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van den Elshout MAM, Wijstma ES, Boyd A, Jongen VW, Coyer L, Anderson PL, Davidovich U, de Vries HJC, Prins M, Schim van der Loeff MF, Hoornenborg E. Sexual behaviour and incidence of sexually transmitted infections among men who have sex with men (MSM) using daily and event-driven pre-exposure prophylaxis (PrEP): Four-year follow-up of the Amsterdam PrEP (AMPrEP) demonstration project cohort. PLoS Med 2024; 21:e1004328. [PMID: 38718068 PMCID: PMC11111007 DOI: 10.1371/journal.pmed.1004328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 05/22/2024] [Accepted: 04/10/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND An increasing number of countries are currently implementing or scaling-up HIV pre-exposure prophylaxis (PrEP) care. With the introduction of PrEP, there was apprehension that condom use would decline and sexually transmitted infections (STIs) would increase. To inform sexual health counselling and STI screening programmes, we aimed to study sexual behaviour and STI incidence among men who have sex with men (MSM) and transgender women who use long-term daily or event-driven PrEP. METHODS AND FINDINGS The Amsterdam PrEP demonstration project (AMPrEP) was a prospective, closed cohort study, providing oral daily PrEP and event-driven PrEP to MSM and transgender women from 2015 to 2020. Participants could choose their PrEP regimen and could switch at each three-monthly visit. STI testing occurred at and, upon request, in-between 3-monthly study visits. We assessed changes in numbers of sex partners and condomless anal sex (CAS) acts with casual partners over time using negative binomial regression, adjusted for age. We assessed HIV incidence and changes in incidence rates (IRs) of any STI (i.e., chlamydia, gonorrhoea, or infectious syphilis) and individual STIs over time using Poisson regression, adjusted for age and testing frequency. A total of 367 participants (365 MSM) commenced PrEP and were followed for a median 3.9 years (interquartile range [IQR] = 3.4-4.0). Median age was 40 years (IQR = 32-48), 315 participants (85.8%) self-declared ethnicity as white and 280 (76.3%) had a university or university of applied sciences degree. Overall median number of sex partners (past 3 months) was 13 (IQR = 6-26) and decreased per additional year on PrEP (adjusted rate ratio [aRR] = 0.86/year, 95% confidence interval [CI] = 0.83-0.88). Overall median number of CAS acts with casual partners (past 3 months) was 10 (IQR = 3-20.5) and also decreased (aRR = 0.92/year, 95% CI = 0.88-0.97). We diagnosed any STI in 1,092 consultations during 1,258 person years, resulting in an IR of 87/100 person years (95% CI = 82-92). IRs of any STI did not increase over time for daily PrEP or event-driven PrEP users. Two daily PrEP users, and no event-driven PrEP users, were diagnosed with HIV during their first year on PrEP. Study limitations include censoring follow-up due to COVID-19 measures and an underrepresentation of younger, non-white, practically educated, and transgender individuals. CONCLUSIONS In this prospective cohort with a comparatively long follow-up period of 4 years, we observed very low HIV incidence and decreases in the numbers of casual sex partners and CAS acts over time. Although the STI incidence was high, it did not increase over time. TRIAL REGISTRATION The study was registered at the Netherlands Trial Register (NL5413) https://www.onderzoekmetmensen.nl/en/trial/22706.
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Affiliation(s)
| | - Eline S. Wijstma
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Anders Boyd
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
- Stichting hiv monitoring, Amsterdam, the Netherlands
- Amsterdam UMC location University of Amsterdam, Amsterdam Institute for Immunology and Infectious Diseases (AII), Amsterdam, the Netherlands
- Amsterdam UMC location University of Amsterdam, Department of Infectious Diseases, Amsterdam, the Netherlands
| | - Vita W. Jongen
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
- Stichting hiv monitoring, Amsterdam, the Netherlands
| | - Liza Coyer
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Peter L. Anderson
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Udi Davidovich
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
- Department of Social Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - Henry J. C. de Vries
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC location University of Amsterdam, Amsterdam Institute for Immunology and Infectious Diseases (AII), Amsterdam, the Netherlands
- Amsterdam UMC location University of Amsterdam, Department of Dermatology, Amsterdam, the Netherlands
| | - Maria Prins
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC location University of Amsterdam, Amsterdam Institute for Immunology and Infectious Diseases (AII), Amsterdam, the Netherlands
- Amsterdam UMC location University of Amsterdam, Department of Infectious Diseases, Amsterdam, the Netherlands
| | - Maarten F. Schim van der Loeff
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC location University of Amsterdam, Amsterdam Institute for Immunology and Infectious Diseases (AII), Amsterdam, the Netherlands
- Amsterdam UMC location University of Amsterdam, Department of Infectious Diseases, Amsterdam, the Netherlands
| | - Elske Hoornenborg
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
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Vanbaelen T, De Baetselier I, Manoharan-Basil SS, Kenyon C. Oral streptococcal susceptibility to azithromycin may be associated with doxycycline use: A post-hoc analysis with implications for doxycycline post exposure prophylaxis. Int J STD AIDS 2024:9564624241246301. [PMID: 38607607 DOI: 10.1177/09564624241246301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Tetracycline and macrolide resistance are frequently linked in streptococci and other species. We aimed to assess the association between doxycycline use and azithromycin MICs in oral streptococci. METHODS Linear regression was used to assess the association between doxycycline use in the prior year and the median MIC per participant of oral streptococcal colonies isolated at the baseline visit of the ResistAZM study. The analysis controlled for receipt of other antimicrobials as well as time since antimicrobial consumption. RESULTS Fifty-six individual colonies confirmed to be streptococci were isolated from 19 individuals at baseline. The azithromycin MICs of these isolates varied considerably between 0.25 mg/L and >256 mg/L (median 28 mg/L; IQR 1-192 mg/L). The consumption of doxycycline in the preceding 12 months was positively associated with median streptococcal azithromycin MIC (coef. 151.6 [95% CI 10.6-292.7]; p = .037). CONCLUSION This post-hoc analysis found that doxycycline use was associated with streptococcal azithromycin susceptibility. Numerous limitations of the study design mean that this study is best considered hypothesis generating. Prospective studies are required to assess if the use of doxycycline could select for macrolide resistance in oral streptococci.
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Affiliation(s)
- Thibaut Vanbaelen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Irith De Baetselier
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Chris Kenyon
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa
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Vanbaelen T, Manoharan-Basil SS, Kenyon C. Four recent insights suggest the need for more refined methods to assess the resistogenicity of doxycycline post exposure prophylaxis. CURRENT RESEARCH IN MICROBIAL SCIENCES 2024; 6:100234. [PMID: 38646593 PMCID: PMC11033152 DOI: 10.1016/j.crmicr.2024.100234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024] Open
Abstract
Two recently published randomized trials of doxycycline post exposure prophylaxis (PEP) have concluded that this intervention is highly effective at reducing the incidence of bacterial sexually transmitted infections (STIs) and has little or no risk of promoting the spread of antimicrobial resistance (AMR). In this perspective piece, we review four types of evidence that suggest that the risk of promoting AMR has been inadequately assessed in these studies. 1) The studies have all used proportion resistant as the outcome measure. This is a less sensitive measure of resistogenicity than MIC distribution. 2) These RCTs have not considered population-level pathways of AMR selection. 3) In populations with very high antimicrobial consumption such as PrEP cohorts, the relationship between antimicrobial consumption and resistance may be saturated. 4) Genetic linkage of AMR means that increased tetracycline use may select for AMR to not only tetracyclines but also other antimicrobials in STIs and other bacterial species. We recommend novel study designs to more adequately assess the AMR-inducing risk of doxycycline PEP.
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Affiliation(s)
- Thibaut Vanbaelen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, 2000, Belgium
| | | | - Chris Kenyon
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, 2000, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, 7700, South Africa
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Vanbaelen T, Manoharan-Basil SS, Kenyon C. 45 years of tetracycline post exposure prophylaxis for STIs and the risk of tetracycline resistance: a systematic review and meta-analysis. BMC Infect Dis 2024; 24:376. [PMID: 38575877 PMCID: PMC10996150 DOI: 10.1186/s12879-024-09275-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/31/2024] [Indexed: 04/06/2024] Open
Abstract
There is considerable interest in the use of doxycycline post exposure prophylaxis (PEP) to reduce the incidence of bacterial sexually transmitted infections (STIs). An important concern is that this could select for tetracycline resistance in these STIs and other species. We searched PubMed and Google Scholar, (1948-2023) for randomized controlled trials comparing tetracycline PEP with non-tetracycline controls. The primary outcome was antimicrobial resistance (AMR) to tetracyclines in all bacterial species with available data. Our search yielded 140 studies, of which three met the inclusion criteria. Tetracycline PEP was associated with an increasedprevalence of tetracycline resistance in Neisseria gonorrhoeae, but this effect was not statistically significant (Pooled OR 2.3, 95% CI 0.9-3.4). PEP had a marked effect on the N. gonorrhoeae tetracycline MIC distribution in the one study where this was assessed. Prophylactic efficacy was 100% at low MICs and 0% at high MICs. In the one study where this was assessed, PEP resulted in a significant increase in tetracycline resistance in commensal Neisseria species compared to the control group (OR 2.9, 95% CI 1.5-5.5) but no significant effect on the prevalence of tetracycline resistance in Staphylococcus aureus. The available evidence suggests that PEP with tetracyclines could be associated with selecting tetracycline resistance in N. gonorrhoeae and commensal Neisseria species.
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Affiliation(s)
- Thibaut Vanbaelen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, 2000, Antwerp, Belgium
| | | | - Chris Kenyon
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, 2000, Antwerp, Belgium.
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, 7700, South Africa.
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Chow EPF, Fairley CK, Kong FYS. STI pathogens in the oropharynx: update on screening and treatment. Curr Opin Infect Dis 2024; 37:35-45. [PMID: 38112085 DOI: 10.1097/qco.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW The rise in antimicrobial resistance in several STI pathogens such as Neisseria gonorrhoeae has become a public health threat as only one first-line treatment remains. Reducing screening interval for gonorrhoea and chlamydia in high-prevalence populations has been proposed to address antimicrobial stewardship, but this remains controversial. This review aimed to revisit the epidemiology of infections at the oropharynx and review the current screening recommendations and treatment guidelines in different populations. RECENT FINDINGS Emerging evidence suggests that the oropharynx is the primary anatomical site for gonorrhoea transmission but maybe not for chlamydia transmission. Most international guidelines recommend 3-monthly oropharyngeal gonorrhoea and chlamydia screening for high-prevalence populations (e.g. men who have sex with men) but not low-prevalence populations (e.g. heterosexuals) given the clinical and public health benefits of screening in low-prevalence populations are still unclear. Doxycycline remains the first-line treatment for oropharyngeal chlamydia in most guidelines. However, some countries have moved from dual therapy (ceftriaxone and azithromycin) to monotherapy (ceftriaxone) for oropharyngeal gonorrhoea treatment to address antimicrobial stewardship. SUMMARY The transmission of gonorrhoea and chlamydia is still not fully understood. Further work will be required to evaluate the benefits and harms of reducing screening in high-prevalence populations.
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Affiliation(s)
- Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University
| | - Fabian Y S Kong
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
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Kenyon C, Gestels Z, Vanbaelen T, Abdellati S, Van Den Bossche D, De Baetselier I, Xavier BB, Manoharan-Basil SS. Doxycycline PEP can induce doxycycline resistance in Klebsiella pneumoniae in a Galleria mellonella model of PEP. Front Microbiol 2023; 14:1208014. [PMID: 37711686 PMCID: PMC10498386 DOI: 10.3389/fmicb.2023.1208014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/03/2023] [Indexed: 09/16/2023] Open
Abstract
Background Four randomized controlled trials have now established that doxycycline post exposure (sex) prophylaxis (PEP) can reduce the incidence of chlamydia and syphilis in men who have sex with men. These studies have concluded that the risk of selecting for antimicrobial resistance is low. We evaluated this risk in vitro and in vivo using a Galleria mellonella infection model. Methods We evaluated how long it took for doxycycline resistance to emerge during passage on doxycycline containing agar plates in 4 species - Escherichia coli, Klebsiella pneumoniae, Neisseria gonorrhoeae and Neisseria subflava. We then assessed if K. pneumoniae could acquire resistance to doxycycline (and cross resistance to other antimicrobials) during intermittent exposure to doxycycline in a Galleria mellonella model of doxycycline PEP. Results In our passage experiments, we found that resistance first emerged in K. pneumoniae. By day 7 the K. pneumoniae MIC had increased from 2 mg/L to a median of 96 mg/L (IQR 64-96). Under various simulations of doxycycline PEP in the G. mellonella model, the doxycycline MIC of K. pneumoniae increased from 2 mg/L to 48 mg/L (IQR 48-84). Ceftriaxone and ciprofloxacin MICs increased over ten-fold. Whole genome sequencing revealed acquired mutations in ramR which regulates the expression of the AcrAB-TolC efflux pump. Conclusion Doxycycline PEP can select for doxycycline, ceftriaxone and ciprofloxacin resistance in K. pneumoniae in a G. mellonella model. The emergent ramR mutations were similar to those seen in circulating strains of K. pneumoniae. These findings suggest that we need to assess the effect of doxycycline PEP on resistance induction on a broader range of bacterial species than has hitherto been the case.
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Affiliation(s)
- Chris Kenyon
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa
| | - Zina Gestels
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Thibaut Vanbaelen
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Said Abdellati
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Dorien Van Den Bossche
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Irith De Baetselier
- Clinical Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Basil Britto Xavier
- STI Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Hospital Outbreak Support Team-HOST, Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
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