Evaluation of six nucleic acid amplification tests used for diagnosis ofNeisseria gonorrhoeaein Russia compared with an international strictly validated real-timeporApseudogene polymerase chain reaction

German evidence- and consensus-based guideline on the management of penile urethritis

Urethritis is a common condition predominantly caused by sexually transmitted pathogens such as Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium. It is not possible to differentiate with certainty between pathogens on the basis of clinical characteristics alone. However, empirical antibiotic therapy is often initiated in clinical practice. The aim of this clinical practice guideline is to promote an evidence-based syndrome-orientated approach to the management of male adolescents and adults with symptoms of urethritis. Besides recommendations for the diagnosis, classification and choice of treatment, this guideline provides recommendations for the indication to empirically treat patients with penile urethritis. A novel feature compared to existing, pathogen-specific guidelines is the inclusion of a flowchart for the syndrome-orientated practical management. For suspected gonococcal urethritis requiring empirical treatment, ceftriaxone is recommended. Due to the risk of Chlamydia trachomatis co-infection, doxycycline should also be prescribed, unless follow-up for the treatment of possible co-infections is assured. For suspected non-gonococcal urethritis, doxycycline is the recommended empirical treatment. In the empiric treatment of both gonococcal and non-gonococcal penile urethritis, azithromycin is reserved for cases where doxycycline is contraindicated. This guideline also includes detailed recommendations on differential diagnosis, pathogen-specific treatments and specific situations, as well as patient counselling and follow-up.

First reported lymphogranuloma venereum cases in Russia discovered in men who have sex with men attending proctologists

BACKGROUND

Several lymphogranuloma venereum (LGV) outbreaks among men who have sex with men (MSM) have been reported throughout the world since 2003. Nevertheless, no LGV cases have been internationally reported from Russia. We evaluated the prevalence of LGV among MSM attending proctologists in Moscow, Russia, and compared the LGV and non-LGV rectal Chlamydia trachomatis (CT) infections.

METHODS

MSM (n = 534) attending for proctologic care were included. Rectal specimens were sampled for CT and Neisseria gonorrhoeae (NG) by nucleic acid amplification tests (NAATs). All CT-positive patients were tested with an LGV-specific NAAT.

RESULTS

In total, 37.3% (95% CI 33.3-41.5; 199/534) of MSM were CT positive. Of these, 68.8% (95% CI 62.1-74.9; 137/199) had LGV and 31.2% (95% CI 25.1-37.9; 62/199) a non-LGV rectal CT infection. Older age (34 years vs. 31 years, p = 0.035) and group-sex practices (67.2% (92/137) vs. 33.9% (21/62), p < 0.0001) were associated with LGV. The LGV-positive MSM were also more likely to be HIV-positive (67.2% (92/137) vs. 41.9% (26/62), p = 0.001). Proctoscopy revealed ulcerative proctitis/proctocolitis in 99.3% (136/137) of LGV-positive MSM. No ulcerative or erosive proctitis was found in the MSM with non-LGV CT infection, but 58.1% (36/62) of them had anorectal disorders. Finally, mild catarrhal or hemorrhagic proctitis was diagnosed in only 21.6% (8/37) of MSM with non-LGV CT infection lacking concomitant NG or syphilis (p < 0.0001).

CONCLUSIONS

LGV is widely spread among MSM attending proctologists in Moscow. Clinically, acute LGV proctitis/proctocolitis can be difficult to distinguish from inflammatory bowel disease that leads to mismanaged LGV infections. LGV diagnostic laboratory testing is essential, however, currently mainly lacking for MSM in Russia. All MSM with CT-positive rectal specimens should be subsequently tested for LGV.

Development and application of Cas13a-based diagnostic assay for Neisseria gonorrhoeae detection and azithromycin resistance identification

BACKGROUND

Gonorrhoea, caused by Neisseria gonorrhoeae, has spread worldwide. Strains resistant to most antibiotics, including ceftriaxone and azithromycin, have emerged to an alarming level. Rapid testing for N. gonorrhoeae and its antimicrobial resistance will therefore contribute to clinical decision making for early diagnosis and rational drug use.

METHODS

A Cas13a-based assay (specific high-sensitivity enzymatic reporter unlocking; SHERLOCK) was developed for N. gonorrhoeae detection (porA gene) and azithromycin resistance identification (A2059G, C2611T). Assays were evaluated for sensitivity with purified dsDNA and specificity with 17 non-gonococcal strains. Performance of SHERLOCK (porA) was compared with Roche Cobas 4800 using 43 urine samples. Identification of azithromycin resistance mutations (A2059G, C2611T) was evaluated using a total of 84 clinical isolates and 18 urine samples. Lateral flow was tested for this assay as a readout tool. Moreover, we directly assayed 27 urethral swabs from patients with urethritis to evaluate their status in terms of N. gonorrhoeae infection and azithromycin resistance.

RESULTS

The SHERLOCK assay was successfully developed with a sensitivity of 10 copies/reaction, except 100 copies/reaction for A2059G, and no cross-reaction with other species. Comparison of the SHERLOCK assay with the Cobas 4800 revealed 100% concordance within 18 positive and 25 negative urine samples. Of the 84 isolates, 21 strains with azithromycin resistance mutations were distinguished and further verified by sequencing and MIC determination. In addition, 62.96% (17/27) strains from swab samples were detected with no mutant strains confirmed by sequencing.

CONCLUSIONS

The SHERLOCK assay for rapid N. gonorrhoeae detection combined with azithromycin resistance testing is a promising method for application in clinical practice.

HIV and other sexually transmitted infections among female sex workers in Moscow (Russia): prevalence and associated risk factors

To estimate the prevalence and factors associated with HIV and five other STIs among outdoor female sex workers (OSFW) and indoor FSW (IFSW).

METHODS

Cross-sectional survey using respondent-driven sampling methodology. Participants answered a bio-behavioural questionnaire and were tested for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), Trichomonas vaginalis (TV), syphilis (lifetime contact) and Mycoplasma genitalium (MG). Weighted HIV and other STIs prevalence and 95% CIs were calculated. Weighted multivariate logistic regression was performed to identify factors associated with having at least one STI (including HIV).

RESULTS

Between October 2017 and July 2018, 385 FSW participants were recruited, among whom 206 (53.5%) were IFSW and 179 (46.5%) were OFSW. The mean age was 31.4 years. Weighted HIV prevalence was 3.1% (95% CI 1.5 to 7.0). Weighted prevalence of other STIs was: 4.1% (95% CI 2.2 to 8.0) for NG, 8.8% (95% CI 5.9 to 13.0) for CT, 12.7% (95% CI 8.6 to 18.0) for TV, 13.9% (95% CI 9.9 to 19.0) for syphilis (lifetime contact) and 14.9% (95% CI 10.5 to 21.0) for MG. STI prevalence was significantly higher among OFSW for CT, TV and MG (p<0.001). In total, 43.2% of the participants had at least one HIV/STI. Factors associated with having HIV/STI were being an OFSW (OR 3.29; 95% CI 1.72 to 6.27); being registered in another Russian region (2.61 (95% CI 1.05 to 6.48)); having never been tested for HIV (2.51 (95% CI 0.98 to 6.41)) and having a low level of knowledge regarding HIV transmission (4.88 (95% CI 0.96 to 24.78)).

CONCLUSION

Prevalence of HIV and STIs was high among FSW in Moscow. OFSW were more vulnerable to STIs. There is an urgent need to tailor programmes for sexual and reproductive health for FSW in Russia.

Bacterial vaginosis-associated vaginal microbiota is an age-independent risk factor for Chlamydia trachomatis, Mycoplasma genitalium and Trichomonas vaginalis infections in low-risk women, St. Petersburg, Russia

The large majority of studies investigating associations between bacterial vaginosis (BV) and sexually transmitted infections (STIs) have been conducted among predominantly young women with high risk for STIs. Since a risky sexual behavior is a significant risk factor for both STIs and BV, this creates a bias toward an increased association between BV and STIs. This study evaluated associations between BV-associated vaginal microbiota and STIs (Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, and Neisseria gonorrhoeae) in a population of women with low risk for STIs and investigated STI outcomes depending on the dominating Lactobacillus species. Repository cervicovaginal samples collected from reproductive-age women from January 2014 to February 2019 were characterized for vaginal microbiota types and the STIs using multiplex real-time PCR assays. In total, 95 STI-positive and 91 STI-negative samples were included. A significant, age-independent association between BV-associated vaginal microbiota and the presence of C. trachomatis, M. genitalium, and T. vaginalis infections was identified (age-adjusted odds ratios 2.92 [95% confidence interval (CI) 1.24–7.03], 2.88 [95% CI 1.19–7.16], and 9.75 × 10⁷ [95% CI 13.03-∞], respectively). Normal vaginal microbiota dominated by Lactobacillus crispatus, L. gasseri, or L. jensenii was a strong protective factor against C. trachomatis and/or M. genitalium infections, whereas L. iners-dominated microbiota was not significantly associated with C. trachomatis and/or M. genitalium positivity. The results of the present study confirm that STI prevention strategies should include interventions that also reduce the incidence of BV and promote a protective vaginal microbiota in both high- and low-risk women.

Evaluation of the new AmpliSens multiplex real-time PCR assay for simultaneous detection of Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis

In this study, we performed an evaluation of the new CE-marked multiplex real-time AmpliSens N.gonorrhoeae/C.trachomatis/M.genitalium/T.vaginalis-MULTIPRIME-FRT PCR assay compared to APTIMA tests, i.e., APTIMA COMBO 2 assay, APTIMA Trichomonas vaginalis assay (FDA-approved), and two different APTIMA Mycoplasma genitalium assays (research use only; one of them only used for discrepancy analysis). Vaginal swabs (n = 209) and first-void urine (FVU) specimens from females (n = 498) and males (n = 554), consecutive attendees (n = 1261) at a dermatovenerological clinic in Sweden, were examined. The sensitivity of the AmpliSens PCR assay for detection of C. trachomatis (6.3% prevalence), M. genitalium (5.7% prevalence), N. gonorrhoeae (0.3% prevalence), and T. vaginalis (0.08% prevalence) was 97.5% (95% confidence interval (CI): 91.2-99.6%), 81.9% (95% CI: 70.7-89.7%), 100% (95% CI: 40.2-100%) and 100% (95% CI: 16.5-100%), respectively. The specificity of the AmpliSens PCR assay was 100% (95% CI: 99.6-100%) for all agents. The analytical sensitivity and specificity for N. gonorrhoeae detection was excellent, i.e., 55 international gonococcal strains detected and 135 isolates of 13 non-gonococcal Neisseria species were negative. In conclusion, the multiplex real-time AmpliSens N.gonorrhoeae/C.trachomatis/M.genitalium/T.vaginalis-MULTIPRIME-FRT PCR assay demonstrated high sensitivity and excellent specificity for the detection of C. trachomatis, N. gonorrhoeae, and T. vaginalis, and excellent specificity but suboptimal sensitivity for M. genitalium detection.

Treatment efficacy, treatment failures and selection of macrolide resistance in patients with high load of Mycoplasma genitalium during treatment of male urethritis with josamycin

Background

Azithromycin has been widely used for Mycoplasma genitalium treatment internationally. However, the eradication efficacy has substantially declined recent decade. In Russia, josamycin (another macrolide) is the recommended first-line treatment for M. genitalium infections, however, no data regarding treatment efficacy with josamycin and resistance in M. genitalium infections have been internationally published. We examined the M. genitalium prevalence in males attending an STI clinic in Moscow, Russia from December 2006 to January 2008, investigated treatment efficacy with josamycin in male urethritis, and monitored the M. genitalium DNA eradication dynamics and selection of macrolide resistance in M. genitalium during this treatment.

Methods

Microscopy and real-time PCRs were used to diagnose urethritis and non-viral STIs, respectively, in males (n = 320). M. genitalium positive patients were treated with recommended josamycin regimen and treatment efficacy was monitored using quantitative real-time PCR. Macrolide resistance mutations were identified using sequencing of the 23S rRNA gene.

Results

Forty-seven (14.7%) males were positive for M. genitalium only and most (85.1%) of these had symptoms and signs of urethritis. Forty-six (97.9%) males agreed to participate in the treatment efficacy monitoring. All the pre-treatment M. genitalium specimens had wild-type 23S rRNA. The elimination of M. genitalium DNA was substantially faster in patients with lower pre-treatment M. genitalium load, and the total eradication rate was 43/46 (93.5%). Of the six patients with high pre-treatment M. genitalium load, three (50%) remained positive post-treatment and these positive specimens contained macrolide resistance mutations in the 23S rRNA gene, i.e., A2059G (n = 2) and A2062G (n = 1).

Conclusions

M. genitalium was a frequent cause of male urethritis in Moscow, Russia. The pre-treatment M. genitalium load might be an effective predictor of eradication efficacy with macrolides (and possibly additional antimicrobials) and selection of macrolide resistance. Additional in vivo and in vitro data are crucial to support the recommendation of using josamycin as first-line treatment for M. genitalium infections in Russia. It would be valuable to develop international M. genitalium management guidelines, and quantitative diagnostic PCRs determining also M. genitalium load and resistance mutations (for macrolides and ideally also moxifloxacin) should ideally be recommended.

Sexually transmitted infections among HIV-infected heavy drinkers in St Petersburg, Russia

The objective of this study was to estimate the prevalence and identify correlates of four sexually transmitted infections (STIs) among HIV-infected Russians reporting heavy alcohol use and recent unprotected sex, we conducted a cross-sectional analysis of baseline data from the HERMITAGE study. The primary outcome was any current STI, based on urine tests for Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis and serological testing for infection with Treponema pallidum. Data on potential demographic and behavioural predictors of STI were obtained from surveys administered at study entry. Of 682 participants, 12.8% (95% confidence interval [CI] 10.3, 15.3) tested positive for at least one STI. In a multivariable model adjusted for gender, age and marital status, only sex trade involvement over the last three months was significantly associated with an increased odds of STI (adjusted odds ratio [AOR] 2.00, 95% CI 1.13, 3.55). Given that STIs were common in this HIV-infected cohort, and that few patient characteristics predicted STI, the current practice of screening HIV-infected Russians for syphilis alone merits re-evaluation.

Sexual behaviours, knowledge and attitudes regarding safe sex, and prevalence of non-viral sexually transmitted infections among attendees of youth clinics in St. Petersburg, Russia

BACKGROUND

Adolescents and young adults are at increased risk of sexually transmitted infections (STIs). Knowledge of STI prevalence and risk factors are essential tools to elaborate preventive strategies. However, internationally reported studies on epidemiology of STIs among the youth in Russia are mainly lacking.

OBJECTIVES

To ascertain sexual behaviours, knowledge and attitudes about safe sex and prevalence and correlates with STIs in attendees of youth clinics in St. Petersburg, Russia.

METHODS

A total of 301 women and 131 men, who self-referred for STI testing, completed a questionnaire and were screened for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis using nucleic acid amplification tests.

RESULTS

The overall STI prevalence was 16.9%, and similar in the female patients and male patients (15.6% and 19.8% respectively). C. trachomatis, N. gonorrhoeae, M. genitalium and T. vaginalis were detected in 13%, 2.5%, 4.6% and 1.2% of the attendees respectively. The men displayed riskier sexual behaviours and worse knowledge and attitudes regarding safe sex compared to the women, with the most distinguishing features being younger age at first intercourse (P < 0.0005), higher numbers of sex partners during lifetime (P = 0.001) and latest 6 months (P < 0.0005), more frequently consuming alcohol (P < 0.0005), poorer knowledge of STI/HIV prevention measures (P < 0.0005), and less positive attitudes towards safe sex (P = 0.001). However, no significant predictors of STI positivity were found in the men. In the women, the strongest predictors of STI positivity were young age (15-19 years) and multiple sex partners (≥ 2) during latest 6 months.

CONCLUSIONS

The overall prevalence of STIs among users of STI services at youth clinics in St. Petersburg was high. Comprehensive epidemiological data on STI prevalence and sexual behaviour correlates are necessary to initiate new and strengthen existing STI prevention programmes for the youth, in Russia as well as in many other settings.

Gonorrhoea surveillance, laboratory diagnosis and antimicrobial susceptibility testing of Neisseria gonorrhoeae in 11 countries of the eastern part of the WHO European region

Quality-assured worldwide surveillance of antimicrobial resistance (AMR) in Neisseria gonorrhoeae is crucial for public health purposes. In the countries of the eastern part of the WHO European region the knowledge regarding gonococcal AMR is limited, and antimicrobials of many different types, sources and quality are used for gonorrhoea treatment. This study surveyed gonorrhoea incidence, laboratory diagnosis and gonococcal AMR testing in 11 independent countries of the former Soviet Union. The national gonorrhoea incidences remain mainly high. In general, gonococcal culture and AMR testing were rarely performed, poorly standardized and rarely quality assured. To establish a gonococcal AMR surveillance programme in Eastern Europe, i.e. the geographical area of the former Soviet Union, several actions have recently been undertaken by the Eastern European Sexual and Reproductive Health (EE SRH) Network and the WHO. The information provided herein will be useful in this respect.