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Background: The risk factors for oropharyngeal gonorrhea have not been examined in sex workers despite the increasing prevalence of gonorrhea infection., Objective: This study aims to determine the risk factors for oropharyngeal gonorrhea in female and gender-diverse sex workers (including cisgender and transgender women, nonbinary and gender fluid sex workers, and those with a different identity) and examine kissing, oral sex, and mouthwash practices with clients., Methods: This mixed methods case-control study was conducted from 2018 to 2020 at 2 sexual health clinics in Melbourne, Victoria, and Sydney, New South Wales, Australia. We recruited 83 sex workers diagnosed with oropharyngeal gonorrhea (cases) and 581 sex workers without (controls). Semistructured interviews with 19 sex workers from Melbourne were conducted., Results: In the case-control study, the median age of 664 sex workers was 30 (IQR 25-36) years. Almost 30% of sex workers (192/664, 28.9%) reported performing condomless fellatio on clients. Performing condomless fellatio with clients was the only behavior associated with oropharyngeal gonorrhea (adjusted odds ratio 3.6, 95% CI 1.7-7.6; P=.001). Most participants (521/664, 78.5%) used mouthwash frequently. In the qualitative study, almost all sex workers reported kissing clients due to demand and generally reported following clients' lead with regard to kissing style and duration. However, they used condoms for fellatio because they considered it a risky practice for contracting sexually transmitted infections, unlike cunnilingus without a dental dam., Conclusions: Our study shows that condomless fellatio is a risk factor for oropharyngeal gonorrhea among sex workers despite most sex workers using condoms with their clients for fellatio. Novel interventions, particularly targeting the oropharynx, will be required for oropharyngeal gonorrhea prevention., (©Tiffany R Phillips, Christopher K Fairley, Kate Maddaford, Anna McNulty, Basil Donovan, Rebecca Guy, Ruthy McIver, Rebecca Wigan, Rick Varma, Jason J Ong, Denton Callander, Gabrielle Skelsey, Mish Pony, Dylan O'Hara, Jade E Bilardi, Eric PF Chow. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 20.05.2024.)

Background: Antimicrobial resistance (AMR) represents a significant threat to global health with Neisseria gonorrhoea emerging as a key pathogen of concern. In Australia, the Australian Gonococcal Surveillance Program (AGSP) plays a critical role in monitoring resistance patterns. However, antibiotic susceptibility test (AST) uptake - a crucial component for effective resistance surveillance - remains to be a limiting factor. The study aims to model the processes involved in generating AST tests for N. gonorrhoea isolates within the Australian healthcare system and assess the potential impact of systematic and policy-level changes., Methods: Two models were developed. The first model was a mathematical stochastic health systems model (SHSM) and a Bayesian Belief Network (BBN) to simulate the clinician-patient dynamics influencing AST initiation. Key variables were identified through systematic literature review to inform the construction of both models. Scenario analyses were conducted with the modification of model parameters., Results: The SHSM and BBN highlighted clinician education and the use of clinical support tools as effective strategies to improve AST. Scenario analysis further identified adherence to guidelines and changes in patient-level factors, such as persistence of symptoms and high-risk behaviours, as significant determinants. Both models supported the notion of mandated testing to achieve higher AST initiation rates but with considerations necessary regarding practicality, laboratory constraints, and culture failure rate., Conclusion: The study fundamentally demonstrates a novel approach to conceptualising the patient-clinician dynamic within AMR testing utilising a model-based approach. It suggests targeted interventions to educational, support tools, and legislative framework as feasible strategies to improve AST initiation rates. However, the research fundamentally highlights substantial research gaps in the underlying understanding of AMR., (© 2024. The Author(s).)

Abstract: The Australian National Neisseria Network (NNN) comprises reference laboratories in each state and territory that report data on antimicrobial susceptibility testing to an agreed group of antimicrobial agents for the Australian Gonococcal Surveillance Programme (AGSP). The AGSP data are presented quarterly in tabulated form, as well as in the AGSP annual report. This report presents national gonococcal antimicrobial resistance surveillance data from 1 October to 31 December 2023., (© Commonwealth of Australia CC BY-NC-ND.)

Background The incidence of sexual assault continues to rise in Australia. This study aimed to describe the nature of assault, HIV/STI positivity, and its management at a sexual health clinic. Methods We performed a chart review of 516 sexual assault cases presenting to Melbourne Sexual Health Centre between 2012 and 2021, collecting data on victim demographics, details of assault, HIV/STI testing and positivity, police involvement, and offer of counselling. Results We included 516 cases: 124 males (24.0%); 384 females (74.4%); and eight transgender (1.6%) victims. The proportion of assault cases presenting to Melbourne Sexual Health Centre increased from 0.1% (37/37,070) in 2012 to 0.2% (56/36,514) in 2021 (P trend =0.006). HIV post-exposure prophylaxis was prescribed for 64.5% (80/124) of males and 12.5% (48/384) of females. Among victims, 69.4% (358/516) were tested for HIV and no one tested positive, while 71.9% (371/516) were tested for syphilis, with 1.6% (6/371) positive. Gonorrhoea and chlamydia were tested at the oropharynx (44.8% [231/516] vs 28.7% [148/516]), genitals (83.7% [432/516] vs 92.4% [477/516]) and anorectum (35.3% [182/516] vs 35.3% [182/516]). Positivity for gonorrhoea and chlamydia were: 2.6% (6/231) vs 2.0% (3/148) at oropharynx, 1.4% (6/432) vs 2.9% (14/477) at genitals, and 5.5% (10/182) vs 7.1% (13/182) at anorectum. According to clinical records, 25.2% (130/516) of victims sought police involvement, and 71.7% (370/516) were offered counselling. Conclusions Sexual assault was an uncommon presentation at Melbourne Sexual Health Centre, with diverse circumstances surrounding assault; however, clinical documentation varied, indicating a need for a standard primary care protocol for clients presenting with acute sexual assault.

Abstract: The Australian National Neisseria Network (NNN) comprises reference laboratories in each state and territory that report data on antimicrobial susceptibility testing to an agreed group of antimicrobial agents for the Australian Gonococcal Surveillance Programme (AGSP). The AGSP data are presented quarterly in tabulated form, as well as in the AGSP annual report. This report presents national gonococcal antimicrobial resistance surveillance data from 1 January to 31 March 2023., (© Commonwealth of Australia CC BY-NC-ND.)

Abstract: The Australian National Neisseria Network (NNN) comprises reference laboratories in each state and territory that report data on antimicrobial susceptibility testing to an agreed group of antimicrobial agents for the Australian Gonococcal Surveillance Programme (AGSP). The AGSP data are presented quarterly in tabulated form, as well as in the AGSP annual report. This report presents national gonococcal antimicrobial resistance surveillance data from 1 July to 30 September 2023., (© Commonwealth of Australia CC BY-NC-ND.)

Abstract: The Australian National Neisseria Network (NNN) comprises reference laboratories in each state and territory that report data on antimicrobial susceptibility testing to an agreed group of antimicrobial agents for the Australian Gonococcal Surveillance Programme (AGSP). The AGSP data are presented quarterly in tabulated form, as well as in the AGSP annual report. This report presents national gonococcal antimicrobial resistance surveillance data from 1 April to 30 June 2023., (© Commonwealth of Australia CC BY-NC-ND.)

Background: In 2018, the World Health Organization commenced a multi-country validation study of the Cepheid GeneXpert for a range of molecular-based point-of-care (POC) tests in primary care settings. One study arm focused on the evaluation of POC tests for screening 'women at risk' for chlamydia (CT), gonorrhoea (NG) and trichomonas (TV) in four countries - Australia, Guatemala, Morocco and South Africa., Methods: Study participants completed a pre-test questionnaire which included demographics, clinical information and general questions on POC testing (POCT). Two vaginal swab samples (either self-collected or clinician collected) from each patient were tested on the GeneXpert at the POC and at a reference laboratory using quality-assured nucleic acid amplification tests (NAATs)., Results: One thousand three hundred and eighty-three women were enrolled: 58.6% from South Africa, 29.2% from Morocco, 6.2% from Guatemala, and 6.0% from Australia. 1296 samples for CT/NG and 1380 samples for TV were tested by the GeneXpert and the reference NAAT. The rate of unsuccessful tests on the GeneXpert was 1.9% for CT, 1.5% for NG and 0.96% for TV. The prevalence of CT, NG and TV was 31%, 13% and 23%, respectively. 1.5% of samples were positive for all three infections; 7.8% were positive for CT and NG; 2.4% were positive for NG and TV; and 7.3% were positive for CT and TV. Compared to reference NAATs, pooled estimates of sensitivity for the GeneXpert tests were 83.7% (95% confidence intervals 69.2-92.1) for CT, 90.5% (85.1-94.1) for NG and 64.7% (58.1-70.7) for TV (although estimates varied considerably between countries). Estimates for specificity were ≥96% for all three tests both within- and between-countries. Pooled positive and negative likelihood ratios were: 32.7 ([CI] 21.2-50.5) and 0.17 (0.08-0.33) for CT; 95.3 (36.9-245.7) and 0.10 (0.06-0.15) for NG; and 56.5 (31.6-101.1) and 0.35 (0.27-0.47) for TV., Conclusion: This multi-country evaluation is the first of its kind world-wide. Positive likelihood ratios, as well as specificity estimates, indicate the GeneXpert POC test results for CT, NG and TV were clinically acceptable for ruling in the presence of disease. However, negative likelihood ratios and variable sensitivity estimates from this study were poorer than expected for ruling out these infections, particularly for TV., Trial Registration: Ethics approval to conduct the ProSPeRo study was granted by the WHO Ethics Review Committee, as well as local ethics committees from all participating countries., (© 2024. The Author(s).)

Background: People who report sexual assault express concerns regarding contracting sexually transmitted infection (STI); however, published literature regarding the risk of STI transmission in this context is sparse., Method: We audited STI and blood-borne virus (BBV) testing at a forensic and medical sexual assault care service in the Australian Capital Territory between 2004 and 2022. Eligibility for testing among 1928 presentations was defined based on risk (eg, reported penetration). Testing at presentation included chlamydia and gonorrhoea 1850, syphilis and BBV 1472, and after 2-6 weeks, 890 out of 1928 (46.2%) and after 3 months 881 out of 1928 (45.7%), respectively., Results: At presentation, 100 out of 1928 (5.2%) individuals were diagnosed with chlamydia, of those, 95 out of 1799 (5.3%) were female, and 5 out of 121 (4.1%) were male. Gonorrhoea was diagnosed in 7 out of 1920 (0.4%), 5 out of 95 female and 2 out of 5 male. Hepatitis B, which was all pre-existing, was diagnosed in 5 out of 1799 (0.3%). Overall, chlamydia prophylaxis was given to 203 out of 1928 (10.5%) and HIV post-exposure prophylaxis to 141 out of 1928 (7.3%).At 2-6 weeks of follow-up, 10 out of 890 (1.1%) individuals were diagnosed with chlamydia, with no gonorrhoea diagnosed. There were no cases of syphilis, hepatitis B or HIV diagnosed at 3-month serology testing in 881 individuals. Chlamydia detection at follow-up was more common in the group aged 15-29 years. Of those provided with chlamydia prophylaxis, 203 out of 1928, only 16 out of 203 (7.9%) were diagnosed with chlamydia., Conclusions: The offer of STI testing is almost universally accepted by individuals presenting for post-sexual assault care. There were no identifiable factors to justify the routine use of chlamydia prophylaxis. STI testing provided an opportunity for screening and should remain part of the clinical care of people who report sexual assault., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To investigate trends in testing and notifications of chlamydia and gonorrhoea during the COVID-19 pandemic in Queensland, Australia., Methods: Statewide disease notification and testing data between 1 January 2015 and 31 December 2021 were modelled using interrupted time series. A segmented regression model estimated the pre-pandemic trend and observed effect of the COVID-19 pandemic response on weekly chlamydia notifications, monthly gonorrhoea notifications and monthly testing figures. The intervention time point was 29 March 2020, when key COVID-19 public health restrictions were introduced., Results: There were 158 064 chlamydia and 33 404 gonorrhoea notifications and 2 107 057 combined chlamydia and gonorrhoea tests across the 72-month study period. All three studied outcomes were increasing prior to the COVID-19 pandemic. Immediate declines were observed for all studied outcomes. Directly after COVID-19 restrictions were introduced, declines were observed for all chlamydia notifications (mean decrease 48.4 notifications/week, 95% CI -77.1 to -19.6), gonorrhoea notifications among males (mean decrease 39.1 notifications/month, 95% CI -73.9 to -4.3) and combined testing (mean decrease 4262 tests/month, 95% CI -6646 to -1877). The immediate decline was more pronounced among males for both conditions. By the end of the study period, only monthly gonorrhoea notifications showed a continuing decline (mean decrease 3.3 notifications/month, p<0.001)., Conclusion: There is a difference between the immediate and sustained impact of the COVID-19 pandemic on reported chlamydia and gonorrhoea notifications and testing in Queensland, Australia. This prompts considerations for disease surveillance and management in future pandemics. Possible explanations for our findings are an interruption or change to healthcare services during the pandemic, reduced or changed sexual practices or changed disease transmission patterns due to international travel restrictions. As pandemic priorities shift, STIs remain an important public health priority to be addressed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There is increased heterosexual transmission of syphilis in Australia, an infection with severe outcomes. Australian policy emphasizes increasing sexually transmissible infection knowledge/awareness. However, little is known about young Australians' perceptions and knowledge of syphilis., Methods: Our online sexual health survey was open May 2 to June 21, 2022, to 16- to 29-year-olds in Australia. We asked participants if they were aware of syphilis, their personal risk perception, and perceived severity of infection and compared with results for chlamydia/gonorrhea. Multivariable and multinomial logistic regressions were used to assess characteristics associated with outcomes. We measured sexually transmissible infection knowledge using 10 true/false statements (5 syphilis, 5 chlamydia/gonorrhea)., Results: Among 2018 participants (69.1% women, 48.9% heterosexual), 91.3% had heard of syphilis (vs. 97.2% for chlamydia and 93.3% for gonorrhea). Older (25-29 years; adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4-4.4) and gay/lesbian (aOR, 2.8; 95% CI, 1.4-5.3) respondents were more likely to have heard of syphilis, as were those who were non-Aboriginal, sexually active, and with a school-based sex education. Syphilis knowledge was lower than chlamydia/gonorrhea knowledge ( P < 0.001). More than half (59.7%) perceived syphilis to have serious health impacts (vs. 36.4% for chlamydia and 42.3% for gonorrhea). Older respondents were more likely (25-29 years; aOR 2.1; 95% CI, 1.6-2.8), and gay/lesbian respondents less likely (aOR, 0.7; 95% CI, 0.6-1.0) to perceive syphilis to have serious health impacts. One-fifth of sexually active participants were unsure of their risk of syphilis., Conclusions: Most young Australians are aware of syphilis, but few have comprehensive knowledge about the infection relative to chlamydia/gonorrhea. Considering increasing heterosexual transmission, syphilis health promotion campaigns should expand their focus., Competing Interests: Conflict of Interest and Sources of Funding: J.S.H. is recipient of an National Health and Medical Research Council fellowship grant. All other authors report no conflicts of interest., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

The Australian Gonococcal Surveillance Programme (AGSP) has continuously monitored antimicrobial resistance in Neisseria gonorrhoeae for more than 40 years. In 2022, a total of 8,199 isolates from patients in the public and private sectors, in all jurisdictions, were tested for in vitro antimicrobial susceptibility by standardised methods. The current treatment recommendation for gonorrhoea, for the majority of Australia, continues to be dual therapy with ceftriaxone and azithromycin. In 2022, of N. gonorrhoeae isolates tested, 0.51% (42/8,199) met the WHO criterion for ceftriaxone decreased susceptibility (DS), defined as a minimum inhibitory concentration value ≥ 0.125 mg/L. Resistance to azithromycin was reported in 3.9% of N. gonorrhoeae isolates, proportionally stable since 2019. There were nine isolates with high-level resistance to azithromycin (MIC value ≥ 256 mg/L) reported in Australia: Queensland (4), New South Wales (3), Victoria (1) and non-remote Western Australia (1). This is the highest number detected annually by the AGSP. In 2022, penicillin resistance was found in 38.8% of gonococcal isolates, and ciprofloxacin resistance in 63.3%, however, there was considerable variation by jurisdiction. In some remote settings, penicillin resistance remains low; in these settings, penicillin continues to be recommended as part of an empiric therapy strategy. In 2022, in remote Northern Territory, one penicillin-resistant isolate was reported; in remote Western Australia, 11.8% of gonococcal isolates (9/76) were penicillin resistant. There were three ciprofloxacin-resistant isolates reported from remote Northern Territory; ciprofloxacin resistance rates remain comparatively low in remote Western Australia (6/76; 7.9%)., (© Commonwealth of Australia CC BY-NC-ND)

Background: Neisseria gonorrhoeae (NG) can lead to serious reproductive and sexual health outcomes, and the annual number of NG notifications in Australia increased steadily from 10329 in 2010 to 29549 by 2020. Australian populations most affected are urban men who have sex with men and First Nations peoples living in remote areas, and a resurgence in urban heterosexuals has been observed since 2012., Methods: A case series analysis of Queensland NG isolates (2010-15) exploring temporal trends and antimicrobial resistance by demographic and geographic distribution and genotype was performed. Proportions describe age, sex, strain, genogroup (NG multi-antigen sequence typing), region, swab site, antimicrobial sensitivity and isolate rates per 100000 population. Dominant genogroups were identified., Results: Among 3953 isolates, the median age was 25years (IQR 20-34years) and most (n =2871/3915, 73%) were men. Brisbane city (68.8) and Far North Queensland (54.1) excluding Cairns showed the highest rates. Forty-six genogroups were documented, seven (G2992, G6876, G1415, G4186, G5, G1407 and G6937) comprised half of all isolates. The predominant male genogroup was G2992 (16%), and G6876 (20%) for females; G5 was predominantly male from 2010 to 2011, but equal in both sexes from 2012 to 2015., Conclusion: Considerable temporal, geographical and demographical diversity was observed in Queensland NG isolates, which has public health implications. Certain genogroups are more transient than others, and evidence suggests bridging from male-dominant networks to heterosexual networks. Molecular surveillance can enhance tracking the epidemiology and movement of NG in Australia, highlighting the necessity of genotyping to expose potentially prevalent strains circulating in undetected or underrepresented networks by current screening methods.

Background: Neisseria gonorrhoeae treatment guided by molecular antimicrobial susceptibility assays could improve treatment options and antimicrobial stewardship; however, few commercial assays are available. We aimed to investigate antimicrobial susceptibility of N gonorrhoeae isolates in New South Wales, Australia, and estimate the potential usefulness of hypothetical combinations of rapid molecular antimicrobial susceptibility assays., Methods: In this proof-of-principle, population-based, retrospective analysis, we assessed N gonorrhoeae susceptibility data for ceftriaxone, azithromycin, ciprofloxacin, and penicillin. Isolates were previously collected as part of the Australian Gonococcal Surveillance Programme between Jan 1, 2008, and Dec 31, 2019. All cultured N gonorrhoeae isolates with susceptibility data to all four antimicrobials were included. However, only one isolate was included if several isolates originated from the same individual within 13 days of the previous isolate originating from that individual, and there were less than two standard double-dilution minimum inhibitory concentrations between the isolates. We assessed the use of different combinations of hypothetical antimicrobial susceptibility assays and treatment combinations in terms of their ability to minimise overall ceftriaxone use, and use specifically in isolates with decreased susceptibility to ceftriaxone, compared with standard non-assay-guided empirical ceftriaxone treatment., Findings: We included 23 089 N gonorrhoeae isolates. The prevalence of antimicrobial sensitivity fluctuated significantly during the study. Isolates with decreased susceptibility to ceftriaxone were more likely to be resistant to one or more antimicrobials than isolates without decreased susceptibility (782 [98·6%] of 793 vs 10 661 [47·8%] of 22 296), particularly ciprofloxacin (p<0·0001) and penicillin (p<0·0001). Compared with empirical ceftriaxone treatment, we estimated that strategies based on the use of hypothetical antimicrobial susceptibility would reduce ceftriaxone use (p<0·0001). However, because of co-resistance, most assay-directed treatment strategies, including those involving use of assays for two antibiotics, would result in only moderate reductions in ceftriaxone use among isolates with decreased susceptibility to ceftriaxone., Interpretation: Individualised treatment guided by molecular antimicrobial susceptibility diagnostics could help to reduce overall ceftriaxone use in gonorrhoea. However, the use of these assays needs to be informed by the non-random nature of co-resistance among circulating N gonorrhoeae strains., Funding: Australian Government and Queensland Government., Competing Interests: Declaration of interests DAL participates on advisory boards for the UK NATSAL-4 study and the GIFT–Africa Consortium (European and Developing Countries Clinical Trials Partnership grant RIA2020I–GIFT–Africa Consortium, 2021–2024), is a member of the WHO Strategic Technical Advisory Committee for HIV, Hepatitis, and STIs, and is council member of the International Society for Infectious Diseases. DMW reports research funding from SpeeDx. SFEB, RSW, and MML declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Abstract: From January 2014 to December 2015, the overall yield of sexually transmitted infections testing among asymptomatic MSM was two-fold higher at a community-based versus clinic-based service. Compared with the clinic-based service, yield of chlamydia (9.0% vs 4.9%; P = 0.010), gonorrhea (6.5% vs 3.1%; P &lt; 0.001), and infectious syphilis (0.9% vs 0.1%; P = 0.024) were all higher at the community-based service., Competing Interests: Conflicts of Interest and Sources of Funding: All authors have no conflicts of interest to declare. ACCESS is funded by the Australian Department of Health., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Objective: Aboriginal women living in remote Australia experience a high burden of both chlamydia and gonorrhoea infections and disproportionately high rates of pelvic inflammatory disease (PID). We estimated for the first time the fraction of PID attributable to these infections in young Aboriginal women living in these settings., Methods: Using published data from two large Australian studies (2002-2013; 2010-2014), we calculated the fraction of emergency department presentations and hospitalisations for PID attributable to chlamydia and/or gonorrhoea infection in Aboriginal women aged 16-29 years living in remote Australia. We used a Monte Carlo simulation to estimate the mean and 95% CIs for the assumed prevalence and population attributable fractions for PID for infection stratifications (chlamydia only, gonorrhoea only and dual infection) as well as for any infection (chlamydia and/or gonorrhoea). Additional outputs were calculated for chlamydia infection with/without gonorrhoea coinfection, and vice versa., Results: The prevalence of chlamydia only was 12.9% (95% CI: 11.6% to 14.2%), gonorrhoea only was 7.8% (95% CI: 6.6% to 8.9%) and dual infection was 6.5% (95% CI: 5.8% to 7.2%); rate ratios of PID were 1.9 (95% CI: 1.5 to 2.3), 5.2 (95% CI: 4.3 to 6.4) and 4.6 (95% CI: 3.8 to 5.5), respectively. The overall fraction of PID attributable to chlamydia and/or gonorrhoea was 40.2% (95% CI: 36.0% to 44.4%); any gonorrhoea was 33.4% (95% CI: 29.2% to 37.8%) and any chlamydia was 20.6% (95% CI: 16.9% to 24.6%)., Conclusion: Our study demonstrates the importance of calculating the fraction of PID related to chlamydia and gonorrhoea in the local context, demonstrating the major contribution gonorrhoea makes to PID hospitalisations among Australian Aboriginal women living in remote settings. To significantly and sustainably reduce the unacceptable rate of PID in this population, strategies are urgently needed to improve timely testing and treatment and recognition and management of PID in primary care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Gonorrhoea caused by Neisseria gonorrhoeae is the second most notified sexually transmitted infection (STI) in Australia and the case numbers for this STI have been increasing globally. Progressive gonococcal infection may lead to disseminated gonococcal infection (DGI), which causes significant morbidity among patients. This study aims to examine the genetic diversity of N. gonorrhoeae isolates collected in Queensland from January 2010 to August 2015 and to determine factors associated with DGI in Queensland., Design: Retrospective surveillance study for epidemiological purposes., Setting: All gonorrhoeae isolates referred by private and public pathology laboratories to the state of Queensland, Australia Neisseria reference laboratory., Methods: Between January 2010 and August 2015, 3953 N. gonorrhoeae isolates from both metropolitan and regional Queensland infections were typed with NG-MAST ( N. gonorrhoeae multiantigen sequence typing) to assess the genetic diversity between strains. Whole-genome sequencing (WGS) was used to investigate strain-related factors associated with DGI., Results: ST6876 was the most common NG-MAST type, detected in 7.6% of the isolates. DGI was significantly more likely in females <30 years (OR 13.02, p<0.0001) and in older males >30 years (OR 6.04, p<0.0001), with most cases originating from North Queensland (OR 8.5, p<0.0001). Strains harbouring PIA class of porB type were associated with DGI (OR 33.23, p<0.0001)., Conclusion: Genotyping techniques, such as NG-MAST and WGS, are proving instrumental in providing an insight into the population structure of N. gonorrhoeae , and genetic mechanisms of pathogenesis, such as for DGI., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Although data from large implementation trials suggest that sexually transmissible infection (STI) risk increases among gay and bisexual men who initiate HIV pre-exposure prophylaxis (PrEP), there are few data on the trends in population-level STI incidence in the years following widespread PrEP implementation. We aimed to describe trends in bacterial STI incidence among gay and bisexual men using PrEP across Australia in the context of broad PrEP availability through Australia's subsidised medicines scheme., Methods: We analysed linked clinical data from HIV-negative gay and bisexual men aged 16 years or older who had been prescribed PrEP across a sentinel surveillance clinical network, including 37 clinics in Australia, between Jan 1, 2016, and Dec 31, 2019. Patients were included if they had STI testing at least twice during the observation period. Repeat testing methods were used to calculate chlamydia, gonorrhoea, syphilis, and any STI incidence rates during individuals' periods of PrEP use. Incidence rate ratios (IRRs) for estimated change in incidence per half calendar year (6-month) period were calculated using negative binomial regression. Secondary analyses compared STI incidence rates across individuals initiating PrEP in each year from 2016 to 2019, as well as by length of time using PrEP (per each additional 6 months of PrEP use)., Findings: 22 730 men were included in the analyses. During the observation period, 11 351 chlamydia infections were diagnosed in 6630 (30·1%) of 22 034 men over 25 991·2 person-years of PrEP use (incidence rate 43·7 cases [95% CI 42·9-44·5] per 100 person-years). Chlamydia incidence decreased from 48·7 cases per 100 person-years in July-December, 2016, to 42·0 cases per 100 person-years in July-December, 2019 (IRR for estimated change per 6-month period 0·98 [95% CI 0·97-0·99]; p=0·0031). 9391 gonorrhoea infections were diagnosed in 5885 (26·9%) of 21 845 men over 24 858·7 person-years of PrEP use (incidence rate 37·8 cases [95% CI 37·0-38·5] per 100 person-years). Gonorrhoea incidence decreased from 45·5 cases per 100 person-years in July-December, 2016, to 37·2 cases per 100 person-years in July-December, 2019 (IRR 0·97 [95% CI 0·96-0·98]; p<0·0001). Declines in chlamydia and gonorrhoea incidence were most prominent in the first 18 months of observation and incidence was stable thereafter. 2062 syphilis infections were diagnosed in 1488 (7·7%) of 19 262 men over 21 978·9 person-years of PrEP use (incidence rate 9·4 cases [95% CI 9·0-9·8] per 100 person-years). Syphilis incidence increased from 6·2 cases per 100 person-years in July-December, 2016, to 9·8 cases per 100 person-years in July-December, 2019 (IRR 1·08 [95% CI 1·05-1·10]; p<0·0001)., Interpretation: Chlamydia and gonorrhoea incidence among gay and bisexual men using PrEP were highest in the early months of PrEP implementation in Australia and stabilised at slightly lower rates thereafter following wider PrEP uptake. Lower prospective STI risk among people initiating PrEP in later years contributed to the observed trends in STI incidence. Widespread PrEP implementation can contribute to increased STI screening and detection., Funding: Australian Department of Health, National Health and Medical Research Council., Competing Interests: Declaration of interests MWT reports speakers' honoraria and investigator-initiated research grants from Gilead Sciences. RG reports research support funding from Gilead Sciences. CB reports honoraria from Gilead Sciences. EJW is the chair of the COVID-19 Taskforce of the Australasian Society of HIV, Viral Hepatitis, and Sexual Health Medicine, and reports investigator-initiated research funding from ViiV Healthcare, and consulting and travel fees from Gilead Sciences. AG reports research grants from Sequris and ViiV Healthcare, receipt of study drug from GlaxoSmithKline, and personal fees from Merck Sharp and Dohme. MEH reports investigator-initiated research grants from Gilead Sciences and Abbvie. MAS reports investigator-initiated research grants from Gilead Sciences and Abbvie and consulting fees from Gilead Sciences. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Abstract: The incidence of Neisseria gonorrhoeae (gonorrhoea) and Treponema pallidum (syphilis) infections in the Australian Capital Territory (ACT) has increased since 2014 in people reporting heterosexual exposure. This population is more likely to present to general practice rather than to specialised sexual health clinics, with potential implications for disease surveillance and control. This study aimed to explore: conformity of self-reported clinical practice with sexually transmitted infection guidelines in general practice; gaps in sexual health knowledge and skills; and areas for improved support from ACT Health Communicable Disease Control. A cross-sectional survey of general practitioners (GPs) and nurse practitioners (NPs) practicing in the ACT was conducted in December 2020, using a 17-item questionnaire and semi-structured interviews. Twenty-three GPs and one NP returned completed surveys (response rate 5.3%); four GPs and one NP participated in interviews. In its complex setting of competing demands, GP practice may not always meet national guidelines. In response to clinical vignettes, although all GPs ordered investigations for gonorrhoea, only 25% of these met the gold-standard by including endocervical or vaginal swabs. With respect to assessing antimicrobial sensitivities to guide treatment, only 58% correctly reported following up a positive gonococcal polymerase chain reaction test with a culture. Around two-thirds of respondents (62.5%) identified the appropriate antibiotic therapy and 75% correctly identified the responsibility of the diagnosing clinician to discuss contact tracing with the patient. Suggestions for increased support focussed on education, communication efficiency, and providing a 'safety net' for follow up., (© Commonwealth of Australia CC BY-NC-ND.)

Background: STI rates have been reported as reduced during the height of the COVID-19 pandemic. Our study evaluates the number of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections recorded relative to the number of tests performed in 2017-2021, thus accurately depicting trends over time and evaluate the effect of COVID-19 restrictions since these were implemented in March 2020., Methods: Data was extracted from an electronic database of pathology and clinical records used at Gold Coast Sexual Health Service (GCSHS) in Queensland, Australia from January 2017 to October 2021. Poisson regression-based interrupted time series analyses were performed for number of tests performed and test positivity over the study period. The COVID-19 period was defined as starting from March 2020 when public health directives were implemented., Results: CT and NG testing dropped significantly in the month after COVID-19 restrictions were brought in, by 30% and 23% respectively. Over the 5year study period, the proportion of positive CT tests has consistently decreased by approximately 0.33% points per year (P ≤0.001). The instigation of COVID-19 restrictions had no effect on this trend. The proportion of NG positive tests remained steady prior to COVID-19 (P =0.96) at approximately 3.5%, decreased immediately at the onset of COVID-19 restrictions to approximately 2.5% (P <0.001) and has remained at this level post-COVID restrictions (P =0.54). Testing at GCSHS continued to target gay and bisexual men, accounting for ≥50% of all tests performed., Conclusion: Our study suggests that there has been a sustained reduction in test positivity of NG infections in the 18months since COVID-19 restrictions were implemented, and that this is not an artifact of reduced testing. It highlights the importance of maintaining health messaging including screening for sexually transmissible infections and maintaining access to services, which may include alternative models of care such as Telehealth, self-testing and collaboration between all sexual health service providers.

Background: In a previous study of men attending Melbourne Sexual Health Centre who had Neisseria gonorrhoeae detected by urine Aptima Combo 2 (AC2) testing, 11% were asymptomatic. This study aimed to determine whether N. gonorrhoeae can be cultured from asymptomatic men screening positive for N. gonorrhoeae by nucleic acid amplification testing (NAAT) of urine., Methods: Between 1 July 2017 and 31 March 2019, all men attending Melbourne Sexual Health Centre were tested for N. gonorrhoeae by AC2 testing of urine whether urethral symptoms were reported or not. NAAT-positive men were recalled and a urethral swab performed for gonococcal culture using modified Thayer-Martin media with determination of minimum inhibitory concentrations (MICs) by agar dilution., Results: There were 1001 cases (860 individuals) positive for N. gonorrhoeae by urine AC2: 892 (89%) reported urethral symptoms; 109 (11%) did not. Twenty-five asymptomatic cases were excluded because of antibiotic use at or following screening. Of the remaining 84 asymptomatic men, 41 (49%) had a urethral swab performed a median of 5 days after screening. Twenty-one men had urethral discharge at the return visit, 11 of whom reported the discharge at the return visit. Of the 41 men who were swabbed, 31 (76%; 95% CI 60% to 88%) were culture positive for N. gonorrhoeae . Among the 21 men who subsequently developed discharge, 19 (90%; 95% CI 70% to 99%) were culture positive. Among the 20 men who remained asymptomatic, 12 (60%; 95% CI 36% to 81%) were culture positive. MIC profiles were obtained from all isolates., Conclusions: Gonorrhoea was isolated in most but not all asymptomatic men screening positive for N. gonorrhoeae by urine NAAT. Clinicians should consider performing urethral culture in such men to ensure optimal surveillance for antimicrobial resistance. Isolation of N. gonorrhoeae by culture in men without discharge indicates these are true infections with viable organisms., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: There is limited evidence about the transmission and prevalence of oropharyngeal gonorrhoea in heterosexuals. From August 2017, Melbourne Sexual Health Centre (MSHC) began testing for oropharyngeal gonorrhoea among heterosexuals with untreated urogenital gonorrhoea. This study aims to determine the positivity of oropharyngeal gonorrhoea among heterosexuals diagnosed with urogenital gonorrhoea at MSHC between August 2017 and May 2020., Methods: We included individuals who had oropharyngeal gonorrhoea testing within 30 days of initial testing. We reported the number and proportion of oropharyngeal gonorrhoea positivity, stratified by gender and contact of gonorrhoea. The χ 2 test was performed to compare the oropharyngeal gonorrhoea positivity between groups., Results: Of 617 individuals with untreated urogenital gonorrhoea, 424 (68.7%) were tested for oropharyngeal gonorrhoea. Oropharyngeal gonorrhoea positivity was 38.9% (95%CI 34.2-43.7%, 165/424), and was higher in women than in men (115/252, 45.6% versus 50/172, 29.1%, p = 0.001). Furthermore, oropharyngeal gonorrhoea positivity was higher among individuals who were contacts of gonorrhoea cases compared to those who were not (29/44, 65.9% versus 136/380, 35.8%, p < 0.001). There was also no significant difference between women who were sex workers and those who were not (30/78, 38.5% versus 85/174, 48.9%, p = 0.126)., Conclusions: Our data suggest that oropharyngeal gonorrhoea infection is common among heterosexual women and heterosexual men with untreated urogenital gonorrhoea. Testing heterosexual women and heterosexual men for oropharyngeal gonorrhoea will identify a significant proportion with unrecognized oropharyngeal infections whose recommended treatment is different in some countries., (Copyright © 2021 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

The ability to treat gonorrhoea with current first-line drugs is threatened by the global spread of extensively drug resistant (XDR) Neisseria gonorrhoeae (NG) strains. In Australia, urban transmission is high among men who have sex with men (MSM) and importation of an XDR NG strain in this population could result in an epidemic that would be difficult and costly to control. An individual-based, anatomical site-specific mathematical model of NG transmission among Australian MSM was developed and used to evaluate the potential for elimination of an imported NG strain under a range of case-based and population-based test-and-treat strategies. When initiated upon detection of the imported strain, these strategies enhance the probability of elimination and reduce the outbreak size compared with current practice (current testing levels and no contact tracing). The most effective strategies combine testing targeted at regular and casual partners with increased rates of population testing. However, even with the most effective strategies, outbreaks can persist for up to 2 years post-detection. Our simulations suggest that local elimination of imported NG strains can be achieved with high probability using combined case-based and population-based test-and-treat strategies. These strategies may be an effective means of preserving current treatments in the event of wider XDR NG emergence., Competing Interests: The authors have declared that no competing interests exist. Author Christine Selvey was unable to confirm their authorship contributions. On their behalf, the corresponding author has reported their contributions to the best of their knowledge.

Objectives: This prospective cohort study aimed to determine the natural history and incidence of oropharyngeal gonorrhoea and chlamydia among a cohort of men who have sex with men (MSM) over a 12-week period, and to examine risk factors associated with incident oropharyngeal infections., Methods: MSM either aged ≥18 years and had a diagnosis of oropharyngeal gonorrhoea by nucleic acid amplification test (NAAT) in the past 3 months or aged 18-35 years who were HIV-negative taking pre-exposure prophylaxis (PrEP) were eligible for this study. Enrolled men were followed up for 12 weeks. Oropharyngeal swabs were collected at week 0 (baseline) and week 12 (end of study). Between these time points, weekly saliva specimens and the number of tongue kissing, penile-oral and insertive rimming partners were collected by post. Oropharyngeal swabs and saliva specimens were tested by NAAT for Neisseria gonorrhoeae and Chlamydia trachomatis . Poisson regression was performed to examine the risk factors (weekly number of partners) associated with incident oropharyngeal gonorrhoea., Results: A total of 100 MSM were recruited. The incidence of oropharyngeal gonorrhoea and chlamydia was 62 (95% CI 37 to 105) and 9 (95% CI 2 to 35)/100 person-years, respectively. The median duration of incident oropharyngeal infection with gonorrhoea was 28 days (IQR=21-36, n=7). The incidence rate ratio (IRR) for oropharyngeal gonorrhoea increased with an increased number of kissing partners (IRR=1.08; 95% CI 1.03 to 1.12) an increased number of penile-oral sex partners (IRR=1.07, 95% CI 1.01 to 1.14) but not with an increased number of insertive rimming partners (IRR=1.11, 95% CI 0.96 to 1.29) or other demographic factors. The IRR and duration of incident oropharyngeal chlamydia were not calculated due to the small number of cases (n=2)., Conclusions: MSM have a high incidence of oropharyngeal gonorrhoea and the median duration of infection was less than 3 months., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background A free online chlamydia and gonorrhoea urine testing service (Webtest) is available for people living in Queensland, Australia. There are two options to provide a urine sample: at a pathology collection centre or by using a home mailing kit. The study aimed to trial these two testing options designed for young people and describe which is the preferred testing choice., Methods: Data for online requests made from 3 August 2017 to 31 December 2019 provides information for age, gender, location of clients, results received, treatment and partner notification reported by people with positive results., Results: For 29 months, there were 4642 Webtest requests and 2906 valid results received. For young people (16-29 years), chlamydia positivity was 8.2% (172/2105; 95% CI, 7.1-9.4) versus 3.2% (26/801; 95% CI, 2.2-4.7) for people aged ≥30 years, and 6.8% (198/2906; 95% CI, 6.0-7.8) for all ages. Home mailing kits were the most popular testing choice, with 68.0% (1977/2906) of results received from urine submitted by post and 32.0% (929/2906) via pathology collection centre., Conclusions: The free online test request service engaged young people at risk of sexually transmissible infections and found home sample collection was most popular.

Abstract: We identified and characterized the first 2 Neisseria gonorrhoeae strains with high-level azithromycin resistance isolated in Japan. These were in the clade of ceftriaxone- and azithromycin-resistant strains isolated in Australia and the United Kingdom. The multilocus sequence typing, N. gonorrhoeae multiantigen sequence typing, and N. gonorrhoeae sequence typing for antimicrobial resistance types of these strains were found in gonococci from eastern Asia., Competing Interests: Conflict of Interest and Sources of Funding: This work was partly supported by Japan Agency for Medical Research and Development (grant number 18fk0108062), JSPS KAKENHI (grant number JP18K09163), and the Ministry of Health, Labour, and Welfare of Japan (grant H30-Shinkou-Ippan-004). The authors declare no conflicts of interest directly relevant to the content of this article., (Copyright © 2020 American Sexually Transmitted Diseases Association. All rights reserved.)

Background This study examined trends in chlamydia, gonorrhoea and syphilis diagnosis, and chlamydia testing and positivity, among older women in Australia between 2000 and 2018., Methods: Using national notifiable disease data and Medicare data, diagnosis rates were calculated for each sexually transmissible infection (STI), as well as testing and positivity rates for chlamydia. Data were compared between two older groups (55-64 and 65-74 years) and two younger groups (15-24 and 25-34 years). Poisson regression examined trends for 2000-18 and 2014-18 separately., Results: Rates for all STIs increased across all age groups and were highest in the two youngest age groups. From 2014 to 2018, chlamydia rates increased the most among those aged 55-64 years [incidence rate ratio (IRR) = 1.06; 95%CI: 1.02-1.10] and declined in those aged 15-24 years (IRR = 0.99; 95%CI: 0.99-0.99). Gonorrhoea rates increased the most among those aged 65-74 years (IRR = 1.47; 95%CI: 1.23-1.77) and least in those aged 15-24 years (IRR = 1.12; 95%CI: 1.10-1.13). Syphilis rates increased the most among those aged 55-64 years (IRR = 1.58; 95%CI: 1.25-1.99) and least in those aged 15-24 years (IRR = 1.29; 95%CI: 1.23-1.35). Chlamydia test positivity declined among younger women but remained stable in older women., Conclusions: In general, STIs are increasing among older women in Australia at a faster rate than among younger women. Although the greatest burden is among younger women, STIs need to be considered and monitored among older women.

Objectives: Accessible health services are a key element of effective human immunodeficiency virus (HIV) and sexually transmitted infection (STI) control. This study aimed to examine whether there were any differences in accessing sexual health services between Medicare-eligible and Medicare-ineligible men who have sex with men (MSM) in Melbourne, Australia., Methods: We conducted a retrospective, cross-sectional study of MSM attending Melbourne Sexual Health Centre between 2016 and 2019. Demographic characteristics, sexual practices, HIV testing practices and STI diagnoses were compared between Medicare-eligible and Medicare-ineligible MSM., Results: We included 5,085 Medicare-eligible and 2,786 Medicare-ineligible MSM. Condomless anal sex in the past 12 months was more common in Medicare-eligible compared to Medicare-ineligible MSM (74.4% vs. 64.9%; p<0.001) although the number of partners did not differ between groups. There was no difference in prior HIV testing practices between Medicare-eligible and Medicare-ineligible MSM (76.1% vs. 77.7%; p=0.122). Medicare-ineligible MSM were more likely to have anorectal chlamydia compared to Medicare-eligible MSM (10.6% vs. 8.5%; p=0.004)., Conclusions: Medicare-ineligible MSM have less condomless sex but a higher rate of anorectal chlamydia, suggesting they might have limited access to STI testing or may be less willing to disclose high-risk behaviour. Implications for public health: Scaling up access to HIV and STI testings for Medicare-ineligible MSM is essential., (© 2020 The Authors.)

Gonorrhoea cases in women have been rising in Australia in the 2010s but the cause of the increase is not well understood. This cross-sectional study aimed to describe the characteristics of genital gonorrhoea infection in women attending the Melbourne Sexual Health Centre, Australia. Gonorrhoea cases were diagnosed by nucleic acid amplification test (NAAT) and/or culture. Genitourinary specimens were obtained in 12 869 clinic visits in women aged 16 years or above between August 2017 and August 2018. Genital gonorrhoea was detected in 142 (1.1%) of the visits. Almost half of the cases were asymptomatic, 47.9% [95% confidence interval (CI) 39.8-56.1%]; yellow, green or pus-like vaginal discharge was present in 11.3% (95% CI 7.0-17.6%) and other genital symptoms in 40.8% (95% CI 33.1-49.1%) of the cases. The mean time between last sexual contact and onset of symptoms was 7.3 days and between the onset of symptoms to presentation to the clinic was 12.1 days. Half of the cases of genital gonorrhoea among women are asymptomatic and these cases would have been missed by testing of only symptomatic women. Further epidemiological and behavioural research is required to understand the temporal changes in sexual practices among women in Australia.

Adverse reproductive health outcomes, such as pelvic inflammatory disease, ectopic pregnancy and tubal factor infertility, have been associated with Chlamydia trachomatis and Neisseria gonorrhoea infections. These reproductive health outcomes could be complemented by measuring subsequent pregnancies to assess impact on fertility. The study design was a cohort study of women in Queensland (QLD), Australia, using data linkage methods to link chlamydia and/or gonorrhea testing records (including an unexposed group undergoing full blood count tests; 2000 and 2005) with the QLD Perinatal Registry (2000-2013). The cohort included 132 962 women, with 69 533 records of pregnancies. Women in the exposed group, with no prior pregnancy, had a reduced odds of a pregnancy during the follow up of the study (20-year-old (at 2005) aOR 0.91 95% CI 0.87-0.95, and 25-year-old aOR 0.71 95% CI 0.68-0.75). Women in the exposed group with a prior pregnancy had increased odds of pregnancy during the follow up of the study (20-year-old (at 2005) aOR 1.72 95% CI 1.59-1.86, and 25-year-old aOR 1.35 95% CI 1.26-1.45). Our data provides further evidence at a population level of the significant impact on reproductive outcomes associated with chlamydia and gonorrhea., (© The Author(s) 2020. Published by Oxford University Press on behalf of FEMS.)

Objectives: Pharyngeal gonorrhoea disproportionately affects men who have sex with men (MSM). We explored temporal trends in pharyngeal gonorrhoea positivity among MSM compared with anorectal and urogenital positivity., Methods: Data (2011-2015) were extracted from 41 publicly funded sexual health clinics participating in a national surveillance network. Positivity was defined as the proportion of first-visit testing occasions where gonorrhoea was detected. Logistic regression explored trends in positivity and correlates of positive pharyngeal tests., Results: From 2011 to 2015, 24 792 MSM tested (16 710 pharyngeal, 19 810 urogenital and 15 974 anorectal first-visit tests). Pharyngeal positivity increased by 183% from 139/3509 (4.0%) in 2011 to 397/3509 (11.3%) in 2015, p-trend <0.001; urogenital positivity by 39% from 257/4615 (5.6%) to 295/3783 (7.8%), p-trend=0.006; and anorectal positivity by 87% from 160/3469 (4.6%) to 286/3334 (8.6%), p-trend <0.001. The annual temporal increase in positivity was greater in the pharynx (OR 1.33; 95% CI 1.27 to 1.38) than at urogenital (OR 1.06; 95% CI 1.02 to 1.10) and anorectal (OR 1.16; 95% CI 1.11 to 1.21) sites. Factors independently associated with pharyngeal gonorrhoea were: younger age (p<0.001), higher numbers of recent sexual partners (p-trend=0.004), contact with a person with a diagnosed STI (p<0.001), injecting drug use (p<0.001), anogenital symptoms (p<0.001) and HIV-positive status (p=0.050)., Conclusion: Temporal increases in gonorrhoea positivity occurred at all anatomical sites, with the greatest increase in the pharynx. Risk factors could be used to help to develop testing and prevention strategies among MSM at highest risk. Strengthening sexual health service delivery, testing and surveillance remain priorities for pharyngeal gonorrhoea control., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

The Australian Gonococcal Surveillance Programme (AGSP) has continuously monitored antimicrobial resistance in clinical isolates of Neisseria gonorrhoeae since 1981. In 2019, a total of 9,668 clinical isolates of gonococci from the public and private sector in all jurisdictions were tested for in vitro antimicrobial susceptibility by standardised methods. The current treatment recommendation for gonorrhoea, for the majority of Australia, continues to be dual therapy with ceftriaxone and azithromycin. Decreased susceptibility (DS) to ceftriaxone (minimum inhibitory concentration [MIC] value ≥ 0.06 mg/L) was found nationally in 1.3% of isolates. Five N. gonorrhoeae clinical isolates were ceftriaxone-resistant (MIC value ≥ 0.25 mg/L), and therefore also resistant to penicillin; all were resistant to ciprofloxacin but susceptible to azithromycin. These isolates were reported from Victoria (3), non-remote Western Australia (1) and New South Wales (1). Resistance to azithromycin (MIC value ≥ 1.0 mg/L) was found nationally in 4.6% of N. gonorrhoeae isolates, continuing a downward trend observed and reported since 2017. Isolates with high-level resistance to azithromycin (MIC value ≥ 256 mg/L) continue to be reported sporadically in Australia, with eight detected in 2019: two each from New South Wales, Queensland, and Victoria, and one each from Tasmania and non-remote Western Australia. In 2019, in Australia, 2,136 gonococcal isolates (22.1%) were penicillin resistant; however, there remains considerable variation by jurisdiction, and in some remote settings there is little resistance and this drug is recommended empiric therapy. In 2019, in the remote Northern Territory, no penicillin resistance was reported, however in remote Western Australia six out of 85 isolates (7.1%) were penicillin resistant. There was no ciprofloxacin resistance reported from isolates tested from remote regions of the Northern Territory, and ciprofloxacin resistance rates remain comparatively low (7/85; 8.2%) in remote Western Australia., (© Commonwealth of Australia CC BY-NC-ND.)

Background: Asymptomatic screening for gonorrhoea in heterosexual men is currently not recommended in many countries including Australia, given the prevalence is relatively low in the heterosexual population. We aimed to determine the proportion of urethral gonorrhoea cases among heterosexual men attending a sexual health clinic that was asymptomatic and symptomatic, the time since last sexual contact to the onset of symptoms and the time to clinic presentation following the onset of symptoms., Methods: This was a cross-sectional study that included heterosexual men aged 16 years or above attending the Melbourne Sexual Health Centre (MSHC) in Australia between August 2017 and August 2018. Gonorrhoea cases were diagnosed by nucleic acid amplification testing (NAAT) and/or culture. Descriptive analyses were conducted for all gonorrhoea cases including demographic characteristics, recent sexual practices, reported urethral symptoms and duration, sexual contact with a person diagnosed with gonorrhoea, investigations performed and laboratory results., Results: There were 116 confirmed cases of urethral gonorrhoea in heterosexual men over the study period of which 6.0% (95% CI: 2.7-12.1%) were asymptomatic. Typical urethral discharge was present in 80.2% (95% CI: 71.9-86.5%) of men. The mean time between last sexual contact and the onset of symptoms was 7.0 days, and between the onset of symptoms to presentation to the clinic was 5.6 days., Conclusions: A small proportion of heterosexual men with urethral gonorrhoea do not have any symptoms. Heterosexual men with urethral symptoms usually seek for healthcare within a week, prompting rapid healthcare-seeking behaviour.

Background The prevalence of sexually transmissible infections has been low among female sex workers (FSWs) in Melbourne, Australia. However, the prevalence of gonorrhoea and chlamydia, especially at extragenital sites, has increased since the mid-2010s. Oro-anal sex (i.e. rimming) has been identified as a risk factor for extragenital gonorrhoea and chlamydia. However, rimming has rarely been studied among the FSW population. The aim of this study was to examine the proportion of FSWs who had had rimming with their male clients., Methods: A cross-sectional survey among FSWs attending the Melbourne Sexual Health Centre in Australia in March 2018 was conducted. All females aged ≥18 years and self-reported as a sex worker were eligible. The survey included questions related to the number of insertive and receptive rimming partners with their male clients in an average working week., Results: Forty-five FSWs completed the survey; five (11.1%; 95% CI: 3.7-24.1%) FSWs had had insertive rimming and 19 (42.2%; 95% CI: 27.7-57.8%) had had receptive rimming with their male clients in an average working week. The median number of insertive rimming partners was two (interquartile range (IQR) 1-5) and the median number of receptive rimming partners was one (IQR 1-3)., Conclusion: Insertive rimming is more commonly practiced than receptive rimming among FSWs with their male clients in an average working week.

Background: Gonorrhea is a significant public health concern. The changing epidemiology of gonorrhea in Australia has highlighted the need for detailed examination of surveillance data to determine population groups at greatest risk for infection., Methods: We analyzed deidentified gonorrhea notification data for the years 2012 to 2017, in Adelaide (N = 3680), calculating age-adjusted notification and antibiotic resistance rates. Age, gender, year, sexual orientation, and socioeconomic status were assessed for associations with gonorrhea notifications using negative binomial, log binomial and spatial autoregressive models. Maps were generated to examine spatial localization of gonorrhea rates in Adelaide., Results: Gonorrhea notification rates in Adelaide increased annually, with a 153% adjusted increase in rates from 2012 to 2017, localized to specific areas and inversely associated with income levels. The increase in rates in 2016 and 2017 was associated with young heterosexuals from low income areas. Azithromycin-resistant notifications increased significantly in 2016 in young heterosexuals. Reinfections were significantly more likely in men who have sex with men than other population groups., Conclusions: This study demonstrates the changing epidemiology of gonorrhea in Adelaide from a largely men who have sex with men profile toward an increase in young heterosexual gonorrhea. This could be seen as a harbinger for future increases in heterosexually transmitted HIV and other sexually transmitted infections in Australia.