Prevalence of Mycoplasma genitalium by anatomical site in men who have sex with men: a systematic review and meta-analysis

OBJECTIVE

To systematically review and appraise published data, to determine the prevalence of Mycoplasma genitalium (MG) in men who have sex with men (MSM) tested at each anatomical site, that is, at the urethra, rectum and/or pharynx.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Ovid Medline, PubMed, Embase were searched for articles from 1st January 1981 (the year MG was first identified) to 1st June 2018.

REVIEW METHODS

Studies were eligible for inclusion if they reported MG prevalence in MSM tested at the urethra, rectum and/or pharynx, in at least 50 MSM, using nucleic acid amplification testing. Data were extracted by anatomical site, symptom and HIV status. Summary estimates (95% CIs) were calculated using random-effects meta-analysis. Subgroup analyses were performed to assess heterogeneity between studies.

RESULTS

Forty-six studies met inclusion criteria, with 34 reporting estimates of MG prevalence at the urethra (13 753 samples), 25 at the rectum (8629 samples) and 7 at the pharynx (1871 samples). MG prevalence was 5.0% (95% CI 3.5 to 6.8; I²=94.0) at the urethra; 6.2% (95% CI 4.6 to 8.1; I²=88.1) at the rectum and 1.0% (95% CI 0.0 to 5.1; I²=96.0) at the pharynx. The prevalence of MG was significantly higher at urethral and rectal sites in symptomatic versus asymptomatic MSM (7.1% vs 2.2%, p<0.001; and 16.1% vs 7.5%, p=0.039, respectively). MG prevalence at the urethra was significantly higher in HIV-positive compared with HIV-negative MSM (7.0% vs 3.4%, p=0.006).

CONCLUSION

MG was common in MSM, particularly at urethral and rectal sites (5% to 6%). MG was more commonly detected in symptomatic men at both sites, and more common in HIV-positive men at the urethra. MG was uncommonly detected in the pharynx. Site-specific estimates are similar to those for chlamydia and will be helpful in informing testing practices in MSM.

PROSPERO REGISTRATION NUMBER

CRD42017058326.

Extragenital Mycoplasma genitalium infections among men who have sex with men

OBJECTIVES

There are limited data on the prevalence of Mycoplasma genitalium (Mgen) coinfection with rectal chlamydia (Chlamydia trachomatis (CT)) and rectal gonorrhoea (Neisseria gonorrhoeae (NG)) infections and few studies examining the prevalence of pharyngeal Mgen in men who have sex with men (MSM). Using transcription-mediated amplification assay, this study aimed to determine the proportion of rectal CT and rectal NG infections in MSM who are coinfected with rectal Mgen, and the proportion of MSM with Mgen detected in the pharynx in order to inform clinical practice.

METHODS

This was a cross-sectional study conducted at Melbourne Sexual Health Centre in Australia. Consecutively collected rectal swabs from MSM that tested positive for CT (n=212) or NG (n=212), and consecutively collected pharyngeal samples (n=480) from MSM were tested for Mgen using the Aptima Mycoplasma genitalium Assay (Hologic, San Diego). Samples were linked to demographic data and symptom status.

RESULTS

Rectal Mgen was codetected in 27 of 212 rectal CT (13%, 95% CI 9 to 18) and in 29 of 212 rectal NG (14%, 95% CI 9 to 19) samples, with no difference in the proportion positive for Mgen. MSM with rectal CT/Mgen coinfection had more sexual partners than those with rectal CT monoinfection (mean 6 vs 11, p=0.06). MSM with rectal NG/Mgen coinfection were more likely to be HIV-positive than those with rectal NG monoinfection (OR=2.96, 95% CI 1.21 to 7.26, p=0.023). MSM with rectal CT/Mgen coinfection were more likely to be using pre-exposure prophylaxis than MSM with rectal NG/Mgen coinfection (OR 0.25, 95% CI 0.10 to 0.65, p=0.002). Pharyngeal Mgen was uncommon and detected in 8 of 464 samples (2%, 95% CI 1% to 3%). Pharyngeal Mgen was associated with having a rectal STI (OR=10.61, 95% CI 2.30 to 48.87, p=0.002), and there was a borderline association with being HIV-positive (p=0.079).

CONCLUSION

These data indicate one in seven MSM treated for rectal CT or rectal NG will have undiagnosed Mgen that is potentially exposed to azithromycin during treatment of these STIs. Rectal Mgen coinfection was associated with specific risk factors which may inform testing practices. Pharyngeal Mgen was uncommon.

Saliva use in sex: Associations with use of smartphone dating applications in men who have sex with men

Smartphone dating applications have become a primary source for men who have sex with men (MSM) to meet sexual partners. It has been found that MSM who used smartphone dating applications are at higher risk of gonorrhoea, but the reasons remain unknown. This study aimed to investigate whether MSM who met their partners via smartphone dating applications are more likely to engage in sexual practices such as rimming (oro-anal sex), and use of partner's saliva as a lubricant, that are associated with the risk of gonorrhoea. A cross-sectional study was conducted among 1672 MSM attending the Melbourne Sexual Health Centre, Australia, between 31 July 2014 and 30 June 2015. Multivariate logistic regression was conducted to examine the associations between sources of meeting partners and the two aforementioned sexual practices. MSM who used smartphone dating applications were 1.78 (95% CI: 1.38-2.28) times more likely to get rimmed, and 1.63 (95% CI: 1.27-2.09) times more likely to use partner's saliva as a lubricant during anal sex, compared to other sources, after adjusting for age and other sources for meeting partners. These practices are highly associated with gonorrhoea.

Incidence of renal Fanconi syndrome in patients taking antiretroviral therapy including tenofovir disoproxil fumarate

The objective of this study was to determine the incidence and predictors of Fanconi Syndrome (FS) in a cohort of patients taking tenofovir disoproxil fumarate (TDF). Clinical records and laboratory investigations from patients receiving TDF between 2002 and 2016 were extracted. FS was defined as normoglycaemic glycosuria and proteinuria and at least one other marker of renal dysfunction. Regression analysis was performed with time to development of FS and the following covariates: ritonavir co-administration, age, gender, co-morbidities (hypertension, hyperlipidaemia, diabetes, viral hepatitis), CD4 cell count nadir and baseline eGFR. One thousand and forty-four patients received TDF without ritonavir and 398 patients with ritonavir. Thirteen cases of FS were identified with a mean duration of exposure of 55 months. The incidence of FS was 1.09/1000PY (0.54-1.63) of TDF exposure (without ritonavir) and 5.50/1000PY (3.66-7.33) of TDF-ritonavir co-administration (p=0.0057). The adjusted hazards ratio for ritonavir co-administration was 4.71 (1.37-16.14, p=0.014). Known risk factors for chronic kidney disease were not associated with development of FS. Ritonavir co-administration, but not other factors, is associated with a greater risk of FS. FS developed late. Known risk factors for chronic kidney disease and length of treatment are not useful for identifying patients most at risk of developing FS in patients taking TDF.

Decline in in-patient treatments of genital warts among young Australians following the national HPV vaccination program

BACKGROUND

There has been a rapid decline in the number of young heterosexuals diagnosed with genital warts at outpatient sexual health services since the national human papillomavirus (HPV) vaccination program started in Australia in 2007. We assessed the impact of the vaccination program on the number of in-patient treatments for genital warts.

METHODS

Data on in-patient treatments of genital warts in all private hospitals were extracted from the Medicare website. Medicare is the universal health insurance scheme of Australia. In the vaccine period (2007-2011) and pre-vaccine period (2000-2007) we calculated the percentage change in treatment numbers and trends in annual treatment rates in private hospitals. Australian population data were used to calculate rates. Summary rate ratios of average annual trends were determined.

RESULTS

Between 2000 and 2011, 6,014 women and 936 men aged 15-44 years underwent in-patient treatment for genital warts in private hospitals. In 15-24 year old women, there was a significant decreasing trend in annual treatment rates of vulval/vaginal warts in the vaccine period (overall decrease of 85.3% in treatment numbers from 2007 to 2011) compared to no significant trend in the pre-vaccine period (summary rate ratio (SRR) = 0.33, p < 0.001). In 25-34 year old women, declining trends were seen in both vaccine and pre-vaccine periods (overall decrease of 33% vs. 24.3%), but the rate of change was greater in the vaccine period (SRR = 0.60, p < 0.001). In 35-44 year old women, there was no significant change in both periods (SRR = 0.91, p = 0.14). In 15-24 year old men, there was a significant decreasing trend in annual treatment rates of penile warts in the vaccine period (decrease of 70.6%) compared to an increasing trend in the pre-vaccine period (SRR = 0.76, p = 0.02). In 25-34 year old men there was a significant decreasing trend in the vaccine period compared to no change in the pre-vaccine period (SRR = 0.81, p = 0.04) and in 35-44 year old men there was no significant change in rates of penile warts both periods, but the rate of change was greater in the vaccine period (SRR = 0.70, p = 0.02).

CONCLUSIONS

The marked decline in in-patient treatment of vulval/vaginal warts in the youngest women is probably attributable to the HPV vaccine program. The moderate decline in in-patient treatments for penile warts in men probably reflects herd immunity.

Correlations between leukocyte count and absolute granulocyte count in patients receiving cancer chemotherapy

The absolute granulocyte count (AGC) has been considered the best index for estimating the risk of infection in patients receiving myelosuppressive therapy. However, many investigators and cooperative oncology groups use the leukocyte count and extrapolate concurrent AGC values from an arbitrary conversion scale. Our review of the literature revealed no analysis of the relationship between the leukocyte count and the AGC in patients receiving cancer chemotherapy. It also failed to provide a method for converting toxicity criteria from one scale to the other. To explore the possible relationship of the leukocyte count to the AGC, we have completed a retrospective analysis of leukocyte count and accompanying AGC in patients receiving cancer chemotherapy. The leukocyte count and the AGC are shown to be linearly related over the entire population, enabling predictable cross-indexing from leukocyte count to AGC by the use of the formula: AGC = -0.7 + 0.8 (leukocyte count). This provides a rational basis for the development of guidelines for drug dosing and toxicity. In the patient group with leukocyte count less than or equal to 4500, however, the magnitude of random variability decreased predictive ability. Numerous patients in this group received differing toxicity scale scores when classified according to the Eastern Cooperative Oncology Group (ECOG) scales for AGC and leukocyte count. In some cases, as much as 46% disagreement occurred. New toxicity scales for AGC and leukocyte count, which were developed based upon the linear relationship above, reduced this disagreement substantially. These scales result in a greater agreement of toxicity ratings, and may provide a more accurate method of classifying toxicity and regulating dosages of chemotherapeutic agents.

The predictive value of the serum digoxin concentration in the management of hospitalized patients

Serum digoxin concentration (SDC) was compared with clinical and ancillary predictors as a guide to adjustment of digoxin dose and as a test for digitalis toxicity in a total of 76 hospitalized patients during a period of 9 months. The mean SDC (3.6 +/- 2.5 nmoles/liter) associated with unexpected discontinuation of therapy was significantly higher (p less than 0.001) than that (1.1 +/- 0.6 nmoles/liter) associated with unaltered digoxin dose, while the mean SDC (0.6 +/- 0.4 nmole/liter) associated with unexpected dose increase was significantly lower (p less than 0.05). There was no significant association between other pharmacokinetic or pharmacodynamic predictors and therapeutic intention. There was a 13% incidence of confirmed digitalis intoxication. The mean SDC (3.6 +/- 1.9 nmoles/liter) of patients presenting and confirmed as digitalis toxic was significantly higher (p less than 0.001) than that (1.4 +/- 0.6 nmoles/liter) involving a situation in which digitalis toxicity could not initially be excluded by other means. The predictive value of an SDC greater than or equal to 2.6 nmoles/liter for toxicity was 80%, and its efficiency for diagnosing both toxicity and nontoxicity was 95%. The SDC was thus shown to be a valid test of digitalis toxicity and to provide extraordinary information enabling the clinician to modulate digoxin therapy precisely.

Fractionated dose cholecystography: a comparison between iopanoic acid and sodium ipodate

Two randomised groups of 100 subjects each, undergoing oral cholecystography, were given either a 6 g fractionated dose of iopanoic acid (Telepaque) or sodium ipodate (Biloptin) to determine the relative merits of this dose schedule. Exclusions to the study were pregnancy and iodine sensitivity. Calculi or abnormal gallbladder opacification were present in 45% of subjects. Both agents were equally effective in demonstrating abnormalities, although bile duct visualisation was better using iopanoic acid (P less than 0.05). Of 46 subjects with abnormal cholecystograms subsequently undergoing surgery, all had the diagnosis confirmed. Side effects occurred in 63% of all subjects, being twice as common in those taking iopanoic acid (P less than 0.01). Sodium ipodate in a large fractionated dose is favoured because of the lower occurrence of side effects without loss of diagnostic accuracy.

Survey of cardiac failure therapy in Australian medical practice: dependence on digoxin level for diagnosis of toxicity

A questionnaire was mailed to 3000 medical practitioners throughout Australia to assess attitudes to cardiac failure therapy. The proportion of responses suitable for analysis was 31%. There was a preference for initiating treatment with a diuretic rather than digoxin and for commencing digoxin in daily maintenance dosage rather than with a loading dose. Two-thirds of the doctors surveyed regulated glycoside therapy by monitoring blood digoxin levels. The answer pattern suggested digoxin level measurement had influenced diagnosis of toxicity.

Thyroid, renal, and hepatic function tests following cholecystography with high-dose contrast agents

Serum biochemical tests were observed for about three weeks following oral cholecystography with fractionated high doses (6 g) of iopanoic acid (Telepaque) or sodium ipodate (Biloptin) in 24 and 29 patients, respectively. Both agents produced similar effects. No significant changes were seen in renal or hepatic function except for a mild increase in bilirubin on day 22. Serum urate decreased 10% on day 4, but the change was not significant. On days 4 and 11, there were significant increases in thyroid-stimulating hormone, thyroxine and free thyroxine index, and a moderate fall in triiodothyronine. Reverse triiodothyronine increased sharply on day 4. The pattern of changes observed suggests that these contrasts interfere with the extrathyroidal deiodination of iodothyronines. The temporary rise in thyroxine and free thyroxine index exceeded reference ranges in about half of all subjects, but they remained clinically euthyroid. Thyroid function tests should be interpreted with caution within three weeks of cholecystography.