The British Association for Sexual Health and HIV United Kingdom guideline on the management of non-gonococcal urethritis (NGU) 2026 provides details on the aetiology and clinical features of NGU, with recommendations on diagnosis and treatment of acute and persistent/recurrent NGU. Non-gonococcal urethritis is characterised by urethral inflammation, and it can be infectious or non-infectious. The most common organisms causing NGU are Chlamydia trachomatis and Mycoplasma genitalium. Diagnosis of NGU is based on clinical history and evidence of an excess of polymorphonuclear leucocytes in the anterior urethra of symptomatic men. Nucleic acid amplification tests to determine the specific aetiology are used to guide treatment and reduce complications. Recommendations include advising patients to abstain from sexual intercourse until they and their partner(s) have completed treatment and follow-up to prevent re-infection.

OBJECTIVE:To evaluate the efficacy of pristinamycin in treating Mycoplasma genitalium infection among patients who experienced failure of resistance-guided treatment regimens. METHODS:This observational study reviewed pharmaceutical and clinical records of patients who received pristinamycin via the named-patient mechanism at a London sexual health service between October 2019 and February 2025. Eligible participants had documented clinical and/or microbiological failure following resistance-guided therapy. Data collected included demographics, sexuality, infection site, macrolide resistance results, prior antibiotic exposure and tetracycline pretreatment. The primary outcome was microbiological cure, defined as a negative test-of-cure ≥4 weeks post treatment. The secondary outcome was clinical cure, defined as resolution of symptoms in the absence of a confirmatory test. We compared proportions with Fisher's exact test for 2×2 comparisons and a single global χ2 test for multicategory comparisons, reporting relative risks with 95% CIs. RESULTS:Sixty-eight patients were identified; 87% were male, 57% were men who have sex with men, and the mean age was 37 years. Nearly all (97%) had macrolide-resistant infections. Most (81%) had previously received moxifloxacin and the median number of prior antimicrobial courses was three. Microbiological cure was achieved in 71% (48/68; 95% CI 58% to 81%) and clinical cure in 76% (52/68; 95% CI 65% to 86%). When stratified by the use or non-use of tetracycline pretreatment and by the indication for the test, no statistically significant difference in either microbiological or clinical cure was observed. CONCLUSIONS:Pristinamycin achieved microbiological and clinical cure rates of 71-76% in patients with macrolide-resistant M. genitalium infection. These findings align with previously published observational data, supporting pristinamycin as an effective and tolerable third-line treatment option following macrolide-based and quinolone-based regimen failure. Development of standardised algorithms is warranted to optimise management of resistant M. genitalium infection.

Chlamydia trachomatis and Mycoplasma genitalium share many similarities, but as much differentiates these two organisms as unites them. These common sexually transmitted bacteria are strongly associated with several acute syndromes in the genito-urinary tract. Although the long-term severe sequelae of Chlamydia trachomatis are well accepted, the data underpinning the complications of Mycoplasma genitalium are less specific and largely observational. Efforts to control Chlamydia trachomatis with comprehensive, large-scale testing programs have yielded limited results, and the control paradigm will shift in the coming years. As diagnostic capabilities for detecting Mycoplasma genitalium have improved, this organism is more widely diagnosed, and the emergence of complex antimicrobial resistance has complicated therapy options. This contribution describes the two organisms' epidemiology, clinical manifestations, and management, and explores new approaches to their control and prevention.

This guideline provides details on the pathology and clinical features of Mycoplasma genitalium infection and makes recommendations for diagnostic tests, treatment regimens and the health promotion principles needed for the effective management of infection, in people aged 16 years or older attending sexual health services. The guideline is primarily aimed at level 3 sexual health services in the UK, although it could also serve as a reference guide for sexually transmitted infections services at other levels. It is updated from the previous guideline published in 2018.

Objectives Since June 2022, there has been a rise in the number of ceftriaxone-resistant Neisseria gonorrhoeae cases detected in England (n = 15), of which a third were XDR. We describe the demographic and clinical details of the recent cases and investigate the phenotypic and molecular characteristics of the isolates. For a comprehensive overview, we also reviewed 16 ceftriaxone-resistant cases previously identified in England since December 2015 and performed a global genomic comparison of all publicly available ceftriaxone-resistant N. gonorrhoeae strains with mosaic penA alleles. Methods All N. gonorrhoeae isolates resistant to ceftriaxone (MIC > 0.125 mg/L) were whole-genome sequenced and compared with 142 global sequences of ceftriaxone-resistant N. gonorrhoeae. Demographic, behavioural and clinical data were collected. Results All cases were heterosexual, and most infections were associated with travel from the Asia-Pacific region. However, some had not travelled outside England within the previous few months. There were no ceftriaxone genital treatment failures, but three of five pharyngeal infections and the only rectal infection failed treatment. The isolates represented 13 different MLST STs, and most had the mosaic penA-60.001 allele. The global genomes clustered into eight major phylogroups, with regional associations. All XDR isolates belonged to the same phylogroup, represented by MLST ST16406. Conclusions Most cases of ceftriaxone-resistant N. gonorrhoeae detected in England were associated with travel from the Asia-Pacific region. All genital infections were successfully treated with ceftriaxone, but there were extragenital treatment failures. Ceftriaxone resistance continues to be associated with the penA-60.001 allele within multiple genetic backgrounds and with widespread dissemination in the Asia-Pacific region.

Background Since June 2022, there has been a rise in the number of ceftriaxone resistant Neisseria gonorrhoeae cases detected in England (n = 15), of which one third were extensively-drug resistant (XDR). We describe the demographic and clinical details of the recent cases and investigate the phenotypic and molecular characteristics of the isolates. For a comprehensive overview, we also reviewed 16 ceftriaxone-resistant cases previously identified in England since December 2015 and performed a global genomic comparison of all publicly available ceftriaxone-resistant N. gonorrhoeae strains with mosaic penA alleles. Methods All N. gonorrhoeae isolates resistant to ceftriaxone (MIC >0.125 mg/L) were whole-genome sequenced and compared with 142 global sequences of ceftriaxone-resistant N. gonorrhoeae. Demographic, behavioural, and clinical data were collected, including treatment and outcomes. Results All cases were heterosexuals, and most infections were associated with travel to or from the Asia-Pacific region. However, some had not travelled outside England within the previous few months. There were no ceftriaxone genital treatment failures, but 3/5 pharyngeal infections and the only rectal infection failed treatment. The isolates represented 13 different multi-locus sequence types (MLSTs), and most had the mosaic penA-60.001 allele. The global genomes clustered into eight major phylogroups, with regional associations. All XDR isolates belonged to the same phylogroup, represented by MLST 16406. Conclusion Ceftriaxone resistance in N. gonorrhoeae continues to be associated with the penA-60.001 allele within multiple genetic backgrounds and with widespread dissemination in the Asia-Pacific region. Heightened surveillance activities have been initiated to detect further cases with the aim of interrupting further transmission. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by UKHSA ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Research Ethics and Governance Group of the UK Health Security Agency waived ethical approval for this work. This analysis was undertaken for health protection purposes under permissions granted to UKHSA to collect and process confidential patient data under Regulation 3 of The Health Service (Control of Patient Information) Regulations 2020 and Section 251 of the National Health Service Act 2006. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.

Background Antimicrobial resistance in Neisseria gonorrhoeae is a global public health concern. Tetracycline resistance (TetR) increased from 39.4% to 75.2% between 2016 and 2021 in N. gonorrhoeae isolates collected through national surveillance in England, despite the absence of use of tetracyclines for the treatment of gonorrhoea.Objectives We investigated whether there was correlation between bacterial sexually transmitted infection (STI) tests performed and treatment with antimicrobials, with increased TetR in N. gonorrhoeae.Methods We examined correlations between bacterial STI tests, antimicrobial treatment and TetR in N. gonorrhoeae, using national surveillance data from three large sexual health services (SHS) in London during 2016-20. Doxycycline prescribing data and antibiograms of a non-STI pathogen from distinct patient groups (sexual health, obstetric and paediatric), at a large London hospital, were analysed to identify if doxycycline use in SHS was associated with resistance in a non-STI organism.Results A substantial increase in TetR was observed, particularly in isolates from gay, bisexual and other MSM (GBMSM). Strong positive correlations were observed exclusively in GBMSM between N. gonorrhoeae TetR and both bacterial STI tests (r = 0.97, P = 0.01) and antimicrobial treatment (r = 0.87, P = 0.05). Doxycycline prescribing increased dramatically during the study period in SHS. Prevalence of TetR in Staphylococcus aureus was higher in isolates sourced from SHS attendees than those from other settings.Conclusions Frequent screening of GBMSM at higher risk of STIs, such as those on pre-exposure prophylaxis (PrEP) leading to/and increased use of doxycycline for the treatment of diagnosed infections, may account for the increase in TetR in N. gonorrhoeae.

IntroductionIn 2023, BASHH released a report of apparent permethrin resistant scabies in England. We sought to evaluate whether permethrin-resistant scabies had been reported in our own service.MethodsElectronic records were searched for scabies diagnostic codes and ivermectin prescriptions. Treatment failure was defined as: i) Pruritus for greater than one week following the second application of topical scabicide ii) New burrows on clinical examination iii) Ongoing transmission following completion of a treatment courseResultsFrom 2017–2023, 33 cases met our criteria for treatment failure. 17 occurred in the calendar year January 2022-January 2023, compared to 16 cases in the preceding 5 years. Of the recent cases the cohort consisted of four women and 13 men. 77% of men identified as MSM, four were living with well controlled HIV. 94% (16/17) of initial diagnoses were made in a community healthcare setting. Potential resistance was hypothesised in secondary care in 82% of cases. Time to consideration of resistance took a mean of 14 weeks (4–36) with patients using a median of 3 (1–5) courses of permethrin. Persistence was confirmed by clinician identified burrows. Symptom resolution following ivermectin occurred in 82% (14/17) after one dose, 12% (2/17) after a second dose, and in one case (and their partner) after five doses.DiscussionOur cohort represents a concerning trend of non-response to first line scabies treatment echoing other reports of permethrin-resistance across Europe. We call for a review of current guidelines and the licensing of ivermectin as a treatment for scabies in the UK.

IntroductionA global outbreak of Mpox has been ongoing since May 2022. Most of the 3553 cases in England (as of 24.02.2023) have been in gay, bisexual and other men who have sex with men (GBMSM), presenting to sexual health services (SHS) with anogenital ulceration and a rash. Historically thought to cause only symptomatic infections, reports of asymptomatic Mpox infections (1.34–6.5%) in GBMSM in two European studies during the current outbreak, prompted investigation of asymptomatic infection in GBMSM in England.MethodsAnonymised, residual clinical specimens from GBMSM routine gonorrhoea/chlamydia screening (01.08.22–07.10.22) were referred to the UK Health Security Agency, from three SHS in London and Southeast England. Specimens were pharyngeal (PS) and rectal swabs (RS) in NAATs buffer (various) and urine (neat/NAATs buffer). DNA was extracted using the QIAsymphony DSP Virus/Pathogen Midi Kit (Qiagen) and tested using an Mpox-specific real-time PCR, performed on the ABI7500 or ViiA7 (Applied Biosystems) platforms.ResultsIn total, 2917 clinical specimens (953/2917, 32.67% PS, 941/2917, 32.26% RS, 1023/2917, 35.07% urine) were received from 1158 GBMSM. Triple-site specimens were not available for all. Four specimens (4/2917, 0.14%) from two individuals (2/1158, 0.17%) tested positive for Mpox. Both attended the same London clinic. The first (week of 08.08.22) was Mpox-positive in the urine specimen only. The second (week of 19.09.22) tested positive at all three sites. The clinic confirmed that no attendee with symptomatic Mpox infection, was known to have attended the clinical sessions from which specimens derived prior to or after collection.DiscussionWe report very low prevalence (0.17%) of asymptomatic Mpox infection suggesting that undetected infection was unlikely to be a main driver of ongoing transmission for high-risk GBMSM attending SHS in England. Further work is required to ascertain if infection is truly asymptomatic and the role this plays in transmission of infection.