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Mycoplasma genitalium is a sexually transmitted bacterium associated with nongonococcal urethritis (NGU) in men and cervicitis, endometritis, and pelvic inflammatory disease in women. Effective treatment is challenging due to the inherent, and increasingly acquired, antibiotic resistance in this pathogen. In our treatment trial conducted from 2007 to 2011 in Seattle, WA, we demonstrated poor efficacy of azithromycin (AZM) and doxycycline (DOX) against M. genitalium among men with NGU. In the present study, we cultured M. genitalium from 74 of 80 (92.5%) PCR-positive men at enrollment (V-1) and defined the MICs of AZM (N = 56 isolates) of DOX (N = 62 isolates). Susceptibility to AZM was bimodal; MICs were >8 μg/ml (44.6%) and 8 μg/ml (18/18 men) than those with isolates that had AZM MICs of 8 μg/ml (12/18 men) than with AZM MICs of

In a vaginal 16S ribosomal RNA gene quantitative PCR study of 17 pelvic inflammatory disease (PID) cases and 17 controls who tested positive for Chlamydia trachomatis, women who additionally tested positive for Atopobium vaginae, Sneathia spp., BVAB-TM7, Megasphaera spp., Eggerthella-like bacterium or Mobiluncus spp. were more likely to develop PID.

Many sexually transmitted infections increase risk of mother-to-child transmission (MTCT) of HIV, but the effect of Mycoplasma genitalium is not known. We hypothesized that M. genitalium infection would be common among HIV-infected pregnant women and could be associated with in-utero and intrapartum MTCT.Observational case-cohort study.The current study used specimens from a Kenyan perinatal MTCT cohort (1999-2005) involving HIV-infected women and their infants, who received short-course zidovudine for prevention of MTCT. Vaginal swabs collected at 32 weeks gestation were tested for M. genitalium using a transcription-mediated amplification assay. Infant perinatal HIV infection was determined at birth and 4 weeks of age by DNA PCR. Using a case-cohort design, a random sample was generated with 3 : 1 control : case ratio; prevalence and correlates of M. genitalium were assessed with chi-squared and t tests; predictors of infant outcomes were analyzed using logistic regression.Among 220 HIV-infected pregnant women evaluated, 47 women (21.4%) had M. genitalium. Antenatal M. genitalium infection was associated with higher HIV RNA in plasma (5.0 vs. 4.6 log10 copies/ml in M. genitalium-positive vs. M. genitalium-negative women, P = 0.02) at 32 weeks. Women with M. genitalium were less likely to report prior sexually transmitted infections and genital ulcers (both P = 0.05). There was no association found between exposure to M. genitalium and perinatal MTCT (odds ratio = 0.72, 95% confidence interval 0.35, 1.51, P = 0.39).Vaginal M. genitalium infection was frequently detected among Kenyan HIV-infected pregnant women and was associated with higher plasma HIV levels, but was not associated with perinatal transmission of HIV.

We assessed the association between recent bacterial vaginosis (BV) and incident Mycoplasma genitalium, a sexually transmitted bacterium associated with adverse female reproductive health outcomes. Female sex workers in Mombasa, Kenya, completed a monthly sexual behavior interview and clinical examination. During February 2005–February 2006, vaginal fluid specimens collected from women every other month were tested for M. genitalium by nucleic acid amplification testing. Vaginal microbiota were assessed monthly and categorized by Nugent score (0–3 = normal microbiota, 4–6 = intermediate microbiota disruption, and 7–10 = BV). A discrete failure time analysis for multiple events using logistic regression was employed to estimate the odds of incident M. genitalium infection at follow-up visits among women with BV (vs. normal microbiota) at the preceding visit. Among the 280 women, 54.3% were positive for human immunodeficiency virus. At baseline, 16.1% had prevalent M. genitalium infection and 40.4% had prevalent BV. There were 59 incident M. genitalium infections among 50 women, for an incidence rate of 34.6 cases per 100 person-years. Following adjustment for age, human immunodeficiency virus status, and time, prior BV was associated with a 3.5-fold increase in odds of incident M. genitalium (adjusted odds ratio = 3.49, 95% confidence interval: 1.86, 6.56). This strong association suggests that BV may enhance susceptibility to M. genitalium infection.

ObjectivesWe sought to determine whether the relationship between a history of vaginal douching and pelvic inflammatory disease (PID) is mediated by endometrial infection with one or more novel bacterial vaginosis (BV)-associated organisms among Atopobium vaginae, the BV-associated bacterium 1 (BVAB1), neathia (Leptotrichia) amnionii and Sneathia sanguinegens.MethodsWe first conducted log-binomial regression analyses to identify risk factors for endometrial infection in 535 adolescent and adult women with clinically suspected PID in the PID Evaluation and Clinical Health (PEACH) study. We then examined whether endometrial infection by the BV-associated organisms mediated the association between a history of vaginal douching and histologically confirmed PID using inverse probability weighted marginal structural models.ResultsVaginal douching was significantly associated with endometrial infection with one or more of the targeted BV-associated organisms (relative risk (RR) 1.21, 95% CI: 1.08 to 1.35). The total effect estimate suggested that vaginal douching increased the risk of endometritis by 24% (RR 1.24, 95% CI: 1.03 to 1.49). The controlled direct effect of this association was attenuated with endometrial infection by one or more BV-associated organisms (adjusted RR (aRR) 1.00, 95% CI: 0.57 to 1.74) and endometrial infection by all four BV-associated organisms (aRR 0.95, 95% CI: 0.53 to 1.70) as intermediate variables.ConclusionsEndometrial infection with one or more of the novel BV-associated organisms partially mediated the relationship between vaginal douching and histologically confirmed endometritis in the PEACH study. Frequent vaginal douching may confer risk for endometritis through increasing the risk of endometrial infection by novel-BV-associated organisms. Other potential pathways should be explored.

From February 2015 to October 2017, among 20 men who have sex with men with Mycoplasma genitalium-associated nongonococcal urethritis, 15% had macrolide resistance and S83I ParC mutations. Azithromycin followed by moxifloxacin cleared Mycoplasma genitalium in 2 of 2 with and 11 of 13 without S83I mutations. Dual failures were cleared after doxycycline. S83I mutations were not associated with moxifloxacin failure.

Background A sensitive and specific serologic test is needed to evaluate the association of Mycoplasma genitalium (MG) infection with serious upper reproductive tract sequelae in women. In this study, we compared the ability of immunoblot and ELISA methods to detect serum antibody reactivity with the immunodominant MgpB and MgpC adherence proteins among MG-infected men with nongonococcal urethritis (NGU). Methods Serum samples collected at two time points (spanning 15–86 days) from 22 MG-infected, PCR-positive men with NGU were assayed for reactivity to MG whole cell lysates by immunoblot, and to the conserved C-terminus of MgpB by ELISA, compared to 19 MG-negative controls. Additionally, we selected six MG(+) men with a variety of immunoblot reactivities and examined their serum specimens for ELISA reactivity to 16 recombinant peptides spanning conserved and variable domains of MgpB and MgpC at two time points. Results Among men with current MG infection, immunoblot detection of MgpB antibodies outperformed an ELISA assay detecting reactivity to the conserved C-terminus of MgpB with 90.9% and 81.8% sensitivity, and 92.3% and 82.3% specificity, respectively. In contrast to immunoblot results, ELISA-reactivity to individual peptides spanning MgpB and MgpC indicated patient antibodies more frequently targeted the C-terminus of MgpC than the C-terminus of MgpB. As expected, most patient sera reacted poorly in ELISAs to recombinant peptides spanning the MgpB and MgpC variable regions as these sequences corresponded to the G37 type strain rather than the infecting strains. Conclusion Our findings suggest that an MG ELISA test could be improved by including conserved portions of both the MgpB and MgpC proteins, providing an alternative to the more labor intensive immunoblot. Such a test will be especially valuable for associating current or past MG infection with serious upper reproductive tract disease in women. Disclosure No significant relationships.

Background The UW-STI consortium seeks to develop novel antimicrobials for the treatment of syndromically similar infections caused by Neisseria gonorrhoeae (GC), Chlamydia trachomatis (CT), and Mycoplasma genitalium (MG). Methods We utilize a structure-based validation pipeline embedded with a gated series of criteria for progressing druggable enzyme targets, and for identifying and advancing compounds active against these protein targets. The pipeline includes orthologous and essential enzyme target identification, structure determination, compound library screening, antimicrobial susceptibility testing, hit optimization, and chemical-genetic target validation. Results To date, we have identified over 80 enzyme candidates that are essential, single copy genes in both GC and MG; 7 GC structures, 1 CT structure and 1 MG structure have been solved by crystallography, and soluble expression has been achieved for 19 GC, 20 CT, and 3 MG recombinant enzymes. Several structures common to two bacteria have been solved including tryptophan-tRNA synthetase, lysyl-tRNA synthetase, and ribose-5-phosphate isomerase A/B. Phenylalanyl-tRNA synthetase (PheRS) is among our highest priority targets and is presented as a proof of concept for multi-organism drug development. PheRS is a validated drug target with divergence from its human counterpart, as modeled by the group. In lieu of crystal structures, the GC PheRS alpha and beta complex was modeled using the Rosetta software suite. Multiple cloning and expression strategies have been employed including surface mutations, solubility tags, engineered truncations, and co-expression of both subunits, in hopes of producing crystals. A PheRS001 inhibitor was synthesized from published literature and proved active against GC PheRS with an IC50 of 93 nM, and in antimicrobial testing against all three bacteria: 120 µg/ml (CT MIC) and 18 µg/ml (MG and GC MIC). Conclusion PheRS is a promising example of our pipeline capabilities in our three-pronged approach to produce 5–10 therapeutic leads and aid in the global fight against antibiotic resistance in sexually-transmitted bacterial infections. Disclosure No significant relationships.

Background Although Mycoplasma genitalium (MG) is an acknowledged cause of nongonococcal urethritis (NGU), access to diagnostic testing is limited. Syndromic management is common, yet little is known about natural history. Methods Between August 2014 and April 2016, 13 heterosexual men aged ≥16 years with MG were identified within a cohort study of men with and without NGU attending an urban sexually transmitted diseases clinic. Men had 6-7 monthly visits. NGU was defined as ≥5 polymorphonuclear leukocytes per high-power field on urethral Gram stain plus either visible urethral discharge or urethral symptoms. Men with NGU received 1 g of azithromycin. Men with persistent NGU received moxifloxacin 400 mg for 14 days. First-void urine was retrospectively tested for MG using transcription-mediated amplification. Resistance-associated mutations were detected by polymerase chain reaction (PCR) and sequencing. Organism load was determined by quantitative PCR. Results Sixty-two percent of MG-positive men had macrolide resistance-mediating mutations (MRMM) at enrollment; 31% had parC mutations (all outside the quinolone resistance-determining region). MG persisted after azithromycin in 7 men, 6 of whom had MRMM. The median duration of persistence in the absence of curative therapy was 143 days (range, 21-228). Five men experienced symptom resolution after azithromycin, but MG persisted for another 89-186 days before moxifloxacin. Organism load was somewhat lower in MRMM than wild-type infections (P = .16). Conclusions The high prevalence of macrolide resistance and long duration of infection after symptom resolution highlights the need for diagnostic MG testing of men with NGU to direct therapy.

Antigenic variation of the immunodominant MgpB and MgpC proteins has been suggested to be a mechanism of immune evasion of the human pathogen Mycoplasma genitalium , a cause of several reproductive tract disease syndromes. Phase variation resulting in the loss of adherence has also been documented, but the molecular mechanisms underlying this process and its role in pathogenesis are still poorly understood. In this study, we isolated and characterized 40 spontaneous, nonadherent phase variants from in vitro -passaged M. genitalium cultures. In all cases, nonadherence was associated with the loss of MgpBC protein expression, attributable to sequence changes in the mgpBC expression site. Phase variants were grouped into seven classes on the basis of the nature of the mutation. Consistent with the established role of RecA in phase variation, 31 (79.5%) variants arose via recombination with MgPa repeat regions that contain mgpBC variable sequences. The remaining mutants arose via nonsense or frameshift mutations. As expected, revertants were obtained for phase variants that were predicted to be reversible but not for those that arose via an irreversible mechanism. Furthermore, phase variants were enriched in M. genitalium cultures exposed to antibodies reacting to the extracellular, conserved C terminus of MgpB but not in cultures exposed to antibodies reacting to an intracellular domain of MgpB or the cytoplasmic HU protein. Genetic characterization of the antibody-selected phase variants confirmed that they arose via reversible and irreversible recombination and point mutations within mgpBC . These phase variants resisted antibody-mediated growth inhibition, suggesting that phase variation promotes immune evasion.

Objectives As pelvic inflammatory disease (PID) aetiology is not completely understood, we examined the relationship between select novel bacteria, PID and long-term sequelae. Methods Fastidious bacterial vaginosis (BV)-associated bacteria ( Sneathia (Leptotrichia) sanguinegens , Sneathia amnionii , Atopobium vaginae and BV-associated bacteria 1 (BVAB1)), as well as Ureaplasma urealyticum and Ureaplasma parvum were identified in cervical and endometrial specimens using organism-specific PCR assays among 545 women enrolled in the PID Evaluation and Clinical Health study. Risk ratios and 95% CIs were constructed to determine associations between bacteria, histologically confirmed endometritis, recurrent PID and infertility, adjusting for age, race, gonorrhoea and chlamydia. Infertility models were additionally adjusted for baseline infertility. Results Persistent detection of BV-associated bacteria was common (range 58% for A. vaginae to 82% for BVAB1) and elevated the risk for persistent endometritis (RR adj 8.5, 95% CI 1.6 to 44.6) 30 days post-cefoxitin/doxycycline treatment, independent of gonorrhoea and chlamydia. In models adjusted for gonorrhoea and chlamydia, endometrial BV-associated bacteria were associated with recurrent PID (RR adj 4.7, 95% CI 1.7 to 12.8), and women who tested positive in the cervix and/or endometrium were more likely to develop infertility (RR adj 3.4, 95% CI 1.1 to 10.4). Associations between ureaplasmas and PID sequelae were modest. Conclusions To our knowledge, this is the first prospective study to demonstrate that S. sanguinegens , S. amnionii , BVAB1 and A. vaginae are associated with PID, failure of the Centers for Disease Control and Prevention-recommended treatment to eliminate short-term endometritis, recurrent PID and infertility. Optimal antibiotic regimens for PID may require coverage of novel BV-associated microbes.

Mycoplasma genitalium is an underappreciated cause of human reproductive tract disease, characterized by persistent, often asymptomatic, infection. Building on our previous experiments using a single female pig-tailed macaque as a model for M. genitalium infection (G. E. Wood, S. L. Iverson-Cabral, D. L. Patton, P. K. Cummings, Y. T. Cosgrove Sweeney, and P. A. Totten, Infect Immun 81:2938–2951, 2013, https://doi.org/10.1128/IAI.01322-12 ), we cervically inoculated eight additional animals, two of which were simultaneously inoculated in salpingeal tissue autotransplanted into abdominal pockets. Viable M. genitalium persisted in the lower genital tract for 8 weeks in three animals, 4 weeks in two, and 1 week in one; two primates resisted infection. In both animals inoculated in salpingeal pockets, viable M. genitalium was recovered for 2 weeks. Recovery of viable M. genitalium from lower genital tract specimens was improved by diluting the specimen in broth and by Vero cell coculture. Ascension to upper reproductive tract tissues was not detected, even among three persistently infected animals. M. genitalium- specific serum antibodies targeting the immunodominant MgpB and MgpC proteins appeared within 1 week in three animals inoculated both cervically and in salpingeal pockets and in one of three persistently infected animals inoculated only in the cervix. M. genitalium -specific IgG, but not IgA, was detected in cervical secretions of serum antibody-positive animals, predominantly against MgpB and MgpC, but was insufficient to clear M. genitalium lower tract infection. Our findings further support female pig-tailed macaques as a model of M. genitalium infection, persistence, and immune evasion.

Background. Azithromycin or doxycycline is recommended for nongonococcal urethritis (NGU); recent evidence suggests their efficacy has declined. We compared azithromycin and doxycycline in men with NGU, hypothesizing that azithromycin was more effective than doxycycline. Methods. From January 2007 to July 2011, English-speaking males ≥16 years, attending a sexually transmitted diseases clinic in Seattle, Washington, with NGU (visible urethral discharge or ≥5 polymorphonuclear leukocytes per high-power field [PMNs/HPF]) were eligible for this double-blind, parallel-group superiority trial. Participants received active azithromycin (1 g) + placebo doxycycline or active doxycycline (100 mg twice daily for 7 days) + placebo azithromycin. Urine was tested for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), Ureaplasma urealyticum biovar 2 (UU-2), and Trichomonas vaginalis (TV) using nucleic acid amplification tests. Clinical cure (

An international multilaboratory collaborative study was conducted to develop standard media and consensus methods for the performance and quality control of antimicrobial susceptibility testing of Mycoplasma pneumoniae , Mycoplasma hominis , and Ureaplasma urealyticum using broth microdilution and agar dilution techniques. A reference strain from the American Type Culture Collection was designated for each species, which was to be used for quality control purposes. Repeat testing of replicate samples of each reference strain by participating laboratories utilizing both methods and different lots of media enabled a 3- to 4-dilution MIC range to be established for drugs in several different classes, including tetracyclines, macrolides, ketolides, lincosamides, and fluoroquinolones. This represents the first multilaboratory collaboration to standardize susceptibility testing methods and to designate quality control parameters to ensure accurate and reliable assay results for mycoplasmas and ureaplasmas that infect humans.

Mycoplasma genitalium-reactive cervicovaginal IgA and IgG antibodies were detected in 51.9% and 70.4% of 27 infected women and 22.2% and 18.5% of 27 uninfected controls, respectively. The predominance of MgpB- and MgpC-reactive antibodies at the site of infection is consistent with their hypothesized role in selecting antigenic variants during persistent infection.

This chapter outlines the need for, and application of, molecular tests for Haemophilus ducreyi, Treponema pallidum, and Mycoplasma genitalium, three sexually transmitted diseases (STDs) pathogens for which commercial molecular tests are not currently available. H. ducreyi and T. pallidum are the causative agents of chancroid and syphilis, respectively, which along with herpes simplex virus (HSV) are responsible for the majority of genital ulcer disease (GUD) cases worldwide. The first PCR assays specific for M. genitalium were simultaneously developed in two laboratories and provided a means of detecting M. genitalium in patient specimens. The authors await further application of these quantitative PCR assays to assess other aspects of M. genitalium infection such as the association of M. genitalium burden in cervical, urine, and vaginal specimens and their association with signs and symptoms of infection at these sites. Unlike most PCRs, TMA assays target rRNA, which is present in multiple copies per cell, thus potentially increasing both the analytical and the clinical sensitivity of M. genitalium detection. Similarly, PCR and TMA assays for M. genitalium have allowed studies defining the association of this emerging pathogen with reproductive tract disease in both men and women. Undoubtedly other, previously uncultivated organisms colonizing the reproductive tract will be detected in the future. Their identification and the subsequent development of specific PCR assays and treatment regimens will expand one's knowledge of reproductive tract pathogens.

Neisseria gonorrhoeae and Chlamydia trachomatis are characterized by different risk factors, thus control strategies for each also differ. In contrast, risk factors for Mycoplasma genitalium have not been well characterized.Between 2000 and 2006, 1090 women ages 14 to 45 attending the Public Health-SeattleKing County Sexually Transmitted Diseases Clinic in Seattle, WA, underwent clinical examination and computer-assisted survey interview. M. genitalium was detected by transcription mediated amplification from self-obtained vaginal swab specimens. C. trachomatis and N. gonorrhoeae were detected by culture from cervical swab specimens.Prevalent M. genitalium infection was detected in 84 women (7.7%), C. trachomatis in 63 (5.8%), and N. gonorrhoeae in 26 (2.4%). Age20 and nonwhite race were associated with increased risk for all 3 organisms. In addition, risk for M. genitalium was higher for women with a black partner (adjusted odds ratio [AOR]: 3.4; 95% confidence interval = 1.83-6.29), those never married (AOR: 2.6; 1.08-6.25), using Depo-Provera (AOR: 2.3; 1.19-4.46), and smoking (AOR: 1.7; 1.03-2.83). Drug use, history of STI in the past year, ≤high school education, meeting and having intercourse the same day, anal sex, douching, and hormonal contraception were associated with N. gonorrhoeae or C. trachomatis, but not with M. genitalium. Number of partners was not associated with any of the 3 organisms.The limited number of risk factors for prevalent infection common to all 3 pathogens suggests that M. genitalium may circulate in different sexual networks than N. gonorrhoeae or C. trachomatis. The predominance of sociodemographic risk factors for M. genitalium, rather than high-risk sexual behaviors, suggests broad-based testing may be the most effective control strategy.

Objective To assess the role of Ureaplasma urealyticum and Ureaplasma parvum in patients with non-gonococcal urethritis (NGU) using specimens from a previously reported study of NGU. Methods Species-specific PCR assays for U urealyticum and U parvum were used to detect these organisms in specimens from men enrolled in a case–control study based in a Seattle STD clinic in order to evaluate their association with NGU. Urethritis was defined by clinical examination and the presence of inflammation on Gram stained smear. Controls had normal examination findings and no evidence of inflammation on Gram stain smear or by the leucocyte esterase test. Results U urealyticum was detected in 26% (31/119) of cases and 16% (19/117) of controls, resulting in an association with NGU (adjusted odds ratio (aOR)=2.3, 95% CI 1.04 to 4.9) after adjusting for age, race, history of prior urethritis and other NGU pathogens ( Chlamydia trachomatis , Mycoplasma genitalium ). The association of U urealyticum and NGU was strongest in white men U parvum was detected in 14% (17/119) cases and 31% (36/117 controls) and thus was negatively associated with NGU (aOR=0.4, 95% CI 0.2 to 0.8). The prevalence of U urealyticum (16%) in controls was higher than that of C trachomatis (3.4%) or M genitalium (4.3%, p Conclusions Unlike U parvum , U urealyticum was associated with urethritis. The strong effect in younger white men and high rates in controls may suggest variability in virulence among U urealyticum strains or in host innate or acquired immunity.

Mycoplasma genitalium is associated with cervicitis and pelvic inflammatory disease in nonpregnant women. We investigated associations between cervical M genitalium, demographic and behavioral risk factors for sexually transmitted infection and preterm birth among low-income Peruvian women.This case-control study, conducted at the Instituto Nacional Materno Perinatal, Lima, Peru, included 661 cases with a spontaneous preterm birth at37 weeks and 667 controls who delivered ator=37 weeks. Within 48 hours after delivery, subjects underwent interviews, medical record review, and collection of cervicovaginal specimens for M. genitalium, Chlamydia trachomatis, and Neisseria gonorrhoeae by nucleic acid amplification testing, and Trichomonas vaginalis by culture. Odds ratios and 95% confidence intervals were calculated for associations between M. genitalium, other genital infections and risk factors, and preterm birth. Multivariable logistic regression was used to adjust for potential confounders.Cervical M. genitalium was detected in 3% of subjects and was significantly associated with C. trachomatis infection (P0.001) and preterm birth (4% vs. 2%; adjusted odds ratio: 2.5, 95% confidence interval: 1.2-5.0, P = 0.014), and marginally associated with T. vaginalis (P = 0.05). M. genitalium detection was also associated with younger maternal age (P = 0.003) but not with other risk factors for preterm birth. The association between cervical M. genitalium detection and preterm birth remained significant after adjustment for maternal age and coinfection with C. trachomatis or T. vaginalis.Cervical M. genitalium detection was independently associated with younger maternal age and preterm birth, suggesting that this organism may be an infectious correlate of spontaneous preterm birth.

Pelvic inflammatory disease (PID), which is an inflammation of the female upper genital tract that is caused by the ascension of organisms from the lower genital tract, affects ∼8% of reproductive-age women in the United States at some time in their lives [1]. Serious sequelae, including recurrent PID, tubal factor infertility, ectopic pregnancy, and chronic pelvic pain, are common sequelae of PID [2]. The sexually transmitted pathogens Chlamydia trachomatis and Neisseria gonorrhoeae cause 30%–50% of PID cases [3-5]. Although the etiology of PID is unknown in the majority of cases, it has been epidemiologically linked to bacterial vaginosis [6]. Mycoplasma genitalium has been identified as a possible etiologic agent of nongonococcal, nonchlamydial PID [7-9]. It has also been detected in cervical and salpingeal samples obtained from women with laparoscopically confirmed salpingitis [10] and in cervical and endometrial specimens obtained from women with endometritis [7]. Because M. genitalium is extremely difficult to culture, epidemiologic studies that assess the role of this organism in reproductive diseases among women are dependent on the development and application of PCR-based assays. Although little is known about the clinical characteristics of M. genitalium PID, evidence suggests that, as is the case in women with chlamydia, lower genital tract infections tend to be asymptomatic [11, 12]. At presentation, the characteristics of women with PID vary, and they may include pelvic pain, abnormal vaginal discharge, bleeding, itching, and/or odor. Although the most common symptom of PID is pelvic pain, many women with PID may have mild pain or no pain, despite evidence of infection and inflammation [13, 14]. The presence and severity of PID symptoms vary by microbiologic etiology, with women who have chlamydial PID being more likely than women who have gonococcal PID to be asymptomatic [15-18]. The purpose of our study was to describe the clinical features of women with lower and/or upper genital tract infection due to M. genitalium in a population of women who presented with clinically suspected PID. We hypothesized that clinical characteristics, symptoms, and pelvic pain at presentation would be less frequent and less severe among women with M. genitalium or C. trachomatis infection than they would be among women with gonococcal PID.

Objectives: As the aetiology of bacterial vaginosis (BV) is not well understood, this study sought to determine the relationships between several fastidious microbes, BV and selected clinical characteristics of BV. Methods: Endometrial and cervical specimens from 50 women with non-gonococcal, non-chlamydial endometritis were tested for Leptotrichia sanguinegens/amnionii , Atopobium vaginae , bacterial vaginosis-associated bacteria 1 (BVAB1), Ureaplasma urealyticum biovar 2 (UU-2) and Ureaplasma parvum using PCR. BV was categorised using Nugent’s and Amsel’s criteria. Odds ratios (OR) adjusted for age and race were estimated using multivariable logistic regression. Results: Although elevated pH was a universal feature, other BV characteristics differed by pathogen, suggesting variable clinical presentation. Only UU-2 was strongly associated with vaginal discharge, but a positive whiff test and a 20% or greater classification of epithelial cells as clue cells were more common among women with L sanguinegens/amnionii , A vaginae and BVAB1. For each of these bacteria, there were trends towards associations with BV defined by Amsel’s criteria ( L sanguinegens/amnionii OR 2.9, 95% CI 0.5 to 15.7; A vaginae OR 2.6, 95% CI 0.6 to 11.4; BVAB1 OR 5.7, 95% CI 1.0 to 31.1) and significant associations with BV defined by Gram stain ( L sanguinegens/amnionii OR 17.7, 95% CI 2.8 to 113.0; A vaginae OR 19.2, 95% CI 3.7 to 98.7; BVAB1 OR 21.1, 95% CI 2.2 to 198.5). Conclusions: L sanguinegens/amnionii , A vaginae and BVAB1 are associated with clinical characteristics consistent with BV and BV defined by Nugent’s and Amsel’s criteria. These fastidious bacteria may cause unrecognised infection, as none was associated with abnormal vaginal discharge.

We assessed the relationship between infection with Mycoplasma genitalium, an emerging sexually transmitted pathogen, and cervical shedding of human immunodeficiency virus (HIV)–1 DNA among 303 HIV-1–positive Kenyan women. HIV-1 shedding was detected by qualitative polymerase chain reaction (PCR) in 154 women (51%); M. genitalium was detected by qualitative PCR in 52 (17%), and organism burden was determined by quantitative PCR. Women with high M. genitalium organism burdens (more than the median of 3195 genomes/mL) were 3-fold more likely to shed HIV-1 DNA than were M. genitalium–negative women (adjusted OR, 2.9 [95% confidence interval, 1.1–7.6]), yet this did not appear to be mediated by traditional measures of cervical inflammation (elevated polymorphonuclear leukocyte count).

Objectives. We sought to determine the prevalence of and risk factors associated with Mycoplasma genitalium infection in a nationally representative sample of young adults in the United States. Methods. Urine specimens from 1714 women and 1218 men who participated in Wave III of the National Longitudinal Study of Adolescent Health (N=14322) were tested for M genitalium. Poststratification sampling weights were used to generate nationally representative estimates. Results. The prevalence of M genitalium was 1.0% compared with 0.4%, 4.2%, and 2.3% for gonococcal, chlamydial, and trichomonal infections, respectively. No M genitalium–positive individuals reported symptoms of discharge. M genitalium prevalence among those who reported vaginal intercourse was 1.1% compared with 0.05% among those who did not. In multivariate analyses, M genitalium prevalence was 11 times higher among respondents who reported living with a sexual partner, 7 times higher among Blacks, and 4 times higher among those who used condoms during their last vaginal intercourse. Prevalence of M genitalium increased by 10% for each additional sexual partner. Conclusions. M genitalium was more prevalent than Neisseria gonorrhoeae but less prevalent than Chlamydia trachomatis, and it was strongly associated with sexual activity.

Mycoplasma genitalium has been associated with cervicitis, endometritis, and tubal factor infertility. Because the ability of this bacterium to ascend and infect the fallopian tube remains undefined, we performed an investigation to determine the prevalence of M genitalium in fallopian tube, endometrial, and cervical specimens from women laparoscopically diagnosed with acute salpingitis in Nairobi, Kenya.Women presenting with pelvic inflammatory disease were laparoscopically diagnosed with salpingitis. Infection with M genitalium in genital specimens was determined by polymerase chain reaction (PCR).Of 123 subjects with acute salpingitis, M genitalium was detected by PCR in the cervix and/or endometrium in nine (7%) participants, and in a single fallopian tube specimen. In addition, those infected with M genitalium were more often HIV infected than women not infected by M genitalium (seven of nine (78%) v 42 of 114 (37%), p0.03).M genitalium is able to ascend into the fallopian tube, but its association with tubal pathology requires further investigation.

BACKGROUND: In recent years, increasing evidence has accumulated that suggests the majority of cases of genital ulcer disease in sub-Saharan Africa are due to viral and not bacterial infections. Although many cross-sectional studies support such a trend, few serial cross-sectional data are available to show the evolution of genital ulcer disease over time. METHODS: We surveyed the prevalence of sexually transmitted diseases (STDs) among patients with STD symptoms and women recruited from family planning clinics in 3 cities in Botswana in 2002 and compared our findings with those from a survey of a similar population conducted in 1993. RESULTS: The observed proportion of cases of genital ulcer disease due to chancroid decreased from 25% in 1993 to 1% in 2002, whereas the proportion of ulcers due to herpes simplex virus increased from 23% in 1993 to 58% in 2002. Although the proportion of ulcers due to syphilis was similar for both surveys, the rate of positive serologic test results for syphilis among patients with genital ulcer disease decreased from 52% in 1993 to 5% in 2002. During this period, decreases in the prevalence of gonorrhea, syphilis-reactive serologic findings, chlamydial infection, and trichomoniasis were also detected among patients with STDs and women from family planning clinics. These changes remained significant after estimates were adjusted for the sensitivity and specificity of diagnostic tests. CONCLUSIONS: Our findings suggest a decrease in the prevalence of bacterial STDs and trichomoniasis, a reduction in the proportion of ulcers due to bacterial causes, and an increase in the proportion of ulcers due to herpes simplex virus during the period 1993-2002. These changes should be taken into consideration when defining new guidelines for the syndromic management of genital ulcer disease.

Although Chlamydia trachomatis and Neisseria gonorrhoeae are established causes of salpingitis, the majority of cases have no known etiology. We used broad-range 16S rDNA polymerase chain reaction to identify novel, possibly uncultivable, bacteria associated with salpingitis and identified bacterial 16S sequences in Fallopian-tube specimens from 11 (24%) of 45 consecutive women with laparoscopically confirmed acute salpingitis (the case patients) and from 0 of 44 women seeking tubal ligations (the control subjects) at Kenyatta National Hospital, Nairobi, Kenya. Bacterial phylotypes most closely related to Leptotrichia spp. were detected as the sole phylotypes in 1, and mixed with other bacterial phylotypes in 2, specimens. Novel bacterial phylotypes and those associated with bacterial vaginosis, including Atopobium vaginae, were identified in 3 specimens. N. gonorrhoeae and Streptococcus pyogenes were identified in 2 and 1 specimens, respectively. The finding of novel phylotypes associated with salpingitis has important implications for the etiology, pathogenesis, and treatment of this important reproductive-tract disease syndrome.

Background: Mycoplasma genitalium is associated with, and could be the cause of, idiopathic cases of urethritis, endometritis, and cervicitis. Further epidemiologic studies on this organism are needed, but currently used polymerase chain reaction (PCR) assays are labor-intensive and culture is insensitive. Goal: The goal was to develop and evaluate a microwell-plate-based PCR assay for M. genitalium. Study Design: We adapted an M. genitalium PCR assay targeting the MgPa gene to a 96-microwell plate format with colorimetric detection of PCR products and incorporation of an internal inhibition control to determine the limit of detection of this assay (termed MgPa-IMW) for M. genitalium DNA and evaluate its performance on cervical and male urine specimens. Results: The MgPa-IMW PCR assay detected 1 and 17 genome copies of M. genitalium (with 27% and 95% confidence) and was able to detect specimens inhibited for amplification. This assay was 100% concordant (50 positive and 50 negative) with the Southern-blot-based PCR assay with cervical specimens. Similarly, this test was 89% concordant with the Southern-blot-based assay for 64 male urine specimens (25 positive, 32 negative, 7 discordant), 97% concordant after correcting for specimens no longer positive by the Southern blot-based assay after freezer storage. Conclusion: The MgPa-IMW assay is sensitive and specific for the detection of M. genitalium in patient specimens and should facilitate large-scale screening for this organism.

Objective Ureaplasma urealyticum biovar 2 (UU-2), but not Ureaplasma parvum (UP), has been associated with non-gonococcal urethritis (NGU), but little is known about species-specific responses to standard therapies. We examined species-specific treatment outcomes and followed men with treatment failure for 9 weeks. Methods From May 2007 to July 2011, men aged ≥16 attending a sexually transmitted disease (STD) clinic in Seattle, Washington, with NGU (urethral discharge or urethral symptoms plus ≥5 polymorphonuclear leucocytes /high-powered field) enrolled in a double-blind, randomised trial. Participants received active azithromycin (1 g) + placebo doxycycline or active doxycycline (100 mg twice a day ×7 days) + placebo azithromycin. Ureaplasma were detected in culture followed by species-specific PCR. Outcomes were assessed at 3, 6 and 9 weeks. At 3 weeks, men with persistent Ureaplasma detection received ‘reverse therapy’ (eg, active doxycycline if they first received active azithromycin). At 6 weeks, persistently positive men received moxifloxacin (400 mg×7 days). Results Of 490 men, 107 (22%) and 60 (12%) were infected with UU-2 and UP, respectively, and returned at 3 weeks. Persistent detection was similar for UU-2-infected men initially treated with azithromycin or doxycycline (25% vs 31%; p=0.53), but differed somewhat for men with UP (45% vs 24%; p=0.11). At 6 weeks, 57% of UU-2-infected and 63% of UP-infected men who received both drugs had persistent detection. Failure after moxifloxacin occurred in 30% and 36%, respectively. Persistent detection of UU-2 or UP was not associated with signs/symptoms of NGU. Conclusions Persistent detection after treatment with doxycycline, azithromycin and moxifloxacin was common for UU and UP, but not associated with persistent urethritis. Trial registration number NCT00358462.

Problem Toll-like (TLR) receptor genetic variants have been implicated in bacterial vaginosis (BV). We determined whether TLR variants are associated with fastidious BV-associated microbes that are linked with infertility following pelvic inflammatory disease (PID). Method of study Sneathia spp., Atopobium vaginae, BVAB1, and Ureaplasma urealyticum were measured in 250 women from the PID Evaluation and Clinical Health (PEACH) study. Relative risk (RR) and 95% confidence intervals (CI) were calculated adjusting for chlamydia and gonorrhea. Principal component analysis was used to adjust for population stratification. A false discovery rate q-value of 0.05 was significant. Results TLR2-1733C>A (P = .003) and TLR2-616A>G (P = .004) were associated with cervical A. vaginae. TLR2-1733C>A and TLR6-438C>T were associated with A. vaginae detection in the endometrium, but this was not significant after adjustment for multiple comparisons (FDR q-value = 0.06). Conclusion Host gene variants in TLR2 signaling pathways were modestly associated with cervical A. vaginae in women with clinical PID.

Haemophilus ducreyi is a gram-negative obligate human pathogen that causes the genital ulcer disease chancroid. Chancroid lesions are deep necrotic ulcers with an immune cell infiltrate that includes macrophages. Despite the presence of these phagocytic cells, chancroid ulcers can persist for months and live H. ducreyi can be isolated from these lesions. To analyze the interaction of H. ducreyi with macrophages, we investigated the ability of H. ducreyi strain 35000 to adhere to, invade, and survive within U-937 cells, a human macrophage-like cell line. We found that although H. ducreyi strain 35000 adhered efficiently to U-937 cells, few bacteria were internalized, suggesting that H. ducreyi avoids phagocytosis by human macrophages. The few bacteria that were phagocytosed in these experiments were rapidly killed. We also found that H. ducreyi inhibits the phagocytosis of a secondary target (opsonized sheep red blood cells). Antiphagocytic activity was found in logarithmic, stationary-phase, and plate-grown cultures and was associated with whole, live bacteria but not with heat-killed cultures, sonicates, or culture supernatants. Phagocytosis was significantly inhibited after a 15-min exposure to H. ducreyi , and a multiplicity of infection of approximately 1 CFU per macrophage was sufficient to cause a significant reduction in phagocytosis by U-937 cells. Finally, all of nine H. ducreyi strains tested were antiphagocytic, suggesting that this is a common virulence mechanism for this organism. This finding suggests a mechanism by which H. ducreyi avoids killing and clearance by macrophages in chancroid lesions and inguinal lymph nodes.

We used PCR assays to determine the etiology of genital ulcers in patients presenting to a sexually transmitted disease clinic in Dakar, Senegal, and evaluated the ability of two PCR tests ( groEL and recD ) and two serological tests (adsorption enzyme immunoassay [EIA] and lipooligosaccharide [LOS] EIA) to detect current Haemophilus ducreyi infection. We found that in this population, H. ducreyi , T. pallidum , and herpes simplex virus HSV DNA were detected in 56, 15, and 13% of 39 genital ulcer specimens, respectively, and H. ducreyi DNA was detected in 60% (3 of 5) of samples from ulcerated bubos. Among 40 consecutive patients with genital ulcer disease and with sufficient sample for both PCR assays, the recD and groEL H. ducreyi PCR assays were 83% concordant, with the recD PCR assay detecting six (15%) additional positive specimens and the groEL assay detecting one (3%) additional positive specimen. Compared to PCR, the adsorption EIA and LOS EIA tests had sensitivities of 71 and 59% and specificities of 57 and 90%, respectively, for the diagnosis of current H. ducreyi infection. While these differences in specificity could be due either to previous infection with H. ducreyi or to the detection of cross-reacting antibodies, only 6% of patients from a nearby family planning clinic gave a positive reaction in both the adsorption EIA and LOS EIA assays, indicating that cross-reacting antibodies are not prevalent among clinic attendees in this city. Our studies indicate that the adsorption EIA detects both current and past infection, while the LOS EIA assay is more specific for current infection with H. ducreyi in this population.

Haemophilus ducreyi , the etiologic agent of chancroid, a genital ulcer disease, produces a cell-associated hemolysin whose role in virulence is not well defined. Hemolysin is encoded by two genes, hhdA and hhdB , which, based on their homology to Serratia marcescens shlA and shlB genes, are believed to encode the hemolysin structural protein and a protein required for secretion and modification of this protein, respectively. In this study, we determined the prevalence and expression of the hemolysin genes in 90 H. ducreyi isolates obtained from diverse geographic locations from 1952 to 1996 and found that all strains contained DNA homologous to the hhdB and hhdA genes. In addition, all strains expressed a hemolytic activity. We also determined that hemolysin is expressed in vivo and is immunogenic, as indicated by the induction of antibodies to hemolysin in both the primate and rabbit disease models as well as in human patients with naturally acquired chancroid. Wild-type strain 35000 and isogenic hemolysin-negative mutants showed no difference in lesion development in the temperature-dependent rabbit model. However, immunization of rabbits with the purified hemolysin protein reduced the recovery of wild-type H. ducreyi , but not hemolysin-negative mutants, from lesions. Our study indicates that hemolysin is a possible candidate for vaccine development due to its immunogenicity, expression in vitro and in vivo by most, if not all, strains, and the effect of immunization on reducing the recovery of viable H. ducreyi in experimental disease in rabbits.

In 1994, an apparent outbreak of atypical genital ulcers was noted by clinicians at the sexually transmitted disease clinic in Jackson, Mississippi. Of 143 patients with ulcers tested with a multiplex polymerase chain reaction (PCR) assay, 56 (39%) were positive for Haemophilus ducreyi, 44 (31%) for herpes simplex virus, and 27 (19%) for Treponema pallidum; 12 (8%) were positive for > 1 organism. Of 136 patients tested for human immunodeficiency virus (HIV) by serology, 14 (10%) were HIV-seropositive, compared with none of 200 patients without ulcers (P < .001). HIV-1 DNA was detected by PCR in ulcers of 6 (50%) of 12 HIV-positive patients. Multivariate analysis indicated that men with chancroid were significantly more likely than male patients without ulcers to report sex with a crack cocaine user, exchange of money or drugs for sex, and multiple sex partners. The strong association between genital ulcers and HIV infection in this population highlights the urgency of preventing genital ulcers in the southern United States.

Objective Doxycycline, one of two recommended therapies for non-gonococcal urethritis (NGU), consists of a 7-day course of therapy (100 mg BID). Since suboptimal adherence may contribute to poor treatment outcomes, we examined the association between self-reported imperfect adherence to doxycycline and clinical and microbiologic failure among men with NGU. Methods Men aged ≥16 years with NGU attending a Seattle, WA, sexually transmitted diseases clinic were enrolled in a double-blind, parallel-group superiority trial from January 2007 to July 2011. Men were randomised to active doxycycline/placebo azithromycin or placebo doxycycline/active azithromycin. Imperfect adherence was defined as missing ≥1 dose in 7 days. Urine was tested for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), and Ureaplasma urealyticum -biovar 2 (UU-2) using nucleic acid amplification tests. Clinical failure (symptoms and ≥5 PMNs/HPF or discharge) and microbiologic failure (positive tests for CT, MG, and/or UU-2) were determined after 3 weeks. Results 184 men with NGU were randomised to active doxycycline and provided data on adherence. Baseline prevalence of CT, MG and UU-2 was 26%, 13% and 27%, respectively. 28% of men reported imperfect adherence, and this was associated with microbiologic failure among men with CT (aRR=9.33; 95% CI 1.00 to 89.2) and UU-2 (aRR=3.08; 95% CI 1.31 to 7.26) but not MG. Imperfect adherence was not significantly associated with clinical failure overall or for any specific pathogens, but it was more common among imperfectly adherent men with CT (aRR=2.63; 0.93–7.41, p=0.07). Conclusions Adherence may be important for microbiologic cure of select pathogens. Factors other than adherence should be considered for CT-negative men with persistent NGU.

Adult pigtailed macaques (Macaca nemestrina) were evaluated for their usefulness as a primate model for chancroid. To initiate infection, 10(7)-10(8) cfu of Haemophilus ducreyi were inoculated into the foreskins of 5 adult males and into the vaginal labia of 4 adult females. Lesions developed in the male macaques that were similar in appearance, histopathologic changes, and progression to those of human disease, including the development of ulcers 6-12 days after infection. In addition, H. ducreyi could be recovered from the lesions up to 20 days after inoculation, humoral antibodies were induced beginning 1 week after inoculation, and inguinal lymphadenopathy was noted in 4 of the 5 males. None of the 4 female macaques inoculated with the same preparation of live H. ducreyi developed comparable lesions. Thus, experimental chancroid in adult male macaques closely resembles human disease and should be useful for future studies of the pathogenesis of chancroid.

After accounting for Mycoplasma genitalium (MG) and other known pathogens, previous estimates suggest that 20%–50% of nongonococcal urethritis (NGU) case patients seen in specialty clinics have no defined etiology [1]. Ureaplasmas may account for some of these idiopathic cases, but existing evidence is conflicting. During the past 50 years, numerous investigators have evaluated the role of ureaplasmas as causative agents of urethritis, utilizing animal models [2, 3], human challenge experiments [4], and epidemiologic data collected from various study populations, with no consensus reached to date. Although some epidemiologic studies of ureaplasmas have demonstrated an association with urethritis [5–15], others have reported similar or higher prevalences of these bacteria among asymptomatic control subjects [16–21]. These disparate results may be explained, in part, by the choice of study population. Many selected case patients and control subjects are from sexually transmitted disease (STD) clinics where attendees have similar characteristics and past exposures, potentially hampering detection of an association [22]. An alternate explanation lies in findings from recent phylogenetic analyses that demonstrate that the 2-biovar system of classification represents 2 distinct species, now designated Ureaplasma parvum (UP; formerly U. urealyticum biovar 1) and U. urealyticum (UU; formerly U. urealyticum biovar 2) [23, 24]. Although indistinguishable by conventional culture methods, UU and UP can be differentiated by polymerase chain reaction (PCR) [24–28]. Genotypic and phenotypic differences between these species are an emerging area of research; markers associated with pathogenic potential have not yet been identified [23, 25, 29–32]. Moreover, the epidemiologic data regarding associations of differentiated UU and UP with NGU are inconclusive [28, 33–35]. We conducted a case-control study using 2 separate control groups to investigate the associations of UU and UP with NGU overall and in prespecified subgroups. We hypothesized that UU, but not UP, would be associated with NGU and that the relationship would be stronger when men who were not STD clinic attendees were compared with case patients (vs the standard STD clinic control subjects). Because we hypothesized that adaptive immunity might attenuate clinical manifestations of infection, we evaluated the associations of UU and UP with NGU among younger men and those with less sexual experience. We posited that the relationships would be stronger among these men.

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.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.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.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.

By studying capabilities inherent in the nerve proper and carefully considering patient complaints and limitations, the surgeon-therapist team may be able to guide patients through a restorative phase via nerve gliding techniques. Nerve symptoms must be heeded when employing rehabilitation techniques. Rather than encouraging the patient to push beyond nerve pain either proximally or distally, the patient is instructed to perform exercises in positions that enhance nerve gliding in a slow, controlled manner. "Tincture of time" is prescribed as the patient advances to a less symptomatic level of function.

Objectives: As Mycoplasma genitalium is associated with pelvic inflammatory disease (PID), we examined the efficacy of a commonly used PID antimicrobial in treating M genitalium upper genital tract infection. Methods: In the PID Evaluation and Clinical Health study of inpatient versus outpatient treatment, 682 women treated with cefoxitin and doxycycline for clinically suspected PID had stored cervical and endometrial specimens available for analysis. In the current sub study, we compared baseline endometritis, short term treatment failure (continued endometritis and pelvic pain 30 days following treatment) and sequelae among women with and without M genitalium, identified using PCR. Results: Endometrial M genitalium was associated with baseline endometritis (adjusted OR 3.0, 95% CI 1.5 to 6.1). Among women with a positive baseline M genitalium test, 41% tested positive again 30 days following treatment. Women testing positive compared to those testing negative for M genitalium at baseline had an increased risk of short-term treatment failure (RR 4.6, 95% CI 1.1 to 20.1). Rates of sequelae, including infertility (22%), recurrent PID (31%) and chronic pelvic pain (42%), were high among women testing positive for endometrial M genitalium at baseline. There was a non-significant trend towards increased infertility, chronic pelvic pain and recurrent PID, and decreased pregnancy and live birth following M genitalium infection. Conclusions: M genitalium is associated with endometritis and short-term PID treatment failure. Cefoxitin and doxycycline, a Centers for Disease Control and Prevention recommended PID treatment regimen, is ineffective for the treatment of M genitalium upper genital tract infection.

At the beginning of the 21st century, we face stable or increasing infection rates for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) in the United States. These are unacceptable circumstances in view of the serious negative impact of these infections on reproductive health and their relatively high prevalence in the United States compared with other industrialized countries.1,2 Clearly, reduction of prevalence and incidence requires improved intervention approaches, including better screening strategies. CT and GC infections in the general population are often asymptomatic and consequently are underdiagnosed.3,4 Targeted screening programs in the United States have resulted in steady declines in the prevalence of these infections in the 1990s, a trend that unfortunately has not been sustained in recent years. Surveillance statistics from the CDC reveal that reported cases of gonorrhea rose sharply from the mid 1960s through the 1970s, declined steadily until the mid 1990s and then plateaued.2 Comparable data for CT infections have been collected only since 1984, and nationwide, case rates appear to have risen steadily through the most recent annual data summary period in 2005. However, screening for CT became widespread only after the advent of affordable, reliable detection methods including nucleic acid amplification tests (NAATs) in the 1990s, and case detection has been increasing steadily ever since.2 Thus, the apparent increase in CT case detection is likely due in part to increased case finding. However, in the northwestern states comprising Public Health Region X, funding for broad-based CT screening among women was initiated in 1988, and data have been collected on the number of tests performed and the percent of CT tests that were positive. In Region X, CT prevalence rates actually dropped steadily between 1988 and 1995 and then remained steady through 1997 (Fig. 1).5 Data from the regional Infertility Prevention Programs have provided good CT prevalence data from participating family planning clinics in the United States since the late 1990s. Infertility Prevention Programs data show that CT rates in women seen in these settings remained steady nationwide through 2005.5 Importantly, in Region X, where screening programs have been in place the longest, the percentage of women tested who have positive tests for CT is now rising, even after statistical adjustment for increases in test sensitivity (Fig. 1). The reasons for the lack of continued decline (and even increases) in both CT and GC prevalence are not entirely clear, but these trends may be consequences of initial screening programs that targeted only a subset of the population (those who attended the clinics), allowing continued spread in underserved sectors of the community (those who did not attend the clinics). Thus, it is logical to conclude that programs for screening all at-risk populations could further reduce sexually transmitted infection (STI) prevalence. Fig. 1 Trends in Chlamydia trachomatis positivity among 15- to 24-year old women tested in family planning clinics in northwestern states of Public Health Region X, 1988 to 2005. Data are from the Centers for Disease Control and Prevention.5 Black bars are unadjusted, ... Possible strategies for reducing STI prevalence include expanding screening to nontraditional settings such as schools, juvenile detention centers, hospital emergency departments, and drug rehabilitation clinics. The availability of highly sensitive NAATs allows the use of specimens other than conventional clinician-obtained endocervical and urethral specimens, such as urine and vaginal specimens, for detection of CT and GC.

Objectives To determine the safety and effectiveness of single-dose rifalazil, a new rifamycin, for the treatment of nongonococcal urethritis (NGU). Study design Randomized, double-blind trial comparing rifalazil, 2.5, 12.5 or 25 mg, with 1.0 g azithromycin for the treatment of NGU. One hundred and seventy men were evaluated for Chlamydia trachomatis, Ureaplasma urealyticum, and Mycoplasma genitalium infection before therapy and 2- and 5-weeks posttreatment. Results C. trachomatis, M. genitalium, and U. urealyticum were present in 42%, 24%, and 28% of subjects, respectively. Microbiologic eradication of C. trachomatis with rifalazil 25 mg at 2- and 5- weeks was 85% and 83%, respectively. Rifalazil was ineffective in eradicating M. genitalium and U. urealyticum. Overall clinical cure rates at 2- and 5-weeks were 86% (95% CI 67-96) and 59% (39-78) in the rifalazil-treated 25 mg group, and 77% (56-91) and 63% (41-81) in the azithromycin-treated group. Conclusions Rifalazil was well tolerated and eradicates C. trachomatis but not M. genitalium and U. ureaplasma in men with NGU.

Objective The objective of this study was to assess the risk factors for and persistence of Mycoplasma genitalium (MG) in a highly exposed female population in Kenya. Study design Two hundred fifty-eight sex workers in Nairobi, Kenya, 18 to 35 years of age, were enrolled. Every 2 months, cervical samples were collected for MG, Chlamydia trachomatis (CT), and Neisseria gonorrhoeae (GC) testing by polymerase chain reaction. Results At enrollment, 16% were infected with MG. Seventy-seven subjects acquired 107 MG infections, giving an incidence of 22.7 per 100 women-years. Incident CT (adjusted hazard ratio [HR] = 2.4; 95% confidence interval [CI] = 1.5-4.0), GC (HR = 2.0; 95% CI = 1.2-3.5), and HIV infection (adjusted HR = 2.2; 95% CI = 1.3-3.7) were associated with an increased risk of MG. Seventeen percent, 9%, and 21% of MG infections persisted 3, 5, and >or=7 months, respectively. Conclusion The high incidence of MG, greater than that for both CT (14.0%) and GC (8%), association with common sexually transmitted infection risk factors, and persistence in the female genital tract supports its role as a common sexually transmitted infection in Kenyan women.

Pelvic inflammatory disease (PID) is a frequent condition of young women, often resulting in reproductive morbidity. Although Neisseria gonorrhoeae and/or Chlamydia trachomatis are/is recovered from approximately a third to a half of women with PID, the etiologic agent is often unidentified. We need PCR to test for M genitalium among a pilot sample of 50 women with nongonococcal, nonchlamydial endometritis enrolled in the PID evaluation and clinical health (PEACH) study. All participants had pelvic pain, pelvic organ tenderness, and leukorrhea, mucopurulent cervicitis, or untreated cervicitis. Endometritis was defined as≥5 surface epithelium neutrophils per×400field absent of menstrual endometrium and/or≥2 stromal plasma cells per×120field. We detected M genitalium in 7 (14%) of the women tested: 6 (12%) in cervical specimens and 4 (8%) in endometrial specimens. We conclude that M genitalium is prevalent in the endometrium of women with nongonococcal, nonchlamydial PID.

Background Rescreening patients after treatment of Chlamydia trachomatis or Neisseria gonorrhoeae infection has had high yield but low rates of participation. Goal The goal of this study was to determine if rescreening for gonorrhea and chlamydial infection in a largely urban sexually transmitted disease population would be more successful if individuals were given the option of submitting a specimen for testing through the mail. Study design We conducted a randomized clinical trial involving 122 patients of whom 62 were assigned to clinic rescreening and 60 were given the option of either mailing a specimen for testing or going to a clinic for rescreening. Results Twenty-seven patients (45%) given the option of either rescreening in the clinic or through the mail and 20 (32%) assigned to clinic rescreening were rescreened within 28 days of enrollment in the study (odds ratio, 1.7; 95% confidence interval, 0.8-3.8). Of the 60 patients randomized to the clinic rescreening or mailing option, 11 of 18 (61%) who opted to mail in a specimen and 16 of 42 (38%) who chose clinic rescreening were rescreened within 28 days of enrollment (P = 0.10). Conclusions Although not statistically significant, this study indicates that mailed rescreening could be a successful method to increase rescreening rates.

Genital ulcers are typically caused by one of three organisms, Haemophilus ducreyi, Treponema pallidum, or herpes simplex virus, which cause chancroid, syphilis, and genital herpes, respectively. Although traditionally these diseases have been differentiated by their clinical presentation, there is considerable overlap in their clinical manifestations (1).

We tested rectal specimens from men who have sex with men for Chlamydia trachomatis by using COBAS PCR (Roche Diagnostics) and ligase chain reaction LCR (Abbott laboratories) and compared three PCR specimen-processing procedures. Chlamydiae were detected by one or more procedures in 22 of 186 specimens. All three PCR tests were positive for 17 specimens, all of which also tested positive by LCR.