2021 European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens.

This guideline intents to offer guidance on the diagnosis and management of patients with gastrointestinal symptoms and a suspected sexually transmitted cause. Proctitis is defined as an inflammatory syndrome of the anal canal and/or the rectum. Infectious proctitis can be sexually transmitted via genital-anal mucosal contact, but some also via digital contact and toys. Neisseria gonorrhoeae, Chlamydia trachomatis (including lymphogranuloma venereum), Treponema pallidum and herpes simplex virus are the most common sexually transmitted anorectal pathogens. Shigellosis can be transferred via oral-anal contact and may lead to proctocolitis or enteritis. Although most studies on these infections have concentrated on men who have sex with men (MSM), women having anal intercourse may also be at risk. A presumptive clinical diagnosis of proctitis can be made when there are symptoms and signs, and a definitive diagnosis when the results of laboratory tests are available. The symptoms of proctitis include anorectal itching, pain, tenesmus, bleeding, constipation and discharge in and around the anal canal. The majority of rectal chlamydia and gonococcal infections are asymptomatic and can only be detected by laboratory tests. Therefore, especially when there is a history of receptive anal contact, exclusion of anorectal infections is generally indicated as part of standard screening for sexually transmitted infections (STIs). Condom use does not guarantee protection from STIs, which are often spread without penile penetration. New in this updated guideline is: (i) lymphogranuloma venereum proctitis is increasingly found in HIV-negative MSM, (ii) anorectal Mycoplasma genitalium infection should be considered in patients with symptomatic proctitis after exclusion of other common causations such N. gonorrhoeae, C. trachomatis, syphilis and herpes, (iii) intestinal spirochetosis incidentally found in colonic biopsies should not be confused with syphilis, and (iv) traumatic causes of proctitis should be considered in sexually active patients.

The Epidemiological and Clinical Characteristics of the Epidemic of Syphilis in Barcelona. / Las características epidemiológicas y clínicas de la epidemia de sífilis en Barcelona.

BACKGROUND: Since 2000, substantial increases in syphilis have been reported in metropolitan areas of Western countries, with increases noted among men who have sex with men (MSM). Clinical manifestations of syphilis might be influenced by concomitant VIH infection and previous episodes of syphilis. The objectives of this study were to describe the epidemiological and clinical characteristics of the cases of syphilis diagnosed in Barcelona. METHODS: Retrospective study of cases with early syphilis diagnosed in the referral STI Unit of Barcelona from January 2003 to December 2013. Revision of medical records with structured collection of epidemiological and clinical data. Univariate and multivariate statistical analyses comparing the characteristics of MSM cases with and without VIH infection and with and without previous syphilis. RESULTS: A total of 1702 cases of syphilis (37% primary, 48% secondary and 14% early latent) were diagnosed, 93% of them in MSM. Among MSM 40% were coinfected with VIH, VIH-positive cases were associated with a previous syphilis (aOR, 5.2 [95% CI, 3.32-8.24]) and with unprotected anal intercourse (aOR, 1.75 [95%CI, 1.17-2.63]). Cases with a history of syphilis presented less often with primary syphilis compared to those without it (27.5% vs. 40%) (aOR, 0.58 [95% CI, 0.44-0.77]). One year after treatment, the clinical and serological evolution were similar between VIH-positive and VIH-negative cases. CONCLUSION: The epidemic of syphilis in Barcelona disproportionately affects MSM and is closelly linked to VIH infection. The presentation of syphilis is influenced by VIH infection and by previous history of syphilis, without significant differences in their evolution after one year of treatment.

2019 European guideline on the management of lymphogranuloma venereum.

New or important issues in this updated version of the 2013 European guideline on the management of lymphogranuloma venereum (LGV): EPIDEMIOLOGY: Lymphogranuloma venereum continues to be endemic among European men who have sex with men (MSM) since 2003. Lymphogranuloma venereum infections in heterosexuals are extremely rare in Europe, and there is no evidence of transmission of LGV in the European heterosexual population. AETIOLOGY AND TRANSMISSION: Chlamydia trachomatis serovars/genovars L2b and L2 are the causative strains in the majority of cases in Europe. CLINICAL FEATURES: Among MSM, about 25% of the anorectal LGV infections are asymptomatic. Genital infections among MSM are rare; the ratio of genital vs. anorectal LGV infections is 1 in 15. DIAGNOSIS: To diagnose LGV, a sample tested C. trachomatis positive with a commercial nucleic acid amplification test (NAAT) platform should be confirmed with an LGV discriminatory NAAT. TREATMENT: Doxycycline 100 mg twice a day orally for 21 days is the recommended treatment for LGV. This same treatment is recommended also in asymptomatic patients and contacts of LGV patients. If another regimen is used, a test of cure (TOC) must be performed.

The Jarisch-Herxheimer reaction in syphilis: could molecular typing help to understand it better?

OBJECTIVES: The Jarisch-Herxheimer reaction (JHR) is a febrile inflammatory reaction that may occur in patients after treatment of syphilis. The overall rate is estimated to be 10-25% with broad variations over time. It appears to be related to factors like stage of the disease or reagin titres. In this study, we aimed to describe the incidence of and risk factors including strain typing for JHR among patients with syphilis. METHODS: From January through October 2015, 224 consecutive patients (82 of them with HIV) who were diagnosed with early syphilis were enrolled in this prospective observational study in a referral STI clinic in Barcelona. An appointment was offered to them after 10-14 days of treatment to inquire about the reaction with the use of a standardized form. Treponema pallidum molecular typing was made to detect a possible strain related to reaction. RESULTS: Overall, 28% of patients developed JHR. This varied from 56% in secondary, 37% in primary to 7% in early latent syphilis. The most frequent types of reaction were fever (57.5%) and worsening of the lesions (31%). The median time to development of JHR was 6 h [IQR 4-10 h] and lasted a median of 9 h [IQR 4-24 h]. The JHR was less probable in early latent compared to primary/secondary syphilis (P = 0.04) and in patients treated with doxycycline compared to those treated with penicillin (P = 0.01). No differences were seen regarding reagin titres or HIV status, and no association with a specific strain was found. CONCLUSIONS: In this study, JHR occurred in a similar frequency as in other contemporary studies. Symptomatic syphilis and treatment with penicillin were associated with an increased risk of JHR, whereas the previous episode of syphilis was associated with a low risk of it. We could not find associations with specific strains of T. pallidum.

Lymphogranuloma venereum in Barcelona, 2007-2012: the role of seroadaptation in men who have sex with men.

This study describes the incidence rate of reported lymphogranuloma venereum (LGV) in men who have sex with men (MSM) in Barcelona from 2007 to 2012. Epidemiological, clinical and sexual behaviour characteristics of LGV cases are described. Seroadaptive behaviours as a transmission risk factor were assessed by a telephone questionnaire during 2012. Data were handled on a strictly confidential basis. LGV annual rate ratios in MSM were compared with cases from 2007. Differences were statistically analysed with a Poisson test. The incidence rate of LGV in MSM aged 15-69 years ranged from 32·1/105 MSM per year in 2007 to 182·7/105 MSM per year in 2012. In 2012, 31/51 LGV cases (61%) answered the telephone questionnaire, of which 84% (26/31) were HIV positive, 39% (12/31) reported having sex according to their partners' serostatus and 7% (2/31) used strategic positioning. The incidence of LGV has increased since 2007 and mainly affects HIV-positive MSM. It is probable that seroadaptation has facilitated LGV transmission.

European guideline for the management of chancroid, 2011.

Chancroid is a sexually acquired disease caused by Haemophilus ducreyi. The infection is characterized by one or more genital ulcers, which are soft and painful, and regional lymphadenitis which may develop into buboes. The infection may easily be misidentified due to its rare occurrence in Europe and difficulties in detecting the causative pathogen. H. ducreyi is difficult to culture. Polymerase chain reaction (PCR) can demonstrate the bacterium in suspected cases. Antibiotics will usually be efficient for curing chancroid.

[Lymphogranuloma venereum: an emerging cause of proctitis in homosexual men in Barcelona]. / Linfogranuloma venéreo: una causa emergente de proctitis en hombres homosexuales en Barcelona.

BACKGROUND AND OBJECTIVE: Lymphogranuloma venereum (LGV) is a systemic sexually transmitted infection (STI) caused by Chlamydia trachomatis serovar L. Since 2003, outbreaks of LGV have been reported in homosexual men in Europe. The objective of this study is to describe an outbreak of LGV in Barcelona in 2007. PATIENTS AND METHODS: Description of a clinical case series of confirmed LGV diagnosed in the STI clinic of Barcelona between September 2007 and January 2008. RESULTS: Seven cases have been confirmed up to January 31, 2008. All were homosexual men, with a mean age of 36, who were sexually promiscuous. Mean time of symptoms of proctitis was 28 days. All the patients were coinfected with human immunodeficiency virus (HIV) for an average period of 5 years. DISCUSSION: This outbreak is similar to other LGV outbreaks that are occurring in Europe. LGV should be considered in the differential diagnosis of proctitis in homosexual men and be treated with 100 mg of doxycycline/12 hours for three weeks. Preventive interventions directed at HIV infected persons are important.

Sexually transmitted Chlamydia trachomatis, Neisseria gonorrhoeae, and HIV-1 infections in two at-risk populations in Barcelona: female street prostitutes and STI clinic attendees.

OBJECTIVE: To determine the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and HIV-1 infections in female street prostitutes and STI clinic attendees in Barcelona. DESIGN: This was a prospective study carried out in two four-month periods over two years. Urine specimens were tested for CT and NG using a PCR pooling algorithm. Among street prostitutes HIV-1 testing in urine was also carried out. RESULTS: The prevalences of CT, NG, and HIV-1 in female street prostitutes (n=301) were 4.7%, 3.7%, and 1.0%, respectively. Women from Eastern Europe had the highest prevalence of CT (p=0.01). Prevalences of CT, NG, and HIV-1 among all clinic attendees (n=536) were 4.3%, 4.5%, and 4.4%, respectively. Prevalence of HIV-1 infection among homosexual men was higher compared with heterosexual men and women (p<0.001). CONCLUSIONS: Overall CT prevalence is currently lower than in other European countries, although it could increase as a result of immigration. Rates of HIV-1 and of NG are higher among homosexual than among heterosexual men.

[Tuberculous infection from an area of high incidence of tuberculosis and with a high proportion of immigrants]. / Estudio de la infección tuberculosa en una zona de gran incidencia de tuberculosis y con un elevado porcentaje de inmigrantes.

BACKGROUND: Historically the district of Ciutat Vella in Barcelona has a high incidence of tuberculosis (TB) and, more recently, it is home to a considerable proportion of immigrants. OBJECTIVES: To determine the prevalence of tuberculous infection (TI) in a pediatric population from this district and evaluate the impact of immigration. METHODS: Children and adolescents aged < 16 years old were screened using the tuberculin skin test (TST) mainly in visits of the healthy child program. Proportions were compared using the x2 test and adjusted odds ratios were estimated through a logistic regression model. RESULTS: Six hundred ninety-nine children were studied. The overall prevalence of positive TST was 3.4 % (95 % CI: 2.2 %-5.1 %). Prevalence increased with age (P 5 0.009) from 1.9 % in children aged 1-5 years old to 6.4 % in children and adolescents aged 10-15 years. A total of 88.3 % of the immigrants had been vaccinated with BCG compared with 2.5 % of autochthonous children and adolescents (P < 0.001). The prevalence ratio between immigrants and autochthonous children was 2.1 (P 5 0.07). Three cases of TB disease were detected among children, but no index case was found in children with TI. CONCLUSIONS: The high TI prevalence found suggest that living in the district is a risk factor, which justifies routine TST screening of all the children living there. The present criteria for the interpretation of TST in immigrants vaccinated with BCG residing in areas of high incidence are dubious.

Previous STI and risk of HIV infection in men.

To determine the prevalence of a previous history of sexually transmitted infection (STI) and its influence as a risk factor for HIV infection among men tested for HIV, data from men having a voluntary HIV test at the STI Unit of Barcelona during a 6-month period of 1998 were analysed. Descriptive and logistic regression analysis were done to examine the prevalence of previous STI and factors associated with HIV infection. Prevalences of HIV were 5.6% in homo/bisexual and 0.5% in heterosexual men (P<0.001). Risk factors for HIV were STI history: odds ratio (OR)=8.7 and homo/bisexual behaviour: OR=6.6; 19.8% of heterosexuals had a history of STI compared with 44.2% of homo/bisexual men (P<0.01). A previous STI was associated with HIV seropositivity in homosexual men.

High rates of tuberculosis infection among children from Ciutat Vella District, Barcelona, 1996-1997.

With tuberculosis (TB) rates of over 160/100,000 in 1997, Ciutat Vella District, Barcelona, is the main community focus of TB in the city. For the purpose of TB screening, 415 children >2 years old from that district received a tuberculin skin test (TST); 27 (6.6%) (95%CI 4.5-9.3) were found to be infected but disease-free. The frequency of a positive TST increased significantly with age, from 0% in the 2-4 year age group to 14.6% in 10-14 year olds. Three culture-positive source adults, two of them sputum smear-positive, who were not previously known were traced from six TST-positive children. Previous BCG vaccination was not associated with a positive TST. These data support the use of universal TST screening in children living in Ciutat Vella District, Barcelona, as a means of identifying and treating TB cases.

[AIDS patients with an unclassified risk factor for HIV]. / Enfermos de SIDA con factor de riesgo del VIH no clasificado.

OBJECTIVES: In the surveillance of the AIDS epidemic via registries there is a small proportion of cases whose route of HIV transmission is unknown (5% for Catalonia, Spain). For reclassification purposes, the aim of this study is to detect similarities between these cases with "not qualified risk" (NQR) with the other main HIV transmission groups. METHODS: All Aids cases (> 12 years) resident in Catalonia and reported between 1988 and 1996 to the AIDS registry (n = 8,559) were compared according to their distribution of "age at diagnosis" and "first indicative AIDS disease". ANOVA and log-linear regression models were applied separately by sex. RESULTS: Evidence of similarity with the NQR group was only found for men; in terms of age at diagnosis, the NQR group was similar to both groups of sexual transmission whilst in terms of Aids indicative disease it was similar to the heterosexual transmission group. As from 1994, a reduction in the incidence of NQR cases was observed and coincided with an increase in the heterosexual group. CONCLUSIONS: According to the characteristics of the NQR cases, it can be concluded that all cases acquired HIV via one of the classic routes of infection, primarily through heterosexual contacts. For this reason, it is advisable that the criteria that define heterosexual HIV transmission be relaxed.

Registro de ensayos con vacunas del Programa Mundial de Vacunas e Inmunización de la OMS / The WHO Global Programme for Vaccines and Immunization Vaccine Trial Registry

En 1995, el Programa Mundial de Vacunas e Immunización de la OMS estableció un registro para ensayos con vacunas. En septiembre de 1996, este registro contenía 50 ensayos de vacunación patrocinados por la OMS, de los cuales 25 (50 por cien) eran estudios ya terminados. Las vacunas que se habían estudiado con mayor frecuencia fueron las de sarampión (9 ensayos), poliovirus (8 ensayos), cólera (8 ensayos), Escherichia coli enterotoxígena (4 ensayos) y neumococo (4 ensayos). Casi 80 por cien de estos ensayos se llevaron a cabo en países en desarrollo, principalmente en el Africa. En los 25 ensayos ya terminados, los resultados investigados fueron la respuesta inmunitaria (24 ensayos), las reacciones adversas (13 ensayos), la morbilidad (4 ensayos) y la mortalidad (1 ensayo). La OMS contribuyó a estos ensayos con el aporte indirecto de fondos, ayuda con el diseño metodológico, visitas a las localidades, el análisis de los datos, la adquisición de vacunas y la investigación de su potencia

[HIV infection in the alternative centers for voluntary detection of anti-HIV antibodies in Cataluna, Spain (1995-1996). VIHDEVO collaborative group]. / Infección por el VIH en los centros alternativos para la detección voluntaria de los anticuerpos anti-VIH en Cataluña (1995-1996). colaborador VIHDEVO.

OBJECTIVE: The knowledge of HIV serostatus may help the treatment and follow up of those infected people, and change the risky behaviours in those not infected. Epidemiological information from people tested can better address the activities of control and prevention of HIV infection. DESIGN: Collection of demographic and epidemiological information. PARTICIPANTS: People voluntary tested in four alternative test settings in Catalonia. MEASUREMENTS AND MAIN RESULTS: Of 1,733 petitions of voluntary testing, 63 (3.7%) were HIV positive. Overall prevalence in men were two fold than in women (4.6% vs 2.3%). In both years of study, the mean age for women HIV positive were higher than the mean age for women with aids. CONCLUSIONS: The results of this study confirm the age and sex pattern found for the HIV infection in other sentinel populations in Catalonia. Some measures should be taken in order to increase the accessibility of young women to the test.

[Prevalence of maternal HIV infection in Catalonia (1994): results of non-related anonymous neonatal screening. VIHNADO Group]. / Prevalencia de la infección materna por el VIH en Cataluña (1994): resultados del cribado neonatal anónimo no relacionado. Grupo VIHNADO.

BACKGROUND: Spain has the highest incidence rate of AIDS in Europe. Catalonia contributes with around 30% of the AIDS cases detected in Spain. From 1990 to 1994 the AIDS heterosexual transmission category increased from 9.6% to 14.6% in Catalonia. The objective of the study was to determine the HIV prevalence in a heterosexual population of pregnant women. SUBJECTS AND METHODS: Unlinked anonymous HIV screening by means of an agglutination assay and an enzyme immunoassay of eluates of dried blood spots from nearly half of the neonates born in Catalonia during 1994. RESULTS: HIV testing was done on 21,074 neonates. Overall HIV prevalence was 0.32% (95% CI: 0.25-0.40). It varied from 0.45% in Barcelona, 0.38-0.29% in the health regions around Barcelona, to 0.20-0.09% in the rest. The mean age of HIV infected women was younger (27) than that of the seronegative ones (29) (p < 0.001). The highest prevalence was 0.61% in women aged 20-24 years. CONCLUSIONS: The HIV prevalence in the heterosexual population of pregnant women in Catalonia is among the highest in Europe. Preventive efforts must begin with schoolchildren and be directed to adolescents and young women. It is convenient that women who want to become pregnant and mothers receiving antenatal care have access to voluntary confidential HIV testing.