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...
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 surveys performed by the german infection serology proficiency testing program. J Clin Microbiol, 2006. 44(4): p. 1335-41.
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?)
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.
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.
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...
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, including proctoscopy is a vital skill for sexual health clinicians and in the age of self-taken samples: we need to continue to teach and maintain this skill. Whether syphilis causes a true proctitis or ulceration of the anal canal remains debatable and is difficult to distinguish clinically, however we recommend that all MSM presenting with proctitis are tested for Syphilis using both PCR testing and serology.
1. Mwasakifwa GE, Nugent C, Varma R.Proctitis in gay and bisexual men. Are Microscopy and proctoscopy worthwhile? Sexually Transmitted Infections 2020 (online first)
2. Pinto Sander N, Fitzpatrick C, Parkes L, Richardson D. Sexually transmitted proctitis in men who have sex with men. Sexually Transmitted Infections 2019;95:471.
3. Nazemi MM, Musher DM, Schell RF, Milo S. Syphilitic proctitis in a homosexual JAMA 1975;231(4)389
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...
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 therapy could not be rapidly applied. On the other hand, adherence and adverse events associated with antibiotics used should be keeping in mind: 89.9% with doxycycline versus 100% with azithromycin, and 15.2% versus 8.6% , respectively.3 Moreover, other authors have described a lower adherence to doxycycline (100 mg/12h, 7 days) in M. genitalium infections and a clinical response <50%.
We think sequential resistance-guided therapy results should be more studied in the real medical practice, taking in care the different contexts of the population studied (general population versus core groups with more previous antibiotic treatments), as well as non-compliance and secondary effects due to unnecessary overtreatment with doxycycline in macrolide susceptible infections.
References
1. Pitt R, Unemo M, Sonnenberg P, Alexander S, Beddows S, Cole MJ, Clifton S, Mercer CH, Johnson AM, Ison CA, Field N. Antimicrobial resistance in Mycoplasma genitalium sampled from the British general population. Sex Transm Infect. 2020. pii: sextrans-2019-054129. doi: 10.1136/sextrans-2019-054129.
2. Piñeiro L, Idigoras P, de la Caba I, López-Olaizola M, Cilla G. Guided antibiotic therapy for Mycoplasma genitalium infections: Analysis of mutations associated with resistance to macrolides and fluoroquinolones. Enferm Infecc Microbiol Clin. 2019;37(6):394-7.
3. Read TRH, Fairley CK, Murray GL, Jensen JS, Danielewski J, Worthington K, Doyle M, Mokany E, Tan L, Chow EPF, Garland SM, Bradshaw CS. Outcomes of Resistance-guided Sequential Treatment of Mycoplasma genitalium Infections: A Prospective Evaluation. Clin Infect Dis. 2019;68(4):554-60.
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...
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 allowed to foster unwanted outcomes.
References
1). Marinho FL, Zauli D. Cross-sectional study of patients tested for STIs using molecular methods in Brazil. Sex Transm Infect. Published
Online First: 26 Dec.2019. doi: 10.1136/sextrans-2019-054362
2). Taylor-Robinson D, Horner P, Pallecaros A. Understanding the terms we use: support for using 'Sexually Shared Microbiota' (SSM). Int J STD
& AIDS. 2020 Jan 16. doi. org/10.1177/09564624. 19885780
3). Taylor-Robinson D, Horner P, Pallecaros A. Diagnosis of some genital-tract infections: part 2. Molecular tests and the new challenges. Int J
STD & AIDS. In press
4). Beeton ML, Payne MS, Jones L. The role of Ureaplasma spp. in the development of nongonococcal urethritis and infertility among men. Clin
Microbiol Revs 2019; 32: 1-16
5). Horner P, Donders G, Cusini M, et al. Should we be testing for urogenital Mycoplasma hominis, Ureaplasma parvum and Ureaplasma urealyticum
in men and women? -- a position statement from the European STI Guidelines Editorial Board. J Eur Acad Dermatol
Venereol 2018; 32: 1845-1851. doi 10.1111/jdv.15146
6). Soni S, Horner P, Rayment M, et al. BASHH UK National Guideline for the Management of Infection with Mycoplasma genitalium. 2018.
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.
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.
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....
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. The observed decrease in incidence rates for all STIs (except syphilis) reported in Table 3 would thus be an artefact of the analysis, rather than a real phenomenon.
If the pre-test person-time would have been taken into account, the analyses might have shown that STI incidences in the after-PrEP period would have been similar or higher than in the before-PrEP period.
More studies are needed that examine whether the incidence rate of STIs increases after initiation of PrEP; appropriate analyses of such data are essential.
References
Beymer MR et al. Does HIV pre-exposure prophylaxis use lead to a higher incidence of sexually transmitted infections? A case-crossover study of men who have sex with men in Los Angeles, California. Sex Trans Infect Epub ahead of print. Doi:10.1136/sextrans.2017-053377
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...
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 problems. Uncontrolled testing and treatment of different groups of people will also advance “the seemingly unstoppable march of MG to complete antibiotic resistance” because M. genitalium has an unusually high probability of developing de novo resistance during treatment with a single 1g dose of azithromycin. We found, in a mathematical modelling study, that an estimated probability of resistance of 12% (95% confidence interval 8 to 17%) can explain why 50% or more of detected M. genitalium infections are already resistant to macrolides in some countries.4
The rational use of new commercial molecular tests, for detection of both M. genitalium and its antimicrobial resistance determinants, should be promoted in the context of international programmes of research and surveillance. Experts have prioritised research to determine whether screening of asymptomatic populations will reduce important clinical disease outcomes.3 Systematic reviews can help, by synthesising the existing research literature and highlight gaps in the research base. A forthcoming systematic review, linked to the review of prevalence studies, will address the dynamics and natural history of M. genitalium (PROSPERO protocols CRD42015020420, CRD42015020405, https://www.crd.york.ac.uk/prospero/) and improve the knowledge base for future mathematical modelling studies. Taylor-Robinson and Ong highlight additional basic research questions about the immunology of M. genitalium and the respiratory pathogen M. pneumoniae.
In our view, diagnostic testing accompanied by testing for macrolide resistance should be limited to defined groups of symptomatic patients and treatment algorithms, such as those recommended in the BASHH guideline,2 must be evaluated in randomised controlled trials. The research community should do all it can to ensure that responsible use of testing for M. genitalium advances the objectives of research and public health, whilst mitigating the spread of antimicrobial resistance.
References
1. Baumann L, Cina M, Egli-Gany D, et al. Prevalence of Mycoplasma genitalium in different population groups: systematic review and meta-analysis. Sex Transm Infect 2018 doi: 10.1136/sextrans-2017-053384
2. Soni S, Horner P, Rayment M, et al. 2018 BASHH UK national guideline for the management of infection with Mycoplasma genitalium. 2018.
3. Martin DH, Manhart LE, Workowski KA. Mycoplasma genitalium From Basic Science to Public Health: Summary of the Results From a National Institute of Allergy and Infectious Disesases Technical Consultation and Consensus Recommendations for Future Research Priorities. J Infect Dis 2017;216(suppl_2):S427-S30. doi: 10.1093/infdis/jix147
4. Cadosch R, Garcia V, Althaus CL, et al. De novo mutations drive the spread of macrolide resistant Mycoplasma genitalium: a mathematical modelling study. bioRxiv 2018:321216.
5. Taylor Robinson D, Ong J. Prevalence of Mycoplasma genitalium. Sexually Transmitted Infections 2018 15.06.2018. https://sti.bmj.com/content/94/4/255.responses (accessed 19.07.2018).
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.
Show More2. 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...
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.
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
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...
Show MoreDear 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.
Show MoreIn 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...
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...
Show MoreSir,
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...
Show MoreError 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....
Show MorePrevalence 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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