Linkage of Whole Genome Sequencing, Epidemiological, and Clinical Data to Understand the Genetic Diversity and Clinical Outcomes of Shigella flexneri among Men Who Have Sex with Men in England.

The public health value of whole genome sequencing (WGS) for Shigella spp. in England has been limited by a lack of information on sexual identity and behavior. We combined WGS data with other data sources to better understand Shigella flexneri transmission in men who have sex with men (MSM). WGS data for all S. flexneri isolates referred to the national reference laboratory were linked to i) clinical and behavioral data collected in seven of 21 health regions in England using a standardized exposure questionnaire and, ii) national HIV surveillance data. We included 926 S. flexneri isolates, of which 43.0% (n = 398) fell phylogenetically within two domestically circulating clades associated with genotypic markers of azithromycin resistance. Approximately one third of isolates in these clades were from people living with HIV, primarily acquired through sex between men. 182 (19.7%) isolates had linked questionnaire data; 88% (84/95) of MSM isolates fell phylogenetically within the domestically circulating clades, while 92% (72/78) of isolates from other cases fell within lineages linked with travel to high-risk regions. There was no evidence of sustained transmission between networks of MSM and the wider community. MSM were more likely to be admitted to hospital and receive antimicrobials. Our study emphasizes the importance of sex between men as a major route of transmission for S. flexneri. Combined WGS, epidemiological and clinical data provide unique insights that can inform contact tracing, clinical management and the delivery of targeted prevention activities. Future studies should investigate why MSM experience more severe clinical outcomes. IMPORTANCE Within the last 2 decades there have been an increasing number of Shigella spp. outbreaks among men who have sex with men (MSM) worldwide. In 2015, Public Health England (PHE) introduced routine whole genome sequencing (WGS) for the national surveillance of Shigella spp. However, the lack of information on sexual identity and behavior has hindered interpretation. Our study illustrates the power of linking WGS data with epidemiological, behavioral, and clinical data. We provide unique population-level insights into different transmission networks that can inform the delivery of appropriate public health interventions and patient management. Furthermore, we describe and compare clinical characteristics and outcomes of S. flexneri infection in MSM and other exposure groups. We found that MSM were more likely to be admitted to hospital and receive antimicrobials, indicating that their infections were potentially more severe. The exact reasons for this are unclear and require further exploration.

Gardnerella vaginalis in urinary tract infections, are men spared?

Gardnerella vaginalis in association with anaerobes has been linked to bacterial vaginosis in women, while urinary tract infections (UTIs) in men have rarely been reported. The aim of the review was to reveal the significance of G. vaginalis UTIs in men. Prevalence of G. vaginalis UTIs in men varied from 0.5 to >27% according to patients' groups. Most patients had comorbidity such as urolithiasis or stents, transplants, tumors and diabetes, however, infections can also affect immunocompetent patients. We observed G. vaginalis-associated bacteriuria and leukocyturia in a kidney transplant man. Complications of the UTIs such as bacteremia (in 9/11 cases), hydronephrosis (4/11) and abscesses or septic emboli have been reported. Bacterial vaginosis in female partners has been a risk factor for UTIs in males. In women, biofilm Gardnerella phenotype, stabilized by Atopobium vaginae and Prevotella bivia was linked to ≥6-fold higher antibiotic resistance rates compared with the planktonic phenotype. Non-susceptibility to metronidazole and levofloxacin was found also in males. Therefore, if aerobic urine cultures are negative, urine and blood samples from male patients with predisposing factors and clinical signs of UTIs and bacteremia, can be taken. Plates should be incubated for 2-4 days in capnophilic/microaerophilic conditions, however only anaerobic incubation can help with detecting G. vaginalis strains which grow only anaerobically. Susceptibility testing of the isolates is highly important. Briefly, adherent G. vaginalis phenotype can be sexually transmissible. Despite the infrequency of G. vaginalis UTIs in men, the infections should be considered since they are often linked to severe complications.

Changes in the prevalence of self-reported sexually transmitted bacterial infections from 2010 and 2017 in two large European samples of men having sex with men-is it time to re-evaluate STI-screening as a control strategy?

BACKGROUND/OBJECTIVES: Many European countries reported increased numbers of syphilis, gonorrhoea and chlamydia diagnoses among men who have sex with men (MSM) in recent years. Behaviour changes and increased testing are thought to drive these increases. METHODS: In 2010 and 2017, two large online surveys for MSM in Europe (EMIS-2010, EMIS-2017) collected self-reported data on STI diagnoses in the previous 12 months, diagnostic procedures, STI symptoms when testing, number of sexual partners, and sexual behaviours such as condom use during the last intercourse with a non-steady partner in 46 European countries. Multivariate regression models were used to analyse factors associated with diagnoses of syphilis, gonorrhoea/chlamydia, and respective diagnoses classified as symptomatic and asymptomatic. If applicable, they included country-level screening rates. RESULTS: Questions on STI diagnoses and sexual behaviours were answered by 156,018 (2010) and 125,837 (2017) participants. Between 2010 and 2017, overall diagnoses with gonorrhoea/chlamydia and syphilis increased by 76% and 83% across countries. Increases were more pronounced for asymptomatic compared to symptomatic infections. The proportion of respondents screened and the frequency of screening grew considerably. Condomless anal intercourse with the last non-steady partner rose by 62%; self-reported partner numbers grew. Increased syphilis diagnoses were largely explained by behavioural changes (including more frequent screening). Gonorrhoea/chlamydia increases were mainly explained by more screening and a change in testing performance. A country variable representing the proportion of men screened for asymptomatic infection was positively associated with reporting symptomatic gonorrhoea/chlamydia, but not syphilis. DISCUSSION/CONCLUSION: The positive association of country-level screening rates with the proportion of symptomatic infections with gonorrhoea/chlamydia may indicate a paradoxical effect of screening on incidence of symptomatic infections. Treatment of asymptomatic men might render them more susceptible to new infections, while spontaneous clearance may result in reduced susceptibility. Before expanding screening programmes, evidence of the effects of screening and treatment is warranted.

Symptoms, Sites, and Significance of Mycoplasma genitalium in Men Who Have Sex with Men.

During 2016-2017, we tested asymptomatic men who have sex with men (MSM) in Melbourne, Australia, for Mycoplasma genitalium and macrolide resistance mutations in urine and anorectal swab specimens by using PCR. We compared M. genitalium detection rates for those asymptomatic men to those for MSM with proctitis and nongonococcal urethritis (NGU) over the same period. Of 1,001 asymptomatic MSM, 95 had M. genitalium; 84.2% were macrolide resistant, and 17% were co-infected with Neisseria gonorrhoeae or Chlamydia trachomatis. Rectal positivity for M. genitalium was 7.0% and urine positivity was 2.7%. M. genitalium was not more commonly detected in the rectums of MSM (n = 355, 5.6%) with symptoms of proctitis over the same period but was more commonly detected in MSM (n = 1,019, 8.1%) with NGU. M. genitalium is common and predominantly macrolide-resistant in asymptomatic MSM. M. genitalium is not associated with proctitis in this population.

Effects of Sexual Network Connectivity and Antimicrobial Drug Use on Antimicrobial Resistance in Neisseria gonorrhoeae.

Contemporary strategies to curtail the emergence of antimicrobial resistance in Neisseria gonorrhoeae include screening for and treating asymptomatic infections in high-prevalence populations in whom antimicrobial drug-resistant infections have typically emerged. We argue that antimicrobial resistance in these groups is driven by a combination of dense sexual network connectivity and antimicrobial drug exposure (for example, through screen-and-treat strategies for asymptomatic N. gonorrhoeae infection). Sexual network connectivity sustains a high-equilibrium prevalence of N. gonorrhoeae and increases likelihood of reinfection, whereas antimicrobial drug exposure results in selection pressure for reinfecting N. gonorrhoeae strains to acquire antimicrobial resistance genes from commensal pharyngeal or rectal flora. We propose study designs to test this hypothesis.

Campylobacter fetus Cluster Among Men Who Have Sex With Men, Montreal, Quebec, Canada, 2014-2016.

From March 2014 to December 2016, a cluster of 13 cases of Campylobacter fetus intestinal and extraintestinal infections, including 2 patients with an aortic mycotic aneurysm, caused significant morbidity. The cluster likely resulted from sexual transmission between men having sex with men living in the greater Montreal area, Quebec, Canada.

Mycoplasma genitalium and Macrolide Resistance-associated Mutations in the Skåne Region of Southern Sweden 2015.

Mycoplasma genitalium is a sexually transmitted infection ordinarily treated with azithromycin. Emerging resistance to macrolide is linked to mutations in the 23S rRNA gene. We analysed the frequency of such mutations of M. genitalium isolates from patients that were symptomatic, and from sexual partners of symptomatic individuals, from October to December of 2015, in the Skåne Region of Sweden. Mutations were analysed by the use of DNA sequencing. Overall, 11.9% (145/1,311) and 17.0% (116/704) of females and males were positive for M. genitalium, respectively. Macrolide resistant mutations were detected in 13% (31/239) of M. genitalium isolates from first-test patient samples. Twenty-one (8.8%) and 10 (4.2%) of the isolates had point mutations of the 23S-gene at position 2072 and 2071, respectively. Two different M. genitalium isolates were detected simultaneously in two cases. In summary, we found a relatively low rate of macrolide-resistant M. genitalium in the region of Southern Sweden.

Can Social Network Analysis Help Address the High Rates of Bacterial Sexually Transmitted Infections in Saskatchewan?

BACKGROUND: Saskatchewan has one of the highest rates of gonorrhea among the Canadian provinces-more than double the national rate. In light of these high rates, and the growing threat of untreatable infections, improved understanding of gonorrhea transmission dynamics in the province and evaluation of the current system and tools for disease control are important. METHODS: We extracted data from a cross-sectional sample of laboratory-confirmed gonorrhea cases between 2003 and 2012 from the notifiable disease files of the Regina Qu'Appelle Health Region. The database was stratified by calendar year, and social network analysis combined with statistical modeling was used to identify associations between measures of connection within the network and the odds of repeat gonorrhea and risk of coinfection with chlamydia at the time of diagnosis. RESULTS: Networks were highly fragmented. Younger age and component size were positively associated with being coinfected with chlamydia. Being coinfected, reporting sex trade involvement, and component size were all positively associated with repeat infection. CONCLUSIONS: This is the first study to apply social network analysis to gonorrhea transmission in Saskatchewan and contributes important information about the relationship of network connections to gonorrhea/chlamydia coinfection and repeat gonorrhea. This study also suggests several areas for change of systems-related factors that could greatly increase understanding of social networks and enhance the potential for bacterial sexually transmitted infection control in Saskatchewan.

Differing Identities but Comparably High HIV and Bacterial Sexually Transmitted Disease Burdens Among Married and Unmarried Men Who Have Sex With Men in Mumbai, India.

BACKGROUND: Although HIV incidence has declined in India, men and transgender women who have sex with men (MSM) continue to have high rates of HIV and sexually transmitted disease (STD). Indian MSM face substantial pressures to marry and have families, but the HIV/STD burden among married Indian MSM is not well characterized. METHODS: A diverse sample of Indian MSM were recruited through respondent-driven sampling. Independent variables that produced a P value of 0.10 or less were then added to a multivariable logistic regression model. RESULTS: Most of the 307 MSM (95 married and 212 unmarried) recruited into the study were younger than 30 years, and less than one-third had more than a high school education. Almost two-thirds of the married men had children, compared with 1.4% of the unmarried men (P < 0.001). The numbers of condomless anal sex acts did not differ by marriage status. Although unmarried MSM more often identified themselves as "kothi" (receptive role), their rates of HIV or bacterial STD were similar to married MSM, with 14.3% being HIV infected. The respondent-driven sampling-adjusted prevalence of any bacterial STD was 18.3% for married MSM and 20% for unmarried MSM (not significant). Participants reported high levels of psychological distress, with 27.4% of married and 20.1% of unmarried MSM reporting depressive symptoms (not significant). CONCLUSIONS: Men who have sex with men in Mumbai had high rates of HIV, STD, and behavioral health concerns. Clinicians need to become more comfortable in eliciting sexual histories so that they can identify MSM who need HIV/STD treatment and/or prevention services.

Long-Lasting Outbreak of Erythromycin- and Ciprofloxacin-Resistant Campylobacter jejuni Subspecies jejuni From 2003 to 2013 in Men Who Have Sex With Men, Quebec, Canada.

From January 2003 to December 2013, sexual transmission of 2 clades of Campylobacter jejuni subspecies jejuni isolates resulted in a prolonged outbreak among men who have sex with men living in Quebec, Canada. The outbreak isolates were acquired locally and were resistant to erythromycin and ciprofloxacin.

Colonization with Escherichia coli Strains among Female Sex Partners of Men with Febrile Urinary Tract Infection.

Of 23 unique Escherichia coli strains from 10 men with febrile urinary tract infections (UTIs) and their female sex partners, 6 strains (all UTI causing) were shared between partners. Molecularly, the 6 shared strains appeared more virulent than the 17 nonshared strains, being associated with phylogenetic group B2, sequence types ST73 and ST127, and multiple specific virulence genes. This indicates that UTIs are sometimes sexually transmitted.

Prevalencia de la infección por Chlamydia trachomatis y factores de riesgo de infecciones transmisibles sexualmente en estudiantes universitarios / Prevalence of Chlamydia trachomatis infection and factors with the risk of acquiring sexually transmitted infections in college students

La infección genital por Chlamydia trachomatis es considerada en la actualidad una de las causas más frecuentes de infecciones transmisibles sexualmente (ITS) a nivel mundial y afecta principalmente al grupo de jóvenes menores de 25 años. El objetivo de este estudio fue determinar la prevalencia de la infección por C. trachomatis en alumnos ingresantes a la Universidad Nacional del Sur (Bahía Blanca, Argentina) y evaluar los factores de riesgo para la adquisición de ITS. Participaron en el estudio 204 jóvenes de edad media de 19 años, que remitieron una muestra de orina de primera micción y respondieron a una encuesta anónima. La investigación de C. trachomatis se realizó sobre 114 muestras válidas mediante una técnica de amplificación génica, cuyo blanco molecular es el gen ompA. Se detectaron 4 casos de infección por C. trachomatis, lo que implicó una prevalencia del 3,5 %. Los factores de riesgo que demostraron estar asociados con la adquisición de esta ITS fueron un historial de 7 o más parejas desde el comienzo de las relaciones sexuales y el contacto con una nueva pareja sexual en los últimos 4 meses. La prevalencia de infección por C. trachomatis reflejó una moderada circulación de este microorganismo en la población estudiada. Si bien algunos aspectos revelados en las encuestas sugieren una población de bajo riesgo para la adquisición de ITS en general, otros datos evidencian lo contrario y alertan sobre la necesidad de incrementar la vigilancia y desarrollar acciones de concienciación y prevención en esta población.

Chlamydia trachomatis genital infection is nowadays considered one of the most frequent causes of sexually transmitted infections (STI) in the world, mainly affecting the group of young people under 25 years old. The aim of this study was to determine the prevalence of C. trachomatis infection in newly admitted students to Universidad Nacional del Sur, Bahía Blanca, Argentina, and to evaluate the risk factors to acquire STI. For that purpose, 204 young college students with a mean age of 19 were involved in this study. Each participant delivered a sample of first-void urine and completed a questionnaire which was then submitted anonymously. The research for C. trachomatis was done on 114 valid samples through a technique of DNA amplification, whose molecular target was the gene ompA. Four cases of infection by C. trachomatis were detected with a prevalence of 3.5 %. The risks factors associated to the infection were a history of 7 or more partners since the start of sexual activity and contact with a new sexual partner in the last 4 months. The prevalence of such infection reflects a moderate circulation of this microorganism in the studied population. This fact, along with some aspects shown by the questionnaire results, would characterize a population having a low risk profile for acquiring STIs. However, some other information obtained from the questionnaires gave some opposite evidence, which would alert us on the need of keeping watch, raising awareness and implementing preventive actions in this population.

[Prevalence of Chlamydia trachomatis infection and factors with the risk of acquiring sexually transmitted infections in college students]. / Prevalencia de la infección por Chlamydia trachomatis y factores de riesgo de infecciones transmisibles sexualmente en estudiantes universitarios.

Chlamydia trachomatis genital infection is nowadays considered one of the most frequent causes of sexually transmitted infections (STI) in the world, mainly affecting the group of young people under 25 years old. The aim of this study was to determine the prevalence of C. trachomatis infection in newly admitted students to Universidad Nacional del Sur, Bahía Blanca, Argentina, and to evaluate the risk factors to acquire STI. For that purpose, 204 young college students with a mean age of 19 were involved in this study. Each participant delivered a sample of first-void urine and completed a questionnaire which was then submitted anonymously. The research for C. trachomatis was done on 114 valid samples through a technique of DNA amplification, whose molecular target was the gene ompA. Four cases of infection by C. trachomatis were detected with a prevalence of 3.5%. The risks factors associated to the infection were a history of 7 or more partners since the start of sexual activity and contact with a new sexual partner in the last 4 months. The prevalence of such infection reflects a moderate circulation of this microorganism in the studied population. This fact, along with some aspects shown by the questionnaire results, would characterize a population having a low risk profile for acquiring STIs. However, some other information obtained from the questionnaires gave some opposite evidence, which would alert us on the need of keeping watch, raising awareness and implementing preventive actions in this population.

Chlamydia trachomatis related knowledge and practices in medical practioners--a survey.

INTRODUCTION: Chlamydia trachomatis is a frequently encountered condition by general physicians, urologists and infectious diseases specialists. It can affect both genders and causes significant morbidity if not treated properly and promptly. In addition, it can cause ophthalmia neonatorum, which manifests as neonatal conjunctivitis in the newborns. METHODOLOGY: The data was collected from fourteen tertiary care hospitals in two provinces of Pakistan during the time period of four months (September-December 2013). Inclusion criteria included all medical practitioners working at those hospitals and there were no limitations of age and gender to participate. The participants were approached through email which included a self administered questionnaire. Written consent was obtained from the participants and the study was approved by the ethical committee of all selected hospital. RESULTS: Overall 130 participants participated with a response rate of 65%. Females were 52.3% and males were 47.7%. In the study 17.7% of male and 29.4% of female participants proclaimed that they referred a patient to an infectious disease specialist in case the diagnosis of Chlamydia was dubious. 72.5% of the male and 55.8% of the female medical practitioners indicated that they yield detailed sexual history from the patients with Chlamydia. Regarding inquiring about the drugs history from the patient at risk of STDs, 22.6% male and 35.3% of female participants informed that they took a detailed drug history. Only 1.5% of the female medical practitioners notified Chlamydia to the partner of diseased patient themselves (provider referral). 24% male and 17.6% female participants had an understanding regarding the definite test of diagnosis for sexually transmitted Chlamydia. CONCLUSION: More sexual health skills development is required in medical practitioners working in Pakistan. The major deficient areas are sexual and drug history taking, management of sexually transmitted diseases and partner notification.

Recent progress in understanding the epidemiology of bacterial vaginosis.

PURPOSE OF REVIEW: Bacterial vaginosis epidemiology has been transformed by new theoretical insights and methodologies, such as molecular sequencing. We summarize the progress made in these domains. RECENT FINDINGS: The vaginal microbiome can be classified in five to eight clusters. Bacterial vaginosis-type clusters typically constitute one of these clusters, but in higher risk women, it can constitute up to three clusters. The vaginal microbiomes may be fairly stable or be subject to rapid changes in their constitutive makeup. Bacterial vaginosis does not appear to be a single entity. Certain bacterial communities are associated with particular symptoms of bacterial vaginosis that are paired with unique adverse outcomes. Biofilm-producing Gardnerella vaginalis are likely to play an important role in initiating the structured polymicrobial biofilm that is a hallmark of bacterial vaginosis. SUMMARY: Longitudinal studies currently underway should help elucidate how to best define bacterial vaginosis and its subtypes. Risk factors and outcomes associated with particular bacterial vaginosis subtypes should also be further clarified through these studies.

Sex, lies, and gastrointestinal tract biopsies: a review of selected sexually transmitted proctocolitides.

There are many insults that result in gastrointestinal tract inflammation. Infections can be particularly challenging because (1) only a limited number of organisms provoke a specific endoscopic and/or histologic appearance; and (2) although some organisms may be present on biopsies, the findings may be so subtle or organisms so few that they are easily missed if the reviewer is not performing a specific search for the offender. Sexually transmitted infections (STI) are rarely a consideration at the time of GI biopsy examination and clinicians rarely inquire about sexual behavior at the time of initial patient interview. Although establishing a definitive STI diagnosis is not possible on histology alone, these infections are associated with inflammatory patterns that may help raise this diagnostic possibility. Becoming familiar with these patterns is necessary as worldwide outbreaks of these infections are being reported. This review aims to provide the pathologist with histologic clues associated with the most frequently encountered bacterial pathogens in the setting of STI proctitis, namely, Chlamydia trachomatis, Neisseria gonorrhoeae, and Treponema pallidum.

Vaginal microbiota and viral sexually transmitted diseases.

Healthy vaginal microbiota is an important biological barrier to pathogenic microorganisms. When this predominantly Lactobacillus community is disrupted, decreased in abundance and replaced by different anaerobes, bacterial vaginosis (BV) may occur. BV is associated with prevalence and incidence of several sexually transmitted infections. This review provides background on BV, discusses the epidemiologic data to support a role of altered vaginal microbiota for acquisition of sexually transmitted diseases and analyzes mechanisms by which lactobacilli could counteract sexually transmitted viral infections.