210 e-Letters

  • Opportunities for behavioral intervention post-treatment for syphilis

    Ang et al [1] discussed rising syphilis incidence among HIV positive men in Singapore. The diagnostic test used for syphilis in this study (RPR) is a non-specific treponemal antibody test. This limitation should be acknowledged while interpreting results. However, it is of good epidemiological value for public health programs for behavioural intervention. An important opportunity for sexual health promotion that can be missed if overlooked is post-treatment follow up for RPR titre monitoring. BASHH guidelines recommend follow up RPR titre post treatment until sero-fast or sustained 4 fold decrease in titre (at 3, 6 and 12 months).
    An audit at our central London clinic showed that 31% of men had a bacterial STI when followed up for RPR monitoring post-treatment for syphilis [2]. Of 32 men (mean age 37 years; range 21- 75 years; 31 MSM), 11 were HIV positive. Six patients attended follow up visits at 3,6, and 12 months post treatment , 9 attended two follow up visits , 6 attended one follow up visit. Ten (31%) had a bacterial STI diagnosis (6 Chlamydia, 6 Gonorrhea, 1 LGV) during follow up. This highlighted the importance of STI screening and sexual health promotion for the MSM cohort during follow up for RPR monitoring in our clinic. Opportunistic screening for STI should be conducted across the globe where resources permit.

    [1] Ang LW, Wong C, Ng O et al. Incidence of syphilis among HIV-infected
    men in Singapore, 2006–2017: temporal tren...

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  • Mixed and mono-infections in non-gonococcal infections

    The paper by Jordan SJ et al (1) is thought stimulating. The CDC guideline to regard 2-4 PMN/HPF as depicting NGU is possibly not widely observed, despite having been said 5 years ago (2). This and the inference that 1 or <1 PMN/HPF means no NGU must put a strain on those counting and poses the question of what variation might exist between observers.
    When 5 different micro-organisms were sought but not found in urethritis, the invitation was there to consider the role of oral and anal bacteria and those occurring in BV. An association between this and NGU has been noted in the past (3). Unfortunately it was not taken into account here. It is also curious that when looking at the role of Ureaplasma species, the authors did not consider U.parvum. Admittedly, others have considered it to be less important than U.urealyticum (4) but not banished it to the graveyard completely.
    Finally, the issue of bacterial load is important in considering pathogenicity. The authors state that they used quantitative PCRs but they did not provide ANY quantitative results. Why is that? These and longitudinal studies are required.
    I believe the conclusion of the authors is not fully founded. Remember, Koch's postulates have been fulfilled for U.urealyticum (5).
    1. Jordan SJ, Toh E, Williams AJ, et al. Aetiology and prevalence of mixed-infections and mono-infections in non-gonococcal urethritis in men: a case-control study. Sex Transm Inf 2020;...

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  • Syphilis proctitis in Men who have sex with men: Response to Richardson et al

    We thank Richardson et al., for their response to our recent publication titled “Proctitis in gay and bisexual men. Are microscopy and proctoscopy worthwhile?”[1]. The authors have previously reported findings of men who have sex with men (MSM) with proctitis, highlighting the polymicrobial nature of proctitis and symptomatic presentations with negative nucleic acid amplification testing (NAAT). However, they observed 8% (6/78) of MSM had syphilis proctitis based on NAAT from rectal mucosa[2] in contrast; we did not identify any.

    Our study and the Richardson study have three main differences. Firstly, in our study, only a small proportion of MSM were tested for rectal syphilis (10.5% (16/154), and all patients were syphilis NAAT negative. Data on syphilis serology was not collected. As per our local guidelines, NAAT for rectal syphilis is based on clinical signs. None of our remaining patients had an appropriate history or clinical signs (ulcers) which would have triggered targeted NAAT for anorectal syphilis.

    Secondly, 43% of GBM in our study were using pre-exposure prophylaxis (PrEP)and undergoing three monthly serological screening for Human Immunodeficiency Virus (HIV) and syphilis delivered as part of comprehensive sexually transmissible infections (STIs) and PrEP package. We postulate that this may have had a “protective” benefit against ‘symptomatic rectal syphilis”, through frequent STI testing or treatment of sexual contacts and engagement with heal...

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  • 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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  • TPPA test accuracy matters

    Although we agree with Ghanem et al. that CSF TPPA titer is a valuable test for the diagnosis of neurosyphilis[1], we would like to emphasize that a cut-off TPPA titer should be recommended with caution as proposed by others [2]. Such semi-quantitative laboratory tests may vary depending on the operator or reagent. Our IQC from a single patient during a 2 years period showed that TPPA inaccuracy is about 2 titers (Table). Moreover, a 2 log2 variation is accepted by organisms providing samples for external quality assessment for syphilis serology [3]. Similarly to what occurs with neuroborreliosis, quantifying anti-treponema pallidum IgG (antiTp- IgG) in CSF, immunoassays in serum and intrathecal antibodies index could be a reliable approach for the diagnosis of neurosyphilis. We found some positive antiTp-IgG index in CSF with TPPA titers below 320, suggesting an intrathecal synthesis of anti-treponema pallidum IgG. The diagnosis of neurosyphilis still lacks a gold standard test and further research is warranted. 1. Ghanem, K.G., Cerebrospinal fluid treponemal antibody titres: a breakthrough in the diagnosis of neurosyphilis. Sex Transm Infect, 2020.
    2. Marra, C.M., et al., Cerebrospinal Fluid Treponema pallidum Particle Agglutination Assay for Neurosyphilis Diagnosis. J Clin Microbiol, 2017. 55(6): p. 1865-1870.
    3. Muller, I., et al., Is serological testing a reliable tool in laboratory diagnosis of syphilis? Meta-analysis of eight external quality control sur...

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  • ?? Similar article published a few years ago

    Dear Editor, I am a contraception doctor working in the UK who reads STI. I have an interest in education. I read Dewsnap et al's publication in this months journal and am shocked as it is almost identical to one from a few years ago. Surely this is blatant Plagiarism although one of the authors is the same. Does the BMJ group know this? is this allowed in the BASHH column. Does BASHH know? does the previous author who wrote the original know (? David Richardson?)

    This should be addressed with COPE?

    Yours Marie


    Please note that this article is almost identical to one written by Daniel Richardson and colleagues in 2017? Did you not use anti plagiarism software? I am an editor of another journal but have keen interest in sexual health and the journal. I am shocked that this has been allowed to go to publication an print. I do not know Daniel Richardson, but they should be informed and action should be taken by you or the BMJ group.

  • Cross-sectional study of patients tested for STIs using molecular methods in Brazil

    Dear David Taylor-Robinson,

    We are very grateful with your contribution.

    It was a study that we evaluated the incidence of these pathogens on population that had done the molecular test to IST in a big laboratory in Brazil, this is only an epidemiological study. The microorganism have been chosen according availability of tests offered, so it was not evaluated the pathogenicity of each microorganism. Besides that our objective is only describe the profile of brazilian population, and did not correltated any data with clinical treatment. The molecular technology in Brazil is used as confirmatory of clinical diagnostic. The microorganism incidence in Brazil could be different from others countries due to characteristics of our population.

    Best regards.

    Danielle Alves Gomes Zauli

  • 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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