Last data update: Apr 29, 2024. (Total: 46658 publications since 2009)
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Impact of the COVID-19 Pandemic on Centers for Disease Control and Prevention-Funded Sexually Transmitted Disease Programs.
Wright SS , Kreisel KM , Hitt JC , Pagaoa MA , Weinstock HS , Thorpe PG . Sex Transm Dis 2021 49 (4) e61-e63 The COVID-19 pandemic impacted STD services. Of 59 U.S.-funded STD programs, 91% reported a great deal to moderate impact from staff reassignment in April 2020, with 28% of respondents reporting permanent reassignment of DIS staff. Telemedicine was implemented in 44%. Decreases in STD case reports were reported by most jurisdictions. |
Genomic analysis of the predominant strains and antimicrobial resistance determinants within 1479 Neisseria gonorrhoeae isolates from the U.S. Gonococcal Isolate Surveillance Project in 2018.
Reimche JL , Chivukula VL , Schmerer MW , Joseph SJ , Pham CD , Schlanger K , St Cyr SB , Weinstock HS , Raphael BH , Kersh EN , Gernert KM . Sex Transm Dis 2021 48 S78-S87 BACKGROUND: The prevalence of Neisseria gonorrhoeae (GC) isolates with elevated minimum inhibitory concentrations (MICs) to various antibiotics continues to rise in the U.S. and globally. Genomic analysis provides a powerful tool for surveillance of circulating strains, antimicrobial resistance determinants, and understanding of transmission through a population. METHODS: GC isolates collected from the U.S. Gonococcal Isolate Surveillance Project (GISP) in 2018 (n=1479) were sequenced and characterized. Whole genome sequencing was used to identify sequence types, antimicrobial resistance profiles, and phylogenetic relationships across demographic and geographic populations. RESULTS: Genetic characterization identified that (1) 80% of the GC isolates were represented in 33 multilocus sequence types, (2) isolates clustered in 23 major phylogenetic clusters with select phenotypic and demographic prevalence, and (3) common antimicrobial resistance determinants associated with low-level or high-level decreased susceptibility or resistance to relevant antibiotics. CONCLUSIONS: Characterization of this 2018 GISP genomic dataset, which is the largest U.S. whole genome sequence data set to date, sets the basis for future prospective studies, and establishes a genomic baseline of GC populations for local and national monitoring. |
STI Prevalence, Incidence, and Costs in the United States: New Estimates, New Approach
Weinstock HS , Kreisel KM , Spicknall IH , Chesson HW , Miller WC . Sex Transm Dis 2021 48 (4) 207 The field of sexually transmitted infection (STI) prevention depends heavily on having current estimates of the health and economic burden of STIs. These estimates guide priorities in research, public health decisions, and governmental policies. Recent estimates have been cited in crucial public health and policy documents, such as STI treatment guidelines,1 STI surveillance reports,2 public health recommendations,3,4 and government budget justifications and priorities.5 Publishing these estimates is one of the most important contributions of the journal, Sexually Transmitted Diseases (STD), to the field. |
Sexually transmitted infections among US women and men: Prevalence and incidence estimates, 2018
Kreisel KM , Spicknall IH , Gargano JW , Lewis FM , Lewis RM , Markowitz LE , Roberts H , Satcher Johnson A , Song R , St Cyr SB , Weston EJ , Torrone EA , Weinstock HS . Sex Transm Dis 2021 48 (4) 208-214 BACKGROUND: The most recent estimates of the number of prevalent and incident sexually transmitted infections (STIs) in the United States (US) were for 2008. We provide updated estimates for 2018 using new methods. METHODS: We estimated the total number of prevalent and incident infections in the US for eight STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus (HPV), sexually transmitted hepatitis B, and sexually transmitted HIV. Updated per capita prevalence and incidence estimates for each STI were multiplied by the 2018 full resident population estimates to calculate the number of prevalent and incident infections. STI-specific estimates were combined to generate estimates of the total number of prevalent and incident STIs overall, and by gender and age group. Primary estimates are represented by medians and uncertainty intervals are represented by the 25th (Q1) and 75th (Q3) percentiles of the empirical frequency distributions of prevalence and incidence for each STI. RESULTS: In 2018, there were an estimated 67.6 (Q1=66.6, Q3=68.7) million prevalent and 26.2 (Q1=24.0, Q3=28.7) million incident STIs in the US. Chlamydia, trichomoniasis, genital herpes, and HPV comprised 97.6% of all prevalent and 93.1% of all incident STIs. Persons aged 15-24 years comprised 18.6% (12.6 million) of all prevalent infections; however, they comprised 45.5% (11.9 million) of all incident infections. CONCLUSIONS: The burden of STIs in the US is high. Almost half of incident STIs occurred in persons aged 15-24 years in 2018. Focusing on this population should be considered essential for national STI prevention efforts. |
Increased methamphetamine, injection drug, and heroin use among women and heterosexual men with primary and secondary syphilis - United States, 2013-2017
Kidd SE , Grey JA , Torrone EA , Weinstock HS . MMWR Morb Mortal Wkly Rep 2019 68 (6) 144-148 During 2013-2017, the national annual rate of reported primary and secondary (P&S) syphilis cases in the United States increased 72.7%, from 5.5 to 9.5 cases per 100,000 population (1). The highest rates of P&S syphilis are seen among gay, bisexual, and other men who have sex with men (collectively referred to as MSM) (2), and MSM continued to account for the majority of cases in 2017 (1). However, during 2013-2017, the P&S syphilis rate among women increased 155.6% (from 0.9 to 2.3 cases per 100,000 women), and the rate among all men increased 65.7% (from 10.2 to 16.9 cases per 100,000 men), indicating increasing transmission between men and women in addition to increasing transmission between men (1). To further understand these trends, CDC analyzed national P&S syphilis surveillance data for 2013-2017 and assessed the percentage of cases among women, men who have sex with women only (MSW), and MSM who reported drug-related risk behaviors during the past 12 months. Among women and MSW with P&S syphilis, reported use of methamphetamine, injection drugs, and heroin more than doubled during 2013-2017. In 2017, 16.6% of women with P&S syphilis used methamphetamine, 10.5% used injection drugs, and 5.8% used heroin during the preceding 12 months. Similar trends were seen among MSW, but not among MSM. These findings indicate that a substantial percentage of heterosexual syphilis transmission is occurring among persons who use these drugs, particularly methamphetamine. Collaboration between sexually transmitted disease (STD) control programs and partners that provide substance use disorder services will be important to address recent increases in heterosexual syphilis. |
An illustration of the potential health and economic benefits of combating antibiotic-resistant gonorrhea
Chesson HW , Kirkcaldy RD , Gift TL , Owusu-Edusei KJr , Weinstock HS . Sex Transm Dis 2018 45 (4) 250-253 Preventing the emergence of ceftriaxone-resistant Neisseria gonorrhoeae can potentially avert hundreds of millions of dollars in direct medical costs of gonorrhea and gonorrhea-attributable HIV infections. In the illustrative scenario we examined, emerging ceftriaxone resistance could lead to 1.2 million additional N. gonorrhoeae infections within 10 years, costing $378.2 million. |
New human immunodeficiency virus diagnoses among men who have sex with men attending STD clinics, STD Surveillance Network, January 2010 to June 2013
Llata E , Braxton J , Asbel L , Kerani RP , Murphy R , Pugsley R , Pathela P , Schumacher C , Tabidze I , Weinstock HS . Sex Transm Dis 2018 45 (9) 577-582 OBJECTIVE: To estimate new HIV diagnosis rates among HIV negative MSM who are repeatedly tested for HIV in sexually transmitted disease (STD) clinics, and assess the impact of demographic and disease-specific characteristics that are associated with higher HIV diagnosis rates. STUDY DESIGN: Retrospective analysis using 2010-2013 data from the STD Surveillance Network (SSuN), a sentinel surveillance system comprised of health departments in 12 cities conducting sentinel surveillance in 40 STD clinics. We analyzed data from all MSM repeatedly (>/=2 times) tested for HIV, with an initial negative HIV test required for staggered cohort entry. Follow-up time was accrued from the date of the first negative HIV test to the most recent negative test or the first positive HIV test. STD diagnoses during the follow-up period were reviewed. We estimated HIV diagnoses rates (number of HIV diagnoses/total number of person-years at risk) by demographic and clinical characteristics with 95% confidence intervals (CI) using an inverse variance weighted random effects model, adjusting for heterogeneity between SSuN jurisdictions. RESULTS: Overall, 640 HIV diagnoses occurred among 14,824 individuals and 20,951.6 person-years (PY) of observation, for an adjusted incidence of HIV diagnosis of 3.0 per 100 PY (95% CI 2.6, 3.4). Rates varied across race/ethnicity groups with the highest rate among Blacks (4.7/100 PY; 95% CI 4.1-5.3) followed by Hispanics, Whites and persons of other races/ethnicities. MSM having a diagnosis of P&S syphilis on or after the first negative HIV test had a higher new HIV diagnosis rate (7.2/100 PY; 95% CI 5.8-9.0) compared to MSM who did not have a P&S syphilis diagnosis (2.8/100 PY; 95% CI 2.6-3.1). MSM who tested positive for rectal gonorrhea (6.3/100 PY; 95% CI 5.7-6.9) or rectal chlamydia (5.6/100 PY; 95% CI 4.6-6.6) had higher rates of new HIV diagnosis when compared to those with negative test results. CONCLUSIONS: MSM attending SSuN STD clinics have high rates of new HIV diagnoses, particularly those with a previous diagnosis of P&S syphilis, rectal chlamydia and/or gonorrhea. STD clinics continue to be important clinical setting for diagnosing HIV among MSM populations. |
Rates of primary and secondary syphilis among white and black non-Hispanic men who have sex with men, US states, 2014
Grey JA , Bernstein KT , Sullivan PS , Kidd SE , Gift TL , Hall EW , Hankin-Wei A , Weinstock HS , Rosenberg ES . J Acquir Immune Defic Syndr 2017 76 (3) e65-e73 BACKGROUND: Men who have sex with men (MSM) in the United States experience an approximately 100-fold greater rate of primary and secondary (P&S) syphilis diagnoses compared to men who have sex with women only. As in the general population, racial/ethnic disparities in P&S syphilis diagnosis rates may exist among MSM, but MSM-specific P&S syphilis rates by race/ethnicity are unavailable. We enhanced a published modeling approach to estimate area-level MSM populations by race/ethnicity and provide the first estimates of P&S syphilis among black and white non-Hispanic MSM. METHODS: We used data from the American Community Survey (ACS), published findings from the National Health and Nutrition Examination Survey (NHANES), and national syphilis surveillance data to estimate state-level rates of P&S syphilis diagnoses among MSM, overall and for black and white non-Hispanic MSM. We also used variability around ACS and NHANES estimates to calculate 95% confidence intervals for each rate. RESULTS: Among 11,359 cases of P&S syphilis among MSM with known race/ethnicity in 2014, 72.5% were among white (40.3%) or black (32.2%) MSM. The national rate of P&S syphilis diagnosis was 168.4/100,000 for white MSM and 583.9/100,000 for black MSM. Regional rates for black MSM ranged from 602.0/100,000 (South) to 521.5/100,000 (Midwest) and were consistently higher than those for white MSM. CONCLUSIONS: Although white MSM accounted for the majority of P&S syphilis diagnoses in 2014, when evaluating diagnoses based on rate per 100,000, black MSM had consistently and markedly higher rates than white MSM, with the highest-impacted states located in the US South. |
Congenital syphilis: trends in mortality and morbidity in the United States, 1999-2013
Su JR , Brooks LC , Davis DW , Torrone EA , Weinstock HS , Kamb ML . Am J Obstet Gynecol 2015 214 (3) 381 e1-9 BACKGROUND: Congenital syphilis (CS) results when an infected pregnant mother transmits syphilis to her unborn child prior to or at delivery. The severity of infection can range from a delivery at term without signs of infection to stillbirth or death after delivery. OBJECTIVES: To describe congenital syphilis (CS) morbidity and mortality during 1999-2013. STUDY DESIGN: National CS case data reported to CDC during 1999-2013 were analyzed. Cases were classified as "dead cases" (stillbirths and deaths up to twelve months after delivery), "morbid cases" (cases with "strong" (physical, radiographic, and/or non-serologic laboratory) evidence of CS), and "non-morbid" cases (cases with a normal physical examination reported, but without strong evidence of infection). Annual rates of these cases were calculated. Cases were compared using selected maternal and infant criteria. RESULTS: During 1999-2013, 6,383 cases of CS were reported: 6.5% (dead), 33.6% (morbid), 53.9% (non-morbid), and 5.9% (unknown morbidity); 81.8% of dead cases were stillbirths. Rates of dead, morbid, and non-morbid cases all decreased over this time period, but the overall proportions that were dead or morbid cases did not significantly change. The overall case fatality ratio during 1999-2013 was 6.5%. Among cases of CS, maternal race/ethnicity was not associated with increased morbidity or death, although most cases (83%) occurred among black or Hispanic mothers. No or inadequate treatment for maternal syphilis, less than ten prenatal visits, and maternal non-treponemal titer ≥ 1:8 increased the likelihood of a dead case; risk of being a dead case increased with maternal non-treponemal titer (chi2 for trend p<0.001). Infants with CS born alive at <28 weeks gestation (RR=107.4, p<0.001) or born weighing <1,500 grams (RR=43.9, p<0.001) were at greatly increased risk of death. CONCLUSIONS: CS remains an important preventable cause of perinatal morbidity and mortality, with comparable case fatality ratios during 1999-2013 (6.5%) and 1992-1998 (6.4%). Detection and treatment of syphilis early during pregnancy remain crucial to reducing CS morbidity and mortality. |
Management of pelvic inflammatory disease in selected US sexually transmitted disease clinics: Sexually Transmitted Disease Surveillance Network, January 2010-December 2011
Llata E , Bernstein KT , Kerani RP , Pathela P , Schwebke JR , Schumacher C , Stenger M , Weinstock HS . Sex Transm Dis 2015 42 (8) 429-33 BACKGROUND: Pelvic inflammatory disease (PID) remains an important source of preventable reproductive morbidity, but no recent studies have singularly focused on US sexually transmitted disease (STD) clinics in relationship to established guidelines for diagnosis and treatment. METHODS: Of the 83,076 female patients seen in 14 STD clinics participating in the STD Surveillance Network, 1080 (1.3%) were diagnosed as having PID from 2010 to 2011. A random sample of 219 (20%) women were selected, and medical records were reviewed for clinical history, examination findings, treatment, and diagnostic testing. Our primary outcomes were to evaluate how well PID diagnosis and treatment practices in STD clinic settings follow the Centers for Disease Control and Prevention (CDC) treatment guidelines and to describe age group-specific rates of laboratory-confirmed Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) in patients clinically diagnosed as having PID in the last 12 months, inclusive of the PID visit. RESULTS: Among the 219 women, 70.3% of the cases met the CDC treatment case definition for PID, 90.4% had testing for CT and GC on the PID visit, and 68.0% were treated with a CDC-recommended outpatient regimen. In the last 12 months, 95.4% were tested for CT or GC, and positivity for either organism was 43.9% in women aged 25 years or younger with PID, compared with 19.4% of women older than 25 years with PID. CONCLUSIONS: Compliance with CDC guidelines was documented for many of the women with PID, though not all. Our findings underscore the need for continued efforts to optimize quality of care and adherence to current guidance for PID management given the anticipated expertise of providers in these settings. |
Bacterial sexually transmitted infections among HIV-infected patients in the United States: estimates from the Medical Monitoring Project
Flagg EW , Weinstock HS , Frazier EL , Valverde EE , Heffelfinger JD , Skarbinski J . Sex Transm Dis 2015 42 (4) 171-9 BACKGROUND: Bacterial sexually transmitted infections may facilitate HIV transmission. Bacterial sexually transmitted infection testing is recommended for sexually active HIV-infected patients annually and more frequently for those at elevated sexual risk. We estimated percentages of HIV-infected patients in the United States receiving at least one syphilis, gonorrhea, or chlamydia test, and repeat (≥2 tests, ≥3 months apart) tests for any of these sexually transmitted infections from mid-2008 through mid-2010. DESIGN: The Medical Monitoring Project collects behavioral and clinical characteristics of HIV-infected adults receiving medical care in the United States using nationally representative sampling. METHODS: Sexual activity included self-reported oral, vaginal, or anal sex in the past 12 months. Participants reporting more than 1 sexual partner or illicit drug use before/during sex in the past year were classified as having elevated sexual risk. Among participants with only 1 sex partner and no drug use before/during sex, those reporting consistent condom use were classified as low risk; those reporting sex without a condom (or for whom this was unknown) were classified as at elevated sexual risk only if they considered their sex partner to be a casual partner, or if their partner was HIV-negative or partner HIV status was unknown. Bacterial sexually transmitted infection testing was ascertained through medical record abstraction. RESULTS: Among sexually active patients, 55% were tested at least once in 12 months for syphilis, whereas 23% and 24% received at least one gonorrhea and chlamydia test, respectively. Syphilis testing did not vary by sex/sexual orientation. Receipt of at least 3 CD4+ T-lymphocyte cell counts and/or HIV viral load tests in 12 months was associated with syphilis testing in men who have sex with men (MSM), men who have sex with women only, and women. Chlamydia testing was significantly higher in sexually active women (30%) compared with men who have sex with women only (19%), but not compared with MSM (22%). Forty-six percent of MSM were at elevated sexual risk; 26% of these MSM received repeat syphilis testing, whereas repeat testing for gonorrhea and chlamydia was only 7% for each infection. CONCLUSIONS: Bacterial sexually transmitted infection testing among sexually active HIV-infected patients was low, particularly for those at elevated sexual risk. Patient encounters in which CD4+ T-lymphocyte cell counts and/or HIV viral load testing occurs present opportunities for increased bacterial sexually transmitted infection testing. |
Comparison of antimicrobial susceptibility of pharyngeal, rectal, and urethral Neisseria gonorrhoeae isolates among men who have sex with men
Kidd S , Zaidi A , Asbel L , Baldwin T , Gratzer B , Guerry S , Kerani RP , Pathela P , Pettus K , Soge OO , Stirland A , Weinstock HS . Antimicrob Agents Chemother 2015 59 (5) 2588-95 The United States' surveillance for Neisseria gonorrhoeae antimicrobial susceptibility is based exclusively on male urethral isolates. These data inform gonorrhea treatment guidelines, including recommendations for treatment of extra-genital infection, but data on the susceptibility of extra-genital isolates are limited. We compared the antimicrobial susceptibility of pharyngeal, rectal, and urethral gonococcal isolates collected from men who have sex with men (MSM) at five sentinel sites throughout the United States. Minimum inhibitory concentrations (MICs) were determined by the agar dilution method. Generalized linear models were used to compare (1) the proportions of isolates with elevated MICs and (2) geometric mean MICs by anatomic site adjusted for city. During December 2011-September 2013, a total of 205 pharyngeal, 261 rectal, and 976 urethral isolates were obtained. The proportion of isolates with elevated ceftriaxone MICs (≥0.125 mug/ml) did not differ by anatomic site (0.5% of pharyngeal, 1.5% of rectal, and 1.7% of urethral isolates; city-adjusted odds ratio [95% CI] 0.4 [0.0, 3.9] for pharyngeal vs. urethral isolates, 0.9 [0.2, 4.2] for rectal vs. urethral isolates). The city-adjusted geometric mean ceftriaxone MICs of pharyngeal (0.0153 mug/ml) and rectal (0.0157 mug/ml) isolates did not differ from that of urethral isolates (0.0150 mug/ml) (ratio of geometric mean MICs [95% CI] 1.02 [0.90, 117] and 1.05 [0.93, 1.19], respectively). Similar results were observed for other antimicrobials, including cefixime and azithromycin. These findings suggest that, at the population level, gonococcal antimicrobial susceptibility surveillance based on urethral isolates from MSM adequately represents the susceptibility of N. gonorrhoeae circulating among MSM. |
Analysis of Neisseria gonorrhoeae azithromycin susceptibility in the United States by the Gonococcal Isolate Surveillance Project, 2005 to 2013
Kirkcaldy RD , Soge O , Papp JR , Hook EW 3rd , Del Rio C , Kubin G , Weinstock HS . Antimicrob Agents Chemother 2014 59 (2) 998-1003 BACKGROUND: Azithromycin, administered with ceftriaxone, is recommended by CDC for treatment of gonorrhea. Many experts have expressed concern about the ease with which Neisseria gonorrhoeae can acquire macrolide resistance. OBJECTIVE: We sought to describe gonococcal azithromycin susceptibility in the United States and determine whether azithromycin susceptibility has changed over time. METHODS: We analyzed 2005-2013 data from the Gonococcal Isolate Surveillance Project, a CDC-supported sentinel surveillance network that monitors gonococcal antimicrobial susceptibility. RESULTS: 44,144 N. gonorrhoeae isolates were tested for azithromycin susceptibility by agar dilution methods. The overall azithromycin MIC50 was 0.25 mug/ml and the MIC90 was 0.5 mug/ml. There were no overall temporal trends in geometric means. Isolates from men who had sex with men had significantly higher geometric mean MICs than isolates from men who have sex exclusively with women. The overall prevalence of reduced azithromycin susceptibility (MIC ≥2 mug/ml) was 0.4% and varied by year from 0.3% (2006 and 2009) to 0.6% (2013). CONCLUSION: We did not find a clear temporal trend in gonococcal azithromycin MICs in the United States and the prevalence of reduced azithromycin susceptibility remains low. These findings support continued use of azithromycin in the combination therapy regimen for gonorrhea. |
HIV, chlamydia, gonorrhea, and primary and secondary syphilis among American Indians and Alaska Natives within Indian Health Service Areas in the United States, 2007-2010
Walker FJ , Llata E , Doshani M , Taylor MM , Bertolli J , Weinstock HS , Hall HI . J Community Health 2014 40 (3) 484-92 National rates from human immunodeficiency virus (HIV) and sexually transmitted disease (STD) surveillance may not effectively convey the impact of HIV and STDs on American Indian/Alaska Native (AI/AN) communities. Instead, we compared average annual diagnosis rates per 100,000 population of HIV, chlamydia (CT), gonorrhea (GC), and primary and secondary (P&S) syphilis, from 2007 to 2010, among AI/AN aged ≥13 years residing in 625 counties in the 12 Indian Health Service Areas, all AI/AN, and all races/ethnicities to address this gap. AI/AN comprised persons reported as AI/AN only, with or without Hispanic ethnicity. Out of 12 IHS Areas, 10 had higher case rates for CT, 3 for GC, and 4 for P&S syphilis compared to rates for all races/ethnicities. Eight Areas had higher HIV diagnosis rates than for all AI/AN, but HIV rates for all IHS Areas were lower than national rates for all races/ethnicities. Two IHS Areas ranking highest in rates of CT and GC and four Areas with highest P&S syphilis also had high HIV rates. STD and HIV rates among AI/AN were greater in certain IHS Areas than expected from observing national rates for AI/AN. Integrated surveillance of overlapping trends in STDs and HIV may be useful in guiding prevention efforts for AI/AN populations. |
Evaluation of gonorrhea test of cure at 1 week in a Los Angeles community-based clinic serving men who have sex with men
Beymer MR , Llata E , Stirland AM , Weinstock HS , Wigen CL , Guerry SL , Mejia E , Bolan RK . Sex Transm Dis 2014 41 (10) 595-600 BACKGROUND: Because of the decreasing susceptibility of Neisseria gonorrhoeae to cephalosporin therapy, the Centers for Disease Control and Prevention recommends test of cure (TOC) 1 week after gonorrhea (GC) treatment if therapies other than ceftriaxone are used. In addition, the Centers for Disease Control and Prevention asks clinicians, particularly those caring for men who have sex with men (MSM) on the west coast, to consider retesting all MSM at 1 week. However, it is unclear if this is acceptable to providers and patients or if nucleic acid amplification tests (NAATs) are useful for TOC at 7 days. METHODS: Between January and July 2012, MSM with GC were advised to return 1 week after treatment for TOC using NAAT. A multivariate logistic regression model was used to determine demographic and behavioral differences between MSM who returned for follow-up and MSM who did not. RESULTS: Of 737 men with GC, 194 (26.3%) returned between 3 and 21 days of treatment. Individuals who returned were more likely to have no GC history (P = 0.0001) and to report no initial symptoms (P = 0.02) when compared with individuals who did not return for TOC. Of those who returned, 0% of urethral samples, 7.4% of rectal samples, and 5.3% of pharyngeal samples were NAAT positive at TOC. CONCLUSIONS: Although TOC may be an important strategy in reducing complications and the spread of GC, low return rates may make implementation challenging. If implemented, extra efforts should be considered to enhance return rates among individuals with a history of GC. If TOCs are recommended at 1 week and NAATs are used, the interpretation of positive results, particularly those from extragenital sites, may be difficult. |
Congenital syphilis investigation processes and timing in Louisiana
Bradley H , Gruber D , Introcaso CE , Foxhood J , Wendell D , Rahman M , Ewell J , Kirkcaldy RD , Weinstock HS . Sex Transm Dis 2014 41 (9) 560-3 BACKGROUND: Congenital syphilis (CS) is a potentially life-threatening yet preventable infection. State and local public health jurisdictions conduct investigations of possible CS cases to determine case status and to inform public health prevention efforts. These investigations occur when jurisdictions receive positive syphilis test results from pregnant women or from infants. METHODS: We extracted data from Louisiana's electronic case management system for 328 infants investigated as possible CS cases in 2010 to 2011. Using date stamps from the case management system, we described CS investigations in terms of processes and timing. RESULTS: Eighty-seven investigations were prompted by positive test results from women who were known to be pregnant by the health jurisdiction, and 241 investigations were prompted by positive syphilis test results from infants. Overall, investigations required a median of 101 days to complete, although 25% were complete within 36 days. Investigations prompted by positive test results from infants required a median of 135 days to complete, and those prompted by positive test results from pregnant women required a median of 41 days. CONCLUSIONS: Three times as many CS investigations began with reported positive syphilis test results from infants as from pregnant women, and these investigations required more time to complete. When CS investigations begin after an infant's birth, the opportunity to ensure that women are treated during pregnancy is missed, and surveillance data cannot inform prevention efforts on a timely basis. Consistently ascertaining pregnancy status among women whose positive syphilis test results are reported to public health jurisdictions could help to assure timely CS prevention efforts. |
The efficacy and safety of gentamicin plus azithromycin and gemifloxacin plus azithromycin as treatment of uncomplicated gonorrhea
Kirkcaldy RD , Weinstock HS , Moore PC , Philip SS , Wiesenfeld HC , Papp JR , Kerndt PR , Johnson S , Ghanem KG , Hook EW 3rd . Clin Infect Dis 2014 59 (8) 1083-91 BACKGROUND: Ceftriaxone is the foundation of currently recommended gonorrhea treatment.There is an urgent need for back-up treatment options for patients withcephalosporin-allergy or infections due to suspected cephalosporin-resistant Neisseria gonorrhoeae. We evaluated the efficacy and tolerability of two combinations of existing non-cephalosporin antimicrobials for treatment of patients with urogenital gonorrhea. METHODS: We conducted a randomized, multisite,open-label, non-comparative trial (ClinicalTrials.gov:NCT00926796) 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 post-treatment among 401 participants in the per protocol population. RESULTS: Microbiological cure was achieved by 100% (lower one-sided exact 95% confidence interval bound, 98.5%) of 202 evaluable participants receiving gentamicin/azithromycin, and 99.5% (lower one-sided exact 95% confidence interval bound, 97.6%) of 199 evaluable participants receiving gemifloxacin/azithromycin. Gentamicin/azithromycin cured 10/10 pharyngeal infections and 1/1 rectal infection; gemifloxacin/azithromycin cured 15/15 pharyngeal and 5/5 rectal infections. Gastrointestinal adverse events were common in both arms. CONCLUSION: 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. |
Ciprofloxacin resistance and gonorrhea incidence rates in 17 cities, United States, 1991-2006
Chesson HW , Kirkcaldy RD , Gift TL , Owusu-Edusei K Jr , Weinstock HS . Emerg Infect Dis 2014 20 (4) 612-9 Antimicrobial drug resistance can hinder gonorrhea prevention and control efforts. In this study, we analyzed historical ciprofloxacin resistance data and gonorrhea incidence data to examine the possible effect of antimicrobial drug resistance on gonorrhea incidence at the population level. We analyzed data from the Gonococcal Isolate Surveillance Project and city-level gonorrhea incidence rates from surveillance data for 17 cities during 1991-2006. We found a strong positive association between ciprofloxacin resistance and gonorrhea incidence rates at the city level during this period. Their association was consistent with predictions of mathematical models in which resistance to treatment can increase gonorrhea incidence rates through factors such as increased duration of infection. These findings highlight the possibility of future increases in gonorrhea incidence caused by emerging cephalosporin resistance. |
Trends in antimicrobial resistance in Neisseria gonorrhoeae in the USA: the Gonococcal Isolate Surveillance Project (GISP), January 2006-June 2012
Kirkcaldy RD , Kidd S , Weinstock HS , Papp JR , Bolan GA . Sex Transm Infect 2013 89 Suppl 4 iv5-iv10 BACKGROUND: Neisseria gonorrhoeae has progressively developed resistance to sulfonamides, penicillin, tetracycline and fluoroquinolones, and gonococcal susceptibility to cephalosporins has been declining worldwide. METHODS: We described trends in gonococcal antimicrobial susceptibility in the USA from January 2006 through June 2012. Susceptibility data for cefixime, ceftriaxone, azithromycin, penicillin, tetracycline and ciprofloxacin were obtained from the Gonococcal Isolate Surveillance Project (GISP), a sentinel surveillance system that monitors antimicrobial susceptibility in urethral gonococcal isolates collected from symptomatic men at 25-30 sexually transmitted disease clinics throughout the USA. RESULTS: The percentage of isolates with elevated cefixime minimum inhibitory concentrations (MICs) (≥0.25 microg/mL) increased from 0.1% in 2006 to 1.4% in 2010-2011 and was 1.1% in the first 6 months of 2012. The percentage with elevated ceftriaxone MICs (≥0.125 microg/mL) increased from 0.1% in 2006 to 0.3%-0.4% during 2009 through the first 6 months of 2012. There were no temporal trends in the prevalence of elevated azithromycin MICs (≥2 microg/mL) (0.2%-0.5%). The prevalence of resistance remained high for penicillin (11.2%-13.2%), tetracycline (16.7%-22.8%) and ciprofloxacin (9.6%-14.8%). CONCLUSIONS: The proportion of gonococcal isolates with elevated cephalosporin MICs increased from 2006 to 2010, but plateaued during 2011 and the first 6 months of 2012. Resistance to previously recommended antimicrobials has persisted. As the number of antimicrobials available for gonorrhoea treatment dwindles, surveillance systems such as GISP will be critical to detect emerging resistance trends and guide treatment decisions. |
Trichomonas vaginalis in selected US sexually transmitted disease clinics: testing, screening, and prevalence
Meites E , Llata E , Braxton J , Schwebke JR , Bernstein KT , Pathela P , Asbel LE , Kerani RP , Mettenbrink CJ , Weinstock HS . Sex Transm Dis 2013 40 (11) 865-9 BACKGROUND: Trichomonas vaginalis is the most prevalent nonviral sexually transmitted infection in the United States, affecting 3.1% of women of reproductive age. Infection is associated with HIV acquisition and pelvic inflammatory disease. In the United States, Centers for Disease Control and Prevention guidelines recommend testing all women with vaginal discharge for T. vaginalis, but except for HIV-infected women, there are no national guidelines for screening asymptomatic persons. The objective of this analysis is to assess testing and screening practices for T. vaginalis among symptomatic and asymptomatic women in the sexually transmitted disease (STD) clinic setting. METHODS: We analyzed data on demographics, clinical presentation, and laboratory testing for all women visiting a clinician in 2010 to 2011 at any of 15 STD clinics participating in the STD Surveillance Network. Prevalence of laboratory-confirmed T. vaginalis infection was calculated among symptomatic women tested and among asymptomatic women screened. RESULTS: A total of 59,176 women visited STD clinicians: 39,979 were considered symptomatic and 19,197 were considered asymptomatic for T. vaginalis infection, whereas 211 were HIV-infected. Diagnostic practices varied by jurisdiction: 4.0% to 96.1% of women were tested or screened for T. vaginalis using any laboratory test. Among 17,952 symptomatic women tested, prevalence was 26.2%. Among 3909 asymptomatic women screened, prevalence was 6.5%. Among 92 HIV-infected women tested/screened, prevalence was 29.3%. CONCLUSIONS: Trichomoniasis is common among STD clinic patients. In this analysis, most STD clinics tested symptomatic women seeking care, in accordance with national guidelines. All HIV-infected women should be screened annually. Additional evidence and national guidance are needed regarding potential benefits of T. vaginalis screening in other asymptomatic women. |
Neisseria gonorrhoeae antimicrobial resistance among men who have sex with men and men who have sex exclusively with women: the Gonococcal Isolate Surveillance Project, 2005-2010
Kirkcaldy RD , Zaidi A , Hook EW 3rd , Holmes KH , Soge O , del Rio C , Hall G , Papp J , Bolan G , Weinstock HS . Ann Intern Med 2013 158 321-8 BACKGROUND: Gonorrhea treatment has been complicated by antimicrobial resistance in Neisseria gonorrhoeae. Gonococcal fluoroquinolone resistance emerged more rapidly among men who have sex with men (MSM) than men who have sex exclusively with women (MSW). OBJECTIVE: To determine whether N. gonorrhoeae urethral isolates from MSM were more likely than isolates from MSW to exhibit resistance to or elevated minimum inhibitory concentrations (MICs) of antimicrobials used to treat gonorrhea. DESIGN: 6 years of surveillance data from the Gonococcal Isolate Surveillance Project. SETTING: Publicly funded sexually transmitted disease clinics in 30 U.S. cities. PATIENTS: Men with a total of 34,600 episodes of symptomatic urethral gonorrhea. MEASUREMENTS: Percentage of isolates exhibiting resistance or elevated MICs and adjusted odds ratios for resistance or elevated MICs among isolates from MSM compared with isolates from MSW. RESULTS: In all U.S. regions except the West, isolates from MSM were significantly more likely to exhibit elevated MICs of ceftriaxone and azithromycin than isolates from MSW (P < 0.050). Isolates from MSM had a high prevalence of resistance to ciprofloxacin, penicillin, and tetracycline and were significantly more likely to exhibit antimicrobial resistance than isolates from MSW (P < 0.001). LIMITATIONS: Sentinel surveillance may not be representative of all patients with gonorrhea. HIV status, travel history, and antimicrobial use data were missing for some patients. CONCLUSION: Men who have sex with men are vulnerable to the emerging threat of antimicrobial-resistant N. gonorrhoeae. Because antimicrobial susceptibility testing is not routinely done in clinical practice, clinicians should monitor for treatment failures among MSM diagnosed with gonorrhea. Strengthened prevention strategies for MSM and new antimicrobial treatment options are needed. |
Chlamydia trachomatis infection among women 26 to 39 years of age in the United States, 1999 to 2010
Torrone EA , Geisler WM , Gift TL , Weinstock HS . Sex Transm Dis 2013 40 (4) 335-7 Using data from a nationally representative survey, we identified predictors of chlamydial infection in women aged 26 to 39 years. Chlamydia prevalence was low overall but varied by sociodemographics and sexual behaviors. Findings support current recommendations that women older than 25 years should not be routinely screened for chlamydial infection. |
Prevalence of Neisseria gonorrhoeae among persons 14 to 39 years of age, United States, 1999 to 2008
Torrone EA , Johnson RE , Tian LH , Papp JR , Datta SD , Weinstock HS . Sex Transm Dis 2013 40 (3) 202-5 BACKGROUND: Prevalence estimates from population-based surveys do not suffer from the same biases as case-report and clinic positivity data and may be better to monitor sexually transmitted disease morbidity over time. METHODS: We estimated the prevalence of Neisseria gonorrhoeae in a nationally representative sample of persons aged 14 to 39 years participating in the National Health and Nutrition Examination Survey. RESULTS: From 1999 to 2008, the overall prevalence of gonorrhea was 0.27% (95% confidence interval, 0.13%-0.47%). In the 2005 to 2006 and 2007 to 2008 cycles, prevalence approached 0% and was based on too few positive sample persons to obtain reliable estimates. In 2004, most infections were found in 1 survey location. DISCUSSION: Given the low prevalence and geographic clustering of disease, gonorrhea estimates from national probability surveys are often imprecise and unstable. In 2008, gonorrhea testing in National Health and Nutrition Examination Survey was discontinued. Continued surveillance of gonorrhea should include case reporting and prevalence estimates from local surveys and sentinel surveillance systems. |
Prevalence of the 23S rRNA A2058G point mutation and molecular subtypes in Treponema pallidum in the United States, 2007 to 2009.
Su JR , Pillay A , Hook EW , Ghanem KG , Wong W , Jackson D , Smith LD , Pierce E , Philip SS , Wilson S , Golden MR , Workowski KA , Chi KH , Parrish DD , Chen CY , Weinstock HS . Sex Transm Dis 2012 39 (10) 794-798 BACKGROUND: The 23S rRNA A2058G point mutation in Treponema pallidum is associated with macrolide antibiotic treatment failure. Its prevalence and potential association with a molecular subtype within the United States are unknown. METHODS: During 2007 to 2009, 11 clinics across the United States sent samples from genital ulcers to the Centers for Disease Control and Prevention. Molecular techniques were used to identify T. pallidum DNA sequences, the A2058G mutation, and subtype of T. pallidum. Accompanying epidemiologic information was abstracted from medical records. RESULTS: A total of 141 samples with T. pallidum were collected from individuals whose median age was 33 years (range, 13-68 years): 118 were male (69% reported as men having sex with men [MSM]). The A2058G mutation was carried in 75 samples (53%) with T. pallidum, with samples from MSM (versus women and other men) more likely carrying the A2058G mutation (65/82 samples versus 8/57 samples; prevalence ratio, 5.7; 95% confidence interval, 2.9-10.8). Of 98 strain-typed samples, 61 (62%) were the 14d9 subtype of T. pallidum, which was also associated with samples with T. pallidum from MSM (prevalence ratio, 3.5; 95% confidence interval, 1.9-6.5). However, among T. pallidum from MSM, the A2058G mutation was not associated with the 14d9 subtype. CONCLUSIONS: The A2058G mutation and 14d9 subtype of T. pallidum were present throughout the United States. Both were more commonly found in T. pallidum from MSM compared with women or other men but were not associated with each other. Treating syphilis with azithromycin should be done cautiously and only when treatment with penicillin or doxycycline is not feasible. (Copyright 2012 American Sexually Transmitted Diseases Association All rights reserved.) |
Trichomonas vaginalis antimicrobial drug resistance in 6 US cities, STD Surveillance Network, 2009-2010
Kirkcaldy RD , Augostini P , Asbel LE , Bernstein KT , Kerani RP , Mettenbrink CJ , Pathela P , Schwebke JR , Secor WE , Workowski KA , Davis D , Braxton J , Weinstock HS . Emerg Infect Dis 2012 18 (6) 939-43 Nitroimidazoles (metronidazole and tinidazole) are the only recommended drugs for treating Trichomonas vaginalis infection, and previous samples that assessed resistance of such isolates have been limited in geographic scope. We assessed the prevalence of in vitro aerobic metronidazole and tinidazole resistance among T. vaginalis isolates from multiple geographic sites in the United States. Swab specimens were obtained from women who underwent routine pelvic examinations at sexually transmitted disease clinics in 6 US cities. Cultured T. vaginalis isolates were tested for nitroimidazole resistance (aerobic minimum lethal concentration [MLC] >50 microg/mL). Of 538 T. vaginalis isolates, 23 (4.3%) exhibited low-level in vitro metronidazole resistance (minimum lethal concentrations 50-100 microg/mL). No isolates exhibited moderate- to high-level metronidazole resistance or tinidazole resistance. Results highlight the possibility that reliance on a single class of antimicrobial drugs for treating T. vaginalis infections may heighten vulnerability to emergence of resistance. Thus, novel treatment options are needed. |
Monitoring HPV type-specific prevalence over time through clinic-based surveillance: a perspective on vaccine effectiveness.
Gaffga NH , Flagg EW , Weinstock HS , Shlay JC , Ghanem KG , Koutsky LA , Kerndt PR , Hsu KK , Unger ER , Datta SD . Vaccine 2012 30 (11) 1959-64 We investigated the feasibility of monitoring trends in prevalence of vaccine-preventable human papillomavirus (HPV) types in different clinic populations. We collected cervical specimens from women presenting to family planning, primary care, and sexually transmitted disease (STD) clinics for routine pap smears in five US cities during 2003-2005. We performed HPV genotyping and calculated annual type-specific prevalences; pre-vaccine era prevalence was highest for HPV 16 (6.0; 95% confidence interval [CI] 5.5-6.6%) and annual prevalences for vaccine-preventable types were stable, with few exceptions, after controlling for clinic type, age group, and city. With sufficient sample size and stable population characteristics, clinic-based surveillance systems can contribute to monitoring HPV vaccine impact in the cervical screening population. |
Primary and secondary syphilis among black and Hispanic men who have sex with men: case report data from 27 states
Su JR , Beltrami JF , Zaidi AA , Weinstock HS . Ann Intern Med 2011 155 (3) 145-51 BACKGROUND: Until 2005, national-level data on the sex of sex partners that describe how primary and secondary syphilis affects men who have sex with men (MSM) of different races or ethnicities were not reported. OBJECTIVE: To present data from 27 states comparing trends in primary and secondary syphilis among MSM of different races or ethnicities. DESIGN: Review of case report data and regression analysis. SETTING: Federal database of case reports in the National Electronic Telecommunications System for Surveillance. PARTICIPANTS: Men reported to be MSM. MEASUREMENTS: Cases of primary and secondary syphilis per 100,000 males of matching race or ethnicity ("rates"), determined by using population data from the National Center for Health Statistics as the denominator to compare age and racial and ethnic differences. RESULTS: For each year during 2005 to 2008, 27 states from all U.S. census regions reported data on the sex of sex partners for 70% or more of male cases of primary and secondary syphilis. Regression analysis revealed significantly different trends in rates of primary and secondary syphilis: Absolute increases in rates among black MSM and Hispanic MSM were, respectively, 8.0 times and 2.4 times the absolute increase in rate among white MSM. By region, rates among MSM increased 30% in the Midwest, 48% in the South, 73% in the Northeast, and 77% in the West. By age group, the largest absolute increase in rates occurred among MSM aged 20 to 29 years. LIMITATION: Results from 27 states may not be generalizable to the United States as a whole. CONCLUSION: Rates of primary and secondary syphilis disproportionately increased among black and Hispanic MSM (compared with white MSM) and among young MSM. Care providers should offer counseling about safer sexual practices and screening for syphilis and other sexually transmitted infections when caring for MSM. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention. |
Epidemiology of syphilis among Hispanic women and associations with congenital syphilis, Maricopa County, Arizona
Kirkcaldy RD , Su JR , Taylor MM , Koumans E , Mickey T , Winscott M , Kenney K , Weinstock HS . Sex Transm Dis 2011 38 (7) 598-602 OBJECTIVE: We investigated factors associated with high rates of congenital syphilis among Hispanic infants in Maricopa County, AZ. METHODS: Using 2004-2008 syphilis case report data from the state and county health departments, we examined characteristics of pregnant and nonpregnant women with syphilis and their male partners. RESULTS: During 2004-2008, 970 women were reported to have syphilis: 49% were Hispanic (of whom 49% were non-US citizens), 27% were white, 13% were black, and 8% were American Indian/Alaskan Native. Although 16% of Hispanic noncitizens reported drug use or high-risk sexual behaviors, 64% of these women had a male sex partner who reported drug use or anonymous sex. Hispanic women with syphilis were more likely to be pregnant (37%) than white (15%) or black women (13%) (P < 0.05), and were overrepresented among pregnant women with syphilis. Pregnant Hispanic noncitizens were treated later than pregnant Hispanic citizens (median 28 weeks gestation vs. 21 weeks, P = 0.01). CONCLUSIONS: Innovative congenital syphilis prevention strategies that are relevant to Hispanic women are warranted. Strategies should address the reproductive health and prenatal care needs of Hispanic women, and may include interventions for their male partners. |
Pelvic inflammatory disease among privately insured women, United States, 2001-2005
Bohm MK , Newman L , Satterwhite CL , Tao G , Weinstock HS . Sex Transm Dis 2009 37 (3) 131-6 BACKGROUND: We explored the utility of using insurance claims data for surveillance of pelvic inflammatory disease (PID). PID rates are an important indicator of population level trends in reproductive morbidity; however, data available to monitor PID trends are limited. National survey data are currently used to estimate PID rates in the United States, but a declining number of cases threaten their future usefulness. METHODS: We performed a retrospective analysis of PID diagnosis rates using administrative claims data from 2001 to 2005. Diagnostic codes were used to identify women aged 15 to 44 in the study population that were diagnosed with acute PID as inpatients, in emergency departments, and in outpatient ambulatory settings. RESULTS: Rates of PID diagnoses among privately insured women declined significantly from 2001 to 2005 among all age groups examined and within all geographic regions. Annual PID diagnosis rates decreased from 317.0 to 236.0 per 100,000 enrollees, representing a 25.5% decline over the study period. The highest rates of PID were among 25- to 29-year-olds (352.8 per 100,000 in 2005) and among those residing in the South (314.3 per 100,000 in 2005). Most women (70.1%) received PID care through physician offices and other outpatient facilities; of these women, approximately 40% were treated by an obstetrician/gynecologist. CONCLUSIONS: The decline in PID diagnoses corresponds with previous reports from national surveys. Claims data offer a much needed new data source that will allow for continued monitoring of PID among a broad population in both inpatient and outpatient clinical settings. |
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