Microscopy of Stained Urethral Smear in Male Urethritis; Which Cutoff Should be Used?

BACKGROUND: The microscopical diagnosis of male urethritis was recently questioned by Rietmeijer and Mettenbrink, lowering the diagnostic criteria of the diagnosis to ≥2 polymorphonuclear leucocytes (PMNL) per high power field (HPF), and adopted by Centers for Disease Control and Prevention in their 2015 STD Treatment Guidelines. The European Non-Gonococcal Urethritis Guideline advocates a limit of ≥5 PMNL/HPF. OBJECTIVE: To determine if syndromic treatment of urethritis should be considered with a cutoff value of ≥2 PMNL/HPF in urethral smear. METHODS: The design was a cross-sectional study investigating the presence and degree of urethritis relative to specific infections in men attending an STI clinic as drop-in patients. RESULTS: The material included 2 cohorts: a retrospective study of 13,295 men and a prospective controlled study including 356 men. We observed a mean chlamydia prevalence of 2.3% in the 0-9 stratum, and a 12-fold higher prevalence (27.3%) in the strata above 9. Of the chlamydia cases, 89.8% were diagnosed in strata above 9. For Mycoplasma genitalium, the prevalence was 1.4% in the 0-9 stratum and 11.2% in the stratum ≥10, and 83.6% were diagnosed in strata above 9. For gonorrhea, a significant increase in the prevalence occurred between the 0-30 strata and >30 strata from 0.2% to 20.7%. The results of the prospective study were similar. CONCLUSIONS: Our data do not support lowering the cutoff to ≥2 PMNL/HPF. However, a standardization of urethral smear microscopy seems to be impossible. The cutoff value should discriminate between low and high prevalence of chlamydia, mycoplasma, and gonorrhea to include as many as possible with a specific infection in syndromic treatment, without overtreating those with few PMNL/HPF and high possibility of having nonspecific or no urethritis.

Urethral inflammatory response to ureaplasma is significantly lower than to Mycoplasma genitalium and Chlamydia trachomatis.

A non-syndromic approach to treatment of people with non-gonococcal urethritis (NGU) requires identification of pathogens and understanding of the role of those pathogens in causing disease. The most commonly detected and isolated micro-organisms in the male urethral tract are bacteria belonging to the family of Mycoplasmataceae, in particular Ureaplasma urealyticum and Ureaplasma parvum. To better understand the role of these Ureaplasma species in NGU, we have performed a prospective analysis of male patients voluntarily attending a drop in STI clinic in Oslo. Of 362 male patients who were tested for NGU using microscopy of urethral smears, we found the following sexually transmissible micro-organisms: 16% Chlamydia trachomatis, 5% Mycoplasma genitalium, 14% U. urealyticum, 14% U. parvum and 5% Mycoplasma hominis. We found a high concordance in detecting in turn U. urealyticum and U. parvum using 16s rRNA gene and ureD gene as targets for nucleic acid amplification testing (NAAT). Whilst there was a strong association between microscopic signs of NGU and C. trachomatis infection, association of M. genitalium and U. urealyticum infections in turn were found only in patients with severe NGU (>30 polymorphonuclear leucocytes, PMNL/high powered fields, HPF). U. parvum was found to colonise a high percentage of patients with no or mild signs of NGU (0-9 PMNL/HPF). We conclude that urethral inflammatory response to ureaplasmas is less severe than to C. trachomatis and M. genitalium in most patients and that testing and treatment of ureaplasma-positive patients should only be considered when other STIs have been ruled out.

[Withdrawal of treatment in severely ill newborn infants]. / Avslutning av behandling ved alvorlig sykdom hos nyfødte.

BACKGROUND: Improvements in diagnostics and treatment in perinatal medicine have enabled us to save more premature and critically ill infants and infants born with severe congenital anomalies. However, some of these children often develop complications with a poor prognosis both for survival and quality of life. An active decision to withdraw treatment is common practice in such cases. Little is known about the impact of this problem in neonatal care in Norway. MATERIAL AND METHODS: The records of 178 infants admitted as newborns and who died in our hospital during the period 1990-1999 were reviewed and analysed according to these groups: death in spite of full treatment, death because of active withdrawal of treatment, and death after palliative treatment. We also evaluated to what extent the parents were involved in the decision making process and how that process was documented in patient records. RESULTS: Death after withdrawal of treatment was identified in 65% of the cases and was mainly seen in critically ill immature and premature infants (74%). The parents were usually involved in the decision, though documentation in patient records of the decision making process was generally poor. The ethical, legal and practical implications of this state of affairs probably need to be reviewed.