Use of Treponema pallidum PCR in testing of ulcers for diagnosis of primary syphilis.

Treponema pallidum PCR (Tp-PCR) has been noted as a valid method for diagnosing syphilis. We compared Tp-PCR to a combination of darkfield microscopy (DFM), the reference method, and serologic testing in a cohort of 273 patients from France and Switzerland and found the diagnostic accuracy of Tp-PCR was higher than that for DFM.

Performance of the 47-kilodalton membrane protein versus DNA polymerase I genes for detection of Treponema pallidum by PCR in ulcers.

Treponema pallidum PCR (Tp-PCR) is a direct diagnostic method for primary and secondary syphilis, but there is no recommendation regarding the best choice of target gene. In this study, we sequentially tested 272 specimens from patients with sexually transmitted ulcers using Tp-PCR targeting the tpp47 and then polA genes. The two methods showed similar accuracies and an almost-perfect agreement.

Chronic prostatitis does not influence urinary PCA3 score.

BACKGROUND: The influence of chronic prostatitis on serum PSA level is well known. Whether it also influences potential new biomarkers of prostate cancer (PCa) has to be determined. We conducted a prospective study to evaluate the effect of chronic prostatitis on the PCa urinary marker PCA3. METHODS: Included were 38 patients, mean-aged of 37.5 years, with clinical suspicion of chronic prostatitis. A simplified version of the Meares-Stamey four-glass localization test was performed and urine specimens were collected for cytological analysis and culture. A postprostatic massage urine sample was used for the urinary PCA3 test. RESULTS: Four patients had an eventual diagnosis of urethritis and all had a PCA3 score less than 5. Among the remaining 34 patients, 7 had bacterial chronic prostatitis (NIH II prostatitis), 11 had abacterial chronic prostatitis (NIH IIIa), and 16 had non inflammatory prostatodynia (NIH IIIb). All these patients had a PCA3 score less than 28, that is, under the cutoff of 35, which is commonly used for prostate cancer diagnosis. Patients with NIH category IIIa prostatitis had significantly higher number of leukocytes and red cells as well as prostate cells in urine samples but their PCA3 scores did not differ from those of other prostatitis patients. CONCLUSION: In this study, NIH II and III chronic prostatitis did not influence the PCA3 score. Our results suggest that increased PCA3 score is unlikely to be explained by the sole chronic prostatitis and warrants prostate biopsies to eliminate prostate cancer.

High-level cefixime- and ceftriaxone-resistant Neisseria gonorrhoeae in France: novel penA mosaic allele in a successful international clone causes treatment failure.

Recently, the first Neisseria gonorrhoeae strain (H041) highly resistant to the expanded-spectrum cephalosporins (ESCs) ceftriaxone and cefixime, which are the last remaining options for first-line gonorrhea treatment, was isolated in Japan. Here, we confirm and characterize a second strain (F89) with high-level cefixime and ceftriaxone resistance which was isolated in France and most likely caused a treatment failure with cefixime. F89 was examined using six species-confirmatory tests, antibiograms (33 antimicrobials), porB sequencing, N. gonorrhoeae multiantigen sequence typing (NG-MAST), multilocus sequence typing (MLST), and sequencing of known gonococcal resistance determinants (penA, mtrR, penB, ponA, and pilQ). F89 was assigned to MLST sequence type 1901 (ST1901) and NG-MAST ST1407, which is a successful gonococcal clone that has spread globally. F89 has high-level resistance to cefixime (MIC = 4 µg/ml) and ceftriaxone (MIC = 1 to 2 µg/ml) and resistance to most other antimicrobials examined. A novel penA mosaic allele (penA-CI), which was penA-XXXIV with an additional A501P alteration in penicillin-binding protein 2, was the primary determinant for high-level ESC resistance, as determined by transformation into a set of recipient strains. N. gonorrhoeae appears to be emerging as a superbug, and in certain circumstances and settings, gonorrhea may become untreatable. Investigations of the biological fitness and enhanced understanding and monitoring of the ESC-resistant clones and their international transmission are required. Enhanced disease control activities, antimicrobial resistance control and surveillance worldwide, and public health response plans for global (and national) perspectives are also crucial. Nevertheless, new treatment strategies and/or drugs and, ideally, a vaccine are essential to develop for efficacious gonorrhea management.

A survey of primary care physician practices in antibiotic prescribing for the treatment of uncomplicated male gonoccocal urethritis.

BACKGROUND: The development of resistance to antimicrobial therapy by Neisseria gonorrhoeae causes on-going problems for individual case management of gonorrhoea. Surveillance data about N. gonorrhoeae have indicated an increase in the incidence of gonorrhoea in France in 2006. As a consequence of the development of antibiotic resistance in N. gonorrhoeae, French guidelines excluded fluoroquinolones as a standard treatment for N. gonorrhoeae. Ceftriaxone became the recommended treatment, associated with azithromycin for Clamydia trachomatis infection. Our aim was to describe the practice patterns of general practitioners (GPs) in managing the antibiotic treatment of patients with symptoms suggestive of uncomplicated male urethritis. METHODS: We developed a clinical vignette describing a man with typical gonococcal urethritis symptoms to elicit questions about antibiotic treatment. We mailed the electronic questionnaire to a random sample of 1000 French GPs belonging to the Sentinelles Network. RESULTS: By the end of the survey period, 350 vignettes were received, yielding a response rate of 35%. Sixty-six GPs (20.2%) prescribed the recommended antibiotics for the simultaneous treatment of N. gonorrhoeae and C. trachomatis infections, while 132 GPs (40.4%) prescribed only non-recommended antibiotics, including ciprofloxacin in 69 cases (21.1%). General practitioners with less than 10 years in practice showed better compliance to guidelines than those with more years in practice (p<0.05). CONCLUSIONS: The results suggest a mismatch between the guidelines and the antibiotic treatment of male uncomplicated urethritis by French GPs, mostly among the subgroup of physicians who have been in practice longer. Educational approaches based on practice feedback need to be developed to improve these deficits in the quality of care.

First neisseria gonorrhoeae genotyping analysis in france: identification of a strain cluster with reduced susceptibility to Ceftriaxone.

Sexually transmitted infections are a major public health problem in France and other European countries. Particularly, surveillance data about Neisseria gonorrhoeae infections have clearly indicated an increase in the incidence of gonorrhoea in France in 2006. The French laboratories participated on voluntary basis in the RENAGO (Réseau National du Gonocoque) network and sent all of their collected strains to the National Reference Center for Neisseria gonorrhoeae. In this first French molecular epidemiological study, 93 isolates collected in 2006 and representative of the French gonorrhoea epidemiology were selected. Antibiotic susceptibility to six antibiotics was determined, and serotyping and N. gonorrhoeae multiantigen sequence typing (NG-MAST) were performed. NG-MAST identified 53 sequence types (STs), of which 13 STs contained 2 to 16 isolates. The major STs identified in France were previously described elsewhere. However, two newly described STs, ST1479 and ST1987, had only been found in France until now. ST1479 was characterized by a multiple-resistance phenotype, whereas ST1987 presented a susceptibility phenotype. Moreover, among the predominant French STs, ST225, which had already been described in many countries, comprised isolates (14/16) resistant to ciprofloxacin and with reduced susceptibility to ceftriaxone. Thus, the surveillance of resistance to antibiotics is a priority in order to adapt treatment and decrease the transmission of resistant strains. Of note, no predominant ST was identified among rectal isolates from men who have sex with men.

Neisseria gonorrhoeae antibiotic resistance in Paris, 2005 to 2007: implications for treatment guidelines.

Quinolone-resistant Neisseria gonorrhoeae rates have increased worldwide since 1994. The objective of this study was to appraise: (i) the antimicrobial susceptibility of Neisseria gonorrhoeae in a venereology clinic in Paris, between 2005 and 2007; and (ii) the factors associated with quinolone-resistant N. gonorrhoeae. A prospective study of consecutive cases was performed for the period 2005 to 2007. Susceptibility of N. gonorrhoeae to five antibiotics (ciprofloxacin, ceftriaxone, spectinomycin, penicillin G and tetracycline) was tested systematically. Clinical and epidemiological data were collected using a standardized form. Male-to-female sex ratio was 22.0. Median age was 30.0 years. Of 115 cases, 84 occurred in men having sex with men (72.6%) and 22 involved the anorectal area (19.1%). The rate of quinolone-resistant N. gonorrhoeae was 37.4% (43/115), without significant association with gender, age, sexual behaviour, past history of sexually transmitted diseases and susceptibility to other antibiotics. All N. gonorrhoeae were susceptible to ceftriaxone and spectinomycin. The rate of quinolone-resistant N. gonorrhoeae in Paris has been increasing since 2004. Ceftriaxone remains the gold standard treatment.

Linear array genotyping and hybrid capture II assay in detecting human papillomavirus genotypes in women referred for colposcopy due to abnormal Papanicolaou smear.

The main objective of this study was to assess the feasibility of human papillomavirus (HPV) genotyping in women referred for colposcopy due to abnormal Papanicolaou (Pap) smear. A series of 248 women referred for colposcopy due to an abnormal Pap smear were analysed with the Roche Linear Array HPV genotyping test detecting 37 most frequent HPV types, and compared with hybrid capture II (HCII) assay for oncogenic (high-risk [HR] HPV) types as well as for p16INK4a expression using immunocytochemistry. All tests were performed in cervical samples collected in PreservCyt liquid media for liquid-based cytology (ThinPrep), and colposcopic biopsy and/or loop electro excision procedure cone biopsy was used as the gold standard. HPV16 was the single most frequent genotype (29/258; 11.7%), followed by HPV51 (4.4%), HPV66 (3.6%), HPV42, 52 and 56 (3.2% for all). Linear array genotyping test significantly predicts both abnormal colposcopy (odds ratio [OR] = 9.0; 3.12-25.93), high-grade squamous intraepithelial lesions (OR = 9.6; 1.26-74.17) and cervical intraepithelial neoplasia (CIN) 3+ (OR = 29.3; 3.95-218.06). In detecting CIN3, linear array was equivalent (97.6%) to colposcopy in sensitivity (SE), both being superior to HCII (92.7%). Concordance between linear array and HCII was moderate (Cohen's kappa kappa = 0.547; 95% confidence interval [CI]: 0.435-659). Specificity (SP) and positive predictive value (PPV) of linear array were significantly improved, if only HPV16 genotype was considered. Performance in the best balance is obtained, when linear array and colposcopy are combined, giving 82.9% SE, 93.9% SP, 73.9% PPV and 96.3% negative predictive value (NPV) as predictor of CIN3+ (OR 74.5; 95% CI: 27.36-202.72). In conclusion, linear array for HR-HPV is a highly sensitive test (97.6%) with high NPV (98.9%) in detecting CIN3+ lesions. HPV16 genotyping alone significantly improves SP and PPV of this test in management of women with abnormal cytology.

Molecular characterization of Treponema pallidum subsp. pallidum in Switzerland and France with a new multilocus sequence typing scheme.

Syphilis is an important public health problem and an increasing incidence has been noted in recent years. Characterization of strain diversity through molecular data plays a critical role in the epidemiological understanding of this re-emergence. We here propose a new high-resolution multilocus sequence typing (MLST) scheme for Treponema pallidum subsp. pallidum (TPA). We analyzed 30 complete and draft TPA genomes obtained directly from clinical samples or from rabbit propagated strains to identify suitable typing loci and tested the new scheme on 120 clinical samples collected in Switzerland and France. Our analyses yielded three loci with high discriminatory power: TP0136, TP0548, and TP0705. Together with analysis of the 23S rRNA gene mutations for macrolide resistance, we propose these loci as MLST for TPA. Among clinical samples, 23 allelic profiles as well as a high percentage (80% samples) of macrolide resistance were revealed. The new MLST has higher discriminatory power compared to previous typing schemes, enabling distinction of TPA from other treponemal bacteria, distinction between the two main TPA clades (Nichols and SS14), and differentiation of strains within these clades.

P16(INK4a) immunocytochemistry in liquid-based cytology samples in equivocal Pap smears: added value in management of women with equivocal Pap smear.

OBJECTIVE: To test whether p1l6(INK4a) immunocytochemistry (ICC) in liquid-based cytology (LBC) is useful with colposcopy in abnormal Pap smears. STUDY DESIGN: A series of 248 women with abnormal Pap smear were analyzed for oncogenic (HR) human papillomavirus (HPV) types using the Hybrid Capture II assay and for p16(INK4a) expression using ICC on cervical samples in PreservCyt liquid media. Colposcopic and loop electrosurgical excision procedure (LEEP) cone biopsy were the gold standard. RESULTS: p16(INK4a) ICC did best as predictor of high-grade squamous intraepithelial lesion, with OR 12.18 (2.72-54.57) (p = 0.0001), showing 88.2% sensitivity (SE), 61.9% specificity (SP), 14.6% positive predictive value (PPV) and 98.6% negative predictive value (NPV). In sorting discrepant cases, p16(INK4a) ICC results in 100% SE and 100% NPV in detecting cervical intraepithelial neoplasia (CIN) 2 lesions among Pap+/biopsy- women. In atypical squamous cells undetermined significance (ASCUS) cytology, adding p16(INK4a) ICC improves specificity of colposcopy from 27.3% to 81.8% and PPV from 42.8% to 71.4%. Best performance is obtained with p16(INK4a) ICC and colposcopy: 83.3% SE, 81.8% SP, 71.4% PPV and 90.0% NPV. CONCLUSION p16(INK4a) is useful in sorting clinically relevant discrepant cases, and p16(INK4a) ICC significantly improves SP and PPV of colposcopy in management of ASCUS cytology.

[Current epidemiology of bacterial STIs in France]. / Épidémiologie actuelle des infections sexuellement transmissibles bactériennes en France.

Sexually transmitted infections (STIs) remains a major problem of public health in France. Voluntary networks of physicians (RésIST) and laboratories (Rénago, Rénachla, lymphogranuloma venereum: LGV network) produce indicators showing the evolution of the main bacterial STIs. In 2010, the main findings were the following. The number of gonococcal infections has increased throughout the decade 2000 to 2010. The decrease in susceptibility of gonococcal strains to first-line antibiotics (extended-spectrum cephalosporins) needs to keep great attention. The number of screening and diagnosis of chlamydial urogenital infections also continues to rise in both sexes, particularly due to increased screening among young people. The relatively stable number of cases of early syphilis and of rectal LGV needs to be confirmed over the coming years. Both of these STIs affect overwhelmingly homo/bisexual men. There is still a high level of HIV co-infection with LGV and syphilis, and to a lesser extent with gonorrhea. We observe that condom use is still inadequate, especially during oral sex.

Detection of human papillomavirus genotypes among high-risk women: a comparison of hybrid capture and linear array tests.

OBJECTIVES: To assess the concordance and performance of 2 different assays in detection of human papillomavirus (HPV) genotypes among women with abnormal Pap smear. STUDY DESIGN: A series of 575 women referred for colposcopy due to an abnormal Pap smear were analyzed with the Linear Array HPV Genotyping test detecting 37 HPV types and compared with Hybrid Capture II (HCII) assay for detection of carcinogenic HPV. Histologic outcomes of cervical intraepithelial neoplasia grade 2 (CIN2) or worse (CIN2+) and CIN3+ were the primary endpoints. Clinical performance, including receiver operating characteristics, was determined for both tests. RESULTS: HCII and linear array (LA) were concordant in 88.1% (433/491; 95% CI 85.3%-91.0%), having a substantial agreement with regular kappa (kappa = 0.70, 95% CI 0.62-0.77) and almost perfect agreement with weighted kappa (ICC = 0.82, 95% CI 0.7-0.85). In detecting CIN2+ and CIN3+, LA is 5% and 6% more sensitive but 9.5% and 8.7% less specific than HCII (area under ROC curve; P = 0.317 and P = 0.875, respectively). CONCLUSIONS: Performance of HCII and LA does not significantly differ in detecting CIN2+ or CIN3+.

Performance of the Roche AMPLICOR human papillomavirus (HPV) test in prediction of cervical intraepithelial neoplasia (CIN) in women with abnormal PAP smear.

OBJECTIVES: To assess the performance of a novel PCR-based assay (Roche AMPLICOR HPV test) in detection of cervical pathology as a part of management for abnormal PAP smear (MAPS) and in women participating in cervical cancer screening. STUDY DESIGN: Altogether, 504 women comprising 270 patients referred for colposcopy due to an abnormal Pap smear and another 234 women participating in cervical cancer screening (tested for comparison) were analyzed for oncogenic (HR) Human papillomavirus (HPV) types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68 using the Roche AMPLICOR HPV test in cervical samples collected in PreservCyt liquid media. Colposcopic biopsy and/or LEEP cone biopsy was used as the gold standard in the triage group, while liquid-based cytology (LBC) was the reference test in the screening group. RESULTS: The prevalence of HPV was significantly higher in the MAPS group (65.9%) than in the screening group (31.2%) (P = 0.0001). There was a poor concordance between the referral PAP and the current LBC, being only moderate in the screening series, ICC (weighted kappa) = 0.291 (95%CI 0.070-0.459) (P = 0.007), and almost poor in the MAPS Series, with ICC = 0.217 (95%CI 0.04-0.384) (P = 0.023). AMPLICOR HPV positivity increased linearly with the increasing grade of cervical lesions. In detecting high-grade (CIN2-3), colposcopy was the most sensitive test (96.5%), very similar to AMPLICOR (95.2%) (P = 0.731), while LBC with HSIL cutoff was by far the most specific test (99.5%) and showed the highest PPV (96.1%). NPV of colposcopy (97.2%) and AMPLICOR (96.7%) were similar (P = 0.839). Together with abnormal colposcopy and HSIL cytology, the AMPLICOR HPV test is a powerful independent predictor of high-grade CIN2-3, and as such suitable to replace cervical cytology in management of women with abnormal PAP test (MAPS). CONCLUSIONS: The Roche AMPLICOR HPV test is comparable to other HPV tests (HCII, PCR) in detecting CIN in MAPS. However, more data are clearly needed on the performance of AMPLICOR test in management of abnormal PAP and particularly as a screening tool.

Gonorrhoea surveillance system in France: 1986-2000.

OBJECTIVE: The objectives of this study were to monitor epidemiologic trends in Neisseria gonorrhoeae (NG) infections and to assess antimicrobial resistance patterns of NG. METHODS: RENAGO, a voluntary-based laboratory surveillance system, including private and public laboratories, was set up in France in 1986. Every NG strain isolated by the participating laboratories was sent to the National Reference Center, Institut Alfred Fournier, Paris, where susceptibility to 6 antibiotics was tested. These laboratories reported monthly numbers of positive NG isolates and associated epidemiologic data. Because the number of laboratories varied every year, the average number of NG isolates per laboratory per year was computed to monitor annual trends in gonorrhea incidence. RESULTS: The average number of NG isolated per laboratory per year decreased steadily from 10.6 in 1986 to 0.6 in 1997 but then yearly increased and reached 1.9 in 2000. Increasing gonorrhea was observed mostly in men and in the Paris area. The proportion of rectal strains increased significantly from 0.9% in 1986 to 9.2% in 2000. From 1998 to 2000, 5.3% of the isolates had reduced susceptibility or were resistant to ciprofloxacin, 7.3% were PPNG strains and 27.4% were resistant to tetracycline, 18.5% had a reduced susceptibility to thiamphenicol, and 1 strain was resistant to the latter. Neither strain was resistant to ceftriaxone or to spectinomycin. CONCLUSION: From 1998 to 2000, gonorrhea markedly increased in France and seemed to affect mainly gay men in Paris, which suggests relapses to risky sexual behaviors and highlights the need for strengthening prevention. During the same period, NG ciprofloxacin resistance has sharply increased and should be carefully monitored because of the wide use of ciprofloxacin single-dose treatment.