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Richardson D, Savary-Trathen A, Fitzpatrick C, Williams D. Estimated prevalence and associations of sexually transmissible bacterial enteric pathogens in asymptomatic men who have sex with men: a systematic review and meta-analysis. Sex Transm Infect 2024:sextrans-2024-056183. [PMID: 38902026 DOI: 10.1136/sextrans-2024-056183] [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: 03/13/2024] [Accepted: 06/09/2024] [Indexed: 06/22/2024] Open
Abstract
OBJECTIVE The reservoir of sexually transmissible bacterial enteric pathogens in asymptomatic men who have sex with men (MSM) may impact future outbreaks, and the evolution of antimicrobial resistance. We aimed to estimate the pooled prevalence and explore any factors associated with Shigella spp, Campylobacter spp, diarrhoeagenic Escherichia coli and Salmonella spp in asymptomatic MSM using the random effects model. METHODS We searched Embase, MEDLINE, CINAHL and Web of Science Core Collections for manuscripts published up to February 2024. One author screened citations and abstracts; two authors independently conducted a full-text review. We included manuscripts which measured the prevalence of Shigella spp, Campylobacter spp, diarrhoeagenic E. coli and Salmonella spp in asymptomatic MSM. Quality and risk of bias was assessed independently by two authors using the Joanna Briggs Institute critical appraisal tools. We calculated pooled prevalence and CIs using the random effects model. RESULTS Six manuscripts were included in the final review. The manuscripts were from Australia (n=2), the UK (n=2), the Netherlands (n=1) and the USA (n=1) and included data from 3766 asymptomatic MSM tested for bacterial enteric pathogens. The prevalence of Shigella spp was 1.1% (95% CI 0.7% to 1.7%), Campylobacter spp 1.9% (95% CI 1.5% to 2.5%), diarrhoeagenic E. coli 3.8% (95% CI 2.1% to 6.7%) and Salmonella spp 0.3% (95% CI 0.1% to 0.6%). Two manuscripts demonstrated that the detection of bacterial enteric pathogen was more frequent in asymptomatic MSM using HIV-pre-exposure prophylaxis (PrEP), living with HIV, reporting <5 new sexual partners in the past 3 months, reporting insertive oral-anal sex and group sex compared with MSM testing negative. CONCLUSION Despite a small number of manuscripts, this review has estimated the pooled prevalence, and highlighted some possible associations with sexually transmissible bacterial enteric pathogens in asymptomatic MSM, which can inform future clinical guidelines, public health control strategies and research to increase our understanding of transmission and the evolution of antimicrobial resistance. PROSPERO REGISTRATION NUMBER CRD42024518700.
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Affiliation(s)
- Daniel Richardson
- Sexual Health & HIV medicine, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
- Global Health & Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Amber Savary-Trathen
- Sexual Health & HIV medicine, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Colin Fitzpatrick
- Sexual Health & HIV medicine, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Deborah Williams
- Sexual Health & HIV medicine, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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2
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Chessell C, Rabuszko L, Richardson D, Llewellyn C. Factors associated with the sexual transmission of Strongyloides stercoralis in men who have sex with men: A systematic review. J Eur Acad Dermatol Venereol 2024; 38:673-679. [PMID: 38013501 DOI: 10.1111/jdv.19664] [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: 03/13/2023] [Accepted: 10/09/2023] [Indexed: 11/29/2023]
Abstract
Strongyloides stercoralis is a parasitic worm with a complex life cycle and can cause significant morbidity, including a proctocolitis and life-threatening hyperinfection syndrome. Limited reports from non-endemic areas, including in men who have sex with men (MSM), suggest sexual transmission of S. stercoralis. In this systematic review of the published literature, we aimed to explore the associated factors of S. stercoralis in MSM. We systematically searched three bibliographical databases (MEDLINE, CINAHL and EMBASE) up to November 2022. We used a two-stage process to assess eligibility: the primary author conducted an initial screen of abstracts, and then three authors conducted independent full manuscripts to determine the final eligible manuscripts. We only included manuscripts written in English that contained data on specific factors associated with sexual transmission in MSM. We used the STROBE checklist to assess the risk of bias and synthesized the narrative data using the SWiM method. Seven manuscripts were eligible for this review (four case reports, one case series, one cross-sectional study and one experimental study), which included 22 individuals from Europe and the Americas. From these studies, S. stercoralis in MSM was associated with living with HIV (including having a low CD4 count and not using antiretrovirals), having a concomitant sexually transmitted infection (Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum and hepatitis C) and a concomitant (sexually transmitted) protozoal infection (Entamoeba histolytica, Giardia lamblia), travel to the S. stercoralis endemic area, multiple sexual partners from endemic areas, oro-anal sexual contact and chemsex. Although limited by the number of cases in the literature, we have highlighted some possible biological and behavioural risk factors associated with the sexual transmission of S. stercoralis in MSM that could be used to both target future research and S. stercoralis public health control interventions.
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Affiliation(s)
- Callum Chessell
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Lucy Rabuszko
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Daniel Richardson
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
- Department of Sexual Health and HIV, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Carrie Llewellyn
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
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3
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Tsai CS, Wang JL, Liao YS, Fukushige M, Chiou CS, Ko WC. Shigellosis in Taiwan: An old enteric pathogen with changing epidemiology and increasing antimicrobial resistance. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023:S1684-1182(23)00206-2. [PMID: 37951802 DOI: 10.1016/j.jmii.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/07/2023] [Accepted: 10/29/2023] [Indexed: 11/14/2023]
Abstract
While the incidence of shigellosis has decreased in developed nations due to improved living conditions and healthcare systems, it remains prevalent in economically developing regions. In recent years, a resurgence of shigellosis has been observed in the United States, Europe, and Taiwan, primarily among men having sex with men and people living with human immunodeficiency virus, along with a rise in antimicrobial resistance. This study aims to review the historical epidemiological trends and drug resistance in shigellosis, with a focus on Taiwan. A comprehensive search was conducted using various databases and sources, including non-English literature in Japanese and Chinese. In developed countries, Shigella sonnei and Shigella flexneri are the most common species, while Shigella dysenteriae infections are sporadic. In Taiwan, the classification and prevalence of Shigella species have evolved over time, with S. flexneri and S. sonnei being the predominant strains. Fluoroquinolone resistance and azithromycin non-susceptibility are the ongoing threat. In conclusion, shigellosis remains a significant global health concern, with recent increases in certain populations and antimicrobial resistance. Further research is necessary to understand the clinical significance and risk factors associated with asymptomatic carriers and to assess the impact of behavioral modifications and interventions in high-risk populations.
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Affiliation(s)
- Chin-Shiang Tsai
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, Dou-Liou Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan
| | - Jiun-Ling Wang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ying-Shu Liao
- Center for Diagnostics and Vaccine Development, Centers for Disease Control, Taichung, Taiwan
| | - Mizuho Fukushige
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Chien-Shun Chiou
- Center for Diagnostics and Vaccine Development, Centers for Disease Control, Taichung, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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4
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Siddiq M, O'Flanagan H, Richardson D, Llewellyn CD. Factors associated with sexually transmitted shigella in men who have sex with men: a systematic review. Sex Transm Infect 2023; 99:58-63. [PMID: 36283806 DOI: 10.1136/sextrans-2022-055583] [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: 07/21/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Outbreaks of sexually transmitted shigella have been reported in men who have sex with men (MSM) since the 1970s and present a major public health issue. Understanding the factors associated with the sexual transmission of shigella may inform future control strategies. METHODS We systematically searched four bibliographical databases (January 2000-February 2022) for manuscripts in English. We used a two-stage process to assess eligibility: the primary author conducted an initial screen and then three authors conducted independent full-text reviews to determine the final eligible manuscripts. We only included manuscripts that included MSM diagnosed with sexually transmitted shigella where specific factors associated with transmission were identified. RESULTS Thirteen manuscripts met the inclusion criteria that included 547 individuals. Sexually transmitted shigella in MSM was associated with: residing in a capital city/urban region, living with HIV (including engaging in seroadaptive sexual behaviour, having a low CD4 count, having a HIV viral load >100 000 and not engaging with HIV care), using HIV pre-exposure prophylaxis, use of geospatial mobile phone applications to meet sexual partners, visiting sex on premises venues, chemsex and recreational drug use, sexual behaviour (including multiple non-regular sexual partners and oral-anal sexual contact) and concomitant STIs. CONCLUSION We have highlighted some important risk behaviours and factors that are associated with sexually transmitted shigella in MSM that can be used to target future shigella control interventions.
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Affiliation(s)
| | | | - Daniel Richardson
- Brighton and Sussex Medical School, Brighton, UK .,Department of Sexual Health & HIV, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Carrie D Llewellyn
- Department of Primary Care & Public Health, Brighton and Sussex Medical School, Brighton, Brighton and Hove, UK
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5
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Mitchell HD, Whitlock G, Zdravkov J, Olsson J, Silalang P, Bardsley M, Blomquist PB, Jenkins C, Thomson NR, Field N, Hughes G. Prevalence and risk factors of bacterial enteric pathogens in men who have sex with men: A cross-sectional study at the UK's largest sexual health service. J Infect 2023; 86:33-40. [PMID: 36343788 PMCID: PMC10564623 DOI: 10.1016/j.jinf.2022.10.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/05/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Outbreaks of bacterial enteric pathogens (BEPs) in men who have sex with men (MSM) associated with antimicrobial resistance are a public health concern. We investigated the prevalence and risk factors of BEPs in MSM to inform infection control. METHODS We conducted a cross-sectional study at a London sexual health clinic between 20/12/2017 and 06/02/2018. Residual rectal swabs from MSM attending for sexually transmitted infection (STI) testing were anonymously tested for a range of BEPs using real-time PCR. A sub-set of samples were tested for the mphA gene (a marker of azithromycin resistance). Results were linked to electronic health records. RESULTS BEPs were detected in 207 of 2116 participants, giving an overall prevalence of 9.8% (95% CI 8.5%-11.1%) ranging from 0.8% (0.4%-1.2%) for Shigella to 4.9% (4.0%-5.9%) for Enteroaggregative E. coli. MSM with BEPs were more likely to have a history of bacterial STIs (p = 0.010), to report more sexual partners (p<0.001), and among HIV-negative MSM, to report current HIV pre-exposure prophylaxis use (p<0.001). Gastrointestinal symptoms were rare (1.7%) and not associated with BEPs. 41.3% of MSM with BEPs and 14.1% of those without BEPs carried mphA (p<0.001). Among the former, this was associated with a history of bacterial STIs (51.5% vs 31.1%, p = 0.003). CONCLUSIONS One in ten MSM had a BEP detected and most did not report symptoms. MphA carriage was common, particularly among those with BEPs. Bacterial STI treatment might contribute to selection of resistant gut organisms, emphasising the need for better antimicrobial stewardship.
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Affiliation(s)
- Holly D Mitchell
- Centre for Molecular Epidemiology and Translational Research, Institute for Global Health, University College London, Mortimer Market Centre, Off Capper Street, London, WC1E 6JB, UK; The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, UK.
| | - Gary Whitlock
- 56 Dean Street, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, W1D 6AQ, UK
| | - Jey Zdravkov
- 56 Dean Street, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, W1D 6AQ, UK
| | - Jenny Olsson
- 56 Dean Street, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, W1D 6AQ, UK; Imperial College School of Medicine, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - Panida Silalang
- Clinical and Public Health Group, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Megan Bardsley
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, UK; Clinical and Public Health Group, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Paula B Blomquist
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, UK; Clinical and Public Health Group, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Claire Jenkins
- Clinical and Public Health Group, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK; The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Gastrointestinal Infections at University of Liverpool, UK
| | - Nicholas R Thomson
- Parasites and Microbes, Wellcome Trust Sanger Institute, Genome Campus, Hinxton, CB10 1SA, UK; Department of Pathogen Molecular Biology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Nigel Field
- Centre for Molecular Epidemiology and Translational Research, Institute for Global Health, University College London, Mortimer Market Centre, Off Capper Street, London, WC1E 6JB, UK
| | - Gwenda Hughes
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, UK; Clinical and Public Health Group, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
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6
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Braam JF, Bruisten SM, Hoogeland M, de Vries HJC, Schim van der Loeff MF, van Dam AP. Shigella is common in symptomatic and asymptomatic men who have sex with men visiting a sexual health clinic in Amsterdam. Sex Transm Infect 2022; 98:564-569. [PMID: 35149579 DOI: 10.1136/sextrans-2021-055274] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/22/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Shigellosis is a reportable infectious disease. It can present as a severe bloody diarrhoea but is often asymptomatic. Shigella can be sexually transmissible. We performed a study among symptomatic and asymptomatic men who have sex with men (MSM) to assess the prevalence of Shigella, Salmonella and Campylobacter. METHODS From March to June 2020, MSM attending the Amsterdam centre for sexual health were consecutively included. Predefined minimal numbers of inclusion of 150, 100 and 50 were determined, respectively, for MSM who reported no diarrhoea, diarrhoea during last month or diarrhoea on the day of visit to clinic. Anal samples were tested for the presence of Shigella, Salmonella and Campylobacter. During the same period, the frequency of these bacteria was assessed in routinely tested samples requested by general physicians or nursing home physicians. Characteristics of included MSM were compared between the men with different diarrhoea anamnesis, and the prevalence of shigellosis was estimated in each group. RESULTS We included 212 MSM without diarrhoea, 109 MSM who recently had diarrhoea and 68 MSM who reported diarrhoea on the day of clinic visit. Thirteen (3.3%, 95% CI 1.7% to 5.6%) MSM were infected with Shigella, none with Salmonella and 7 (1.8%, 95% CI 0.7% to 3.7%) with Campylobacter. Shigella prevalence was 2.8% (95% CI 1.0% to 6.1%) in asymptomatic men, 3.7% (95% CI 1.0% to 9.1%) in men who recently had diarrhoea and 4.4% (95% CI 0.9% to 12.4%) in men with current diarrhoea (p=0.799). Shigella was more frequently found in MSM who had used pre-exposure prophylaxis (PrEP) in the preceding 3 months (10/151), compared with those not having used PrEP (2/146) or being HIV positive (1/75) (p=0.038). Shigella was significantly more often detected among MSM compared with routinely obtained faecal samples being 11/770 (1.4%) (p=0.031). CONCLUSION Shigella infections are relatively common in both symptomatic and asymptomatic MSM. Future studies should focus on the risk of onward transmission via asymptomatic persons. Samenvatting Introductie Shigellose is een meldingsplichtige infectieziekte. Het kan zich presenteren als een ernstige bloederige diarree, maar is vaak asymptomatisch. Shigella kan seksueel overdraagbaar zijn. We hebben een onderzoek uitgevoerd onder symptomatische en asymptomatische mannen die seks hebben met mannen (MSM) om de prevalentie van Shigella, Salmonella en Campylobacter te bepalen. Methoden Van maart tot juni 2020 werden achtereenvolgens MSM van het Amsterdamse centrum voor seksuele gezondheid opgenomen. Vooraf gedefinieerde minimale aantallen van inclusie van respectievelijk 150, 100 en 50 waren bepaald voor MSM die geen diarree, diarree in de afgelopen maand of diarree op de dag van bezoek aan de kliniek meldden. Anale monsters werden getest op de aanwezigheid van Shigella, Salmonella en Campylobacter. In dezelfde periode werd de frequentie van deze bacteriën bepaald in routinematig geteste monsters aangevraagd door huisartsen of verpleeghuisartsen. Kenmerken van geïncludeerde MSM werden vergeleken tussen mannen met verschillende diarree anamnese, en de prevalentie van shigellose werd in elke groep geschat. Resultaten We includeerden 212 MSM zonder diarree, 109 MSM die onlangs diarree hadden en 68 MSM die diarree meldden op de dag van het bezoek aan de kliniek. Dertien (3,3%, 95% CI 1,7-5,6%) MSM waren geïnfecteerd met Shigella, geen enkele met Salmonella, en 7 (1,8%, 95% CI 0,7-3,7%) met Campylobacter. De prevalentie van Shigella was 2,8% (95%CI 1,0-6,1%) bij asymptomatische mannen, 3,7% (95%CI 1,0-9,1%) bij mannen die recent diarree hadden en 4,4% (95%CI 0,9-12,4%) bij mannen met huidige diarree (P=0,799). Shigella werd vaker gevonden bij MSM die in de voorgaande drie maanden (10/151) PrEP hadden gebruikt dan bij mensen die geen PrEP hadden gebruikt (2/146) of hiv-positief waren (1/75) (p=0,038). Shigella werd significant vaker gedetecteerd bij MSM in vergelijking met routinematig verkregen fecale monsters, namelijk 11/770 (1,4%) (p=0,031). Conclusie Shigella infecties komen relatief vaak voor bij zowel symptomatische als asymptomatische MSM. Toekomstige studies moeten zich richten op het risico van verdere overdracht via asymptomatische personen.
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Affiliation(s)
- Joyce F Braam
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands
| | - Sylvia M Bruisten
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands.,Department of Medical Microbiology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Mariska Hoogeland
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands
| | - Henry J C de Vries
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands.,Department of Dermatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Maarten F Schim van der Loeff
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands.,Department of Internal Medicine, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Alje P van Dam
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands.,Department of Medical Microbiology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
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McNeil CJ, Kirkcaldy RD, Workowski K. Enteric Infections in Men Who Have Sex With Men. Clin Infect Dis 2022; 74:S169-S178. [PMID: 35416972 DOI: 10.1093/cid/ciac061] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Enteric pathogens are often associated with exposure to food, water, animals, and feces from infected individuals. However, in sexual networks of men who have sex with men (MSM), transmission of enteric pathogens may occur during direct or indirect oral-anal contact. METHODS We performed a scoping review of the literature for studies prior to July 2019 with key terms for gastrointestinal syndromes ("proctitis," "enteritis," "proctocolitis"), enteric pathogens or sexually transmitted infections (STIs), and outbreaks using multiple electronic databases. RESULTS We identified 5861 records through database searches, bibliography reviews, and keyword searches, of which 117 references were included in the pathogen-specific reviews. CONCLUSIONS The strength of observational data describing enteric pathogens in MSM and possible sexual transmission of enteric pathogens varies by pathogen; however, a robust body of literature describes the sexual transmission of Campylobacter, Giardia lamblia, and Shigella (particularly antimicrobial-resistant strains) in sexual networks of MSM. Providers are encouraged to consider enteritis or proctocolitis in MSM as possibly having been sexually transmitted and encourage targeted STI testing. Risk/harm reduction and prevention messages should also be incorporated, though there is an acknowledged paucity of evidence with regards to effective strategies. Further research is needed to understand the transmission and prevention of enteric pathogens in MSM.
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Affiliation(s)
- Candice J McNeil
- Department of Internal Medicine, Section on Infectious Diseases, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Robert D Kirkcaldy
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kimberly Workowski
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.,Department of Medicine, Emory University, Atlanta, Georgia
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Chow EPF, Lee D, Bond S, Fairley CK, Maddaford K, Wigan R, Fehler G, Lange SA, De Petra V, Bissessor M, Bradshaw CS, Howden BP, Hocking JS, Williamson DA, Chen MY. Nonclassical Pathogens as Causative Agents of Proctitis in Men who Have Sex With Men. Open Forum Infect Dis 2021; 8:ofab137. [PMID: 34671693 PMCID: PMC8521645 DOI: 10.1093/ofid/ofab137] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background This study aimed to identify enteric and sexually acquired rectal pathogens,
other than chlamydia and gonorrhea, associated with symptomatic proctitis in
men who have sex with men (MSM). Methods Anorectal swab samples were obtained from MSM presenting with rectal symptoms
and a clinical diagnosis of proctitis at the Melbourne Sexual Health Centre
between January 2017 and March 2019. Samples that tested positive for
Neisseria gonorrhoeae and Chlamydia
trachomatis were excluded. As a comparison group, anorectal
samples were also obtained from MSM not reporting symptoms of proctitis
between November 2018 and February 2019. Samples from both groups were
tested for 15 viral, bacterial, and protozoal enteric pathogens using
polymerase chain reaction. Results Anorectal samples from 499 men with symptomatic proctitis and 506
asymptomatic men were analyzed. Age, HIV status, and pre-exposure
prophylaxis (PrEP) use did not differ between men with proctitis and
asymptomatic men. Treponema pallidum was more common in men
with proctitis (risk difference [RD], 3.6%; 95% CI, 2.0%–5.2%). Most
men with anorectal T. pallidum presented with painful anal
primary infections. Shigella spp. was more common among men
with proctitis compared with asymptomatic men (RD, 1.8%; 95% CI,
0.1%–3.5%). Most men with Shigella did not report
diarrhea. Mycoplasma genitalium was more common in men with
proctitis (RD, 4.3%; 95% CI, 1.1%–7.5%). Herpes simplex virus
(HSV)–1 (RD, 10.1%; 95% CI, 6.8%–13.3%) and HSV-2 (RD, 7.2%; 95%
CI, 4.5%–10.0%) were more common with proctitis. Conclusions Testing for T. pallidum, Shigella, and HSV
should be considered in MSM presenting with symptomatic proctitis. These
data provide support for M. genitalium as a significant
cause of proctitis. A comprehensive diagnostic evaluation is required for
MSM with proctitis.
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Affiliation(s)
- Eric P F Chow
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Darren Lee
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity at The University of Melbourne, Melbourne, Victoria, Australia
| | - Stephanie Bond
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Christopher K Fairley
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Kate Maddaford
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Rebecca Wigan
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Glenda Fehler
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Sigrid A Lange
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity at The University of Melbourne, Melbourne, Victoria, Australia
| | - Vesna De Petra
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity at The University of Melbourne, Melbourne, Victoria, Australia
| | - Melanie Bissessor
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Catriona S Bradshaw
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Benjamin P Howden
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity at The University of Melbourne, Melbourne, Victoria, Australia
| | - Jane S Hocking
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Deborah A Williamson
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity at The University of Melbourne, Melbourne, Victoria, Australia.,Department of Microbiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Marcus Y Chen
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
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Potential for Phages in the Treatment of Bacterial Sexually Transmitted Infections. Antibiotics (Basel) 2021; 10:antibiotics10091030. [PMID: 34572612 PMCID: PMC8466579 DOI: 10.3390/antibiotics10091030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 12/30/2022] Open
Abstract
Bacterial sexually transmitted infections (BSTIs) are becoming increasingly significant with the approach of a post-antibiotic era. While treatment options dwindle, the transmission of many notable BSTIs, including Neisseria gonorrhoeae, Chlamydia trachomatis, and Treponema pallidum, continues to increase. Bacteriophage therapy has been utilized in Poland, Russia and Georgia in the treatment of bacterial illnesses, but not in the treatment of bacterial sexually transmitted infections. With the ever-increasing likelihood of antibiotic resistance prevailing and the continuous transmission of BSTIs, alternative treatments must be explored. This paper discusses the potentiality and practicality of phage therapy to treat BSTIs, including Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, Streptococcus agalactiae, Haemophilus ducreyi, Calymmatobacterium granulomatis, Mycoplasma genitalium, Ureaplasma parvum, Ureaplasma urealyticum, Shigella flexneri and Shigella sonnei. The challenges associated with the potential for phage in treatments vary for each bacterial sexually transmitted infection. Phage availability, bacterial structure and bacterial growth may impact the potential success of future phage treatments. Additional research is needed before BSTIs can be successfully clinically treated with phage therapy or phage-derived enzymes.
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10
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Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1-187. [PMID: 34292926 PMCID: PMC8344968 DOI: 10.15585/mmwr.rr7004a1] [Citation(s) in RCA: 793] [Impact Index Per Article: 264.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
These guidelines for the treatment of persons who have or are at risk for
sexually transmitted infections (STIs) were updated by CDC after consultation
with professionals knowledgeable in the field of STIs who met in Atlanta,
Georgia, June 11–14, 2019. The information in this report updates the
2015 guidelines. These guidelines discuss 1) updated recommendations for
treatment of Neisseria gonorrhoeae, Chlamydia trachomatis,
and Trichomonas vaginalis; 2) addition of
metronidazole to the recommended treatment regimen for pelvic inflammatory
disease; 3) alternative treatment options for bacterial vaginosis; 4) management
of Mycoplasma genitalium; 5) human papillomavirus vaccine
recommendations and counseling messages; 6) expanded risk factors for syphilis
testing among pregnant women; 7) one-time testing for hepatitis C infection; 8)
evaluation of men who have sex with men after sexual assault; and 9) two-step
testing for serologic diagnosis of genital herpes simplex virus. Physicians and
other health care providers can use these guidelines to assist in prevention and
treatment of STIs.
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11
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Kuhn KG, Hvass AK, Christiansen AH, Ethelberg S, Cowan SA. Sexual Contact as Risk Factor for Campylobacter Infection, Denmark. Emerg Infect Dis 2021; 27:1133-1140. [PMID: 33754996 PMCID: PMC8007285 DOI: 10.3201/eid2704.202337] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Campylobacteriosis is a disease of worldwide importance, but aspects of its transmission dynamics, particularly risk factors, are still poorly understood. We used data from a matched case-control study of 4,269 men who have sex with men (MSM) and 26,215 controls, combined with national surveillance data on Campylobacter spp., Salmonella spp., and Shigella spp., to calculate matched odds ratios (mORs) for infection among MSM and controls. MSM had higher odds of Campylobacter (mOR 14, 95% CI 10–21) and Shigella (mOR 74, 95% CI 27–203) infections, but not Salmonella (mOR 0.2, 95% CI 0–13), and were less likely than controls to have acquired Campylobacter infection abroad (χ2 = 21; p<0.001). Our results confirm that sexual contact is a risk factor for campylobacteriosis and also suggest explanations for unique features of Campylobacter epidemiology. These findings provide a baseline for updating infection risk guidelines to the general population.
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12
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Greninger AL, Addetia A, Starr K, Cybulski RJ, Stewart MK, Salipante SJ, Bryan AB, Cookson B, Gaudreau C, Bekal S, Fang FC. International Spread of Multidrug-Resistant Campylobacter coli in Men Who Have Sex With Men in Washington State and Québec, 2015-2018. Clin Infect Dis 2021; 71:1896-1904. [PMID: 31665255 PMCID: PMC7643735 DOI: 10.1093/cid/ciz1060] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 10/23/2019] [Indexed: 12/13/2022] Open
Abstract
Background Campylobacter species are among the most common causes of enteric bacterial infections worldwide. Men who have sex with men (MSM) are at increased risk for sexually transmitted enteric infections, including globally distributed strains of multidrug-resistant Shigella species. Methods This was a retrospective study of MSM-associated Campylobacter in Seattle, Washington and Montréal, Québec with phenotypic antimicrobial resistance profiles and whole genome sequencing (WGS). Results We report the isolation of 2 clonal lineages of multidrug-resistant Campylobacter coli from MSM in Seattle and Montréal. WGS revealed nearly identical strains obtained from the 2 regions over a 4-year period. Comparison with the National Center for Biotechnology Information’s Pathogen Detection database revealed extensive Campylobacter species clusters carrying multiple drug resistance genes that segregated with these isolates. Examination of the genetic basis of antimicrobial resistance revealed multiple macrolide resistance determinants including a novel ribosomal RNA methyltransferase situated in a CRISPR (clustered regularly interspaced short palindromic repeats) array locus in a C. coli isolate. Conclusions As previously reported for Shigella, specific multidrug-resistant strains of Campylobacter are circulating by sexual transmission in MSM populations across diverse geographic locations, suggesting a need to incorporate sexual behavior in the investigation of clusters of foodborne pathogens revealed by WGS data.
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Affiliation(s)
- Alexander L Greninger
- Departments of Laboratory Medicine and Microbiology, University of Washington School of Medicine, Seattle, Washington, USA
- Correspondence: A. L. Greninger, University of Washington, 1616 Eastlake Ave E, Suite 320, Seattle, WA 98102 ()
| | - Amin Addetia
- Departments of Laboratory Medicine and Microbiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kimberly Starr
- Departments of Laboratory Medicine and Microbiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Robert J Cybulski
- Department of Pathology and Area Laboratory Services, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Mary K Stewart
- Departments of Laboratory Medicine and Microbiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Stephen J Salipante
- Departments of Laboratory Medicine and Microbiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Andrew B Bryan
- Departments of Laboratory Medicine and Microbiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Brad Cookson
- Departments of Laboratory Medicine and Microbiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Christiane Gaudreau
- Microbiologie médicale et infectiologie, Centre hospitalier de l’Université de Montréal, Québec, Canada
- Département de microbiologie, infectiologie et immunologie, Université de Montréal, Québec, Canada
| | - Sadjia Bekal
- Département de microbiologie, infectiologie et immunologie, Université de Montréal, Québec, Canada
- Laboratoire de santé publique du Québec, Institut national de santé publique du Québec, Sainte-Anne-de-Bellevue, Québec, Canada
| | - Ferric C Fang
- Departments of Laboratory Medicine and Microbiology, University of Washington School of Medicine, Seattle, Washington, USA
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13
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Chadwick DR, Sutherland RK, Raffe S, Pool E, Beadsworth M. British HIV Association guidelines on the management of opportunistic infection in people living with HIV: the clinical management of gastrointestinal opportunistic infections 2020. HIV Med 2020; 21 Suppl 5:1-19. [PMID: 33271637 DOI: 10.1111/hiv.13004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- D R Chadwick
- Centre for Clinical Infection, James Cook University Hospital, Middlesbrough, UK
| | - R K Sutherland
- Regional Infectious Diseases Unit, NHS Lothian, Edinburgh, UK
| | - S Raffe
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Erm Pool
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | - Mbj Beadsworth
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital (Liverpool University Hospitals Foundation Trust), Liverpool, UK
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14
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Williamson DA, Chow EPF, Lee D, Maddaford K, Sait M, Easton M, Ingle D, Wigan R, De Petra V, Howden BP, Fairley CK, Chen MY. Risk Factors for Asymptomatic Enteric Pathogen Detection Among Men Who Have Sex With Men. Open Forum Infect Dis 2019; 6:ofz326. [PMID: 31660405 PMCID: PMC6798250 DOI: 10.1093/ofid/ofz326] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/09/2019] [Indexed: 11/15/2022] Open
Abstract
Improved knowledge of factors that promote outbreaks of enteric pathogens among men who have sex with men (MSM) could enable targeted public health interventions. We detected enteric pathogens in 57 of 519 (11%) asymptomatic MSM, and we found that enteric pathogen detection was associated with both oroanal sex (rimming) and group sex.
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Affiliation(s)
- Deborah A Williamson
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Australia
| | - Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Darren Lee
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Australia
| | - Kate Maddaford
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia
| | - Michelle Sait
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Australia
| | - Marion Easton
- Victorian Department of Health and Human Services, Melbourne, Australia
| | - Danielle Ingle
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Australia
| | - Rebecca Wigan
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia
| | - Vesna De Petra
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Australia
| | - Benjamin P Howden
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Marcus Y Chen
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Australia
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15
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Escolà-Vergé L, Arando M, Vall M, Rovira R, Espasa M, Sulleiro E, Armengol P, Zarzuela F, Barberá MJ. Outbreak of intestinal amoebiasis among men who have sex with men, Barcelona (Spain), October 2016 and January 2017. ACTA ACUST UNITED AC 2018; 22:30581. [PMID: 28797327 PMCID: PMC5553055 DOI: 10.2807/1560-7917.es.2017.22.30.30581] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 07/26/2017] [Indexed: 11/23/2022]
Abstract
Entamoeba histolytica has been recently recognised as an emerging sexually transmissible pathogen in men who have sex with men (MSM), causing sporadic outbreaks in countries where it is not endemic. Here we report two closed clusters of invasive amoebiasis occurring in Barcelona, Spain, in October 2016 (four cases) and in January 2017 (four cases).
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Affiliation(s)
- Laura Escolà-Vergé
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Maider Arando
- Sexually Transmitted Infections Unit (Drassanes). Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Martí Vall
- Sexually Transmitted Infections Unit (Drassanes). Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Roger Rovira
- Sexually Transmitted Infections Unit (Drassanes). Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Mateu Espasa
- Microbiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Elena Sulleiro
- Microbiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Pere Armengol
- Sexually Transmitted Infections Unit (Drassanes). Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Francesc Zarzuela
- Microbiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - María-Jesús Barberá
- Sexually Transmitted Infections Unit (Drassanes). Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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16
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Mohan K, Hibbert M, Rooney G, Canvin M, Childs T, Jenkins C, Simms I, Kirwan P, Delpech V, Yin Z, Hughes G, Field N. What is the overlap between HIV and shigellosis epidemics in England: further evidence of MSM transmission? Sex Transm Infect 2017; 94:67-71. [PMID: 28490580 DOI: 10.1136/sextrans-2016-052962] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 04/01/2017] [Accepted: 04/18/2017] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Evidence suggests that sexual transmission between men has replaced foreign travel as the predominant mode of Shigella transmission in England. However, sexuality and HIV status are not routinely recorded for laboratory-reported Shigella, and the role of HIV in the Shigella epidemic is not well understood. METHODS The Modular Open Laboratory Information System containing all Shigella cases reported to Public Health England (PHE) and the PHE HIV and AIDS Reporting System holding all adults living with diagnosed HIV in England were matched using a combination of Soundex code, date of birth and gender. RESULTS From 2004 to 2015, 88 664 patients were living with HIV, and 10 269 Shigella cases were reported in England; 9% (873/10 269) of Shigella cases were diagnosed with HIV, of which 93% (815/873) were in men. Shigella cases without reported travel history were more likely to be living with HIV than those who had travelled (14% (751/5427) vs 3% (134/4854); p<0.01). From 2004 to 2015, the incidence of Shigella in men with HIV rose from 47/100 000 to 226/100 000 (p<0.01) peaking in 2014 at 265/100 000, but remained low in women throughout the study period (0-24/100 000). Among Shigella cases without travel and with HIV, 91% (657/720) were men who have sex with men (MSM). HIV preceded Shigella diagnosis in 86% (610/720), and 65% (237/362) had an undetectable viral load (<50 copies/mL). DISCUSSION We observed a sustained increase in the national rate of shigellosis in MSM with HIV, who may experience more serious clinical disease. Sexual history, HIV status and STI risk might require sensitive investigation in men presenting with gastroenteritis.
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Affiliation(s)
- Keerthi Mohan
- Department of HIV and STI, National Infection Service, Public Health England, London, UK
| | - Matthew Hibbert
- Department of HIV and STI, National Infection Service, Public Health England, London, UK
| | - Graeme Rooney
- Department of HIV and STI, National Infection Service, Public Health England, London, UK
| | - Malcolm Canvin
- Department of HIV and STI, National Infection Service, Public Health England, London, UK
| | - Tristan Childs
- Department of HIV and STI, National Infection Service, Public Health England, London, UK
| | - Claire Jenkins
- Gastrointestinal Infection Reference Service, Microbiology Services Centre, National Infection Service, Public Health England, London, UK
| | - Ian Simms
- Department of HIV and STI, National Infection Service, Public Health England, London, UK
| | - Peter Kirwan
- Department of HIV and STI, National Infection Service, Public Health England, London, UK
| | - Valerie Delpech
- Department of HIV and STI, National Infection Service, Public Health England, London, UK
| | - Zheng Yin
- Department of HIV and STI, National Infection Service, Public Health England, London, UK
| | - Gwenda Hughes
- Department of HIV and STI, National Infection Service, Public Health England, London, UK
| | - Nigel Field
- Department of HIV and STI, National Infection Service, Public Health England, London, UK.,Research Department of Infection and Population Health, University College London, London, UK
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