New approaches, such as vaccination, are needed to address increasing gonorrhea rates and the threat of antibiotic-resistant gonorrhea. Although prospects for a gonococcal vaccine have advanced, vaccine acceptability is crucial to maximizing population-level protection among key groups, such as men who have sex with men (MSM). We assessed correlates of acceptability of a potential gonococcal vaccine among sexually active MSM in the United States.
Methods
We used data from the American Men's Internet Study (AMIS) conducted during 8/2019–12/2019. We calculated frequencies of socio-demographic characteristics, vaccine acceptability (responses classified as willing or unwilling) and preferred location for vaccine receipt. Using log-binomial regression analyses, we calculated unadjusted prevalence rates (PR) and 95% confidence intervals (CI) to evaluate factors associated with vaccine acceptability. Reference group for vaccine acceptability was unwilling to accept a vaccine.
Results
Of 10,130 MSM, 83.5% were willing to accept a potential vaccine and 16.5% were unwilling. Preferred locations for vaccination were primary care provider's offices (83.5%) and sexual health clinics (64.6%). Willingness to accept a vaccine was more likely among young MSM (15–24 years [PR=1.09, 95% CI=1.05–1.12], 25–29 years [PR=1.13, 95% CI=1.09–1.17], and 30–39 years [PR=1.10, 95% CI=1.05–1.14]) compared to older MSM (≥40 years), and MSM who reported condomless anal sex (PR=1.09, 95% CI=1.06–1.12), a bacterial sexually transmitted disease (STD) test (PR=1.18, 95% CI=1.15–1.21), HIV pre-exposure prophylaxis use (PR=1.17, 95% CI=1.14–1.19), HIV positivity (PR=1.05, 95% CI=1.02–1.09), a bacterial STD (PR=1.04, 95% CI=1.02–1.07), and a healthcare provider visit (PR=1.11, 95% CI=1.06–1.16) in the past 12 months. MSM who reported ≤high school education (PR=0.93, 95% CI=0.90–0.97) were less willing to accept a vaccine compared to those with >high school education.
Conclusion
Most respondents were willing to accept a potential gonococcal vaccine. These findings can inform the planning and implementation of a future gonococcal vaccination program that targets MSM.
This article summarizes a multistate outbreak of heterosexual syphilis, including 134 cases of syphilis in adults and adolescents and at least 2 cases of congenital syphilis, which occurred on an American Indian reservation in the United States during 2013-2015. In addition to providing salient details about the outbreak, the article seeks to document the case-finding and treatment activities undertaken, their relative success or failure, and the lessons learned from a coordinated, multiagency response. Of 134 adult cases of syphilis, 40% were identified by enhanced, interagency contact tracing and partner services, 26% through symptomatic testing, and 16% through screening of asymptomatic individuals as the result of an electronic medical record screening prompt. A smaller proportion of cases were identified by community screening events in high-morbidity communities; high-risk venue-based screening events; other screening, including screening upon request; and prenatal screening at first trimester, third trimester, and day of delivery. Future heterosexual syphilis outbreak responders should act quickly to coordinate a package of high-yield case-finding and treatment activities-potentially including activities that seek to do the following: (1) increase prenatal screening, (2) improve community awareness and symptomatic test seeking, (3) educate providers and improve general screening for syphilis, (4) implement electronic medical record reminders for providers, (5) screen high-morbidity communities and at high-risk venues, and (6) form novel partnerships to accomplish partner services work when the context does not allow for traditional, disease intervention specialist-only partner services.
To what degree population-level antibiotic use contributes to Neisseria gonorrhoeae (NG) resistance in the US is unclear. We investigated whether outpatient prescribing is associated with NG antibiotic susceptibility.
Methods
Using data from the Gonococcal Isolate Surveillance Project (GISP; a US surveillance system that samples male urethral isolates) during 2005–2013, we calculated annual geometric mean minimum inhibitory concentrations (MICs) of azithromycin, cefixime, and ceftriaxone by site. We used QuintilesIMS data (captures>70% of US outpatient prescriptions and projects to 100% coverage) to calculate annual cephalosporin and macrolide rates prescribing per 1000 men by each county corresponding to a GISP site. For descriptive analyses, we calculated site-specific medians of these measures. We constructed multivariable linear mixed models for each agent with annual prescribing rates as the exposure and one-year lagged geometric mean MIC as the outcome.
Results
Annual geometric mean cefixime MICs increased from 0.009 µg/ml (2005) to 0.021 (2013), ceftriaxone from 0.005 (2006) to 0.01 (2007–2013), and azithromycin from 0.171 (2011) to 0.242 (2008). Western sites had the highest median cefixime MICs (0.018–0.03 by site); Southern sites had the lowest (0.016–0.019). Northeastern (0.298), Midwestern (0.258–0.314), and Western (0.136–0.295) sites had the highest median azithromycin MICs; Southern site had the lowest (0.1–0.234). Ceftriaxone MICs demonstrated little geographic variation. Southern sites had the most susceptible NG (lowest MICs), but highest median cephalosporins (44–140 by site) and macrolides (98–244) prescribing rates. Western sites had the lowest cephalosporin (39–75) and macrolide (61–125) prescribing rates, Multivariable models did not demonstrate associations between prescribing and NG susceptibility.
Conclusion
Using these data, we found no association between US antibiotic prescribing rates and NG susceptibility. Elucidation of factors contributing to resistance, including further investigation of antibiotic use, is warranted.
Support:
The Melon Institute and Metabolism Corp are funded by the University of Oxbridge, UK
We examined partner seeking and sexual behaviors among a representative sample of US adults (n = 1161) during the first year of the COVID-19 pandemic. Approximately 10% of survey respondents sought a new partner, with age and sexual identity being associated with partner seeking behavior. Approximately 7% of respondents had sex with a new partner, which marks a decrease as compared with a prepandemic estimate from 2015 to 2016 in which 16% of US adults reported having sex with a new partner during the past year. Among respondents who had in-person sex with a new partner during the first year of the pandemic, public health guidelines for in-person sexual activity were infrequently followed.
Background. Ceftriaxone is the foundation of currently recommended gonorrhea treatment. There is an urgent need for backup treatment options for patients with cephalosporin allergy or infections due to suspected cephalosporin-resistant Neisseria gonorrhoeae. We evaluated the efficacy and tolerability of 2 combinations of existing noncephalosporin antimicrobials for treatment of patients with urogenital gonorrhea. Methods. We conducted a randomized, multisite, open-label, noncomparative trial in 5 outpatient sexually transmitted disease clinic sites in Alabama, California, Maryland, and Pennsylvania. Patients aged 15–60 years diagnosed with uncomplicated urogenital gonorrhea were randomly assigned to either gentamicin 240 mg intramuscularly plus azithromycin 2 g orally, or gemifloxacin 320 mg orally plus azithromycin 2 g orally. The primary outcome was microbiological cure of urogenital infections (negative follow-up culture) at 10–17 days after treatment among 401 participants in the per protocol population. Results. Microbiological cure was achieved by 100% (lower 1-sided exact 95% confidence interval [CI] bound, 98.5%) of 202 evaluable participants receiving gentamicin/azithromycin, and 99.5% (lower 1-sided exact 95% CI bound, 97.6%) of 199 evaluable participants receiving gemifloxacin/azithromycin. Gentamicin/azithromycin cured 10 of 10 pharyngeal infections and 1 of 1 rectal infection; gemifloxacin/azithromycin cured 15 of 15 pharyngeal and 5 of 5 rectal infections. Gastrointestinal adverse events were common in both arms. Conclusions. Gentamicin/azithromycin and gemifloxacin/azithromycin were highly effective for treatment of urogenital gonorrhea. Gastrointestinal adverse events may limit routine use. These non-cephalosporin-based regimens may be useful alternative options for patients who cannot be treated with cephalosporin antimicrobials. Additional treatment options for gonorrhea are needed. Clinical Trials Registration. NCT00926796.
In Brief A discussion of the article by Tsoumanis et al., as well as why we screen, how we measure impact, and how we can better evaluate population-level benefits of sexually transmitted disease screening.
This issue of AM:STARs, Hot Topics in Adolescent Health, presents a wide array of articles exploring some of the most exciting advances and controversies in adolescent health. These topics and other evolving areas are presented to guide the reader toward providing state of the art clinical care to adolescents, as well as reviewing new research that will shape the future of adolescent health.Topics include:Nutritional and metabolic controversies including the diagnosis of gluten intolerance, vitamin D deficiency and metabolic syndrome in adolescents, and the use of bariatric surgery to treat the comorbidities of adolescent obesity.New diagnostic considerations, including updated DSM-5 diagnostic criteria for mental health disorders such as mood dysregulation, eating disorders, and ADHD.Reproductive health advances including new diagnostic techniques and treatment regimens for HIV and other sexually transmitted infections, as well as the expanding use of long-acting reversible contraceptives.New frontiers in adolescent medicine including office-based management of opiate addiction, support of gender nonconforming youth, and the use of mindfulness practices in the care of a variety of conditions.AM:STARs: Adolescent Medicine: State of the Art Reviews is the official publication of the American Academy of Pediatrics Section on Adolescent Health. Published 3 times per year, the journal offers adolescent medicine specialists and other primary care physicians who treat adolescent patients with state of the art information on all matters relating to adolescent health and wellness.
GONORRHEA HAS AFFECTED HUMANS FOR CENTUries and remains common. Worldwide, an estimated 106.1 million cases occur annually. In 2011, gonorrhea again was the second most commonly reported notifiable infection in the United States with 321 849 cases reported. Because gonorrhea often can be asymptomatic, the true disease burden may be closer to 700 000. Gonorrhea disproportionately affects racial, ethnic, and sexual minorities. Untreated gonococcal infection can lead to pelvic inflammatory disease, ectopic pregnancy, and infertility in women and can facilitate transmission of human immunodeficiency virus. Childhood blindness still affects infants born to mothers infected with gonorrhea, particularly in resource-limited countries. For years, gonorrhea has been easily treated with a single oral dose of antibiotics. However, Neisseria gonorrhoeae has progressively acquired resistance to each new agent: sulfonamides in the 1940s, penicillins and tetracyclines in the 1970s and 1980s, and fluoroquinolones by 2007 in the United States. Since then, cephalosporins have been the only antibiotics recommended for gonorrhea treatment. However, gonococcal susceptibility to oral cephalosporins is declining, and the effectiveness of these drugs is threatened. Increasing cephalosporin minimum inhibitory concentrations (MICs), an early warning of impending resistance, and treatment failures with cephalosporins have been reported from east Asia since the early 2000s and recently have been reported from Europe. In the United States, the Gonococcal Isolate Surveillance Project (GISP), a national surveillance system that monitors trends in antibiotic susceptibility, has documented increasing cefixime MICs since 2009. The steepest cefixime MIC increases have been reported in the western United States and among individuals who have had male-to-male sexual contact, the region and population in which fluoroquinolone resistance initially emerged. However, data are lacking on the cefixime MICs at which clinical effectiveness wanes. In this issue of JAMA, Allen and colleagues report a retrospective cohort study conducted to determine the risk of gonorrhea treatment failure associated with N gonorrhoeae strains exhibiting reduced cefixime susceptibility (defined by the authors as MIC 0.12 g/mL). The authors used data from an Ontario clinic that routinely obtained cultures from patients with gonorrhea; treated them with cefixime, 400 mg, orally; and requested test of cure 2 to 4 weeks after treatment. Patients were considered to have experienced treatment failure if, at follow-up, they were culture-positive with a gonococcal isolate that was identical to the pretreatment isolate by molecular characterization and they denied sexual reexposure. Of 291 patients with positive cultures for N gonorrhoeae, 133 (46%) returned for tests of cure, 9 (6.8%) of whom met the case definition for treatment failure. Among the 28 patients whose pretreatment isolates demonstrated cefixime MICs 0.12 g/mL or greater, 25% failed treatment. To account for possible bias, the authors also calculated treatment failure rate assuming that those who did not return were successfully treated; in this analysis, the treatment failure rate among patients whose pretreatment isolates demonstrated reduced cefixime susceptibility was 11.9% (7/59). Several caveats should be noted in interpreting these results. At least some of the patients who met the treatment failure case definition may have been reinfected. The treatment failure case definition relied on medical record documentation that a patient was not reexposed and molecular techniques to determine that pretreatment and posttreatment isolates were identical. Social desirability bias, stigma, or shame could contribute to inaccurate reporting of interim sexual activity. Furthermore, although pretreatment and posttreatment isolates were identical by molecular techniques, patients reinfected from an untreated partner would be expected to be reinfected with the same strain.
