More than 60 percent of US adults report that they had adverse childhood experiences (ACEs). For this study of 930,000 children born during the period 1999-2003, we used linked administrative, survey, and criminal justice data to measure the association between ACEs (parental death; separation; incarceration; or criminal charge for intimate partner violence, substance use disorder, or child sexual or nonsexual abuse) and socioeconomic disadvantages at ages 18-22 during 2017-21. After childhood socioeconomic status was controlled for, young adults with ACEs were more likely to have been charged with felonies, have become teenage parents, live in a household with poverty or housing assistance, be enrolled in Medicaid, and be employed, and were less likely to be enrolled in an educational institution. These outcomes were most likely among young adults with multiple ACEs or lower childhood socioeconomic status. Using new linked data opportunities, this study provides large-scale, person-level longitudinal evidence of the long-lasting and substantial societal cost of ACEs.

This report provides new CDC recommendations for tests that can support a diagnosis of syphilis, including serologic testing and methods for the identification of the causative agent Treponema pallidum. These comprehensive recommendations are the first published by CDC on laboratory testing for syphilis, which has traditionally been based on serologic algorithms to detect a humoral immune response to T. pallidum. These tests can be divided into nontreponemal and treponemal tests depending on whether they detect antibodies that are broadly reactive to lipoidal antigens shared by both host and T. pallidum or antibodies specific to T. pallidum, respectively. Both types of tests must be used in conjunction to help distinguish between an untreated infection or a past infection that has been successfully treated. Newer serologic tests allow for laboratory automation but must be used in an algorithm, which also can involve older manual serologic tests. Direct detection of T. pallidum continues to evolve from microscopic examination of material from lesions for visualization of T. pallidum to molecular detection of the organism. Limited point-of-care tests for syphilis are available in the United States; increased availability of point-of-care tests that are sensitive and specific could facilitate expansion of screening programs and reduce the time from test result to treatment. These recommendations are intended for use by clinical laboratory directors, laboratory staff, clinicians, and disease control personnel who must choose among the multiple available testing methods, establish standard operating procedures for collecting and processing specimens, interpret test results for laboratory reporting, and counsel and treat patients. Future revisions to these recommendations will be based on new research or technologic advancements for syphilis clinical laboratory science.

INTRODUCTION: There is limited recent information regarding the impact of interpersonal violence on an individual's non-health-related experiences and attainment, including criminal activity, education, employment, family status, housing, income, quality of life, or wealth. This study aimed to identify publicly available representative data sources to measure the socioeconomic impact of experiencing interpersonal violence in the U.S. METHODS: In 2022, the authors reviewed data sources indexed in Data.gov, the Inter-university Consortium for Political and Social Research data archive, and the U.S. Census Bureau's Federal Statistical Research Data Center network to identify sources that reported both nonfatal violence exposure and socioeconomic status-or data sources linking opportunities to achieve both measures-over time (i.e., longitudinal/repeated cross-sections) at the individual level. Relevant data sources were characterized in terms of data type (e.g., survey), violence measure type (e.g., intimate partner violence), socioeconomic measure type (e.g., income), data years, and geographic coverage. RESULTS: Sixteen data sources were identified. Adverse childhood experiences, intimate partner violence, and sexual violence were the most common types of violence faced. Income, education, and family status were the most common socioeconomic measures. Linked administrative data offered the broadest and the most in-depth analytical opportunities. CONCLUSIONS: Currently, linked administrative data appears to offer the most comprehensive opportunities to examine the long-term impact of violence on individuals' livelihoods. This type of data infrastructure may provide cost-effective research opportunities to better understand the elements of the economic burden of violence and improve targeting of prevention strategies.

A Neisseria gonorrhoeae multilocus sequence type (MLST) ST7363 strain was isolated from a patient at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, in 2010 and completely sequenced. This strain is susceptible to ceftriaxone and cefixime. A complete circular chromosome and circular plasmids were assembled from combined Oxford Nanopore Technologies (ONT) and Illumina sequencing.

During the 2017-2018 National Health and Nutrition Examination Survey, urine samples from participants aged 14-59 years were tested for Mycoplasma genitalium infection. Overall prevalence was 1.7% (95% CI: 1.1%, 2.7%). Prevalence was similar between males (1.8%, 95% CI: 0.9%, 3.1%) and females (1.7%, 95% CI: 0.8%, 3.0%).

BACKGROUND: Trichomonas vaginalis (TV) is a sexually transmitted parasite associated with multiple adverse outcomes in women. Estimating TV incidence is challenging due to its largely asymptomatic presentation. METHODS: Per capita prevalence was estimated using the National Health and Nutrition Examination Survey, 2013-2018. Incidence was estimated using ordinary differential equations assuming static incidence at steady state and fit using Bayesian techniques. Model inputs included estimates of: proportion of asymptomatic cases, natural clearance, and time to symptomatic treatment seeking. Posterior distributions were drawn, and uncertainty reported, from 25th (Q1) to 75th (Q3) percentiles. Aggregated measures were estimated by combining component distributions. RESULTS: Among 15-59 year-olds in 2018, the number of prevalent TV infections was 2.5 (Q1=2.4, Q3=2.7) million overall, 435,000 (Q1=382,000, Q3=492,000) among men, and 2.1 (Q1=2.0, Q3=2.2) million among women; the number of incident infections was 7.4 (Q1=6.6, Q3=8.3) million, 4.1 (Q1=3.5, Q3=4.9) million, and 3.2 (Q1=2.7, Q3=3.7) million among all persons, men, and women, respectively. Persons aged 15-24 years comprised 15.7% and 17.6% of all prevalent and incident infections, respectively; prevalence and incidence in both sexes increased with age. Incidence in both sexes were highly dependent upon estimates of natural clearance, which were based on little data. CONCLUSIONS: Prevalence and incidence of TV are substantial in the United States, particularly among those aged ≥25 years. Though estimated prevalence is higher in women, estimated incidence is higher in men. Data on key parameters of TV infection are limited; future research should focus on clarifying the natural history of TV.

BACKGROUND: Men who have sex with men (MSM) using HIV pre-exposure prophylaxis (PrEP) may be at high risk for bacterial sexually transmitted infections (STIs). We examined the prevalence of extragenital gonorrhea and chlamydia by PrEP status among a multisite sample of US MSM. METHODS: MSM aged ≥18 years were recruited through venue-based sampling to participate in the 2017 National HIV Behavioral Surveillance. In 5 cities (San Francisco, Washington DC, New York City, Miami, and Houston), participants completed a questionnaire, HIV testing, and pharyngeal and rectal STI specimen self-collection. We measured prevalence of pharyngeal and rectal gonorrhea and chlamydia among self-reported non-HIV-positive MSM who reported using or not using PrEP in the previous 12 months. RESULTS: Overall, 29.6% (481/1627) of non-HIV-positive MSM reported PrEP use in the past year. MSM who reported PrEP use were more likely to have any STI (ie, extragenital gonorrhea and/or chlamydia) than MSM not on PrEP [14.6% vs. 12.0%, adjusted prevalence ratio (aPR) = 1.5, 95% confidence interval (CI) : 1.1 to 2.0], reflecting differences in rectal chlamydia prevalence (8.7% vs. 6.0%, aPR = 1.6, 95% CI: 1.1 to 2.4). PrEP use was not associated with pharyngeal chlamydia, pharyngeal gonorrhea, or rectal gonorrhea. CONCLUSIONS: The prevalence of extragenital STI was high for both MSM on PrEP and those not on PrEP in the past year. MSM on PrEP were more likely to have rectal chlamydia but not pharyngeal STIs or rectal gonorrhea. Our findings support regular STI testing at exposed anatomic sites as recommended for sexually active MSM, including those on PrEP.

BACKGROUND: Antibiotic-resistant gonorrhoea has been a chronic public health burden since the mid-1930s. Recent emergence of isolates resistant to the current recommended antibiotics for gonorrhoea further magnifies the threat of untreatable gonorrhoea. The lack of new, effective antibiotics highlights the need for better understanding of the population structure of Neisseria gonorrhoeae in order to provide greater insight on how to curtail the spread of antimicrobial-resistant N. gonorrhoeae. OBJECTIVES: To explore a potential application of MALDI-TOF MS to differentiate N. gonorrhoeae displaying different levels of susceptibility to the antibiotic azithromycin. METHODS: We conducted MALDI-TOF MS using the Bruker Biotyper on 392 N. gonorrhoeae isolates collected through the Gonococcal Isolate Surveillance Project (GISP) and/or the Strengthening the United States Response to Resistant Gonorrhea (SURRG) project. The MALDI-TOF MS spectra were visually analysed to assess the presence of distinctive peak(s). Statistical analysis was performed to assess the relationship between gonococcal isolates with the distinct protein peak and antibiotic susceptibility. RESULTS: In this study, we were able to differentiate N. gonorrhoeae isolates into two distinct subpopulations using MALDI-TOF MS. Isolates were distinguished by the presence or absence of a spectral peak at 11 300 Da. Notably, these two groups exhibited different levels of susceptibility to azithromycin. CONCLUSIONS: We have shown that in addition to its ability to identify N. gonorrhoeae, MALDI-TOF MS could also be used to differentiate gonococcal isolates with different levels of susceptibility to azithromycin.

US gonorrhea rates are rising, and antibiotic-resistant Neisseria gonorrhoeae (AR-Ng) is an urgent public health threat. Since implementation of nucleic acid amplification tests for Ng identification, capacity for culturing Ng in the US has declined, along with the ability to perform culture-based antimicrobial susceptibility testing (AST). Yet, AST is critical for detecting and monitoring AR-Ng. In 2016, CDC established the Antibiotic Resistance Laboratory Network (AR Lab Network) to shore up national capacity for detecting several resistance threats including Ng. AR-Ng testing, a sub-activity of CDC's AR Lab Network, is performed in a tiered network of approximately 35 local laboratories, four regional laboratories (state public health laboratories in MD, TN, TX, WA), and CDC's national reference laboratory. Local laboratories receive specimens from approximately 60 clinics associated with the Gonococcal Isolate Surveillance Project (GISP), enhanced GISP (eGISP), and Strengthening the U.S. Response to Resistant Gonorrhea (SURRG). They isolate and ship up to 20,000 isolates to regional laboratories for culture-based agar dilution AST with seven antibiotics and for whole genome sequencing of up to 5,000 isolates. The CDC further examines concerning isolates and monitors genetic AR markers. During 2017 and 2018, the network tested 8,214 and 8,628 Ng isolates, and CDC received 531 and 646 concerning isolates, and 605 and 3,159 sequences, respectively. In summary, the AR Lab Network supported laboratory capacity for Ng-AST and associated genetic marker detection, expanding pre-existing notification and analysis systems for resistance detection. Continued, robust AST and genomic capacity can help inform national public health monitoring and intervention.

Rising azithromycin nonsusceptibility among Neisseria gonorrhoeae isolates threatens current treatment recommendations, but the cause of this rise is not well understood. We performed an ecological study of seasonal patterns in macrolide use and azithromycin resistance in N. gonorrhoeae, finding that population-wide macrolide use is associated with increased azithromycin nonsusceptibility. These results, indicative of bystander selection, have implications for antibiotic prescribing guidelines.

Among the US civilian noninstitutionalized population aged 14 to 59 years in 2013 to 2016, prevalence of Trichomonas vaginalis infection in urine was 1.3% overall. Prevalence was 2.1% among females, 0.5% among males, and highest at 9.6% among non-Hispanic black females. Estimate instability limited analysis of factors beyond sex, age, and race/Hispanic ethnicity.

Antimicrobial-resistant Neisseria gonorrhoeae (NG) infection is a global public health threat, and there is a critical need to monitor patterns of resistance and risk factors. In collaboration with the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (CDC), and the Thailand Department of Disease Control (DDC), Ministry of Public Health (MoPH) implemented the first Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) in November 2015. Men presenting with urethritis at two clinical settings in Bangkok, Thailand (Bangrak Hospital [BH] and Silom Community Clinic @TropMed [SCC @TropMed]) provided demographic and behavioral information and had a urethral swab for Gram's stain and NG culture collected. The NG isolates were evaluated for antimicrobial susceptibility by the Epsilometer test (Etest) to determine minimum inhibitory concentrations (MICs) for cefixime (CFM), ceftriaxone (CRO), azithromycin (AZI), gentamicin (GEN), and ciprofloxacin (CIP). From November 2015 -October 2016, 1,102 specimens were collected from 1,026 symptomatic men; 861 (78.1%) specimens were from BH and 241 (21.9%) specimens were from SCC @TropMed. Among the 1,102 specimens, 582 (52.8%) had intracellular Gram-negative diplococci and 591 (53.6%) had NG growth (i.e., NG infection); antimicrobial susceptibility testing (AST) was performed on 590 (99.8%) NG isolates. Among all symptomatic men, 293 (28.6%) had sex with men only, 430 (41.9%) were ages 18-29 years, 349 (34.0%) had antibiotic use in the last 2 weeks, and 564 (55.0%) had NG infection. Among 23 men with repeat NG infection during this first year of surveillance, 20 (87.0%) were infected twice, 2 (8.7%) were infected three times, and 1 (4.3%) was infected more than four times. All NG isolates were susceptible to CFM and CRO, and had MICs below 2 mug/mL for AZI and below 16 mug/mL for GEN. Overall, 545 (92.4%) isolates were resistant to CIP. This surveillance activity assessed individual patients, and included demographic and behavioral data linked to laboratory data. The inclusion of both individual and laboratory information in EGASP could help identify possible persistent infection and NG treatment failures. Expansion of EGASP to additional global settings is critical to assess trends and risk factors for NG, and to monitor for the emergence of resistance.

Chlamydia trachomatis (CT) infections remain highly prevalent. CT reinfection occurs frequently within months after treatment, likely contributing to sustaining the high CT infection prevalence. Sparse studies have suggested CT reinfection is associated with a lower organism load, but it is unclear whether CT load at the time of treatment influences CT reinfection risk. In this study, women presenting for treatment of a positive CT screening test were enrolled, treated and returned for 3- and 6-month follow-up visits. CT organism loads were quantified at each visit. We evaluated for an association of CT bacterial load at initial infection with reinfection risk and investigated factors influencing the CT load at baseline and follow-up in those with CT reinfection. We found no association of initial CT load with reinfection risk. We found a significant decrease in the median log10 CT load from baseline to follow-up in those with reinfection (5.6 CT/ml vs. 4.5 CT/ml; P = 0.015). Upon stratification of reinfected subjects based upon presence or absence of a history of CT infections prior to their infection at the baseline visit, we found a significant decline in the CT load from baseline to follow-up (5.7 CT/ml vs. 4.3 CT/ml; P = 0.021) exclusively in patients with a history of CT infections prior to our study. Our findings suggest repeated CT infections may lead to possible development of partial immunity against CT.

Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) are the most frequently reported notifiable diseases in the United States and costs for diagnosis and treatment of these two infections are approximately $700 million per year. A proposed new method for screening for these two infections is self-tests; similar to at-home pregnancy and HIV tests which do not include sending collected specimens to a laboratory for diagnosis. However, no such self-tests for sexually transmitted diseases (STD) have been approved by the Food and Drug Administration (FDA). To determine the acceptability of such a test, we used three surveys, conducted in 2017, including the American Men's Internet Survey, the SummerStyles survey, and the DocStyles survey to ask potential users about their interest in this type of test and how they might use it. Among our sampled population of men who have sex with men, 79.5% said they would prefer to take this type of test at home and 73.9% said they would be willing to pay at least $20 for the test. Among young adults (18-29years), 54.1% indicated that they would like to take this test at home and 64.5% were willing to pay more than $10 for such a test. Among sampled physicians, 85.1% were "likely" or "very likely" to use an FDA-approved STD self-test in their office to screen for CT or GC. Self-tests for STDs are on our horizon and we need to be prepared to integrate these tests into our healthcare systems.

Chlamydia trachomatis (CT) serological assays with improved sensitivity over commercially available assays are needed to evaluate the burden of CT infection and effectiveness of prevention efforts. We evaluated the performance of a CT outer membrane complex protein B (OmcB) ELISA in the detection of anti-CT antibody responses in CT-infected women. OmcB ELISA was less sensitive than our CT elementary body (EB ELISA), but was highly specific. The magnitude of the antibody response was higher in African Americans and those with prior CT infection. Unlike EB ELISA, the IgG1 response to CT OmcB was short-lived and not maintained by repeat CT infection.

OBJECTIVES: To assess potentially missed sexually transmitted infections (STIs), we compared clinically diagnosed STIs to laboratory-confirmed diagnoses of gonorrhoea (GC), chlamydia (CT) and trichomonas (Tvag). DESIGN: Secondary analysis of a randomised controlled trial. SETTING: We used data and specimens previously collected for the Sino-Implant Study in Kingston, Jamaica. PARTICIPANTS: The Sino-Implant Study randomised 414 women to receive a levonorgestrel implant at either baseline or 3 months post-enrolment to evaluate unprotected sex after implant initiation. This analysis used 254 available vaginal swab samples. OUTCOME MEASURES: Clinically diagnosed STIs were determined from medical records by assessing clinical impressions and prescriptions. Laboratory-confirmed STIs included GC, CT and Tvag tested by Aptima Combo 2 for CT/GC and Aptima Tvag assays (Hologic, San Diego, California, USA). Log-binomial regression models fit with generalised estimating equations were used to estimate associations of clinically diagnosed STIs with laboratory-confirmed diagnoses and demographic and behavioural characteristics. RESULTS: Overall, 195 (76.8%) women had laboratory-confirmed STI (CT, GC or Tvag) while only 65 (25.6%) women had clinically diagnosed cervicitis and/or vaginitis during the study period. Clinical diagnosis missed 79.7% of laboratory-confirmed STIs: 85% of GC (n=17/20), 78.8% of CT (n=141/179) and 80.0% of Tvag (n=180/225). Hormonal contraceptive use in the month prior to the study visit was significantly associated with clinical diagnosis at any time point (prevalence ratio (PR): 1.65, 95% CI 1.07 to 2.54). As age increased, clinically missed infections significantly decreased (PR: 0.98 per year increase, 95% CI 0.97 to 1.00). CONCLUSIONS: The prevalence of laboratory-confirmed STIs was much higher than what was captured by clinical diagnosis. GC, CT and Tvag were not accurately detected without lab confirmation. Missed diagnoses decreased with older age. Increased laboratory capacity and refinement of the syndromic approach are needed to protect the health of sexually active Jamaican women. TRIAL REGISTRATION NUMBER: NCT01684358.

New technology may soon allow individuals to test themselves for chlamydia and gonorrhea. These new self-tests might help increase screening, but they will also bring new issues for treatment, prevention, and surveillance. Providers will need to decide how to respond to patients who present after a positive screening test and how to approach partner testing and treatment. Research will be needed to identify approaches to increase screening using these tests. Laboratory-based surveillance will not capture infections if testing does not involve a laboratory, so new surveillance techniques will be needed. Self-tests are new tools that will soon be available. We should be prepared to use them.

Monitoring trends in antimicrobial drug-resistant Neisseria gonorrhoeae is a critical public health and global health security activity because the number of antimicrobial drugs available to treat gonorrhea effectively is rapidly diminishing. Current global surveillance methods for antimicrobial drug-resistant N. gonorrhoeae have many limitations, especially in countries with the greatest burden of disease. The Enhanced Gonococcal Antimicrobial Surveillance Program is a collaboration between the World Health Organization and the Centers for Disease Control and Prevention. The program aims to monitor trends in antimicrobial drug susceptibilities in N. gonorrhoeae by using standardized sampling and laboratory protocols; to improve the quality, comparability, and timeliness of gonococcal antimicrobial drug resistance data across multiple countries; and to assess resistance patterns in key populations at highest risk for antimicrobial drug-resistant gonorrhea so country-specific treatment guidelines can be informed.

The gentamicin minimum inhibitory concentrations (MICs) of Neisseria gonorrhoeae isolates were determined. Seventy-three percent of isolates demonstrated an MIC range of 8 to 16 mug/mL, and 27% demonstrated an MIC of 4 mug/mL or less. Significant associations between gentamicin MIC and resistance or reduced susceptibility to other antimicrobials were found.

PURPOSE: Neisseria gonorrhoeae is a sexually transmitted bacterial pathogen that continues to evolve to become resistant to known antibiotics. In preparing for potential emergence, the Centers for Disease Control and Prevention recommends that clinical laboratories maintain or develop protocols to assess antibiotic susceptibly for this organism. This study examines the intra-laboratory variability of using the Etest method to provide consistent MIC values for N. gonorrhoeae and also compared the results of the Etest to known agar dilution MIC values. METHODOLOGY: Clinical N. gonorrhoeae isolates, 100 paired duplicates, were tested by eight laboratories for antibiotic susceptibility to ceftriaxone, cefixime and azithromycin using Etest strips.Results/Key findings. Overall, >80 % of the paired Etest MIC values were within one log2 dilution of the replicate. When compared to the agar dilution reference method, the cefixime Etest MIC values were consistently underreported by one dilution (seven laboratories) or two dilutions (one laboratory). The azithromycin Etest MIC values agreed 90.7 % with the agar dilution MIC values while the agreement with ceftriaxone was 90.9 %. CONCLUSION: Overall, the Etest method yielded reproducible MIC values within each laboratory with the azithromycin and ceftriaxone MIC results consistent to the reference agar dilution method while the cefixime result tended to provide a lower MIC value.

We investigated whether outpatient antimicrobial drug prescribing is associated with Neisseria gonorrhoeae antimicrobial drug susceptibility in the United States. Using susceptibility data from the Gonococcal Isolate Surveillance Project during 2005-2013 and QuintilesIMS data on outpatient cephalosporin, macrolide, and fluoroquinolone prescribing, we constructed multivariable linear mixed models for each antimicrobial agent with 1-year lagged annual prescribing per 1,000 persons as the exposure and geometric mean MIC as the outcome of interest. Multivariable models did not demonstrate associations between antimicrobial drug prescribing and N. gonorrhoeae susceptibility for any of the studied antimicrobial drugs during 2005-2013. Elucidation of epidemiologic factors contributing to resistance, including further investigation of the potential role of antimicrobial drug use, is needed.

Background.: The Centers for Disease Control and Prevention (CDC) currently recommends dual therapy with ceftriaxone and azithromycin for gonorrhea to ensure effective treatment and slow emergence of antimicrobial resistance. Since 2013, the prevalence of reduced azithromycin susceptibility increased in the United States; however, these strains were highly susceptible to cephalosporins. We report on a cluster of N. gonorrhoeae isolates demonstrating high-level azithromycin resistance, several of which also demonstrated decreased ceftriaxone susceptibility. Methods.: Eight N. gonorrhoeae isolates collected from 7 patients on Oahu seen 21 April through 10 May 2016 underwent routine Etest antimicrobial susceptibility testing by Hawaii Department of Health. All demonstrated elevated azithromycin minimum inhibitory concentrations (MICs) >256 mul/mL and elevated ceftriaxone MICs (≥0.125 mug/mL). Isolates were sent to University of Washington and CDC for confirmatory agar dilution testing, and sequence data were sent to CDC for analysis. All patients were interviewed and treated, and when possible, partners were interviewed, tested, and treated. Results.: All isolates had azithromycin MICs >16 microg/mL and 5 had ceftriaxone MICs = 0.125 microg/mL by agar dilution. All isolates were beta-lactamase positive, and were resistant to penicillin, tetracycline, and ciprofloxacin. Genomic analysis revealed genetic relatedness. No patients reported recent travel or antibiotic use and no male patients reported male sex partners. All patients were successfully treated. Conclusions.: This cluster of genetically related gonococcal isolates with decreased ceftriaxone susceptibility and high-level azithromycin resistance may bring the threat of treatment failure in the United States with the current recommended dual therapy one step closer.

BACKGROUND: Chlamydia trachomatis infection is highly prevalent among young women in the United States. Prevention of long-term sequelae of infection, including tubal factor infertility, is a primary goal of chlamydia screening and treatment activities. However, the population attributable fraction of tubal factor infertility associated with chlamydia is unclear, and optimal measures for assessing tubal factor infertility and prior chlamydia in epidemiologic studies have not been established. Black women have increased rates of chlamydia and tubal factor infertility compared to white women, but have been underrepresented in prior studies of the association of chlamydia and tubal factor infertility. OBJECTIVES: To estimate the population attributable fraction of tubal factor infertility associated with Chlamydia trachomatis infection by race (black, non-black), and assess how different definitions of C. trachomatis seropositivity and tubal factor infertility affect population attributable fraction estimates. STUDY DESIGN: We conducted a case-control study, enrolling infertile women attending infertility practices in Birmingham, AL and Pittsburgh, PA during October 2012 - June 2015. Tubal factor infertility case status was primarily defined by unilateral or bilateral fallopian tube occlusion (cases) or bilateral fallopian tube patency (controls) on hysterosalpingogram. Alternate tubal factor infertility definitions incorporated history suggestive of tubal damage or were based on laparoscopic evidence of tubal damage. We aimed to enroll all eligible women, with an expected ratio of one and three controls per case for black and non-black women, respectively. We assessed C. trachomatis seropositivity with a commercial assay and a more sensitive research assay; our primary measure of seropositivity was defined as positivity on either assay. We estimated C. trachomatis seropositivity and calculated C. trachomatis-TFI odds ratios and population attributable fraction, stratified by race. RESULTS: We enrolled 107 black women (47 cases, 60 controls) and 620 non-black women (140 cases, 480 controls). C. trachomatis seropositivity by either assay was 81% (95% confidence interval 73%, 89%) among black and 31% (95% confidence interval 28%, 35%) among non-black participants (P<0.001). Using the primary C. trachomatis seropositivity and tubal factor infertility definitions, no significant association was detected between chlamydia and tubal factor infertility among blacks (odds ratio 1.22, 95% confidence interval 0.45, 3.28) or non-blacks (odds ratio 1.41, 95% confidence interval 0.95, 2.09), and the estimated population attributable fraction was 15% (95% confidence interval -97%, 68%) among blacks and 11% (95% confidence interval -3%, 23%) among non-blacks. Use of alternate serologic measures and tubal factor infertility definitions impacted the magnitude of the chlamydia-tubal factor infertility association, and resulted in a significant association among non-blacks. CONCLUSIONS: Low population attributable fraction estimates suggest factors in addition to chlamydia contribute to tubal factor infertility in the study population. However, high background C. trachomatis seropositivity among controls, most striking among black participants, could have obscured an association with tubal factor infertility and resulted in a population attributable fraction that underestimates the true etiologic role of chlamydia. Choice of chlamydia and tubal factor infertility definitions also impacts odds ratio and population attributable fraction estimates.

BACKGROUND: There is limited information on rates of STIs in Jamaica due to syndromic management and limited aetiological surveillance. We examined the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) and characteristics associated with STIs among sexually active women who participated in a randomised trial of a progestin implant initiation in Jamaica (the Sino-Implant Study (SIS)). METHODS: SIS was a randomised trial conducted in Kingston, Jamaica, from 2012 to 2014 to evaluate whether initiation of the Sino-Implant (II) led to more unprotected sex among women ages 18-44 years. Data collected included self-reported demographic, sexual behaviour information; and vaginal swabs collected at baseline, 1-month and 3-month follow-up visits for a biomarker of recent semen exposure (prostate-specific antigen (PSA)) and for STIs. We examined associations between STIs and PSA, demographics, sexual behaviour and insertion of an implant, with a repeated-measures analysis using generalised estimating equations (SAS Institute, V.9.3). RESULTS: Remnant vaginal swabs from 254 of 414 study participants were tested for STIs. At baseline, 29% of participants tested for STIs (n=247) had laboratory-confirmed CT, 5% NG, 23% TV and 45% any STI. In a repeated-measures analysis adjusted for study arm (immediate vs delayed implant insertion), those with PSA detected did not have an increased prevalence of any STI (prevalence ratio (PR)=1.04 (95% CI 0.89 to 1.21)), whereas prevalence decreased for each 1-year increase in age (PR=0.98 (95% CI 0.97 to 0.99)). Immediate implant insertion was not associated with increases in any STI in subsequent visits (PR=1.09 (95% CI 0.94 to 1.27)). CONCLUSIONS: Although the prevalence of laboratory-confirmed STIs was high, the immediate initiation of a contraceptive implant was not associated with higher STI prevalence rates over 3 months. TRIAL REGISTRATION NUMBER: NCT01684358.

BACKGROUND: Rectal STI coinfection models enhance the understanding of rectal HIV transmission risk factors. MATERIALS AND METHODS: Rhesus macaques (n=9) were exposed to one of three rectal Chlamydia trachomatis (CT) challenges: C. trachomatis L2 (CT-L2 ); C. trachomatis serovar E (CT-E), followed by CT-L2 ; or CT-E, treatment/clearance, then CT-L2 . Infections were monitored by PCR. Weekly blood and rectal secretion/lavage samples were collected for cytokine analyzes and/or epithelial sloughing, occult, and overt blood determinations. RESULTS: Chlamydial infections were successfully established in each animal, with varying degrees of persistence. Mucosal IL-1beta was upregulated in animals consecutively infected with CT-E then CT-L2 (P=.05). Epithelial sloughing was also significantly increased post-infection in this group (P=.0003). CONCLUSIONS: This study demonstrates successful rectal infection of rhesus macaques with CT-E and CT-L2 and describes measures of assessing rectal inflammation and pathology. Different infection strategies yield varying inflammatory and pathologic outcomes, providing well-described models for future SIV/SHIV susceptibility studies.

During 2016, eight Neisseria gonorrhoeae isolates from 7 patients in Hawaii were resistant to azithromycin; 5 had decreased in vitro susceptibility to ceftriaxone. Genomic analysis demonstrated a distinct phylogenetic clade when compared with local contemporary strains. Continued evolution and widespread transmission of these strains might challenge the effectiveness of current therapeutic options.

Chlamydia trachomatis (CT) elementary body (EB) ELISA was used to investigate serum anti-CT IgG1 (long-lived response) and IgG3 (short-lived response indicating more recent infection) from treatment (enrollment) and 6-month follow-up visits in 77 women previously classified as having spontaneous resolution of chlamydia. 71.4% of women were IgG1+IgG3+, consistent with more recent chlamydia resolution. 15.6% were IgG3- at both visits, suggesting absence of recent chlamydia. Using EB ELISA, we demonstrated about one in six women classified as having spontaneous resolution of chlamydia might have been exposed to CT but not infected. Further, we classified their possible infection stage.

Since the introduction of antimicrobials in the first half of the twentieth century, Neisseria gonorrhoeae has repeatedly acquired resistance to the drugs used for treatment. The victims of the bacterium’s relentless acquisition of resistance have included sulfonamides, penicillin, tetracycline, and fluoroquinolones. During the past several years, gonococcal resistance has received substantial attention in the United States. Circulating strains of N. gonorrhoeae have been found to have reduced susceptibility to recommended treatment options, the antibiotic pipeline remains at a trickle, and STD public health programs are stretched increasingly thin as syphilis, chlamydia, and gonorrhea case rates are increasing.[1] Taking its place among the ranks of Clostridium difficile and carbapenem-resistant Enterobacteriaceae, N. gonorrhoeae was labeled an “urgent” antibiotic resistance threat by the Centers for Disease Control and Prevention in 2013.[2] | N. gonorrhoeae antimicrobial resistance is a reminder of our global interconnectedness. Penicillinase-producing N. gonorrhoeae, fluoroquinolone-resistant N. gonorrhoeae, and strains with reduced cephalosporin susceptibility seem to have initially emerged or at least been initially detected in East Asia before being detected in other countries around the world in subsequent years, including the United States.[3–5] In some ways, gonococcal resistance trends and developments in East Asia have served as a canary in a coal mine, allowing us to anticipate possible future developments elsewhere. Thus antimicrobial susceptibility surveillance data from Japan, such as presented in this issue by Yasuda et al, are welcome contributions to our understanding of gonococcal resistance worldwide.[6]

BACKGROUND: Chlamydia trachomatis (CT) and Trichomonas vaginalis (TV), two prevalent sexual transmitted infections, are known to increase HIV risk in women and could potentially diminish pre-exposure prophylaxis (PrEP) efficacy, particularly for topical interventions that rely on local protection. We investigated in macaques whether co-infection with CT/TV reduces protection by vaginal TFV gel. METHODS: Vaginal TFV gel dosing previously shown to provide 100% or 74% protection when applied either 30 minutes or 3 days before SHIV challenge was assessed in pigtailed macaques co-infected with CT/TV and challenged twice-weekly with SHIV162p3 for up to 10 weeks (2 menstrual cycles). Three groups of six macaques received either placebo or 1% TFV gel 30 minutes or 3 days before each SHIV challenge. We additionally assessed TFV and TFV-diphosphate (TFV-DP) concentrations in plasma and vaginal tissues in CT/TV co-infected (n = 4) and uninfected (n = 4) macaques. RESULTS: CT/TV co-infections were maintained during the SHIV challenge period. All macaques that received placebo gel were SHIV-infected after a median of 7 challenges (1 menstrual cycle). In contrast, no infections were observed in macaques treated with TFV gel 30 minutes before SHIV challenge (p < 0.001). Efficacy was reduced to 60% when TFV gel was applied 3 days before SHIV challenge (p = 0.07). Plasma TFV and TFV-DP concentrations in tissues and vaginal lymphocytes were significantly higher in CT/TV co-infected compared to CT/TV uninfected macaques. CONCLUSIONS: Our findings in this model suggest that CT/TV co-infection may have little or no impact on the efficacy of highly effective topical TFV modalities and highlight a significant modulation of TFV pharmacokinetics.

BACKGROUND: We assessed the validity of testing for antimicrobial susceptibility of clinical and mutant Neisseria gonorrhoeae (GC) isolates by disk diffusion in comparison to agar dilution, and Etest(R) (bioMerieux, France), respectively, for three third generation extended spectrum cephalosporins (ESC): ceftriaxone (CRO), cefixime (CFX), and cefpodoxime (CPD). METHODS: One hundred and five clinical isolates and ten laboratory-mutants were tested following Clinical Laboratory Standard Institute (CLSI) and manufacturer's standards for each of the three methods. The measured diameters by the disk diffusion method were tested for correlation with the MIC values by agar dilution. In addition, comparisons with the Etest(R) were made. Categorical results for concordance, based on standard CLSI cutoffs, between the disk diffusion and the other two methods, respectively, were tested using the Chi-square statistics. Reproducibility was tested for CFX across a 6-month interval by repeated disk tests. RESULTS: Across all 115 specimens, the disk diffusion tests produced good categorical agreements, exhibiting concordance of 93.1%, 92.1%, and 90.4% with agar dilution and 93.0%, 92.1%, and 90.4% with Etest(R), for CRO, CFX, and CPD, respectively. Pearson correlations between disk-diffusion diameters and agar dilution MIC's were -0.59, -0.67, and -0.81 for CRO, CFX, and CPD, respectively. The correlations between disk diffusion and Etest(R) were -0.58, -0.73, and -0.49. Pearson correlation between the CFX disk readings over a 6-month interval was 91%. CONCLUSIONS: Disk diffusion tests remain to be a useful, reliable and fast screening method for qualitative antimicrobial susceptibility testing for ceftriaxone, cefixime, and cefpodoxime.