Non-chlamydial Non-gonococcal Urethritis Research Articles

Should We Be Testing for Mycoplasma genitalium on Initial Presentation? Trends in Persistent/Recurrent Urethritis Among Men Presenting for Care in STD Clinics, 2015-2019, STD Surveillance Network.

Mycoplasma genitalium is a major contributor to persistent/recurrent urethritis cases. However, there are limited published studies on recent trends of persistent/recurrent urethritis. A retrospective analysis was conducted of men presenting with symptomatic urethritis in 16 sexually transmitted disease (STD) clinics from 2015 to 2019. Poisson regression was used to assess trends in the annual proportions of urethritis episodes with follow-up (FU) characterized with persistent/recurrent urethritis symptoms. Results were also stratified by results of chlamydia (CT) and gonorrhea (NG) testing and treatment prescribed. There were 99,897 urethritis episodes, from 67,546 unique men. The proportion of episodes with persistent/recurrent symptomatic FU visits increased 50.8% over a 4-year period (annual percentage change [APC], 11.3%; 95% confidence interval [CI], 6.5-16.3). Similar trends were observed in nonchlamydial nongonococcal urethritis episodes (APC, 12.7%; 95% CI, 6.8-18.9) but increases among those positive for NG (APC, 12.1%; 95% CI, -2.3 to -28.5) or for CT (APC, 7.3%; 95% CI, -6.7 to 23.5) were not statistically significant. Among episodes who received azithromycin as first-line treatment, increases in the proportion of persistent/recurrent FU visits were observed (APC, 12.6%; 95% CI, 8.6-16.7). For episodes where first-line treatment was doxycycline, no significant increases were detected (APC, 4.3%; 95% CI, -0.3 to 9.2). We found an increase in the proportion of urethritis episodes with persistent or recurrent symptoms over time. Given these observed trends in episodes negative for NG or CT, an etiology not detectable by routine diagnostics was a likely factor in increased persistence, suggesting patients with urethritis may benefit from diagnostic testing for M. genitalium during an initial symptomatic presentation.

UAA-AAUS guideline for M. genitalium and non-chlamydial non-gonococcal urethritis

Non-chlamydial non-gonococcal urethritis (NCNGU) is defined as urethritis with neither Neisseria gonorrhoeae nor Chlamydia trachomatis. Possible causative agents of NCNGU include Mycoplasma genitalium, Ureaplasma urealyticum, Ureaplasma parvum, Mycoplasma hominis, Trichomonas vaginalis, and so on. Among these microorganisms, the pathogenicity of M. genitalium and T. vaginalis to the male urethra has been confirmed so far.The Asian Association of Urinary Tract Infection and Sexually Transmitted Infection (AAUS) belonging to the Urological Association of Asia (UAA) had developed the guidelines regarding NCNGU and the present guidelines were updated from previous edition. Relevant references were meticulously reviewed again and latest studies were collected. In addition to the levels of evidence, the recommendation grades were defined using the modified GRADE methodology. Herein, we present the new edition of the UAA-AAUS guidelines for M. genitalium and non-chlamydial non-gonococcal urethritis.

1532. Demographics and Population Epidemiology of Mycoplasma genitalium infection: Correlation to Co-Infection and prior STI history

BackgroundDespite reports in the past few years that Americans are having less sex, the US Centers for Disease Control and Prevention (CDC) recently reported in 2019 that sexually transmitted infection (STI) cases are at an all-time high in the United States. The CDC report included statistics on confirmed cases of Chlamydia trachomatis and Neisseria gonorrhoeae, but did not include data for Trichomonas vaginalis and Mycoplasma genitalium. Although Trichomonas vaginalis and Mycoplasma genitalium are generally recognized agents responsible for STI’s, there is limited prevalence data in the United States.MethodsHerein we present STI prevalence and socio-demographic epidemiological data associated with patients enrolled in a multicenter STI study using the automated multiplex qualitative CE marked assay, Alinity m STI. The enrolled study population reflected a diverse number of participants with an approximately equal male to female ratio, prior STI history, single and married, education levels from primary to post-graduate, as well as different ethnicities.ResultsParticipants in this study population who have previously been diagnosed with an STI had an overall Mycoplasma genitalium prevalence rate that was approximately double those who have not been previously diagnosed with an STI. Furthermore, the co-infection rate for Mycoplasma genitalium and Trichomonas vaginalis was as high as 2.5% for vaginal swab specimens with an overall Mycoplasma genitalium prevalence of 11.6%. The overall prevalence of Trichomonas vaginalis in women was 12.3%. Neisseria gonorrhoeae had the lowest overall prevalence in men and women at 2.4%, and Chlamydia trachomatis at had an overall prevalence of 9.8%.ConclusionMycoplasma genitalium infections are generally asymptomatic in both men and women that contributes to up to 35% of non‐chlamydial non‐gonococcal urethritis in men and linked to cervicitis and pelvic inflammatory disease in women. Left untreated or not accurately diagnosed, STIs can cause significant, serious long-term health consequences including sexual, reproductive, and psychological well-being that present an extensive challenge and burden to public health in the United States.DisclosuresJose Santiago, PhD, Abbott (Employee)

Is Non-Chlamydial Non-Gonococcal Urethritis Associated with Significant Clinical Complications in Men? A Systematic Review

Background: It is estimated that between 50 and 89% of non-gonococcal urethritis is not caused by Chlamydia trachomatis. Associations between non-chlamydial non-gonococcal urethritis (NCNGU) with balanoposthitis, epididymo-orchitis and reactive arthritis have been suggested, but evidence to support these often-theoretical relationships is sparse and further investigation is called for. Concerns over increasing antimicrobial resistance has rendered the need for clarity over this question ever more pressing in recent years. A review of the current evidence on the complications of NCNGU in men is therefore urgently warranted. Objective: This systematic review summarizes and evaluates the available evidence that NCNGU, whether symptomatic or asymptomatic, causes the significant complications that are already well-recognized to be associated with non-gonococcal urethritis. These significant complications are epididymo-orchitis, balanoposthitis, and sexually-acquired reactive arthritis (Reiter's syndrome) including arthritis or conjunctivitis. Summary: We conducted a systematic review and qualitative synthesis using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis framework. Five databases (PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and British Nursing Index) were searched. We included studies that measured clinical outcome after diagnosis of NCNGU in men. Bias was assessed using variations of the Newcastle-Ottawa scale. Data were extracted and entered into a pre-written data abstraction proforma. Seven peer-review studies were included. This included 2 retrospective cohort studies, 1 case series, 2 case reports and 2 cross-sectional studies. The studies described and analyzed 3 types of complication: balanitis, posthitis and/or meatitis; reactive arthritis and/or conjunctivitis; and epididymitis. All studies reported one or more complications. Key Messages: This review identifies an important avenue for future research: while the available evidence suggests that NCNGU has the potential to cause significant complications in men, with the strongest evidence existing for balanitis, posthitis and/or meatitis, the nature and significance of these relationships is far from clear. The findings of this review suggest that prospective, adequately powered research into whether there is a causal link between NCNGU and significant clinical complications in men would be highly worthwhile. The findings of this review raise important questions about the utility of the term NCNGU in research and clinical practice.

The clinical efficacy of garenoxacin for male non-gonococcal urethritis

Sitafloxacin (STFX) is an alternative treatment against azithromycin-resistant Mycoplasma genitalium (MG), whereas STFX-resistant MG have appeared recently. Therefore, another antimicrobial regimen for non-chlamydial non-gonococcal urethritis (NGU) is required. Garenoxacin (GRNX) is a fluoroquinolone against respiratory infections, not against urethritis in Japan, but its in-vitro antimicrobial activity against MG is known as similar to or higher than that of moxifloxacin.To clarify the efficiency of GRNX against MG, we examined the clinical efficacy of GRNX for NGU. Seventy-nine male patients with NGU were enrolled and treated with GRNX once daily for 7 days. For assessing microbiological and clinical efficacies, the bacteria including Chlamydia trachomatis (CT), MG, Mycoplasma hominis (MH), Ureaplasma urealyticum (UU) and Ureaplasma parvum (UP) were detected by means of nucleic acid amplification tests before- and after-treatment.After excluded 3 patients, seventy-six patients were evaluated: the median age; 31 (20–61) years, vaginal infection (66%); the most common infectious route and commercial sex worker (43%); the most common source. There were 50 bacteria-positive NGU cases, including 10 multiple bacterial infections. Clinical cure rate was 85.7% (36/42). Detection frequency of each bacterium was similar to the previous reported. The eradication rates of CT, MG, MH, UU and UP were 96.1%, 71.4%, 100%, 85.7% and 100%, respectively.These results indicate that GRNX has the excellent efficacies for NGU except those of MG. Further study of drug-resistant MG urethritis; for instance, studies on the clinical effectiveness of long-term such as 2-week medication of GRNX or the efficacy of alternative treatment regimens are necessary.

Infectious human adenoviruses are shed in urine even after disappearance of urethral symptoms.

BackgroundUrethritis is a common sexually transmitted disease, and human adenoviruses (HAdVs) have been found to be associated with nonchlamydial nongonococcal urethritis. However, the level and viability of HAdV in the urine of patients with urethritis remain unclear.MethodsMale patients with urethritis and an asymptomatic group were screened using their First-void urine (FVU) for urethritis-related pathogens to identify those with HAdV DNA. FVU and gargle fluid were collected from all patients including from those in the asymptomatic group. A swab of eye discharge was also collected from patients with eye symptoms. The pharyngeal and/ or ocular fluid was also screened only in cases in which FVU was positive for HAdV DNA. HAdVs were isolated using A549 cell lines and typed by sequencing, and viral shedding during 2 years was quantified using real-time PCR. The prevalence of HAdV was assessed in the urethritis and asymptomatic groups, and viral load, isolated HAdV types, and urethral symptoms were compared between the groups.ResultsThe positive detection rate of HAdV DNA was significantly higher in the urethritis group than in the asymptomatic group. Of 398 patients with urethritis, HAdV was isolated in all 32 cases (23 cases in which only HAdV DNA was detected with a mean of 2 × 109 copies/mL in urine samples). Of 124 control cases, one had HAdV monoinfection. The most frequently detected HAdV type was 56, followed by types 37 and 64. Regarding the relationship between symptoms and isolated HAdVs, the virus was isolated for up to 12 days after urethritis symptoms disappeared.ConclusionsHAdVs were significantly detected and isolated from the FVU of patients with urethritis. Furthermore, high levels of infectious HAdVs are excreted in urine for a long period even after urethritis symptoms disappear.

Sustained influence of infections on prostate-specific antigen concentration: An analysis of changes over 10 years of follow-up.

To extend our previous observation of a short-term rise in prostate-specific antigen (PSA) concentration, a marker of prostate inflammation and cell damage, during and immediately following sexually transmitted and systemic infections, we examined the longer-term influence of these infections, both individually and cumulatively, on PSA over a mean of 10 years of follow-up in young active duty U.S. servicemen. We measured PSA in serum specimens collected in 1995-7 (baseline) and 2004-6 (follow-up) from 265 men diagnosed with chlamydia (CT), 72 with gonorrhea (GC), 37 with non-chlamydial, non-gonococcal urethritis (NCNGU), 58 with infectious mononucleosis (IM), 91 with other systemic or non-genitourinary infections such as varicella; and 125-258 men with no infectious disease diagnoses in their medical record during follow-up (controls). We examined the influence of these infections on PSA change between baseline and follow-up. The proportion of men with any increase in PSA (>0 ng/mL) over the 10-year average follow-up was significantly higher in men with histories of sexually transmitted infections (CT, GC, and NCNGU; 67.7% vs 60.8%, P = 0.043), systemic infections (66.7% vs 54.4%, P = 0.047), or any infections (all cases combined; 68.5% vs 54.4%, P = 0.003) in their military medical record compared to controls. While PSA has been previously shown to rise during acute infection, these findings demonstrate that PSA remains elevated over a longer period. Additionally, the overall infection burden, rather than solely genitourinary-specific infection burden, contributed to these long-term changes, possibly implying a role for the cumulative burden of infections in prostate cancer risk.

Prevalence of Mycoplasma genitalium in different population groups: systematic review andmeta-analysis

BackgroundMycoplasma genitalium is a common cause of non-gonococcal non-chlamydial urethritis and cervicitis. Testing of asymptomatic populations has been proposed, but prevalence in asymptomatic populations is not well established. We aimed...

Macrolide and fluoroquinolone resistance in Mycoplasma genitalium in two Swedish counties, 2011-2015.

Mycoplasma genitalium, causing non-gonococcal non-chlamydial urethritis and associated with cervicitis, has developed antimicrobial resistance (AMR) to both the macrolide azithromycin (first-line treatment) and the fluoroquinolone moxifloxacin (second-line treatment). Our aim was to estimate the prevalence of resistance, based on genetic AMR determinants, to these antimicrobials in the M. genitalium population in two Swedish counties, Örebro and Halland, 2011-2015. In total, 672 M. genitalium positive urogenital samples were sequenced for 23S rRNA and parC gene mutations associated with macrolide and fluoroquinolone resistance, respectively. Of the samples, 18.6% and 3.2% in Örebro and 15.2% and 2.7% in Halland contained mutations associated with macrolide and fluoroquinolone resistance, respectively. The predominating resistance-associated mutations in the 23S rRNA gene was A2059G (n = 39) in Örebro and A2058G (n = 13) and A2059G (n = 13) in Halland. The most prevalent possible resistance-associated ParC amino acid alterations were S83I (n = 4) in Örebro and S83N (n = 2) in Halland. Resistance-associated mutations to both macrolides and fluoroquinolones were found in 0.7% of samples. Our findings emphasize the need for routine AMR testing, at a minimum for macrolide resistance, of all M. genitalium-positive samples and regular national and international surveillance of AMR in M. genitalium, to ensure effective patient management and rational antimicrobial use.

'Haemophilus quentini' in the urethra of men complaining of urethritis symptoms.

We isolated a cryptic genospecies of Haemophilus influenzae referred to as 'Haemophilus quentini' in the urethra of 3 men complaining of urethritis symptoms. H.influenzae strains, which had been isolated from the urethra in 77 of 1518 men complaining of urethritis symptoms, identified by the conventional test, and stored, were re-cultured for this study. Sixty-seven strains surviving storage were screened by a PCR-based assay specific for the cryptic genital Haemophilus genospecies. Three strains (HI09003, HI11006, and HI14016) were screened by PCR and identified as 'H.quentini' by 16S rRNA sequencing. The men positive for HI09003 and HI11006 were diagnosed as having non-chlamydial non-gonococcal urethritis (NGU), and their demographic and clinical features were similar to those of NGU caused by other pathogens. The man positive for HI14016 was ultimately diagnosed as having condyloma acuminatum on the glans. The 3 strains of 'H.quentini' produced no β-lactamase and were susceptible to ampicillin and other antimicrobial agents, including cephalosporins, fluoroquinolones, tetracyclines, and macrolides, recommended for treatment for urethritis. 'H.quentini' would be an uncommon pathogen in men with urogenital infections. Based on the clinical features of the two patients with 'H.quentini'-positive NGU, it would be difficult to predict the presence of 'H.quentini' in the urethra. The 3 strains of 'H.quentini' were susceptible to a variety of antimicrobial agents. Further accumulation of data regarding 'H.quentini' infections is needed to characterize the pathogenic roles of this genospecies in urogenital infections and to establish appropriate management of 'H.quentini' infections.

Cost-effectiveness of microscopy of urethral smears for asymptomatic Mycoplasma genitalium urethritis in men in England.

The objective was to determine whether or not the limited use of urethral microscopy to diagnose asymptomatic and symptomatic non-chlamydial, non-gonococcal urethritis (NCNGU) in men is a cost-effective strategy to avert pelvic inflammatory disease (PID), ectopic pregnancy or infertility in female partners. Outputs from a transmission dynamic model of NCNGU in a population of 16-30 year olds in England simulating the number of consultations, PID cases and patients treated over time amongst others, were used along with secondary data to undertake a cost-effectiveness analysis carried out from a health care provider perspective. The main outcome measure was cost per case of PID averted. A secondary outcome measure was cost per major outcome averted, where a major outcome is a case of symptomatic PID, ectopic pregnancy, or infertility. Offering a limited number of asymptomatic men urethral microscopy was more effective than the current practice of no microscopy in terms of reducing the number of cases of PID with an incremental cost-effectiveness ratio of £15,700, meaning that an investment of £15,800 is required to avert one case of PID. For major outcomes averted, offering some asymptomatic men urethral microscopy was again found to be more effective than no microscopy, but here an investment of £49,900 is required to avert one major outcome. Testing asymptomatic men for NCNGU in a small number of genitourinary medicine settings in England is not cost-effective, and thus by maintaining the current practice of not offering this patient group microscopy, this continues to make savings for the health care provider.

Insight into infection‐mediated prostate damage: Contrasting patterns of C‐reactive protein and prostate‐specific antigen levels during infection

To investigate mechanisms underlying our previous observation of a large rise in serum prostate-specific antigen, a marker of prostate pathology, during both sexually transmitted and systemic infections, we measured serum high-sensitivity C-reactive protein (hsCRP), a marker of systemic inflammation, in our previous case-control study of young, male US military members and compared our findings to those for PSA. We measured hsCRP before and during infection for 299 chlamydia, 112 gonorrhea, and 59 non-chlamydial, non-gonococcal urethritis (NCNGU) cases; before and after infection for 55 infectious mononucleosis (IM) and 90 other systemic/non-genitourinary cases; and for 220-256 controls. Only gonorrhea cases were significantly more likely to have a large hsCRP rise (≥1.40 mg/L or ≥239%) during infection than controls (P < 0.01). However, gonorrhea, IM, and other systemic/non-genitourinary cases were more likely to have a rise of any magnitude up to one year post-diagnosis than controls (p = 0.038-0.077). These findings, which differ from those for PSA, suggest distinct mechanisms of elevation for hsCRP and PSA, and support both direct (eg, prostate infection) and indirect (eg, systemic inflammation-mediated prostate cell damage) mechanisms for PSA elevation. Future studies should explore our PSA findings further for their relevance to both prostate cancer screening and risk.

The Ballseye programme: a mixed-methods programme of research in traditional sexual health and alternative community settings to improve the sexual health of men in the UK

BackgroundSexually transmitted infection (STI) diagnoses are increasing and efforts to reduce transmission have failed. There are major uncertainties in the evidence base surrounding the delivery of STI care for men.AimTo improve the sexual health of young men in the UK by determining optimal strategies for STI testing and careObjectivesTo develop an evidence-based clinical algorithm for STI testing in asymptomatic men; model mathematically the epidemiological and economic impact of removing microscopy from routine STI testing in asymptomatic men; conduct a pilot randomised controlled trial (RCT) of accelerated partner therapy (APT; new models of partner notification to rapidly treat male sex partners of people with STIs) in primary care; explore the acceptability of diverse venues for STI screening in men; and determine optimal models for the delivery of screening.DesignSystematic review of the clinical consequences of asymptomatic non-chlamydial, non-gonococcal urethritis (NCNGU); case–control study of factors associated with NCNGU; mathematical modelling of the epidemiological and economic impact of removing microscopy from asymptomatic screening and cost-effectiveness analysis; pilot RCT of APT for male sex partners of women diagnosed withChlamydia trachomatisinfection in primary care; stratified random probability sample survey of UK young men; qualitative study of men’s views on accessing STI testing; SPORTSMART pilot cluster RCT of two STI screening interventions in amateur football clubs; and anonymous questionnaire survey of STI risk and previous testing behaviour in men in football clubs.SettingsGeneral population, genitourinary medicine clinic attenders, general practice and community contraception and sexual health clinic attenders and amateur football clubs.ParticipantsMen and women.InterventionsPartner notification interventions: APTHotline [telephone assessment of partner(s)] and APTPharmacy [community pharmacist assessment of partner(s)]. SPORTSMART interventions: football captain-led and health adviser-led promotion of urine-based STI screening.Main outcome measuresFor the APT pilot RCT, the primary outcome, determined for each contactable partner, was whether or not they were considered to have been treated within 6 weeks of index diagnosis. For the SPORTSMART pilot RCT, the primary outcome was the proportion of eligible men accepting screening.ResultsNon-chlamydial, non-gonococcal urethritis is not associated with significant clinical consequences for men or their sexual partners but study quality is poor (systematic review). Men with symptomatic and asymptomatic NCNGU and healthy men share similar demographic, behavioural and clinical variables (case–control study). Removal of urethral microscopy from routine asymptomatic screening is likely to lead to a small rise in pelvic inflammatory disease (PID) but could save &gt; £5M over 20 years (mathematical modelling and health economics analysis). In the APT pilot RCT the proportion of partners treated by the APTHotline [39/111 (35%)], APTPharmacy [46/100 (46%)] and standard patient referral [46/102 (45%)] did not meet national standards but exceeded previously reported outcomes in community settings. Men’s reported willingness to access self-sampling kits for STIs and human immunodeficiency virus infection was high. Traditional health-care settings were preferred but sports venues were acceptable to half of men who played sport (random probability sample survey). Men appear to prefer a ‘straightforward’ approach to STI screening, accessible as part of their daily activities (qualitative study). Uptake of STI screening in the SPORTSMART RCT was high, irrespective of arm [captain led 28/56 (50%); health-care professional led 31/46 (67%); poster only 31/51 (61%)], and costs were similar. Men were at risk of STIs but previous testing was common.ConclusionsMen find traditional health-care settings the most acceptable places to access STI screening. Self-sampling kits in football clubs could widen access to screening and offer a public health impact for men with limited local sexual health services. Available evidence does not support an association between asymptomatic NCNGU and significant adverse clinical outcomes for men or their sexual partners but the literature is of poor quality. Similarities in characteristics of men with and without NCNGU precluded development of a meaningful clinical algorithm to guide STI testing in asymptomatic men. The mathematical modelling and cost-effectiveness analysis of removing all asymptomatic urethral microscopy screening suggests that this would result in a small rise in adverse outcomes such as PID but that it would be highly cost-effective. APT appears to improve outcomes of partner notification in community settings but outcomes still fail to meet national standards. Priorities for future work include improving understanding of men’s collective behaviours and how these can be harnessed to improve health outcomes; exploring barriers to and facilitators of opportunistic STI screening for men attending general practice, with development of evidence-based interventions to increase the offer and uptake of screening; further development of APT for community settings; and studies to improve knowledge of factors specific to screening men who have sex with men (MSM) and, in particular, how, with the different epidemiology of STIs in MSM and the current narrow focus on chlamydia, this could negatively impact MSM’s sexual health.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Background review for the 2016 European guideline on Mycoplasma genitalium infections.

Mycoplasma genitalium is a cause of 10-35% of non-chlamydial non-gonococcal urethritis in men and in women, and is associated with cervicitis and pelvic inflammatory disease (PID). Transmission of M. genitalium occurs through direct mucosal contact. In women, symptoms include vaginal discharge, dysuria or symptoms of PID - abdominal pain and dyspareunia. In men, urethritis, dysuria and discharge predominates. Asymptomatic infections are frequent. In this review, we present the evidence base for the recommendations in the 2016 European guideline on M. genitalium infections and describe indications for testing, recommended diagnostic methods, treatment and patient management. The guideline was prepared on behalf of the European branch of The International Union against Sexually Transmitted Infections; the European Academy of Dermatology and Venereology; the European Dermatology Forum; the European Society of Clinical Microbiology and Infectious Diseases; the Union of European Medical Specialists. The European Centre for Disease Prevention and Control and the European Office of the World Health Organisation also contributed to their development.

2016 European guideline on Mycoplasma genitalium infections.

Mycoplasma genitalium infection contributes to 10-35% of non-chlamydial non-gonococcal urethritis in men. In women, M. genitalium is associated with cervicitis and pelvic inflammatory disease (PID). Transmission of M. genitalium occurs through direct mucosal contact. Asymptomatic infections are frequent. In women, symptoms include vaginal discharge, dysuria or symptoms of PID - abdominal pain and dyspareunia. In men, urethritis, dysuria and discharge predominates. Besides symptoms, indication for laboratory test is a high-risk sexual behaviour. Diagnosis is achievable only through nucleic acid amplification testing (NAAT). If available, NAAT diagnosis should be followed with an assay for macrolide resistance. Therapy for M. genitalium is indicated if M. genitalium is detected or on an epidemiological basis. Doxycycline has a low cure rate of 30-40%, but does not increase resistance. Azithromycin has a cure rate of 85-95% in macrolide susceptible infections. An extended course appears to have a higher cure rate. An increasing prevalence of macrolide resistance, most likely due to widespread use of azithromycin 1 g single dose without test of cure, is drastically decreasing the cure rate. Moxifloxacin can be used as second-line therapy, but resistance is increasing. Uncomplicated M. genitalium infection should be treated with azithromycin 500 mg on day one, then 250 mg on days 2-5 (oral), or josamycin 500 mg three times daily for 10 days (oral). Second line treatment and treatment for uncomplicated macrolide resistant M. genitalium infection is moxifloxacin 400 mg od for 7-10 days (oral). For third line treatment of persistent M. genitalium infection after azithromycin and moxifloxacin doxycycline 100 mg two times daily for 14 days can be tried and may cure 30%. Pristinamycin 1 g four times daily for 10 days (oral) has a cure rate of app. 90%. Complicated M. genitalium infection (PID, epididymitis) is treated with moxifloxacin 400 mg od for 14 days.

Ureaplasma parvum and Mycoplasma genitalium are found to be significantly associated with microscopy-confirmed urethritis in a routine genitourinary medicine setting.

Inflammation of the urethra defined by an excess of polymorphonuclear leukocytes in the absence of sexually transmitted Chlamydia trachomatis and Neisseria gonorrhoeae is called non-chlamydial non-gonococcal urethritis (NCNGU). Although Mycoplasma genitalium is now recognised as causing a sexually transmitted infection, the clinical significance of the other Mollicute species is less clear. This study used specific real-time quantitative polymerase chain reaction assays to detect and quantify four Mollicute species, M. genitalium, M. hominis, Ureaplasma urealyticum and U. parvum, in urine specimens from men with and without NCNGU. A total of 165 urine specimens from male patients attending a genitourinary medicine clinic were eligible for the study, with microscopy-confirmed (≥5 polymorphonuclear leukocytes in urethral swab) NCNGU in 75 (45.5%) and non-confirmed NCNGU in 90 (54.5%). Chi-squared statistical analysis indicated a significantly higher prevalence of U. parvum (17.3% vs. 5.6%; p = 0.03) and M. genitalium (12% vs. 0%; p < 0.001) in NCNGU. In a subset analysis, M. genitalium was also significantly (p = 0.03) higher in men who have sex with men (MSM; 13.5%) compared to non-MSM (3.1%). No significant associations were reported for U. urealyticum and M. hominis In conclusion, this study supports a clinically significant role in NGNCU for both U. parvum and M. genitalium.

P129 How common is Mycoplasma genitalium? Systematic review and meta-analysis

Background Mycoplasma genitalium is a common cause of non-gonococcal non-chlamydial urethritis but prevalence rates in asymptomatic populations are not well-established. Objectives To estimate the prevalence of M. genitalium in adult women and men in general population and clinic based samples. Methods We searched Embase, Medline, IndMED, AIM and LILACS. We examined eligible studies in forest plots and conducted random effects meta-analysis if appropriate. Between study heterogeneity was examined by use of the I 2 statistic. Results Of 4355 screened abstracts, 55 studies were eligible. In high income countries that described samples from the general population, prevalence estimates ranged from 0.5 to 3.3% (pooled prevalence 1.4% (95% confidence intervals, CI 0.9 to 1.9%, I 2 72.2%). In three studies with population-based random sampling prevalence was 1.2% (95% CI 0.9 to 1.6%, I 2 30.1%). Pooled estimates of prevalence in other populations were: pregnant women 1.2% (95% CI 0.4 to 1.9%, I 2 85.1%, 4 studies); men who have sex (MSM) in the general population 2.3% (95% CI 1.6 to 3.1, I 2 0%, 3 studies); and clinic-based samples of MSM 5.2% (95% CI 4.2% to 6.1%, I 2 0%, 2 studies). In female sex workers in low income countries, prevalence estimates ranged from 13.2 to 26.3% (4 studies). Discussion Prevalence rates of M. genitalium in the overall general population, population-based samples of MSM and pregnant women in high income countries are low. Estimates of prevalence are higher in MSM in clinic-based samples and in female sex workers in low income countries.

P09.11 Should we screen formycoplasma genitalium? evidence synthesis using a transmission-dynamic model

Introduction There is increasing concern about Mycoplasma genitalium as a cause of urethritis, cervicitis, PID, infertility and ectopic pregnancy. Currently there is no licensed test specific for M. genitalium in the UK, where urethral smear microscopy is recommended in GUM clinics, for symptomatic men only. NAATs testing has been advocated, particularly to detect asymptomatic infection. However, M. genitalium ’s natural history is poorly-understood, making the impact and cost-effectiveness of screening unclear. Methods We used a transmission-dynamic model to synthesise evidence from epidemiological and behavioural studies, and surveillance data for Non-Chlamydial, Non-Gonococcal Urethritis (NCNGU), to better-understand the natural history of M. genitalium . The model is stratified by sex, and incorporates heterogeneous sexual behaviour, symptomatic and asymptomatic infection; PID; care-seeking due to symptoms and routine screening; and treatment failure. We fitted to national surveillance data, (allowing for uncertainty in studies measuring the amount of NCNGU caused by M. genitalium ). We examined the effects of implementing NAAT testing for both sexes in GUM and GP settings. Results Introducing NAAT testing for all men (asymptomatic and symptomatic, in GPs and GUM) detects much more infection in men and treatment reduces transmission to women, whilst testing of women reduces prevalence in women and incidence in men. Introducing NAAT testing for both sexes reduces cumulative PID incidence over 20 years by 13.1%(IQR:9.6%–18.3%). However, there is important uncertainty in M. genitalium ’s natural history parameters, leading to uncertainty in the absolute reduction in PID and other sequelae. Particularly important are the proportion of infections that are symptomatic in men and women; duration of untreated infection; and incidence of PID, infertility and ectopic pregnancy attributable to M. genitalium . Conclusion Further empirical work is required to improve understanding of the key aspects of M. genitalium ’s natural history which we have identified before it will be possible to determine if screening is cost-effective. Disclosure of interest statement This presentation reports independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0707–10208). In addition, PJW thanks the UK Medical Research Council for Centre funding (grant MR/K010174/1) and also thanks the UK National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Modelling Methodology at Imperial College London in partnership with Public Health England (PHE) for funding (grant HPRU-2012–10080). The views expressed in this paper are those of the authors and not necessarily those of the NHS, the NIHR, the Department of Health, or Public Health England. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. We have no conflicts of interest.

An estimate of the proportion of symptomatic gonococcal, chlamydial and non-gonococcal non-chlamydial urethritis attributable to oral sex among men who have sex with men: a case–control study

BackgroundSexually transmitted infections (STIs) of the pharynx are common among men who have sex with men (MSM); the degree to which these infections are transmitted through oral sex is unknown.MethodsWe...

Mycoplasma genitalium: update on diagnosis, treatment and resistance

Mycoplasma genitalium is a sexually transmitted bacterium and a major causative agent of non-chlamydial non-gonococcal urethritis (NGU) with approximately 20–35% of NGU cases attributed to this infection. In women it has been associated with cervicitis, endometritis, and pelvic inflammatory disease. There are a limited number of commercial nucleic acid amplification assays available for its detection, however none are yet FDA approved and most laboratories are either using these commercial or in-house developed assays to provide diagnostic results. Mycoplasma genitalium infection is primarily treated with macrolide antibiotic azithromycin. However, it has been shown that use of azithromycin in the treatment of NGU and other infections has resulted in increased macrolide resistance, attributed to mutations on the 23S rRNA gene. The currently recommended second line treatment, moxifloxacin, is a fluoroquinolone antibiotic. Moxifloxacin is relatively expensive, can result in side effects and is not suitable in pregnant women, which limits its widespread usage. Resistance to moxifloxacin has also been reported with its increasing use. Detection, appropriate treatment and test of cure of M. genitalium are important in control of this infection.