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Background: Mycoplasma genitalium is a major contributor to persistent/recurrent urethritis cases. However, there are limited published studies on recent trends of persistent/recurrent urethritis., Methods: A retrospective analysis was conducted of men presenting with symptomatic urethritis in 16 sexually transmitted disease (STD) clinics from 2015 to 2019. Poisson regression was used to assess trends in the annual proportions of urethritis episodes with follow-up (FU) characterized with persistent/recurrent urethritis symptoms. Results were also stratified by results of chlamydia (CT) and gonorrhea (NG) testing and treatment prescribed., Results: There were 99,897 urethritis episodes, from 67,546 unique men. The proportion of episodes with persistent/recurrent symptomatic FU visits increased 50.8% over a 4-year period (annual percentage change [APC], 11.3%; 95% confidence interval [CI], 6.5-16.3). Similar trends were observed in nonchlamydial nongonococcal urethritis episodes (APC, 12.7%; 95% CI, 6.8-18.9) but increases among those positive for NG (APC, 12.1%; 95% CI, -2.3 to -28.5) or for CT (APC, 7.3%; 95% CI, -6.7 to 23.5) were not statistically significant. Among episodes who received azithromycin as first-line treatment, increases in the proportion of persistent/recurrent FU visits were observed (APC, 12.6%; 95% CI, 8.6-16.7). For episodes where first-line treatment was doxycycline, no significant increases were detected (APC, 4.3%; 95% CI, -0.3 to 9.2)., Conclusions: We found an increase in the proportion of urethritis episodes with persistent or recurrent symptoms over time. Given these observed trends in episodes negative for NG or CT, an etiology not detectable by routine diagnostics was a likely factor in increased persistence, suggesting patients with urethritis may benefit from diagnostic testing for M. genitalium during an initial symptomatic presentation., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Sexual behavior may influence the composition of the male urethral microbiota, but this hypothesis has not been tested in longitudinal studies of men who have sex with men (MSM)., Methods: From December 2014 to July 2018, we enrolled MSM with nongonococcal urethritis (NGU) attending a sexual health clinic. Men attended 5 in-clinic visits at 3-week intervals, collected weekly urine specimens at home, and reported daily antibiotics and sexual activity on weekly diaries. We applied broad-range 16S rRNA gene sequencing to urine. We used generalized estimating equations to estimate the association between urethral sexual exposures in the prior 7 days (insertive oral sex [IOS] only, condomless insertive anal intercourse [CIAI] only, IOS with CIAI [IOS + CIAI], or none) and Shannon index, number of species (observed, oral indicator, and rectal indicator), and specific taxa, adjusting for recent antibiotics, age, race/ethnicity, HIV, and preexposure prophylaxis., Results: Ninety-six of 108 MSM with NGU attended ≥1 follow-up visit. They contributed 1140 person-weeks of behavioral data and 1006 urine specimens. Compared with those with no urethral sexual exposures, those with IOS only had higher Shannon index ( P = 0.03 ) but similar number of species and presence of specific taxa considered, adjusting for confounders; the exception was an association with Haemophilus parainfluenzae . CIAI only was not associated with measured aspects of the urethral microbiota. IOS + CIAI was only associated with presence of H. parainfluenzae and Haemophilus ., Conclusions: Among MSM after NGU, IOS and CIAI did not seem to have a substantial influence on measured aspects of the composition of the urethral microbiota., Competing Interests: Conflict of Interest of Sources of Funding: This work was supported by the National Institutes of Health (grant number U19 AI113173). L.C.C. was supported by the National Institutes of Health (grant number TL1 TR002318 trainee support). K.A.T. was supported by the University of Washington/Fred Hutch Center for AIDS Research, a program funded by the National Institutes of Health (grant number P30 AI027757). Study data were collected and managed using Research Electronic Data Capture (REDCap) tools hosted at the University of Washington Institute of Translational Health Sciences and supported by the National Institutes of Health (grant number UL1 TR002319). C.M.K. has received donations of test kits and reagents from Hologic, Inc. M.R.G. has conducted studies unrelated to this work supported by grants from Hologic, Inc. L.E.M. has received research support and honoraria from Hologic, Inc., and Nabriva Therapeutics. All other authors declare that they have no conflict of interest., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Mycoplasma genitalium (MG) is associated with urethritis in men and weakly associated with pelvic inflammatory disease in women. Mycoplasma genitalium coinfections with Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) are commonly reported; however, little is known about their interaction. One study suggested that MG/NG coinfections might increase the bacterial load of NG, which has been shown to have a higher transmission potential. As even less is known about the impact of a simultaneous MG/CT infection, we assessed whether patients with urogenital MG/CT coinfections have a higher bacterial load than patients with a single infection., Methods: There were 1673 urogenital samples from patients from a population-based chlamydia study, and our sexually transmitted infection clinic tested for both CT and MG. When positive, the load was quantified. Nonparametric tests compared the CT and MG load, and linear regression analyses tested the association of the CT and MG load within a patient., Results: In 60 MG-positive patients, MG load ranged from 1.7 to 6.0 log10 copies/ml, similar to the CT load distribution. Only 6 patients were MG-positive and CT-negative, but the MG load distribution was similar to that of CT-positive patients (n.s.). The MG and CT load was unrelated in coinfected persons (n.s.)., Conclusions: We found no correlation between the CT and MG load in urogenital samples, and the MG load distribution was similar in CT-positive and CT-negative patients. These results could have implications for the transmission risk of these infections., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Extragenital gonorrhea (GC) and chlamydia (CT) are usually asymptomatic and only detected through screening. Ceftriaxone plus azithromycin is the recommended GC treatment; monotherapy (azithromycin or doxycycline) is recommended for CT. In urethral CT-positive/urethral GC-negative persons who are not screened extragenitally, CT monotherapy can lead to GC undertreatment and may foster the development of gonococcal antimicrobial resistance. We assessed urethral and extragenital GC and CT positivity among men who have sex with men (MSM) attending sexually transmitted disease clinics., Methods: We included visit data for MSM tested for GC and CT at 30 sexually transmitted disease clinics in 10 jurisdictions during January 1, 2015, and June 30, 2019. Using an inverse-variance random effects model to account for heterogeneity between jurisdictions, we calculated weighted test visit positivity estimates and 95% confidence intervals (CI) for GC and CT at urethral and extragenital sites, and extragenital GC among urethral CT-positive/GC-negative test visits., Results: Of 139,718 GC and CT test visits, we calculated overall positivity (GC, 16.7% [95% CI, 14.4-19.1]; CT, 13.3% [95% CI, 12.7-13.9]); urethral positivity (GC, 7.5% [95% CI, 5.7-9.3]; CT, 5.2% [95% CI, 4.6-5.8]); rectal positivity (GC, 11.8% [95% CI, 10.4-13.2]; CT, 12.6% [95% CI, 11.8-13.4]); and pharyngeal positivity (GC, 9.1% [95% CI, 7.9-10.3]; CT, 1.8% [95% CI, 1.6-2.0]). Of 4566 urethral CT-positive/GC-negative test visits with extragenital testing, extragenital GC positivity was 12.5% (95% CI, 10.9-14.1)., Conclusions: Extragenital GC and CT were common among MSM. Without extragenital screening of MSM with urethral CT, extragenital GC would have been undetected and undertreated in approximately 13% of these men. Undertreatment could potentially select for antimicrobial resistance. These findings underscore the importance of extragenital screening in MSM.

Identifying pathogen-specific signs or symptoms of nongonococcal urethritis could improve syndromic management accuracy. We evaluated nongonococcal urethritis signs and symptoms in 220 men with single-pathogen infections (Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, or Ureaplasma urealyticum) or idiopathic urethritis. No individual sign or symptom accurately predicted the infectious etiology.

In 2015, we identified a non-groupable clade of Neisseria meningitidis that causes urethritis in men (the US_NmUC). Because repeat infection is common with Neisseria gonorrhoeae, we examined whether reinfection also occurs with the US_NmUC. We provide evidence that men are susceptible to repeat episodes of urethritis from the US_NmUC.

We evaluated the prevalence of Mycoplasma genitalium coinfection in 302 chlamydia-infected women seen at a sexually transmitted disease clinic in Birmingham, AL. M genitalium coinfection was detected in 22 (7.3%). No participant characteristics predicted coinfection. Among coinfected women, M genitalium was detected again in 6 (28.6%) of 21 women returning for a 3-month follow-up visit after azithromycin treatment.

Background: Mycoplasma genitalium was previously less common among men who have sex with men (MSM) compared with men with only female partners (MSW) in men with nongonococcal urethritis (NGU) in Sydney, Australia. We aimed to determine the prevalence of M. genitalium and of macrolide-resistant M. genitalium in men with NGU and to compare differences between prevalence and resistance rates between MSM and MSW., Methods: We enrolled 588 men with NGU in a prospective study at two urban sexual health services. The ResistancePlus MG assay (SpeeDx, Australia) was used to detect both M. genitalium, and macrolide resistance-associated mutations in first-void urine samples. Demographic, behavioral and clinical data were analyzed to investigate associations with M. genitalium infection or the presence of macrolide resistance., Results: Mycoplasma genitalium prevalence was 12.8% (75 of 588) overall and among MSM (12.8% [39 of 306]) and MSW (12.8% [36 of 282]; risk ratio [RR], 1.00; 95% confidence interval [CI], 0.65-1.52). Overall, 70.7% (53 of 75) of M. genitalium strains were macrolide-resistant, with significantly more resistance among MSM (89.7%, 35 of 39) than MSW (50%, 18 of 36) (RR, 1.80; 95% CI, 1.27-2.54; P = 0.001). On multivariate analysis, the presence of M. genitalium macrolide resistance mutations was independently associated with having male sexual partners compared with having only female partners (RR, 1.55; 95% CI, 1.02-2.38; P = 0.042)., Conclusions: Prevalence of M. genitalium among men with NGU is now similar for MSW and MSM and has increased locally from 5.2% to 12.8% within the last 10 years. Men who have sex with men are significantly more likely than MSW to harbor macrolide-resistant M. genitalium infections. This has treatment implications.

To evaluate self-reported symptoms to guide urethritis diagnosis, symptomatic men being evaluated for urethritis were asked about 7 symptoms captured during history taking. Discharge and dysuria were significantly associated with urethritis and, when combined with genital irritation and itching, identified 95% of urethritis cases; odor and urinary frequency performed poorly.

Introduction: Sexually transmitted infections (STIs) are managed syndromically in most developing countries. In Zimbabwe, men presenting with urethral discharge are treated with a single intramuscular dose of kanamycin or ceftriaxone in combination with a week's course of oral doxycycline. This study was designed to assess the current etiology of urethral discharge and other STIs to inform current syndromic management regimens., Methods: We conducted a study among 200 men with urethral discharge presenting at 6 regionally diverse STI clinics in Zimbabwe. Urethral specimens were tested by multiplex polymerase chain reaction testing for Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis. In addition, serologic testing for syphilis and HIV was performed., Results: Among the 200 studied men, one or more pathogens were identified in 163 (81.5%) men, including N. gonorrhoeae in 147 (73.5%), C. trachomatis in 45 (22.5%), T. vaginalis in 8 (4.0%), and M. genitalium in 7 (3.5%). Among all men, 121 (60%) had a single infection, 40 (20%) had dual infections, and 2 (1%) had 3 infections. Among the 45 men with C. trachomatis, 36 (80%) were coinfected with N. gonorrhoeae. Overall, 156 (78%) men had either N. gonorrhoeae or C. trachomatis identified. Of 151 men who consented to HIV testing, 43 (28.5%) tested positive. There were no differences in HIV status by study site or by urethral pathogen detected., Conclusions: Among men presenting at Zimbabwe STI clinics with urethral discharge, N. gonorrhoeae and C. trachomatis are the most commonly associated pathogens. Current syndromic management guidelines seem to be adequate for the treatment for symptomatic men, but future guidelines must be informed by ongoing monitoring of gonococcal resistance.

Background: Macrolide and fluoroquinolone resistance is alarmingly emerging in M. genitalium worldwide. This article provides the first estimates of the current prevalence of macrolide and fluoroquinolone resistance-mediating mutations in Barcelona, Spain, and identifies risk factors associated with the acquisition of these resistances., Methods: The study was conducted retrospectively with specimens submitted between February 2013 and March 2014 to the microbiology department of the Vall d'Hebron Hospital, Barcelona, where M. genitalium was detected using nucleic acid amplification methods. DNA sequencing of 23S ribosomal RNA gene and parC was performed in the Statens Serum Institut, Copenhagen, to detect genotypic macrolide and fluoroquinolone resistance markers, respectively., Results: Macrolide resistance-mediating mutations were detected in 35% (95% confidence interval, 24%-47%) of the M. genitalium-positive episodes, whereas 8% (95% confidence interval, 3%-17%) carried fluoroquinolone resistance mutations. Of them, three cases harbored multidrug resistance to both classes of antibiotics. Men who had sex with men (P = 0.002) and treatment with azithromycin within the previous 12 months (P = 0.006) were strongly associated with macrolide resistance., Conclusion: The widespread appearance of resistances, also in Spain, makes imperative the implementation of combined diagnostic-resistance detection assays for M. genitalium to facilitate the optimization of antibiotic treatment in the management of nongonococcal urethritis and potentially reduce the transmission of resistances.

Background: There have been few comprehensive studies on Haemophilus influenza-positive urethritis., Methods: In this retrospective study, we enrolled 68 men with H. influenzae-positive urethritis, including coinfections with Neisseria gonorrhoeae, Chlamydia trachomatis, and/or genital mycoplasmas: 2, 3, 20, and 43 treated with ceftriaxone, levofloxacin, sitafloxacin, and extended-release azithromycin (azithromycin-SR), respectively. We assessed microbiological outcomes in 54 men and clinical outcomes in 46 with H. influenzae-positive monomicrobial nongonococcal urethritis. We determined minimum inhibitory concentrations (MICs) of 6 antimicrobial agents for 59 pretreatment isolates., Results: H. influenzae was eradicated from the men treated with ceftriaxone, levofloxacin, or sitafloxacin. The eradication rate with azithromycin-SR was 85.3%. The disappearance or alleviation of urethritis symptoms and the decreases in leukocyte counts in first-voided urine were significantly associated with the eradication of H. influenzae after treatment. For the isolates, ceftriaxone, levofloxacin, sitafloxacin, azithromycin, tetracycline, and doxycycline MICs were ≤0.008-0.25, 0.008-0.5, 0.001-0.008, 0.12-1, 0.25-16, and 0.25-2 μg/mL, respectively. The azithromycin MICs for 3 of 4 strains persisting after azithromycin-SR administration were 1 μg/mL. H. influenzae with an azithromycin MIC of 1 μg/mL increased chronologically., Conclusions: H. influenzae showed good responses to the chemotherapies for urethritis. The significant associations of the clinical outcomes of the chemotherapies with their microbiological outcomes suggested that H. influenzae could play pathogenic roles in urethritis. All isolates, except for one with decreased susceptibility to tetracyclines, were susceptible to the examined agents. However, the increase in H. influenzae with an azithromycin MIC of 1 μg/mL might threaten efficacies of azithromycin regimens on H. influenzae-positive urethritis.

Background: The microscopical diagnosis of male urethritis was recently questioned by Rietmeijer and Mettenbrink, lowering the diagnostic criteria of the diagnosis to ≥2 polymorphonuclear leucocytes (PMNL) per high power field (HPF), and adopted by Centers for Disease Control and Prevention in their 2015 STD Treatment Guidelines. The European Non-Gonococcal Urethritis Guideline advocates a limit of ≥5 PMNL/HPF., Objective: To determine if syndromic treatment of urethritis should be considered with a cutoff value of ≥2 PMNL/HPF in urethral smear., Methods: The design was a cross-sectional study investigating the presence and degree of urethritis relative to specific infections in men attending an STI clinic as drop-in patients., Results: The material included 2 cohorts: a retrospective study of 13,295 men and a prospective controlled study including 356 men. We observed a mean chlamydia prevalence of 2.3% in the 0-9 stratum, and a 12-fold higher prevalence (27.3%) in the strata above 9. Of the chlamydia cases, 89.8% were diagnosed in strata above 9. For Mycoplasma genitalium, the prevalence was 1.4% in the 0-9 stratum and 11.2% in the stratum ≥10, and 83.6% were diagnosed in strata above 9. For gonorrhea, a significant increase in the prevalence occurred between the 0-30 strata and >30 strata from 0.2% to 20.7%. The results of the prospective study were similar., Conclusions: Our data do not support lowering the cutoff to ≥2 PMNL/HPF. However, a standardization of urethral smear microscopy seems to be impossible. The cutoff value should discriminate between low and high prevalence of chlamydia, mycoplasma, and gonorrhea to include as many as possible with a specific infection in syndromic treatment, without overtreating those with few PMNL/HPF and high possibility of having nonspecific or no urethritis.

Background: This study was done to diagnose Mycoplasma genitalium infection based on bacterial load in urine specimens from symptomatic and asymptomatic men., Methods: Urine specimens from 94 men with visible urethral discharge, 206 with burning on micturition and 75 without symptoms presenting to a family practitioner were tested for M. genitalium as well as Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis by transcription-mediated amplification assays. A quantitative polymerase chain reaction assay was used to determine the bacterial load for all specimens in which M. genitalium was the only organism detected., Results: Among the 375 specimens collected, M. genitalium was detected in 59 (15.7%) men (both symptomatic and asymptomatic) using the transcription-mediated amplification assay, and in 45 (12.0%) of the total population, it was the only pathogen detected. One or more pathogens were detected in 129 (43%) of the symptomatic men, with N. gonorrhoeae in 50 (16.7%); C. trachomatis in 37 (12.3%) and T. vaginalis present in 24 (8.0%) patients. Among the 17 patients where mixed infections were detected, M. genitalium with N. gonorrhoeae was the most common (11/17; 64.7%). Patients with visible urethral discharge had significantly higher M. genitalium concentrations than those with burning on micturition. The median M. genitalium load in symptomatic men was significantly higher than that in asymptomatic men., Conclusions: This study confirms the high prevalence of M. genitalium among men with urethritis in South Africa and demonstrates that there is a strong association with M. genitalium bacterial load and clinical urethritis. As the number of organisms increased, the severity of the symptoms increased, an indication of the role that the organism plays in disease progression.

Background: Periodic etiological surveillance of sexually transmitted infection (STI) syndromes is required to validate treatment algorithms used to control STIs. However, such surveys have not been performed in Zimbabwe over the past decade., Methods: A cross-sectional study design was used to determine the prevalence of the key STI etiological agents causing male urethral discharge (MUD). Urethral swab specimens were collected for molecular analysis and Neisseria gonorrhoeae isolation from consenting men 18 years and older who presented with MUD to the 12 clinics in Harare, Zimbabwe, between November 2010 and May 2011. A validated in-house multiplex polymerase chain reaction assay was used to detect the presence of N. gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium. Gonococci were cultured on selective media, and antimicrobial susceptibilities were determined locally for ciprofloxacin, kanamycin, ceftriaxone, and cefixime using Etest strips, and minimum inhibitory concentrations were reported using defined breakpoints., Results: Among 130 participants, N. gonorrhoeae was the most frequent pathogen detected (106; 82.8%), followed by C. trachomatis (15; 11.7%), M. genitalium (6; 4.7%), and T. vaginalis (2; 1.6%). Four (6.1%) of the 66 gonococci isolated were resistant to fluoroquinolones, whereas all viable isolates were susceptible to kanamycin, cefixime, and ceftriaxone., Conclusions: Gonorrhea is the most important cause of MUD in men in Harare, and our study highlights the emergence of fluoroquinolone-resistant N. gonorrhoeae. Further STI surveys are required in other regions of Zimbabwe to obtain a nationally representative picture of gonococcal burden and antimicrobial resistance among MUD patients.

Background: Approximately 45% of nongonococcal urethritis cases have no identified etiology. Novel bacteria recently associated with bacterial vaginosis (BV) in women may be involved. We evaluated the association of idiopathic nongonococcal urethritis and 5 newly described BV-associated bacteria (BVAB)., Methods: Heterosexual men 16 years or older attending a sexually transmitted disease clinic in Seattle, Washington, from May 2007 to July 2011 and negative for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium, and Ureaplasma urealyticum-biovar2 were eligible. Cases had urethral discharge or 5 or more polymorphonuclear leukocytes per high-power field in urethral exudates. Controls had no urethral discharge and less than 5 polymorphonuclear leukocytes per high-power field. Urine was tested for Atopobium spp., BVAB-2, BVAB-3, Megasphaera spp., and Leptotrichia/Sneathia spp. using quantitative taxon-directed polymerase chain reaction., Results: Cases (n = 157) and controls (n = 102) were of similar age, education, and income, and most were white. Leptotrichia/Sneathia spp. was significantly associated with urethritis (24/157 [15.3%] vs. 6/102 [5.9%], P = 0.03). BVAB-2 was more common in cases than in controls (7/157 [4.5%] vs. 1/102 [1.0%], P = 0.15), and BVAB-3 (n = 2) and Megasphaera spp. (n = 1) were only detected in men with urethritis, but these bacteria were found only in men who also had Leptotrichia/Sneathia spp. Atopobium spp. was not associated with urethritis. The quantity of bacteria did not differ between cases and controls. Among treated cases, doxycycline was more effective than azithromycin for clinical cure of men with Leptotrichia/Sneathia spp. (9/10 vs. 7/12, P = 0.16) and BVAB-2 (3/3 vs. 0/3, P = 0.10)., Conclusions: Leptotrichia/Sneathia spp. may be urethral pathogens or contribute to a pathogenic microbiota that can also include BVAB-2, BVAB-3, and Megasphaera spp. Doxycycline may be more effective than azithromycin against these newly identified bacteria.

Corynebacterium propinquum is usually considered part of the normal human oropharyngeal flora and is rarely responsible for clinical infection. We report here what seems to be the first case of acute purulent urethral discharge in a young Iranian man with urethritis acquired after orogenital contact. Attention should be devoted to less common nondiphtheriae Corynebacterium species for differential diagnosis.

We evaluated 236 asymptomatic men for urethritis, assessed sexual behaviors, and tested urine for pathogens. Asymptomatic urethritis was present in 38 (16.1%). Of these, nearly half (42.1%) had a previously unrecognized discharge on examination; only 18.4% had a known pathogen. Correlates included black race, anal intercourse, and number of sex partners.

Background: To determine sexually transmitted infection (STI) prevalence, and patient characteristics associated with detection of urethritis/cervicitis pathogens, among HIV-infected individuals offered voluntary STI screening at a South African HIV treatment center., Methods: Individuals, asymptomatic for genital discharge, were screened for Neisseria gonorrhoeae (NG), Chlamydia trachomatis, Trichomonas vaginalis (TV), Mycoplasma genitalium (MG) infections (real-time polymerase chain reaction assay), for syphilis and herpes simplex type 2 (serologically), and for bacterial vaginosis and Candida (microscopy, women only). Patients' most recent CD4 and viral load results were recorded. Demographic, clinical, and behavioral data were collected by nurse-administered questionnaire., Results: Compared with men (n = 551), women (n = 558) were younger (mean age, 35.0 vs. 37.9 years; P < 0.001), reported more STIs in the past year (65.5% vs. 56.5%; P = 0.002), had more urethritis/cervicitis pathogens detected (21.3% vs.16.4%, P = 0.035), and were less aware of their partner's HIV status (53.1% vs. 62.3%; P = 0.007). The overall prevalence of individual urethritis/cervicitis pathogens was TV (7.6%), MG (6.1%), NG (5.4%), and C. trachomatis (2.1%). Multivariate analysis highlighted 4 significant factors associated with the detection of specific urethritis/cervicitis pathogens, namely female gender (TV, adjusted odds ratio [aOR] 2.53, 95% confidence interval [CI]: 1.47-4.37), having a regular sexual partner in the past 3 months (NG, aOR 2.26, 95% CI: 1.01-5.08), suboptimal condom use with regular partners (TV, aOR 2.07, 95% CI: 1.25-3.42), and a history of genital warts in the past year (NG, 2.25, 95% CI: 1.26-4.03)., Conclusions: Asymptomatic urethritis/cervicitis pathogens were highly prevalent in this population. Few urethritis/cervicitis pathogen-associated patient characteristics were identified, emphasizing the need for affordable STI diagnostics to screen HIV-infected patients.

Background: Men are recommended to not urinate for at least 1 hour before urine testing for Chlamydia trachomatis, but some studies have shown that recent urination does not impact test sensitivity for nucleic acid amplification tests. The objective of this study was to estimate the sensitivity of chlamydia testing using samples obtained 20-minutes post void., Methods: We recruited men returning to Sydney Sexual Health Centre for treatment of urethral Chlamydia trachomatis infection between July 2009 and February 2011. A short questionnaire was used to elicit symptoms, and 2 first-void urine samples were collected-the first after the standard 1 hour minimum and the second 20 minutes later. Men with clinical or microbiologic evidence of urethritis, men receiving antibiotic treatment, and those who had urinated within the last hour were excluded. Samples were tested using Roche COBAS Amplicor PCR. The proportion of samples testing positive at 20 minutes post void was determined using the 1-hour post void sample as a gold standard., Results: Thirty-one men with confirmed chlamydia infection were included in the analysis. Of these, 29 of 31 (93.5%) were positive at 20 minutes (95% CI: 78.6%-99.2%)., Conclusions: The sensitivity of 20-minute voiding intervals in asymptomatic men remains reasonably high relative to standard voiding intervals. Removing the barrier of a 1-hour voiding interval should be considered during opportunistic screening.

Background: We determined the prevalence of urethral Mycoplasma genitalium (MG) infection and whether infection was associated with circumcision status among men enrolled in the randomized trial of medical male circumcision to prevent HIV acquisition in Kisumu, Kenya., Methods: MG and Trichomonas vaginalis were detected in first void urine by APTIMA transcription-mediated amplification assay. first void urine and urethral swabs were assessed for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) by polymerase chain reaction assay. Herpes simplex virus type 2 antibodies were detected by IgG ELISA. Multivariable logistic regression identified factors associated with MG infection., Results: Specimens were collected between July and September 2010, and 52 (9.9%; 95% confidence interval [CI]: 7.3%-12.4%) MG infections were detected among 526 men. N. gonorrhoeae and T. vaginalis were not associated with MG. CT coinfection was 5.8% in MG-infected men, and 0.8% among MG-uninfected men (P = 0.02). MG infection was predominantly asymptomatic (98%). The prevalence of MG was 13.4% in uncircumcised men versus 8.2% in circumcised men (P = 0.06). Being circumcised nearly halved the odds of MG (adjusted odds ratio [aQR] = 0.54; 95% CI: 0.29-0.99), adjusted for other variables significant at the P < 0.05 level: herpes simplex virus type 2 infection (aOR = 2.05; 95% CI: 1.05-4.00), CT infection (aOR = 2.69; 95% CI: 1.44-5.02), and washing the penis ≤1 hour after sex (aOR = 0.47; 95% CI: 0.24-0.95)., Conclusions: MG infection was reduced among men who were circumcised, adding to the benefits of male circumcision in preventing several sexually transmitted infections.

Background: Given recent increasing case rates of Chlamydia trachomatis infection, we evaluated trends in chlamydia rates and related health outcomes in women and men aged 15 to 44 years who were enrolled in a Pacific Northwest health plan., Methods: We identified chlamydia, pelvic inflammatory disease (PID), ectopic pregnancy, and male urethritis cases occurring annually during 1997-2007 using computerized health plan databases, calculating rates per 100,000 person-years (py) by gender and 5-year age groups. We also calculated annual chlamydia testing rates., Results: In women, chlamydia testing rates increased by approximately 23% (220 tests per 1000 py in 1997 to 270 tests per 1000 in 2007). Chlamydia diagnosis rates rose from 449 cases/100,000 py in 1997 to 806/100,000 in 2007, a 79% increase (P = 0.01). Increases were greatest during 2005-2007, also the period of major conversion to nucleic acid amplification test. PID rates in this interval declined steadily from 823 cases/100,000 py to 473/100,000 (P < 0.01). Ectopic pregnancy rates remained unchanged. In men, chlamydia testing rates increased nearly 3.5-fold, from 12 to 42 tests per 1000 py. Chlamydia rates for men also rose significantly throughout the study interval (from 91 cases/100,000 py to 218/100,000; P < 0.01) as did urethritis diagnosis rates (P < 0.01)., Conclusion: Between 1997 and 2007, annual health plan chlamydia rates increased significantly for both women and men. These trends may be due in part to increased testing rates and increased use of more sensitive tests, but they likely do not explain the increased urethritis rates. During this same interval, we observed steady declines in PID rates, consistent with other national data sources.

We describe herein a case of uropathogenic Escherichia coli urethritis and orchiepididymitis in a heterosexual man, which he had acquired sexually from his girlfriend. The identity of the genital isolates from both partners was confirmed by pulsed-field gel electrophoresis.

Background: The recent emergence and spread of antimicrobial-resistant Neisseria gonorrhoeae has compromised treatment and control of gonorrhea. We determined recent trends in antimicrobial susceptibility of the isolates, analyzed recent use of antigonococcal agents, and investigated the relationship between fluoroquinolone nonsusceptibility and amino acid substitutions within the fluoroquinolone resistance-determining regions in Korea., Methods: The antimicrobial susceptibilities of 977 isolates of N. gonorrhoeae collected from 2000 to 2006 in Korea were determined with penicillin, ceftriaxone, spectinomycin, tetracycline, and ciprofloxacin disks. Some of the randomly selected isolates were tested by the Clinical and Laboratory Standards Institute agar dilution method, to determine subtle changes in susceptibility to the above antibiotics and cefixime. β-lactamase was detected using a cefinase disk., Results: All of the isolates exhibited plasmid- or chromosomally mediated resistance to penicillin; however, the proportions of penicillinase-producing N. gonorrhoeae decreased rapidly from 64% in 2000 to 21% in 2006. All isolates were susceptible to third-generation cephalosporins, except for 1 isolate that was not susceptible to cefixime. The proportion of ciprofloxacin-resistant isolates increased from 26% in 2000 to 83% in 2006. Of 7 substitution types, 5 (Ser-91-Phe in Gyrase A (GyrA), Ser-87-Arg in ParC subunit of topoisomerase IV (ParC); Ser-91-Phe and Asp-95-Ala in GyrA, and Ser-87-Asn in ParC; Ser-91-Phe and Asp-95-Gly in GyrA, and Asp-86-Asn in ParC; Ser-91-Tyr in GyrA; Ser-91-Phe in GyrA, and Asp-86-Asn in ParC) were new ones not identified in our 2004 study. All isolates were susceptible to spectinomycin. About half of the patients in our current study (52.6%-58.1%, depending on the year) received spectinomycin treatment. Majorities were resistant to tetracycline, and the rate of highly tetracycline-resistant N. gonorrhoeae increased from 3% in 2000 to 9% in 2006., Conclusions: The incidence of penicillinase-producing N. gonorrhoeae declined significantly, but none of the isolates were susceptible to penicillin G. All isolates were susceptible to spectinomycin, in contrast majority were resistant to tetracycline. Inappropriate use of fluoroquinolone was frequent. The minimum inhibitory concentrations of ceftriaxone were within the susceptible range for all isolates, but those of cefixime were slightly higher, and it was 0.5 μg/mL (nonsusceptible) for 1 isolate.

We compared a simple, one-step staining procedure using a mixture of methylene blue and gentian violet to Gram stain for the detection of gonococcal urethritis. The sensitivity and specificity of both Gram stain and methylene blue/gentian violet stain were 97.3% and 99.6%, respectively. There was a 100% correlation between the 2 methods.

Gonococcal isolates (n = 4336) were collected from men with urethritis at the Fulton County STD Clinic between 1988 and 2006. Antimicrobial susceptibility was performed by agar dilution. Increasing numbers of isolates from men who have sex with men and with fluoroquinolone resistance were noted. New antimicrobials effective against gonorrhea are urgently needed.

In a sexually transmitted disease clinic-based sample of men who have sex with women, positivity for urethral Chlamydia trachomatis and Neisseria gonorrhoeae was 3.5% and 3.1%, respectively, among patients whose only urethral exposure in the previous 3 months was receiving fellatio from a woman. Urethral infections acquired by fellatio might contribute to ongoing disease spread.

Background: Nongonococcal urethritis (NGU) is common, yet up to 50% of cases have no defined etiology. The extent to which risk profiles and clinical presentations of pathogen-associated and idiopathic cases differ is largely unknown., Methods: Urethral swabs and urine specimens were collected from 370 NGU treatment trial participants who sought care at a sexually transmitted disease clinic in Seattle, WA from 2007 to 2009 and had a visible urethral discharge and/or microscopic evidence of urethral inflammation assessed by Gram-stain (≥5 polymorphonuclear leukocytes per high-powered field [PMNs/HPF]). Neisseria gonorrhoeae, Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), Trichomonas vaginalis (TV), and Ureaplasma urealyticum (UU) were detected in urine, using nucleic acid amplification tests. Cases negative for all assessed pathogens were considered idiopathic. Bivariate and multivariate analyses identified clinical, sociodemographic, and behavioral factors associated with detection of specific pathogens., Results: After excluding 3 participants with gonococcal infection, pathogens were detected in only 50.7% of the 367 eligible cases: CT in 22.3%, MG in 12.5%, TV in 2.5%, and UU in 24.0%, with multiple pathogens detected in 9.5%. In all, 3.5% of cases were negative for CT, MG, and TV but lacked speciated ureaplasma results. The remaining cases (45.8%) were considered idiopathic. Pathogen detection was associated with young age, black race, risky sexual behaviors, cloudy or purulent discharge, and visible discharge plus≥5 PMNs/HPF. In contrast, idiopathic cases were more likely to report prior NGU, were older and less likely to be black, or have an abnormal urethral discharge on examination, compared to all other cases. These cases were not associated with any high risk behaviors., Conclusions: NGU is a heterogeneous condition. Pathogen detection was associated with a variety of traditional risk factors and clinical features; whereas, idiopathic cases tended to be diagnosed among lower-risk men.

Background: The role of hormonal contraception on acquisition of gonorrhea has not been well-characterized, as the transmission dynamics of Neisseria gonorrhoeae are poorly understood. The purpose of this study is to determine the influence of hormonal contraception on gonococcal infection in women exposed to males with gonococcal urethritis., Methods: Females aged 15 to 35 years reporting sexual contact to a male partner diagnosed with N. gonorrhoeae were enrolled. Demographic and sexual histories, physical findings, and laboratory tests were collected. Women testing positive and negative for cervical N. gonorrhoeae were compared using chi and Fisher exact tests, with multivariable logistic regression performed on those factors independently associated with gonococcal infection on univariate analysis., Results: N. gonorrhoeae infection occurred in 68 of 107 (64%) women. Women using combined hormonal contraception were significantly less likely than nonusers to test positive for N. gonorrhoeae (32% vs. 76%; prevalence ratio: 0.42; 95% confidence interval: 0.22, 0.78; P = 0.006). Gonorrhea was also less common in depomedroxyprogesterone acetate users. A new sexual partner was also associated with testing positive for gonorrhea (35% vs. 13%; prevalence ratio: 1.47; 95% confidence interval: 1.13, 1.90; P = 0.004)., Conclusions: Women using combined hormonal contraceptives or depomedroxyprogesterone acetate were less likely to test positive for N. gonorrhoeae after sexual exposure compared with nonusers. Our data suggest that, in addition to contraceptive benefits, modern hormonal contraception may have a protective effect on the acquisition of N. gonorrhoeae.

Background: Malawi adopted syndromic management of sexually transmitted infections in 1993. Based on clinical efficacy and cost, gentamicin 240 mg intramuscularly, and doxycycline 100 mg twice daily x 7 days was selected as the first line regimen to treat urethritis. We sought to establish current laboratory-based Neisseria gonorrhoeae antibiotic susceptibility patterns for Malawi and describe the pattern of susceptibility since syndromic management began., Methods: Between May 15 and August 10, 2007, 126 men with urethritis attending the STD clinic at Kamuzu Central Hospital in Lilongwe had history, genital exam, and urethral swabs taken. All were treated with gentamicin and doxycycline in accordance with Malawi guidelines. Gonorrhea was diagnosed by Gram stain and culture. Antimicrobial susceptibility patterns in gonococcal isolates were determined by disk diffusion and E-test minimum inhibitory concentration (MIC) determination and agar dilution MIC determination., Results: One hundred six isolates were cultured, and MICs were determined for 100. High levels of resistance to tetracycline and penicillin were observed, but isolates were uniformly susceptible to both gentamicin and ciprofloxacin. Susceptibility patterns identified by the agar dilution MIC and E-test MIC agreed., Conclusions: The most recent study continues the trend of high susceptibility of gonococcal isolates to gentamicin in Malawi after 14 years of use and suggests agar dilution MICs may be substituted with the simpler E-test methods in future susceptibility testing. However because of the lack of susceptibility criteria for aminoglycosides for N. gonorrhoeae and the difficulty obtaining clinical/in vitro correlates in this setting, caution should be exercised in using these data for modifying treatment regimens.

Objective: To ascertain the effectiveness of kanamycin for the treatment of gonorrhoea in Maputo, Mozambique., Methods & Design: A cross-sectional study design was employed. Urethral and cervical specimens were collected for the isolation of Neisseria gonorrhoeae from patients attending Centro de Saúde do Porto. Antimicrobial susceptibilities were determined for kanamycin, spectinomycin, ciprofloxacin, ceftriaxone, cefixime, tetracycline and penicillin., Results: Twenty-two (40%) Neisseria gonorrhoeae isolates were intermediate and 4(7%) were resistant to kanamycin; 42(77%) displayed high level resistance to tetracycline (MIC > or = 16 mg/L); 34 (65%) were penicillinase producers, and 52 (95%) had spectinomycin MICs of 64 mg/L. All isolates were susceptible to ciprofloxacin (MIC < or = 0.06 mg/L), ceftriaxone (MIC < or = 0.015 mg/L) and cefixime (MIC < or = 0.015 mg/L)., Conclusion: The observations underscore the need for broader susceptibility surveillance studies to elucidate the pattern and extent of drug resistance in Mozambique. A review of the current treatment guidelines for genital discharge syndrome is warranted.

Background: The Centers for Disease Control and Prevention recommends that men who have sex with men (MSM) be screened annually for gonorrhea (GC) infection at the urethral, pharyngeal, or rectal site based on recent sexual exposure. This evaluation estimated the proportion of GC infections in MSM that would be missed if only urethral or urine specimens were tested., Methods: Culture of specimens from all sites and urethral (or urine) nucleic acid amplification test (NAAT) results for gonorrhea were reviewed for all identified MSM attending the San Diego County STD Clinic during 1997-2003., Results: During the 7-year period, 7333 MSM were tested for GC and 1157 (15.8%) had a positive test result at > or =1 sites. Overall, 10.8% of urethral, 9.8% of rectal, and 4.0% of pharyngeal tests were positive. Among 5812 patients who had a urethral and a rectal or pharyngeal specimen tested, 970 were positive and among those, 369 (38%) had a negative test result in their urethral or urine specimen. Among 163 patients who had only a rectal and/or pharyngeal specimen tested for GC, 16 (9.8%) were positive. If the clinic had tested only urethral or urine specimens, 33% of total gonorrhea cases among MSM [385 (369 + 16) of 1157] would have been missed., Conclusion: GC screening strategies for MSM should include testing of rectal and pharyngeal specimens based on exposure. Given the decline of culture availability, efforts are needed to encourage laboratories to validate NAATs for rectal/pharyngeal specimens, which will likely increase exposure-based screening of MSM.

Background: We previously reported a significant association between Ureaplasma urealyticum (biovar 2) and nongonococcal urethritis (NGU). We also found that the presence of Ureaplasma parvum (biovar 1) in the male urethra might be the result of colonization., Objective: The objective of this study was to clarify the pathogenic role of human Ureaplasma in NGU by assessing the association of bacterial loads with clinical findings and inflammatory responses in the urethra., Study Design: The 16S rRNA gene of Ureaplasma was quantified by a TaqMan-based real-time polymerase chain reaction assay in first-pass urine from 37 men with Ureaplasma-positive nonmycoplasmal nonchlamydial NGU (NMNCNGU) and 30 Ureaplasma-positive men without urethritis., Results: U. urealyticum (biovar 2) loads in 23 men with NMNCNGU were significantly higher than those in 14 men without urethritis. However, U. parvum (biovar 1) loads did not differ significantly between 14 men with NMNCNGU and 20 men without urethritis., Conclusion: The association of increased U. urealyticum (biovar 2) loads with symptomatic urethritis suggests that U. urealyticum (biovar 2) may be a pathogen of NGU. Our results also suggest that the presence of U. parvum (biovar 1) may not be significant in the development of NGU.

Objectives: Syndromic management guidelines for male urethritis syndrome and female discharge syndrome (nonpregnant) in South Africa advocate the use of ciprofloxacin for potential infection with Neisseria gonorrhoeae. In 2003, reports of clinical failure of gonorrhea following ciprofloxacin treatment prompted a clinic-based surveillance to detect the presence of resistant isolates., Study: Urethral samples for the isolation of N gonorrhoeae were obtained from consecutive male patients with urethral discharge attending the largest sexually transmitted disease clinic in KwaZuluNatal. Molecular typing of isolates was performed by means of N gonorrhoeae multiantigen sequence typing (NG-MAST)., Results: Of 139 isolates, 31 (22%) were resistant to ciprofloxacin (minimum inhibitory concentration >or=1 mg/l). NG-MAST revealed novel, as well as previously described, sequence types (ST). The largest cluster of our isolates belonged to ST 217. This ST has been reported among ciprofloxacin-resistant isolates from Europe., Conclusion: : The results underscore the urgency of review of the current treatment guidelines for discharge disease in KwaZuluNatal.

Background: Gram stain is used to detect urethral inflammation, suggestive of infection, in men and guide therapeutic decisions. In the absence of signs, symptoms, or polymorphonuclear leukocytes (PMNs) on urethral Gram stain, treatment and sometimes testing is deferred., Goal: Determine the proportion of men with chlamydia or gonorrhea diagnosed by nucleic acid amplification testing (NAAT) or culture who lack Gram stain evidence of inflammation and compare their clinical characteristics to men with inflammation., Methods: Records from 2629 men presenting for routine sexually transmitted disease care with urethral PMN count and NAAT data were retrospectively analyzed. A subpopulation tested by NAAT and culture was analyzed. Men receiving antibiotics within the prior month or those reporting a sexual partner with trichomoniasis were excluded., Results: Among 2266 eligible men, 353 (16%) had chlamydia and 462 (20%) had gonorrhea. Among chlamydia-infected men, PMNs per oil-immersion field (oif) on Gram stain were > or =5 in 291 (82%), 1 to 4 in 20 (6%), and none in 42 (12%). In men with gonorrhea, PMNs/oif were > or =5 in 433 (94%), 1 to 4 in 6 (1%), and none in 23 (5%). Urethral symptoms, discharge, and/or > or =5 PMNs/oif were absent in 47 (13%) and 22 (5%) of chlamydial and gonococcal infections, respectively (including no PMNs/oif and 1-4 PMNs/oif). None of these 47 chlamydial-infected men and only 4 of 22 men with gonorrhea received therapy at the time of initial examination., Conclusions: Twelve percent of chlamydial and 5% of gonococcal infections had no Gram stain evidence of urethral inflammation. Absence of symptoms and discharge is not uncommon in chlamydial infection detected by NAAT, and without testing, many infections will go untreated, furthering the possibility of complications or partner transmission.

Objective: The objective of this study was to compare urogenital swab specimens and first void urine (FVU) specimens from male and female patients at a sexually transmitted disease clinic for the detection of Mycoplasma genitalium and Chlamydia trachomatis infections using in-house, inhibitor-controlled polymerase chain reaction (PCR)., Study Design: Urethral swabs and FVU were collected from 1856 men and 753 women who also had a cervical swab collected. A positive diagnosis of infection was made if any 1 of the specimens tested positive and were confirmed in a second PCR assay targeting independent genes., Results: M. genitalium DNA and C. trachomatis DNA were detected in 126 (6.8%) and 246 (13.3%) of the male sample sets and in 51 (6.8%) and 73 (9.7%) of the female specimen sets, respectively. Using our in-house PCR and sample preparation methods, FVU was found to be the most sensitive diagnostic specimen for both pathogens, but for optimal sensitivity, it should be supplemented with a cervical specimen in women. In a small subset of female FVUs, storage at -20 degrees C led to false-negative M. genitalium PCR results in 27% of specimens found positive when a sample preparation was performed before freezing. The age-specific prevalence of M. genitalium in men was almost constant between 18 and 45 years of age in contrast to C. trachomatis infections, which were more common in younger men., Conclusion: Urine appeared to be a better diagnostic specimen than the urethral swab for M. genitalium and C. trachomatis detection by PCR in this cohort of sexually transmitted disease clinic attendees but should be supplemented with a cervical specimen in women.

Background: The tiny (T)-strain mycoplasmas, designated in 1974 as Ureaplasma urealyticum, have been divided into 2 species, Ureaplasma parvum (biovar 1) and U. urealyticum (biovar 2), but association of each of these species with nongonococcal urethritis (NGU) remains unclear., Goal: The goal of this study was to determine whether U. parvum (biovar 1) or U. urealyticum (biovar 2) is associated with NGU., Study Design: The prevalences of U. parvum (biovar 1) and U. urealyticum (biovar 2) in 572 patients with urethritis were compared with those in 141 men without urethritis., Results: The prevalence of U. urealyticum (biovar 2) in men with NGU (15.8%) or with nonchlamydial NGU (18.0%) was significantly higher than that in men without urethritis (7.8%). The prevalence of U. parvum (biovar 1) in men with NGU (8.5%) or with nonchlamydial NGU (11.1%) did not differ significantly from that in men without urethritis (13.5%)., Conclusion: Our results showed a significant association between U. urealyticum (biovar 2) and NGU. They also suggest that the presence of U. parvum (biovar 1) in the male urethra might be the result of colonization.

Background: Noninvasive urine samples have been used to diagnose Chlamydia trachomatis infections, with the assumption that the first-void urine (FVU), defined as the first 20 to 30 ml at any micturition, would be the optimal collection. We compared testing technologies on first, second, and third volumes for diagnosis., Goal: The goal was to test in nonculture assays three sequential volumes of urine from men also undergoing urethral swabbing for C trachomatis culture specimens., Study Design: A total of 237 men attending an STD clinic (C trachomatis prevalence, 11%) collected three containers of urine (each containing 20-30 mL) for testing in four nonculture assays. A urethral swab specimen was tested in cell culture., Results: The numbers of men positive by testing of FVU with nucleic acid amplification (LCx chlamydia), nucleic acid hybridization (PACE 2), enzyme immunoassay (Chlamydiazyme), and a leukocyte esterase dipstick were 26, 7, 14, and 11, respectively; urethral culture identified 6 of the infected men. Comparative testing of all voids from the 26 men positive by the FVU assays demonstrated a reduction of LCx-positives. Non-amplified-test positivity declined precipitously in subsequent voids, approaching zero in the third void. The presence of symptoms and time of last void up to 8 hours had little effect on the number of positives detected by LCx of FVU., Conclusion: Amplified testing of FVU was most effective for diagnosing infection in these men.

Background: There are few studies of recent trends in the etiology and epidemiologic characteristics of specific microorganisms causing urethritis in men., Goal: The objective of the current study was to show the clinical experience in our country and to evaluate the trends in the prevalence of the pathogens in male urethritis, as well as the epidemiologic patterns in a series of 2101 patients., Study Design: This was a descriptive study of the etiological agents causing urethritis in our sexually transmitted disease clinics in a period of 12 years (1989-2000), with a comparison of two periods of time., Results: There were 97 cases of gonococcal urethritis (4.6%), 2004 of nongonococcal urethritis (95.4%), and 82 of mixed urethritis (3.9%). An association was found between gonococcal urethritis and heterosexual men; between chlamydial urethritis and homosexual/bisexual men; Ureaplasma urealyticum urethritis and heterosexual men and patients younger than 30 years of age; and between trichomonal urethritis and patients more than 30 years of age and the presence of HIV antibodies., Conclusion: During the period of research there was a significant decrease in cases of Neisseria gonorrhoeae and Chlamydia trachomatis urethritis and an increase in those of U urealyticum urethritis. In conclusion, this report describes changes in the etiology and epidemiologic patterns of urethritis in our country in recent years.

Background: Chronic nongonococcal urethritis (NGU) is a well-recognized clinical problem in genitourinary medicine clinics, but its etiology and optimal management are poorly understood., Goal: The authors showed previously that antibody to chlamydial hsp60 is associated with urethritis 30 to 92 days after treatment of acute NGU (chronic NGU) and that the detection of ureaplasmas or is associated with chronic NGU in which symptoms or signs are present. The aim was to determine whether these associations are independent of each other., Study Design: This was a longitudinal prospective follow-up study over a 3-month period of 86 men with acute NGU. Men were tested for, ureaplasmas, and antibody to chlamydia hsp60 at presentation and during follow-up., Results: The detection of either ureaplasmas or (OR, 29.45; 95% CI, 1.78-487) and the occurrence of hsp60 antibody at 30 to 92 days' follow-up (OR, 26.45; 95% CI, 1.34-523) were associated independently with the development of chronic NGU 30 to 92 days after treatment of acute NGU. The presence of chlamydial hsp60 antibody at 30 to 92 days was not associated with the development of chronic NGU in which symptoms or signs were present (P= 0.363). Chlamydial hsp60 antibody associated, however, with chronic NGU in which there were no symptoms or signs (P = 0.01)., Conclusion: The results suggest that the immune response to chlamydial hsp60 may have a role in the etiology of chronic NGU in asymptomatic men who have no discharge on examination. The clinical relevance of this is unknown.

Background: A previous study demonstrated that Digene's Hybrid Capture 2 (HC2) DNA tests for detection of and (CT/GC) could be performed using cervical swab specimens collected in GenProbe transport media with significantly greater sensitivity for the detection of than with the GenProbe PACE 2 system., Goal: The goal was to assess the performance of HC2 tests in comparison with GenProbe PACE 2 tests for the detection of CT/GC in male urethral swab specimens., Study Design: A total of 1,202 male urethral swab specimens were collected in GenProbe PACE transport medium. All specimens were first tested with the PACE 2 system, followed by masked HC2 CT/GC testing. The GenProbe AMPLIFIED CT Assay (AMP CT) and PCR/SHARP Signal System (SHARP) were used for adjudication of discrepant results., Results: The prevalence rates for this population were 8.4% for and 14.6% for, based on the adjudicated results. The relative sensitivity and specificity for the detection of were 97.0% and 99.8% for HC2 and 69.3% and 98.3% for PACE 2, respectively. The relative sensitivities for the detection of were 98.9% for HC2 and 99.4% for PACE 2, with the same specificity of 99.9% for both tests. Agreement between the two testing methods was 95.4% for and 99.6% for., Conclusion: The HC2 test is compatible with the GenProbe collection medium, with significantly greater sensitivity than the GenProbe PACE 2 test for detecting and similar sensitivities for detecting.

Background: Azithromycin and doxycycline are recommended for treatment of genital Chlamydia trachomatis infection. A systematic review comparing these antibiotics could affect treatment guidelines., Goal: The goal was to perform a meta-analysis to evaluate the efficacy and tolerance of azithromycin versus doxycycline for genital chlamydial infection., Study Design: Studies were identified by searching computerized English-language databases for the period 1975 to August 2001, supplemented by a manual bibliographic search. Criteria for inclusion were (1) randomized trial design; (2) regimens of oral doxycycline (100 mg twice daily for 7 days) and oral azithromycin (1 g once); (3) males >15 years of age and nonpregnant females >15 years of age; (4) and evaluation of microbial cure at follow-up. Data were extracted on diagnostic assay, follow-up time, study design, sponsorship, patients' characteristics, adverse events, attrition rates, and outcomes., Results: Twelve trials met the inclusion criteria; 1543 patients were evaluated for microbial cure and 2171 for adverse events. Cure rates were 97% for azithromycin and 98% for doxycycline. Adverse events occurred in 25% and 23% of patients treated with azithromycin and doxycycline, respectively. After pooling of the data, differences in efficacy and risk were computed. The efficacy difference for microbial cure (0.01; 95% CI, -0.01-0.02) and the risk difference for adverse events (0.01; 95% CI, -0.02-0.04) between the two drugs were not statistically significant., Conclusion: Azithromycin and doxycycline are equally efficacious in achieving microbial cure and have similar tolerability. Further head-to-head trials comparing these antibiotics are unnecessary.

Background: Chlamydia trachomatis and Neisseria gonorrhoeae are known to cause urethritis. However, only a small number of studies in Eastern European countries have investigated the causes of urethritis., Goals: To determine the prevalence of C trachomatis and N gonorrhoeae among men with symptomatic urethritis in Istanbul, Turkey, and to determine whether contact with a commercial sex worker increased the likelihood of chlamydial infections., Study Design: Men with a diagnosis of urethritis at the Istanbul Faculty of Medicine were screened for C trachomatis and N gonorrhoeae by Abbott's ligase chain reaction (LCR) using either urethral swabs or first-void urine. N gonorrhoeae cultures were done on a subset of these patients., Results: The study enrolled 813 men. All of the men denied condom use during their previous sexual exposures. The overall prevalence of C trachomatis, as determined by LCR, was 15.7%. Only 192 patients were screened for both organisms. N gonorrhoeae prevalence was 9.4%. There was no difference in the chlamydia prevalence between men who had contact with commercial sex workers (CSWs) and men who had no such contact (15.3% versus 17.2%). However, clients of foreign CSWs were more likely to have chlamydia than clients of registered Turkish CSWs., Conclusions: C trachomatis and N gonorrhoeae are commonly found in Turkish men with urethritis. The findings did not show more chlamydial infection among men who had contact with CSWs than among men who had no such contact. The failure to use condoms among these men must be addressed.

Background: Reinfection, a common occurrence with gonorrhea, may result from a lack of protective immune response, or from the tremendous gonococcal strain variation., Goal: A two-phase study in human volunteers tested whether experimental infection with Neisseria gonorrhoeae MS11mkC would protect against reinfection with the same organisms., Study Design: In phase 1, an intraurethral inoculum of 57,000 piliated, transparent (opacity protein-negative [Opa-]) MS11mkC N gonorrhoeae infected 14 of 15 (93%) volunteers. The volunteers were encouraged to delay treatment for at least 5 days. In phase 2, which began 2 weeks after treatment for the initial infection, volunteers were inoculated with 7,100 piliated, Opa- MS11mkC., Results: The phase 2 challenge infected 6 of 14 (43%) previously infected volunteers and 5 of 10 (50%) naïve control subjects. Phase 1 volunteers who resisted reinfection were significantly more likely to have had a fourfold or greater increase in lipooligosaccharide immunoglobulin G during phase 1 than those who did not resist reinfection (P = 0.026)., Conclusions: Although infection did not provide protection from reinfection under the conditions used, the results suggest that immunity to reinfection is more complex than anticipated by the experimental design.