214 e-Letters

  • Food for thought in PID treatment

    The study by Dean et al. (1) on the treatment of PID was complicated and thought-provoking. Could it be that "mild" PID comprised many cases that were not PID at all? This issue bedevilled studies in the past, so why not here? Am I right in thinking that randomisation was used to try to maintain an evenness of disease severity between the two treatment arms, that is standard (SoC) with ofloxacin plus metronidazole, and an intervention arm (IA) with intramuscular ceftriaxone plus azithromycin and metronidazole? This is an important point when the outcome of each arm is to be compared. Presumably, after diagnosis treatment began without delay, not waiting for the results of microbiological tests which, in fact, showed M.genitalium in about 10% of cases in each arm, a proporttion seen by others (3) in acute PID. Standard treatment was judged to be slightly superior to the alternative treatment. Tests of microbiological cure 6 to 8 weeks after the study started showed a few azithromycin- resistant cases of M.genitalium, roughly comparable in the two arms. Not being aware of this at the start of treatment seems excusable. The reader must also realize that it was a situation experienced up to 9 years ago before an abrupt termination of the study. Today the scene is different, resistance of M.genitalium to azithromycin and other antibiotics being common (4). It has become clear that M.genitalium should be sought early followed rapidly by treatment guided by nothing othe...

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  • Comment on “Is COVID-19 affecting the epidemiology of STIs? The experience of syphilis in Rome”

    Dear editor,
    We thank Dr. Latini et al. for providing the data for the potential effects of SARS-CoV-2 pandemic on sexual lifestyle and epidemiology of sexually transmitted infections (STIs).1 In the study the author highlighted the importance to check the lasting effects of SARS-CoV-2 on STIs. As China is the first country to generally alleviate lockdown of most cities since beginning of April and the returns to usual lifestyle for nearly 6 months, we’re able to tract the epidemiology of STIs during the post-outbreak period in China.
    According to the monthly report disclosed by Chinese Center for Disease Control and Prevention (Accessed from http://www.nhc.gov.cn/jkj/pqt/new_list.shtml), during the lockdown period of the first quarter, the number of newly diagnosed cases of HIV, syphilis and gonorrhea were 9695, 102273 and 16439, which reduced substantially by 27.3%, 19.3% and 38.2% compared to the previous year. After lockdown alleviation, the number of new cases returned, but not exceeding the previous years. The total new cases of HIV, syphilis and gonorrhea changed by -4.4%, -5.6% and -18.9% in the second quarter and -7.8%, -9.5% and +0.7% in the third quarter compared with 2019, respectively. As the number of new STIs in China is constantly growing in the past years, the reduction of new cases of STIs in 2020 after lockdown alleviation indicates a lasting effect of SARS-CoV-2. This may result from...

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  • Management of asymptomatic Mycoplasma genitalium to mitigate the threat of drug resistance

    Peter J White, MRC Centre for Outbreak Analysis & Modelling and NIHR Health Protection Research Unit in Modelling and Health Economics, Imperial College London.
    Other Contributors:
    Joanna Lewis, MRC Centre for Outbreak Analysis & Modelling, Imperial College London.
    Paddy J Horner, Population Health Sciences, and NIHR Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol.

    Pitt et al. commented “asymptomatic patients are not recommended for M. genitalium testing except sexual contacts... The current approach might need rethinking if asymptomatic infections are found to be an important reservoir for AMR and/or a source of infection and disease”.[1]
    Recent analysis of the POPI cohort found 4.9% (95%CrI 0.4%–14.1%) of M. genitalium infections in women progressed to pelvic inflammatory disease, compared with 14.4% (5.9%–24.6%) of Chlamydia trachomatis infections.[2] Combined with its lower prevalence this means that M. genitalium is a much less important cause of disease in women than C. trachomatis.[2]
    There is considerable uncertainty in the natural history and epidemiology of M. genitalium,[3] and we don’t know the importance of asymptomatic infection in transmission. Low bacterial load might limit infectivity but a long duration of infection[2,3] means there may be many potentially-infectious sex-acts. In fact, the BASHH guidelines are motivated by concern about transmission from asymptomatic...

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  • Authors response to Loebers eLetter

    We apologise for the delay in responding to your letter. We were only recently notified of this by email. Thank you for taking the time to construct your letter in response to our published short report, to which you raise several points which require addressing.

    Firstly we feel it is important to highlight that although this service evaluation focussed specifically on HIV, we acknowledged that the HIV sampling kit was part of a more comprehensive STI kit (syphilis, chlamydia, and gonorrhoea tests). We were upfront with this fact in our report, and therefore refute the claim by the responder that our paper failed to consider the wider test portfolio required by sexual health screening services.

    Of greater concern to us, we note a major error in the calculations from the data provided by the responders for their “RRR” and “HIV result obtained/ STI kit requested” values. This is important, as the foundation of their concluding statement is based on this error. The responder's have incorrectly used the number of returned kits (256,717) instead of the number of requested kits (319,485) in calculating the RRR (request-to-return ratio) and the “HIV result obtained/STI kit requested” proportion. Applying the correct calculation, the RRR value using the responder's data is not 1.36 (256,717/188,187) but 1.70 (319,485/188,187). The “HIV result obtained/STI kit requested” proportion using the correct calculation is 58.9% (188,187/319,485) and not 73.3%...

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  • 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