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ObjectivesA Finnish Chlamydia trachomatis (CT) new variant was detected in 2019 that escaped detection in the Hologic Aptima Combo 2 (AC2) assay due to a C1515T mutation in the CT 23S rRNA target region. Reflex testing of CT-negative/CT-equivocal specimens as well as those positive for Neisseria gonorrhoeae (NG) with the Hologic Aptima CT (ACT) assay was recommended to identify any CT variants.MethodsFrom June to October 2019, specimens with discrepant AC2/ACT CT results were submitted to Public Health England and screened for detectable CT DNA using an inhouse real-time (RT)-PCR. When enough DNA was present, partial CT 23S rRNA gene sequencing was performed. Analysis of available relative light units and interpretative data was performed.ResultsA total of 317 discordant AC2/ACT specimens were collected from 315 patients. Three hundred were tested on the RT-PCR; 53.3% (n=160) were negative and 46.7% (n=140) were positive. Due to low DNA load in most specimens, sequencing was successful for only 36 specimens. The CT 23S rRNA wild-type sequence was present in 32 specimens, and two variants with C1514T or G1523A mutation were detected in four specimens from three patients. Of the discordant specimens with NG interpretation, 36.6% of NG-negative/CT-negative AC2 specimens had detectable CT DNA on the inhouse RT-PCR vs 53.3% of NG-positive/CT-negative specimens.ConclusionsNo widespread dissemination of AC2 diagnostic-escape CT variants has occurred in England. We however identified the impact of NG positivity on the discordant AC2/ACT specimens; a proportion appeared due to NG positivity and the associated NG signal, rather than any diagnostic-escape variants or low DNA load. Several patients with gonorrhoea may therefore receive false-negative AC2 CT results. Single diagnostic targets and multiplex diagnostic assays have their limitations such as providing selection pressure for escape mutants and potentially reduced sensitivity, respectively. These limitations must be considered when establishing diagnostic pathways.

BackgroundChlamydial infection is associated with tubal factor infertility (TFI); however, assessment of prior chlamydial infection and TFI is imperfect. We previously evaluated a combination of serological assays for association with TFI. We now describe the chlamydial contribution to TFI using a newer Chlamydia trachomatis Pgp3 enhanced serological (Pgp3) assay.MethodsIn our case-control study of women 19–42 years old with hysterosalpingogram-diagnosed TFI (cases) and non-TFI (controls) in two U.S. infertility clinics, we assessed possible associations and effect modifiers between Pgp3 seropositivity and TFI using adjusted odds ratios (aOR) with 95% confidence intervals (CI) stratified by race. We then estimated the adjusted chlamydia population attributable fraction (aPAF) with 95% CI of TFI.ResultsAll black (n=107) and 618 of 620 non-black women had Pgp3 results. Pgp3 seropositivity was 25.9% (19.3–33.8%) for non-black cases, 15.2% (12.3–18.7%) for non-black controls, 66.0% (95% CI 51.7–77.8%) for black cases, and 71.7% (59.2–81.5%) for black controls. Among 476 non-black women without endometriosis (n=476), Pgp3 was associated with TFI (aOR 2.6 [1.5– 4.4]), adjusting for clinic, age, and income; chlamydia TFI aPAF was 19.8% (95% CI 7.7–32.2%) in these women. Pgp3 positivity was not associated with TFI among non-black women with endometriosis nor among black women (regardless of endometriosis).ConclusionsAmong non-black infertile women without endometriosis in these clinics, 20% of TFI was attributed to chlamydia. Better biomarkers are needed to estimate chlamydia TFI PAF, especially in black women.

Ectopic pregnancy (EP) is defined as the implantation of an embryo outside of the uterus and is a leading cause of first trimester maternal mortality and morbidity. This article discusses a possible role for epithelial to mesenchymal transition in the pathogenesis of EP, given the notable similarity of protein expression between the two processes.

Current understanding of the causes of treatment failure inGenomic DNA was extracted fromSeven isolates from persistently infected patients and five isolates from successfully treated patients were sequenced. No previously reported SNVs associated with antimicrobial resistance were found. A unique SNV was identified in theNo genomic evidence was found to explain the differences in clinical outcome for our two groups of patients. A mutation unrelated to antimicrobial susceptibility was found in an isolate from a persistently infected patient. The cause of these persistent infections with

ObjectivesOnline testing for sexually transmitted infections (STIs) may contribute to overcoming barriers to traditional testing such as stigma and inconvenience. However, regulation of these tests is lacking, and the quality of services is variable, with potential short- and long-term personal, clinical and public health implications. This study aimed to evaluate online tests available in the UK against national standards.MethodsProviders of online STI tests (self-sampling and self-testing) in the UK were identified by an internet search of Google and Amazon (June 2020). Website information on tests and care was collected, and further information requested from providers via an online survey, sent twice (July 2020, April 2021). The information obtained was compared to British Association for Sexual Health and HIV (BASHH) guidelines for diagnostics and standards of STI management.Results31 providers were identified: 13 self-test, 18-self-sample, and two laboratories that serviced multiple providers. Seven responded to the online survey. Many conflicts with national guidelines were identified, including: lack of health promotion information, lack of sexual history taking, use of tests licensed for professional use only marketed for self-testing, inappropriate infections tested for, incorrect specimen type used, and lack of advice for post-diagnosis management.ConclusionsVery few online providers met the BASHH national STI management guidelines standards that were assessed, and there is concern that this will also be the case in areas that were not covered by this study. For-profit providers were the least compliant, with concerning implications for patient care and public health. Regulatory change is urgently needed to ensure that online providers are compliant with national guidelines to ensure high-quality patient care, and providers are held to account if non-compliant.Key message boxOnline providers help overcome many barriers to STI testing and are increasingly popular, but quality of services is not assuredMany online testing services, particularly for-profit providers, did not comply with national guidelinesSubstandard services can lead to serious personal, clinical and public healthimplications, such as inappropriate testing, inappropriate antimicrobial prescribing, unnecessary emotional distress and missed diagnosesRegulatory change is required to ensure online providers comply with national guidelines and are held to account when they do not

We synthesized evidence from the POPI sexual-health cohort study and estimated that 4.9% (95% credible interval, .4–14.1%) of Mycoplasma genitalium infections in women progress to pelvic inflammatory disease versus 14.4% (5.9–24.6%) of chlamydial infections. For validation, we predicted PID rates in 4 age groups that agree well with surveillance data.

ObjectivesContinuous improvement in the delivery of health services is increasingly being demanded in the UK at a time when budgets are being cut. Simulation is one approach used for understanding and assessing the likely impact of changes to the delivery of health services. However, little is known about the usefulness of simulation for analysing the delivery of sexual health services (SHSs). We propose a simulation method to model and evaluate patient flows and resource use within an SHS to inform service redesign.MethodsWe developed a discrete event simulation (DES) model to identify the bottlenecks within the Unity SHS (Bristol, UK) and find possible routes for service improvement. Using the example of the introduction of an online service for sexually transmitted infection (STI) and HIV self-sampling for asymptomatic patients, the impact on patient waiting times was examined as the main outcome measure. The model included data such as patient arrival time, staff availability and duration of consultation, examination and treatment. We performed several sensitivity analyses to assess uncertainty in the model parameters.ResultsWe identified some bottlenecks under the current system, particularly in the consultation and treatment queues for male and female walk-in patients. Introducing the provision of STI and HIV self-sampling alongside existing services decreased the average waiting time (88 vs 128 min) for all patients and reduced the cost of staff time for managing each patient (£72.64 vs £88.74) compared with the current system without online-based self-sampling.ConclusionsThe provision of online-based STI and HIV self-sampling for asymptomatic patients could be beneficial in reducing patient waiting times and the model highlights the complexities of using this to cut costs. Attributing recognition for any improvement requires care, but DES modelling can provide valuable insights into the design of SHSs ensuing in quantifiable improvements. Extension of this method with the collection of additional data and the construction of more informed models seems worthwhile.

The 2019 published National Institute for Health and Care Excellence abortion care guidance (NG140) recommends that antibiotic prophylaxis is offered to women who are having a surgical abortion and, when using doxycycline, a 100 mg two times a day for 3 days should be considered. The rationale to the recommendation states ‘a three day course because this may be as effective and adherence is likely to be better with a shorter outcome’. This is a shorter duration than that presented as part of the consultation. Originally, ‘the committee agreed that 7 days of doxycycline should be considered as it would be sufficient to treat sexually transmitted infections (STIs), if present. Further, there was expert knowledge that there is no evidence of increased antimicrobial resistance (AMR) with 7 days, compared with 3 days, of treatment. This is also consistent with the UK national recommendations for treating chlamydia’.1 The …

Background Up to 18% of genital Chlamydia infections and 9% of Gonorrhoea infections in England are diagnosed in Primary Care. Evidence suggests that a substantial proportion of these cases are not managed appropriately in line with national guidelines. With the increase in sexually transmitted infections and the emergence of antimicrobial resistance, their timely and appropriate treatment is a priority. We investigated feasibility and acceptability of extending the National Chlamydia Screening Programme’s centralised, nurse-led, telephone management (NLTM) as an option for management of all cases of chlamydia and gonorrhoea diagnosed in Primary Care. Methods Randomised feasibility trial in 11 practices in Bristol with nested qualitative study. In intervention practices patients and health care providers (HCPs) had the option of choosing NLTM or usual care for all patients tested for Chlamydia and Gonorrhoea. In control practices patients received usual care. Results One thousand one hundred fifty-four Chlamydia/gonorrhoea tests took place during the 6-month study, with a chlamydia positivity rate of 2.6% and gonorrhoea positivity rate of 0.8%. The NLTM managed 335 patients. Interviews were conducted with sixteen HCPs (11 GPs, 5 nurses) and 12 patients (8 female). HCPs were positive about the NLTM, welcomed the partner notification service, though requested more timely feedback on the management of their patients. Explaining the NLTM to patients didn’t negatively impact on consultations. Patients found the NLTM acceptable, more convenient and provided greater anonymity than usual care. Patients appreciated getting a text message regarding a negative result and valued talking to a sexual health specialist about positive results. Conclusion Extension of this established NLTM intervention to a greater proportion of patients was both feasible and acceptable to both patients and HCP, could provide a better service for patients, whilst decreasing primacy care workload. The study provides evidence to support the wider implementation of this NLTM approach to managing chlamydia and gonorrhoea diagnosed in primary care.

At present, we have no evidence that we are doing more good than harm detecting and subsequently treating Mycoplasma hominis, Ureaplasma parvum and Ureaplasma urealyticum colonizations/infections. Consequently, routine testing and treatment of asymptomatic or symptomatic men and women for M. hominis, U. urealyticum and U. parvum are not recommended. Asymptomatic carriage of these bacteria is common, and the majority of individuals do not develop any disease. Although U. urealyticum has been associated with urethritis in men, it is probably not causal unless a high load is present (likely carriage in 40-80% of detected cases). The extensive testing, detection and subsequent antimicrobial treatment of these bacteria performed in some settings may result in the selection of antimicrobial resistance, in these bacteria, true' STI agents, as well as in the general microbiota, and substantial economic cost for society and individuals, particularly women. The commercialization of many particularly multiplex PCR assays detecting traditional non-viral STIs together with M. hominis, U. parvum and/or U. urealyticum has worsened this situation. Thus, routine screening of asymptomatic men and women or routine testing of symptomatic individuals for M. hominis, U. urealyticum and U. parvum is not recommended. If testing of men with symptomatic urethritis is undertaken, traditional STI urethritis agents such as Neisseria gonorrhoeae, Chlamydia trachomatis, M. genitalium and, in settings where relevant, Trichomonas vaginalis should be excluded prior to U. urealyticum testing and quantitative species-specific molecular diagnostic tests should be used. Only men with high U. urealyticum load should be considered for treatment; however, appropriate evidence for effective treatment regimens is lacking. In symptomatic women, bacterial vaginosis (BV) should always be tested for and treated if detected.

ObjectivesTo investigate experiences of implementing a new rapid sexual health testing, diagnosis and treatment service.DesignA theory-based qualitative evaluation with a focused ethnographic approach using non-participant observations and interviews with patient and clinic staff. Normalisation process theory was used to structure interview questions and thematic analysis.SettingA sexual health centre in Bristol, UK.Participants26 patients and 21 staff involved in the rapid sexually transmitted infection (STI) service were interviewed. Purposive sampling was aimed for a range of views and experiences and sociodemographics and STI results for patients, job grades and roles for staff. 40 hours of observations were conducted.ResultsImplementation of the new service required co-ordinated changes in practice across multiple staff teams. Patients also needed to make changes to how they accessed the service. Multiple small ‘pilots’ of process changes were necessary to find workable options. For example, the service was introduced in phases beginning with male patients. This responsive operating mode created challenges for delivering comprehensive training and communication in advance to all staff. However, staff worked together to adjust and improve the new service, and morale was buoyed through observing positive impacts on patient care. Patients valued faster results and avoiding unnecessary treatment. Patients reported that they were willing to drop-off self-samples and return for a follow-up appointment, enabling infection-specific treatment in accordance with test results, thus improving antimicrobial stewardship.ConclusionsThe new service was acceptable to staff and patients. Implementation of service changes to improve access and delivery of care in the context of stretched resources can pose challenges for staff at all levels. Early evaluation of pilots of process changes played an important role in the success of the service by rapidly feeding back issues for adjustment. Visibility to staff of positive impacts on patient care is important in maintaining morale.

We identified two new Chlamydia trachomatis (CT) variants escaping Aptima Combo 2 (AC2) assay detection, in clinical specimens of two patients. One had a C1514T mutation the other a G1523A mutation, both within the AC2 23S rRNA target region. The prevalence of such variants among persons tested for CT in England was estimated to be fewer than 0.003%.

Introduction: Antimicrobial resistant (AMR) gonorrhoea is a global public health threat. In London, diagnoses of gonorrhoea in men who have sex with men (MSM) have increased year on year since 2010. Importantly, our last-line treatment (ceftriaxone) is used in first-line therapy. However, over half of tested isolates are still sensitive to previously recommended drugs, e.g. ciprofloxacin. Discriminatory point-of-care tests (POCT) to detect drug sensitivity are under development, enabling individualised resistance guided therapy. Static models have been used previously to evaluate the cost-effectiveness of POCT, but these are limited in not accounting for dynamic changes in disease epidemiology resulting from changes to testing and treatment practice.Methods: We developed an individual-based dynamic transmission model of gonorrhoea infection in MSM living in London, incorporating ciprofloxacin-sensitive and resistant strains. The time-dependent sexual contact network is captured by periodically restructuring active connections to reflect the transience of contacts. We explored different strategies to improve treatment selection, including discriminatory POCT, and selecting partner treatment based on either index case or partner susceptibility. Outcomes included population prevalence of gonorrhoea and drug dose counts.Results: The new model is flexible and fast and is able to capture essential elements of gonorrhoea epidemiology (low prevalence, heterogeneous behaviour, dynamic sexual network). In this case study we show that using POCT to detect ciprofloxacin-sensitive infections could result in a large decrease in ceftriaxone doses (by 70% compared to the reference case in our simulations). It also suggests that ceftriaxone use can be reduced with existing technologies, albeit to a lesser degree: either using index case sensitivity profiles to direct treatment of partners, or testing notified partners with strain discriminatory laboratory tests prior to treatment, reduced ceftriaxone use in our model (by 27% and 47% respectively). Conclusion: POCT to detect ciprofloxacin-sensitive gonorrhoea are likely to dramatically reduce reliance on ceftriaxone but requires the implementation of new technology. In the meantime, we could significantly reduce the proportion of unnecessary ceftriaxone treatment by testing partners before treatment. Alternatively, index case sensitivity profiles could be used to select effective treatments for partners.

This is the first British Association for Sexual Health and HIV (BASHH) guideline for the diagnosis and management of Mycoplasma genitalium in people aged 16 years and older. The guideline is primarily aimed at level 3 sexually transmitted infection (STI) management services within the UK, although it could also serve as a reference guide for STI services at other levels.

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Background In 1998 the United Kingdom Chief Medical Officer recommended action to reduce the prevalence and morbidity associated with chlamydial infection. The introduction of NAAT testing from 2003 and the roll-out of the National Chlamydia Screening Programme (NCSP) in England from 2004 to 2008 (all regions participating) resulted in large increases in chlamydia screening and diagnoses: 2.3 million tests were reported in 2010 among 15 to 24 year-olds, equivalent to 44% of women and 24% of men in this age group. We investigated rates of diagnoses of pelvic inflammatory disease (PID) in women attending specialist sexual health services (SSHS) since 2007. Methods Data were extracted from the GUMCAD surveillance system from 2007–2017. To explore the effect of changes in access to SSHS over this time, total number of attendances were also extracted and changes in PID diagnoses were compared to those of a symptomatic clinical presentation with no active control programme, vaginosis/vaginitis (bacterial vaginosis, candidiasis, trichomoniasis). Results Between 2007 and 2017 PID diagnoses decreased by 18%. Chlamydia-associated-PID (CT-PID) diagnoses decreased by 46%, and the% of PIDs associated with CT fell from 14.7% (∼2,400) to 9.7% (∼1,300). GC-associated-PID increased 34% (to ∼300). Decreases were greater in under 25s and in years up to 2011/12. Attendances by women under 25 increased over this time, and there was a 6% increase in diagnoses of vaginitis/vaginosis, with CT-PID decreasing by 49% relative to vaginitis/vaginosis. Conclusion There has been a marked decline in diagnoses of CT-PID, and all PID, at SSHS subsequent to the introduction of wide-spread chlamydia screening. This has occurred despite an increase in attendances at SSHS and access for symptomatic women (vaginosis/vaginitis). Further work will explore trends by region and in general practice, and will determine whether CT-PID rates might be a metric for the success of chlamydia control. Disclosure No significant relationships.

Background England’s National Chlamydia Screening Programme (NCSP) recommends that sexually active people

Background The development of antimicrobial resistance (AMR) to macrolides and extended-spectrum cephalosporins (ESC) in Neisseria gonorrhoeae (NG), is a major public health concern. While macrolide AMR is increasing globally, ESC AMR is low and extensive drug-resistance (XDR) rare. Methods We report the clinical management and microbiology of two recent cases of XDR NG in the UK. Results Case A (female) presented to a sexual health clinic (SHC) in October 2018 with urinary symptoms. She cleared the infection following treatment with ceftriaxone 500 mg plus azithromycin 1g. She had recently had vaginal intercourse with ≥1 male partner in Ibiza, Spain. Case B (female) presented to a SHC elsewhere in England in November 2018 with anal and genital symptoms. She had recently had unprotected vaginal, oral and anal sex with an asymptomatic man who had been in Ibiza and had links with the same sexual network as case A. He tested NG NAAT-negative in December without treatment. Case B initially responded clinically to treatment with ceftriaxone 1g, but symptoms relapsed and she remained culture-positive 2 weeks later. She failed subsequent treatment with gentamicin 240 mg plus azithromycin 2g but cleared the infection with 3 days of IV ertapenem. Both isolates were resistant to ceftriaxone (MIC 1.0 mg/L), cefixime, penicillin, ciprofloxacin and tetracycline, had intermediate susceptibility to azithromycin (MIC 0.5 mg/L), and were susceptible to spectinomycin. Whole genome sequencing indicated that both isolates were from the FC428 clone, which has been reported sporadically globally, usually with epidemiological links to the Asia-Pacific region. Conclusion These FC428 clone isolates are able to cause both asymptomatic and symptomatic infection with a variable response to ceftriaxone and azithromycin treatment. This clone is likely to increase over time in Europe and threatens the effectiveness of gonorrhoea treatment. Surveillance of AMR, test-of-cure, extra-genital sampling and partner notification are vital to maintain effective treatment and prevent spread. Disclosure No significant relationships.

Background Antimicrobial resistant (AMR) gonorrhoea is a global public health threat. Diagnoses of gonorrhoea have increased in England over the last decade. Guidelines in UK now recommend single dose ceftriaxone, so preserving the efficacy of ceftriaxone is essential. In England, over half of tested isolates remain sensitive to previously recommended drugs, e.g. ciprofloxacin. We evaluate options for improving antibiotic stewardship, through better use of existing surveillance data or new diagnostic tests. Methods We previously developed an agent-based stochastic network model of gonorrhoea transmission, including ciprofloxacin-sensitive and resistant strains for MSM. This has been modified, to add a heterosexual population and a full model including bridging between MSM and heterosexuals. A novel feature is the time-varying network which breaks and reforms connections within a fixed cumulative network to capture behavioural heterogeneity in duration and number of partnerships. We explored different strategies to facilitate individualised treatment selection, including discriminatory POCT, and selecting treatment based on either index case or partner susceptibility. Results Our MSM model suggests, based on 50% resistance to ciprofloxacin at baseline, that using POCT to detect ciprofloxacin-sensitive infections could reduce ceftriaxone doses by 70%. If index case susceptibility information were to be used to determine partner treatment, ceftriaxone use could be reduced by 27%. In the heterosexual model, the prevalence is much lower and could only be maintained through assuming higher transmission probability or duration of infection or via bridging to the higher prevalence MSM group. Conclusion Novel POCT which identify susceptible infections are likely to come to market soon, but are costly. Mathematical models can evaluate the trade-offs between increasing test costs and reduced time to treatment or between delaying treatment to confirm susceptibility and reduce use of ceftriaxone in partners. The flexible model structure will be used in future to implement evolution of resistance and the impact of vaccination. Disclosure No significant relationships.

Background Increasing evidence indicates that Mycoplasma genitalium (Mgen) is a sexually-transmitted infection that can lead to pelvic inflammatory disease (PID) and possibly infertility. Resistance to azithromycin, which has been the first-line treatment, has been widely reported. To develop optimal testing and treatment guidelines, it is necessary to understand the natural history of Mgen and the burden of associated disease. Several observational studies have provided valuable data, but no study has synthesized the available evidence to estimate the population burden of Mgen-associated disease. Methods The POPI study was a chlamydia screening trial recruiting sexually active female students aged ≤27 years in London, 2004–2006. Women provided vaginal samples at baseline and follow-up, and were assessed for one-year incidence of PID by genitourinary doctors using participant questionnaires and medical records. Mgen infections were identified retrospectively from stored samples, using NAATs. We used the published data on Mgen prevalence, persistence of infection over median 16 (range 12–21) months’ follow-up, and one-year incidence of PID in women infected or not infected with Mgen at enrollment. We conducted a Bayesian evidence synthesis using a simple (Susceptible-Infected-Susceptible) mathematical model of infection, with uninformative priors on all parameters. Results In the POPI trial, 6.26% (1.82, 15.11)% (posterior median; 95% credible interval) of Mgen infections led to PID. We estimate that there were 1.96 (0.16,6.27) new Mgen-related PID cases per 1000 women per year, and a total of 6728 (537,21547) cases per year in 16–27-year-old English women. 10.8% (0.9,33.0)% of the current burden of PID is caused by Mgen infection. Conclusion Our model synthesises different types of data to understand the burden of Mgen infection and PID. Further data will be included to increase the precision of estimates, which are currently subject to wide uncertainty. We recommend studies in men, with urethritis as the disease outcome, which could be analysed with a similar model. Disclosure No significant relationships.

The ability to increase access to STI and HIV diagnoses and treatment through home testing has been demonstrated to be both acceptable and popular and should herald a bright future. But the lack of appropriate regulation and the financial imperative for commercial organisations of profitability is having a number of unintended consequences. 1) How is the data being shared with public health, which produces population STI and HIV statistics? Failure to integrate all sources will result in an incomplete picture affecting public health priorities. 2) In the United Kingdom a number of on-line providers are offering premium multi-plex testing and in some cases individual NAAT testing for Ureaplasma urealyticum, Mycoplasma hominis, Mycoplasma genitalium and Gardnerella vaginosis for which there is a) no evidence that detecting and treating them in asymptomatic individuals does more good than harm and/or b) no association with disease at low load. Companies may refer patients to Wikipedia for information or develop their own with misleading statements such as ‘If Ureaplasma infection is left untreated, there is an increased risk of getting other STIs, including HIV…. In women there is also an increased likelihood of infertility if there is a prolonged Ureaplasma infection.’ This results in over-diagnosis, unnecessary patient anxiety and inappropriate antimicrobial therapy increasing the risk of antimicrobial resistance to tetracycline, macrolides and metronidazole. 3) The performance of these multi-plex assays is also unclear. Which is of relevance in the diagnosis and treatment of chlamydia, gonorrhoea, trichomonas and M. genitalium which has implications for patients and public health STI control programmes. Should we be concerned and if so what needs to be done? We need regulation fit for purpose with mandatory sharing of anonymised data and governance from national/international expert bodies on STIs and HIV – but who will take ownership of this and fund it? Disclosure No significant relationships.

Background Our recent case-control study explored the Chlamydia trachomatis population attributable fraction (PAF) for tubal factor infertility (TFI) using an elementary body enzyme-linked immunosorbent serological assay (EB-ELISA) or a commercially available (Medac) major outer membrane protein ELISA to measure prior chlamydial infection. We examined data from this study using a Pgp3 enhanced ELISA (Pgp3). Methods In this study of women with TFI by hysterosalpingogram (cases) and non-TFI infertility (controls) in two U.S. infertility clinics, we assessed anti-C. trachomatis seropositivity by Pgp3. We then assessed the association between chlamydia seropositivity and TFI using adjusted odds ratios (aOR) along with 95% confidence intervals (CI) stratified by race. Finally, the adjusted chlamydia TFI PAF (aPAF) and 95% CI based on the Pgp3 assay were estimated. Results All black (n=107) and 618 of 620 non-black women had Pgp3 results. Seropositivity frequency by Pgp3 was 66% (95% CI 52–80%) for black cases, 72% (60–83%) for black controls, 26% (19–33%) for non-black cases, and 15% (12–18%) for non-black controls. Pgp3 was not associated with TFI among black women (aOR 1.1 [95% CI 0.4–3.3]). Among non-black women, Pgp3 seropositivity was associated with TFI (aOR 1.8 [95% CI 1.1–3.0]) adjusting for clinic, age, income, trichomonas, and endometriosis. Using Pgp3 and adjusting for the same variables, chlamydia TFI aPAF was 12% (95% CI 1–22%) in non-black women. Conclusion Among non-black women, Pgp3 ELISA seropositivity was associated with TFI. Assays to estimate chlamydia TFI PAF merit further investigation, especially in black women. Chlamydial TFI may be prevented in all women by early identification and treatment of chlamydia. Disclosure No significant relationships.

Background There is currently considerable interest the complex relationship between PrEP and STI incidence. Our Challenges and Opportunities of PrEP (CHOP) study uses qualitative and quantitative methods to ascertain the changes in behaviour and STI rates in high risk men/transgender/nonbinary persons who have sex with men (MSM/TPSM) before and after commencement of the PrEP Impact trial (‘Impact’) in our clinic (01/12/2017). Methods We performed retrospective data analysis of clinic and laboratory records for MSM/TPSM attendees who attended a British sexual health clinic in a large urban area between 01/12/2016 and 28/02/2019. We used logistic regression to compare STI diagnoses (chlamydia, gonorrhoea and syphilis at any site) and sexual risk score in two time periods (1: 01/12/2016 – 31/11/17 and 2: 01/12/2017 to 28/02/2019). Results Of 72,667 attendances, 10,918 were MSM/TPSM and, excluding duplicate entries (164) and those who were already HIV positive (236), this left 3,407 individuals with 10,518 attendances: 4,378 (period 1) and 6,140 (period 2). Mean HIV acquisition risk score at first visit in period 1 was 5.8 and 5.4 in period 2. In period 1 at first visit 13.5% (266/1,975) had one or more STI compared with 20.2% (289/1143) in period 2, a rise of 6.7%. Logistic regression showed OR1.6 (p STI diagnoses for subsequent visits in period 1, 6.3% (151/2403) attendances had one or more STIs diagnosed, and in period 2 10.9% (513/4708). This is a rise of 4.6% (OR 1.8 (p Conclusion Although risk score was similar during both time periods, STI rates were significantly higher both at first visit and at subsequent visits. The qualitative aspect of this study will explore whether this reflects attracting more high risk MSM/TPSM into the service or whether use of PrEP increases risk-taking behaviour. Disclosure No significant relationships.

We describe detection in the United Kingdom (UK) of the drug-resistant Neisseria gonorrhoeae FC428 clone, with ceftriaxone resistance and intermediate azithromycin resistance. Two female patients developed infection following contact with UK-resident men from the same sexual network linked to travel to Ibiza, Spain. One case failed treatment with ceftriaxone, and azithromycin and gentamicin, before successful treatment with ertapenem. Both isolates had indistinguishable whole-genome sequences. Urgent action is essential to contain this drug-resistant strain.

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We evaluate the utility of the National Surveys of Attitudes and Sexual Lifestyles (Natsal) undertaken in 2000 and 2010, before and after the introduction of the National Chlamydia Screening Programme, as an evidence source for estimating the change in prevalence ofChlamydia trachomatis(CT) in England, Scotland and Wales. Both the 2000 and 2010 surveys tested urine samples for CT by Nucleic Acid Amplification Tests (NAATs). We examined the sources of uncertainty in estimates of CT prevalence change, including sample size and adjustments for test sensitivity and specificity, survey non-response and informative non-response. In 2000, the unadjusted CT prevalence was 4.22% in women aged 18–24 years; in 2010, CT prevalence was 3.92%, a non-significant absolute difference of 0.30 percentage points (95% credible interval −2.8 to 2.0). In addition to uncertainty due to small sample size, estimates were sensitive to specificity, survey non-response or informative non-response, such that plausible changes in any one of these would be enough to either reverse or double any likely change in prevalence. Alternative ways of monitoring changes in CT incidence and prevalence over time are discussed.

Despite Mycoplasma genitalium (MG) being increasingly recognised as a genital pathogen in men and women, awareness and utility of commercially available MG-testing has been low. The opinion of UK sexual health clinicians and allied professionals was sought on how MG-testing should be used. Thirty-two consensus statements were developed by an expert group and circulated to clinicians and laboratory staff, who were asked to evaluate their level of agreement with each statement; 75% agreement was set as the threshold for defining consensus for each statement. A modified Delphi approach was used and high levels of agreement obviated the need to test the original statement set further. Of 201 individuals who received questionnaires, 60 responded, most (48) being sexual health consultants, more than 10% of the total in the UK. Twenty-seven (84.4%) of the statements exceeded the 75% threshold. Respondents strongly supported MG-testing of patients with urethritis, pelvic inflammatory disease or unexplained persistent vaginal discharge, or post-coital bleeding. Fewer favoured testing patients with proctitis and support was divided for routinely testing Chlamydia-positive patients. Testing of current sexual contacts of MG-positive patients was supported, as was a test of cure for MG-positive patients, although agreement fell below the 75% threshold. Respondents agreed that all consultant- or specialist-led services should have access to testing for MG (98.3%). There was strong agreement for having MG-testing available for specific patient groups, which may reflect concern over antibiotic resistance and the desire to comply with clinical guidelines that recommend MG-testing in sexual health clinic settings.

Introduction Antimicrobial resistant (AMR) gonorrhoea is a global public health threat. In London, diagnoses in men who have sex with men (MSM) have more than quadrupled from 2010 to 2015. Importantly, our last-line treatment (ceftriaxone) is used in first-line dual therapy. However, over half of tested isolates are still sensitive to older drugs, e.g. ciprofloxacin. Discriminatory point-of-care tests (POCT) to detect drug sensitivity are under development, enabling individualised treatment decisions. Methods An individual-based transmission model of gonorrhoea infection in MSM was developed, incorporating ciprofloxacin-sensitive and resistant strains, using novel heuristic approach to capture partnership dynamics. We explored different strategies to improve treatment selection including a) discriminatory POCT, b) partner treatment based on index case susceptibility, and c) variably delayed positivity testing prior to treatment (pre-screening). Results The flexible model structure enabled us to credibly simulate London gonorrhoea transmission dynamics - assuming 2–10% prevalence and 10–50 daily diagnoses per 100,000 MSM. Simulations show that a) using POCT to detect ciprofloxacin sensitive infections resulted in a 70% decrease in ceftriaxone doses, and b) using index case sensitivity profile to direct treatment of partners could reduce ceftriaxone use by 27%. Discussion POCT are likely to dramatically reduce reliance on ceftriaxone. In the meantime, we could use existing data more informatively. If lab turnaround times are fast enough, index case sensitivity profiles could be used to select effective treatments for partners. This new framework addresses limitations of previous models and provides a flexible platform for exploring control options for AMR gonorrhoea.

Introduction Genital infection with Chlamydia trachomatis (CT) is the most commonly-diagnosed bacterial sexually transmitted infection in England. The National Chlamydia Screening Programme (NCSP) was implemented nationwide in 2008, offering opportunistic CT testing to people under 25. Not all chlamydia infections result in a lasting antibody response, however, monitoring age-specific seroprevalence of antibodies against CT over time may offer insights into the impact of this intervention. We explored trends in seroprevalence from 2007 up to 2015. Methods Samples were obtained from the PHE Seroepidemiology Unit, which collects unlinked, anonymous, residual sera submitted to laboratories in England for routine investigations. Samples known to come from GUM clinics were excluded. Sera from 2007–2015 from women aged 15–30 (n=9,798) were tested using an indirect IgG ELISA for chlamydia Pgp3 antibody. Women in 2007 had limited exposure to the NCSP, increasing over time. Age-standardised seroprevalence was calculated for 17–24 year-olds using 2015 population data. Samples were classified by the number of years individuals were eligible for the screening programme, based on year of birth. Results Age-standardised seroprevalence among 17–24 year-olds varied, being highest at 20.3% (95% CI 17.2–23.4) in 2007 and lowest at 15.5% (95% CI 10.0–20.9) in 2015, although no clear trend was seen. Although incomplete data were available for those with ‘limited’ and ‘high’ exposure to the NCSP, age-specific seroprevalence did not vary by exposure to NCSP. Conclusion There was no evidence that age-specific seroprevalence varied by exposure to the NSCP. Interpretation of this is complicated by the potential effects of antibody prevalence waning over time, and being affected by factors such as treatment and re-infection. Other limitations include a high number (86.2%) of specimens from ‘unknown’ source which could have been from GUM clinics. Multi-parameter evidence synthesis models are being developed to explore the use of these data to estimate incidence.

Background: Although understanding chlamydia incidence assists prevention and control, analyses based on diagnosed infections may distort the findings. Therefore, we determined incidence and examined risks in a birth cohort based on self-reports and serology.Methods: Self-reported chlamydia and behavior data were collected from a cohort born in New Zealand in 1972/3 on several occasions to age 38 years. Sera drawn at ages 26, 32, and 38 years were tested for antibodies to Chlamydia trachomatis Pgp3 antigen using a recently developed assay, more sensitive in women (82.9%) than men (54.4%). Chlamydia incidence by age period (first coitus to age 26, 26-32, and 32-38 years) was calculated combining self-reports and serostatus and risk factors investigated by Poisson regression.Results: By age 38 years, 32.7% of women and 20.9% of men had seroconverted or self-reported a diagnosis. The highest incidence rate was to age 26, 32.7 and 18.4 years per 1000 person-years for women and men, respectively. Incidence rates increased substantially with increasing number of sexual partners. After adjusting age period incidence rates for partner numbers, a relationship with age was not detected until 32 to 38 years, and then only for women.Conclusions: Chlamydia was common in this cohort by age 38, despite the moderate incidence rates by age period. The strongest risk factor for incident infection was the number of sexual partners. Age, up to 32 years, was not an independent factor after accounting for partner numbers, and then only for women. Behavior is more important than age when considering prevention strategies.

Chlamydia is a common sexually transmitted infection (STI) in young people. It is often asymptomatic, but untreated infection can have significant long-term complications that may present to non-sexual health specialities. These include pelvic inflammatory disease (PID) and infertility in women. Current diagnostic techniques are sensitive and highly specific and are approved for patient-taken samples. This means non-specialist settings are well placed to diagnose and treat chlamydia in individuals from high-risk groups who may not access hospital-based healthcare services. The English National Chlamydia Screening Programme (NCSP) aims for all sexually active young men and women under the age of 25 to be aware of chlamydia and its effects, and have access to services providing screening, prevention and treatment, but there remains debate about its cost-effectiveness. Testing for chlamydia should be used as an opportunity to screen for other STIs including gonorrhoea, HIV and syphilis where indicated and also as a chance to offer advice for those engaging in high-risk sexual behaviour. Non-gonococcal urethritis is an important cause of urethral discharge and dysuria in men and is usually sexually transmitted. However, it can occur in stable relationships and in 30% no micro-organism is detected. Diagnosis and treatment are best undertaken in a specialist sexual health centre, although management is possible in a community setting. There is debate about the efficacy of current recommended treatments and national guidelines should be consulted for up-to-date antibiotic regimens.

Purpose of review Mycoplasma genitalium is a sexually transmitted infection that causes significant morbidity in men and women and is a co-factor in HIV transmission. However, commercial diagnostic tests are not generally available for M. genitalium and sub-optimal treatment is often given. We review the literature on the burden of infection, how it may present in clinical practice and the effectiveness of current treatment regimens. Recent findings In-vivo and in-vitro data strongly suggest that M. genitalium is an important cause of urethritis, cervicitis, pelvic inflammatory disease and potentially asymptomatic proctitis. Studies now consistently demonstrate suboptimal eradication rates with the current treatment regimens recommended first line for the treatment of nongonococcal urethritis. Concurrently, there has been a rapid emergence of antibiotic resistance in M. genitalium, with macrolide resistance now appearing to be endemic in some centres, and quinolone resistance is beginning to emerge. Summary In the absence of specific M. genitalium diagnostic and antimicrobial resistance testing, azithromycin 1 g should not be used for the management of patients with symptomatic disease potentially caused by M. genitalium. This review offers an alternative evidence-based approach to managing such patients that should, theoretically, reduce the risk of the development of antimicrobial resistance.

The consultation version of the first BASHH guideline for the management of Mycoplasma genitalium was launched on 11 July.1 This coincided with a 1-day M. genitalium educational event in London, supported by Hologic and attended by 150 delegates from all over the UK. The morning sessions covered basic science and relevant clinical data, and Michelle Cole from Public Health England (PHE) talked about the mechanisms of antimicrobial resistance (AMR) in M. genitalium . In the afternoon we heard about diagnostic testing and the challenges of implementation, and Gwenda Hughes presented the arguments against screening for M. genitalium , recommending that testing should be directed at individuals with relevant symptoms and their current sexual partners. The day ended with a lively interactive session with four complex case presentations and expert panel and audience discussion. While feedback from the day was excellent, the concerns around funding and setting up M. genitalium testing were quite apparent. The publication of the National Institute for Health and …

Objective To measure the coverage and uptake of systematic postal screening for genital Chlamydia trachomatis and the prevalence of infection in the general population in the United Kingdom. To investigate factors associated with these measures. Design Cross sectional survey of people randomly selected from general practice registers. Invitation to provide a specimen collected at home. Setting England. Participants 19 773 men and women aged 16-39 years invited to participate in screening. Main outcome measures Coverage and uptake of screening; prevalence of chlamydia. Results Coverage of chlamydia screening was 73% and was lower in areas with a higher proportion of non-white residents. Uptake in 16-24 year olds was 31.5% and was lower in men, younger adults, and practices in disadvantaged areas. Overall prevalence of chlamydia was 2.8% (95%confidence interval 2.2% to 3.4%) in men and 3.6% (3.1% to 4.9%) in women, but it was higher in people younger than 25 years (men 5.1%; 4.0% to 6.3%; women 6.2%; 5.2% to 7.8%). Prevalence was higher in the subgroup of younger women who were harder to engage in screening. The strongest determinant of chlamydial infection was having one or more new sexual partners in the past year. Conclusions Postal chlamydia screening was feasible, but coverage was incomplete and uptake was modest. Lower coverage of postal screening in areas with more non-white residents along with poorer uptake in more deprived areas and among women at higher risk of infection could mean that screening leads to wider inequalities in sexual health.

Background Uptake of the English National Chlamydia Screening Programme is lower than predicted necessary to result in a rapid fall in chlamydia prevalence. Peer-led approaches may increase screening uptake but their feasibility and acceptability to young people is not known. Methods Focus groups and interviews with young women and men. Following interview, chlamydia postal kits were introduced to participants and their opinions on giving these out to their peers sought. Participants were asked for their views and experiences of discussing chlamydia screening and distributing kits to their friends 4–8 weeks after the focus group/interview. All kits returned to the laboratory over a 9-month period were recorded. Results Six men (mean age 19 years) and six women (mean age 20 years) were recruited. In total 45 kits were distributed, 33 (73%) to female participants. 22 (67%) and 3 (25%) of kits given to females and males, respectively, were given to peers. Ten kits (22%; seven female, three male) all of which had been given out by females, were returned for testing. Participants generally felt positive about the idea of peer-led screening (PLS) using postal kits. However, embarrassment was a key theme, particularly among men. Generally women but not men were able to discuss PLS among their close friends. Both sexes felt PLS would be easier if kits were readily available in multiple sites, and chlamydia screening was more widely promoted. Conclusion Female PLS but not male PLS was successful in recruiting peers to participate in chlamydia screening. An evaluation of the acceptability and cost-effectiveness of PLS is now indicated.

Background Nucleic acid amplification tests are being increasingly used for the routine diagnosis of Neisseria gonorrhoeae (GC), although culture remains essential for monitoring antimicrobial resistance. The authors investigated how symptoms and infection site influenced test sensitivity. Methods This was a retrospective study at two centres of patients diagnosed as having GC by Aptima Combo 2 (AC2) confirmed with Aptima GC and/or culture. Results The study included 251 men (71%) and 105 women (29%). The sensitivity for AC2 and culture in the lower genital tract of men with symptoms was 99% (95% CI 95% to 100%) and 79% (95% CI 71% to 85%) and for asymptomatic men was 94% (95% CI 69% to 100%) and 29% (95% CI 11% to 56%), respectively. At the rectum, the sensitivity in symptomatic men was 91% (95% CI 57% to 100%) and 55% (95% CI 25% to 82%) and in asymptomatic men 75% (95% CI 47% to 92%) and 44% (95% CI 21% to 69%) for AC2 and culture, respectively. In symptomatic women, the sensitivity from the genital site was 100% (95% CI 95% to 100%) and 53% (95% CI 38% to 68%) and for asymptomatic women 100% (95% CI 87% to 100%) and 47% (95% CI 30% to 65%) for AC2 and culture, respectively. Conclusions The AC2 with AGC confirmation performs well at genital and extra-genital sites for detecting GC. Culture for GC using transport swabs performs poorly in asymptomatic men, symptomatic and asymptomatic women and at extra-genital sites. With the improved performance of nucleic acid amplification tests and the increase in GC antimicrobial resistance, research is needed into how best to optimise GC culture in settings where direct plating is not feasible.

Chlamydia trachomatis infection of the genital tract is the most common sexually transmitted infection and has a world-wide distribution. The consequences of infection have an adverse effect on the reproductive health of women and are a common cause of infertility. Recent evidence also suggests an adverse effect on male reproduction. There is a need to standardise the approach in managing the impact of C. trachomatis infection on reproductive health. We have surveyed current UK practice towards screening and management of Chlamydia infections in the fertility setting. We found that at least 90% of clinicians surveyed offered screening. The literature on this topic was examined and revealed a paucity of solid evidence for estimating the risks of long-term reproductive sequelae following lower genital tract infection with C. trachomatis. The mechanism for the damage that occurs after Chlamydial infections is uncertain. However, instrumentation of the uterus in women with C. trachomatis infection is associated with a high risk of pelvic inflammatory disease, which can be prevented by appropriate antibiotic treatment and may prevent infected women from being at increased risk of the adverse sequelae, such as ectopic pregnancy and tubal factor infertility. Recommendations for practice have been proposed and the need for further studies is identified.

A letter in response to: ‘ Suboptimal adherence to doxycycline and treatment outcomes among men with non-gonococcal urethritis: a prospective cohort study ’ and ‘ Empiric NSU treatment needs updating ’.1 ,2 The effect of suboptimal adherence to a 7-day 100 mg twice daily doxycycline regimen on treatment failure in men with non-gonococcal urethritis (NGU) was assessed by Khosropour et al .1 The authors conclude that suboptimal adherence to doxycycline, defined as missing one or more doses, is associated with microbiological failure in chlamydial NGU in men.1 We …

Objective To evaluate the effectiveness of a practice nurse led strategy to improve the notification and treatment of partners of people with chlamydia infection. Design Randomised controlled trial. Setting 27 general practices in the Bristol and Birmingham areas. Participants 140 men and women with chlamydia (index cases) diagnosed by screening of a home collected urine sample or vulval swab specimen. Interventions Partner notification at the general practice immediately after diagnosis by trained practice nurses, with telephone follow up by a health adviser; or referral to a specialist health adviser at a genitourinary medicine clinic. Main outcome measures Primary outcome was the proportion of index cases with at least one treated sexual partner. Specified secondary outcomes included the number of sexual contacts elicited during a sexual history, positive test result for chlamydia six weeks after treatment, and the cost of each strategy in 2003 sterling prices. Results 65.3% (47/72) of participants receiving practice nurse led partner notification had at least one partner treated compared with 52.9% (39/68) of those referred to a genitourinary medicine clinic (risk difference 12.4%, 95% confidence interval −1.8% to 26.5%). Of 68 participants referred to the clinic, 21 (31%) did not attend. The costs per index case were £32.55 for the practice nurse led strategy and £32.62 for the specialist referral strategy. Conclusion Practice based partner notification by trained nurses with telephone follow up by health advisers is at least as effective as referral to a specialist health adviser at a genitourinary medicine clinic, and costs the same. Trial registration Clinical trials: NCT00112255.

Background/introduction Evidence suggests alcohol and drug use correspond to poorer sexual health outcomes. NICE recommend routine screening for alcohol use disorders, with adults and young people regularly attending GUM services identified as a high risk group. Assessment for drug and alcohol misuse enables health promotion through brief intervention. Aim(s)/objectives To assess the prevalence of cigarette, alcohol and drug use within our GUM clinic population. Methods Patients were requested to complete a questionnaire as part of the clinic triage form, including data on smoking status, alcohol use using AUDIT-C and recreational drug use. Cases were randomly selected for retrospective review over two week-long periods in June-July 2015. Results 493 patients were reviewed: 261 (52.9%) female vs 232 (47.1%) male. Ages ranged from 14–79 (median = 28). 27.9% were current smokers (F = 26.8%, M = 29.2%). 391 (79.3%) patients completed questions to allow adequate assessment of their alcohol use. 220 (56.3%) scored ≥5 using the AUDIT-C screening tool, indicating need for further discussion. 317/409 (77.5%) disclosed binge drinking. Of the 418 patients (84.8%) who responded, 73 (17.5%) admitted recreational drug use. The most common method of use disclosed was smoking (71.2%), followed by snorting (49.3%) and pills (30.1%). (31 reported more than 1 method.) Discussion/conclusion Over half of patients attending our clinic warranted further assessment or brief intervention regarding their alcohol use. Recreational drug use and smoking was higher than that of the general population. Further staff training and developing links with local support services will improve the holistic management of our patients.

Background Opportunistic screening of people aged under 25 years for genital Chlamydia trachomatis infection (chlamydia) was nationally implemented in England in 2008, but its impact is poorly understood. Antibodies to C trachomatis persist after infection, thus providing a marker of past infection. We aimed to explore the effect of screening on cumulative incidence of chlamydia (incidence of infection by a given age), as measured by C trachomatis antibodies. Methods Anonymised serum samples from participants in the nationally representative Health Surveys for England (HSE) were tested for C trachomatis antibodies using two novel in-house Pgp3 ELISAs, which have demonstrated superior sensitivity to commercial assays. Determinants of being seropositive were explored with logistic regression among women (n=1402) and men (1119) aged 16–44 years in 2010–12 (years when questions about sexual behaviour were included in the survey). Seroprevalence trends among 16–24-year-old women (n=3361) were investigated over ten timepoints from 1994 to 2012. Findings During 2010–12, Pgp3 seroprevalence among participants aged 16–44 years was 24·4% (95% CI 22·0–27·1) in women and 13·9% (11·8–16·2) in men. Seroprevalence increased with age (up to 33·5% [27·5–40·2] in 30–34-year-old women; 18·7% [13·4–25·6] in 35–39-year-old men) and with years since first sexual intercourse (38·2% [32·0–44·7] in women and 22·3% [16·2–29·8] in men aged 15–19 years). Total number of lifetime sexual partners and younger age at first sex were significantly associated with being seropositive (>10 lifetime sexual partners vs 1–4: odds ratio 3·84 women [95% CI 2·68–5·51], 5·95 men [3·41–10·35]; vs >16: 2·26 women [1·61–3·16], 2·14 men [1·41–3·24]). 76·7% of seropositive 16–24-year-olds had never been diagnosed with chlamydia: among women, seroprevalence did not differ between the first (1994–96) and second (2001–02) periods sampled (prevalence ratio 1·04, 0·87–1·25); a non-significant decline was observed from 2008 to 2012 (prevalence ratio per year 0·94, 0·84–1·05). Interpretation Our application of Pgp3 ELISAs demonstrates a high lifetime risk of chlamydia among women and that a large proportion of infections go undiagnosed. A decrease in age-specific cumulative incidence after national implementation of opportunistic chlamydia screening has not yet been demonstrated. We propose that these assays be used more widely to assess the effect of chlamydia control programmes. Funding The Health Survey for England was funded by the Health and Social Care Information Centre. Testing of stored serum samples was funded by the Health Protection Agency (now Public Health England). The funders played no part in the design, conduct, analysis, or reporting of this study, or in the decision to submit the abstract for publication.

Nucleic acid amplification tests are being increasingly used for the routine diagnosis of Neisseria gonorrhoeae (GC), although culture remains essential for monitoring antimicrobial resistance. The authors investigated how symptoms and infection site influenced test sensitivity.This was a retrospective study at two centres of patients diagnosed as having GC by Aptima Combo 2 (AC2) confirmed with Aptima GC and/or culture.The study included 251 men (71%) and 105 women (29%). The sensitivity for AC2 and culture in the lower genital tract of men with symptoms was 99% (95% CI 95% to 100%) and 79% (95% CI 71% to 85%) and for asymptomatic men was 94% (95% CI 69% to 100%) and 29% (95% CI 11% to 56%), respectively. At the rectum, the sensitivity in symptomatic men was 91% (95% CI 57% to 100%) and 55% (95% CI 25% to 82%) and in asymptomatic men 75% (95% CI 47% to 92%) and 44% (95% CI 21% to 69%) for AC2 and culture, respectively. In symptomatic women, the sensitivity from the genital site was 100% (95% CI 95% to 100%) and 53% (95% CI 38% to 68%) and for asymptomatic women 100% (95% CI 87% to 100%) and 47% (95% CI 30% to 65%) for AC2 and culture, respectively.The AC2 with AGC confirmation performs well at genital and extra-genital sites for detecting GC. Culture for GC using transport swabs performs poorly in asymptomatic men, symptomatic and asymptomatic women and at extra-genital sites. With the improved performance of nucleic acid amplification tests and the increase in GC antimicrobial resistance, research is needed into how best to optimise GC culture in settings where direct plating is not feasible.