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Objectives: To estimate trends in prevalence and incidence of syphilis, gonorrhea and chlamydia in adult men and women in South Africa., Methods: The Spectrum-STI tool estimated trends in prevalence and incidence of active syphilis, gonorrhea and chlamydia, fitting South African prevalence data. Results were used, alongside programmatic surveillance data, to estimate trends in incident gonorrhea cases resistant to first-line treatment, and the reporting gap of symptomatic male gonorrhea and chlamydia cases treated but not reported as cases of urethritis syndrome., Results: In 2017 adult (15-49 years) the estimated female and male prevalences for syphilis were 0.50% (95% CI: 0.32-0.80%) and 0.97% (0.19-2.28%), for gonorrhea 6.6% (3.8-10.8%) and 3.5% (1.7-6.1%), and for chlamydia 14.7% (9.9-21%) and 6.0% (3.8-10.4%), respectively. Between 1990 and 2017 the estimated prevalence of syphilis declined steadily in women and men, probably in part reflecting improved treatment coverage. For gonorrhea and chlamydia, estimated prevalence and incidence showed no consistent time trend in either women or men. Despite growing annual numbers of gonorrhea cases - reflecting population growth - the estimated number of first line treatment-resistant gonorrhea cases did not increase between 2008 and 2017, owing to changes in first-line antimicrobial treatment regimens for gonorrhea in 2008 and 2014/5. Case reporting completeness among treated male urethritis syndrome episodes was estimated at 10-28% in 2017., Conclusion: South Africa continues to suffer a high STI burden. Improvements in access and quality of maternal, STI and HIV health care services likely contributed to the decline in syphilis prevalence. The lack of any decline in gonorrhea and chlamydia prevalence highlights the need to enhance STI services beyond clinic-based syndromic case management, to reinvigorate primary STI and HIV prevention and, especially for women, to screen for asymptomatic infections., Competing Interests: The views expressed in this paper are those of the authors and do not necessarily represent the position of Avenir Health, South Africa’s National Institute for Communicable Diseases, the World Health Organization, the U.S. Centers for Disease Control and Prevention, or other organizations. The authors have declared that no competing interests exist.

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

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

The objective was to determine the occurrence of four urethral pathogens in urine specimens from symptomatic men using transcription mediated amplification (TMA) assay. Urethral swab and urine specimens from 300 men presenting to a family practitioner were Gram stained and tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and Mycoplasma genitalium using three TMA assays respectively. Except for T. vaginalis, the other recognized pathogens viz. N. gonorrhoeae, C. trachomatis and M. genitalium were detected in significantly larger numbers of patients with urethral discharge than in those with burning on micturition (BOM). The overall prevalences were 16.7% for N. gonorrhoeae, 12.3% C. trachomatis, 8.0% T. vaginalis and 17.3% M. genitalium. With regard to microscopic evidence of urethritis, significant associations were found for N. gonorrhoeae and C. trachomatis, but not for M. genitalium and T. vaginalis. This study demonstrated that in symptomatic men attending family practice, M. genitalium and T. vaginalis are also important aetiological agents of urethritis and hence treatment strategies be they syndromic management or laboratory directed should cover for these causative agents. The microscopic diagnosis of urethritis may not be important for treatment strategies. The current syndromic treatment guidelines for developing countries including South Africa need modification.

Objectives: To determine the prevalence of sexually transmitted infections (STI) and HIV among men attending an outreach STI/HIV screening service in informal settlements in South Africa over a 3-month period., Methods: A mobile clinic van was utilised to offer men: (1) urine screening for gonorrhoea, trichomoniasis, chlamydial and Mycoplasma genitalium infections; (2) serological screening for syphilis and herpes simplex virus type 2 (HSV-2); (3) on-site HIV voluntary counselling and testing. Urethritis pathogens were detected by molecular methods. HIV serostatus was determined using rapid tests. Demographic, sexual behaviour and clinical data were recorded on a nurse-administered questionnaire. Statistical analysis utilised the chi(2) test., Results: 309 men attended the service; 304 (98%) requested serological screening for syphilis and HSV-2, 301 (97%) underwent urine-based screening for urethritis pathogens and 269 (87%) had an HIV test. Over 90% of men were asymptomatic for STI. Gonorrhoea was more prevalent in the symptomatic group (p<0.001); there were no significant differences in the prevalence of other urethritis pathogens between the groups. The total number of infections with each urethritis pathogen was highest in the asymptomatic group with twice as much gonorrhoea, 25 times as much chlamydial infection, six times as much trichomoniasis and nine times as much M genitalium infection compared with the symptomatic group. The overall HIV prevalence among clinic attendees was 29.7%., Conclusions: The uptake of both STI and HIV testing was high among men attending the service. The relatively high burden of both STI and HIV among the male clinic attendees has implications for the transmission of HIV.

Objectives: The objectives of this study were to assess the prevalence of ciprofloxacin-resistant gonorrhoea in two South African cities and to investigate the association between the isolation of ciprofloxacin-resistant Neisseria gonorrhoeae and the HIV serostatus of patients., Methods: Gonococci were cultured from endourethral swabs taken from consecutive men with urethritis attending clinics in Johannesburg and Cape Town. Minimum inhibitory concentrations (MIC) for ciprofloxacin and ceftriaxone were determined with E-tests. Isolates with a ciprofloxacin MIC of 1 mg/l or greater were defined as resistant and isolates with a ceftriaxone MIC of 0.25 mg/l or less were defined as susceptible. Rapid tests were used to screen and confirm the presence of HIV antibodies. Survey data from 2004 were used as a baseline to assess trends in gonococcal resistance to ciprofloxacin., Results: In 2004, the prevalence of ciprofloxacin resistance was 7% in Cape Town and 11% in Johannesburg. In 2007, 37/139 (27%) Cape Town isolates and 47/149 (32%) Johannesburg isolates were resistant to ciprofloxacin; in comparison with 2004 data, this represents 2.9-fold and 1.9-fold increases, respectively. All isolates were fully susceptible to ceftriaxone. There was a significant association between HIV seropositivity and the presence of ciprofloxacin-resistant gonorrhoea among patients (p = 0.034)., Conclusions: Johannesburg and Cape Town have witnessed significant rises in the prevalence of ciprofloxacin-resistant gonorrhoea among men with urethritis. The resistant phenotype is linked to HIV seropositivity. There is now an urgent need to change national first-line therapy for presumptive gonococcal infections within South Africa.

Objectives: To determine the prevalence of urethritis pathogens amongst male symptomatic urethritis (MUS) patients, genital ulcer (GUS) patients without urethritis symptoms and men requesting HIV testing at a voluntary counselling and testing (VCT) clinic., Methods: A prospective study was conducted in Johannesburg, South Africa. Men from the three groups were screened for urethritis pathogens using molecular tests. Culture for Neisseria gonorrhoeae and, initially, trichomoniasis was performed. Antimicrobial susceptibility testing was undertaken for ciprofloxacin on all gonococcal isolates; ciprofloxacin resistant isolates were screened for ceftriaxone resistance., Results: 664 participants were recruited (438 MUS, 76 GUS and 158 VCT) over 2 years. Gonorrhoea was detected in 62.3% MUS, 15.8% GUS and 3.2% VCT participants. Chlamydial infection was detected in 19.3% MUS, 13.2% GUS and 8.2% VCT participants. Trichomoniasis was detected in 4.9% MUS, 19.7% GUS and 3.8% VCT participants. Mycoplasma genitalium infection was detected in 14.4% MUS, 13.2% GUS and 7.0% VCT participants. Ciprofloxacin resistance increased from 13.0% in the first year to 26.3% in the second year; all resistant isolates were susceptible to ceftriaxone., Conclusions: Urethritis pathogens, including Trichomonas vaginalis, should be covered in syndromic management treatment of genital ulcers in the absence of clinical urethritis. Consideration should be given to adding metronidazole to existing MUS treatment. Ciprofloxacin can no longer be relied upon to treat presumptive gonococcal infections in South Africa.

Resistant Neisseria gonorrhoeae has been evolving. This study assessed the antimicrobial susceptibility profile of isolates in the Pretoria region, South Africa. Isolates of N. gonorrhoeae from men with urethritis were tested for susceptibility to eight antimicrobial agents by disc diffusion, Etest and agar dilution methods. Chromosomal resistance to penicillin was found in 16% of isolates, 16% showed plasmid-mediated resistance and decreased susceptibility was seen in 73% of isolates. For the first time, there is evidence of high-level tetracycline resistance (36%). Ciprofloxacin resistance emerged at 7%. All isolates remained susceptible to ceftriaxone. In view of these findings of the emergence of quinolone-resistant N. gonorrhoeae, national treatment guidelines for syndromic management of sexually transmitted infections need to be urgently reviewed. The injectable preparation, ceftriaxone has to be considered as a first-line agent for the management of gonococcal infections. Overall, the gonococcal isolates in the Pretoria region remain susceptible to ceftriaxone, cefoxitin, cefpodoxime and spectinomycin.

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

Objective: To assess whether syndromic management of genital ulcer disease was sound, if based on the premise that men with genital ulcers rarely have a concomitant urethral infection., Methods: Specimens were taken in 1998 from 186 mine workers in Carletonville, South Africa, who were seen consecutively with genital ulcers. The specimens comprised a swab from the ulcer, a urethral swab for a Gram stained smear, and 10-15 ml of a first catch urine sample. The latter was tested by ligase chain reaction assays for Neisseria gonorrhoeae and Chlamydia trachomatis specific DNA sequences and by a polymerase chain reaction (PCR) assay for Mycoplasma genitalium. Ulcer inducing micro-organisms were detected either by a multiplex PCR assay, or in the case of lymphogranuloma venereum (LGV) serologically, and human immunodeficiency virus (HIV) infection was detected by an enzyme linked immunosorbent assay (ELISA) test., Results: Most (54%) of the ulcers were chancroidal, 18% were herpetic (HSV type 2), 6.5% primary syphilitic, and 3.2% due to LGV. More than one micro-organism was detected in 9.1% of the ulcers and less than 10% were undiagnosed. Microscopic examination of the urethral smears showed that 99 (53%) of the men had urethritis, of whom 45 (45%) were infected with N gonorrhoeae. Of the 54 men (55%) who had non-gonococcal urethritis (NGU), 11 (19.6%) harboured C trachomatis or M genitalium. Almost two thirds (64.5%) of the men had HIV infection, but this did not seem to have influenced the aetiology of the ulcers. Nor was a particular ulcer associated with one type of urethritis more than the other. Neither C trachomatis nor M genitalium was associated significantly with non-gonococcal urethritis (NGU) in either HIV positive or HIV negative men., Conclusion: The combination of antibiotics used for the management of genital ulcer disease in men in this South African mining population needs to be widened to encompass frequently occurring concomitant gonococcal urethritis and NGU infections. This means treatment with long acting penicillin, combined with ciprofloxacin and azithromycin or erythromycin. A similar situation may exist in other geographical locations with a need to provide appropriate antimicrobial combinations depending on the patterns of infection detected.

The occurrence of Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium was determined by molecular techniques in urine specimens from 182 black South African men who had symptoms and/or overt signs of urethritis. Eighty-six (47.3%) of these men were infected with N. gonorrhoeae. There were 185 men without overt evidence of urethritis, 16 (8.6%) of whom were also infected with N. gonorrhoeae. Of the 96 men who had non-gonococcal urethritis, 14 (14.6%) were infected with C. trachomatis, 16 (16.7%) with M. genitalium and only one with both microorganisms. In comparison, 15 (8.9%) of 169 men without overt urethritis and without N. gonorrhoeae were infected with C. trachomatis and 15 (8.9%) with M. genitalium, proportions that were about half the size of those in the group with overt urethritis.

Trichomonas vaginalis was diagnosed in 42 (19%) of 227 adult males with urethral discharge. In 27 men (15%) T. vaginalis was isolated together with Neisseria gonorrhoeae. Non-gonococcal urethritis was diagnosed in 15 patients and T. vaginalis was isolated from 47% of such patients. Stained smear preparations, i.e. RapiDiff and acridine orange of modified Diamond's media, were superior to wet smear microscopy for the identification of T. vaginalis. RapiDiff stain was the most sensitive and identified 41 of 42 (98%) positive cultures. It is recommended that all turbid culture media should be stained for the optimal diagnosis of trichomoniasis.

Objective: To investigate the aetiology of acute epididymitis in a developing community with a view of determining appropriate antimicrobial therapy., Setting: City Health Sexually Transmitted Diseases Clinic, King Edward VIII Hospital, Durban, South Africa., Participants: 144 adult men with clinically diagnosed acute epididymitis., Method: Endourethral swab and midstream urine (MSU) specimens were processed to detect sexually transmitted pathogens and urinary tract infections., Results: The majority of patients (93%) were less than 35 years of age. Neisseria gonorrhoeae and/or Chlamydia trachomatis were detected in 78% of patients: N gonorrhoeae in 57%, C trachomatis in 34% and both in 13%. Escherichia coli was cultured more frequently from MSU specimens of older patients, 30% versus 3%. In 53% of patients urethritis was diagnosed by the presence of inflammatory cells in endourethral smears in the absence of a visible urethral discharge., Conclusion: In our setting of a busy clinic with limited facilities, we recommend the performance of a Gram stain on endourethral specimens from patients with acute epididymitis. If inflammatory cells and Gram negative diplococci are detected, treatment with antimicrobial agents to cover both penicillinase-producing N gonorrhoeae strains and C trachomatis is recommended. If Gram negative diplococci are not detected in the presence of microscopic evidence of urethritis, treatment for chlamydial infection alone is recommended.

The incidence of infections with Neisseria gonorrhoeae, Chlamydia trachomatis and mycoplasmas has been assessed in White men with urethritis who were attending a Johannesburg clinic for sexually transmitted diseases. Infection with N. gonorrhoeae was demonstrated in 54% of 212 patients with urethritis. C. trachomatis was isolated from 37% of patients with non-gonococcal urethritis, and from 25% with proven gonococcal infection. Although T-mycoplasmas were isolated significantly more often from patients with urethritis (41%) than from controls (23%) (P less than 0,05) their role in the aetiology of urethritis is uncertain.