Extragenital Sites Research Articles

1542. Provider Uptake of Extragenital Screening for Gonorrhea and Chlamydia in Active Duty Air Force Members with Incident HIV Diagnosis

BackgroundThe prevalence of Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT) is much higher at extragenital anatomic sites among men who have sex with men (MSM) with HIV infection. National guidelines recommend that all MSM with HIV infection undergo screening for extragenital sexually transmitted infections (EG-STIs), however uptake is low in many primary care settings. We evaluated EG-STI screening by primary care providers (PCPs) for US Air Force (USAF) members with incident HIV infection.MethodsAll USAF members newly diagnosed with HIV infection who received initial HIV specialty care with Infectious Disease (ID) providers at Brooke Army Medical Center from 2016-2018 (n=98) were included. A retrospective chart review was conducted to evaluate STI screening performed by PCPs within 1 week of HIV diagnosis compared to screening at entry into ID care. Demographic, clinical, laboratory and behavioral risk data were collected. STI screening included GC/CT EG-STIs, urethral GC/CT, syphilis, and hepatitis B and C.ResultsPatients were predominantly male (97.9%) with a median age of 26 (IQR 23, 32) years at HIV diagnosis (Table 1). A previous history of STIs was reported in 53 (54.1%) patients and the majority of males self-identified as MSM (66.3%) or bisexual (22.5%). The median time from HIV diagnosis to ID evaluation was 26 days (IQR 9, 33). PCPs performed any STI screening in 61 (62.2%) patients (Table 2). EG-STI screening was conducted in 3 (3.1%) patients overall and in (3.4%) MSM/bisexuals. A total of 31 (31.6%) patients had missed STIs; the majority due to EG-STIs of the rectum (71%) and pharynx (21.9%). All EG-STIs would have been missed by urethral GC/CT screening alone.Table 1 Table 2 ConclusionEG-STI screening uptake was low among PCPs evaluating USAF members with incident HIV infection. Underutilization of EG-STI screening can result in missed infections and forward transmission of GC/CT. Barriers to low uptake need to be explored. Continued education and training of PCPs may be necessary to improve uptake of EG-STI screening.Disclosures All Authors: No reported disclosures

1541. Prevalence of Asymptomatic Sexually Transmitted Infections (STIs) in a Philadelphia Ryan White HIV population

BackgroundIn 2018, Philadelphia County ranked 7th, 8th and 16th for chlamydia (CT), gonorrhea (GC), and syphilis cases, respectively, in the Centers for Disease Control (CDC) STI Surveillance Report. Asymptomatic presentations and lack of routine screening, especially at extragenital (i.e., pharyngeal and rectal) sites, increase the challenge of timely diagnosis and treatment. We determined extent of screening, reported symptoms, and asymptomatic infections.MethodsWe analyzed records of 372 patients receiving care at an urban, university-based Ryan White HIV clinic from 2016-2018. Outcomes included: positive GC/CT nucleic acid amplification tests from genital, pharyngeal, and rectal sites as well as new diagnoses of syphilis. We collected demographic data, risk factors for HIV transmission, time from HIV diagnosis, number of clinic visits, multiple sex partners, partner with STI, and injection drug use. We used logistic regression to model factors associated with STIs and determined prevalence of asymptomatic STIs.ResultsOf 372 participants, 234 (63%) were men, 262 (70%) were Black, 245 (66%) were over 40 years old, 148 (40%) identified as MSM, 140 (38%) reported inconsistent condom use, 89 (24%) reported multiple sex partners, 35 (9%) reported injection drug use, 141 (38%) had past STI, and 26 (7%) had partner with past STI. Mean time from HIV diagnosis was 12.3 years (SD, 8.8) and mean number of clinic visits was 2/year. Testing included 720 GC/CT urine, 176 GC/CT pharyngeal, 143 GC/CT rectal swabs and 887 syphilis blood tests. Asymptomatic GC/CT infections were seen in urine 6/22 (27%), pharyngeal 12/14 (86%) and rectal 28/31 (90%) swabs. And, of 39 new diagnoses of syphilis, 23 (59%) were asymptomatic. In multivariate analysis, men (aOR, 12.2, 95%CI, 2.7-55.3), < 40 years (3.2, 1.7-6.1), with clinic visit in 2018 (1.4, 1.2-1.8), and partner with STI (1.7, 0.9-2.8) were more likely to have a positive GC/CT test. Patients with positive syphilis test were more likely men (4.6, 1.1-20.2), with multiple sex partners (3.7, 1.7-8.0), and more recent HIV diagnosis (1.1, 1.0-1.1).Prevalence of Asymptomatic STIs ConclusionResults indicate the importance of routine, site-specific STI screening among patients living with HIV. Our findings can inform screening strategies among urban HIV populations.Disclosures All Authors: No reported disclosures

Prevalence of and Factors Associated With Genital and Extragenital Chlamydia and Gonorrhea Among Transgender Women in HIV Care in the United States, 2005 to 2016.

Data on testing rates and prevalence of and factors associated with genital and extragenital chlamydia and gonorrhea among transgender women with HIV in the United States are limited. This retrospective cohort analysis included transgender women living with HIV enrolled in the US Centers for AIDS Research Network of Integrated Clinical Systems cohort between January 2005 and December 2016 with chlamydia or gonorrhea testing performed in HIV clinic. The primary outcome was a positive test result for chlamydia or gonorrhea at urogenital or extragenital (rectal/pharyngeal) sites. Factors associated with infection were examined using logistic regression and generalized estimating equations to account for multiple tests per woman. Among 312 transgender women in HIV care, 252 (81%) were tested for chlamydia or gonorrhea at least once. Annual testing rates were low: 23% to 53% at genital sites and 24% to 47% at extragenital sites. A total of 88 infections were detected, and 22% of women (55/252) had at least one positive test result. Most infections occurred at extragenital sites (80% of chlamydia and 82% of gonorrhea positive test results). Factors associated with infection in an adjusted model were as follows: age 18 to 29 years compared with ≥50 years (adjusted odds ratio [aOR], 7.6; 95% confidence interval [CI], 1.8-31.2), CD4 count >350 compared with CD4 <200 (aOR, 5.5; 95% CI, 1.2-25.1), and higher engagement in HIV care (aOR, 2.2; 95% CI, 1.0-4.5). Among transgender women living with HIV, testing rates for chlamydia and gonorrhea are inadequate, particularly at extragenital sites where most infections occur.

Recurrent Genital Ulcers

Papulonecrotic tuberculid represents a hypersensitivity reaction toMycobacterium tuberculosisor its products that disseminate through hematogenous route to the skin from an internal tuberculous focus. It is characterized by recurrent eruptions of asymptomatic, dusky red papules, which undergo ulceration and crusting, and eventually heal after a few weeks with varioliform scarring. Although it most commonly involves extragenital sites, isolated glans penis involvement has been reported very rarely.

Men and Women Have Similar Neisseria gonorrhoeae Bacterial Loads: a Comparison of Three Anatomical Sites.

Neisseria gonorrhoeae is a common bacterial sexually transmitted infection (STI). Currently, there are limited data on the bacterial load in both men and women and on both genital and extragenital sites. Therefore, we quantified N. gonorrhoeae bacterial loads in a large population of women, heterosexual men, and men who have sex with men (MSM) at three different anatomical sites. N. gonorrhoeae-positive samples (n = 1265) of STI clinic consultations (n = 944) were tested for N. gonorrhoeae with the Roche Cobas 4800 system, and quantification cycle (Cq) values were used as an inversely proportional measure for N. gonorrhoeae bacterial load after interpolation from a standard curve. Bacterial loads were compared between sample materials and sexes using t tests. The following mean N. gonorrhoeae loads were observed: urine, 4.5 ± 1.0 log10 CFU/ml; vaginal swabs, 4.3 ± 1.1 log10 CFU/ml; anorectal swabs (women), 4.0 ± 1.2 log10 CFU/ml; anorectal swabs (men), 4.5 ± 1.3 log10 CFU/ml; oropharyngeal swabs (women), 2.8 ± 0.9 log10 CFU/ml; and oropharyngeal swabs (men), 3.2 ± 1.0 log10 CFU/ml. Oropharyngeal swabs had a significantly lower N. gonorrhoeae load (P < 0.001) than genital and anorectal samples. Loads did not differ between men and women. This is the first study that determined N. gonorrhoeae load in both women and men at three anatomical sites. The substantial N. gonorrhoeae load at all sample sites suggest that all sites may have transmission potential. However, the oropharyngeal site presents the lowest bacterial load. Men and women have a similar N. gonorrhoeae loads on separate anatomical sites, arguing for similar transmission potential and similar clinical relevance.

Diagnosis and Management of Vulvovaginal Lichen Planus.

Genital lichen planus is a debilitating disorder that lacks definitive recommendations regarding diagnosis and treatment. The aim of this study was to present best practices from available evidence for the diagnosis and treatment of genital lichen planus. We conducted a narrative review of the literature on genital lichen planus by searching PubMed using the following search terms: "vulvar lichen planus" OR (vulvar diseases[mesh] OR vulva[mesh]) AND lichen planus[mesh] OR vulvar[ti] AND "lichen planus"[ti]. We included all languages and years in the search. The search resulted in 273 citations that we reviewed for relevancy and selected 60 as the foundation for this review that focuses on genital sites. Diagnosis can be made without biopsy, and when a biopsy is taken, the pathologic findings may be nonspecific. Topical ultrapotent corticosteroids are most commonly used as first-line treatment of genital lichen planus. When patients present with genital lichen planus, a complete review of systems and a thorough physical examination should be performed because of the prevalence of extragenital sites. Treatment of genital disease should start with a topical, ultrapotent steroid, and follow-up visits should occur to ensure improvement and to monitor for adverse drug reactions and malignancy.

Mesenchymal lesions of the vulva.

Mesenchymal lesions of the vulva include site-specific entities limited to the lower genital tract, as well as a range of non-site-specific tumors that are more common at extragenital sites. Site-specific lesions include fibroepithelial stromal polyp, cellular angiofibroma, angiomyofibroblastoma, and aggressive angiomyxoma. Non-site-specific tumors that may occur in the vulva include those of smooth muscle, skeletal muscle, vascular, neural, adipocytic, and uncertain differentiation. This review discusses both site-specific and non-site-specific vulvar mesenchymal lesions including non-neoplastic proliferations, benign neoplasms, locally aggressive neoplasms with a predilection for local recurrence, neoplasms of indeterminate biologic potential, and frankly malignant neoplasms with a high risk of distant metastasis and death. Accurate diagnosis is essential for proper management, and is facilitated by correlation with clinical findings and targeted application of immunohistochemical and molecular studies.

Extragenital testing increases case detection of gonorrhea and chlamydia: The impact of implementing nucleic acid amplification testing.

Nucleic acid amplification testing (NAAT) was validated in Ontario in 2018 to test for chlamydia and gonorrhea at extragenital (pharyngeal, rectal) sites. Prior to this validation, extragenital testing could be done only by culture in Ontario. The objective of this study was to determine the number and proportion of gonorrhea and chlamydia cases that were detected exclusively through extragenital (pharyngeal and/or rectal) testing after the implementation of extragenital NAAT for these two infections at Sexual Health Clinic among gay, bisexual, and other men who have sex with men (gbMSM). Case and laboratory data from before and after NAAT implementation were used to compare the rates of diagnosis of gonorrhea and chlamydia among gbMSM who presented at Sexual Health Clinics and the percent increase in diagnoses in gbMSM in the entire population. Among gbMSM seen at the clinic after implementation of NAAT testing, 70% of gonorrhea cases and 65% of chlamydia cases were detected exclusively at extragenital sites, corresponding to a four and two-fold increase, respectively, in the average annual number of cases diagnosed. As well, although approximately 50% more pharyngeal than rectal testing occurred, a higher proportion of chlamydia cases were detected rectally than would have been expected; this was not the case for gonorrhea, where most infections were pharyngeal. It is important that clinicians perform extragenital testing among gbMSM who have sexual contact involving extragenital sites with more than one partner.

A Quality Improvement Project Using Microlearning to Increase Provider Adherence to Extragenital Sexually Transmitted Infection Screening Guidelines in Men Who Have Sex With Men.

The Centers for Disease Control and Prevention (CDC) recommend screening men who have sex with men who are living with HIV for sexually transmitted infections at appropriate extragenital contact sites for bacterial sexually transmitted infections. In an effort to increase provider adherence to CDC recommended guidelines at a Ryan White Clinic, microlearning educational sessions were used. A quality improvement project was designed to determine the rate of provider adherence to CDC guidelines pre/post microlearning sessions. Student t-test was used to compare the number of patients who received urine and extragenital screening to those who received urine-only screening, to before and after the microlearning sessions. The rate of extragenital screening significantly increased after the microlearning sessions (4/460 vs. 70/507, p < .0001). The rate of urine screening remained unchanged (p = 1). Although extragenital screening significantly increased, it remained low. A decision tree in the electronic medical record to prompt providers to screen was developed.

To pool or not to pool? Screening of Chlamydia trachomatis and Neisseria gonorrhoeae in female sex workers: pooled versus single-site testing

ObjectivesAs Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are the most commonly reported STIs in Belgium and the majority of women infected are asymptomatic, targeted screening of patients in specified...

Evaluation of Self-Collection as a Method of Extragenital STI Screening.

The goal of this study is to improve overall screening, detection, and treatment of Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT) at our institution. An observational study with two phases was conducted at a U.S. Army Medical Center. Previously collected samples from January 2014 through December 2015 were compared to prospectively collected data from March 2016 through December 2017. All data were collected from a convenience sample of active duty, HIV-positive men who have sex with men. Concordance between provider-collected and self-collected extragenital screening (EGS) samples was evaluated. The rate of detection using EGS was higher than previously found using urogenital screening alone. Our prospective analysis revealed that expanding screening to include extragenital sites increased rates of detection of GC and CT. Our rates of GC detection at the pharynx and rectum, and CT detection at the rectum, were higher than those reported in the literature for men who have sex with men. Rates of CT infection at the pharynx were comparable with those reported in the literature. Detection of GC at the pharynx was exactly concordant between self-collected and provider-collected samples. Concordance of GC and CT detection at the rectum was very good. The kappa coefficient for detection of CT at the pharynx was zero, which corresponded to 44 out of 45 concordant observations. Prior to implementation of EGS at our institution, we missed the opportunity to detect a substantial number of GC/CT infections with urogenital screening alone. Our results suggest that self-collection is a reliable method of EGS as compared to provider collection of samples.

Population-level Benefits of Extragenital Gonorrhea Screening Among Men Who Have Sex With Men: An Exploratory Modeling Analysis.

Men who have sex with men (MSM) are disproportionately burdened by gonorrhea and face high rates of extragenital (rectal and pharyngeal) infection, which is mostly asymptomatic and often missed by urogenital-only screening. Extragenital screening likely remains below Centers for Disease Control and Prevention-recommended levels. Because increasing screening coverage is often resource-intensive, we assessed whether improved extragenital screening among men already presenting at clinics could lead to substantial reductions in prevalence and incidence. We calibrated an agent-based model of site- and race-specific gonorrhea infection in MSM to explicitly model multisite infection within an individual and transmission via anal, orogenital, and ororectal sex. Compared with current screening levels, we assessed the impact of increasing screening at (1) both extragenital sites, (2) only the rectal site, and (3) only the pharyngeal site among men already being urogenitally screened. All scenarios reduced prevalence and incidence, with improved screening at both extragenital sites having the largest effect across outcomes. Extragenitally screening 100% of men being urogenitally screened reduced site-specific prevalence by an average of 42% (black MSM) and 50% (white MSM), with these values dropping by approximately 10% and 20% for each race group when targeting only the rectum and only the pharynx, respectively. However, increasing only rectal screening was more efficient in terms of the number of screens needed to avert an infection as this avoided duplicative screens due to rectum/pharynx multisite infection. Improved extragenital screening substantially reduced site-specific gonorrhea prevalence and incidence, with strategies aimed at increasing rectal screening proving the most efficient.

Aztreonam for Neisseria gonorrhoeae: a systematic review and meta-analysis.

Ceftriaxone is the only consistently active antimicrobial agent recommended for the treatment of Neisseria gonorrhoeae. Although some new antimicrobials are in development, the necessity to expand treatment options in the near term may require using older drugs that have not been widely used to treat gonorrhoea. We conducted a literature review of clinical trials and case series, published from 1983 to 2017, reporting treatment efficacy results following administration of 1 g aztreonam intramuscularly or IV for uncomplicated gonococcal infections. We summed trial data, stratified by anatomical site of infection, and calculated summary efficacy estimates and 95% CI for each site of infection. The 10 identified clinical trials enrolled 678, 38 and 16 individuals with urogenital, rectal and pharyngeal gonorrhoea, respectively. Aztreonam had an efficacy of 98.6% (95% CI: 97.5%-99.4%) for urogenital, 94.7% (95% CI: 82.3%-99.4%) for rectal and 81.3% (95% CI: 54.4%-96.0%) for pharyngeal gonococcal infections. Although most clinical trials included in this meta-analysis were conducted >30 years ago, aztreonam appears to have excellent efficacy for urogenital gonorrhoea; its efficacy at extragenital sites remains uncertain.

Extragenital Gonorrhea and Chlamydia Positivity and the Potential for Missed Extragenital Gonorrhea With Concurrent Urethral Chlamydia Among Men Who Have Sex With Men Attending Sexually Transmitted Disease Clinics-Sexually Transmitted Disease Surveillance Network, 2015-2019.

Extragenital gonorrhea (GC) and chlamydia (CT) are usually asymptomatic and only detected through screening. Ceftriaxone plus azithromycin is the recommended GC treatment; monotherapy (azithromycin or doxycycline) is recommended for CT. In urethral CT-positive/urethral GC-negative persons who are not screened extragenitally, CT monotherapy can lead to GC undertreatment and may foster the development of gonococcal antimicrobial resistance. We assessed urethral and extragenital GC and CT positivity among men who have sex with men (MSM) attending sexually transmitted disease clinics. We included visit data for MSM tested for GC and CT at 30 sexually transmitted disease clinics in 10 jurisdictions during January 1, 2015, and June 30, 2019. Using an inverse-variance random effects model to account for heterogeneity between jurisdictions, we calculated weighted test visit positivity estimates and 95% confidence intervals (CI) for GC and CT at urethral and extragenital sites, and extragenital GC among urethral CT-positive/GC-negative test visits. Of 139,718 GC and CT test visits, we calculated overall positivity (GC, 16.7% [95% CI, 14.4-19.1]; CT, 13.3% [95% CI, 12.7-13.9]); urethral positivity (GC, 7.5% [95% CI, 5.7-9.3]; CT, 5.2% [95% CI, 4.6-5.8]); rectal positivity (GC, 11.8% [95% CI, 10.4-13.2]; CT, 12.6% [95% CI, 11.8-13.4]); and pharyngeal positivity (GC, 9.1% [95% CI, 7.9-10.3]; CT, 1.8% [95% CI, 1.6-2.0]). Of 4566 urethral CT-positive/GC-negative test visits with extragenital testing, extragenital GC positivity was 12.5% (95% CI, 10.9-14.1). Extragenital GC and CT were common among MSM. Without extragenital screening of MSM with urethral CT, extragenital GC would have been undetected and undertreated in approximately 13% of these men. Undertreatment could potentially select for antimicrobial resistance. These findings underscore the importance of extragenital screening in MSM.

Oro-anal sexual practice among female sex workers in Melbourne: implication for extragenital gonorrhoea and chlamydia transmission.

A cross-sectional survey among FSWs attending the Melbourne Sexual Health Centre in Australia in March 2018 was conducted. All females aged ≥18 years and self-reported as a sex worker were eligible. The survey included questions related to the number of insertive and receptive rimming partners with their male clients in an average working week. Forty-five FSWs completed the survey; five (11.1%; 95% CI: 3.7-24.1%) FSWs had had insertive rimming and 19 (42.2%; 95% CI: 27.7-57.8%) had had receptive rimming with their male clients in an average working week. The median number of insertive rimming partners was two (interquartile range (IQR) 1-5) and the median number of receptive rimming partners was one (IQR 1-3). Insertive rimming is more commonly practiced than receptive rimming among FSWs with their male clients in an average working week.

Gonorrhoea.

The bacterium Neisseria gonorrhoeae causes the sexually transmitted infection (STI) gonorrhoea, which has an estimated global annual incidence of 86.9 million adults. Gonorrhoea can present as urethritis in men, cervicitis or urethritis in women, and in extragenital sites (pharynx, rectum, conjunctiva and, rarely, systemically) in both sexes. Confirmation of diagnosis requires microscopy of Gram-stained samples, bacterial culture or nucleic acid amplification tests. As no gonococcal vaccine is available, prevention relies on promoting safe sexual behaviours and reducing STI-associated stigma, which hinders timely diagnosis and treatment thereby increasing transmission. Single-dose systemic therapy (usually injectable ceftriaxone plus oral azithromycin) is the recommended first-line treatment. However, a major public health concern globally is that N. gonorrhoeae is evolving high levels of antimicrobial resistance (AMR), which threatens the effectiveness of the available gonorrhoea treatments. Improved global surveillance of the emergence, evolution, fitness, and geographical and temporal spread of AMR in N. gonorrhoeae, and improved understanding of the pharmacokinetics and pharmacodynamics for current and future antimicrobials in the treatment of urogenital and extragenital gonorrhoea, are essential to inform treatment guidelines. Key priorities for gonorrhoea control include strengthening prevention, early diagnosis, and treatment of patients and their partners; decreasing stigma; expanding surveillance of AMR and treatment failures; and promoting responsible antimicrobial use and stewardship. To achieve these goals, the development of rapid and affordable point-of-care diagnostic tests that can simultaneously detect AMR, novel therapeutic antimicrobials and gonococcal vaccine(s) in particular is crucial.

Is there a future for the ongoing use of azithromycin for the treatment of Neisseria gonorrhoeae?

Abstract Effective treatment for Neisseria gonorrhoeae is an ongoing concern because of its growing resistance to all current recommended treatments. Infections at extragenital sites, particularly the oropharynx, are important to cure because of their role in ongoing transmission and because resistance is believed to originate at this site. This commentary reports on the results of a randomised control trial (RCT) that compared ceftriaxone 500mg plus 2g of azithromycin or gentamicin 240mg plus 2g azithromycin for the treatment of extragenital gonorrhoea infection, and found 100% microbial cure for both treatment regimens. While this regimen offers an alternative effective treatment, it is likely to be valuable only while azithromycin resistance remains low, raising the issue of whether we should continue to use azithromycin as part of dual therapy with ceftriaxone for NG. Continued use of azithromycin with ceftriaxone for NG and other widespread azithromycin use among individuals at risk of gonorrhoea may lead to further rises in azithromycin resistance, thereby removing the usefulness of the combination of gentamicin plus 2g azithromycin from future options should ceftriaxone resistance become widespread.

Increasing Sexually Transmitted Infection Detection Through Screening at Extragenital Sites

Chlamydia and gonorrhea are often asymptomatic, having a significant impact on reproductive health. Current practice focuses on urine-based screening to detect these sexually transmitted infections (STIs), leading to missed infections at extragenital sites. Universal screening is a method to improve screening and increase detection. The objective of this study was to increase screening, detection, and treatment of STIs at extragenital sites to reduce transmission, antibiotic resistance, and reproductive health sequelae. Academic detailing sessions were implemented to increase universal screening and patient self-collection at extragenital sites. Universal STI screening will improve screening methods, increase STI detection rates, and decrease transmission of disease.

Performance assessment of the Allplex™ STI Essential real-time PCR assay for the diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis infections in genital and extra-genital sites

Abstract Background Commercial kits performing Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) nucleic acid amplification tests (NAATs) for genital samples are recommended in association with culture, but the majority of real-time polymerase chain reaction (PCR) methods have not received regulatory approval for diagnostics in extra-genital sites. Since 2017, only the Hologic® Aptima Combo2 assay has an in vitro diagnostic (IVD) certification from the European Medicine Evaluation Agency. Methods We assessed the Allplex™ STI-Essential Assay (EA) for the diagnosis of NG and CT in both genital and extra-genital sites. The performance of the extraction step was studied by means of a standard curve between the concentration of expected cultivable gonococci and the cycle threshold (Ct). Three later-generation NAATs were used as comparators, particularly to assess the specificity (Sp). Results A relation between the gonococcal concentration, expressed as colony-forming unit (CFU) per milliliter logarithm, and the Ct was shown to be linear irrespective of the matrices (95% confidence interval [CI]). The detection limit was 10 CFU/mL, contrasting with the relatively poor sensitivity of culture due to inhibitory effects such as pH and the overgrowth of the commensal flora. NG molecular diagnostic is complex and the method comparisons showed some discrepancies when Ct was above 34. We decided to include interpretative comments on our reports on the basis of the Ct result. For CT, comparisons displayed a satisfactory agreement, and the detection limit was 50 copies/mL. Conclusions The Seegene Allplex™ STI-EA showed acceptable performance characteristics for the detection of genital and extra-genital NG and CT.

The role of saliva in gonorrhoea and chlamydia transmission to extragenital sites among men who have sex with men: new insights into transmission.

IntroductionGonorrhoea and chlamydia cases have been rising among gay, bisexual and other men who have sex with men (MSM) over the last decade. The majority of cases are extragenital and occur at the oropharynx and anorectum. The aim of this narrative review was to review the risk factors and mode of transmission for gonorrhoea and chlamydia at the oropharynx and anorectum among MSM.Results and discussionNew evidence suggests that oropharyngeal gonorrhoea can be transmitted by kissing in addition to through the established route of condomless oral sex; and anorectal gonorrhoea can be acquired when saliva is used as a lubricant for anal sex and rimming in addition to the established route of condomless penile‐anal sex in MSM. In contrast, condomless penile‐anal sex remains the major route for chlamydia transmission.ConclusionsSubstantial transmission of gonorrhoea may occur with practices other than the established routes of condomless oral and/or anal sex and hence condoms may not be effective in preventing gonorrhoea transmission to extragenital sites. In contrast, condoms are effective for chlamydia control because it is mainly transmitted through condomless penile‐anal sex. Novel interventions for gonorrhoea that reduce the risk of transmission at extragenital site are required.