 45 men included in the analysis, the median time to N. gonorrhoeae NAAT clearance was 3 days (95% confidence interval [CI], 2 to 5 days). Time to clearance for >95% of the cohort was 12 days (95% CI, 10 days to an undefined time). Men with a history of N. gonorrhoeae infection cleared faster than men without such history (8 days versus 17 days for >95% time to clearance; P = 0.03). In the absence of reexposure, positive N. gonorrhoeae Aptima Combo 2 assay results obtained prior to 12 days after treatment are likely false-positive results.

Screening of Anorectal and Oropharyngeal Samples Fails to Detect Bacteriophages Infecting Neisseria gonorrhoeae

There are real concerns that Neisseria gonorrhoeae may become untreatable in the near future due to the rapid emergence of antimicrobial resistance. Alternative therapies are thus urgently required. Bacteriophages active against N. gonorrhoeae could play an important role as an antibiotic-sparing therapy. To the best of our knowledge, no bacteriophages active against N. gonorrhoeae have ever been found. The aim of this study was to screen for bacteriophages able to lyse N. gonorrhoeae in oropharyngeal and anorectal swabs of 74 men who have sex with men attending a sexual health clinic in Antwerp, Belgium. We screened 210 swabs but were unable to identify an anti-gonococcal bacteriophage. This is the first report of a pilot screening that systematically searched for anti-gonococcal phages directly from clinical swabs. Further studies may consider screening for phages at other anatomical sites (e.g., stool samples, urine) or in environmental settings (e.g., toilet sewage water of sex clubs or sexually transmitted infection clinics) where N. gonorrhoeae can be found.

Test of Cure Return Rate and Test Positivity, Strengthening the US Response to Resistant Gonorrhea, United States, 2018-2019

BACKGROUND

Reduced antibiotic susceptibility (RS) in Neisseria gonorrhoeae (GC) may increase treatment failure. Conducting tests of cure (TOC) for patients with RS-GC may facilitate identification of treatment failures.

METHODS

We examined 2018 to 2019 data from 8 jurisdictions participating in the US Centers for Disease Control and Prevention's Strengthening US Response to Resistant Gonorrhea project. Jurisdictions collected GC isolates and epidemiological data from patients and performed antimicrobial susceptibility testing. Minimum inhibitory concentrations of ceftriaxone, 0.125 μg/mL or greater; cefixime, 0.250 μg/mL or greater; or azithromycin, 2.0 μg/mL or greater were defined as RS. Patients with RS infections were asked to return for a TOC 8 to 10 days posttreatment. We calculated a weighted TOC return rate and described time to TOC and suspected reasons for any positive TOC results.

RESULTS

Overall, 1165 patients were diagnosed with RS infections. Over half returned for TOC (weighted TOC, 61%; 95% confidence interval, 50.1%-72.6%; range by jurisdiction, 32%-80%). Test of cure rates were higher among asymptomatic (68%) than symptomatic patients (53%, P = 0.001), and men who have sex with men (62%) compared with men who have sex with women (50%; P < 0.001). Median time between treatment and TOC was 12 days (interquartile range, 9-16). Of the 31 (4.5%) TOC patients with positive results, 13 (42%) were suspected because of reinfection and 11 (36%) because of false-positive results. There were no treatment failures suspected to be due to RS-GC.

CONCLUSIONS

Most patients with a RS infection returned for a TOC, though return rates varied by jurisdiction and patient characteristics. Test of cure can identify and facilitate treatment of reinfections, but false-positive TOC results may complicate interpretation and clinical management.

Changes in the prevalence of self-reported sexually transmitted bacterial infections from 2010 and 2017 in two large European samples of men having sex with men-is it time to re-evaluate STI-screening as a control strategy?

BACKGROUND/OBJECTIVES

Many European countries reported increased numbers of syphilis, gonorrhoea and chlamydia diagnoses among men who have sex with men (MSM) in recent years. Behaviour changes and increased testing are thought to drive these increases.

METHODS

In 2010 and 2017, two large online surveys for MSM in Europe (EMIS-2010, EMIS-2017) collected self-reported data on STI diagnoses in the previous 12 months, diagnostic procedures, STI symptoms when testing, number of sexual partners, and sexual behaviours such as condom use during the last intercourse with a non-steady partner in 46 European countries. Multivariate regression models were used to analyse factors associated with diagnoses of syphilis, gonorrhoea/chlamydia, and respective diagnoses classified as symptomatic and asymptomatic. If applicable, they included country-level screening rates.

RESULTS

Questions on STI diagnoses and sexual behaviours were answered by 156,018 (2010) and 125,837 (2017) participants. Between 2010 and 2017, overall diagnoses with gonorrhoea/chlamydia and syphilis increased by 76% and 83% across countries. Increases were more pronounced for asymptomatic compared to symptomatic infections. The proportion of respondents screened and the frequency of screening grew considerably. Condomless anal intercourse with the last non-steady partner rose by 62%; self-reported partner numbers grew. Increased syphilis diagnoses were largely explained by behavioural changes (including more frequent screening). Gonorrhoea/chlamydia increases were mainly explained by more screening and a change in testing performance. A country variable representing the proportion of men screened for asymptomatic infection was positively associated with reporting symptomatic gonorrhoea/chlamydia, but not syphilis.

DISCUSSION/CONCLUSION

The positive association of country-level screening rates with the proportion of symptomatic infections with gonorrhoea/chlamydia may indicate a paradoxical effect of screening on incidence of symptomatic infections. Treatment of asymptomatic men might render them more susceptible to new infections, while spontaneous clearance may result in reduced susceptibility. Before expanding screening programmes, evidence of the effects of screening and treatment is warranted.