eLetters

203 e-Letters

  • Re: Management of Mycoplasma genitalium infection in general population with low macrolide resistance rates

    We thank Piñeiro et al for their interest in our study using data from Britain’s third National Survey of Sexual Attitudes and Lifestyle (Natsal-3).1 This was a probability sample survey undertaken in 2010-12, with Mycoplasma genitalium testing results from urine available for over 4,500 participants aged 16-44 years.2 In this follow-up paper, we reported genotypic data on mutations associated with macrolide and fluoroquinolone resistance.

    We read with interest that Piñeiro et al also found relatively low levels (<20%) of macrolide resistance in a Spanish, mainly general population sample in 2014-17.3 However, the low macrolide resistance (16%) found in our study is probably due not only to the general population sample, but also to the specimens being collected nearly a decade ago. Since 2010-12, there is evidence that macrolide resistance in M. genitalium has rapidly increased globally, and we anticipate finding higher levels of genotypic macrolide resistance in the general population in Britain in 2022 when Natsal-4 is expected to report findings.4 These data will be important to inform national and international understanding of incidence and prevalence as well as updated management and infection control strategies.

    We appreciate both the relatively low treatment failure rate in the referenced Spanish study by Piñeiro et al,3 and the treatment strategy...

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  • Syphilis proctitis in Men who have sex with men: response to Mwasakifwa GE et al

    We read with interesting the recent report by Mwasakifwa and colleagues demonstrating that presence of mucopurulent ano-rectal discharge on clinical examination was associated with identification of a sexually transmitted organism by NAAT testing in men who have sex with men (MSM) with symptomatic proctitis.1 We also showed that sexually transmitted proctitis in MSM is often associated with more than one organism and that even with sensitive NAAT testing, there are a significant proportion of cases of MSM with proctitis with negative microbiology tests.2 We were however surprised that Mwasakifwa and colleagues did not identify any cases of syphilis in their analysis. This may have been because syphilis PCR testing was only conducted in a small proportion of cases? Ano-rectal syphilis was first described between 1945-1966 although most of these cases had anal ulceration with pain on defecation. Syphilis ‘proctitis’ was first described in 1975 from the USA in a man with rectal pain and discharge.3 In our series of MSM with proctitis, we reported 6/78(8%) cases of syphilis based upon PCR testing from the rectal mucosa during proctoscopy.2 The recent increase in infectious syphilis particularly in MSM is likely to increase the number of cases of ano-rectal syphilis. The clinical features of syphilis as the epidemic evolves may be changing and more MSM are presenting with painful lesions than was previously believed. We do agree that clinical examination of the ano-rectal area...

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  • Management of Mycoplasma genitalium infection in general population with low macrolide resistance rates

    Dear Editor,

    We have read the interesting manuscript “Antimicrobial resistance in Mycoplasma genitalium sampled from the British general population”, from Pitt et al.1 In 56 M. genitalium-positive specimens, macrolide resistance was detected in 9 (16.1%). These results agree with the low rate of resistance (<20%) detected in studies carried out mainly in general population,2 but contrast with the higher rates (>40%) obtained in patients mainly attended in sexually transmitted infections units.3 These two scenarios (general versus core population) could be considered in the management of the M. genitalium infection.
    In our context (80-90% general population), the macrolide resistance rate was 16.3% (43/263).2 After detection of macrolide resistance-associated mutations with rapid techniques, guided antibiotic therapy was prescribed (azithromycin 500 mg day 1 and 250 mg days 2-5, or moxifloxacin) , and sexual partners control and test of cure after 3 weeks recommended. Despite patients adhering to the antibiotic regimen initially indicated, treatment failure was 6%.
    Recently, a resistance-guided sequential treatment with doxycycline followed with azithromycin or moxifloxacin has been proposed.3 In this study the macrolide resistance rate was 68% and the treatment failure 7%. In our opinion, this strategy could be appropriate in populations with high macrolide resistance rate (main conclusion of this study), and healthcare contexts in that guided ther...

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  • Testing for STIs in Brazil using molecular methods

    The Research Letter by Marinho FL and Zauli D (1) is interesting, but it raises several contentious issues. Understanding the prevalence of genital-tract micro-organisms that constitute the genital microbiome (2) is important (3) and the authors were concerned with this in respect of six micro-organisms that were detected by a molecular method (PCR). Whether they give them equal weight so far as pathogenicity is concerned is unclear because they did not relate them to any specific clinical disease. We appreciate that any micro-organism mentioned, including U. urealyticum, might have pathogenic potential under certain circumstances (4), but finding U. urealyticum as the most prevalent (62.47%) followed by M. hominis (9.31%) does not elevate their status as pathogens and raises clinically important questions of whether these micro-organisms, including U. parvum, should be tested for at all in a diagnostic procedure, unless part of a research programme, and, if tested, whether such positive results justify treatment. Admittedl the authors do not expressly state that, on the basis of a positive test result, patients would be treated automatically with antibiotics. Nevertheless, we must emphasize that the use of antibiotics in many such cases would seem inappropriate, not least because it might promote antibiotic resistance, sometimes in microbes of undoubted importance, such as N. gonorrhoeae and M. genitalium (6). Modern molecular technology is a boon, but it must not be al...

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  • Jarisch–Herxheimer reaction during treatment of congenital syphilis

    Sir,

    We read with interest the informative Short Report by Wang et al. about Jarisch–Herxheimer reaction during therapy of congenital syphilis [1] and wish to make a few comments:

    1. The authors included in their review all patients hospitalized between 1 January 2010 to 31 November 2015. However, no such date like 31 November 2015 actually exists.

    2. Authors state that 'rapid pulse and breathing' were present in all 11/11 patients of Jarisch–Herxheimer reaction. However, they have not stated the age of these patients in the study. 'Pulse and breathing' are age-dependent variables, and in neonates pulse rate may be up to 120 to 160 beats per minute, and breathing up to 40 to 60 breaths per minute. Therefore, it is important to see how many of the Jarisch–Herxheimer reaction cases were neonates as in many of these case, pulse and respiratory may be within normal range.

    3. The recommended duration of treatment for congenital syphilis is 10 days and not 14 days as followed in this study [2].

    References:

    1. Wang C, He S, Yang H, Liu Y, Zhao Y, Pang L. Unique manifestations and risk factors of Jarisch-Herxheimer reaction during treatment of child congenital syphilis. Sex Transm Infect. 2018 Dec;94(8):562-564.

    2. CDC 2015 Sexually Transmitted Diseases Treatment Guidelines. Congenital syphilis. Available at https://www.cdc.gov/std/tg2015/congenital.htm...

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  • Error in the calculation of person-time in the before-PrEP period by Beymer et al.

    Error in the calculation of person-time in the before-PrEP period by Beymer et al.

    S.H. Hulstein, E. Hoornenborg,  M.F. Schim van der Loeff

    Department of Infectious Diseases, GGD Amsterdam

    Studies on STI incidence and PrEP use are often hampered by the absence of STI incidence data in the period before PrEP; Beymer et al.1  set out to improve on this. They report on the STI incidence before and after initiation of PrEP in a cohort of men who have sex with men (MSM) at the Los Angeles LGBT Center, California, US. We fear that there are some flaws in the analysis, which may affect the conclusions.

    The analysis was based on 275 men who were tested at least once in the period before PrEP was started, and at least once after PrEP was started. The reported persontime in the before- PrEP period was just over half the person-time after PrEP initiation (93.60 versus 168.93), but the numbers of tests before and after PrEP initiation were not very different: 755 and 908, respectively. This discrepancy could not be explained by differences in their frequency of STI testing, which were reported to be similar in the before- and after-PrEP period. An explanation  is that the person-time before the first STI visit was not taken into account. This would mean that the person-time in the before-PrEP period was underestimated, in turn leading to an artificially high before-PrEP STI incidence....

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  • Research on Mycoplasma genitalium is more important than expanding testing

    Prevalence of Mycoplasma genitalium

    Response to: Taylor-Robinson D and Ong J

    Authors: Nicola Low, Lukas Baumann, Manuel Cina, Myrofora Goutaki, Hammad Ali, Dianne Egli-Gany

    Correspondence to: Nicola Low, Professor of Epidemiology and Public Health, Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland. nicola.low@ispm.unibe.ch; Tel: +41 31 631 30 92

    Title: Research on Mycoplasma genitalium is more important than expanding testing

    We are glad that Taylor-Robinson and Ong offer some support for the conclusion of our systematic review,1 that asymptomatic populations, in the community or in clinics, should not be tested routinely for M. genitalium. The first British Association of Sexual Health and HIV (BASHH) guideline about the management of Mycoplasma genitalium, published on 8th July 2018, supports this conclusion.2 We would like to clarify, however, that the absence of evidence for clinical and public health benefit of screening3 and the harm of inducing de novo mutations and spreading resistance to macrolide antimicrobials4 are more important than economic considerations.

    Taylor-Robinson and Ong’s statement that “testing worldwide should continue to support or modify this conclusion”5 could lead to pro...

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  • Prevalence of Mycoplasma genitalium

    The work by Baumann et al.(1) is valuable because it indicates populations for which screening for Mycoplasma genitalium (MG)) is not worthwhile economically. However, as molecular detection tests are now available commercially, testing worldwide should continue to support or modify this conclusion and so help in the development of management guidelines and also provide data for MG modelling.
    Another aspect of infection which requires more attention is the precise role of MG in balanoposthitis, epididymitis,, chronic prostatitis, reactive arthritis, and, of course, pelvic inflammatory disease, all of which, apart from chronic prostatitis, have some association with MG (2).
    In addition, it is noteworthy that Mycoplasma pneumoniae (MP), which infects the respiratory tract, and is also responsible for some autoimmune side effects, does so in early childhood without causing disease. The latter usually occurs as an immunological response to reinfection later in life. MG is different genomically from MP but has much in common antigenically and might behave in a similar way to MP. Could asymptomatic MG infection, which is seen occasionally, be an example of this? Potentiation or even inhibition of MG infection in the genital tract by MP infection in the respiratory tract earlier in life is also possible. This idea is not supported by studies in mice, but the human situation might be quite different. In this regard, use of an existing specific serological test for MG m...

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  • Response to van Aar et al.

    Dear Editor,

    We read with interest the short report by van Aar et al. discussing potential implications of chlamydia expedited partner therapy (EPT) which entails patient delivered partner therapy.1 The authors highlight a number of factors which may influence the benefit-risk balance of providing EPT, many of which resonate with our experience of Accelerated Partner Therapy (APT).2 APT is an adaptation of EPT, which includes a telephone consultation between the sex partner and prescriber (to meet UK prescribing guidance), provision of a self-sampling kit for sexually transmitted infections (STIs) and HIV for a sex partner in addition to antibiotics and information on STIs and HIV. APT has been piloted among predominately heterosexual contacts of chlamydia and gonorrhoea.3

    The authors report a chlamydia positivity rate of 34.2% among chlamydia-notified partners in the Netherlands and proposed that the use of EPT for all contacts risks exposing the majority of contacts to potentially unnecessary antimicrobial therapy. Furthermore, just over 1% of these contacts also had gonorrhoea, accounting for about 10% of all gonorrhoea infections detected during the study time period, raising additional concerns about inadequate therapy and antimicrobial resistance.

    In England in 2016, chlamydia positivity among chlamydia contacts attending specialist sexual health services (SHS) was 40%, representing 19% of all chlamydia diagnoses made in SHS that year.4 This is...

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  • Impact of Expedited Partner Therapy (EPT) Implementation on Chlamydia Incidence in the USA

    Impact of Expedited Partner Therapy (EPT) Implementation on Chlamydia Incidence in the USA
    Letter to the Editor:
    Assuming that a sexual partner has only one Sexually Transmitted Infection (STI) is a dangerous practice and should be discouraged. The Expedient Partner Therapy implementation on Chlamydia is one such assumption. In a study conducted by (Zemouri, Wi, Kiarie, Seuc, Moqasale et.al 2016) they highlighted that Sexually Transmitted Infection (STI) case management is one of the top priorities in controlling STIs to break the chain of infection and transmission. They further reiterated that Syndromic case management provides a standardized evidence-based approach using clinical management algorithms, and flowcharts that can be used consistently across providers. Clinicians that treat patients with STIs should be cognizant that Expedited Partner Treatment is inadequate because there is at least a third infected sexual partner other than the partner being treated.
    Another factor that should be considered when administering Expedited Partner Therapy is the possibility, of the partner, manifesting other symptoms of a STI to be treated that has not yet been identified in the patient. It is useful to administer the risk score test which is a 6 point research base quiz to each patient being treated for STI. These questions can only be answered by the patient for it to be considered reliable. Each question has a number of points assigned to potential ans...

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