Antibiotic treatment of symptomatic Mycoplasma genitalium infection in Scandinavia: a controlled clinical trial.

OBJECTIVES: To evaluate the microbiological cure rate after treatment with tetracyclines or azithromycin in patients infected with M genitalium. METHODS: One hundred and fifty-two men and 60 women positive for M genitalium were recruited. Patients treated either with doxycyline for 9 days or with azithromycin 1 g stat. were compared. Those still positive for M genitalium after primary doxycycline treatment received an extended course of azithromycin 500 mg on day 1 followed by 250 mg daily for the following 4 days, whereas those with treatment failure after azithromycin received doxycycline 100 mg twice daily for 15 days. RESULTS: The eradication rate after azithromycin 1 g stat. was 85% (95% CI 69 to 94) in men (n = 39) and 88% (95% CI 64 to 99) in women (n = 17) and after doxycycline 17% (95% CI 9 to 27) in men (n = 76) and 37% (95% CI 19 to 58) in women (n = 27). Extended azithromycin eradicated M genitalium from 96% (95% CI 85 to 99) of the men (n = 47) and from all six women who failed on doxycycline. Extended doxycycline treatment was insufficient. Persistent urethral inflammation was seen in a substantial portion of the men after eradication of M genitalium regardless of the antibiotic drug, indicating a poor predictive value of urethral smears in evaluation of persistent or recurrent infection. CONCLUSIONS: Azithromycin was more effective than doxycycline in treating patients infected with M genitalium. The extended course of azithromycin was highly effective but was given after the initial treatment with doxycycline. Randomised clinical trials are needed to compare the different dosages of azithromycin.

Recurrent genital herpes in a population attending a clinic for sexually transmitted diseases.

Patients with recurrent genital herpes attending a sexually transmitted disease clinic were studied and transmission of the infection was elucidated by evaluating serostatus in their partners. Of 84 patients attending for recurrent genital herpes, 94% had a herpes simplex virus type 2 (HSV-2) infection and only 6% (5 patients) a type 1 infection. The mean age of the patients was 36 years and the duration of their infection was up to 37 years (median 4 years). In most patients the number of recurrences had not decreased between the first year and the last year. About half had experienced a more severe first episode infection. Of the patients, 64% were not aware of asymptomatic shedding and the risk of sexual transmission without clinical symptoms. Of 67 steady partners of patients with genital HSV-2, 15% had a history of genital herpes. By HSV serology, HSV-2 antibodies (indicating subclinical genital herpes) were demonstrated in more than half of the partners. The duration of the relationship or condom use did not seem to influence the frequency of transmission to the partner, which may indicate an individual susceptibility for acquiring a genital HSV-2 infection. Eleven per cent of the patients were on suppressive antiviral therapy, while 39% had no experience of antiviral therapy. Type-specific HSV serology was found to be of value in counselling partners of patients with genital herpes.

First episodes of genital herpes in a Swedish STD population: a study of epidemiology and transmission by the use of herpes simplex virus (HSV) typing and specific serology.

OBJECTIVES: To determine the proportion of herpes simplex virus type 1 (HSV-1) and HSV type 2 (HSV-2) in first episodes of genital herpes. To evaluate the use of HSV specific serology for classifying first episodes of genital herpes and for defining HSV serostatus in the patients' sexual partners. METHODS: 108 consecutive patients with first episodes of genital herpes seen at three STD clinics in Sweden from 1995 to 1999 were included in the study. HSV culture and typing were performed and serum was tested for antibodies against a type common HSV antigen and a type specific HSV-2 antigen, glycoprotein G2 (gG2). A structured interview including questions about sexual behaviour and sexual partners was taken. "Steady" partners were offered a blood test for HSV serology and counselling. RESULTS: Of 108 patients, 11 had a negative HSV culture. Of the 97 who were HSV culture positive, 44% (43/97) were typed as HSV-1 and 56% (54/97) as HSV-2. For 86 of these 97 patients, HSV serology from the initial visit was available. Of 52 primary infections, thus initially seronegative, 64% were HSV-1 infections and of 19 female primary infections 16 (84%) were HSV-1. In 17% the first episode of genital herpes corresponded to the first clinical recurrence of an infection acquired earlier in life. There was a significant correlation between having orogenital sex and being infected with HSV-1 and also a history of labial herpes in the partner. Only 20% of partners of patients with an HSV-2 infection had a history of genital herpes. CONCLUSIONS: Almost half of first episodes of genital herpes are caused by HSV-1. In young women with a primary genital infection, HSV-1 is much more frequent than HSV-2. Besides HSV typing, we found specific HSV serology of value for classifying first episodes and for diagnosing a subclinical HSV-2 infection in partners. Anamnestic data supported the suggestion that the orogenital route of transmission was common in genital HSV-1 infections.

Occurrence and treatment of Mycoplasma genitalium in patients visiting STD clinics in Sweden.

Two hundred and thirty-three men and 85 women visiting STD clinics in western Sweden between April 1997 and March 1998 were examined for Mycoplasma genitalium and Chlamydia trachomatis. The bacteria were identified by the polymerase chain reaction (PCR) technique. Three women (3.5%) and 18 men (7%) were positive for M. genitalium. Seventeen (14%) of the 115 men with urethritis were infected but only one of the men was without urethritis. After treatment with tetracyclines for 10 days, one woman and 8 of the 13 men still harboured M. genitalium. M. genitalium-infected men did not have more life-time partners than other men visiting STD clinics. More men positive for M. genitalium gave a history of previous urethritis but the difference was not significant.

Epidemiologic characteristics of two different populations of women with Chlamydia trachomatis infection and their male partners.

Two groups of women under the age of 26 with chlamydial infection (A-asymptomatic women from a screening program, B-traditional STD clinic patients) and their partners were compared with respect to history of STD, sexual behavior, contraception, and indices for income and social welfare expense. The mean number of partners was 1.3 in group A and 1.8 in group B. Women in group B, in spite of more frequent condom use, demonstrated greater risk behavior both with respect to STD and to unwanted pregnancy and also had higher indices for social welfare expense. More group A partners than group B partners were asymptomatic and chlamydia negative. Group B partners also more often had low income as well as high social welfare expense indices. In both groups, complicated chains of transmission were found, and the need for expert contact tracing in both types of patient groups is stressed.

Contact tracing in the control of genital Chlamydia trachomatis infection.

Four different types of contact tracing for partners of Chlamydia trachomatis infected patients were compared with respect to reinfections during two 15-month periods in 1979/80 and in 1983/84. Between the two study periods a gradual improvement in contact tracing occurred. No reduction in overall reinfections was observed in the second period, reinfections occurring within 12 weeks were similar in the two periods. Treatment of the regular partner (by giving the woman a prescription for her partner) without examination or further partner follow-up resulted in few reinfections. A system of partner referral without verification that partners actually appeared for examination resulted in significantly more reinfections by the regular partner than a system with non-mandatory verification: 60 of 997 women (6%) compared with 6 of 645 (1%). The addition of C. trachomatis infection to the existing STD legislation resulted in fewer identified partners refusing examination than previously, one of 254 men (0.4%) compared with 40 of 223 (18%) before legal inclusion.

Contact tracing for human immunodeficiency virus (HIV) infection.

Contact tracing--or partner notification--is a generally accepted method for the control of sexually transmitted diseases (STDs), but its use as an epidemiological tool against the spread of acquired immunodeficiency syndrome (AIDS) has been questioned. The authors find contact tracing for infection with human immunodeficiency virus (HIV) quite feasible; it makes it possible for health care providers to reach people at high risk for infection in order to offer them counseling and testing. Contact tracing must be performed by someone directly engaged in caring for the HIV infected patient, as well as in giving support and aiding the patient through possible crisis reactions. Through this approach the authors were able to identify 188 contacts to 91 index patients. Thirty-eight of the contacts were seropositive for HIV infection, and 21 of these were previously unaware of their infection.

Long-term oral acyclovir treatment prevents recurrent genital herpes.

Thirty-three patients with frequently recurring genital herpes completed a randomized double-blind, crossover trial with oral acyclovir 200 mg 4 times a day and placebo for periods of 12 weeks. Five patients (15%) had full recurrence during acyclovir treatment and 31 (94%) while receiving placebo. The median time to first recurrence was 20 days for placebo and more than 84 days for acyclovir. It was concluded that acyclovir was well tolerated and an effective treatment to suppress the disease in selected cases of severe and frequently recurring genital herpes. However, the relapses seem to occur with the same rate as before, when the suppressive acyclovir treatment is stopped.

Acute epididymitis and Chlamydia trachomatis.

Prostatitis and epididymitis, which are the most common complications of urethritis in men below 35 years of age may be associated with Chlamydia trachomatis infection. Chlamydiae have been isolated from expressed prostatic fluid in men with urethritis complicated by prostatitis and epididymitis. Epididymitis seem to be an established complication of chlamydial urethritis particularly when urethritis is complicated with prostatitis. Since epididymitis may lead to reduced fertility, prompt antibiotic treatment using tetracyclines should be administered to patients with this condition.

Intestinal parasitic infection and other sexually transmitted diseases in asymptomatic homosexual men.

76/133 (57%) asymptomatic homosexual men harboured intestinal parasites. Of these, 40 had Entamoeba histolytica or Giardia lamblia, or both. In a control group of heterosexual men, no pathogenic protozoa were found. Stool specimen cultures for Salmonella, Shigella, and Campylobacter were negative. 7% of the homosexual men were infected with Neisseria gonorrhoeae in the pharynx or rectum, or both, and 5% with Chlamydia trachomatis in the urethra or rectum. Serological evidence of syphilis was detected in 18 men (13.5%) of whom 2 were untreated. Serological markers of hepatitis A were found in 20% and of hepatitis B in 48%. The prevalence of antibodies to cytomegalovirus was higher in homosexual than in heterosexual men (88% versus 59%).

Treatment of complicated infections of the male genital tract, with emphasis on Chlamydia trachomatis.

Prostatitis and epididymitis, which are the most common complications of urethritis in men below 35 years of age, may be associated with Chlamydia trachomatis infection. Chlamydiae have been isolated from expressed prostatic fluid in men with urethritis complicated by prostatitis and from the epididymis in men with acute epididymitis. Tetracyclines are effective treatment for genital chlamydial infections, including those affecting the accessory genital glands. Two 7-day courses of lymecycline, separated by a 10-day interval, eradicated C. trachomatis from 26 men with prostatitis and genital chlamydial infection. With erythromycin, results of treatment were unsatisfactory. Since acute prostatitis carries a risk of chronic infection, and since epididymitis, in particular, may lead to reduced fertility, prompt antibiotic treatment should be administered to patients with either of these two conditions.

Isolation of Chlamydia trachomatis from the urethra and from prostatic fluid in men with signs and symptoms of acute urethritis.

Chlamydia trachomatis was isolated from the urethra in 71 of 275 men primarily attending the outpatient clinic of the Department of Urology because of symptoms of acute urethritis, and with more than four polymorphonuclear leukocytes in each of at least five fields of the swabbed urethral exudate (x1000). C. trachomatis was isolated from 34 of 48 men below 26 years of age, while only 37 of the 227 men aged 26 years or older harboured chlamydial infection. C. trachomatis was isolated from the prostatic secretion of 26 men with acute urethritis and more than 20 polymorphonuclear leukocytes in 10 or more random fields (x450) in the stripped prostatic fluid, suggesting a positive correlation between chlamydial infection and sub-acute silent prostatitis. Among 70 men with C. trachomatis isolated from the urethra, the organism had disappeared at re-examination within 10 days in 19 (27%). Such a disappearance was found in only one of 26 men (4%) in whom C. trachomatis had been isolated not only from the urethra but also from stripped prostatic fluid. Four weeks after two treatment cycles of lymecycline 300 mg twice daily for 7 days with an interval of 10 days, C. trachomatis was but isolated in any urethral specimen, nor from the expressed prostatic fluid.

Genital Chlamydia trachomatis infection in women.

Specimens for isolation of Neisseria gonorrhoeae, Chlamydia trachomatis, Candida albicans, and Trichomonas vaginalis were collected from 585 women attending clinics for venereal diseases. The isolation rates in women attending clinics for venereal diseases. The isolation rates in women with and without genitourinary symptoms, the course of untreated chlamydial infection, the occurrence of chlamydial urethritis, and the response to antibiotic treatment were investigated. A 30% incidence of chlamydial amd gonococcal infection was observed. In most cases the gonococcal infection affected both the cervix and the urethra, whereas the chlamydial infection was restricted to either the cervix or the urethra. Sampling of secretions from the urethra revealed chlamydial infections (15%) that otherwise would have remained undetected. In untreated cases chlamydiae persisted for at least 6 weeks. Bacteriologically, chlamydial infections responded equally well to doxycycline, erythromycin, and a combination of trimethoprim and sulfamethoxazole. however, symptoms persisted in 34% of the women.

The risk of transmission of genital Chlamydia trachomatis infection is less than that of genital Neisseria gonorrhoeae infection.

A total of 211 men with 237 female sexual partners and a total of 155 women with 156 male consorts were examined for genital infection with Chlamydia trachomatis and Neisseria gonorrhoeae. The index patients had either single chlamydial or gonococcal infections or dual infections with both microorganisms. Analysis of recovery rates for groups of sexual consorts indicated that gonorrhea was contracted more frequently than chlamydial infection. Thus, when index patients had dual infections, 45% and 28% of their female and male consorts, respectively, had chlamydial infection, but 64% and 77%, respectively, had gonorrhea. When index patients had single infections with C. trachomatis or N. gonorrhoeae, chlamydial infections were observed in consorts of 45% (women) and 28% (men), but gonococcal infections were observed in 80% (women) and 81% (men). Moreover, a significantly larger proportion of consorts of patients with chlamydial infection eluded infection than did partners of patients with gonorrhea. Women who used an intrauterine contraceptive device had chlamydial and gonococcal infections more often than those who used other forms of contraception, or no contraceptive.

PIP: A total of 211 men with 237 female sexual partners and a total of 155 women with 156 male consorts were examined for genital infection with Chlamydia trachomatis and Neisseria gonorrhoeae. The index patients had either single chlamydial or gonococcal infections or dual infections with both microorganisms. Analysis of recovery rates for groups of sexual consorts indicated that gonorrhea was contracted more frequently than chlamydial infection. Thus, when index patients had dual infections, 45% and 28% of their female and male consorts, respectively, had chlamydial infection, but 64% and 77%, respectively, had gonorrhea. When index patients had single infections with C. trachomatis or N. gonorrhoeae, chlamydial infections were observed in consorts of 45% (women) and 28% (men), but gonococcal infections were observed in 80% (women) and 81% (men). Moreover, a significantly larger proportion of consorts of patients with chlamydial infection eluded infection than did partners of patients with gonorrhea. Women who used an IUD had chlamydial and gonococcal infections more often than those who used other forms of contraception or no contraception at all.

Susceptibility of Chlamydia trachomatis to antibiotics in vitro and in vivo.

The susceptibility of Chlamydia trachomatis to antibiotics was studied in vitro and in patients with nongonococcal urethritis. The minimal inhibitory concentrations of cloxacillin, erythromycin, pivampicillin, oxytetracycline, and doxycycline, which were the most effective drugs, were 10, 0.5, 0.25, 0.1, and 0.5 microgram/ml, respectively. The clinical observations suggested that of the antibiotics studied, doxycycline, erythromycin, and trimethoprim-sulfamethoxazole were effective for treatment of chlamydial infection and nongonococcal urethritis. Trimethoprim-sulfamethoxazole seemed less efficient for treatment of patients with nongonococcal urethritis whose cultures were chlamydia-negative. Pivampicillin, although it was active in vitro against C. trachomatis, did not produce a satisfactory clinical response. Untreated patients had symptoms of urethritis and chlamydial infection for three weeks. Incubation periods of a week or less were recorded for about half of the patients who had nongonococcal urethritis, both those whose cultures were chlamydia-positive and those whose cultures were chlamydia-negative. However, a few patients in both groups reported incubation periods of four weeks or more.

Chlamydia trachomatis infection and veneral disease.

Chlamydia trachomatis was isolated by the irradiated McCoy cell technique from 44 out of 103 men with non-gonorrhoeic urethritis and from 11 out of 15 patients with post-gonococcal urethritis. In women attending the venereal diseases clinics, chlamydial infection was observed in 49 out of 130 patients (38%), an infection incidence of the same order of magnitude as the one noted for gonococcal infection (40%). In 19% both infections occurred simultaneously. Treatment with tetracycline eliminated symptoms and chlamydial infection in almost all cases. The significance of the findings is discussed.

Influence of copper salts on gonococci.

No difference in the incidence of gonorrhoea was observed at a venereal disease clinic between women using a copper-coil intrauterine device (IUD) and women using oral contraceptives. Experiments in vitro demonstrated that copper sulphate has a deleterious effect on Neisseria gonorrhoeae, but the presence of serum protects the gonococci from the toxic effect of copper ions.