Chlamydia trachomatis and Neisseria gonorrhoeae infection and the sexual behaviour of men who have sex with men

BACKGROUND

Rates of bacterial sexually transmitted infections (STIs) continue to rise among men who have sex with men (MSM) in the UK.

OBJECTIVE

To evaluate factors associated with Chlamydia trachomatis and Neisseria gonorrhoeae among MSM attending a genitourinary medicine clinic in inner London.

STUDY DESIGN

599 MSM undergoing testing for STIs were recruited. Specimens for ligase chain reaction (LCR), strand displacement amplification (SDA) assay and culture were collected from the pharynx, urethra and rectum for the detection of C trachomatis and N gonorrhoeae. Details regarding demographics, symptoms, signs and sexual behaviour were recorded. Associations of these factors with each infection were tested, adjusting for other risk factors.

RESULTS

The prevalence of C trachomatis and N gonorrhoeae was 11.0% and 16.0%, respectively. LCR and SDA performed well for the detection of C trachomatis and N gonorrhoeae from urethra and rectum. Using either method, compared with our current testing policy, over 18% of those with C trachomatis and N gonorrhoeae would not have had their infection diagnosed or treated. Age, sexual behaviour, urethral and rectal symptoms and signs were strongly associated with both infections. A total of 33.7% of men reported at least one episode of unprotected anal intercourse in the previous month. Men reporting multiple episodes were markedly more likely to be HIV positive.

CONCLUSION

The prevalence of infection, rates of partner acquisition and unprotected anal intercourse reported among these MSM are alarming. Improved detection of C trachomatis and N gonorrhoeae using nucleic acid amplification tests has major public health implications for STI and possibly HIV transmission in this population.

Could epithelial ovarian cancer be associated with chlamydial infection?

PURPOSE OF INVESTIGATION

Epithelial ovarian cancer (EOC) is the leading cause of death from gynaecological malignancy in the UK. The pathogenesis of this disease is poorly understood. Our hypothesis was that chlamydial infection might play a role in the pathogenesis of EOC.

METHODS

122 serum samples of patients undergoing surgery for benign or malignant gynaecological conditions were analysed. There was a total of 41 patients with EOC (33.6%), 27 with benign cystadenomas (22.1%) and 54 with normal ovaries (44.3%).

RESULTS

There was a higher incidence of IgA seropositivity and lower incidence of IgG seropositivity in the EOC group compared with the other groups; however, this was not statistically significant. There was no statistical difference in the serum IgM antibodies to chlamydia in the three different groups.

CONCLUSION

Although chronic infection and persistent inflammation may contribute to the pathogenesis of EOC, and chlamydia is a common genital tract pathogen, our study did not find an association between chlamydia and EOC.

Factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises

The epidemics of severe acute respiratory syndrome (SARS) in 2003 highlighted both short- and long-range transmission routes, i.e. between infected patients and healthcare workers, and between distant locations. With other infections such as tuberculosis, measles and chickenpox, the concept of aerosol transmission is so well accepted that isolation of such patients is the norm. With current concerns about a possible approaching influenza pandemic, the control of transmission via infectious air has become more important. Therefore, the aim of this review is to describe the factors involved in: (1) the generation of an infectious aerosol, (2) the transmission of infectious droplets or droplet nuclei from this aerosol, and (3) the potential for inhalation of such droplets or droplet nuclei by a susceptible host. On this basis, recommendations are made to improve the control of aerosol-transmitted infections in hospitals as well as in the design and construction of future isolation facilities.

Reducing hospital-acquired infection by design: the new University College London Hospital

The planning and building of new University College London Hospital has provided a challenge to the Infection Control Team to ensure all areas are easy to clean, air flows are correct and appropriate and that there is every opportunity for handwashing. The seven year process illustrates the paper by Stockley et al. ['Stockley JM, Constantine CE, Orr KE, The Association of Medical Microbiologists' New Hospital Developments Project Group. Building new hospitals: a UK infection control perspective.

Gastrointestinal endoscopy decontamination failure and the risk of transmission of blood-borne viruses: a review

The risk of blood-borne virus transmission with an inadequately decontaminated endoscope during gastrointestinal endoscopy remains unclear, although it is likely to be low. A systematic review of the literature was undertaken to determine previous episodes of blood-borne virus transmission in these circumstances. In total, 31 articles were included in this review. No articles relating to possible transmission of human immunodeficiency virus were identified. The articles included were generally case series or case reports and were written prior to the comprehensive endoscope decontamination guidelines in use today. The results suggest that hepatitis B and hepatitis C transmission are low during endoscopy with an inadequately decontaminated endoscope.

Polymorph count for predicting non-gonococcal urethral infection: a model using Chlamydia trachomatis diagnosed by ligase chain reaction

BACKGROUND/OBJECTIVES

The criteria for the diagnosis of non-gonococcal urethritis (NGU) on a Gram stained urethral smear are derived from previous studies which used culture as a diagnostic test for Chlamydia trachomatis. Our objectives were (1). to re-assess the relation between urethral polymorph count and C trachomatis infection, using ligase chain reaction (LCR) as the diagnostic test; and (2). to assess other possible predictors of C trachomatis infection such as symptoms, signs, demographic and behavioural variables.

METHODS

We collected data from 363 men consecutively attending a genitourinary medicine clinic (excluding those with gonorrhoea and follow up visits) who had a urethral smear and a urethral LCR test for C trachomatis. The sensitivity and specificity of a discrete cut off in urethral polymorphonuclear leucocyte (PMNL) count as a diagnostic test for chlamydia urethritis were calculated. The associations between other variables, such as age and symptoms, and this infection were also estimated.

RESULTS

8% of men had C trachomatis infection and 26% of men had a PMNL count of 5 or more. Of those men with chlamydia 37% did not have NGU; 20% of men with NGU had chlamydia. Adjusted odds ratios for risk of chlamydial infection were significant for age less than 30 relative to 40 years and over (adj OR 13.6; 95% confidence interval 1.69 to 110), a PMNL count of 20 or more (6.56; 2.15 to 20.0), a PMNL count of 5-19 (3.59; 1.41 to 9.15), and the symptom of dysuria (3.27; 1.32 to 8.08). However a PMNL count of 5 or more was only 63% sensitive and 77% specific for C trachomatis infection. No association between sexual behaviour and chlamydial infection was found in this setting.

CONCLUSIONS

The PMNL count is associated with presence of chlamydial infection but a large proportion of men with chlamydia have PMNL counts below the recommended cut off for a diagnosis of NSU. Lower age and the presence of symptoms may be as predictive as the urethral polymorph count for chlamydial urethritis and possibly for other urethral infections.

Chlamydophila pneumoniae infection of the central nervous system in patients with multiple sclerosis

BACKGROUND

Chlamydophila pneumoniae has been postulated as an aetiological agent in the pathophysiology of multiple sclerosis. Previous studies show conflicting results.

OBJECTIVE

To investigate patients with multiple sclerosis and other neurological diseases for evidence of past or present infection with C pneumoniae.

METHODS

19 patients with multiple sclerosis and 29 with other neurological diseases were studied. Evidence was sought for past or present infection with C pneumoniae using polymerase chain reaction (PCR) and cell culture of cerebrospinal fluid (CSF), and enzyme linked immunosorbent assay and microimmunofluorescence of serum.

RESULTS

C pneumoniae was grown from the CSF of one patient with multiple sclerosis. PCR was negative in all cases. Anti-chlamydial antibodies were detected in the same proportion in each group.

CONCLUSIONS

This study does not support the theory of an association between C pneumoniae and multiple sclerosis.

Efficacy and safety of azithromycin as monotherapy or combined with metronidazole compared with two standard multidrug regimens for the treatment of acute pelvic inflammatory disease

The objective of the study was to compare the efficacy of azithromycin, alone or with metronidazole, versus two standard multidrug regimens for the treatment of acute pelvic inflammatory disease (PID). Patients with PID were treated with once-daily intravenous (i.v.) azithromycin 500 mg for 1 day or 2 days followed by once-daily azithromycin 250 mg orally for a total of 7 days, alone or with three-times-daily metronidazole 400 mg or 500 mg i.v. then orally for a total of 12-14 days. The comparators were either metronidazole + doxycycline + cefoxitin + probenecid or doxycycline + amoxycillin/clavulanate given at standard recommended doses for up to 21 days. In total, 309 patients were treated for PID. The diagnosis was confirmed laparoscopically in 74.8% of patients. Rates of clinical success for azithromycin, alone (97.1%) or with metronidazole (98.1%), were comparable to those for the comparator regimens (94.6%). Eradication rates for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma hominis and anaerobes were also comparable for each of the treatment groups. Both azithromycin regimens were well tolerated. In conclusion, azithromycin, alone or with metronidazole, provides a shorter, simpler treatment option for the successful management of acute PID.

Conjunctivitis due to Chlamydophila felis (Chlamydia psittaci feline pneumonitis agent) acquired from a cat: case report with molecular characterization of isolates from the patient and cat

Conjunctivitis due to Chlamydiaceae other than Chlamydia trachomatis is rarely reported because of infrequent occurrence or inadequate investigation. A case of chronic non-trachomatis chlamydial conjunctivitis is described. After full clinical information was supplied to the laboratory, a non-trachomatis chlamydia was recovered from the patient's eye. This organism, and a subsequent isolate from one of the patient's cats, were shown to be indistinguishable examples of the recently described species Chlamydophila felis. The infection was most likely acquired from the patient's cats. A prolonged course of doxycycline was required to eradicate the infection.

The human transmissible spongiform encephalopathies (TSEs): implications for dental practitioners

Transmissible spongiform encephalopathies (TSEs) are rare, fatal degenerative brain diseases which affect humans and certain animals, and are caused by inheritance or acquisition of prions (PrPs). Inherited TSEs include Fatal Familial Insomnia (FFI), Gerstmann-Straussler-Scheinker syndrome (GSS) and other less well clinically characterised disorders, while the human infective TSEs include sporadic, iatrogenic and variant Creutzfeldt-Jakob disease (vCJD). The causative prions are found especially in neural tissues and spinal fluid, and in the case of vCJD, in lymphoreticular tissue. Available epidemiological evidence suggests that normal social or routine clinical contact with affected patients does not present a risk to health care workers, relatives or the community. Isolation of patients is not considered necessary. Nevertheless as the prions are resistant to conventional chemical, irradiation and heat sterilisation methods, highly specific cross-infection control measures are required for the dental management of patients with, or at notable risk, of TSE. The present article reviews current knowledge of the clinical consequences of prion disease and provides information regarding necessary changes to the cross-infection routine when managing patients infected, or at risk of, prion disease.

Concurrent gonococcal and chlamydial infection: how best to treat

Clinicians treating concurrent gonococcal and chlamydial infections have a variety of drugs to choose from. Neisseria gonorrhoeae is adept at developing resistance and the choice of antibiotic must be dictated to some extent by the patterns of resistance in the locality of the clinician. In contrast, resistance of Chlamydia trachomatis to some classes of drugs has been shown in vitro but does not appear to be clinically important at present. The success of treatment depends on patient compliance with the drug administration schedule. With these organisms, which can be carried asymptomatically, many patients are unlikely to comply with courses of antibiotics. Although single-dose therapy with azithromycin is available and established for chlamydial genital infection, it is more expensive and difficult to justify in a cash limited Healthcare system, and its efficacy for treating concurrent gonococcal infection requires further study. In patients where compliance is likely to be of concern, its use may be justified. Another major deterrent for completing antibiotic courses is the adverse effect profile. Most of the available drugs cause only minor adverse effects, in particular gastrointestinal. Ofloxacin has a better profile than doxycycline but is considerably more expensive. Newer fluoroquinolones, found to be effective in vitro, are being assessed in clinical studies. However, more evidence is required before recommending these over the tried and tested therapies.

Quinolones in sexually transmitted diseases: state of the art

Progress in the development of fluoroquinolones for the treatment of sexually transmitted diseases has been slow. New compounds have appeared with good in vitro activity against the gonococcus, Chlamydia trachomatis and the genital mycoplasmas. However, there have been increasing reports of clinically relevant resistance by the gonococcus, and chlamydial and mycoplasmal resistance in vitro has been described. Formally reported treatment studies have not been forthcoming, despite an emerging role for the newer fluoroquinolones in the ambulatory treatment of pelvic inflammatory disease.

Evaluation of self-taken samples for the presence of genital Chlamydia trachomatis infection in women using the ligase chain reaction assay

The aim of this study was to evaluate the sensitivity and acceptability of self-taken vulval-introital (VI) samples, first-catch urine (FCU) samples and clinician-obtained cervical samples for the presence of genital Chlamydia trachomatis infections in women using the ligase chain reaction (LCR) assay. One hundred and four patients were enrolled, of whom 54 patients had chlamydial DNA in at least one of the samples tested. The sensitivity of the cervical sample was 96.3%, vulval-introital sample in LCR buffer 92.6%, vulval-introital swab collected dry 88.9%, FCU stored at +2-8 degrees C 81.5%, FCU stored at room temperature 77.8% and FCU stored with 2% w/v boric acid at room temperature 87.0%. Self-taken vulval-introital LCR samples were shown to be an acceptable alternative to a clinician-obtained LCR sample. The addition of boric acid may overcome the need for a continuous cold chain for FCU samples.

Evaluation of microbicidal activity of a new disinfectant: Sterilox 2500 against Clostridium difficile spores, Helicobacter pylori, vancomycin resistant Enterococcus species, Candida albicans and several Mycobacterium species

The microbicidal activity of a new disinfectant Sterilox, a super-oxidized water, containing a mixture of oxidizing substances, was tested against Clostridium difficile spores, Helicobacter pylori, vancomycin resistant Enterococcus species, Candida albicans and several Mycobacterium species using membrane filters. All tests were performed in duplicate with and without added horse serum at 1% and 5% v/v. Distilled water, 0.35% peracetic acid (Nu-Cidex) and 2% glutaraldehyde were included as controls. Sterilox: spore suspension (9:1 v/v) achieved log10 kill of > 5 with 5% horse serum in 2 min against H. pylori, vancomycin resistant Enterococcus species, C. albicans and four atypical Mycobacterium species: M. avium, M. chelonei, M. xenopi and M. smegmatis. Sporicidal activity of Sterilox against Clostridium difficile was markedly diminished in the presence of 5% horse serum. Sterilox may be an effective alternative in endoscopy units, as it is a potent microbicidal agent and the manufacturer claims it is not corrosive to metal and is nontoxic to biological tissues.

Sexually transmitted organisms in sexually abused children

OBJECTIVE

To establish the prevalence of sexually transmitted organisms and other genital organisms in potentially sexually abused children.

DESIGN

Prospective study of children attending an inner London department of community paediatrics for evaluation of possible sexual abuse.

SUBJECTS

Children under 16 referred for evaluation of possible sexual abuse.

OUTCOME MEASURES

Prevalence of sexually transmitted organisms in relation to age, symptoms, and type of abuse.

RESULTS

Swabs were taken from 159 of 242 girls evaluated. The overall prevalence of sexually transmitted organisms was 3.7%: three girls were infected with gonorrhoea, four with Trichomonas vaginalis, and two with Chlamydia trachomatis. One girl had all three infections plus mycoplasmas. Mycoplasmas were identified in 22% of girls swabbed. Of 30 boys swabbed, none yielded a sexually transmitted organism.

CONCLUSIONS

There is a low prevalence of definitely sexually transmitted organisms in children who might have been abused. Other organisms possibly associated with sexual activity can be identified in this population. Screening for infection should be mandatory in presumed sexually abused girls with vaginal discharge and ideally should be undertaken in all children attending for evaluation of sexual abuse.

The laboratory investigation of vaginal discharge

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The Vitek analyser for routine bacterial identification and susceptibility testing: protocols, problems, and pitfalls

Automated and semiautomated technology in microbiology has seen great advances in recent years. The choice of automated equipment for the identification and susceptibility testing of bacteria in a routine diagnostic laboratory depends on speed, accuracy, ease of use, and cost factors. The Vitek analyser (bioMerieux, UK) was installed in a busy diagnostic teaching hospital laboratory in London. This report describes one year's experience. Changes to work practice as a result of incorporating the equipment into the laboratory, and the advantages and disadvantages of automation in key areas are described in detail, together with possible solutions to problems. The Vitek analyser was found to be valuable for the speed and accuracy with which results were available for the common bacterial pathogens. Results of susceptibility testing were standardised according to NCCLS guidelines and used breakpoint MICs to ascertain susceptibility and resistance; they were an improvement on disc testing. This equipment is not a reference facility for difficult to identify organisms and many manual techniques, including some disc susceptibility testing, will have to be retained by the laboratory.

The in-vitro activity of grepafloxacin against Chlamydia spp., Mycoplasma spp., Ureaplasma urealyticum and Legionella spp

The activity of grepafloxacin, a new orally active fluoroquinolone, was compared with the activities of ofloxacin, clarithromycin and doxycycline against Chlamydia pneumoniae, Chlamydia trachomatis, Mycoplasma pneumoniae, Mycoplasma hominis and Ureaplasma urealyticum, and with the activities of ofloxacin, clarithromycin and rifampicin against Legionella spp. Grepafloxacin (MIC range 0.06-0.12 mg/L) was some 8-16 times more active than ofloxacin against the chlamydiae, showing activity similar to that of doxycycline, and equal or two- to four-fold less active than clarithromycin. Grepafloxacin was four-fold more active than ofloxacin against M. pneumoniae (MIC 0.06-0.5 mg/L) and U. urealyticum (MIC 0.12-1.0 mg/L), but 16 times more active against M. hominis (MIC 0.015-0.05 mg/L). Grepafloxacin was highly active against Legionella spp. (MIC 0.008-0.03 mg/L), showing equivalent activity to ofloxacin, clarithromycin and rifampicin.

In-vitro activity of trovafloxacin, a new fluoroquinolone, against recent clinical isolates

Trovafloxacin (CP-99,219) was very active against Gram-negative species examined including Haemophilus influenzae, Moraxella catarrhalis, Legionella spp., Neisseria spp. and Escherichia coli (MIC90s < or = 0.03 mg/L). In general trovafloxacin was twice as active as ofloxacin but only half as active as ciprofloxacin against Gram-negative species. Trovafloxacin was active against Gram-positive organisms, including Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes and Enterococcus faecalis (MIC90s < or = 0.25 mg/L). Against these organisms activity was eight to 16 times greater for trovafloxacin than for either ofloxacin or ciprofloxacin. In addition, Chlamydia spp., Mycoplasma spp. and Ureaplasma urealyticum were eight to 16 times more susceptible to trovafloxacin than to either ofloxacin or ciprofloxacin. These in-vitro data show that trovafloxacin is a broad-spectrum fluoroquinolone with greater activity against clinically important Gram-positive species compared with ofloxacin or ciprofloxacin.

Modern diagnosis and management of genital Chlamydia trachomatis infection

Chlamydia trachomatis infection is now the commonest bacterial, sexually transmitted infection in the UK. Uncomplicated genital chlamydial infection often does not produce symptoms in men or women, but patients may present with sequelae. New diagnostic techniques are available to identify C. trachomatis more easily and new antibiotic regimens provide effective treatment. These factors, together with heightened awareness within the medical profession and the general population, should help to reduce the prevalence of this infection.

Comparison of the ligase chain reaction with cell culture for the diagnosis of Chlamydia trachomatis infection in women

OBJECTIVE

To determine the sensitivity and specificity of ligase chain reaction (LCR) analysis of cervical and urine specimens from women compared with cell culture of cervical and urethral specimens for the diagnosis of genitourinary chlamydial infection.

METHODS

Women (n = 624) attending the Genitourinary Medicine Clinic at University College London Hospitals, were enrolled. Patients who had received antibiotics within the previous two weeks were excluded. Specimens were obtained from the urethra and cervix for chlamydial culture, and from the cervix for LCR. A specimen of first void urine was also obtained for LCR. Discrepancies were resolved by direct immunofluorescence or a major outer membrane protein targeted LCR, or both.

RESULTS

The prevalence of Chlamydia trachomatis in 600 patients, using an expanded standard of a positive cell culture or two confirmed positive non-culture tests, was 13.2% (79/600). Cervical culture detected 68.4% and urethral culture 62% of all positive results compared with 81% detected by cervical LCR and 69% by urine LCR. Cervical and urethral culture combined detected 87.3% whereas cervical and urine LCR combined detected 91.1% of positive cases. Specificity of LCR was 100% in the cervix and 99.8% in urine.

CONCLUSION

This study demonstrates that LCR analysis of cervical and urine specimens is a reliable method for the diagnosis of chlamydial genital infection in women. However, the study also demonstrates that no single test will detect all chlamydial infections. Conventional non-culture tests and cell culture may grossly underestimate the prevalence of chlamydial infection. LCR analysis of a cervical specimen was superior to conventional cell culture without blind passage as a single test for diagnosing chlamydial infection in women, followed by LCR of a urine specimen.

Azithromycin in the management of Chlamydia trachomatis infections

The unique pharmacological profile of the azalide macrolide azithromycin, coupled with its in vitro activity against both Chlamydia trachomatis and the ureaplasmas, suggested that genital infections caused by these bacteria could be successfully treated with a single dose of the antibiotic. This has now been confirmed in worldwide clinical studies. A single oral dose of azithromycin 1 g eradicates C. trachomatis in almost 100% of cases of non-gonococcal urethritis and cervicitis. Unfortunately, there are no specific clinical signs for genital chlamydial infection. It is therefore necessary to use therapy effective against known and unknown pathogens for treating lower genital tract infection. Clinical cure rates for both chlamydial and non-chlamydial, non-gonococcal infections compare favourably with standard 7-day doxycycline therapy, being in excess of 85%. Side effects are few (< 20%) and essentially minor.

Assessment of the efficacy of a low temperature hydrogen peroxide gas plasma sterilization system

The STERRAD 100 sterilization system (Johnson & Johnson Medical Ltd) uses low temperature hydrogen peroxide gas plasma for sterilization of heat labile equipment. The efficacy of the machine was tested by contaminating a standard set of instruments with different organisms and using a filtration method to assess recovery of organisms from the wash fluids of instruments post-sterilization. Experiments were performed under clean (the organism only) and dirty (organism mixed with egg protein) conditions. A parallel study conducted using a 3M STERIVAC ethylene oxide sterilizer could not be completed owing to closure of the ethylene oxide plant. For sterilization of instruments with long and narrow lumens, hydrogen peroxide adaptors are necessary. The STERRAD 100 sterilizer can achieve effective sterilization of heat labile instruments with a reduction of 6 log10 cfu/mL of organisms tested. This method has the advantages over ethylene oxide sterilization of safety, ease of maintenance and no requirement for aeration time.

Clinical, laparoscopic and microbiological findings in acute salpingitis: report on a United Kingdom cohort

OBJECTIVE

To determine the clinical features and microbial aetiology of acute salpingitis in women attending an inner city teaching hospital.

DESIGN

Prospective, longitudinal cohort study.

SUBJECTS

One hundred and forty-seven women presenting consecutively with acute abdominal pain and clinical signs of acute salpingitis were evaluated microbiologically and laparoscopically.

RESULTS

One hundred and four women (70.7%) had acute salpingitis diagnosed at laparoscopy. Other pathological conditions were identified in 20 women (13.6%). No visually identifiable pathology was found in 23 (15.6%). Thirty-five women with acute salpingitis had evidence of pelvic adhesions (33.7%). Bilateral tubal occlusion was present in 6 (5.8%) cases. Chlamydia trachomatis was identified in the genital tract in 40 (38.5%) of the women with acute salpingitis and Neisseria gonorrhoeae in 15 (14.4%). A dual infection was present in eight cases (7.7%). Serological evidence suggested that a further seven women (6.7%) had acute chlamydial infections at the time of diagnosis. C. trachomatis was identified in the genital tract of 5/23 (21.7%) of the women who had no laparoscopic evidence of intra-abdominal pathology.

CONCLUSIONS

The responsible care of women with suspected acute salpingitis depends on establishing an accurate diagnosis, so that appropriate therapy can be instigated. This study provides evidence to challenge the outpatient management of acute salpingitis on clinical grounds alone as potentially inadequate. Early laparoscopy in hospitalised women improves diagnostic precision and accurately determines disease severity, providing prognostic information for future fertility. In this urban population, sexually transmitted micro-organisms were the commonest pathogens found in the genital tract of women with acute salpingitis. The high prevalence of C. trachomatis in these women suggests that appropriate chemotherapy for acute salpingitis should always include a specific antichlamydial agent.

Varicella gangrenosa with toxic shock-like syndrome due to group A streptococcus infection in an adult: case report

Varicella gangrenosa is a rare and serious complication of chickenpox that has been described in children only. We describe a case of an adult with varicella gangrenosa that presented as necrotizing fasciitis of a limb. This infection is caused by group A streptococcal superinfection of the skin lesions due to chickenpox. It can be misdiagnosed, with fatal consequences. Because of prompt recognition and aggressive surgical and medical treatment, the patient survived without loss of the affected limb.

Quinolones in sexually transmitted diseases. Global experience

The role of quinolones in sexually transmitted diseases is still being defined. In vitro and in vivo efficacy of established agents against gonorrhoea after a single oral dose is well established, although problems with emerging resistance have been identified. However, among these agents only ofloxacin is reliably active against Chlamydia trachomatis infection, and only as a course of treatment. Preliminary trials with sparfloxacin are encouraging. Other new agents show potentially useful in vitro activity, but clinical studies are awaited. To date, clinical activity of quinolones in bacterial vaginosis has been disappointing. The efficacy of newer agents with anaerobic activity will be of interest. Chancroid can be cured with ciprofloxacin or ofloxacin; resistance has been reported, but is not yet clinically significant. Ofloxacin appears to be effective therapy for pelvic inflammatory disease, without the need for additional anaerobe cover. The possibility of improved clinical efficacy justifies further in vitro and in vivo studies.

Chlamydial urethritis in heterosexual men attending a genitourinary medicine clinic: prevalence, symptoms, condom usage and partner change

A prospective study of 356 consecutive heterosexual male patients attending the Department of Genitourinary Medicine at University College Hospital was carried out to determine the prevalence of Chlamydia trachomatis. Patients were asked about their symptoms, use of condoms and change of sexual partner. The prevalence of non-gonococcal urethritis (NGU--chlamydia positive and negative urethritis) was 37% (131 of 356). C. trachomatis was shown to be the causative organism in 24% (31 of 131) of patients with NGU. The prevalence of other STDs in men with C. trachomatis and with non-chlamydial urethritis was 15% and 10% respectively. Men with C. trachomatis were significantly more likely than men with non-chlamydial urethritis to be asymptomatic (56% vs 35%). The prevalence of C. trachomatis was highest in men who had changed partner in the previous 3 months (20 of 32 men). A third of men never used condoms in the first 3 months of a new relationship and over half failed to use them after 3 months. There was no evidence that the reported use of condoms reduced the rate of infection with C. trachomatis.

Endoscope decontamination: a comparison of the Wolf 35100 and DSD-91 systems

The Wolf 35100 and DSD-91 endoscope disinfection machines were compared. Using a total viable count method, the degree of contamination of an Olympus GIFXQ20 endoscope was assessed following inoculation with a suspension of Pseudomonas aeruginosa and again following disinfection cycles in each machine, using 2% glutaraldehyde as the disinfectant. Both machines performed satisfactorily, with an average reduction of between 7 and 8 log10 cfu ml-1 P. aeruginosa following disinfection. The dilution effect on the glutaraldehyde of repeated disinfection cycles was also assessed for each machine. After 40 cycles in the DSD-91 and 25 cycles in the Wolf 35100 machines, the dilution of glutaraldehyde may give rise to concern, especially if adequate pre-cleaning of the endoscope is not carried out. The DSD-91 machine has certain advantages over the Wolf 35100 in terms of endoscope capacity, running costs and ease of maintenance. Both machines give similar results for endoscope disinfection.

Antibiotic chemotherapy of bacterial sexually transmitted diseases in adults: a review

Treatment regimens for sexually transmitted infections continue to evolve. The natural history of syphilis in HIV-infected patients is leading to more aggressive policies in terms of both investigation and treatment. In particular, treatment protocols for late syphilis, especially neurosyphilis, are under scrutiny. Epidemiological change typified by the spread of penicillinase-producing Neisseria gonorrhoeae (PPNG) has led to a search for new agents to treat gonorrhoea, with a more extensive use of cephalosporin and quinolone antibiotics emerging. The problem of compliance with the antibiotic courses presently required for chlamydial infection may be close to being solved with the development of newer macrolide agents. Single dose azithromycin, although expensive, seems to be as effective as longer courses with other agents. Furthermore, its efficacy in gonococcal infection is also encouraging. Increased understanding of the pathogenesis and natural history of pelvic inflammatory disease (PID) and bacterial vaginosis (BV) has led to rationalization of treatment policies for these conditions.