Mycoplasma genitalium among women with nongonococcal, nonchlamydial pelvic inflammatory disease

The Impact and Correlation of Anxiety and Depression on Pressure Pain Threshold of Acupoints in Patients with Chronic Pelvic Inflammatory Disease

Background

Chronic pelvic inflammatory disease (CPID) is a clinically common gynecological disease. Patients experience chronic pelvic pain and often accompany with emotional dysfunction. However, the impact and correlation of anxiety and depression on pain sensitization is not completely known.

Objective

To explore the differences and correlations among anxiety, depression, and pressure pain threshold (PPT) of acupoints in patients with CPID.

Methods

One hundred and forty-seven patients with CPID were recruited. The Visual Analog Scale (VAS) and short-form McGill Pain Questionnaire (SF-MPQ) were used to assess pain. Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) were used to evaluate the emotional state of patients. The PPT of acupoints was collected using an electronic Von Frey by two licensed acupuncturists.

Results

The CPID patients were divided into anxiety-depression group (group A) or nonanxiety-depression group (group B), according to the SAS and SDS scores. Finally, there were 73 patients in group A and 74 patients in group B. Group A had significantly higher SAS, SDS, VAS, and SF-MPQ scores than group B (P < 0.05). In addition, significant differences were observed in the PPTs of ST28 (R), ST29 (R), SP10 (R), SP9 (R), SP9 (L), ST36 (R), and LR3 (L) between the two groups (P < 0.05). No considerable differences in PPTs at the other acupoints were observed between the two groups. SAS scores showed a positive correlation with PPTs of ST29 (R), SP10 (R), SP9 (L), ST36 (R), and LR3 (L). No remarkable correlation was observed between the SDS scores and PPTs.

Conclusion

Anxiety and depression can affect the PPT of some acupoints in CPID patients, which may provide a reference for acupoint selection for acupuncture treatment of CPID with emotional disorders. This trial is registered with ChiCTR2100052632.

Moxifloxacin monotherapy for treatment of uncomplicated pelvic inflammatory disease: A systematic review and meta-analysis with trial sequential analysis of randomized controlled trials

PURPOSE

The aim of this study was to evaluate the efficacy and safety of moxifloxacin monotherapy for the treatment of uncomplicated pelvic inflammatory disease (uPID).

METHODS

The literatures from PubMed, ScienceDirect, Google Scholar, Cochrane library and the http://clinicaltrials.gov/ were retrieved until February 2023. Only randomized controlled trials (RCTs) comparing the efficacy and safety of moxifloxacin with other antibiotics for treating uPID were included. The primary outcomes were clinical cure rate (CCR), bacteriological success rates (BSR) and risk of drug-related adverse events (AEs). We used random-effects modelled meta-analysis, trial sequential analysis, and the Grading of Recommendations Assessment, Development, and Evaluation. This study was registered in the International Prospective Register of Systematic Reviews (registration number: CRD42023428751).

RESULTS

A total of four RCTs that enrolled 3201 women patients with uPID were included. In the per-protocol populations, no significant difference was observed between patients given moxifloxacin and those given other antibiotics with regard to CCR at test-of-cure (TOC) (2485 patients, odds ratio [OR] = 0.84, 95% confidence interval [CI] 0.68-1.04, p = 0.12). Similarly, there was no statistically significant difference between patients given moxifloxacin and those given other antibiotics in terms of BSR at TOC (471 patients, OR = 1.17, 95% CI 0.70-1.96, p = 0.56) in the microbiologically valid population. However, drug-related AEs occurred less frequently with moxifloxacin than with other antibiotics (2973 patients, OR = 0.74, 95% CI 0.64-0.86, p < 0.0001), especially gastrointestinal AEs (2973 patients, OR = 0.59, 95% CI 0.47-0.74, p < 0.00001).

CONCLUSIONS

In the treatment of uPID, moxifloxacin monotherapy can achieve similar efficacy as other combination therapy regimens. Moreover, moxifloxacin had a better safety profile than that of comparators. Based on its additional advantages (i.e., better safety profile, no dosage adjustment and better compliance), moxifloxacin may be a more fascinating option compared with the currently used regimens.

Mycoplasma genitalium infection in the female reproductive system: Diseases and treatment

Mycoplasma genitalium is a newly emerged sexually transmitted disease pathogen and an independent risk factor for female cervicitis and pelvic inflammatory disease. The clinical symptoms caused by M. genitalium infection are mild and easily ignored. If left untreated, M. genitalium can grow along the reproductive tract and cause salpingitis, leading to infertility and ectopic pregnancy. Additionally, M. genitalium infection in late pregnancy can increase the incidence of preterm birth. M. genitalium infections are often accompanied by co-infection with other sexually transmitted pathogens (Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis) and viral infections (Human Papilloma Virus and Human Immunodeficiency Virus). A recent study suggested that M. genitalium plays a role in tumor development in the female reproductive system. However, few studies endorsed this finding. In recent years, M. genitalium has evolved into a new "superbug" due to the emergence of macrolide-and fluoroquinolone-resistant strains leading to frequent therapy failures. This review summarizes the pathogenic characteristics of M. genitalium and the female reproductive diseases caused by M. genitalium (cervicitis, pelvic inflammatory disease, ectopic pregnancy, infertility, premature birth, co-infection, reproductive tumors, etc.), as well as its potential relationship with reproductive tumors and clinical treatment.

The Burden of and Trends in Pelvic Inflammatory Disease in the United States, 2006-2016

BACKGROUND

Pelvic inflammatory disease (PID) is an infection of the upper genital tract that has important reproductive consequences to women. We describe the burden of and trends in PID among reproductive-aged women in the United States during 2006-2016.

METHODS

We used data from 2 nationally representative probability surveys collecting self-reported PID history (National Health and Nutrition Examination Survey, National Survey of Family Growth); 5 datasets containing International Classification of Diseases, Ninth/Tenth Revision codes indicating diagnosed PID (Healthcare Utilization Project; National Hospital Ambulatory Medical Care Survey, emergency department component; National Ambulatory Medical Care Survey; National Disease Therapeutic Index; MarketScan); and data from a network of sexually transmitted infection (STI) clinics (Sexually Transmitted Disease Surveillance Network). Trends during 2006-2016 were estimated overall, by age group and, if available, race/ethnicity, region, and prior STIs.

RESULTS

An estimated 2 million reproductive-aged women self-reported a history of PID. Three of 4 nationally representative data sources showed overall declines in a self-reported PID history, and PID emergency department and physician office visits, with small increases observed in nearly all data sources starting around 2015.

CONCLUSIONS

The burden of PID in the United States is high. Despite declines in burden over time, there is evidence of an increase in recent years.

Sexually Transmitted Infections Treatment Guidelines, 2021

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.

Recent advances in understanding and combatting Mycoplasma genitalium

Mycoplasma genitalium has emerged over the last 30 years as a sexually transmitted infection (STI). As data have accumulated, our understanding of this pathogen and its role in disease continues to evolve. This in turn creates new challenges and complexities. Questions remain regarding the natural history of M. genitalium, its contribution to disease and long-term sequelae. A decline in cure rates for first-line anti-microbials has been observed. This is likely in part due to high usage of single-dose azithromycin in the sexual health field but also due to the intrinsic ability of M. genitalium to rapidly acquire anti-microbial resistance. Consequently, the term 'the new STI superbug' is not infrequently used by the media to describe this pathogen. Currently available antibiotics have side effects that, though rare, are potentially serious. This leads to inherent questions regarding the benefit of testing for and treating M. genitalium, particularly in asymptomatic individuals or in genital syndromes where the benefit of treatment is not well established. In this review, we summarize the most recent evidence and literature regarding M. genitalium and explore areas of research where disparities exist. We discuss the contribution of M. genitalium to genital syndromes, particularly those where data are conflicting, in order to inform indications for testing and treatment. Avoidance of increasing anti-microbial resistance with astute anti-microbial stewardship is paramount if we are to successfully manage M. genitalium infection. We examine the state of play regarding anti-microbial resistance and how to combat this, including currently available anti-microbials, resistance-guided therapy and novel therapeutic approaches. We aim to provide an overview of the current understanding of M. genitalium and the implications for current clinical practise and suggestions for future research.

Sequence variation and immunogenicity of the Mycoplasma genitalium MgpB and MgpC adherence proteins during persistent infection of men with non-gonococcal urethritis

Mycoplasma genitalium is a sexually transmitted bacterial pathogen that infects men and women. Antigenic variation of MgpB and MgpC, the immunodominant adherence proteins of M. genitalium, is thought to contribute to immune evasion and chronic infection. We investigated the evolution of mgpB and mgpC sequences in men with non-gonococcal urethritis persistently infected with M. genitalium, including two men with anti-M. genitalium antibodies at enrollment and two that developed antibodies during follow-up. Each of the four patients was persistently infected with a different strain type and each patient produced antibodies targeting MgpB and MgpC. Amino acid sequence evolution in the variable regions of MgpB and MgpC occurred in all four patients with changes observed in single and multiple variable regions over time. Using the available crystal structure of MgpC of the G37 type strain we found that predicted conformational B cell epitopes localize predominantly to the variable region of MgpC, amino acids that changed during patient infection lie in these epitopes, and variant amino acids are in close proximity to the conserved sialic acid binding pocket. These findings support the hypothesis that sequence variation functions to avoid specific antibodies thereby contributing to persistence in the genital tract.

A Need for Standardization of the Diagnosis and Treatment of Pelvic Inflammatory Disease: Pilot Study in an Outpatient Clinic in Quito, Ecuador

Background

Pelvic inflammatory disease (PID) diagnosis is often challenging as well as its treatment. This study sought to characterize the diagnostic and therapeutic trend among physicians at the outpatient level, in Quito, Ecuador, where currently no nationwide screening or specific clinical guideline has been implemented on PID or its main microbiological agents.

Methods

A retrospective analysis of medical records with pelvic inflammatory disease diagnosis in an outpatient clinic was performed. Electronic medical records from 2013 to 2018 with any pelvic inflammatory disease-related diagnoses were retrieved. Information with regard to age, sexually related risk factors, symptoms and physical exam findings, ancillary tests, method of diagnosis, and antibiotic regimens was extracted.

Results

A total of 186 records were included. The most frequent clinical manifestations were vaginal discharge (47%) and pelvic pain (39%). In the physical examination, leucorrhea was the most frequent finding (47%), followed by lower abdominal tenderness (35%) and cervical motion tenderness in 51 patients (27%). A clinical diagnosis was established in 60% of patients, while 37% had a transvaginal sonography-guided diagnosis. Antibiotic treatment was prescribed with standard regimens in 3% of cases, while other regimens were used in 93% of patients. Additionally, an average of 1.9 drugs were prescribed per patient, with a range from 1 to 5, all in different combinations and dosages.

Conclusions

No standardized methods of diagnosis or treatment were identifiable. These findings highlight the need for standardization of the diagnosis and treatment of PID attributed to chlamydial and gonococcal infections.

[Recurrent Urogynecological Infections]

Recurrent Urogynecological Infections Abstract. Changes in the urogenital microbiome of the bladder, urethra, vagina and cervix can cause recurrent infections. We distinguish between obligate and facultative pathogens. In the case of facultative pathogens, treatment with antibiotic, antiviral or antifungal drugs should only be considered in cases with attributable symptoms. Sexually transmitted diseases (STD) manifest either urogenitally alone or in association with an ascending infection of the adnexa as a pelvic inflammatory disease. STD may be asymptomatic, as in cases of chlamydia, or may cause a high burden of symptoms, impairment of quality of life or infertility. The aim of this minireview is to give an overview of the pathogenicity of the different germs and their treatment.

Mycoplasma genitalium infection among HIV-infected pregnant African women and implications for mother-to-child transmission of HIV

OBJECTIVE

Many sexually transmitted infections increase risk of mother-to-child transmission (MTCT) of HIV, but the effect of Mycoplasma genitalium is not known. We hypothesized that M. genitalium infection would be common among HIV-infected pregnant women and could be associated with in-utero and intrapartum MTCT.

DESIGN

Observational case-cohort study.

METHODS

The current study used specimens from a Kenyan perinatal MTCT cohort (1999-2005) involving HIV-infected women and their infants, who received short-course zidovudine for prevention of MTCT. Vaginal swabs collected at 32 weeks gestation were tested for M. genitalium using a transcription-mediated amplification assay. Infant perinatal HIV infection was determined at birth and 4 weeks of age by DNA PCR. Using a case-cohort design, a random sample was generated with 3 : 1 control : case ratio; prevalence and correlates of M. genitalium were assessed with chi-squared and t tests; predictors of infant outcomes were analyzed using logistic regression.

RESULTS

Among 220 HIV-infected pregnant women evaluated, 47 women (21.4%) had M. genitalium. Antenatal M. genitalium infection was associated with higher HIV RNA in plasma (5.0 vs. 4.6 log10 copies/ml in M. genitalium-positive vs. M. genitalium-negative women, P = 0.02) at 32 weeks. Women with M. genitalium were less likely to report prior sexually transmitted infections and genital ulcers (both P = 0.05). There was no association found between exposure to M. genitalium and perinatal MTCT (odds ratio = 0.72, 95% confidence interval 0.35, 1.51, P = 0.39).

CONCLUSION

Vaginal M. genitalium infection was frequently detected among Kenyan HIV-infected pregnant women and was associated with higher plasma HIV levels, but was not associated with perinatal transmission of HIV.

Streptococcus constellatus Peritonitis and Subsequent Septic Shock following Intrauterine Device Removal

Background

Previous reports have described cases of abscess formation by Streptococcus constellatus involving the oral cavity, gastrointestinal tract, and septic thrombophlebitis of the right ovarian vein with subsequent bacteremia and septic shock. Ascending infection from the genital tract to the fallopian tubes resulting in peritonitis from Streptococcus constellatus is a rare clinical circumstance where there is minimal information in the literature to guide its diagnosis, management, and expected prognosis.

Case

A 36-year-old G3P0111 developed a tubo-ovarian abscess two weeks after intrauterine device (IUD) removal and then rapidly decompensated with septic shock from peritonitis due to Streptococcus constellatus infection. The patient was also newly diagnosed with diabetes and in diabetic ketoacidosis (DKA) on presentation. She received broad-spectrum antibiotic coverage and required two exploratory surgical procedures to obtain source control. Two Interventional Radiology- (IR-) guided drainage procedures were subsequently performed to drain remaining fluid collections. Her recovery involved a prolonged ICU stay. On hospital day seventy-three, after receiving approximately 8 weeks of antibiotics and the above noted procedures the patient was discharged to a subacute rehabilitation facility.

Conclusion

Streptococcus constellatus is a highly pathogenic organism once a systemic septic infection has become established that can cause an ascending genital tract infection resulting in tubo-ovarian abscess formation, peritonitis, and septic shock.

[Pelvic inflammatory diseases: Microbiologic diagnosis - CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]

OBJECTIVES

To determine the microorganisms potentially involved in pelvic inflammatory diseases (PIDs) and the different diagnostic methods of PID.

METHODS

PubMed and International Guidelines search.

RESULTS

PIDs have various microbial causes. The pathogenic role of the main agents of sexually transmitted infections (STIs), Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium is well demonstrated (NP1). C. trachomatis is the most commonly described bacterium in PID (NP1), especially in women under 30 years old. PIDs also occur in situations that decrease the effectiveness of the cervix microbiological lock, such as bacterial vaginosis, allowing facultative vaginal bacteria such as Escherichia coli, Streptococcus agalactiae and anaerobes to ascend to the uterine cavity. Nevertheless, participation of the diverse bacteria of the vaginal microbiota, in particular anaerobes, and the polymicrobial character of PIDs are still differently appreciated. In the case of uncomplicated PID, to obtain a microbiological diagnosis, endocervical sampling is recommended during gynecological examination under speculum (grade B). A first swab allows for a smear on a slide for direct examination (Gram, MGG). A second swab, in an adapted transport medium, is useful for standard culture with N. gonorrhoeae and facultative vaginal flora bacteria cultures, with antibiotic susceptibility testing. A third swab, in an appropriate transport medium, allows for the search for N. gonorrhoeae, C. trachomatis, and if possible M. genitalium by nucleic acid amplification techniques (NAATs), (NP1). It is possible to only use one swab in a transport medium suitable for (i) survival of bacteria and (ii) NAATs. When the diagnosis of PID is clinically compatible, a positive NAAT for one or more of the three STI-associated bacteria on a genital sample supports the PID diagnosis (NP1). On the other hand, a negative NAAT does not allow the exclusion of an STI agent for PID diagnosis (NP1). In situations where speculum use is not possible, vaginal sampling will be performed by default. In case of complicated IGH, tuboperitoneal samples can be performed either radiologically or surgically. Since these sites are sterile, any bacteria present will be considered pathogenic (NP2). C. trachomatis serology is not interesting as a first line diagnostic tool for PID diagnosis and is not useful for monitoring the evolution of PID (NP1).

Culture- and PCR-based detection of BV associated microbiological profile of the removed IUDs and correlation with the time period of IUD in place and the presence of the symptoms of genital tract infection

Objectives

The long-term use of intrauterine devices (IUDs) may lead to biofilm formation on the surface. The aim of this study was to perform the culture- and PCR-based detection of bacteria/fungi from the biofilm of the removed IUDs with different time periods in place.

Methods

For a 2-year period, 100 IUD users were involved in the study. In the majority of the cases, IUDs were removed because of the patients’ complaints. Beside the aerobic and anaerobic culture, species-specific PCR was carried out to detect Chlamydia trachomatis Neisseria gonorrhoeae and the “signalling” bacteria of bacterial vaginosis (BV) in the biofilm removed by vortexing.

Results

Sixty-eight percent of IUDs were used for more than 5 years, 32% were removed after 10 years in place. In 28% of the IUDs ≥ 3 different anaerobic species typically found in BV with or without other aerobic bacteria were found by culture method. Streptococcus agalactiae (14%) and Actinomyces spp. (18%) were also isolated frequently. The PCR detection of Gardnerella vaginalis, Atopobium vaginae, Mobiluncus spp. and Ureaplasma urealyticum were 62%, 32%, 23% and 16%, respectively. Seventy-six percent of the IUDs were PCR positive at least for one “signalling” bacterium of BV. C. trachomatis was detected by PCR only in one IUD together with other aerobic and anaerobic bacteria, while the presence of N. gonorrhoeae could not be confirmed from the biofilm of these removed devices.

Conclusion

Sexually transmitted infections (STI)-related bacteria—except for one patient—were not detected on the IUDs removed due to different reasons including clinical symptoms of infection. Presence of any BV “signaling” anaerobic bacteria were detected in a much higher number in the biofilm of the removed IUDs by PCR-based method compared to use culture method (76 versus 28 samples). Different aerobic and anaerobic bacteria colonized an equal number of IUDs, independent of the time-period in place, which may be relevant, if the IUD is removed due to planned pregnancy or due to a fear from upper genital tract infection caused by anaerobic bacteria including Actinomyces spp.

Discovery of Blood Transcriptional Endotypes in Women with Pelvic Inflammatory Disease

Sexually transmitted infections with Chlamydia trachomatis and/or Neisseria gonorrhoeae and rates of pelvic inflammatory disease (PID) in women continue to rise, with reinfection being common because of poor adaptive immunity. Diagnosis remains imprecise, and pathogenesis data are derived primarily from monoinfection of mice with C. trachomatis or N. gonorrhoeae By comparing blood mRNA responses of women with C. trachomatis- and/or N. gonorrhoeae-induced PID and histologic endometritis with those from women with C. trachomatis and/or N. gonorrhoeae infection limited to their cervix and asymptomatic uninfected women determined via microarray, we discovered important pathogenic mechanisms in PID and response differences that provide a pathway to biomarker discovery. Women with N. gonorrhoeae- and/or C. trachomatis-induced PID exhibit overexpression of myeloid cell genes and suppression of protein synthesis, mitochondrial oxidative phosphorylation, and T cell-specific genes. Coinfected women exhibited the greatest activation of cell death pathways and suppression of responses essential for adaptive immunity. Women solely infected with C. trachomatis expressed elevated levels of type I and type II IFN genes, and enhanced type I IFN-induced chemokines in cervical secretions were associated with ascension of C. trachomatis to the endometrium. Blood microarrays reveal discrete pathobiological endotypes in women with PID that are driven by pathogen invasion of the upper genital tract.

Should we screen for the sexually-transmitted infection Mycoplasma genitalium? Evidence synthesis using a transmission-dynamic model

There is increasing concern about Mycoplasma genitalium as a cause of urethritis, cervicitis, pelvic inflammatory disease (PID), infertility and ectopic pregnancy. Commercial nucleic acid amplification tests (NAATs) are becoming available, and their use in screening for M. genitalium has been advocated, but M. genitalium's natural history is poorly-understood, making screening's effectiveness unclear. We used a transmission-dynamic compartmental model to synthesise evidence from surveillance data and epidemiological and behavioural studies to better understand M. genitalium's natural history, and then examined the effects of implementing NAAT testing. Introducing NAAT testing initially increases diagnoses, by finding a larger proportion of infections; subsequently the diagnosis rate falls, due to reduced incidence. Testing only symptomatic patients finds relatively little infection in women, as a large proportion is asymptomatic. Testing both symptomatic and asymptomatic patients has a much larger impact and reduces cumulative PID incidence in women due to M. genitalium by 31.1% (95% range:13.0%-52.0%) over 20 years. However, there is important uncertainty in M. genitalium's natural history parameters, leading to uncertainty in the absolute reduction in PID and sequelae. Empirical work is required to improve understanding of key aspects of M. genitalium's natural history before it will be possible to determine the effectiveness of screening.

Should we screen for the sexually-transmitted infection Mycoplasma genitalium? Evidence synthesis using a transmission-dynamic model

There is increasing concern about Mycoplasma genitalium as a cause of urethritis, cervicitis, pelvic inflammatory disease (PID), infertility and ectopic pregnancy. Commercial nucleic acid amplification tests (NAATs) are becoming available, and their use in screening for M. genitalium has been advocated, but M. genitalium's natural history is poorly-understood, making screening's effectiveness unclear. We used a transmission-dynamic compartmental model to synthesise evidence from surveillance data and epidemiological and behavioural studies to better understand M. genitalium's natural history, and then examined the effects of implementing NAAT testing. Introducing NAAT testing initially increases diagnoses, by finding a larger proportion of infections; subsequently the diagnosis rate falls, due to reduced incidence. Testing only symptomatic patients finds relatively little infection in women, as a large proportion is asymptomatic. Testing both symptomatic and asymptomatic patients has a much larger impact and reduces cumulative PID incidence in women due to M. genitalium by 31.1% (95% range:13.0%-52.0%) over 20 years. However, there is important uncertainty in M. genitalium's natural history parameters, leading to uncertainty in the absolute reduction in PID and sequelae. Empirical work is required to improve understanding of key aspects of M. genitalium's natural history before it will be possible to determine the effectiveness of screening.

The prevalence of, and risk factors for, mycoplasma genitalium infection among infertile women in Ibadan: A cross-sectional study

BACKGROUND

The association of mycoplasma genitalium (M. genitalium) with infertility has been documented. The infections are asymptomatic and difficult to diagnose. Understanding the associated risk factors will help in facilitating better screening measures for at-risk groups.

OBJECTIVE

The aim was to determine the prevalence of, and risk factors for, M. genitalium infection among infertile women in Ibadan.

MATERIALS AND METHODS

In this cross-sectional study, 402 women (267 infertile and 135 fertile) referred to 2 hospitals in Ibadan between March and November 2015 were enrolled. Information was obtained, using structured questionnaire, on sociodemographic and behavioral characteristics of the respondents while endocervical swabs were obtained for detection of M. genitalium. MgPa gene was diagnosed using the conventional Polymerase chain reaction. Bands corresponding to 495kb were documented as positive for M. genitalium.

RESULTS

Among the infertile women, 43 (16.1%) had evidence of M. genitalium infection as against 3 (2.2%) of women without infertility (p<0.001). Associated risk factors included having more than one lifetime sexual partner (OR=10.13, 95% CI: 3.76-33.97); husbands having other sexual partners (OR=12.88, 95% CI: 2.08-90.63); being a serial monogamist (OR=6, 95% CI: 4.35-8.27) and low socio-economic status (OR=2.80, 95% CI: 1.28-6.10). No relationship exists between the previous history of sexually transmitted infections and M. genitalium.

CONCLUSION

The risk factors for M. genitalium infection are similar to those peculiar to other sexually transmitted infections. Its routine screening should be incorporated into the current protocol for microbiological evaluation of infertile women.

Recruitment of Minority Adolescents and Young Adults into Randomised Clinical Trials: Testing the Design of the Technology Enhanced Community Health Nursing (TECH-N) Pelvic Inflammatory Disease Trial

PURPOSE

Pelvic inflammatory disease (PID) disproportionately affects adolescent and young adult (AYA) women and can negatively influence reproductive health trajectories. Few randomized controlled trials (RCTs) have focused on strategies to improve outpatient adherence or to reduce reproductive morbidity in this population. This paper describes the research methods and preliminary effectiveness of recruitment, retention, and intervention strategies employed in a novel RCT designed to test a technology-enhanced community-health nursing (TECH-N) intervention among urban AYA with PID.

METHODS

AYA women aged 13-25 years were recruited during acute PID visits in outpatient clinics and emergency departments (ED) to participate in this IRB-approved trial. Participants completed an audio-computerized self-interview (ACASI), provided vaginal specimens, and were randomized to standard treatment or the intervention. Intervention participants received text-messaging support for 30 days and a community health nurse (CHN) interventionist performed a home visit with clinical assessment within 5 days after enrollment. All patients received a full course of medications and completed research visits at 14-days (adherence), 30 days and 90 days with by an outreach worker. STI testing performed at the 30-and 90-day visits. Exploratory analyses using descriptive statistics were conducted to examine recruitment, retention, and follow-up data to test the overall design of the intervention.

RESULTS

In the first 48 months, 64% of 463 patients were eligible for the study and 81.2% of 293 eligible patients were recruited for the study (63.3%); 238 (81.2%) of eligible patients were enrolled. Most participants were African American (95.6%) with a mean age of 18.6 (2.3). Ninety-four percent of individuals assigned to the TECH-N intervention completed the nursing visits. All completed visits have been within the 5-day window and over 90% of patients in both arms have been retained over the 3-month follow-up period. Biological data suggests a shift in the biological milieu with the predominance of Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis infections.

CONCLUSIONS

Preliminary data from the TECH-N study demonstrated that urban, low-income, minority AYA with PID can effectively be recruited and retained to participate in sexual and reproductive health RCTs with sufficient investment in the design and infrastructure of the study. Community-based sexual health interventions appear to be both feasible and acceptable in this population.

Sexually transmitted diseases treatment guidelines, 2015

These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.

Loop-mediated isothermal amplification (LAMP) for the rapid detection of Mycoplasma genitalium

Mycoplasma genitalium is a sexually transmissible, pathogenic bacterium and a significant cause of nongonococcal urethritis in both men and women. Due to the difficulty of the culture of M. genitalium from clinical samples, the laboratory diagnosis of M. genitalium infection is almost exclusively carried out using nucleic acid amplification tests. Loop-mediated isothermal amplification (LAMP) is a novel nucleic acid amplification technology, utilising a set of 4 primers specific to 6 distinct regions of the target DNA sequence, in order to amplify target DNA in a highly specific and rapid manner. A LAMP assay was designed to the pdhD gene of M. genitalium, and the limit of detection of the assay was determined as 10 fg of M. genitalium genomic DNA, equating to ~16 copies of the M. genitalium genome, which was equally sensitive as a gold standard 16S rRNA polymerase chain reaction assay.

Mycoplasma genitalium infection and female reproductive tract disease: a meta-analysis

To determine the association between Mycoplasma genitalium infection and female reproductive tract syndromes through meta-analysis, English-language, peer-reviewed studies were identified via PubMed, Embase, Biosis, Cochrane Library, and reference review. Two reviewers independently extracted data. Random-effects models were employed to calculate summary estimates, between-study heterogeneity was evaluated using I(2) statistics, publication bias was assessed via funnel plots and the Begg and Egger tests, and methodologic quality was rated. Mycoplasma genitalium infection was significantly associated with increased risk of cervicitis (pooled odds ratio [OR], 1.66 [95% confidence interval {CI}, 1.35-2.04]), pelvic inflammatory disease (pooled OR, 2.14 [95% CI, 1.31-3.49]), preterm birth (pooled OR, 1.89 [95% CI, 1.25-2.85]), and spontaneous abortion (pooled OR, 1.82 [95% CI, 1.10-3.03]). Risk of infertility was similarly elevated (pooled OR, 2.43 [95% CI, .93-6.34]). In subanalyses accounting for coinfections, all associations were stronger and statistically significant. Testing of high-risk symptomatic women for M. genitalium may be warranted.

Sexually transmitted diseases: epidemiological and clinical aspects in adults

Sexually transmitted diseases (STDs) are the first 10 causes of unpleased diseases in young adult women in the world. The concept of STDs includes a series of syndromes caused by pathogens that can be acquired by sexual intercourse or sexual activity.Adolescents and young adults are responsible for only 25% of the sexually active population and they represent almost 50% of all newly acquired STDs.In this way, we evaluated the epidemiological and clinical aspects of most relevant pathogens as Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, Haemophilus Ducreyi, Trichomonas vaginalis, herpes simplex virus, human papilloma virus (HPV) with the exception of hepatitis, and HIV infections for which we suggest specific guidelines.To attain this objective, we analyzed the results of epidemiological and clinical aspects of STDs through a review of the literature using MEDLINE and PubMed database for original articles published using the terms "sexual transmitted disease, epidemiology, diagnosis and therapy" from 2005 to 2014.

Mycoplasma genitalium is associated with increased genital HIV type 1 RNA in Zimbabwean women

BACKGROUND

Mycoplasma genitalium is a common sexually transmitted infection associated with human immunodeficiency virus (HIV) infection. Some studies suggest that M. genitalium may increase the risk of HIV acquisition. However, results have been inconsistent, and this association has never been examined longitudinally.

METHODS

Stored endocervical samples from a longitudinal cohort study of 131 Zimbabwean women in whom HIV-1 seroconversion recently occurred were tested for detection and quantity of M. genitalium using polymerase chain reaction analysis. The associations between M. genitalium and the detection and quantity of genital HIV type 1 (HIV-1) RNA, the detection and quantity of plasma HIV-1 RNA, and the CD4(+) T-cell count was analyzed using mixed-effects regression analysis.

RESULTS

M. genitalium was detected in 10.5% of stored specimens (44 of 420), and infection persisted for up to 300 days. M. genitalium was independently associated with detection of genital HIV-1 RNA (adjusted odds ratio, 2.67; 95% confidence interval, .99-7.20), after adjustment for plasma viral load, viral set point, CD4(+) T-cell count, herpes simplex virus type 2 detection, and gonorrhea. There was no evidence of an association between M. genitalium detection or quantity and either plasma HIV-1 RNA load or CD4(+) T-cell count.

CONCLUSIONS

The growing evidence for an association between M. genitalium and HIV genital shedding and the high prevalence and persistence of M. genitalium in this population suggest that further research into this association is important. Consideration of the cost-effectiveness of M. genitalium screening interventions may be warranted.

Clinical characteristics associated with Mycoplasma genitalium among female sex workers in Nairobi, Kenya

The prevalence of Mycoplasma genitalium is high in vulnerable populations of women in low-resource settings. However, the epidemiology of infection in these populations is not well established. To determine the prevalence of Mycoplasma genitalium and its association with cervical cytology and other correlates, we recruited 350 female sex workers (FSW) who were 18 to 50 years old in Nairobi, Kenya, for a cross-sectional study. A questionnaire was administered at baseline to obtain information on sociodemographics and sexual behaviors. Women underwent a pelvic exam, during which a physician collected cervical-exfoliation samples for conventional cytology and sexually transmitted infection (STI) testing. Samples were tested for M. genitalium and other STI organisms (Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis) and the E6/E7 mRNA of human papillomavirus (HPV) by Aptima nucleic amplification assays. The prevalence of M. genitalium was 12.9%. FSW who engaged in sexual intercourse during menses were less likely to have M. genitalium infection than those who did not (odds ratio [OR], 0.3; 95% confidence interval [95% CI], 0.1, 0.9). M. genitalium was also less prevalent among FSW who had worked in prostitution for >5 years (6.2%) than among those who had worked for <3 years (17.6%) (OR, 0.3; 95% CI, 0.1, 0.8). FSW who reported more frequent condom use were more likely to be infected with M. genitalium than those who reported less frequent use (OR, 3.8; 95% CI, 1.2, 11.6). These correlates differ from those found in M. genitalium studies conducted with FSW from West Africa and China. Further longitudinal analyses assessing associations with persistent M. genitalium infection are needed.

Pelvic inflammatory disease: identifying research gaps--proceedings of a workshop sponsored by Department of Health and Human Services/National Institutes of Health/National Institute of Allergy and Infectious Diseases, November 3-4, 2011

In November 2011, the National Institutes of Health convened a workshop of basic researchers, epidemiologists, and clinical experts in pelvic inflammatory disease to identify research gaps hindering advances in diagnosis, treatment, and prevention. This article summarizes the presentations, discussions, and conclusions of this group and highlights significant controversies that reveal aspects of pelvic inflammatory disease research that would most greatly benefit from the application of newer molecular, immunologic, and radiologic techniques. Multiple limitations to performing new clinical trials exist; however, emerging data from ongoing clinical trials will add to the current body of knowledge regarding prevention and treatment strategies. In addition, use of established health care databases could serve as a valuable tool for performance of unbiased epidemiologic outcome studies.

Chronic endometritis due to common bacteria is prevalent in women with recurrent miscarriage as confirmed by improved pregnancy outcome after antibiotic treatment

Recurrent miscarriage (RM) is defined as 3 or more miscarriages before 20 weeks' pregnancy. In recent years, interest has been focused on chronic endometritis (CE), a subtle inflammation thought to be associated with RM. We aimed to evaluate the relationships between CE and RM. The records of 360 women with unexplained RM were retrospectively analyzed. Data from hysteroscopy, endometrial histology, endometrial culture, and polymerase chain reaction for chlamydia, performed before and after antibiotic treatment for CE, were analyzed. The occurrence of successful pregnancies within 1 year after treatment was also evaluated. Results showed that 208 (57.8%) women with RM showed CE at hysteroscopy; 190 (91.3%), positive at hysteroscopy, were also positive at histology, and 142 (68.3%) had positive cultures. Common bacteria were found in 110 (77.5%) patients. Mycoplasma and Ureaplasma were found in 36 (25.3%) patients and Chlamydia in 18 patients (12.7%). In 102 (71%) women, antibiogram-based antibiotic treatment normalized hysteroscopy, histology, and cultures (group 1); while in 40 (28.2%) patients, CE was still present at hysteroscopy (group 2). In 16 of the 66 patients positive at hysteroscopy, but not at cultures, the hysteroscopy becomes normal (group 3) after a Centers for Disease Control and Prevention-based therapy; while in 50 women, CE was still present (group 4). One year after treatment, group 1 showed a significantly higher number of pregnancies (78.4%) compared to group 2 (17.5%; P < .001) and group 4 (15.3%; P = .005). The CE is frequent in women with RM. Antibiotic treatment seems to be associated with an improved reproductive outcome.

Pelvic inflammatory disease: current concepts in pathogenesis, diagnosis and treatment

Pelvic inflammatory disease (PID) is characterized by infection and inflammation of the upper genital tract in women and can cause significant reproductive health sequelae for women. Although a definitive diagnosis of PID is made by laparoscopic visualization of inflamed, purulent fallopian tubes, PID is generally a clinical diagnosis and thus represents a diagnostic challenge. Therefore, diagnosis and treatment algorithms advise a high index of suspicion for PID in any woman of reproductive age with pelvic or abdominal pain. Antibiotic therapy should be started early, and given for an adequate period of time to reduce the risk of complications. Coverage for anaerobic organisms should be considered in most cases.

Mycoplasma genitalium: An emergent sexually transmitted disease?

This article summarizes the epidemiologic evidence linking Mycoplasma genitalium to sexually transmitted disease syndromes, including male urethritis, and female cervicitis, pelvic inflammatory disease, infertility, and adverse birth outcomes. It discusses the relationship of this bacterium to human immunodeficiency virus infection and reviews the available literature on the efficacy of standard antimicrobial therapies against M genitalium.

The immune effects of multiple antigen peptides containing the mimic epitopes of the adhesion protein of Mycoplasma genitalium

The purpose of this study was to investigate the humoral and cellular immune responses stimulated by multiple antigen peptides (MAPs) containing the mimic epitopes of Mycoplasma genitalium adhesion protein (MgPa). Three MAPs containing the mimic epitopes of MgPa were synthesized on a branched polylysine matrix. After purification and characterization, these MAPs were used to immunize BALB/c mice. The immunoglobulin G (IgG) antibody and the subtype of IgG antibody in the serum of the immunized mice were detected by indirect ELISA (enzyme-linked immunosorbent assay). The proliferation of the spleen lymphocyte was detected using the MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide) assay. The gamma interferon (IFN-γ) and interleukin-4 (IL-4) levels in the cultured supernatant of spleen lymphocytes were measured by ELISA. The 3 different MAPs were prepared with high purity. Levels of IgG, IgG1, and IgG2a antibodies were elevated in the mice serum immunized by all 3 MAPs. The major antibody isotype was IgG2a. Importantly, mice immunized with a mixture of the 3 MAPs produced significantly more antibodies than those immunized with a single MAP (p < 0.05). Moreover, these MAPs could stimulate the proliferation of spleen lymphocytes of immunized mice and induce the production of IFN-γ and IL-4. The IFN-γ and IL-4 levels stimulated by the mixed MAPs were significantly higher than those stimulated by a single MAP (p < 0.01). The 3 different MAPs could induce strong cellular and humoral immune responses. The immunoreactivity of the mixed MAPs was stronger than that of the single MAP.

Recurrent PID, subsequent STI, and reproductive health outcomes: findings from the PID evaluation and clinical health (PEACH) study

PEACH trial data were used to evaluate the relationship between subsequent sexually transmitted infection and recurrent pelvic inflammatory disease on infertility and chronic pelvic pain (CPP). Recurrent pelvic inflammatory disease was associated with an almost 2-fold increase in infertility and more than 4-fold increase in CPP. Subsequent sexually transmitted infection was associated with CPP, but not infertility.

Beyond "safe sex"--can we fight adolescent pelvic inflammatory disease?

Pelvic inflammatory disease (PID) is a common disorder affecting sexually active adolescents. The Centers for Disease Control and Prevention (CDC) and European CDC report Chlamydia trachomatis as the most common sexually transmitted infection and one of the main etiological agents causing PID. C. trachomatis' and PID's high prevalence may be attributed to multiple factors including high-risk sexual behaviors, sensitive laboratory diagnostics (polymerase chain reaction), and the introduction of chlamydia screening programs. The pathogenesis of C. trachomatis infection is complex with recent data highlighting the role of toll-like receptor 2 and four in the mediation of the inflammatory cascade. The authors review the etiology of the disease, explore its pathogenesis, and discuss a variety of strategies that may be implemented to reduce the prevalence of C. trachomatis including: (a) behavioral risk reduction, (b) effective screening of asymptomatic females, (c) targeted male screening, (d) implementation of a sensitive, rapid, self-administered point-of-care testing, and (e) development of an effective vaccine.

Intrauterine devices and pelvic inflammatory disease among adolescents

Adolescents may be ideal candidates for intrauterine device (IUD) use, given high rates of unintended pregnancy and less successful use of short-acting contraceptive methods. Concerns about elevated risks of pelvic inflammatory disease in adolescents, with the consequences of infertility, ectopic pregnancy, and pelvic pain, prevent many clinicians from inserting IUDs in adolescents. The body of evidence examining risks of pelvic infection related to IUD use specifically in adolescents is limited, but is reassuring that the absolute risk of pelvic infection is small and that the benefits of IUD use likely outweigh the risks.

[Microbiologic basis of diagnosis and treatment of pelvic inflammatory disease]

Pelvic inflammatory disease (PID) is caused by a large spectrum of micro-organisms. However, the microbiological cause is unknown in approximately half of cases according to varying series. In the context of sexually transmitted disease (STD), the most frequently identified microorganisms causing PID are Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium. In such cases, bacterial vaginosis and Trichomonas vaginalis are frequently associated. In case of complicated PID or when PID is the consequence of delivery, abortion, intra-uterine procedure, bacteria that come from vaginal carriage may be encountered: Enterobacteriacae, Staphylococcus spp., Streptococcus spp., anaerobes. Mycopslama hominis as well as Ureaplasma urealyticum may also be found in this context. The microbiological diagnosis may be performed on samples of vaginal liquid, endocervix or, when available, surgical specimens. The microbiological diagnostic procedures that are used to identify these microrgansims are reviewed. Vaginal sampling may help to identify N. gonorrhoeae, C. trachomatis and M. genitalium using nucleic acid amplification tests (NAAT), and is also of interest because of the epidemiological association of PID to bacterial vaginosis and trichomoniasis. Samples from the endocervix, and if available, from endometrial biopsy surgical procedures, should be processed to detect N. gonorrhoeae, C. trachomatis and M. genitalium using NAAT, and to search for the presence of Neisseria gonorrhoeae (antibiogram should be performed), facultative anaerobes, anaerobes and capnophilic bacteria. The antibiotic treatment should at least cover N. gonorrhoeae, C. trachomatis and M. genitalium, and for most of the authors, anaerobes. In case, microbiological studies demonstrate the role of other bacteria (e.g., Enterobacteriacae), theses should be treated according to the results of antibiogram.

Mycoplasma genitalium infection in women attending a sexually transmitted infection clinic: diagnostic specimen type, coinfections, and predictors

In female sexually transmitted infection clinic attendees, Mycoplasma genitalium was more frequently detected using vaginal (53/73) versus endocervical (43/73) specimens. In women without other sexually transmitted infections, M. genitalium detection (N = 44) was associated with age ≤22 years (odds ratio, 2.53; P = 0.006) and clinical evidence of cervicitis (odds ratio, 2.11; P = 0.03).

Recent perspectives in the diagnosis and evidence-based treatment of Mycoplasma genitalium

Mycoplasma genitalium is a globally important sexually transmitted pathogen. Men infected with M. genitalium frequently present with dysuria, while women may present with or without urogenital symptoms. In some populations, M. genitalium is significantly associated with HIV-1 infection, and is also an etiological agent in pelvic inflammatory disease. However, there is insufficient evidence to establish a causative role of the organism in obstetric complications, including tubal factor infertility. Although several nucleic acid amplification tests offer rapid, sensitive methods for detecting M. genitalium, there is no standardized assay. Available evidence supports treatment of M. genitalium infections with an extended regimen of azithromycin and resistant strains respond to moxifloxacin. Accumulating evidence indicates growing fluoroquinolone resistance, including against moxifloxacin, emphasizing the need for new therapeutic strategies to treat M. genitalium infections.

Mycoplasma genitalium in cervicitis and pelvic inflammatory disease among women at a gynecologic outpatient service

OBJECTIVE

We sought to analyze the prevalence and clinical manifestations of Mycoplasma genitalium infection in a heterogeneous population of women.

STUDY DESIGN

The study was designed as a cross-sectional case-control study. Women attending a gynecological outpatient service from 2003 through 2008 were invited to participate.

RESULTS

The prevalence of M genitalium was 2.1% and of Chlamydia trachomatis was 2.8% among 5519 tested women. A total of 679 women were included. Both pelvic inflammatory disease (PID) and cervicitis were independently associated with M genitalium (odds ratio, 9.00; 95% confidence interval, 1.62-49.89 and odds ratio, 3.80; 95% confidence interval, 2.06-7.03, respectively). Women with C trachomatis had a higher frequency of both PID (18.3% vs 4.9%, P < .001) and cervicitis (33.4% vs 22.3%, P < .001) than women with M genitalium.

CONCLUSION

M genitalium was an independent and strong risk factor for both cervicitis and PID although, compared to C trachomatis, clinical manifestations were less frequent.

Mycoplasma genitalium: an emerging cause of pelvic inflammatory disease

Mycoplasma genitalium is a sexually transmitted pathogen that is increasingly identified among women with pelvic inflammatory disease (PID). Although Chlamydia trachomatis and Neisseria gonorrhoeae frequently cause PID, up to 70% of cases have an unidentified etiology. This paper summarizes evidence linking M. genitalium to PID and its long-term reproductive sequelae. Several PCR studies have demonstrated that M. genitalium is associated with PID, independent of gonococcal and chlamydial infection. Most have been cross-sectional, although one prospective investigation suggested that M. genitalium was associated with over a thirteenfold risk of endometritis. Further, a nested case-control posttermination study demonstrated a sixfold increased risk of PID among M. genitalium positive patients. Whether or not M. genitalium upper genital tract infection results in long-term reproductive morbidity is unclear, although tubal factor infertility patients have been found to have elevated M. genitalium antibodies. Several lines of evidence suggest that M. genitalium is likely resistant to many frequently used PID treatment regimens. Correspondingly, M. genitalium has been associated with treatment failure following cefoxitin and doxycycline treatment for clinically suspected PID. Collectively, strong evidence suggests that M. genitalium is associated with PID. Further study of M. genitalium upper genital tract infection diagnosis, treatment and long-term sequelae is warranted.

Mycoplasma genitalium: should we treat and how?

Mycoplasma genitalium is associated with acute and chronic urethritis in men. Existing data on infection in women are limited and inconsistent but suggest that M. genitalium is associated with urethritis, cervicitis, pelvic inflammatory disease, and possibly female infertility. Data are inconclusive regarding the role of M. genitalium in adverse pregnancy outcomes and ectopic pregnancy. Available data suggest that azithromycin is superior to doxycycline in treating M. genitalium infection. However, azithromycin-resistant infections have been reported in 3 continents, and the proportion of azithromycin-resistant M. genitalium infection is unknown. Moxifloxacin is the only drug that currently seems to uniformly eradicate M. genitalium. Detection of M. genitalium is hampered by the absence of a commercially available diagnostic test. Persons with persistent pelvic inflammatory disease or clinically significant persistent urethritis or cervicitis should be tested for M. genitalium, if possible. Infected persons who have not previously received azithromycin should receive that drug. Persons in whom azithromycin therapy fails should be treated with moxifloxicin.

Limitations of the criteria used to diagnose histologic endometritis in epidemiologic pelvic inflammatory disease research

While endometrial neutrophils and plasma cells are criteria used to diagnose histologic endometritis in epidemiologic pelvic inflammatory disease (PID) research, plasma cell misidentification and nonspecificity may limit the accuracy of these criteria. Herein, we examined: (1) the identification of endometrial plasma cells with conventional methyl green pyronin-based methodology versus plasma cell-specific (CD138) immunostaining, (2) the prevalence of endometrial plasma cells among women at low risk for PID, and (3) endometrial leukocyte subpopulations among women diagnosed with acute or chronic histologic endometritis by conventional criteria. We observed an absence of CD138+ cells in 25% of endometrial biopsies in which plasma cells had been identified by conventional methodology, while additional immunohistochemical analyses revealed indistinguishable inflammatory infiltrates among women diagnosed with acute or chronic endometritis by conventional criteria. Among women considered at lower risk for PID development, flow cytometric analyses detected plasma cells in 30% of endometrial biopsy specimens, suggesting that these cells, even when accurately identified, only nonspecifically identify upper genital tract inflammatory processes. Combined, our findings underscore the limitations of the criteria used to diagnose histologic endometritis in PID-related research and suggest that satisfactory understanding of PID pathogenesis, treatment, and prevention is hindered by continued use of these criteria.

A review of the epidemiology, diagnosis and evidence-based management of Mycoplasma genitalium

Mycoplasma genitalium is attracting increasing recognition as an important sexually transmitted pathogen. Presented is a review of the epidemiology, detection, presentation and management of M. genitalium infection. Accumulating evidence suggests that M. genitalium is an important cause of non-gonococcal, non-chlamydial urethritis and cervicitis, and is linked with pelvic inflammatory disease and, possibly, obstetric complications. Although there is no standard detection assay, several nucleic acid amplification tests have >95% sensitivity and specificity for M. genitalium. To date, there is a general lack of established protocols for screening in public health clinics. Patients with urethritis or cervicitis should be screened for M. genitalium and some asymptomatic sub-groups should be screened depending on individual factors and local prevalence. Investigations estimating M. genitalium geographic prevalence document generally low incidence, but some communities exhibit infection frequencies comparable to that of Chlamydia trachomatis. Accumulating evidence supports an extended regimen of azithromycin for treatment of M. genitalium infection, as data suggest that stat 1 g azithromycin may be less effective. Although data are limited, azithromycin-resistant cases documented to date respond to an appropriate fluoroquinolone (e.g. moxifloxacin). Inconsistent clinical recognition of M. genitalium may result in treatment failure and subsequent persistence due to ineffective antibiotics. The contrasting nature of existing literature regarding risks of M. genitalium infection emphasises the need for further carefully controlled studies of this emerging pathogen.

Mycoplasma genitalium: an emerging cause of sexually transmitted disease in women

Mycoplasma genitalium is an emerging sexually transmitted pathogen implicated in urethritis in men and several inflammatory reproductive tract syndromes in women including cervicitis, pelvic inflammatory disease (PID), and infertility. This comprehensive review critically examines epidemiologic studies of M. genitalium infections in women with the goal of assessing the associations with reproductive tract disease and enhancing awareness of this emerging pathogen. Over 27,000 women from 48 published reports have been screened for M. genitalium urogenital infection in high- or low-risk populations worldwide with an overall prevalence of 7.3% and 2.0%, respectively. M. genitalium was present in the general population at rates between those of Chlamydia trachomatis and Neisseria gonorrhoeae. Considering more than 20 studies of lower tract inflammation, M. genitalium has been positively associated with urethritis, vaginal discharge, and microscopic signs of cervicitis and/or mucopurulent cervical discharge in seven of 14 studies. A consistent case definition of cervicitis is lacking and will be required for comprehensive understanding of these associations. Importantly, evidence for M. genitalium PID and infertility are quite convincing and indicate that a significant proportion of upper tract inflammation may be attributed to this elusive pathogen. Collectively, M. genitalium is highly prevalent in high- and low-risk populations, and should be considered an etiologic agent of select reproductive tract disease syndromes in women.