Mycoplasma genitalium among young adults in the United States: an emerging sexually transmitted infection

Antimicrobial treatment and resistance in sexually transmitted bacterial infections

Sexually transmitted infections (STIs) have been part of human life since ancient times, and their symptoms affect quality of life, and sequelae are common. Socioeconomic and behavioural trends affect the prevalence of STIs, but the discovery of antimicrobials gave hope for treatment, control of the spread of infection and lower rates of sequelae. This has to some extent been achieved, but increasing antimicrobial resistance and increasing transmission in high-risk sexual networks threaten this progress. For Neisseria gonorrhoeae, the only remaining first-line treatment (with ceftriaxone) is at risk of becoming ineffective, and for Mycoplasma genitalium, for which fewer alternative antimicrobial classes are available, incurable infections have already been reported. For Chlamydia trachomatis, in vitro resistance to first-line tetracyclines and macrolides has never been confirmed despite decades of treatment of this highly prevalent STI. Similarly, Treponema pallidum, the cause of syphilis, has remained susceptible to first-line penicillin.

Mycoplasma genitalium prevalence, co-infection and macrolide resistance-associated mutations in Southern Vietnam

Mycoplasma genitalium is an emerging sexually transmitted infection, with increasing rates of macrolide resistance and some ways of treatments being recommended by many countries. This study aimed to investigate the prevalence of M. genitalium infection, M. genitalium co-infection with other sexually transmitted organisms, and the frequency of macrolide antibiotic resistance genotypes identified in urethral specimens collected from male and urethral, vaginal and cervical specimens from female who visited the STIs clinic of HCMC Hospital of Dermato-Venereology, Vietnam. The results obtained positive samples for C. trachomatis was 8.46%, N. gonorrhoeae was 6.28%, and M. genitalium was 5.95%. Fifty-five out of 90 M. genitalium samples were found to have mutations in the 23S rRNA gene associated with macrolide resistance (61.11%). M. genitalium/C. trachomatis co-infection was 6.19%, and M. genitalium/N. gonorrhoeae was 1.22%. The percentage of M. genitalium carrying the macrolide resistance mutant gene co-infected with C. trachomatis accounted for 37.50%. The high prevalence of the M. genitalium mutations associated with macrolide resistance showed the importance of M. genitalium testing.

Clinical Presentations and Treatment Outcomes of Mycoplasma genitalium Infections at a Large New York City Health Care System

BACKGROUND

Mycoplasma genitalium (MG) is an emerging sexually transmitted infection. Treatment of MG is complicated by increasing resistance to primary treatment regimens, including macrolides and fluoroquinolones. Understanding the various clinical presentations and relative effectiveness of treatments for MG is crucial to optimizing care.

METHODS

Patients with a positive MG nucleic acid amplification test between July 1, 2019, and June 30, 2021, at a large health system in New York City were included in a retrospective cohort. Demographics, clinical presentations, coinfections, treatment, and follow-up microbiologic tests were obtained from the electronic medical record. Associations with microbiologic cure were evaluated in bivariate and multivariable logistic regression models.

RESULTS

Five hundred two unique patients had a positive MG nucleic acid amplification test result during the study period. Male individuals presented predominantly with urethritis (117 of 187 [63%]) and female individuals with vaginal symptoms (142 of 315 [45%]). Among patients with follow-up testing who received a single antibiotic at the time of treatment, 43% (90 of 210) had persistent infection and 57% (120 of 210) had microbiologic cure. Eighty-two percent of patients treated with moxifloxacin had microbiologic cure compared with 41% of patients receiving azithromycin regimens ( P < 0.001). In multivariable analysis, treatment with moxifloxacin was associated with 4 times the odds of microbiologic cure relative to low-dose azithromycin (adjusted odds ratio [aOR], 4.18; 95% confidence interval, 1.73-10.13; P < 0.01).

CONCLUSIONS

Clinical presentations of MG vary, with urethritis or vaginal symptoms in most cases. Among patients who received a single antibiotic, only treatment with moxifloxacin was significantly associated with microbiologic cure relative to low-dose azithromycin.

Mycoplasma genitalium infection among gay, bisexual and other men who have sex with men in Montréal, Canada

Background

The bacteria Mycoplasma genitalium has been identified as a causative agent of urethritis in men, especially in gay, bisexual and other men who have sex with men (gbMSM). Canadian clinic-based data have identified a high prevalence of M. genitalium and resistance to antibiotic treatments. This article estimates the prevalence of M. genitalium infections among Montréal gbMSM, explores correlates for M. genitalium infection and estimates the prevalence of mutations associated with antimicrobial resistance (AMR).

Methods

Engage Cohort Study is a multi-site longitudinal study on sexually active gbMSM, aged 16 years and older, recruited via respondent-driven sampling in Montréal, Toronto and Vancouver. Participants completed a questionnaire on behaviour and were tested for sexually transmitted and blood-borne infections at each visit. For this sub-study, Montréal participants with a follow-up visit that occurred between November 2018 and November 2019 were included.

Results

A total of 2,064 samples were provided by 716 participants. Prevalence of M. genitalium infection was 5.7% at rectal and/or urethral sites, 4.0% at rectal site and 2.2% at urethral site. Correlates for M. genitalium infection were younger age and reporting six or more sexual partners in the past six months. Prevalence of macrolide resistance associated mutations (MRAM), quinolone resistance associated mutations (QRAM) and either MRAM or QRAM, was 82%, 29% and 85%, respectively.

Conclusion

This first population-based study among gbMSM in Canada documents a high prevalence of urethral and rectal M. genitalium infection and high levels of AMR. Our results highlight the importance of access to testing and AMR detection when indicated.

[Urethritis-spectrum of pathogens, diagnostics and treatment]

A broad spectrum of bacteria, fungi, protozoa and viruses can cause urethritis. In particular, N. gonorrhoeae, C. trachomatis, M. genitalium and T. vaginalis are the focus of diagnostic considerations as classic pathogens associated with sexually transmitted infections (STI). A step-by-step procedure is needed to make a definitive diagnosis. Microscopy with a staining preparation provides an initial differentiation between gonoccocal and non-gonococcal urethritis in symptomatic men as a point-of-care (POC) test. Nucleic acid amplification technology (NAAT) is used for specific and sensitive pathogen detection and, as a multiplex diagnostic test, offers the possibility of detecting several organisms from the same sample. In addition, compared to culture, no vital organisms are required, which allows the collection and use of more diverse and less invasive biological samples (e.g. first stream urine in men or vaginal swabs). Susceptibility testing by culture remains essential for N. gonorrhoeae as resistance is emerging. The treatment of urethritis depends on the suspected or proven pathogen according to the current guidelines. Treatment failure can be caused by many factors (coinfection, lack of therapy adherence, reinfection or resistance of the pathogen) and requires a repeated diagnostic and therapeutic procedure and differentiated approach.

Retrospective Evaluation of Mycoplasma genitalium Prevalence and Macrolide Resistance in a Study Cohort of Pregnant Women in Birmingham, AL, From 1997 to 2001

ABSTRACT

In a prospective study conducted in 2020 to 2021, macrolide resistance-associated mutations were found in 41% of pregnant persons in Birmingham, AL, with Mycoplasma genitalium detected. We retrospectively evaluated M. genitalium in 203 pregnant persons participating in a study conducted in 1997 to 2001 in Birmingham and adjacent areas and found a prevalence of 11% (95% confidence interval, 6.9%-15.7%), but no macrolide resistance-associated mutations.

Viruses, bacteria and parasites: infection of the male genital tract and fertility

BACKGROUND

Infertility affects one couple out of six worldwide. Male infertilty can result from congenital or acquired factors, of which pathogens that reach the genital tract through sexual contact or blood dissemination. The impact of major viral, bacterial and parasitic infections on the male genital tract and fertility has been summarized.

RESULTS AND CONCLUSIONS

A systematic review of articles published in the Google Scholar and PubMed databases was conducted. It turns out that viruses, as well as bacteria and parasites are major inducers of male genital tract infections and ensuing infertility through damage to the organs and subsequent loss of function and/or through direct damage to the sperm cells. Moreover, not only male infertility results from such infections but these can also be transmitted to women and even to the offspring, thus highlighting the need to efficiently detect, treat and prevent them.

Update in Epidemiology and Management of Mycoplasma genitalium Infections

Mycoplasma genitalium is a frequent cause of urogenital syndromes in men and women and is associated with adverse sequelae in women. M genitalium also infects the rectum, and may cause proctitis, but rarely infects the pharynx. Diagnosis requires nucleic acid amplification testing. Antibiotic resistance is widespread: more than half of infections are resistant to macrolides and fluoroquinolone resistance is increasing. Resistance-guided therapy is recommended for symptomatic patients, involving initial treatment with doxycycline to reduce organism load followed by azithromycin for macrolide-sensitive infections or moxifloxacin for macrolide-resistant infections. Neither screening nor tests of cure are recommended in asymptomatic persons.

Advances in Diagnostics of Sexually Transmitted Infections

Sexually transmitted infections (STIs) are caused by various pathogens, many of which have common symptoms. Diagnostic tests are critical to supporting clinical evaluations in making patient management decisions. Molecular diagnostics are the preferred test type when available, especially in asymptomatic patients for many STIs. However, for some infections, serology offers the best insight into infectious status. Clinicians should be aware of the performance characteristics of the available STI diagnostic tests and understand how to use them. Point-of-care tests are helpful to implement rapid and accurate treatment responses, which are particularly helpful in certain at-risk populations.

Emerging multidrug resistance contributes to treatment failure in Mycoplasma genitalium infected patients in China

The increased treatment failure in patients with sexually transmitted Mycoplasma genitalium infection is associated with antimicrobial resistance. We performed a retrospective survey of antimicrobial clinical outcomes in M. genitalium-infected patients. In addition, we detected macrolide, fluoroquinolone and tetracycline resistance-associated markers to determine their role in treatment failure. The overall incidence of treatment failure was 28.29%, regardless of the drug used. In the present study, the prevalence of macrolide resistance-associated mutations in the 23S rRNA gene was 64%; that of fluroquinolone resistance-associated S83/D87 substitutions in the parC gene was 67.5%; and that of the tetracycline resistance-associated C1192T mutation in the 16S rRNA gene was 22.5%. Furthermore, evidence of dual antimicrobial resistance was found in 46.4% of pretreatment samples, and triple antimicrobial resistance was identified in 9.9%. These findings regarding the emergence of multidrug-resistant strains of M. genitalium in China are concerning and emphasize the importance of guiding M. genitalium treatment with antimicrobial resistance assays.

Incidence and laboratory diagnosis of sexually-transmitted infections among university students in a high-prevalence community

Objective: The purpose of this study was to determine the incidence of four sexually-transmitted infection (STI) agents among university students. Participants: A total of 1744 Milwaukee, Wisconsin metropolitan area student encounters at two university health clinics. Methods: Following consent, participants completed an eight-item demographic and behavioral questionnaire and provided a specimen for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium RNA testing. Results: C. trachomatis (7.2%) and M. genitalium (6.7%) detection rates were highest, with C. trachomatis more likely to result in symptomatic infection in males and females. Female M. genitalium detection rates did not differ as a function of symptomatic status. Students identifying as African American were more likely to test positive for M. genitalium than other races/ethnicities. M. genitalium detection in both genders was a function of reported condom usage. Conclusions: Students would benefit from familiarity with emerging STI agents, as well as behaviors associated with increased risk of STI.

Ureaplasma urealyticum and Mycoplasma hominis urogenital infections associate with semen inflammation and decreased sperm quality

Ureaplasma urealyticum and Mycoplasma hominis are among the most prevalent sexually transmitted infections proposed to induce urogenital inflammation and impair sperm quality. However, the topic remains controversial since contradictory findings have been reported. Herein, we performed a comprehensive analysis of U. urealyticum and M. hominis urogenital infections and their association with urogenital inflammation (i.e., leukocyte subsets and inflammatory cytokines in semen,) and sperm quality parameters in a cohort of men with couple's primary infertility undergoing initial infertility evaluation or with lower urinary tract symptoms and no infertility-related complaints. Overall, U. urealyticum and M. hominis infection was detected in 17.0% and 23.6% of patients, respectively, whereas the coinfection was detected in 3.8% of patients only. Remarkably, similar infection frequencies were found in the different patient subpopulations analyzed. Moreover, infections were associated with elevated semen levels of TNF, IL-1β, and IL-6 and/or increased counts of total leukocytes and their subsets, including CD4 and CD8 T lymphocytes and neutrophils. In addition, M. hominis infection and the coinfection with U. urealyticum were associated with impairments in sperm quality variables. Our results indicate that U. urealyticum and M. hominis male urogenital infections induce urogenital inflammation and decrease sperm quality, thus impairing male fertility potential. Screening for U. urealyticum and M. hominis infections and performing a comprehensive analysis of different leukocyte subsets and inflammatory cytokines in semen may be clinically helpful in the diagnosis and follow-up of male urogenital infection.

Distribution of Macrolide Resistant Mycoplasma genitalium in Urogenital Tract Specimens From Women Enrolled in a US Clinical Study Cohort

BACKGROUND

This study evaluated the distribution of macrolide-resistant Mycoplasma genitalium in multiple urogenital specimens collected from women enrolled in a prospective multicenter US clinical study.

METHODS

Four female urogenital specimens (vaginal swab, urine, endocervical swab, ectocervical brush/spatula) collected from each subject were tested using a transcription-mediated amplification (TMA) assay for M. genitalium. TMA-positive specimens were evaluated by reverse transcription-polymerase chain reaction and bidirectional Sanger sequencing of M. genitalium 23S rRNA to identify the presence of macrolide-resistance-mediating mutations (MRMs) at base positions 2058/2059.

RESULTS

Of 140 women with ≥1 TMA-positive specimens, 128 (91.4%) yielded M. genitalium 23S rRNA sequence. MRMs were found in 52% of vaginal specimens, 46.3% of urine specimens, 37.8% of endocervical specimens, and 46% of ectocervical specimens. There were 44 unique specimen type/sequence phenotype combinations of M. genitalium infection. Most (81; 63.3%) women had single specimen-sequence phenotype (macrolide-susceptible, MRM, or both) infections, while 24 (18.8%) women had multiple specimen-sequence phenotype concordant infections, and 23 (17.9%) women had multiple specimen-sequence phenotype discordant infections. The sensitivity for any single specimen type to detect overall urogenital tract macrolide-resistant M. genitalium infection status was 96.3% for vaginal swab samples, 82.6% for urine samples, 70.8% for endocervical swab samples, and 82.1% for ectocervical brush/spatula liquid Pap samples.

CONCLUSIONS

The distribution of M. genitalium infections in female urogenital tract specimens is highly complex, with multiple phenotypic combinations of the organism infecting a significant proportion of women at different anatomic specimen collection sites. Vaginal swab sampling yielded the highest sensitivity for identifying women with macrolide-resistant M. genitalium urogenital tract infections.

A Systematic Review and Meta-Analysis of Efficacy and Safety of Azithromycin Versus Moxifloxacin for the Initial Treatment of Mycoplasma genitalium Infection

Mycoplasma genitalium is recognized as a remarkable pathogen since azithromycin-resistant strains and treatment failure have been increasingly reported. Nevertheless, international guidelines still recommend azithromycin as a first-line treatment and moxifloxacin as a second-line treatment. We performed a systematic review and meta-analysis to validate the efficacy and safety of both drugs in the initial treatment of M. genitalium. We systematically searched the EMBASE, PubMed, Scopus, Ichushi, and CINAHL databases up to December 2021. We defined efficacy as clinical and microbiologic cure, and safety as persistent diarrhea. Overall, four studies met the inclusion criteria: one showed clinical cure (azithromycin treatment, n = 32; moxifloxacin treatment, n = 6), four showed microbiologic cure (n = 516; n = 99), and one showed safety (n = 63; n = 84). Moxifloxacin improved the microbiologic cure rate compared with azithromycin (odds ratio [OR] 2.79, 95% confidence interval [CI], 1.06–7.35). Clinical cure and safety did not show a significant difference between azithromycin and moxifloxacin treatments (OR 4.51, 95% CI 0.23–88.3; OR 0.63, 95% CI 0.21–1.83). Our meta-analysis showed that moxifloxacin was more effective than azithromycin at eradicating M. genitalium infections and supports its preferential use as a first-line treatment.

2021 European guideline on the management of Mycoplasma genitalium infections

Mycoplasma genitalium infection contributes to 10-35% of non-chlamydial non-gonococcal urethritis in men. In women, M. genitalium is associated with cervicitis and pelvic inflammatory disease (PID) in 10-25%. Transmission of M. genitalium occurs through direct mucosal contact.

CLINICAL FEATURES AND DIAGNOSTIC TESTS

Asymptomatic infections are frequent. In men, urethritis, dysuria and discharge predominate. In women, symptoms include vaginal discharge, dysuria or symptoms of PID - abdominal pain and dyspareunia. Symptoms are the main indication for diagnostic testing. Diagnosis is achievable only through nucleic acid amplification testing and must include investigation for macrolide resistance mutations.

THERAPY

Therapy for M .genitalium is indicated if M. genitalium is detected. Doxycycline has a cure rate of 30-40%, but resistance is not increasing. Azithromycin has a cure rate of 85-95% in macrolide-susceptible infections. An extended course of azithromycin appears to have a higher cure rate, and pre-treatment with doxycycline may decrease organism load and the risk of macrolide resistance selection. Moxifloxacin can be used as second-line therapy but resistance is increasing.

RECOMMENDED TREATMENT

Uncomplicated M. genitalium infection without macrolide resistance mutations or resistance testing: Azithromycin 500 mg on day one, then 250 mg on days 2-5 (oral). Second-line treatment and treatment for uncomplicated macrolide-resistant M. genitalium infection: Moxifloxacin 400 mg od for 7 days (oral). Third-line treatment for persistent M. genitalium infection after azithromycin and moxifloxacin: Doxycycline or minocycline 100 mg bid for 14 days (oral) may cure 40-70%. Pristinamycin 1 g qid for 10 days (oral) has a cure rate of around 75%. Complicated M. genitalium infection (PID, epididymitis): Moxifloxacin 400 mg od for 14 days. MAIN CHANGES FROM THE 2016 EUROPEAN M.

GENITALIUM GUIDELINE

Due to increasing antimicrobial resistance and warnings against moxifloxacin use, indications for testing and treatment have been narrowed to primarily involve symptomatic patients. The importance of macrolide resistance-guided therapy is emphasised.

Epidemiological, clinical and laboratory differences between male urethral infections due to Haemophilus spp. and those due to Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and Ureaplasma urealyticum: A descriptive study

OBJECTIVE

To describe the epidemiological, clinical and laboratory characteristics of male patients diagnosed with Haemophilus spp. urethral infection and to compare them with the characteristics of male patients diagnosed with N. gonorrhoeae, C. trachomatis, M. genitalium and U. urealyticum urethral infection. Over the past 2 years, an increase in urethral infections due to Haemophilus spp. was observed.

MATERIALS AND METHODS

All male patients who attended our Department of Sexually Transmitted Infections between January 2018 and February 2019 were retrospectively studied; they underwent conventional bacteriological and multiplex PCR studies in the urethra at the same time.

RESULTS

Of the 86 patients studied, a unique microorganism was detected in 76 cases, N. gonorrhoeae in 24, Haemophilus spp. in 21 (16 H. parainfluenzae and 5 H. influenzae), C. trachomatis in 19, M. genitalium in 8 and U. urealyticum in 4; 10 cases presented more than one microorganism. In case of multiple aetiological agents, sexual partnership was multiple. In the Haemophilus group, 81% reported only unprotected oral insertive sex; symptoms lasted for more than one week in 62% of the patients.

CONCLUSIONS

Haemophilus is an aetiological agent of non-gonococcal urethritis whose incidence is clearly increasing; the main route of transmission is oral sex. The most common reason for consultation is dysuria and testicular pain, while urethral discharge was predominant for the other causes of urethral infection. Due to the high frequency of antibiotic resistance in the Haemophilus group, it is necessary to confirm eradication by performing a test of cure.

Burden of Mycoplasma genitalium and Bacterial Coinfections in a Population-Based Sample in New Mexico

ABSTRACT

In this population-based US study, the overall prevalence of Mycoplasma genitalium was 1.95% (95% confidence interval [CI], 1.62%-2.34%), declining from 6.12% (95% CI, 4.72%-7.92%) in women aged 21 to 24 years to 0.48% (95% CI, 0.25%-0.94%) in women aged 40 to 64 years. The prevalence of coinfections with Chlamydia trachomatis and Trichomonas vaginalis was low.

Prevalence of Urogenital Mycoplasma genitalium Infection, United States, 2017 to 2018

ABSTRACT

During the 2017-2018 National Health and Nutrition Examination Survey, urine samples from participants aged 14 to 59 years were tested for Mycoplasma genitalium infection. Overall prevalence was 1.7% (95% confidence interval [CI], 1.1%-2.7%). Prevalence was similar between males (1.8% [95% CI, 0.9%-3.1%]) and females (1.7% [95% CI, 0.8%-3.0%]).

Azithromycin and Doxycycline Resistance Profiles of U.S. Mycoplasma genitalium Strains and Their Association with Treatment Outcomes

Mycoplasma genitalium is a sexually transmitted bacterium associated with nongonococcal urethritis (NGU) in men and cervicitis, endometritis, and pelvic inflammatory disease in women. Effective treatment is challenging due to the inherent, and increasingly acquired, antibiotic resistance in this pathogen. In our treatment trial conducted from 2007 to 2011 in Seattle, WA, we demonstrated poor efficacy of azithromycin (AZM) and doxycycline (DOX) against M. genitalium among men with NGU. In the present study, we cultured M. genitalium from 74 of 80 (92.5%) PCR-positive men at enrollment (V-1) and defined the MICs of AZM (N = 56 isolates) of DOX (N = 62 isolates). Susceptibility to AZM was bimodal; MICs were >8 μg/ml (44.6%) and <0.004 μg/ml (55.4%) for these isolates. The association of MIC with treatment efficacy was determined for men initially treated with either AZM (N = 30) or DOX (N = 24). Men treated with AZM were more likely to experience microbiologic treatment failure (P < 0.001) if infected with isolates that had AZM MICs of >8 μg/ml (18/18 men) than those with isolates that had AZM MICs of <0.004 μg/ml (1/12 men). Clinical treatment failure also was more likely to occur (P = 0.002) with AZM MICs of >8 μg/ml (12/18 men) than with AZM MICs of <0.004 μg/ml (1/12 men). In contrast, DOX MICs ranged from <0.125 to 2 μg/ml and were not correlated with microbiologic (P = 0.71) or clinical treatment (P = 0.41) failure, demonstrating no relationship between DOX MICs and treatment efficacy. Given the rapid spread of AZM resistance and the emergence of quinolone resistance, the current second-line therapy, monitoring MICs and evaluating other potential treatments for M. genitalium will be critical.

Integrating the Human and Animal Sides of Mycoplasmas Resistance to Antimicrobials

Mycoplasma infections are frequent in humans, as well as in a broad range of animals. However, antimicrobial treatment options are limited, partly due to the lack of a cell wall in these peculiar bacteria. Both veterinary and human medicines are facing increasing resistance prevalence for the most commonly used drugs, despite different usage practices. To date, very few reviews have integrated knowledge on resistance to antimicrobials in humans and animals, the latest dating back to 2014. To fill this gap, we examined, in parallel, antimicrobial usage, resistance mechanisms and either phenotype or genotype-based methods for antimicrobial susceptibility testing, as well as epidemiology of resistance of the most clinically relevant human and animal mycoplasma species. This review unveiled common features and differences that need to be taken into consideration in a "One Health" perspective. Lastly, two examples of critical cases of multiple drug resistance are highlighted, namely, the human M. genitalium and the animal M. bovis species, both of which can lead to the threat of untreatable infections.

Prevalence of leukocyturia in a cohort of French asymptomatic aircrews

OBJECTIVES

Sexually transmitted infections (STIs) can cause leukocyturia. We aimed to estimate the prevalence of leukocyturia in asymptomatic aircrews and the proportion of STIs in those presenting leukocyturia.

METHODS

The LEUCO survey was a prospective cohort study conducted among aircrews between 14th October 2019 and 13th March 2020 at the Toulon aeromedical centre in France. All participants performed a dipstick urinalysis. Those positive for leukocyturia were offered STI screening by nucleic acid amplification test (NAAT) for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium and Trichomonas vaginalis.

RESULTS

Among the 2236 included asymptomatic participants (1912 men and 324 women), 127 (36 men and 91 women) were positive for leukocyturia. The prevalence of leukocyturia was 1.9% (1.3-2.6) in men and 28.1% (23.3-33.3) in women (p < 0.001). In men positive for leukocyturia, the NAAT positivity rate for C. trachomatis, N. gonorrhoeae, M. genitalium and T. vaginalis was 28.6% (3.7-71.0) in the age group 18-24, 20.0% (0.5-71.6) in the age group 25-34, and zero in the older age group (p 0.65). In women positive for leukocyturia it was 16.7% (4.7-37.4) in the age group 18-24, 18.2% (2.3-51.8) in the age group 25-34, and zero in the older age group (p 0.16).

CONCLUSIONS

In asymptomatic individuals, leukocyturia is rare in men and more common in women. In asymptomatic adults under 35 years of age with leukocyturia, multiplex NAAT shows a high proportion of STIs and might be useful in improving STI detection.

Occurrence of urogenital mycoplasmas in men with the common genitourinary diseases

Many serious and fatal infections with urogenital mycoplasmas in immunocompromised patients have been reported. M. genitalium is recognized as a cause of male urethritis and other common genitourinary diseases. The aim of the study was to estimate prevalence of urogenital mycoplasmas which can cause complications in men with common genitourinary diseases. Study included 85 men with genitourinary tract carcinoma (n = 35), urolithiasis (n = 36), and BPH (benign prostatic hyperplasia) (n = 14). The control group consisted of 50 healthy men. FVU (first void urine) samples were examined by PCR for the presence of urogenital mycoplasmas DNA. Occurrence of urogenital mycoplasmas was significantly more common in study group compared with control 24/85 (28.2%) and 7/50 (14%), respectively (p = 0.05). In men with urolithiasis, positive results for mycoplasmas DNA were significantly more frequent than in control: 33.3% vs. 14% (p < 0.05). In patients with urolithiasis DNA of U. urealyticum was most often found, while in the genitourinary carcinoma and BPH groups, U. parvum was more frequent. Incidence of M. fermentans was also significantly higher in the urolithiasis group vs. control (p = 0.03). A higher percentage of positive results for urogenital mycoplasma DNA in study group has been found. Further studies are required to confirm the role of urogenital mycoplasmas in the development of infectious complications among patients with urolithiasis, genitourinary carcinoma, and BPH.

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.

Prevalence and Epidemiology of Mycoplasma genitalium in a Pacific-Region Military Population

BACKGROUND

Mycoplasma genitalium is an important emerging sexually transmitted pathogen commonly causing urethritis in men, cervicitis, and pelvic inflammatory disease in women with potential of infertility. Accumulating evidence identifies the prevalence of M. genitalium similar to long recognized pathogens, Chlamydia trachomatis and Neisseria gonorrhoeae. The purpose of this study was to establish the prevalence and epidemiology of M. genitalium in a mid-Pacific military population.

METHODS

A prospective analysis was conducted from routine specimens collected as standard of care for sexually transmitted infection (STI) testing at Tripler Army Medical Center on Oahu, HI. The prevalence of M. genitalium was determined using the Aptima M. genitalium assay, a transcription-mediated amplification test. A multivariate analysis was performed to assess the associations for this infection with other STIs and demographic factors.

RESULTS

A total of 1876 specimens were tested in a 6-month period including 6 sample types from 1158 females and 718 males. Subject ages ranged from 18 to 76 years, with a median of 24 years (interquartile range, 21-29 years). The prevalence of M. genitalium was 8.8% overall (n = 165), 7.1% in females and 11.6% in males. Coinfection with M. genitalium occurred with another sexually-transmitted pathogen in 43 patients (18.3%), with C. trachomatis as the most common organism (n = 38).

CONCLUSIONS

These data contribute to the evidence base for M. genitalium and STI screening in an active-duty military.

Association of Chlamydia and Mycoplasma infections with susceptibility to ovarian cancer: A systematic review and meta-analysis

BACKGROUND

Ovarian cancer is one of the most prevalent cancers with a high mortality rate in women. Published studies indicate that inflammation, DNA damage, and pelvic inflammatory disease (PID) are the most important risk factors for ovarian cancer and this could be induced and exacerbated by infectious agents such as Chlamydia trachomatis and Mycoplasma genitalium. The aim of this study was to determine the association between Chlamydia and Mycoplasma infections and the risk of ovarian cancer.

METHODS

We carried out a comprehensive search of PubMed, Scopus, Web of Science, Embase, and Google Scholar without limitation on publication date. All relevant studies which investigatived probable potential connection between Chlamydia and Mycoplasma infection and development of ovarian cancer were included.

RESULTS

Eighteen studies comprising a total of 8207 patients were evaluated in the study and this showed that the frequency of infection with Chlamydia and Mycoplasma among ovarian cancer patients was 32.6 % and 23 %, respectively. The results suggested that Chlamydia trachomatis infection increased the overall risk for ovarian cancer by 1.344 fold (OR: 1.344; 95 %CI: 1.19-1.50). Moreover, infection with Mycoplasma infections showed a week but not significant increased risk of ovarian cancer (OR: 1.12; 95 %CI: 0.86-1.44). However, the test for heterogeneity was significant among these studies.

CONCLUSION

This study confirmed the clinical relevance of Chlamydia and Mycoplasma infection and development of the ovarian cancer risk, although the significance was marginal and study heterogeneity was significant. This highlights the need for further studies in this area.

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.

Mycoplasma genitalium infection in women reporting dysuria: A pilot study and review of the literature

Mycoplasma genitalium (MG) infection, a sexually transmitted infection (STI), causes cervicitis and may cause reproductive sequelae and adverse pregnancy outcomes. Some MG-infected women report dysuria, a symptom frequently attributed to urinary tract infection (UTI). Given potential MG-associated morbidity and the likelihood that UTI treatment would be ineffective in eradicating MG, an improved understanding of MG infection frequency and clinical significance in young women reporting dysuria is needed. We conducted MG testing on stored urogenital specimens collected in a pilot study on frequency of STIs in young women presenting to an emergency department for dysuria evaluation and performed a literature review on MG infection frequency in women reporting dysuria. Among 25 women presenting for dysuria evaluation in our pilot study, 6 (24.0%) had MG detected and one-third had co-infection with chlamydia and one-third with trichomoniasis; half with MG detected did not receive an antibiotic with known efficacy against MG, while the other half received azithromycin. In five studies identified in the literature review, dysuria was reported by 7%-19% of women and MG detected in 5%-22%. MG infection is common in young women with dysuria and empiric UTI treatment may not be effective against MG. Studies evaluating the clinical significance of MG infection in women reporting dysuria are needed.

Results from a large cross-sectional study assessing Chlamydia trachomatis, Ureaplasma spp. and Mycoplasma hominis urogenital infections in patients with primary infertility

Female and male infertility have been associated to Chlamydia trachomatis, Ureaplasma spp. and Mycoplasma hominis urogenital infections. However, evidence from large studies assessing their prevalence and putative associations in patients with infertility is still scarce. The study design was a cross-sectional study including 5464 patients with a recent diagnosis of couple's primary infertility and 404 healthy control individuals from Cordoba, Argentina. Overall, the prevalence of C. trachomatis, Ureaplasma spp. and M. hominis urogenital infection was significantly higher in patients than in control individuals (5.3%, 22.8% and 7.4% vs. 2.0%, 17.8% and 1.7%, respectively). C. trachomatis and M. hominis infections were significantly more prevalent in male patients whereas Ureaplasma spp. and M. hominis infections were more prevalent in female patients. Of clinical importance, C. trachomatis and Ureaplasma spp. infections were significantly higher in patients younger than 25 years. Moreover, Ureaplasma spp. and M. hominis infections were associated to each other in either female or male patients being reciprocal risk factors of their co-infection. Our data revealed that C. trachomatis, Ureaplasma spp. and M. hominis are prevalent uropathogens in patients with couple's primary infertility. These results highlight the importance of including the screening of urogenital infections in the diagnostic workup of infertility.

Retrospective analysis of infection and antimicrobial resistance patterns of Mycoplasma genitalium among pregnant women in the southwestern USA

BACKGROUND

Mycoplasma genitalium is a sexually transmitted infection (STI) pathogen. There have been no published studies concerning symptomatology, prevalence data, antibiotic resistance profiling or reports of co-infection with other STI in pregnant women.

OBJECTIVE

To describe these characteristics among pregnant women attending prenatal clinics in a large tertiary care centre.

DESIGN

Remnant genital samples collected from pregnant women between August 2018 and November 2019 were tested for M. genitalium and Trichomonas vaginalis by the transcription-mediated amplification technique. Specimens with detectable M. genitalium RNA were sequenced for 23S rRNA mutations associated with azithromycin resistance and parC and gyrA mutations associated with resistance to moxifloxacin. Demographic, obstetric and STI co-infection data were recorded.

RESULTS

Of the 719 samples, 41 (5.7 %) were positive for M. genitalium. M. genitalium infection was associated with black race, Hispanic ethnicity and young age (p=0.003, p=0.008 and p=0.004, respectively). M. genitalium infection was also associated with T. vaginalis co-infection and Streptococcus agalactiae (group B Streptococcus) colonisation (p≤0.001 and p=0.002, respectively). Of the 41 positive samples, 26 (63.4%) underwent successful sequencing. Eight (30.8%) had 23S rRNA mutations related to azithromycin resistance. One of 26 (3.8%) positive samples with sequencing results had the gyrA gene mutation and 1 of 18 sequenced samples (5.6%) had the parC gene mutation associated with moxifloxacin resistance.

CONCLUSIONS

Prevalence rates of M. genitalium in pregnant women was 5.7%. M. genitalium infection disproportionately affects young black women co-infected with T. vaginalis. Pregnant women remain at risk for persistent infection with M. genitalium due to decreased azithromycin susceptibility.

Genital Mycoplasma, Shigellosis, Zika, Pubic Lice, and Other Sexually Transmitted Infections: Neither Gone Nor Forgotten

ABSTRACT

Most estimates of the combined burden and cost of sexually transmitted infections (STIs) in the United States have focused on 8 common STIs with established national surveillance strategies (chlamydia, gonorrhea, syphilis, trichomoniasis, genital herpes, human papillomavirus, and sexually transmitted human immunodeficiency virus and hepatitis B). However, over 30 STIs are primarily sexually transmitted or sexually transmissible. In this article, we review what is known about the burden of "other STIs" in the United States, including those where sexual transmission is not the primary transmission route of infection. Although the combined burden of these other STIs may be substantial, accurately estimating their burden due to sexual transmission is difficult due to diagnostic and surveillance challenges. Developing better estimates will require innovative strategies, such as leveraging existing surveillance systems, partnering with public health and academic researchers outside of the STI field, and developing methodology to estimate the frequency of sexual transmission, particularly for new and emerging STIs.

Mycoplasma genitalium and Bacterial Vaginosis-Associated Bacteria in a Non-Clinic-Based Sample of African American Women

BACKGROUND

Mycoplasma genitalium is associated with adverse reproductive problems. However, prevalence estimates from studies that screen women not seeking care are rare. Studies have reported co-occurrence of M. genitalium with bacterial vaginosis (BV), but no prior study of specific BV-associated bacteria has been conducted in African Americans whose reproductive tract infection burden is high.

METHODS

Using quantitative polymerase chain reaction, we screened vaginal swabs for M. genitalium, 9 BV-associated bacteria, and 4 Lactobacillus species from 200 participants drawn from a cohort of African Americans 23 to 35 years old. Sexual history, herpes serostatus, and Nugent score had been assessed. Prevalence of M. genitalium was computed. The associations of other vaginal bacteria with M. genitalium were examined with binomial regression.

RESULTS

M. genitalium prevalence was 18%. Detection and quantity of 2 BV-associated bacteria were significantly associated with a higher prevalence of M. genitalium (Leptotrichia/Sneathia: detection prevalence ratio (PR) of 2.9 [95% confidence interval {CI}, 1.1-7.7] and quantity PR of 1.2 [95% CI, 1.0-1.3]; Megasphaera phylotype 1: detection PR of 2.2 [95% CI, 1.2-4.2] and quantity PR of 1.1 [95% CI, 1.0-1.2]). Increased quantity of L. iners was also positively associated with M. genitalium (PR, 1.3 [95% CI, 1.0-1.8]). Nugent ≥7, herpes serostatus, and lifetime number of sex partners were not associated with M. genitalium.

CONCLUSIONS

Specific BV-associated microbes and L. iners were associated with M. genitalium, but Nugent ≥7 was not. Studies are needed to confirm a high prevalence of M. genitalium in African Americans and to understand its interactions with other vaginal bacteria.

Mycoplasma genitalium Infection in Young Women Without Urogenital Symptoms Presenting to a Community-Based Emergency Department in Birmingham, Alabama

ABSTRACT

We used the Food and Drug Administration-cleared Aptima Mycoplasma genitalium assay to evaluate for M. genitalium infection among young women without urogenital symptoms presenting to a community-based emergency department in Birmingham, Alabama, between August 2016 to August 2019 for evaluation of nongynecological concerns. M. genitalium was detected in 23 (14.8%) of 155 women.

In vitro activity of the first-in-class triazaacenaphthylene gepotidacin alone and in combination with doxycycline against drug-resistant and -susceptible Mycoplasma genitalium

Mycoplasma genitalium has developed resistance to first-line azithromycin and second-line moxifloxacin. Third-line pristinamycin is only 75% effective. Gepotidacin, a novel triazaacenaphthylene topoisomerase II inhibitor, blocks bacterial DNA replication. We determined the in vitro activity of gepotidacin alone and in combination with doxycycline against a diverse collection of Mycoplasma genitalium isolates (n = 54).

Minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) were determined by a Vero-cell culture method. Macrolide resistance was present in 31 (57%) isolates, fluoroquinolone resistance in 18 (33%) isolates, and 17 (31%) had dual resistance. Synergy testing was performed for gepotidacin and doxycycline by checkerboard analysis for two macrolide- and two dual-resistant isolates.

Gepotidacin was active against all 54 M. genitalium isolates with median and modal MICs of 0.125 mg/L and MIC₉₀ of 0.25 mg/L (range ≤0.016–0.5 mg/L). No difference in gepotidacin MIC between macrolide-resistant and -susceptible isolates (p = 0.24) or between fluoroquinolone-, dual-resistant and -susceptible isolates (p = 0.2) was demonstrated. Gepotidacin MBCs were available for 44 M. genitalium isolates with median MIC of 0.064 mg/L and median MBC of 0.125 mg/L. All isolates had ≤4-fold difference between MIC and MBC, suggesting bactericidal effect for gepotidacin. Checkerboard analysis indicated synergistic effect for gepotidacin in combination with doxycycline [fractional inhibitory concentration index (ΣFICI) of 0.5] for two isolates and additive/indifference (ΣFICI at 0.62 and 0.75) for two isolates.

Gepotidacin warrants further evaluation in clinical treatment trials for M. genitalium. Combination therapy with doxycycline should be clinically studied to assess effect and potential protection against development and/or spread of gepotidacin resistance.

Macrolide and fluoroquinolone associated mutations in Mycoplasma genitalium in a retrospective study of male and female patients seeking care at a STI Clinic in Guangzhou, China, 2016-2018

Background

Antimicrobial resistance in M. genitalium is a growing clinical problem. We investigated the mutations associated with macrolide and fluoroquinolone resistance, two commonly used medical regimens for treatment in China. Our aim is to analyze the prevalence and diversity of mutations among M. genitalium-positive clinical specimens in Guangzhou, south China.

Methods

A total of 154 stored M. genitalium positive specimens from men and women attending a STI clinic were tested for macrolide and fluoroquinolone mutations. M. genitalium was detected via TaqMan MGB real-time PCR. Mutations associated with macrolide resistance were detected using primers targeting region V of the 23S rRNA gene. Fluoroquinolone resistant mutations were screened via primers targeting topoisomerase IV (parC) and DNA gyrase (gyrA).

Results

98.7% (152/154), 95.5% (147/154) and 90.3% (139/154) of M. genitalium positive samples produced sufficient amplicon for detecting resistance mutations in 23S rRNA, gyrA and parC genes, respectively. 66.4% (101/152), 0.7% (1/147) and 77.7% (108/139) samples manifested mutations in 23S rRNA, gyrA and parC genes, respectively. A2072G (59/101, 58.4%) and S83I (79/108, 73.1%) were highly predominating in 23S rRNA and parC genes, respectively. Two samples had amino acid substitutions in gyrA (M95I and A96T, respectively). Two samples had two amino acid substitutions in parC (S83I + D87Y). 48.6% (67/138) of samples harbored both macrolide and fluoroquinolone resistance-associated mutations. The most common combination of mutations was A2072G (23S rRNA) and S83I (parC) (40/67, 59.7%). One sample had three amino acid changes in 23S rRNA, gyrA and parC genes (A2072G + A96T + S83I).

Conclusions

The high antimicrobial resistance rate of M. genitalium in Guangzhou is a very worrying problem and suggests that antimicrobial resistance testing and the development of new antibiotic regimens are crucially needed.

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.

Mycoplasma and Ureaplasma carriage in pregnant women: the prevalence of transmission from mother to newborn

Background

Mycoplasma and Ureaplasma have been extensively studied for their possible impact on pregnancy, and their involvement in newborn diseases. This work examined Mycoplasma and Ureaplasma carriage among gravidas women and newborns in Israel, as well as associations between carriage and demographic characteristics, risk factors, pregnancy outcomes, and newborn morbidity rates.

Methods

A total of 214 gravidas women were examined for vaginal pathogen carriage through standard culture and polymerase chain reaction assay. Pharyngeal swabs were collected from newborns of carrier mothers. Clinical and demographic data were collected and infected newborn mortality was monitored for 6 months.

Results

Nineteen mothers were carriers, with highest prevalence among younger women. Pathogen carriage rates were 2.32% for Mycoplasma genitalium (Mg), 4.19% for Ureaplasma parvum (Up) and 2.32% for Ureaplasma urealyticum (Uu). Arab ethnicity was a statistically significant risk factor (p = 0.002). A higher prevalence was seen among women residing in cities as compared to villages. Thirteen (68%) newborns born to carrier mothers were carriers as well, with a higher prevalence among newborns of women delivering for the first time, compared to women that had delivered before. Infection rates among newborns were 20% for Mg (p = 0.238), 100% for Up (p < 0.01), and 28.5% for Uu (p = 0.058), with more male than female newborns being infected. No association was found between maternal carriage and newborn morbidity.

Conclusions

Maternal Mycoplasma or Ureaplasma carriage may be associated with ethnicity and settlement type. Further studies will be needed to identify factors underlying these associations and their implications on delivery.

Epidemiology of genital infections caused by Mycoplasma hominis, M. genitalium and Ureaplasma urealyticum in Iran; a systematic review and meta-analysis study (2000-2019)

BACKGROUND

Although many species of mycoplasmas regard as normal flora, but some species causes serious genital disease. In Iran several epidemiological studies have documented the prevalence of Mycoplasma hominis, M. genitalium and Ureaplasma urealyticum in genital disorders. This meta-analysis is going to represent the prevalence of M. hominis, M. genitalium and U. urealyticum among Iranian couples and the correlation between mycoplasmas infection and infertility.

METHODS

We search online databases from January 2000 to June 2019. We used following MeSH keywords (Prevalence, M. hominis, M. genitalium, U. urealyticum, male, female, fertility, Infertility, genitourinary tract infection and Iran) with all possible combinations with "OR" and "AND". Finally, forty-four articles from 2670 were chosen for data extraction and analysis by software using STATA version 14.0.

RESULTS

This meta-analysis revealed that the prevalence of U. urealyticum was 17.53% in Iran and the prevalence of M. genitalium and M. hominis were 11.33 and 9.68% respectively. The rate of M. genitalium, M. hominis and U. urealyticum infection in women with symptoms of genitourinary tract infection was higher than men with genitourinary tract infection (6.46% vs 5.4, 7.67% vs 5.88 and 21.04% vs 12.13%, respectively). As expected, the prevalence of M. genitalium, U. urealyticum and M. hominis among infertile women (12.73, 19.58 and 10.81%) were higher than fertile women (3%, 10. 85% and 4. 35%). Similarly, the prevalence of M. hominis and U. urealyticum among infertile men (14 and 21.18%) were higher than fertile men (4 and 3%). Based on this analysis, the rate of U. urealyticum was higher than M. genitalium and M. hominis among infertile men and women compared to the fertile group. The prevalence rate of M. genitalium, M. hominis and U. urealyticum in central provinces is higher than other parts of Iran.

CONCLUSIONS

This meta-analysis reemphasizes a significant relationship between the infertility rate and U. urealyticum, M. genitalium and M. hominis infections. Our finding help to plan the prevalence map of M. hominis, M. genitalium and U. urealyticum in Iran but further studies are needed to suggest routine screening of the pathogens.

Mycoplasma genitalium Detection in Urogenital Specimens from Symptomatic and Asymptomatic Men and Women by Use of the cobas TV/MG Test

Mycoplasma genitalium (MG) infections are a growing concern within the field of sexually transmitted infections. However, diagnostic assays for M. genitalium have been limited in the United States. As most infections are asymptomatic, individuals can unknowingly pass the infection on, and the prevalence is likely to be underestimated. Diagnosis of M. genitalium infection is recommended using a nucleic acid test. This multicenter study assessed the performance of the cobas Trichomonas vaginalis (TV)/MG assay (cobas) for the detection of M. genitalium, using 22,150 urogenital specimens from both symptomatic and asymptomatic men and women collected at geographically diverse sites across the United States.

Mycoplasma genitalium (MG) infections are a growing concern within the field of sexually transmitted infections. However, diagnostic assays for M. genitalium have been limited in the United States. As most infections are asymptomatic, individuals can unknowingly pass the infection on, and the prevalence is likely to be underestimated. Diagnosis of M. genitalium infection is recommended using a nucleic acid test. This multicenter study assessed the performance of the cobas Trichomonas vaginalis (TV)/MG assay (cobas) for the detection of M. genitalium, using 22,150 urogenital specimens from both symptomatic and asymptomatic men and women collected at geographically diverse sites across the United States. The performance was compared to a reference standard of three laboratory-developed tests (LDTs). The specificity of the cobas assay for M. genitalium ranged from 96.0% to 99.8% across symptomatic and asymptomatic men and women. The sensitivities in female vaginal swabs and urine samples were 96.6% (95% confidence interval [CI], 88.5 to 99.1%) and 86.4% (95% CI, 75.5 to 93.0%), respectively. The sensitivities in male urine and meatal swab samples were 100% (95% CI, 94.0 to 100%) and 85.0% (95% CI, 73.9 to 91.9%), respectively. This study demonstrated that the cobas assay was highly sensitive and specific in all relevant clinical samples for the detection of M. genitalium.

Antibodies Against Chlamydia trachomatis and Ovarian Cancer Risk in Two Independent Populations

BACKGROUND

Pelvic inflammatory disease (PID) has been associated with ovarian cancer risk. To clarify the role of Chlamydia trachomatis and other infectious agents in the development of ovarian cancer, we evaluated the association of serologic markers with incident ovarian cancer using a staged approach in two independent populations.

METHODS

Studies included: 1) a case-control study in Poland (244 ovarian cancers/556 control subjects) and 2) a prospective nested case-control study in the PLCO Cancer Screening Trial (160 ovarian cancers/159 control subjects). Associations of serologic marker levels with ovarian cancer risk at diagnostic as well as higher thresholds, identified in Poland and independently evaluated in PLCO, were estimated using multivariable adjusted logistic regression.

RESULTS

In the Polish study, antibodies (based on laboratory cut-point) against the chlamydia plasmid-encoded Pgp3 protein (serological gold standard) were associated with increased ovarian cancer risk (adjusted odds ratio [OR] = 1.63, 95% confidence interval [CI] = 1.20 to 2.22); when a positive result was redefined at higher levels, ovarian cancer risk was increased (cut-point 2: OR = 2.00, 95% CI = 1.38 to 2.89; cut-point 3 [max OR]: OR = 2.19, 95% CI = 1.29 to 3.73). In the prospective PLCO study, Pgp3 antibodies were associated with elevated risk at the laboratory cut-point (OR = 1.43, 95% CI = 0.78 to 2.63) and more stringent cut-points (cut-point 2: OR = 2.25, 95% CI = 1.07 to 4.71); cut-point 3: OR = 2.53, 95% CI = 0.63 to 10.08). In both studies, antibodies against other infectious agents measured were not associated with risk.

CONCLUSIONS

In two independent populations, antibodies against prior/current C. trachomatis (Pgp3) were associated with a doubling in ovarian cancer risk, whereas markers of other infectious agents were unrelated. These findings lend support for an association between PID and ovarian cancer.

A profile of the cobas® TV/ MG test for the detection of Trichomonas vaginalis and Mycoplasma genitalium

Introduction: Trichomonas vaginalis and Mycoplasma genitalium are highly prevalent sexually transmitted pathogens that may be asymptomatic or may cause cervicitis and pelvic inflammatory disease in women and urethritis in men. Our limited understanding of the epidemiology of these infections has been hampered by a lack of diagnostic capacity, but the new cobas® TV/MG assay runs on the cobas® 6800/8800 platform offers a solution to this gap in our current diagnostic capacity.Areas covered: This article will describe what we know about the epidemiology and impact of untreated infections with these organisms as well as current recommendations for testing. The features and performance of the cobas 6800/8800 and the TV/MG assay will be described based on the emerging data related to this assay.Expert commentary: Molecular diagnostics for trichomonas and mycoplasma that can be performed on a high-throughput system with the flexibility to order only those tests required are needed in order to reduce the burden of disease and of consequences of undiagnosed infections caused by these pathogens. As a result of the complexities in the needs for testing in different populations, sample-specific flexibility in test ordering is an absolute need in the molecular laboratory.

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.

Molecular Testing for Mycoplasma genitalium in the United States: Results from the AMES Prospective Multicenter Clinical Study

A prospective multicenter clinical study involving subjects from 21 sites across the United States was conducted to validate the performance of a new in vitro diagnostic nucleic acid amplification test (NAAT) for the detection of Mycoplasma genitalium.

A prospective multicenter clinical study involving subjects from 21 sites across the United States was conducted to validate the performance of a new in vitro diagnostic nucleic acid amplification test (NAAT) for the detection of Mycoplasma genitalium. Seven urogenital specimen types (n = 11,556) obtained from 1,778 females, aged 15 to 74 years, and 1,583 males, aged 16 to 82 years, were tested with the Aptima Mycoplasma genitalium assay, an investigational transcription-mediated amplification (TMA) NAAT for the detection of M. genitalium 16S rRNA. Infected status for enrolled subjects was established using results obtained from testing either self-collected vaginal swab or clinician-collected male urethral swab specimens with a composite reference method consisting of three transcription-mediated amplification NAATs targeting unique regions of M. genitalium 16S or 23S rRNA. M. genitalium prevalence was 10.2% in females and 10.6% in males; prevalence was high in both symptomatic and asymptomatic subjects for both sexes. Compared to the subject infected status standard, the investigational test had sensitivity and specificity estimates, respectively, of 98.9% and 98.5% for subject-collected vaginal swabs, 92.0% and 98.0% for clinician-collected vaginal swabs, 81.5% and 98.3% for endocervical swabs, 77.8% and 99.0% for female urine, and 98.2% and 99.6% for male urethral swabs, 88.4% and 97.8% for self-collected penile meatal swabs, and 90.9% and 99.4% for male urine specimens. For all seven specimen types, within-specimen positive and negative agreements between the investigational test and the composite reference standard ranged from 94.2% to 98.3% and from 98.5 to 99.9%, respectively. These results provide clinical efficacy evidence for the first FDA-cleared NAAT for M. genitalium detection in the United States.

Prevalence of Mycoplasma genitalium and Azithromycin-resistant Infections Among Remnant Clinical Specimens, Los Angeles

BACKGROUND

Mycoplasma genitalium is an important cause of bacterial sexually transmitted diseases. Diagnosis and susceptibility testing of M. genitalium are limited by the fastidious nature of the organism. Therefore, the prevalence of infection and azithromycin resistance are poorly studied.

METHODS

We conducted an exploratory study on remnant clinical specimens. We collected remnant DNA from consecutive urine samples and clinical swabs (cervical/vaginal, rectal, and pharyngeal) previously tested for Neisseria gonorrhoeae and Chlamydia trachomatis using the Cobas 4800 CT/NG assay (Roche Molecular Systems, Pleasanton, CA) between March-April 2017 from across the University of California, Los Angeles Health System. We then retrospectively tested all specimens with the ResistancePlus MG (550) kit, a molecular assay for the detection of M. genitalium and genetic mutations associated with azithromycin resistance.

RESULTS

Among 500 specimens, the prevalence of M. genitalium was 1.1% (95% confidence interval [CI], 0.04%-3.0%) in urine samples (n = 362), 17.4% (95% CI, 5.7%-39.6%) in rectal swabs (n = 23), and 1.9% (95% CI, 0.3%-7.3%) in cervical/vaginal swabs (n = 106). The prevalence of N. gonorrhoeae was 0.6% in urine samples and 4.3% in rectal swabs, whereas the prevalence of C. trachomatis was 2.2% in urine samples, 4.3% in rectal swabs and 3.8% in cervical/vaginal swabs. Of the 10 M. genitalium positive specimens, 8 (80.0%) had a mutation associated with azithromycin resistance.

CONCLUSIONS

The prevalence of M. genitalium infection in our population varied by anatomic site of infection. Most M. genitalium infections had at least 1 mutation associated with azithromycin resistance.

Mycoplasma genitalium, a stealth female reproductive tract

Mycoplasma genitalium was first isolated from the urethral swabs of two symptomatic men with urethritis in 1980. It is a sexually transmitted bacterium associated with a number of urogenital conditions in women like cervicitis, endometritis, pelvic inflammatory disease, infertility, and susceptibility to human immunodeficiency virus (HIV). However, M. genitalium may also act like a stealth pathogen at female reproductive tract, giving no symptoms. Its prevalence varies between different groups, with the average being 0.5-10% in the general population and 20-40% in women with sexually transmitted infections. The recommended treatment of this infection is azithromycin as a single 1-g dose. However, in recent years, macrolide resistance has increased which is significantly lowering the cure rate, being less than 50% in some studies. New treatment regimens need to be investigated due to increasing drug resistance. The discussion and suggestion of an algorithm for management of this infection is the highlight of this paper.

Current status of countermeasures for infectious diseases and resistant microbes in the field of urology

A worldwide increase in antimicrobial-resistant microbes due to the improper use of antimicrobial agents, along with a lack of progress in developing new antimicrobials, is becoming a societal problem. Although carbapenem-resistant Enterobacteriaceae, which are resistant to carbapenem antimicrobials, first appeared in 1993, treatment options remain limited. Mechanisms behind antimicrobial resistance involve changes to microbial outer membranes, drug efflux pump abnormalities, β-lactamase production and the creation of biofilms around cell bodies. Genetic information related to these forms of antimicrobial resistance exists on chromosomes and plasmids, and when located on the latter can easily be transmitted to other strains, no matter the species, which creates a risk of antimicrobial resistance spreading exceptionally rapidly. To prevent the spread of antimicrobial resistance, the World Health Organization in 2015 published an action plan on antimicrobial resistance, based on which World Health Organization member countries have laid out specific policies and targets. Urinary tract infections are a type of healthcare-associated infection, and the sexually transmitted disease pathogen, Neisseria gonorrhoeae, has been included in a list of microbes that pose a risk to human health published by the US Centers for Disease Control and Prevention. Urologists face numerous problems when attempting to use antimicrobials properly, which is one method of dealing with antimicrobial resistance. Therefore, this article describes the current state of resistant microbes associated with urinary tract infections and countermeasures for antimicrobial resistance, including new antimicrobials.

Design and Validation of Transcription-Mediated-Amplification Nucleic Acid Amplification Tests for Mycoplasma genitalium

Mycoplasma genitalium is a sexually transmitted bacterium linked to adverse sexual and reproductive health outcomes in women and men. M. genitalium is difficult to culture, and in the absence of validated amplified molecular methods for diagnosis of infection, there is no reference standard available for use as a comparator for the validation of new M. genitalium diagnostic tests. We evaluated the analytical and clinical performance of three transcription-mediated amplification (TMA) tests for M. genitalium, each targeting unique rRNA sequences, for use as a composite comparator for clinical validation of the Aptima Mycoplasma genitalium (AMG) assay, an in vitro diagnostic (IVD) TMA test that targets 16 s rRNA of M. genitalium Analytical sensitivity, specificity, and strain inclusivity of all four TMA tests were determined using nine laboratory strains of M. genitalium and 56 nontarget bacteria, protozoa, and viruses. Analytical sensitivity of the tests for M. genitalium ranged from 0.017 to 0.040 genome equivalents/ml. None of the nontarget organisms evaluated cross-reacted with any test. A composite comparator reference standard consisting of the 3 alternate (Alt) TMA tests was used to evaluate the clinical performance of the AMG assay by testing residual vaginal swab, female urine, and male urine specimens obtained from 1,400 adult subjects from three U.S. clinical sites. Using this reference standard to establish infected specimen status, the sensitivity, specificity, and overall agreement of the AMG IVD assay were 100%, 99.9%, and 99.9%, respectively. These results demonstrate the utility of molecular composite reference standard methodology for the clinical validation of future IVD tests for this organism.

British Association for Sexual Health and HIV national guideline for the management of infection with Mycoplasma genitalium (2018)

This is the first British Association for Sexual Health and HIV (BASHH) guideline for the diagnosis and management of Mycoplasma genitalium in people aged 16 years and older. The guideline is primarily aimed at level 3 sexually transmitted infection (STI) management services within the UK, although it could also serve as a reference guide for STI services at other levels.

Does the Sex Risk Quiz Predict Mycoplasma genitalium Infection in Urban Adolescents and Young Adult Women?

BACKGROUND

Mycoplasma genitalium (MG) is a common sexually transmitted infection (STI), but there are limited strategies to identify individuals at risk of MG. Previously, a sex risk quiz was used to predict STIs including Chlamydia trachomatis, Neisseria gonorrhoeae, and/or Trichomonas vaginalis. The original quiz categorized individuals 25 years or younger as at risk of STIs, but the Centers for Disease Control and Prevention identifies females younger than 25 years as at risk of STIs. In this study, the quiz was changed to categorize females younger than 25 years as high risk. The objective was to determine if the age-modified risk quiz predicted MG infection.

METHODS

A cross-sectional analysis of a prospective longitudinal study was performed including female adolescents and young adults (AYAs) evaluated in multiple outpatient clinics. Participants completed an age-modified risk quiz about sexual practices. Scores ranged from 0 to 10 and were categorized as low risk (0-3), medium risk (4-7), and high risk (8-10) based on the STI prevalence for each score. Vaginal and/or endocervical and/or urine specimens were tested for MG, T. vaginalis, C. trachomatis, and N. gonorrhoeae using the Aptima Gen-Probe nucleic amplification test.

RESULTS

There were 693 participants. Most participants reported having 0 to 1 sexual partners in the last 90 days (91%) and inconsistent condom use (84%). Multivariable logistic regression analysis controlling for race, education, and symptom status demonstrated that a medium-risk score predicted MG infection among AYAs younger than 25 years (adjusted odds ratio, 2.56 [95% confidence interval, 1.06-6.18]).

CONCLUSION

A risk quiz may be useful during clinical encounters to identify AYA at risk of MG.