Mycoplasma genitalium: the next sexually transmitted superbug?

Antimicrobial resistance and treatment failures are the biggest challenges

The publication of national treatment guidelines does not usually generate headlines in national newspapers. However, the recent release of draft management guidelines for Mycoplasma genitalium infection was accompanied by high profile media coverage suggesting that it is the next sexually transmitted “superbug.” So what are the facts behind these headlines, and how concerned should we be?

First isolated in 1981, M genitalium is the smallest known self replicating bacterium. Most infections are probably asymptomatic and have no adverse health outcomes. Nonetheless, evidence that M genitalium is associated with serious genitourinary and reproductive health morbidity is accumulating.

In men, there is an unequivocal association with non-gonococcal urethritis, and it is detected in up to 40% of men with persistent and recurrent urethritis. In women, a recent meta-analysis found significant associations with a range of clinical syndromes and adverse reproductive health outcomes, including cervicitis, postcoital bleeding, pelvic inflammatory disease, preterm birth, and spontaneous abortion, and a weak association with infertility.

The population prevalence of M genitalium infection ranged from 1.3% to 3.9% and was higher in countries with a low development index. In Britain, a probability sample survey estimated a prevalence of around 1.3% in the sexually active British population aged 16-44 years.4 In common with many other sexually transmitted infections (STIs), M genitalium infection rates can be considerably higher in men who have sex with men, sex workers, and people attending STI clinics.

Antimicrobial resistance

The main concern is M genitalium’s increasing resistance to azithromycin and moxifloxacin, the recommended first and second line treatments in Europe, North America, and Australia, especially in the Asia-Pacific region. For example, single nucleotide polymorphisms in region V of the 23S rRNA gene, which confer macrolide resistance, were found in over 60% of M genitalium specimens from people attending STI clinics in Australia in 2015. Furthermore, selective pressure can lead to the emergence of macrolide resistance after exposure to suboptimal levels of drug.

Importantly, resistance markers are highly correlated with treatment failure, especially when the organism load is high.

New project approved for 2018: Provision and Accessibility of Pre-exposure Prophylaxis (PrEP) in North England and the West Midlands.

Project title: Exploring perspectives on provision and accessibility of Pre-exposure prophylaxis (PrEP) in North England and the West Midlands.

Principal Investigator Professor Marie Claire Van Hout

Team: Professor Vivian Hope; Mr Jim McVeigh: Mrs Jennifer Germain

Site: Public Health Institute, Liverpool John Moores University, Liverpool

The United Kingdom (UK) has a concentrated HIV epidemic, with an estimated 101,200 people living with HIV in 2015. A decrease in diagnoses among men who have sex with men (MSM), the group most affected by HIV transmission, has recently been observed, and is probably due to increased frequency of testing (3 monthly) among those at greatest risk and rapid treatment for those testing positive.

Pre-exposure prophylaxis (PrEP) is an evidence based biomedical HIV prevention strategy which involves HIV negative individuals taking antiretroviral drugs to reduce probability of infection if exposed. The UK PROUD study found PrEP reduced HIV infection risk by 86% among MSM. PrEP is available on the NHS in Wales and Scotland. In October 2017, the IMPACT trial commenced in England, with PrEP being rolled out to 10,000 eligible people.

The project will explore and describe MSM and health professional perspectives on PrEP using qualitative interviews in three Northern cities (Liverpool, Manchester, Sheffield) and one city in the West Midlands (Birmingham) where PrEP is available through the IMPACT trial. Interviews with a purposive sample of participants (8-12 MSM and 4-8 health professionals per city) will focus on: PrEP awareness and sources of information including eligibility, compliance, drug interaction and online sourcing; impact of PrEP on HIV testing patterns, hepatitis C, sexual risk and other sexually transmitted infections; and on issues related to accessing PrEP and optimal service provision

The project is timely given the current IMPACT trial in England, with results informing policy, practice and professional training.

STIRF invites applicants for PhD Studentship

The Sexually Transmitted Infection Research Foundation (STIRF) is a local charity which supports research relating to all aspects of sexual health including clinical practice, public health, microbiology, health economics and behavioural science.

STIRF wishes to fund a PhD Studentship up to a maximum of £60 000 over 3-4 years and is inviting applications with a closing date of July 31, 2018.

Applications would only be considered from universities in the following UK health regions:

West Midlands, Trent, Yorkshire, Northern and North West regions

For details of how to apply go to:

Applications for part funding of PhD in sexual health and related topics

 

Invitation to apply for research funds: 2017 round

We invite researchers in various fields related to sexual health, HIV and other sexually transmitted viruses to apply for research funds.

Sexually Transmitted Infections Research Foundation (STIRF) was set up to pump prime research projects relating to the epidemiology, pathophysiology, management, and health care delivery of sexually transmitted infections and HIV in the West Midlands, Trent, Yorkshire, Northern and North West regions.

The primary aim is to provide initial funding to allow promising projects from researchers early in their career to obtain preliminary results as a prelude to acquire further funds from larger funding bodies.

We invite applications from researchers in the above regions on projects relating to sexually transmitted diseases and HIV. All projects will be initially screened by the Scientific Committee of STIRF and those considered suitable will be sent for peer review by experts in the field.

The following fields of research will be considered in relation to STIs and HIV

  • Epidemiology of HIV and other sexually transmitted diseases
  • Research on HPV and other sexually transmissible malignancies
  • Health care delivery including views of clients
  • Issues relating to deprived or marginalised communities.
  • Pathophysiology of diseases and syndromes
  • Inter-relationship between diseases
  • Treatment modalities
  • Complications of treatment and co-morbidities

 

Applications should not exceed £50,000 in the first year. Depending on satisfactory reports a further £25,000 may be available for the second year. Joint funding with other grant giving bodies will be considered.

For further information and guidance on how to apply visit

http://stirf.org/application-for-research-funds-from-stirf/

 

Deadline for applications is 31th December 2017

Applications using the appropriate form downloaded from the STIRF web site should be sent by email to:

Dr Mohsen Shahmanesh, (Hon Secretary STIRF)

Stirfweb@gmail.com

Is antiretroviral treatment for HIV increasing the susceptibility to syphilis

Recently, the world has experienced a rapidly escalating outbreak of infectious syphilis primarily affecting men who have sex with men (MSM); many are taking highly active antiretroviral therapy (ARV) for HIV-1 infection.

Treatment with ARV reduces risk of infection (because of greatly reduced viral load) and near-normal life expectancy for those on treatment. The currently accepted hypothesis is that these factors result in increased sexual risk-taking, especially unprotected anal intercourse, leading to more non-HIV-1 sexually transmitted infections, including gonorrhoea, chlamydia and syphilis.

However, syphilis incidence has increased more rapidly than other STDs. In a recent open access article in the journal Sexually Transmitted Infections, Reckart and colleagues hypothesise that ART itself  may alter the innate and acquired immune responses to Treponema pallidum, the bacterium causing infectious syphilis, and that this biological explanation plays an important role in the current syphilis epidemic.

In a leading article in the same journal, Susan Tuddenham and colleagues (only available to subscribers), find the hypothesis intriguing despite some flaws. They go on to suggest that further work is necessary to look at the mechanisms underlying the current syphilis epidemic.

In the same issue David Glidden et al point out that in the early double blind trials with pre-exposure prophylaxis (PrEP) no increase in syphilis was found between those taking PrEP and those taking placebo. These findings would suggest that short term exposure to ART has no effect on the acquired immune responses to Treponema pallidum.

Sexually transmitted infections: challenges ahead

A commissioned article in Lancet Infectious Diseases on July 9, 2017 highlights some of the major issues and challenges facing us in the growing global epidemic of sexually transmitted infections (STI). Authors Prof Mabhus Unemo et al summarise the key issues as follows:

WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research.

In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control.

Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease.

The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials.

Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches.

STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control.

Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation.

Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.

Read full article on Lancet Infectious Diseases

Cuts to sexual health services are putting patients at risk

Cuts to sexual health services in parts of England are placing the care of patients at risk, a new report has warned according to a report published in the BMJ.

The research by the healthcare think tank the King’s Fund concluded that budget cuts of more than 20% to genitourinary medicine (GUM) services in some parts of the country had led to service closures and staffing cuts that have harmed patient care. Experts said that the findings were particularly worrying given that numbers of diagnoses of sexually transmitted infections such as syphilis and gonorrhoea were rising.

Current pressures on services were also having a negative effect on staff morale and leading some staff to consider alternative careers, the report warned.

The researchers analysed data and interviewed frontline staff to examine the effect of funding pressure on patient care across four service areas: GUM, district nursing, elective hip replacements, and neonatal care.

Their findings indicated that sexual health and district nursing had been hardest hit which undermined the vision set out in NHS England’s Five Year Forward View to strengthen prevention and community based services.

The authors said that sexual health services such as GUM had become more prone to budgetary cuts since moving from the NHS to local government, because of local authorities’ legal obligation to balance their books.

Centenary of nationwide free access to sexual health clinics in England and Wales

STI began in 1925 as the British Journal of Venereal Disease, and you can read early editions on the sti.bmj.com website. The very first issue covers skin complaints often mistaken for syphilis, the use of bismuth and malaria inoculation to treat syphilis, and the establishment of a network of clinics following a Royal Commission.1 It also discusses diathermy in the treatment of gonorrhoea!

A hundred years ago, we had no effective treatment for gonorrhoea, and it is sobering to realise we may soon be in the same position. The GRASP surveillance system which tracks antimicrobial resistance in England and Wales shows indications that we are not far from ceftriaxone treatment failures in a report by Town et al.2 In an age of nucleic acid based diagnostics, we need alternatives to culture for detecting resistance. A fascinating report by Graham et al reports that whole genome sequencing can be achieved with urine specimens, including the detection of markers associated with resistance.3 On a related note, this month’s editorial by Nigel Garrett reflects on the perhaps brief life of syndromic management.4
Read full article

 

Measuring patient experience and outcome in health care settings on receiving care after sexual violence

We are delighted to receive support from STIRF and the Queen Elizabeth Hospital Birmingham Charity (QEHBC) to fund research in the area of sexual violence.

The project aims to increase our understanding of what matters to patients when they attend health care settings after experiencing sexual violence. This is on the background of the reporting of sexual offences in the UK being at the highest level since introduction of the National Crime Recording Standard in 2002, and also an awareness that it can be extremely difficult for patients to present to health care services, disclose what has happened and seek support.

This systematic review will collect data from a wide range of sources and will be reviewed in a robust and thorough manner, to look at patient experience and outcome after attending a range of health care settings. Identifying key themes and practice that are of greatest importance to patients will then be disseminated to a wide and relevant audience so that this can be put into practice.

Rachel Caswell