Brazilian Clinical Practice Guidelines for Sexually Transmitted Infections That Cause Urethral Discharge: Assessment According to the AGREE II and Critical Analysis Based on the WHO Recommendations.

BACKGROUND: Sexually transmitted infections (STI) can have severe consequences. In Brazil, case management is recommended by the Clinical Protocol and Therapeutical Guidelines for Comprehensive Care for People with STIs (PCDT-IST). This study assessed the quality of PCDT-IST (2021) and reviewed the main recommendations for the management of STI that cause urethral discharge compared with the World Health Organization (WHO) STI Guidelines. METHODS: The PCDT-IST (2021) quality was independently assessed by 4 appraisers using the Appraisal of Guidelines Research and Evaluation instrument, version II (AGREE II). The PCDT-IST (2021) and the WHO Guidelines for the Management of Symptomatic STI (2021) were compared considering 14 different assessment domains. RESULTS: The PCDT-IST (2021) scores in the AGREE II domains were: Rigor of Development (58%), Applicability (35%), Editorial Independence (38%), Scope and Purpose (78%), Stakeholder Involvement (74%), and Clarity and Presentation (82%). The overall score was 67%, and all appraisers recommended the Brazilian guideline. Regarding the PCDT-IST (2021) and the WHO STI Guidelines (2021) comparation, 10 domains would be relevant for further reviewing the Brazilian recommendations: Diagnostic tests; Etiological approach; Treatment for recurrent urethral discharge; Treatment for urethritis without etiological agent identification; Treatment for gonococcal urethritis; Treatment for chlamydial urethritis; Retreatment for gonococcal infections; Treatment for Mycoplasma genitalium urethritis; Treatment for Trichomonas vaginalis urethritis; 10. Flowcharts. CONCLUSIONS: The PCDT-IST (2021) has a reasonable degree of quality. However, the domains of Applicability, Rigor of Development, and Editorial Independence must be better ensured. The guidelines comparison will help to select key topics that should be addressed with priority in the following national STI guidelines updates.

SOCIO-ECONOMIC FEATURES OF SEXUALLY TRANSMITTED INFECTIONS AMONG MSM IN GEORGIA.

The aim of our study was to investigate correlation between socio-Economic conditions and prevalence of Sexually Transmitted Infections among gay individuals (men who have sex with men, MSM) in Georgia. The study was conducted in 5 main cities in different regions of Georgia (Tbilisi, Batumi, Kutaisi, Zugdidi, and Telavi). During 2015-2019, social workers, LGBT community and non-governmental organizations (NGOs), conducted screening of MSM for STI, which was achieved by disseminating required information through electronic and print media, resulting in maximum involvement of MSM in screening programs for STI disseminating. A specially designed questionnaire/survey has been used to investigate the correlations between the following parameters, such as: age, educational attainment (non-completed secondary, secondary, non-completed High School, completed High School), economic income (extremely low, low, middle, high), awareness of STI (yes/no), sources of information (healthcare worker, internet/media, sex partner, social workers and/or NGOs (supporters of LGBT community, others), residence type (urban/rural); frequency of safe sex (using condoms for the last 6 months), number of sexual partners (>3) and etc., among the persons involved in the study. The following prevalence rates of STIs among the MSM population in Georgia during 2015-2019 were defined: for syphilis it appeared to be approximately 25.76%; for gonorrhea - 18.63%, and for chlamydia - 21.98%, respectively. The results of current study indicated that low-income levels and educational attainment are the key socioeconomic risk factors leading to high rates of STI prevalence among MSM. On the contrary, STI rates were inversely correlated with the level of education of the studied population. The odds ratio (OR) for syphilis between with the low and high incomes groups was 1.18 (p=0.023); for gonorrhea, the OR between the above stated groups s was 1.32 (p=0.001); for chlamydia OR was not significant - 0.89 (p=0.118). OR for syphilis between informed and uninformed about STI groups was 1.92 (p<0.001); the OR between the same groups was 2.24 (p<0.001), and in the case of chlamydia - 1.59 (p<0.001). Analysis of information obtained MSM from the selected sources over years showed that the contribution of the social and electronic media was decreased (50.5% to 38.1%, p<0.001) as well as the contribution of the social workers and/or non-governmental (LGBT community supporters) organizations (24,2% to 15.5%, p<0.001); that was mainly due to the acquisition of qualified information from medical workers (from 12.0% to 25.0%, p<0.001) and the high level of reliability of sexual partnership (from 13.2% to 21.1%, p<0.001). The OR for syphilis cases between the Rural/Urban groups was OR=1.60 (p=0.002); for gonorrhea, the OR between the same groups was 1.74 (p<0.001); and for chlamydiosis, the OR was 1.80 (p<0.001). Low-income levels and educational attainment are considered as main socio-economic risk-factors for high STI prevalence observed among the MSM. Healthcare workers and sexual partners are viewed as the main and reliable sources of sexual health information in MSM group. Although the obtained findings need further investigation and confirmation, preliminary results show that screening and prevention programs together with extensive dissemination of sexual health information may decrease prevalence of STI among MSM. And all are of great importance.

Management of gonorrhoea in a hospital network: are we following best practice?

Background Gonorrhoea is usually managed in community sexual health or general practice, but a proportion of cases present to hospital settings. In this study, we examined how gonorrhoea was managed through a large hospital network and what the implications may be for public health management. METHODS: A retrospective chart review was performed of the management of patients with Neisseria gonorrhoeae infection diagnosed at a large Australian healthcare network from January 2015 to May 2018. Documentation rates of five parameters of care were assessed: (1) the presence (or absence) of previous sexually transmissible infections (STIs); (2) recent travel; (3) discussion of HIV testing; (4) contact tracing; and (5) public health notification. RESULTS: In all, 110 cases (48 male, 62 female) were analysed. Most cases were in the 15-39 years age group; 98 cases (89%) were symptomatic, and 12 (11%) were screening tests. The most common presenting syndromes were pelvic inflammatory disease (32%; 31/98 symptomatic cases), urethritis (26%; 25/98) and epididymo-orchitis (13%; 13/98). None of the five parameters assessed were documented in most cases. Documentation was most likely to occur in patients admitted to hospital. When HIV testing was performed, no new cases of HIV were identified. CONCLUSION: Infections with gonorrhoea present on a regular basis to hospital practice, but overall management is suboptimal. Automated prompts for other recommended tests, including HIV testing when testing for other sexually transmissible diseases is ordered, may improve management. Better awareness of best practice is needed, which can be facilitated with ongoing education. However, the greatest benefit is likely achieved by linking patients back to community-based services, which are best placed to provide ongoing long-term care.

Microscopic examination of Gram-stained smears for anogenital gonorrhoea in men who have sex with men is cost-effective: evidence from a modelling study.

OBJECTIVE: To assess the cost-effectiveness of three testing strategies with or without light microscopic Gram-stained smear (GSS) evaluation for the detection of anogenital gonorrhoea among men who have sex with men (MSM) at the Amsterdam STI clinic using a healthcare payer perspective. METHODS: Three testing strategies for MSM were compared: (1) GSS in symptomatic MSM only (currently practised strategy), (2) no GSS and (3) GSS in symptomatic and asymptomatic MSM. The three testing protocols include testing with nucleic acid amplification test to verify the GSS results in (1) and (3), or as the only test in (2). A transmission model was employed to calculate the influence of the testing strategies on the prevalence of anogenital gonorrhoea over 10 years. An economic model combined cost data on medical consultations, tests and treatment and utility data to estimate the number of epididymitis cases and quality-adjusted life years (QALY) associated with gonorrhoea. Incremental cost-effectiveness ratios (ICERs) for the testing scenarios were estimated. Uncertainty and sensitivity analyses were performed. RESULTS: No GSS testing compared with GSS in symptomatic MSM only (current strategy) resulted in nine extra epididymitis cases (95% uncertainty interval (UI): 2-22), 72 QALYs lost (95% UI: 59-187) and €7300 additional costs (95% UI: -€185 000 (i.e.cost-saving) to €407 000) over 10 years. GSS testing in both symptomatic and asymptomatic MSM compared with GSS in symptomatic MSM only resulted in one prevented epididymitis case (95% UI: 0-2), 1.1 QALY gained (95% UI: 0.1-3.3), €148 000 additional costs (95% UI: €86 000 to-€217 000) and an ICER of €177 000 (95% UI: €67 000-to €705 000) per QALY gained over 10 years. The results were robust in sensitivity analyses. CONCLUSIONS: GSS for symptomatic MSM only is cost-effective compared with no GSS for MSM and with GSS for both symptomatic and asymptomatic MSM.

The impact of HIV infection and socioeconomic factors on the incidence of gonorrhea: A county-level, US-wide analysis.

BACKGROUND: Gonorrhea is the second most commonly reported identifiable disease in the United States (U.S.). Importantly, more than 25% of gonorrheal infections demonstrate antibiotic resistance, leading the Centers for Disease Control and Prevention (CDC) to classify gonorrhea as an "urgent threat". METHODS: We examined the association of gonorrhea infection rates with the incidence of HIV and socioeconomic factors. A county-level multivariable model was then constructed. RESULTS: Multivariable analysis demonstrated that HIV incidence [Coefficient (Coeff): 1.26, 95% Confidence Interval (CI): 0.86, 1.66, P<0.001] exhibited the most powerful independent association with the incidence of gonorrhea and predicted 40% of the observed variation in gonorrhea infection rates. Sociodemographic factors like county urban ranking (Coeff: 0.12, 95% CI: 0.03, 0.20, P = 0.005), percentage of women (Coeff: 0.41, 95% CI: 0.28, 0.53, P<0.001) and percentage of individuals under the poverty line (Coeff: 0.45, 95% CI: 0.32, 0.57, P<0.001) exerted a secondary impact. A regression model that incorporated these variables predicted 56% of the observed variation in gonorrhea incidence (Pmodel<0.001, R2 model = 0.56). CONCLUSIONS: Gonorrhea and HIV infection exhibited a powerful correlation thus emphasizing the benefits of comprehensive screening for sexually transmitted infections (STIs) and the value of pre-exposure prophylaxis for HIV among patients visiting an STI clinic. Furthermore, sociodemographic factors also impacted gonorrhea incidence, thus suggesting another possible focus for public health initiatives.

The utility and cost of Chlamydia trachomatis and Neisseria gonorrhoeae screening of a male infertility population.

OBJECTIVE: To determine the utility and cost of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) screening in infertile males. DESIGN: Cohort study. SETTING: Canadian tertiary-level male infertility clinic and university-affiliated laboratories. PATIENT(S): 5,588 male infertility patients. INTERVENTION(S): CT and NG testing on 8,972 urine and semen samples. MAIN OUTCOME MEASURE(S): Prevalence of CT and NG infection in infertile males versus general male population in Canada over 8 years (2003-2010) and the reagent cost to detect one case of CT or NG. RESULT(S): In infertile males, the prevalence rate for CT and NG was 0.304% and 0.0537%, which was statistically significantly lower (3.4- and 8.1-fold lower, respectively) than the age-adjusted general population prevalence. With the reagents costing $86.20 per patient tested, the reagent cost alone to diagnose one case of CT or NG was $38,669. CONCLUSION(S): The prevalence of CT and NG in this study are among the lowest reported in the male infertility literature. These findings question the utility of CT/NG screening in this low-risk population and emphasize that decisions about the utility of screening must be based on the prevalence rates of the disease in the studied population.

The value of screening for sexually transmitted diseases in an HIV clinic.

Because bacterial sexually transmitted diseases (STDs) facilitate HIV transmission, screening for and treatment of STDs among HIV-infected persons should prevent HIV spread to partners. Before screening programs for gonorrhea and Chlamydia infection should be widely established in HIV clinics, it is useful to know the prevalence of these infections. This study analyzed the results of a urine-based screening program for gonorrhea and Chlamydia in a New Orleans HIV clinic and compared the positivity rates to the prevalence in the local community. Among persons screened in the HIV clinic, 1.7% (46/2629) had gonorrhea and 2.1% (56/2629) had Chlamydia infection. Among persons aged 18-29 years, the test positivity for gonorrhea was similar in the HIV clinic to that of persons in sociodemographically similar community samples (3.1 versus 2.4%, adjusted odds ratio 1.6, P = 0.11) and the test positivity for Chlamydia infection was lower (5.4% versus 10.5%, adjusted odds ratio 0.6, P < 0.01). Based on a previously published mathematical model, it was estimated that treatment of all 46 gonorrhea and 56 Chlamydia infections in the HIV clinic may have averted 9 HIV infections among sex partners and saved far more in future medical costs than the cost of the screening. Routine screening for gonorrhea and Chlamydia infection should be considered in HIV clinics.

A cost-effectiveness evaluation of testing and treatment of Chlamydia trachomatis infection among asymptomatic women infected with Neisseria gonorrhoeae.

BACKGROUND: Because patients infected with Neisseria gonorrhoeae are frequently coinfected with Chlamydia trachomatis, routine dual treatment of patients with N gonorrhoeae infection is frequently practiced and has long been recommended. GOAL: The goal of this study was to examine the cost-effectiveness of routine dual treatment of women with infection, with or without separate testing for C trachomatis, compared with an alternative of testing for both infections and restricting treatment for C trachomatis to women testing positive for C trachomatis. STUDY DESIGN: A decision analysis compared the cost-effectiveness of these options using cases of pelvic inflammatory disease prevented as the outcome. Parameter values were taken from the literature. RESULTS: Routine dual treatment is not an effective or cost-effective replacement for testing for C trachomatis, but it can increase the number of cases of C trachomatis treated when combined with testing. Dual treatment results in more overtreatment of infection C trachomatis than treatment based on test results. CONCLUSIONS: Testing for both infections is more cost-effective than routine presumptive treatment for C trachomatis. Providing both presumptive treatment and testing for C trachomatis can also be cost-effective in some settings.

[Incidence and management of male urethritis in the district of Tunis]. / Incidence et prise en charge des urétrites chez l'homme dans le district de Tunis.

BACKGROUND: The aim of the study was to evaluate the incidence of male urethritis and the relative frequency of the different etiological agents in order to adapt standard case management. METHODS: The incidence of urethritis has been estimated with a postal study made on a sample of druggists (1/10) of the area. The total observation period was four weeks. The relative frequency of the etiological agents and the positive predictive value (PPV) of the therapeutic approach based on antibiotic treatment of gonorrhoea and Chlamydia trachomatis was achieved on 92 cases of male urethritis attending general physicians in two polyclinics. RESULTS: The annual incidence of male urethritis was estimated at 680 per 100,000. The relative frequency of etiological agents was as 34.7% for Neisseria gonorrhoea, 7.6% for Chlamydia trachomatis and was found at 3.3% for Trichomonas vaginalis; the PPV was only 43% because of the high proportion of negative results reported by the laboratory. CONCLUSION: Gonococcal urethritis incidence tends to decrease regarding non gonococcal urethritis and the therapeutic approach appears to be warranted.

Evaluation of syndromic patient management algorithm for urethral discharge.

OBJECTIVE: To determine feasibility, validity, and cost effectiveness of the syndromic approach to male patients with urethral discharge in Bandung, Indonesia. METHODS: The WHO algorithm on urethral discharge with no microscopy available was evaluated. Patients presented with a complaint of urethral discharge and if discharge was confirmed the algorithm was applied. Treatment covered gonococcal and chlamydial infection (ciprofloxacin 500 mg single oral dose plus doxycycline 100 mg, twice daily orally for 7 days). The gold standard for validation was gonococcal culture and chlamydia antigen detection. RESULTS: 140 male patients with a complaint of urethral discharge were enrolled; 119 had confirmed discharge and entered the decision tree: 107 were followed and 104 (97%) were clinically cured. Of the three patients with persistent discharge, one had a purulent urethral discharge, diagnosed as gonococcal urethritis and he was probably reinfected; two patients had a serous discharge and microbiological tests were negative. Overall, 106 out of 107 patients (99%) were microbiologically cured. Sensitivity of the algorithm is 100% and its positive predictive value (PPV) is 75% or 97% if validated against gold standard microbiological tests or Gram stain, respectively. Cost per patient is rupiah (Rp)5.894 ($US2.56) for the algorithm compared with Rp43.024 ($18.70) for full microbiological diagnosis. The cost estimate for an algorithm of urethral discharge with microscopy available is Rp6.432 ($2.80) CONCLUSION: The "symptom and sign" algorithm is fully adapted to the prevailing situation in primary healthcare settings, is acceptable to healthcare workers and patients (who are effectively treated at their first visit), is highly cost effective, is 100% sensitive (no false negatives, which is not the case with microbiological diagnosis), and has a high PPV, between 75% and 97%. It is an excellent patient management tool and a sound basis for partner notification so that it should have a major impact on STD/HIV control and prevention in both men and women.

Cost-effective treatment of uncomplicated gonorrhoea including co-infection with Chlamydia trachomatis.

We evaluated the cost effectiveness of treating uncomplicated gonorrhoea in a theoretical cohort of 1000 adults (nonpregnant women of reproductive age, or men) with either intramuscular ceftriaxone 125 mg or a single oral dose of cefixime 400 mg, ofloxacin 400 mg or ciprofloxacin 500 mg. We assumed that all patients were also empirically treated for uncomplicated chlamydial infection, with either a single oral dose of azithromycin 1 g, or oral doxycycline 100 mg twice daily for 7 days. Treatment of gonorrhoea with intramuscular ceftriaxone was found to be the most cost-effective alternative. This was followed by treatment with the either of the fluoroquinolones (ofloxacin or ciprofloxacin), then cefixime. For empirical treatment of uncomplicated chlamydial infection, doxycycline was more cost effective than azithromycin when approximately more than 80% of the patients were assumed to comply with the doxycycline regimen. When patients' compliance was poor with the doxycycline regimen, the azithromycin therapy became more cost effective from a societal viewpoint. Nevertheless, its relatively high cost to the individual patient with limited financial resources might prevent him or her from filling prescriptions. Any decrease in patients' compliance with the azithromycin therapy would favour treatment with doxycycline.

Epidemiological treatment and tests of cure in gonococcal infection: evidence for value.

OBJECTIVES: To evaluate the evidence for value of using epidemiological treatment and of using tests of cure in the management of gonococcal infections. METHODS: Medline was used to search the literature for well-conducted studies that had a bearing on the evaluation of these issues. CONCLUSIONS: Epidemiological treatment is treatment given to named contacts of patients after a history of exposure to disease but without or in advance of confirmatory pathological findings. It may be given when the clinician considers that the risk to the patient of unnecessary treatment is outweighed by the risk of complications of the infection or the probability of transmission of the infection to other contacts. It may be appropriate where detection by microscopy is relatively unreliable such as when infection of the cervix, rectum, or pharynx is suspected. If epidemiological treatment is given, then it does not obviate the need for confirmatory tests to be sent, tests of cure to be done, or for contact tracing. At least one test of cure is mandatory following treatment of gonorrhoea. The test of cure in women should include a blind rectal swab. For infection of the pharynx and rectum the chances of a false negative test of cure are higher and, therefore, more than one test of cure is required. An additional test of cure is also necessary in patients with salpingitis or disseminated gonococcal infection. This paper is a discussion of two interrelated issues in the management of gonorrhoea. It is based on two presentations by the author at a workshop organised by Dr Mark Fitzgerald entitled Development of audit measures and guidelines for good practice in the management of gonorrhoea and held at the Royal College of Physicians, London, in May 1995. The conclusions reached are based on the consensus view of the participants. For simplicity the two issues are dealt with consecutively.

Pelvic inflammatory disease: clinical overview.

Acute pelvic inflammatory disease (PID) adversely affects the health of 1 million American women annually. The best understood etiologic organisms are Chlamydia trachomatis and Neisseria gonorrhea; however, information regarding the contributions of facultative and causative anaerobes continues to emerge. Chronic PID presents a diagnostic and management challenge to health care providers. Because of morbidity and sequelae the importance of early detection of, and intervention for, upper tract pelvic infections cannot be overemphasized. Nursing interventions in PID prevention, early assessment, accurate diagnosis, and thorough treatment can have a positive impact on women's health.

Risk assessment and laboratory diagnosis of trichomoniasis in men.

Control of Trichomonas vaginalis is assuming higher priority because recent studies have suggested that trichomoniasis enhances susceptibility to human immunodeficiency virus infection and the risk for delivery of low-birth weight infants. In a cross-sectional study, 50 cases were identified among 447 men attending a sexually transmitted disease clinic. As previously reported, trichomoniasis was associated with nonchlamydial nongonococcal urethritis. Other risk factors included sexual contact with an infected woman or prior treatment for trichomoniasis or nongonococcal urethritis. Urethral and first-void urine cultures were positive in 80% and 68% of positive cases, respectively. When combined, these two cultures diagnosed 49 (98%) of 50 cases. These data suggest that criteria for selection of men for culture should include presence of nonchlamydial nongonococcal urethritis, recent exposure to trichomoniasis, or a history of trichomoniasis or nongonococcal urethritis. In addition, combining urethral and urine sediment cultures may prove accurate for evaluating T. vaginalis infection.

Emergency department screening for syphilis in patients with other suspected sexually transmitted diseases.

STUDY OBJECTIVE: To evaluate targeted screening for syphilis among a high-risk group of emergency department patients. STUDY DESIGN AND TYPE OF PARTICIPANTS: During a four-month period, 260 patients with suspected sexually transmitted diseases other than syphilis had rapid plasma reagins drawn to determine the incidence of otherwise unsuspected syphilis. RESULTS: Twenty-two patients (8%) had a reactive rapid plasma reagin. Of these, 16 (6%) also had a reactive FTA-ABS and were determined to have syphilis. The cost for screening was $104.90 for each patient with syphilis. Using Poisson regression to control for changing rates over time and for prior differences in rates of syphilis detection in the three hospitals involved in the study, it was determined that our intervention led to 2.4-fold as many cases identified as would have been expected considering prior rates and the increasing incidence of syphilis. CONCLUSION: Syphilis screening of this high-risk population in the ED is warranted.

Cost-effectiveness of combined treatment for endocervical gonorrhea. Considering co-infection with Chlamydia trachomatis.

Three treatment regimens are currently recommended for penicillin-susceptible Neisseria gonorrhoeae infection of the cervix: ampicillin, tetracycline, and a combination of ampicillin and tetracycline. To evaluate the cost-effectiveness of these options, we developed a decision analysis model and analyzed the efficacy of each treatment in curing gonorrhea, as well as coexisting Chlamydia trachomatis infection, and in preventing subsequent pelvic inflammatory disease, ectopic pregnancy, and infertility. We included direct costs of medication and expenditures for management of unresolved infections and associated complications. Combination treatment is more than twice as cost-effective as tetracycline and seven times as cost-effective as ampicillin when the medical cost of managing pelvic inflammatory disease is considered. When the costs of ectopic pregnancies and infertility are included, the cost-effectiveness of combination treatment increases further.

Prevalence of pharyngeal gonorrhea in general medical patients with sore throats.

The prevalence of pharyngeal gonorrhea was investigated in a previously unstudied population: adult patients seeking care for sore throats and other symptoms of respiratory infection in general medical practices. The complaint of sore throat accounts for at least 15 million patient visits each year in the United States. A prospective study of 239 patients in three different settings revealed prevalences of 1% (95% confidence interval of 0.1-3%) in the 192 patients with sore throats, and of zero (95% confidence interval of zero to 3.4%) in 47 patients with respiratory infection symptoms other than sore throat. The data support the position that routine pharyngeal culturing for Neisseria gonorrhoeae for patients who have sore throats is not cost-efficient.