Complicated Staphylococcus aureus infections often require prolonged intravenous (IV) antibiotic therapy, which poses challenges for patients, particularly those with unstable housing or substance use disorders, and leads to increased healthcare costs. Logistical barriers, including frequent lab monitoring and the need for nurse visits, add complexity to traditional outpatient antibiotic therapy. This study describes the integration of dalbavancin, a long-acting lipoglycopeptide antibiotic, into a county hospital's formulary as an outpatient therapy alternative for patients unsuitable for standard IV therapy. Dalbavancin has demonstrated clinical efficacy in treating infective endocarditis and osteomyelitis. One of our local hospitals' internal data indicated that dalbavancin's cost per patient is significantly lower than standard care. This article discusses dalbavancin administration implementation via an infusion center post-discharge. The therapy plan, including dosing instructions and coordination mechanisms, was integrated into the electronic medical record system to streamline administration.

The study describes the experience of an Infectious Diseases (ID) electronic consultation (eConsult) service at a county hospital between October 1, 2022, and September 30, 2024. The service, primarily used by primary care providers (PCPs), aims to enhance clinical decision-making and reduce wait times by providing timely expert opinions. Two hundred eighty eConsults were completed, with 72.1

Background The United States Food and Drug Administration recently announced a national blood culture (BC) bottle shortage; the exact date of restoration is still being determined. Aim Implement a workflow to mitigate the BC bottle shortage at our hospital. Methods We created the following clinical decision support workflow in electronic medical record to help mitigate BC bottle use: (a) limit to two BC in 24 hours, (b) only repeat BC if 72 hours have passed from the prior sets, (c) do not repeat BC for coagulase-negative Staphylococcus bacteremia when considered a contaminant (i.e., no implanted vascular device), (d) do not repeat BC for Streptococcus bacteremia, (e) do not repeat cultures for Gram-negative rod bacteremia unless an unknown source, immunosuppression, or clinical worsening. Findings Post implementation, our weekly average BC bottle use decreased to 29.5%. Conclusion Within three weeks of the BC bottle shortage announcement, we successfully deployed evidence-based BC restrictions in the electronic medical record (EMR), reducing our BC orders by 29.5%. We encourage others to consider and potentially replicate our workflow to contribute to diagnostic stewardship.

Objectives: To compare debridement, antibiotics, and implant retention (DAIR) and intramedullary nail (IMN) removal with subsequent strategy for fracture stabilization in the treatment of tibia fracture-related infections (FRIs) occurring within 90 days of initial IMN placement.Design: Retrospective case-control.Setting: Four academic, Level 1 trauma centers.Patients: Sixty-six patients who subsequently received unplanned operative treatment for FRI diagnosed within 90 days of initial tibia IMN.Intervention: DAIR versus IMN removal pathways.Main Outcome Measurements: Fracture union.Results: Twenty-eight patients (42.4%) were treated with DAIR and 38 (57.6%) via IMN removal with subsequent strategy for fracture stabilization. Mean follow-up was 16.3 months. At final follow-up, ultimate bone healing was achieved in 75.8% (47/62), whereas 24.2% (15/62) had persistent nonunion or amputation. No significant difference was observed in ultimate bone healing (P = 0.216) comparing DAIR and IMN removal. Factors associated with persistent nonunion or amputation were time from injury to initial IMN (P < 0.001), McPherson systemic host grade B (P = 0.046), and increasing open-fracture grade, with Gustilo-Anderson IIIB/IIIC fractures being the worst (P = 0.009). Fewer surgeries after initial FRI treatment were positively associated with ultimate bone healing (P = 0.029).Conclusions: Treatment of FRI within 90 days of tibial IMN with DAIR or IMN removal with subsequent strategy for fracture stabilization results in a high rate, nearly 1 in 4, of persistent nonunion or amputation, with neither appearing superior for improving bone healing outcomes.Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective:To determine if race-ethnicity is correlated with case-fatality rates among low-income patients hospitalized for COVID-19. Research Design:Observational cohort study using electronic health record data. Patients:All patients assessed for COVID-19 from March 2020 to January 2021 at one safety net health system. Measures:Patient demographic and clinical characteristics, and hospital care processes and outcomes. Results:Among 25,253 patients assessed for COVID-19, 6,357 (25.2%) were COVID-19 positive: 1,480 (23.3%) hospitalized; 334 (22.6%) required intensive care; and 106 (7.3%) died. More Hispanic patients tested positive (51.8%) than non-Hispanic Black (31.4%) and White patients (16.7%, P<.001]. Hospitalized Hispanic patients were younger, more often uninsured, and less likely to have comorbid conditions. Non-Hispanic Black patients had significantly more diabetes, hypertension, obesity, chronic kidney disease, and asthma (P<.05). Non-Hispanic White patients were older and had more cigarette smoking history, COPD, and cancer. Non-Hispanic White patients were more likely to receive intensive care (29.6% vs 21.1% vs 20.8%, P=.007) and more likely to die (12% vs 7.3% vs 3.5%, P<.001) compared with non-Hispanic Black and Hispanic patients, respectively. Length of stay was similar for all groups. In logistic regression models, Medicaid insurance status independently correlated with hospitalization (OR 3.67, P<.001) while only age (OR 1.076, P<.001) and cerebrovascular disease independently correlated with in-hospital mortality (OR 2.887, P=.002). Conclusions:Observed COVID-19 in-hospital mortality rate was lower than most published rates. Age, but not race-ethnicity, was independently correlated with in-hospital mortality. Safety net health systems are foundational in the care of vulnerable patients suffering from COVID-19, including patients from under-represented and low-income groups.

Objectives: Fracture related infection (FRI) is a severe, potentially limb-threatening complication after fracture fixation. Dilemma exists with regard to removing or retaining implants while treating the infection. The purpose of this study was to compare primary bone union and infection clearance in patients who had an infection following intramedullary nailing of the tibia treated either by retaining the implant or by removing the implant. Methods: Patients from two level-I trauma centers were identified through billing registries and retrospectively reviewed between January 2013 and December 2020. We identified 44 patients who had a diagnosis of FRI within 90 days of their initial fixation and returned to the OR for operative treatment of the infection. The incidences of both primary union and infection clearance were calculated for both groups and multiple parameters that may be associated with success or failure were assessed. Results: Four patients did not have complete records and were excluded. Of the remaining patients, 20 (50%) achieved infection clearance. Twenty-three (59%) patients achieved primary union whereas 16 (41%) had a primary outcome of either delayed union, nonunion, or amputation (one additional patient excluded as healing status unknown). Further analysis showed no significant difference (X2 (39) = 1.13, p < .29) in infection clearance between patients treated with nail retention (64%) versus nail removal (68%). No significant difference was seen in primary bone union (X2 (39) = 3.24, p < .07) with 36% of patients treated with nail retention and 68% of patients treated with nail removal reaching primary union; however, this does trend toward an association. Fewer surgeries performed for infection and complication after initial fixation was positively associated with infection clearance (p < .04, M=4.6, SD=2.13, df=39) and primary union (p < .001, M=4, SD=2, df=38). Conclusion: Infection clearance seems similarly possible with both nail retention and nail removal strategies, with fewer number of surgeries performed for infection and complication improving the likelihood of infection clearance and bone union. This may suggest that more severe FRI’s are less likely to unite and clear infection. Nail removal may play a role in increasing primary bone union; however, a larger sample size is needed for more definitive assessment.

With the largest viral loads in both symptomatic and asymptomatic patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) present in the oral and nasal cavities, agents that act on these two areas have the potential for large therapeutic and prophylactic benefit. A literature review was conducted to elucidate the possible agents useful in treatment of SARS-CoV-2. These agents were evaluated for their current applications, adverse reactions, their current state of study, and any future considerations in their management of coronavirus disease 2019 (COVID-2019). Our review has found that, while there are many promising agents with proven efficacy in their in-vitro efficacy against SARS-CoV-2, more clinical trials and in-vivo studies, as well as safety trials, must be conducted before these agents can be effectively implemented.

ObjectiveTo provide a state of the art review of intranasal antiviral drug delivery and to discuss current applications, adverse reactions, and future considerations in the management of coronavirus disease 2019 (COVID‐19).Data SourcesPubMed, Embase, and Clinicaltrials.gov search engines.Review MethodsA structured search of the current literature was performed of dates up to and including April 2020. Search terms were queried as related to topics of antiviral agents and intranasal applications. A series of video conferences was convened among experts in otolaryngology, infectious diseases, public health, pharmacology, and virology to review the literature and discuss relevant findings.ConclusionsIntranasal drug delivery for antiviral agents has been studied for many years. Several agents have broad‐spectrum antiviral activity, but they still require human safety and efficacy trials prior to implementation. Intranasal drug delivery has potential relevance for future clinical trials in the settings of disease spread prevention and treatment of SARS‐CoV‐2 and other viral diseases.Implications for PracticeIntranasal drug delivery represents an important area of research for COVID‐19 and other viral diseases. The consideration of any potential adverse reactions is paramount.

WHITE JOURNAL FORMAT) 48 Objective: To provide a state-of-the-art review of intranasal antiviral drug delivery and to discuss 49 current applications, adverse reactions, and future considerations in the management of 50 Coronavirus Disease (COVID-19). 51 Data sources: PubMed, Embase, and www.clinicaltrials.gov search engines. 52 Review Methods: A structured search of the current literature was performed of dates up to and 53 including April 2020. Search terms related to topics of antiviral agents and intranasal 54 applications were queried. A series of video conferences was convened of experts in 55 otolaryngology, infectious diseases, public health, pharmacology, and virology to review the 56 literature and discuss relevant findings. 57 Conclusions: Intranasal drug delivery for antiviral agents have been studied for many years. 58 Several agents have broad-spectrum antiviral activity, but they still require human safety and 59 efficacy trials prior to implementation. Intranasal drug delivery has potential relevance for future 60 clinical trials in the settings of disease spread prevention and treatment of SARS-CoV-2 and 61 other viral diseases. 62 Implications for Practice: Intranasal drug delivery represents an important area of research for 63 COVID-19 and other viral diseases. The consideration of any potential adverse reactions is 64

The ocular manifestations of syphilis are varied. Ocular syphilis can occur during any stage of infection and involve virtually any part of the eye. In immunocompetent individuals, the most common etiologies include syphilitic uveitis. Although the clinical presentation of ocular syphilis in HIV-infected patients is also widespread, posterior segment involvement has been more commonly described particularly in patients with AIDS. The diagnosis of syphilitic retinitis is challenging since its clinical presentation mimics retinitis caused by other viral etiologies. In addition, HIV-infected individuals with syphilis are more likely to develop aberrant serologic responses. Recognition of syphilitic retinitis and prompt initiation of penicillin therapy is of critical importance since syphilitic retinitis generally responds well to treatment and loss of vision is reversible. In this report, we describe a 39-year-old female with advanced stages of AIDS who developed necrotizing retinitis due to syphilis. Prompt initiation of intravenous penicillin led to excellent visual outcome for this patient despite significantly decreased visual acuity on presentation.

Background. Persistent infection with oncogenic human papillomavirus (HPV) is associated with an increased risk of cervical malignancy. Redetection of type-specific HPV after a period of nondetection may be caused by reactivation of a low-level persistent infection. Little is known about factors associated with type-specific HPV redetection.Methods. For a longitudinal cohort of adolescent women with frequent behavioral and sexually transmitted infection (STI) information (every 3 months), Cox proportional hazard models were used to assess the influence of sexual behaviors and STIs on the redetection of oncogenic or high-risk HPV infections.Results. A total of 210 type-specific high-risk HPV detection episode periods were identified in this longitudinal cohort; 71 (33.8%) were characterized by a period of nondetection followed by redetection. Chlamydia trachomatis (hazard ratio [HR], 3.14; 95% confidence interval [CI], 1.44-6.86) was associated with redetection; redetection was >2 times more likely with each additional self-reported sex partner in the past 3 months (HR, 2.26; 95% CI, 1.35-3.78).Conclusions. This study demonstrates the role of C. trachomatis and number of recent sexual partners in type-specific HPV redetection. Given that persistent oncogenic HPV infections are associated with cancer-related outcomes, understanding the potential role of such factors in the pathogenesis of HPV-related outcomes is important.

Background Mycoplasma genitalium (MG) causes non-gonococcal urethritis as well as asymptomatic infections although most data on the incidence and natural history of MG is from adults. Methods Participants were 14–17 year old men in a longitudinal study of STI and the urethral microbiome. Urine samples were collected monthly and batch tested retrospectively for MG DNA using PCR. Urine samples were tested in real-time for chlamydia, gonorrhoea, trichomonas and white blood cells (WBC): infections by these organisms were treated. White blood cell count (WBC) was measured by automated cell count of fresh urine. Dysuria and urethral discharge were self-reported on cell phone diaries. Results Among 75 participants (mean age 16.0 at enrollment), 6 (8.0%) men have at least one MG positive sample, with a total of 14 MG positive monthly urine samples. The prevalence of Chlamydia or gonorrhoea infection was 19/75 (25.3%) and 1/75 (1.3%), respectively. All but one participant was positive for at least two consecutive months, and one participant was positive for 4 consecutive months. One participant was positive only once, was co-infected with chlamydia, but treatment could not be confirmed. No other MG positive visits occurred simultaneously with other STI. None of the participants reported symptoms or sexual behaviours within a 15 day window of the positive visit. Average urine WBC was 21.8 WBC/ml urine although only 3/14 MG positive samples were associated with urine WBC > 28.5/ml (commonly used as a diagnostic threshold for pyuria). Conclusions MG in adolescent men is more common than gonorrhoea, persistent without treatment for up to 120 days, and is typically not associated with symptoms or pyuria. These data add to emerging understanding of the prevalence and natural history of sexually transmitted MG and support the importance of more detailed understanding of sexual and reproductive health morbidity associated with these infections.

Genital herpes in adolescents is most often caused by herpes simplex virus 1 (HSV 1). HSV 1 recurs less, sheds less, and is therefore less likely to be transmitted. Appropriate testing is described, as well as psychological ramifications and counseling interventions. Human papillomavirus (HPV) is a common sexually-transmitted infection with the highest prevalence rates in adolescent and young women. HPVs that infect mucosal epithelium are classified as high- or low-risk based on their causal association with clinical outcomes. The majority of HPV infections clear without causing any clinical disease. However, persistent infection with one or more of the 13 high-risk HPV types puts women at risk for high-grade dysplasia (a precursor for cervical cancer) and cervical cancer. HPV 16 and HPV 18 cause approximately 70% of cervical cancers and the majority of HPV-associated anal, vulvar, vaginal, and oral cancers. HPV 6 and HPV 11 cause approximately 90% of genital warts. Diagnosis of genital warts is typically based on physical exam. Genital warts usually present as painless papules and occasionally become large and disfiguring, especially in immunocompromised patients. Multifocal lesions are common; therefore, inspection of the entire genital area is warranted during a physical exam. HPV DNA testing is not appropriate for the diagnosis of warts, but may be useful in screening for cervical dysplasia and cancer in adults. Treatment options for genital warts include topical patient-applied therapy, topical provider-applied therapy, ablative therapy, and surgical excision. Treatment decisions are based on patient preference, provider experience, and size and location of warts. Chlamydia trachomatis (CT) is the most common bacterial sexually-transmitted infection (STI) in the US with the highest prevalence rates reported amongst adolescent and young adult females. Symptoms and signs of chlamydia infection may include vaginal discharge and cervicitis; however, the majority of female chlamydial infections are asymptomatic. Therefore, annual screening of all sexually-active females aged 25 years or younger is the standard of care. If untreated, chlamydial infection may progress to pelvic inflammatory disease (PID) and the associated morbidities of ectopic pregnancy, infertility, and chronic pelvic pain. Women often seek care for sexually-transmitted infections (STIs) from their gynecologist. Adolescent and young adult women are disproportionately affected by STIs. Gonorrhea is a common STI of the urethra, cervix, fallopian tubes, rectum, and pharynx. Presenting symptoms vary by anatomic site, and may include vaginal or anal discharge, pharyngitis, and tenosynovitis. Infection with gonorrhea may be asymptomatic and has serious sequelae if left untreated. Treatment for gonorrhea includes a combination of antibiotics such as ceftriaxone and azithromycin or doxycycline. All patients presenting for STI screening or gonorrhea treatment should be tested for other STIs, such as chlamydia, trichomonas, and HIV, and counseled on contraception. Trichomonas vaginalis (TV) is a sexually-transmitted infection that is as common as chlamydia in adolescent women. It is a vaginal pathogen that causes inflammation and breakdown of the vaginal mucosal barrier. Many infections are asymptomatic, and untreated infections can have serious health consequences. Point-of-care testing and treatment are highly effective. Providers who care for at-risk teens should have a low threshold for screening for TV. Adolescents are at risk for HIV both though risk-taking behavior as well as biologic mechanisms, and should be routinely screened for HIV infection. Medical providers should be aware of the gynecologic conditions that may indicate concurrent HIV infection. HIV-positive adolescents have unique gynecologic needs requiring modified guidelines for STI and cervical cancer screening, as well as attention to reproductive health, including preconception, contraceptive concerns, and prenatal care. Sexually-transmitted infections (STIs) may go unnoticed or present with a rash or bump. Lack of awareness of the presentations of the less common disease means lack of accurate diagnosis and treatment. Awareness of both common and obscure STIs will allow you to treat all STIs appropriately, speedily, and safely.

Objectives Human papillomavirus (HPV) infections are common in adolescent women, while the rare cancerous sequelae of HPV infections do not generally occur until the 4th or 5th decades of life. This prospective study of a cohort of adolescent women was performed to further our knowledge of the natural history of incident and prevalent HPV infections. Methods Self-vaginal swabs collected from high-risk, unvaccinated adolescent women in a longitudinal study were analysed for HPV DNA. Sera were collected at enrolment and later tested for HPV antibodies. Statistical analysis was performed to determine the HPV genotype distribution and duration of detection, and to determine rates of seropositivity and seroconversion for HPV types represented in the assays. Results 146 subjects (mean enrolment age=15.4 years; mean duration of follow-up=5.8 years) had samples adequate for analysis of HPV detection, and 95 of these subjects had paired sera available. The cumulative prevalence for high-risk and low-risk HPV types was 95.9% and 91.1%, respectively. HPV types 6, 11, 16 and 18 (HPV types represented in the quadrivalent vaccine) were found at some point in 40.4%, 6.2%, 48% and 24% of participants, respectively. Serological data confirmed exposure to these vaccine-covered types, as well as to other high-risk HPV types. Conclusions In this cohort of adolescent women, high- and low-risk HPV types were frequently detected, and serological data confirmed exposure in most subjects. The high-prevalence HPV types represented in the quadrivalent HPV vaccine further support vaccination of women at an age well before sexual debut.

(See the major article by Gravitt et al, on pages 272–80.) Human papillomavirus (HPV) can be detected in exfoliated cervical cells or vaginal swab samples from approximately 25%–50% of young, sexually active women, according to cross-sectional studies, and from a higher percentage, according to longitudinal studies. In up to 90% of cases, the infection “clears” within 1 or 2 years, meaning that specific HPV types cannot be detected by polymerase chain reaction (PCR) assays of cervical or vaginal swab samples [1]. “Clearance” implies that the individual is no longer infected and does not need to worry about possible long-term sequelae of the infection. Proving that HPV is absolutely gone is, of course, impossible. An alternative hypothesis is that HPV can exist in a low-level persistent state and can reactivate later in life and cause disease. Determining that an HPV infection has cleared should not be based on 1 or 2 negative test results, as nearly all studies have done [2–5]. Several studies involving younger women indicate that type-specific HPV can be detected again after a long period of apparent clearance, but it has not been established whether type-specific HPV redetection is due to reactivation of a low-level persistent infection or the result of a new infection [6–9]. The questions of why and how low-level persistence happens are not understood. A small focus of infected cells may simply be inadequately sampled, or the HPV load may drop to only a few copies per cell at the time of HPV integration into the host genome, making detection unlikely. The resulting low viral copy number may be below the lower limit of detection of standard HPV PCR assays, resulting in falsely negative HPV testing results. This small focus of cells could persist under immunologic control until waning control later in life allows lesion expansion and subsequent HPV redetection. Although our understanding of HPV is incomplete, relatively more is known about early events (at the time of initial infection) and late events (the malignancies associated with oncogenic HPV), compared with the long period between initial infection and the diagnosis of cervical cancer. The prevalence of HPV infection peaks in the early 20s, and after a gradual decline, a second peak in HPV prevalence occurs in the fifth or sixth decades of life in North American, European, and Central/South American women [10]. Cervical cancer, essentially all of which is caused by infection with oncogenic HPV types, also peaks around the fifth or sixth decades of life. Many studies have demonstrated that persistent oncogenic HPV detection is associated with cervical cancer. “Persistence” in these studies was generally defined as 2–4 semiannually collected cervical swabs positive for the same HPV type, just prior to the diagnosis of the high-grade cervical lesion. The question remains of when this infection initially occurred: is it the same HPV isolate acquired in the woman's teens or early 20s, or does it involve a new infection acquired later in life (during ages 45–60 years), in the years immediately prior to the diagnosis of cancer? A study by Gravitt et al in this issue of the Journal was performed to address these and other questions about HPV detection and possible reactivation of a preexisting or “prevalent” HPV infection in older women [11]. This study involved cohort analysis, a method used to identify birth cohorts at increased risk for specific outcomes (such as detection of oncogenic HPV) and risk factors for those outcomes. Cohort effects are variations in the risk of a health outcome according to birth year (or years) that are related to differences in the exposure of the cohort to risk factors for that particular outcome [12]. The authors enrolled a cohort of 843 women aged 35–60 years and stratified these women into 2 groups: those with <5 lifetime sex partners (and, thus, at a lower risk of oncogenic HPV acquisition), and those with ≥5 lifetime sex partners (and, thus, at a higher risk of oncogenic HPV infection). The age-specific HPV prevalence was estimated in these 2 groups of women. The age-specific prevalence of oncogenic HPV declined among women with <5 lifetime sex partners but not among those with ≥5 lifetime sex partners. Additionally, the population attributable risk for oncogenic HPV infection due to ≥5 lifetime sex partners was higher among older women (87.2%), compared with younger woman (28.0%). In contrast, the population attributable risk associated with a new sex partner was 28% among younger women, compared with 7.7% among older women. The authors concluded that there might be an interaction of age and lifetime number of sex partners on oncogenic HPV infection. The authors also concluded that this interaction of age and lifetime number of sex partners on oncogenic HPV infection suggested that older women might be at risk for HPV “reactivation.” Thus, the older women in the study, who were likely infected with oncogenic HPV during the interval spanning the late 1960s through the 1970s—the period of the US sexual revolution—had a lower overall risk of HPV infection, because they reported a lower overall number of lifetime number of sex partners. However, oncogenic HPV prevalence declined with age only among older women with <5 lifetime sex partners. One can conclude from this study that the risk of oncogenic HPV reactivation may increase after the age of 50 years and that reactivation contributes to a large fraction of HPV detection at older ages, compared with the fraction resulting from new HPV infections. What is the importance of HPV reactivation? What is the cause of reactivation? Among immunosuppressed individuals, oncogenic HPV present for many years at very low levels may be responsible for the high rate of HPV-related disease. The high rate of disease among these individuals may result from reactivation of low-level persistent HPV as immunity wanes [13]. What about the phenomenon known as immunosenescence, which involves a reduction in many aspects of immune system function and naturally occurs during the aging process? Immunosenescence leading to reactivation of HPV has been hypothesized as an explanation for higher prevalence proportions among older women [14]. In summary, although we now have safe and effective vaccines to prevent infection and disease with the 2 most important oncogenic HPV types (HPV 16 and HPV 18) in younger women, it will be decades before reductions in cervical cancer will be seen. Women >30 years old who are unvaccinated today are at continued risk of cervical cancer for the next 20–30 years. The questions asked by Gravitt et al have great importance from epidemiologic, behavioral, and clinical perspectives. Older women should not be told that detection of HPV always indicates a new infection, but rather that detection of HPV could result from an infection acquired many years ago. Further research is needed to help better understand the natural history of HPV infection in older women and to understand the importance of HPV persistence and reactivation in all women.

BACKGROUND Genital human papillomavirus (HPV) infection is believed to be primarily sexually transmitted. Few studies have documented the detection of HPV in the vagina before first vaginal intercourse. METHODS We used a longitudinally followed cohort of adolescent females without prior vaginal intercourse to examine the frequency of detection of vaginal HPV and the association between first reported HPV detection and noncoital sexual behaviors. RESULTS HPV was detected in 45.5% of subjects (10 of 22) before first vaginal sex. Seven of these 10 subjects reported noncoital behaviors that, in part, might have explained genital transmission. CONCLUSIONS HPV can be detected in the vagina before first sexual intercourse, highlighting the need for early vaccination.

Background: The natural history of Neisseria gonorrhoeae (GC) infections is largely unknown. The objective of the current study was to use sequential weekly vaginal samples and molecular techniques to describe the natural history of incident gonorrhea infections in adolescent women. Methods: A cohort of 387 adolescent women aged 14 to 17 were enrolled from urban, primary care clinics and followed longitudinally for a period of up to 8 years. Weekly vaginal swabs and daily diaries were provided during 12-week periods biannually, beginning and ending with a clinic visit, where all identified infections were treated. For this study, specimens and data from 16 women who became infected with GC during a weekly sampling period were analyzed. Results: GC organism load was highly variable between subjects. The number of organisms did not significantly differ across the first 6 weeks of infection (P = 0.59). Organism load did not differ among women with a previously documented GC infection at week 1 (P = 0.43) or across the first 6 weeks of infection (P = 0.67). The association of concurrent chlamydial infection on gonorrhea organism load was borderline significant over the first 6 weeks of infection (P = 0.06). Conclusions: Individual shedding patterns varied widely, and GC organism load did not decline in women for at least several weeks and were not associated with genitourinary symptoms. Chlamydia coinfection is associated with higher GC organism loads, potentially increasing chances of transmission. This study utilized a standardized quantification technique to assess GC organism load.