Clinical Pearls & Morning Reports
Published May 20, 2020
From a nadir in the 1990s, the rates of gonorrhea, syphilis, and chlamydia infections have increased substantially in high-income countries, with particular increases among men who have sex with men (MSM). Read the NEJM Review Article here.
Q: What are some of the emerging sexually transmissible infections?
A: Concurrent with the increase in established sexually transmitted infections are emerging epidemics and outbreaks of “nonclassical” sexually transmissible pathogens that cause a wide range of clinical syndromes. These pathogens include enteric pathogens (e.g., shigella and hepatitis A virus), those spread by close contact (e.g., Neisseria meningitidis), and recently characterized pathogens that can spread through sexual contact (e.g., Zika virus).
Q: What types of sexually transmitted disease have been associated with Neisseria meningitidis?
A:N. meningitidis colonizes the nasopharynx in approximately 10% of healthy persons and, less frequently, also colonizes other mucosal sites, such as the cervix, urethra, and rectum. The pathogen has increasingly been recognized as sexually transmissible, with two distinct clinical contexts emerging: N. meningitidis–associated urethritis in heterosexual men and invasive meningococcal disease in MSM.
A: In 2018, an increase in HAV infections disproportionately affecting MSM was reported in Europe, with approximately 1400 cases occurring across 16 European countries between June 2016 and May 2017. Coinfection with HIV has been common among HAV-infected MSM. Efforts to control recent outbreaks of HAV infection among MSM have been multimodal, focusing on awareness raising in the community and among health care professionals; vaccination of MSM, and enhanced health services for all sexual contacts (“partner management”), including through the use of dating apps and websites. Recent data suggest that previous HAV vaccination in persons with HIV infection may not reliably provide protection against the development of HAV infection. Accordingly, provision of postexposure prophylaxis (consisting of immune globulin and monovalent HAV vaccine) may be considered for persons with HIV infection who have had a recent high-risk exposure to HAV, irrespective of status with regard to previous HAV vaccination.
A: A key emerging issue is increasing antimicrobial resistance in N. gonorrhoeae, which the CDC has identified as an urgent threat to public health in the United States. It is estimated that there are approximately 550,000 drug-resistant N. gonorrhoeae infections per year in the United States. Of particular concern is reduced susceptibility to ceftriaxone, azithromycin, or both — the two major drugs recommended for first-line treatment in most high-income countries. One of the major features of sexually transmitted shigellosis is resistance to multiple antimicrobial agents, particularly azithromycin and ciprofloxacin, with outbreaks of antimicrobial-resistant shigellosis reported among MSM in Europe, North America, Australia, and Asia. In some countries, treatment guidelines for nongonococcal urethritis have shifted away from single-dose azithromycin as first-line treatment, in part because of macrolide resistance in Mycoplamsa genitalium. Treatment regimens for M. genitalium infection are evolving, with emerging reports of dual resistance to both macrolides and fluoroquinolones.