A comprehensive overview of urogenital, anorectal and oropharyngeal Neisseria gonorrhoeae testing and diagnoses among different STI care providers: a cross-sectional study

Availability of Extragenital Chlamydia and Gonorrhea Testing in 6 High-Incidence States

BACKGROUND

Extragenital testing (rectal and oropharyngeal) of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) increases the detection of CT/NG infections, compared with genital testing alone. The Centers for Disease Control and Prevention recommends annual extragenital CT/NG screening for men who have sex with men, and additional screenings for women and transgender or gender-diverse individuals if certain sexual behaviors and exposures are reported.

METHODS

Prospective computer-assisted telephonic interviews were conducted with 873 clinics between June 2022 and September 2022. The computer-assisted telephonic interview followed a semistructured questionnaire that included closed-ended questions on the availability and accessibility of CT/NG testing.

RESULTS

Of the 873 clinics, CT/NG testing was offered in 751 clinics (86.0%), and extragenital testing was offered in only 432 clinics (57.5%). Most clinics (74.5%) with extragenital testing do not offer tests unless patients request them and/or report symptoms. Additional barriers to accessing information on available CT/NG testing include clinics not picking up the telephone, disconnecting the call, and unwillingness or inability to answer questions.

CONCLUSIONS

Despite evidence-based recommendations from the Centers for Disease Control and Prevention, the availability of extragenital CT/NG testing is moderate. Patients seeking extragenital testing may encounter barriers such as fulfilling specific criteria or being unable to access information on testing availability.

In Vitro Analysis of Matched Isolates from Localized and Disseminated Gonococcal Infections Suggests That Opa Expression Impacts Clinical Outcome

Gonorrhea is the second most common sexually transmitted infection, which is primarily localized but can be disseminated systemically. The mechanisms by which a localized infection becomes a disseminated infection are unknown. We used five pairs of Neisseria gonorrhoeae isolates from the cervix/urethra (localized) and the blood (disseminated) of patients with disseminated gonococcal infection to examine the mechanisms that confine gonococci to the genital tract or enable them to disseminate to the blood. Multilocus sequence analysis found that the local and disseminated isolates from the same patients were isogenic. When culturing in vitro, disseminated isolates aggregated significantly less and transmigrated across a polarized epithelial monolayer more efficiently than localized isolates. While localized cervical isolates transmigrated across epithelial monolayers inefficiently, those transmigrated bacteria self-aggregated less and transmigrated more than cervical isolates but comparably to disseminating isolates. The local cervical isolates recruited the host receptors of gonococcal Opa proteins carcinoembryonic antigen-related cell adhesion molecules (CEACAMs) on epithelial cells. However, the transmigrated cervical isolate and the disseminated blood isolates recruit CEACAMs significantly less often. Our results collectively suggest that switching off the expression of CEACAM-binding Opa(s), which reduces self-aggregation, promotes gonococcal dissemination.

Placing sexually transmitted infection surveillance data in perspective by using national probability sample surveys

BACKGROUND

Many European countries do not have comprehensive sexually transmitted infection (STI) surveillance in place. The objective was to investigate whether national probability sample surveys are useful in placing STI surveillance into perspective.

METHODS

We used data from the Dutch national cross-sectional probability sample survey on sexual health 2016 (18-34-year-old sexually active individuals). Descriptive analyses were performed regarding STI testing (last year). Test numbers were extrapolated from the survey and compared with surveillance data from sexual health centres (SHCs) (complete) and general practitioners (GPs) (representative estimates from 7% of all GPs). Statistical differences in characteristics between SHC attendees and general population (according to weighted survey participants) were determined using χ2 statistic. Predictors of recent testing at GPs or SHCs were determined using multinomial multivariable logistic regression.

RESULTS

Of the 17 222 survey invitees, 3217 (19%) were eligible for analyses. Testing uptake was higher in women (17.2%, 14.8-20.0%) than men (11.5%, 9.1-14.3%). The majority of tests were conducted by GPs followed by SHCs and hospitals. Number of tests extrapolated from the survey was similar to SHC surveillance data, but higher than GP surveillance data (women only). Testing at SHCs was associated with high-risk behaviour and with living in highly urbanized areas. Low education level and older age were, next to high-risk behaviour factors, determinants of testing at GPs.

CONCLUSIONS

National probability sample surveys are useful for placing STI surveillance data into perspective by providing insights in testing patterns in the general population and identifying strengths and weaknesses of national surveillance systems.

Background review for the '2020 European guideline for the diagnosis and treatment of gonorrhoea in adults'

Gonorrhoea is a major public health concern globally. Increasing incidence and sporadic ceftriaxone-resistant cases, including treatment failures, are growing concerns. The 2020 European gonorrhoea guideline provides up-to-date evidence-based guidance regarding the diagnosis and treatment of gonorrhoea. The updates and recommendations emphasize significantly increasing gonorrhoea incidence; broad indications for increased testing with validated and quality-assured nucleic acid amplification tests (NAATs) and culture; dual antimicrobial therapy including high-dose ceftriaxone and azithromycin (ceftriaxone 1 g plus azithromycin 2 g) OR ceftriaxone 1 g monotherapy (ONLY in well-controlled settings, see guideline for details) for uncomplicated gonorrhoea when the antimicrobial susceptibility is unknown; recommendation of test of cure (TOC) in all gonorrhoea cases to ensure eradication of infection and identify resistance; and enhanced surveillance of treatment failures when recommended treatment regimens have been used. Improvements in access to appropriate testing, test performance, diagnostics, antimicrobial susceptibility surveillance and treatment, and follow-up of gonorrhoea patients are essential in controlling gonorrhoea and to mitigate the emergence and/or spread of ceftriaxone resistance and multidrug-resistant and extensively drug-resistant gonorrhoea. This review provides the detailed background, evidence base and discussions, for the 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults (Unemo M, et al. Int J STD AIDS. 2020).

2020 European guideline for the diagnosis and treatment of gonorrhoea in adults

Gonorrhoea is a major public health concern globally. Increasing incidence and sporadic ceftriaxone-resistant cases, including treatment failures, are growing concerns. The 2020 European gonorrhoea guideline provides up-to-date evidence-based guidance regarding the diagnosis and treatment of gonorrhoea. The updates and recommendations emphasize significantly increasing gonorrhoea incidence; broad indications for increased testing with validated and quality-assured nucleic acid amplification tests and culture; dual antimicrobial therapy including high-dose ceftriaxone and azithromycin (ceftriaxone 1 g plus azithromycin 2 g) OR ceftriaxone 1 g monotherapy (ONLY in well-controlled settings, see guideline for details) for uncomplicated gonorrhoea when the antimicrobial susceptibility is unknown; recommendation of test of cure (TOC) in all gonorrhoea cases to ensure eradication of infection and identify resistance; and enhanced surveillance of treatment failures when recommended treatment regimens have been used. Improvements in access to appropriate testing, test performance, diagnostics, antimicrobial susceptibility surveillance and treatment, and follow-up of gonorrhoea patients are essential in controlling gonorrhoea and to mitigate the emergence and/or spread of ceftriaxone resistance and multidrug-resistant and extensively drug-resistant gonorrhoea. For detailed background, evidence base and discussions, see the background review for the present 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults (Unemo M, et al. Int J STD AIDS. 2020).

Misclassification of sexual health risks in a self-identified low risk cohort of men who have sex with men (MSM) enrolled in a community based PrEP program

The CDC recommends PrEP for MSM at substantial risk of HIV acquisition, leaving clinicians unsure whether to prescribe PrEP to MSM who do not disclose HIV risk factors. A longitudinal cohort of MSM requesting PrEP despite reporting during a clinical visit either 100% condom use or participation in oral sex only and no other risk factors was followed over 13 months at a community clinic in San Francisco to assess the accuracy of their HIV risk perception. Participants completed a sexual and substance use behavior questionnaire at baseline, outside of the clinical visit and were followed by quarterly HIV/STI testing and condom use change questionnaires. Condomless sex increased from 0% at baseline to 12% at month 1, peaked at 34% at month 7, and then decreased again to 8% at month 13. Rates of pharyngeal GC/CT varied from 7% at baseline to 12% at month 13, while rectal GC/CT decreased from 6% at baseline to 0% at month 13. The rate of syphilis was 1% both at baseline and at month 13, however, 11% and 15% of clients tested positive for syphilis at months 1 and 7 respectively.

Factors associated with anorectal Chlamydia trachomatis or Neisseria gonorrhoeae test positivity in women: a systematic review and meta-analysis

OBJECTIVES

There has been considerable discussion about anorectal Chlamydia trachomatis (CT) in women, with some calling for anorectal CT screening, but little about anorectal Neisseria gonorrhoeae (NG). Given that urogenital NG is more strongly associated with pelvic inflammatory disease, this is an evidence gap. This systematic review and meta-analysis investigates the associations between anorectal CT in women and CT positivity at other sites (urogenital/oropharyngeal) and with anal intercourse, and compares these with anorectal NG within the same study populations.

METHODS

Electronic databases were searched for English-language studies published to October 2018 using the following terms: ("Chlamydia" OR "Chlamydia trachomatis") AND (("anal" OR "rect*" OR "anorect*") OR ("extra?genital" OR "multi?site")). Studies were included if anorectal NG data were available. Random-effects meta-analyses calculated pooled estimates; heterogeneity was investigated using meta-regression.

RESULTS

25 studies were eligible. Anorectal CT positivity ranged from 0% to 17.5%, with a summary estimate of 8.0% (95% CI 7.0 to 9.1; I²=88.5%). Anorectal NG positivity ranged from 0% to 17.0%, with a summary estimate of 2.1% (95% CI 1.6 to 2.8; I²=92.7%). The association between urogenital and anorectal positivity was stronger for NG than CT (summary prevalence ratio (PR)=89.3 (95% CI 53.1 to 150.3; I²=80.1%), PR=32.2 (95% CI 25.6 to 40.7; I²=70.3%), respectively), and between oropharyngeal and anorectal positivity it was stronger for NG than CT (PR=34.8 (95% CI 10.2 to 118.2; I²=89.9%), PR=8.8 (95% CI 6.8 to 11.5; I²=58.1%), respectively). Anal intercourse was associated with anorectal NG (PR=4.3; 95% CI 2.2 to 8.6; I²=0.0%) but not with anorectal CT (PR=1.0; 95% CI 0.7 to 1.4; I²=0.0%).

CONCLUSIONS

Anorectal CT is more common than anorectal NG, but anorectal NG is more strongly associated with anal intercourse, urogenital and oropharyngeal NG, suggesting that ongoing discussion about anorectal CT should also include NG. Longitudinal data are required to further understanding of the aetiology of anorectal STIs and assess whether anorectal screening is needed in women.

TRIAL REGISTRATION NUMBER

CRD42df017080188.

Pharyngeal Chlamydia and gonorrhea: a hidden problem

In this study we assessed the prevalence and predictors of pharyngeal infections due to Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in a cohort of patients attending an STI Clinic. From January 2016 to September 2018, 893 patients attending the STI Clinic of St Orsola-Malpighi Hospital (Bologna, Italy) and reporting unprotected oral sex were enrolled. A pharyngeal swab for the molecular detection of CT and NG was collected from each patient. Positive CT samples were further genotyped by an omp1 gene PCR. A total of 134 cases of gonorrhea (15%) and 34 chlamydial infections (3.8%) were detected in the pharyngeal site, with no significant differences between males (all men who have sex with men [MSM]) and females. More than 90% of the infections were completely asymptomatic, suggesting that symptoms were not predictors of a pharyngeal infection ( P = 0.7). On the contrary, a history of sexual contacts with a partner positive for CT and/or NG ( P < 0.0001), HIV positivity ( P = 0.01), and the presence of concurrent genital and/or rectal infections ( P < 0.0001) were significantly associated with CT/NG pharyngeal infections. Pharyngeal lymphogranuloma venereum cases were rare (prevalence: 0.4%), asymptomatic, and only found in MSM. Better knowledge about pharyngeal CT/NG infections could help to set up effective strategies for their prevention.

Low gonorrhoea antimicrobial resistance and culture positivity rates in general practice: a pilot study

Objective

In the Netherlands, the Gonococcal Resistance to Antimicrobials Surveillance (GRAS) programme is carried out at Centres for Sexual Health (CSH), which provide care for sexual high-risk populations. However, half of gonorrhoea infections are diagnosed in general practice (GP). We performed a pilot study to explore expanding GRAS to GPs using laboratory-based surveillance. Additionally, antimicrobial resistance patterns of GP and CSH patients were compared.

Methods

Three laboratories from different regions were included, which all perform gonorrhoea diagnostics for GPs and used ESwab for patient sampling. Additional culturing for all GP patients with gonorrhoea took place from February to July 2018. After positive PCR-nucleic acid amplification test, residual ESwab material was used for culture. In positive cultures, susceptibility testing was performed for azithromycin, ciprofloxacin, cefotaxime and ceftriaxone using Etest.

Results

During the study period, 484 samples were put in culture. 16.5% of cultures were positive (n=80). Antimicrobial resistance levels were low, with 2.6% resistance to azithromycin, 21.5% to ciprofloxacin and 0.0% to cefotaxime and ceftriaxone. Resistance levels in CSH GRAS data (first half of 2018) were 19.2% for azithromycin, 31.5% for ciprofloxacin, 1.9% for cefotaxime and 0.0% for ceftriaxone.

Conclusions

Culture positivity rates for GP patients were low, probably due to long transportation times and awaiting PCR test results before attempting culture. Positivity rates might be improved by making changes in sampling and/or transportation methods, but that would require involvement of GPs and patients instead of keeping the surveillance lab based. Resistance levels appeared to be lower at GPs than at the CSH, indicating that resistance might emerge first in more high-risk populations. It is important to consider all potentially relevant patient populations when establishing a gonococcal antimicrobial resistance surveillance programme. However, based on the findings from this study the current GRAS programme will not be extended to GPs.

Quantitative Examination of Antibiotic Susceptibility of Neisseria gonorrhoeae Aggregates Using ATP-utilization Commercial Assays and Live/Dead Staining

The emergence of antibiotic resistant Neisseria gonorrhoeae (GC) is a worldwide health threat and highlights the need to identify individuals who fail treatment. This Gram-negative bacterium causes gonorrhea exclusively in humans. During infection, it is able to form aggregates and/or biofilms. The minimum inhibitory concentration (MIC) test is used for to determine susceptibility to antibiotics and to define appropriate treatment. However, the mechanism of the eradication in vivo and its relationship to laboratory results are not known. A method that examines how GC aggregation affects antibiotic susceptibility and shows the relationship between aggregate size and antibiotic susceptibility was developed. When GC aggregate, they are more resistant to antibiotic killing, with bacteria in the center surviving ceftriaxone treatment better than those in the periphery. The data indicate that N. gonorrhoeae aggregation can reduce its susceptibility to ceftriaxone, which is not reflected using the standard agar plate-based MIC methods. The method used in this study will allow researchers to test bacterial susceptibility under clinically relevant conditions.

Prevalence of Ureaplasma urealyticum, Chlamydia trachomatis, Neisseria gonorrhoeae and herpes simplex virus in Beijing, China

The prevalence of sexually transmitted infection (STI) pathogens in Beijing, China, is rarely reported. In this study, 34 911 symptomatic outpatients with suspected genital infections who attended outpatient clinics in a tertiary care hospital were included to investigate the updated prevalence of Ureaplasma urealyticum (UU), Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and herpes simplex virus (HSV) from 1 January 2013 to 31 December 2016 in Beijing, China. Results indicated that a decrease trend (UU, CT, NG and HSV) in male and an increase trend (UU, CT and NG) in female were observed during the period. Patients aged 20–39 years old were mostly affected by these pathogens, while the prevalence in patients aged 20–29 years old was the highest, The prevalence of UU in male was significantly lower than in female (31.5% vs. 49.3%, P < 0.05), while the prevalence of NG in male was significantly higher than in female (2.5% vs. 0.8%, P < 0.05). In patients with co-infections, 60.6% of male and 71.4% of female were co-infected by UU + CT. In total, 11.9% and 88.1% of patients with HSV infections were confirmed to be infected by HSV-1 and HSV-2. This study could contribute to a better understanding of the current epidemiological features of UU, NG, CT and HSV among symptomatic patients attending an outpatient clinic in Beijing, China, and thus facilitate to develop more effective intervention, prevention and treatment of STI.

Neisseria gonorrhoeae Aggregation Reduces Its Ceftriaxone Susceptibility

Antibiotic resistance in Neisseria gonorrhoeae (GC) has become an emerging threat worldwide and heightens the need for monitoring treatment failures. N. gonorrhoeae, a gram-negative bacterium responsible for gonorrhea, infects humans exclusively and can form aggregates during infection. While minimal inhibitory concentration (MIC) tests are often used for determining antibiotic resistance development and treatment, the knowledge of the true MIC in individual patients and how it relates to this laboratory measure is not known. We examined the effect of aggregation on GC antibiotic susceptibility and the relationship between bacterial aggregate size and their antibiotic susceptibility. Aggregated GC have a higher survival rate when treated with ceftriaxone than non-aggregated GC, with bacteria in the core of the aggregates surviving the treatment. GC lacking opacity-associated protein or pili, or expressing a truncated lipooligosaccharide, three surface molecules that mediate GC-GC interactions, reduce both aggregation and ceftriaxone survival. This study demonstrates that the aggregation of N. gonorrhoeae can reduce the susceptibility to antibiotics, and suggests that antibiotic utilization can select for GC surface molecules that promote aggregation which in turn drive pathogen evolution. Inhibiting aggregation may be a potential way of increasing the efficacy of ceftriaxone treatment, consequently reducing treatment failure.

Test of cure, retesting and extragenital testing practices for Chlamydia trachomatis and Neisseria gonorrhoeae among general practitioners in different socioeconomic status areas: A retrospective cohort study, 2011-2016

Background

For Chlamydia trachomatis (CT), a test of cure (TOC) within 3–5 weeks is not recommended. International guidelines differ in advising a Neisseria gonorrhoeae (NG) TOC. Retesting CT and NG positives within 3–12 months is recommended in international guidelines. We assessed TOC and retesting practices including extragenital testing in general practitioner (GP) practices located in different socioeconomic status (SES) areas to inform and optimize local test practices.

Methods

Laboratory data of 48 Dutch GP practices between January 2011 and July 2016 were used. Based on a patient’s first positive CT or NG test, the proportion of TOC (<3 months) and retests (3–12 months) were calculated. Patient- and GP-related factors were assessed using multivariate logistic regression analyses.

Results

For CT (n = 622), 20% had a TOC and 24% had a retest at the GP practice. GP practices in low SES areas were more likely to perform a CT TOC (OR:1.8;95%CI:1.1–3.1). Younger patients (<25 years) were more likely to have a CT TOC (OR:1.6;95%CI:1.0–2.4). For CT (n = 622), 2.4% had a TOC and 6.1% had a retest at another STI care provider. For NG (n = 73), 25% had a TOC and 15% had a retest at the GP practice. For NG (n = 73), 2.7% had a TOC and 12.3% had a retest at another STI care provider. In only 0.3% of the consultations patients were tested on extragenital sites.

Conclusion

Almost 20% of the patients returned for a CT TOC, especially at GP practices in low SES areas. For NG, 1 out of 4 patients returned for a TOC. Retesting rates were low for both CT (24%) and NG (15%), (re)infections including extragenital infections may be missed. Efforts are required to focus TOC and increase retesting practices of GPs in order to improve CT/NG control.

Screening for HIV, hepatitis B and syphilis on dried blood spots: A promising method to better reach hidden high-risk populations with self-collected sampling

Introduction

Many people at high risk for sexually transmitted infections (STIs), e.g., men who have sex with men (MSM), are not optimally reached by current sexual health care systems with testing. To facilitate testing by home-based sampling or sampling in outreach setting we evaluated dried blood spots (DBS), a method for self-collected blood sampling for serological screening of HIV, hepatitis B (HBV) and syphilis. The aims of this study were to assess the acceptability and feasibility of self-collected DBS and to compare the test results for screening of HIV, HBV and syphilis from DBS with blood drawn by venous puncture.

Methods

DBS were collected from men who have sex with men (MSM), visiting the STI clinic of the public health service South Limburg (n = 183) and HIV positive and HBV positive patients (n = 34), visiting the outpatient clinics of the Maastricht University Medical Centre in the period January 2012–April 2015. The 93 first participating MSM visiting the STI clinic were asked to fill in a questionnaire about the feasibility and acceptability about self-collection of DBS in a setting without going to a health care facility and were asked to collect the DBS themselves. Serological screening tests for HIV (HIV combi PT, Roche), HBV (HBsAg, Roche) and syphilis (Treponema pallidum Ig, Biokit 3.0) were performed on DBS and on blood drawn by venous puncture, which was routinely taken for screening.

Results

In total 217 participants were included in the study with a median age of 40 years (range between 17–80). Of MSM 84% agreed that it was clear and easy to do the finger-prick, while 53% agreed that it was clear and easy to apply the blood onto the DBS card. Also, 80% of MSM would use the bloodspot test again. In 91% (198) of DBS, sufficient material was collected to perform the three tests. No difference was observed in DBS quality between self-collected DBS and health care worker collected DBS. For HIV (n = 195 DBS-serum pairs) sensitivity and specificity were 100%. For HBV the sensitivity for HBsAg (n = 202) was 90% and specificity was 99%. For syphilis (n = 191) the sensitivity of the DBS was 93% with a specificity of 99%. Analysis of the DBS of HIV positive participants (n = 38) did show similar test performance for HBV and syphilis as in HIV negatives.

Conclusion

DBS is an acceptable self-sampling method for MSM, as there was no difference in DBS quality in self-collected and health care worker collected DBS. Test performance, i.e., its high sensitivity (>90%) and specificity (>99%) measures show that DBS is a valid alternative for venous blood puncture. Especially when DBS is combined with home-collected sampling for Chlamydia trachomatis and Neisseria gonorrhoeae, complete STI screening can be done in outreach setting and/or home-collected sampling in MSM.