Does gonorrhoea screening intensity play a role in the early selection of antimicrobial resistance in men who have sex with men (MSM)? A comparative study of Belgium and the United Kingdom

Minimum inhibitory concentrations of Neisseria gonorrhoeae strains in clients of the Amsterdam sexual health clinic with a Dutch versus an international sexual network

OBJECTIVES

International travel combined with sex may contribute to dissemination of antimicrobial-resistant (AMR) Neisseria gonorrhoeae (Ng). To assess the role of travel in Ng strain susceptibility, we compared minimum inhibitory concentrations (MICs) for five antibiotics (ie, azithromycin, ceftriaxone, cefotaxime, cefixime and ciprofloxacin) in strains from clients with an exclusively Dutch sexual network and clients with an additional international sexual network.

METHODS

From 2013 to 2019, we recorded recent residence of sexual partners of clients (and of their partners) with Ng at the Center for Sexual Health of Amsterdam. We categorised clients as having: (1) exclusively sexual partners residing in the Netherlands ('Dutch only') or (2) at least one partner residing outside the Netherlands. We categorised the country of residence of sexual partners by World Bank/EuroVoc regions. We analysed the difference of log-transformed MIC of Ng strains between categories using linear or hurdle regression for each antibiotic.

RESULTS

We included 3367 gay and bisexual men who had sex with men (GBMSM), 516 women and 525 men who exclusively had sex with women (MSW) with Ng. Compared with GBMSM with a 'Dutch only' network, GBMSM with: (1) a Western European network had higher MICs for ceftriaxone (β=0.19, 95% CI=0.08 to 0.29), cefotaxime (β=0.19, 95% CI=0.08 to 0.31) and cefixime (β=0.06, 95% CI=0.001 to 0.11); (2) a Southern European network had a higher MIC for cefixime (β=0.10, 95% CI=0.02 to 0.17); and (3) a sub-Saharan African network had a lower MIC for ciprofloxacin (β=-1.79, 95% CI=-2.84 to -0.74). In women and MSW, higher MICs were found for ceftriaxone in clients with a Latin American and Caribbean network (β=0.26, 95% CI=0.02 to 0.51).

CONCLUSIONS

For three cephalosporin antibiotics, we found Ng strains with slightly higher MICs in clients with partner(s) from Europe or Latin America and the Caribbean. International travel might contribute to the spread of Ng with lower susceptibility. More understanding of the emergence of AMR Ng is needed.

Frequent screening for asymptomatic chlamydia and gonorrhoea infections in men who have sex with men: time to re-evaluate?

There is increasing debate regarding the harms and benefits of frequent asymptomatic screening for Chlamydia trachomatis and Neisseria gonorrhoeae in men who have sex with men (MSM). One concern is that frequent asymptomatic screening could result in increased antimicrobial resistance in an array of sexually acquired infections and other pathogens, due to selection pressure exerted by frequent broad-spectrum antimicrobial usage within some sexual networks. Here, we outline the harms and benefits of frequent C trachomatis and N gonorrhoeae screening in MSM in high-income settings and propose that screening frequency be reduced. We describe the evidence gaps that should be further explored to better understand the implications of reducing the frequency of asymptomatic C trachomatis and N gonorrhoeae screening in MSM and the surveillance systems that should be in place to prepare for such changes.

Pay-it-forward gonorrhea and chlamydia testing among men who have sex with men and male STD patients in China: the PIONEER pragmatic, cluster randomized controlled trial protocol

BACKGROUND

Gonorrhea and chlamydia are the most common sexually transmitted diseases (STDs) among men who have sex with men (MSM) in China. Previous studies have shown pay-it-forward (PIF) interventions to be associated with a substantial increase in gonorrhea and chlamydia test uptake compared to standard-of-care. We propose a 'pay-it-forward' gonorrhea and chlamydia testing randomized controlled trial (PIONEER). The trial would evaluate the effectiveness of two pay-it-forward strategies in promoting testing uptake compared to the standard of care (in which men pay for their tests out-of-pocket) among MSM and male STD patients in China.

METHODS

PIONEER will be a three-armed, pragmatic cluster randomized controlled trial (RCT), conducted across 12 clinics (six MSM-led and six public STD clinics) to compare the effectiveness of three implementation strategies. Each facility will be randomized to a standard pay-it-forward intervention of gonorrhea/ chlamydia testing with minimal encouragement for testing, a community-engaged pay-it-forward arm, or a control arm where men pay for their tests out-of-pockets. The primary outcome will be dual gonorrhea/chlamydia test uptake. Secondary outcomes will include syphilis testing, amount donated in pay-it-forward, number of positive gonorrhea and chlamydia tests, and measures of antimicrobial resistance. A sequential transformative mixed methods design will be used to evaluate the implementation process in type 2 effectiveness-implementation hybrid design. Data sources will include survey on acceptability, and feelings and attitudes towards the interventions among participants; testing and treatment uptake data from clinic records, WeChat records, and qualitative data to gain insights into men's perceptions and attitudes towards the pay-it-forward, mechanisms driving uptake, and donating behaviors. Implementers and organizers will be interviewed about fidelity and adherence to protocol, sustainability of pay-it-forward intervention, and barriers and facilitators of implementing the intervention.

DISCUSSION

PIONEER will substantially increase gonorrhea/chlamydia testing among MSM in China, providing an innovative and new financial mechanism to sustain STD screening among sexual minorities in low- and middle-income countries. This study will answer compelling scientific questions about how best to implement pay-it-forward and the individual and organizational characteristics that moderate it.

TRIAL REGISTRATION

The study with identification number NCT05723263 has been registered on clinicaltrials.gov/.

Is there an association between previous infection with Neisseria gonorrhoeae and gonococcal AMR? A cross-sectional analysis of national and sentinel surveillance data in England, 2015-2019

OBJECTIVES

Quarterly STI screening is recommended for high-risk gay, bisexual and other men who have sex with men (MSM) in the UK, but frequent antibiotic exposure could potentially increase the risk of antimicrobial resistance (AMR) developing in Neisseria gonorrhoeae. We investigated whether repeat diagnosis of gonorrhoea in those attending sexual health services (SHS) was associated with reduced antimicrobial susceptibility.

METHODS

Antimicrobial susceptibility data relating to the most recent gonorrhoea diagnosis for each individual included in the Gonococcal Resistance to Antimicrobials Surveillance Programme (2015-2019) were matched to their historical records in the national GUMCAD STI surveillance data set (2012-2019). The number of gonorrhoea diagnoses in the previous 3 years was calculated for each SHS attendee. Logistic regression was used to examine the associations between the number of diagnoses and reduced susceptibility to ceftriaxone (minimum inhibitory concentration (MIC) >0.03 mg/L), cefixime (MIC >0.06 mg/L) and azithromycin (MIC >0.25 mg/L) at the time of the latest diagnosis.

RESULTS

Of 6161 individuals included in the analysis, 3913 (63.5%) were MSM, 1220 (19.8%) were heterosexual men and 814 (13.2%) were women. Among MSM, 2476 (63.3%) had 1 past gonorrhoea diagnosis, 1295 (33.1%) had 2-4, 140 (3.6%) 5-9, and 2 (0.1%) ≥10. Most women and heterosexual men (91.7%) had one past gonorrhoea diagnosis; none had more than four. Reduced ceftriaxone and cefixime susceptibility was more common among MSM with two to four gonorrhoea diagnoses (3.8% and 5.8%, respectively) compared with those with one (2.2% and 3.9%, respectively). After adjusting for potential confounding, this association remained (adjusted OR: 1.59, 95% CI 1.07 to 2.37, p=0.02; adjusted OR: 1.54, 95% CI 1.11 to 2.14, p=0.01). No evidence was found for any other associations.

CONCLUSIONS

Among MSM, repeat diagnosis of gonorrhoea may be associated with reduced ceftriaxone and cefixime susceptibility. As these are last-line therapies for gonorrhoea, further research is needed to assess the impact of intensive STI screening on AMR.

Spontaneous clearance of asymptomatic anogenital and pharyngeal Neisseria gonorrhoeae: a secondary analysis from the NABOGO trial

INTRODUCTION

Spontaneous clearance of asymptomatic Neisseria gonorrhoeae (NG) does occur, but data are scarce. We aimed to assess spontaneous clearance among patients with asymptomatic anal, pharyngeal, vaginal and urethral NG infections who participated in the New AntiBiotic treatment Options for uncomplicated GOnorrhoea (NABOGO) trial. In addition, we assessed the determinants associated with spontaneous clearance.

METHODS

The NABOGO trial (Trial registration number: NCT03294395) was a randomised controlled, double-blind, single-centre trial assessing non-inferiority of ertapenem, gentamicin and fosfomycin to ceftriaxone for treatment of uncomplicated gonorrhoea. For asymptomatic NABOGO participants, we collected pre-enrolment and enrolment visit samples before trial medication was given. Spontaneous clearance was defined as a positive pre-enrolment nucleic acid amplification test (NAAT) result, followed by a negative NAAT at enrolment. We compared the median time between pre-enrolment and enrolment visits for patients who cleared spontaneously and for those who did not. Determinants of spontaneous clearance were assessed using logistic regression.

RESULTS

Thirty-two of 221 (14.5%) anal NG infections cleared spontaneously, 17 of 91 (18.7%) pharyngeal, 3 of 13 (23.1%) vaginal and 9 of 28 (32.1%) urethral NG infections. The median time between the pre-enrolment and enrolment visit was longer for patients who cleared their pharyngeal infection spontaneously compared with those who did not (median 8 days (IQR=7-11) vs 6 days (IQR=4-8), p=0.012); no determinants of clearance at other sites were identified. Overall, patients with more days between the pre-enrolment and enrolment visit were more likely to clear spontaneously (adjusted OR=1.06 per additional day, 95% CI 1.01 to 1.12). No association between location of NG infection and spontaneous clearance was found.

CONCLUSIONS

A significant proportion of asymptomatic patients cleared their NG infections spontaneously. Given these results, treatment of all NG infections after a one-time NAAT may be excessive, and more research on the natural history of NG is needed to improve antibiotic stewardship.

Recent insights suggest the need for the STI field to embrace a more eco-social conceptual framework: A viewpoint

A large number of countries are being confronted with twin epidemics of increasing STI incidence and antimicrobial resistance (AMR). This has led to calls to intensify STI screening of high STI prevalence populations. The available evidence suggests that this will have little impact on STI prevalence but a significant deleterious effect on AMR. We suggest that this call to intensify STI screening is one of the several errors that stem from the way that the STI-field has been dominated by a biomedical individualistic conceptual framework. This framework views STIs as obligate pathogens that can and should be eradicated by intensive seek-and-destroy activities. We evaluate five types of evidence that suggest that a multi-level, socio-ecological framework would provide a more accurate portrayal of the important determinants of STI prevalence and AMR spread. By incorporating concepts such as limiting STI screening to scenarios with clear evidence of net-benefit and considering 'antimicrobial footprint' thresholds, this framework would be more likely to result in a better balance between targeting STI prevalence whilst minimizing the risk of AMR emerging.

Novel strategies for prevention and treatment of antimicrobial resistance in sexually-transmitted infections

PURPOSE OF REVIEW

Antimicrobial resistance in sexually acquired infection (STI) pathogens is an important global public health threat. There is an urgent need for novel STI treatment and prevention strategies to tackle the rising incidence of STIs in high-income settings and the static progress in low- and middle-income settings over the past decade. The purpose of this review was to describe the research outlining the emergence of resistance in common STI pathogens and new strategies for their treatment and prevention.

RECENT FINDINGS

Rates of STIs have dramatically increased over the past decade. Further, antimicrobial resistance to first-line agents among key STI pathogens continues to emerge globally. Recent findings demonstrate promising results regarding the efficacy of novel antimicrobial treatment strategies for these pathogens, including several new, repurposed and unique combinations of antimicrobials. In addition, a number of new biomedical prevention strategies, such as antibacterial mouthwash and doxycycline chemoprophylaxis, are being investigated as novel prevention strategies for bacterial STIs.

SUMMARY

Significant progress has been made in the development of novel antimicrobials for the treatment of antimicrobial-resistant sexually acquired pathogens. However, due to the rapid development of resistance to antimicrobials demonstrated by these pathogens in the past, further research and development of effective prevention strategies should be prioritized.

Gonorrhoea treatment combined with population-level general cephalosporin and quinolone consumption may select for Neisseria gonorrhoeae antimicrobial resistance at the levels of NG-MAST genogroup: An ecological study in Europe

OBJECTIVES

The prevalence of Neisseria gonorrhoeae NG-MAST genogroup G1407, associated with decreased susceptibility to extended-spectrum cephalosporins and fluoroquinolone resistance, has declined in Europe and it switched from circulating predominantly in men who have sex with men (MSM) in 2009-2010 to heterosexuals in 2013. We hypothesise that changes to gonorrhoea treatment guidelines combined with differences in country-level consumption of cephalosporins and quinolones contributed to this shift.

METHODS

Linear regression was used to evaluate the association between changes in prevalence of G1407 between 2009-2010 and 2013 and country-level consumption of quinolones and cephalosporins in 2011/12 in 20 European countries.

RESULTS

Whilst the prevalence of G1407 declined between 2009-2010 and 2013 in the EU/EEA, its absolute prevalence increased by 10% or more in three countries. The national prevalence of G1407 in 2013 was positively associated with population-level general cephalosporin and quinolone consumption in the preceding 2 years. The association between the prevalence of G1407 and proportion of the national sample derived from MSM was non-significant in 2009-2010 and was negative in 2013.

CONCLUSIONS

Our results are broadly compatible with the hypothesis that changes in gonorrhoea therapy to the more efficacious ceftriaxone (plus azithromycin) from 2010 to 2011 onwards resulted in a reduced prevalence of the resistance-associated G1407 overall but in MSM in particular. High population-level consumption of quinolones and cephalosporins in certain countries then contributed to the selection of G1407 predominantly in heterosexuals in these countries.

Screening for STIs in PrEP cohorts results in high levels of antimicrobial consumption

Screening for STIs in men who have sex with men receiving HIV pre-exposure prophylaxis resulted in high consumption of macrolides, extended spectrum cephalosporins, fluoroquinolones and tetracyclines. The consumption of macrolides was 52 times as high as that reported for community-level consumption in certain European countries.

Toward a Set of Criteria to Decide Which STIs to Screen for in PrEP Cohorts

Contemporary HIV preexposure prophylaxis (PrEP) cohorts are characterized by high rates of partner change and as a result have high and fairly stable prevalences of N. gonorrhoeae and C. trachomatis. The available evidence suggests that intensive 3-monthly screening in this setting does not have a large effect on the prevalence of these infections but results in high antimicrobial exposures. Gonorrhea/chlamydia screening may thus be doing more harm than good. Compelling arguments can, however, be made to screen for HIV, hepatitis C, and syphilis in PrEP cohorts. In this perspective piece, we explore the logical basis for deciding which STIs to screen for in PrEP cohorts. We propose that a Delphi consensus methodology is used to derive, assess, and apply a broadly accepted set of criteria to evaluate which STIs to screen for in these cohorts. Finally, to illustrate the utility of the process, we derive and apply our own list of criteria as to which STIs to screen for. This process leads to a controversial conclusion, namely that stopping gonorrhea/chlamydia screening in a controlled and phased manner may offer net health benefits to PrEP cohorts.

Epidemiology and prevention of sexually transmitted infections in men who have sex with men at risk of HIV

Since 2012, the increasingly widespread promotion and uptake of HIV treatment as prevention and pre-exposure prophylaxis in men who have sex with men has been associated with increased sexually transmitted infections (STIs). However, numbers of STI cases have been rising for more than 20 years and the introduction of biomedical HIV interventions cannot explain the majority of the rises in STIs. The increases appear to have occurred mostly because of gradual changes in behaviour over many years, coupled in some settings with more condomless anal intercourse, and as a result of the increased screening for previously undetected asymptomatic infections. If control of STIs is to be improved, then a far greater emphasis on increased use of existing effective STI control strategies will be required, in addition to the investigation of new interventions. Central to effective STI control is accessible clinical care and screening services, which are currently inadequate in most settings. Insufficient action carries a risk of increased STI epidemics, including of newly resistant organisms.

How actively should we screen for chlamydia and gonorrhoea in MSM and other high-ST-prevalence populations as we enter the era of increasingly untreatable infections? A viewpoint

A number of national and international organizations are advocating more intensive screening for Chlamydia trachomatis and Neisseria gonorrhoeae in high-prevalence populations as a way to reduce the prevalence of these infections. In this article, we review the available evidence and conclude that there is a paucity of evidence to support this approach. We further hypothesize that increasing screening intensity in high-prevalence populations will result in a considerable risk for the emergence of antimicrobial resistance in Neisseria gonorrhoeae and other pathobionts.

Prevalence of macrolide resistance in Treponema pallidum is associated with macrolide consumption

We hypothesized that the large global variations in the prevalence of macrolide resistance in Treponema pallidum are related to differences in population-level macrolide consumption. The hypothesis was tested by, at a country-level, regressing the peak prevalence of macrolide resistance against the national macrolide consumption in the year prior to this, controlling for the year of the resistance prevalence estimate. A strong association was found between the per capita consumption of macrolides and macrolide resistance (coefficient 0.7, 95 % confidence interval 0.2-0.12, P=0.009).