Background While the contribution of Mycoplasma genitalium (MG) to symptoms in men is well described, less is known about its association with common genital symptoms in women. We aimed to determine the prevalence of MG and macrolide resistance, and its association with common genital symptoms in women attending a sexual health service, to inform indications for testing and clinical practice. Methods We undertook a cross-sectional study of symptomatic and asymptomatic women attending Melbourne Sexual Health Centre (MSHC), between April 2017 and April 2019. Women were tested for MG and macrolide resistance, Chlamydia trachomatis (CT), Neisseria gonorrhoeae, Trichomonas vaginalis, bacterial vaginosis and vulvovaginal candidiasis. Women completed a questionnaire on symptoms, and symptomatic women underwent examination. The prevalence of MG (and macrolide resistance) and other genital infections was calculated with 95% CIs, and associations between these outcomes and specific genital symptoms were examined using logistic regression. Results Of 1318 women, 83 (6%, 95% CI: 5% to 8%) had MG, of which 39 (48%, 95% CI: 36% to 59%) had macrolide-resistant MG; 103 (8%, 95% CI: 6% to 9%) women had CT. MG prevalence was similar in asymptomatic (10 of 195; 5%) and symptomatic (73 of 1108; 7%) women, p=0.506. MG was associated with mucopurulent cervicitis on examination (adjusted OR=4.38, 95% CI: 1.69 to 11.33, p=0.002), but was not associated with other specific genital symptoms or signs. Conclusions MG was as common as CT among women attending MSHC. MG was not associated with genital symptoms, but like CT, was significantly associated with cervicitis. These data provide evidence that routine testing for MG in women with common genital symptoms is not indicated. The presence of macrolide resistance in 48% of women supports use of resistance-guided therapy.

Background To address the increasing incidence of gonorrhoea and antimicrobial resistance, we compared the efficacy of Listerine and Biotène mouthwashes for preventing gonorrhoea among men who have sex with men (MSM). Methods The OMEGA trial was a multicentre, parallel-group, double-blind randomised controlled trial among MSM, done at three urban sexual health clinics and one general practice clinic in Australia. Men were eligible if they were diagnosed with oropharyngeal gonorrhoea by nucleic acid amplification test (NAAT) in the previous 30 days or were aged 16–24 years. They were randomly assigned to receive Listerine (intervention) or Biotène (control) via a computer-generated sequence (1:1 ratio, block size of four). Participants, clinicians, data collectors, data analysts, and outcome adjudicators were masked to the interventions after assignment. Participants were instructed to rinse and gargle with 20 mL of mouthwash for 60 s at least once daily for 12 weeks. Oropharyngeal swabs were collected by research nurses every 6 weeks, and participants provided saliva samples every 3 weeks, to be tested for Neisseria gonorrhoeae with NAAT and quantitative PCR. The primary outcome was proportion of MSM diagnosed with oropharyngeal N gonorrhoeae infection at any point over the 12-week period, defined as a positive result for either oropharyngeal swabs or saliva samples by NAAT, and the cumulative incidence of oropharyngeal gonorrhoea at the week 12 visit. A modified intention-to-treat analysis for the primary outcome was done that included men who provided at least one follow-up specimen over the 12-week study period. The trial was registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12616000247471). Findings Between March 30, 2016, and Oct 26, 2018, 786 MSM were screened and 256 were excluded. 264 MSM were randomly assigned to the Biotène group and 266 to the Listerine group. The analysis population included 227 (86%) men in the Biotène group and 219 (82%) in the Listerine group. Oropharyngeal gonorrhoea was detected in ten (4%) of 227 of MSM in the Biotène group and in 15 (7%) of 219 in the Listerine group (adjusted risk difference 2·5%, 95% CI −1·8 to 6·8). The cumulative incidence of oropharyngeal gonorrhoea at the week 12 visit did not differ between the two mouthwash groups (adjusted risk difference 3·1%, 95% CI −1·4 to 7·7). Interpretation Listerine did not reduce the incidence of oropharyngeal gonorrhoea compared with Biotène. However, previous research suggests that mouthwash might reduce the infectivity of oropharyngeal gonorrhoea; therefore, further studies of mouthwash examining its inhibitory effect on N gonorrhoeae are warranted to determine if it has a potential role for the prevention of transmission. Funding Australian National Health and Medical Research Council.

Screening for Chlamydia trachomatis and Neisseria gonorrhoeae at the pharyngeal, urogenital, and anorectal sites is recommended for men who have sex with men (MSM). Combining the three individual-site samples into a single pooled sample could result in significant cost savings, provided there is no significant sensitivity reduction. The aim of this study was to examine the sensitivity of pooled samples for detecting chlamydia and gonorrhea in asymptomatic MSM using a nucleic acid amplification test.

BACKGROUND Macrolide-resistance in Mycoplasma genitalium (MG) exceeds 50% in many regions and quinolone-resistance is increasing. We recently reported that resistance-guided therapy (RGT) using doxycycline followed by sitafloxacin or 2.5g-azithromycin cured 92% and 95% of macrolide-resistant and macrolide-susceptible infections, respectively. We now present the data on RGT using doxycycline-moxifloxacin, the regimen recommended in international guidelines, and extend the data on the efficacy of doxyxycline-2.5g azithromycin and subsequent de novo macrolide-resistance. METHODS Patients attending Melbourne Sexual Health Centre between 2017-2018 with STI-related syndromes were treated with doxycycline for 7 days and recalled if positive for MG. Macrolide-susceptible cases then received 2.5g azithromycin (1g, then 500mg daily for 3 days) and resistant cases received moxifloxacin (400 mg daily, 7 days). Test of cure (TOC) was recommended 14-28 days post-completion of antimicrobials. Adherence and adverse effects were recorded. RESULTS A total of 383 patients (81 females/106 heterosexual males/196 men-who-have-sex-with-men) were included. Microbial cure following doxycycline-azithromycin was 95.4% (95% CI 89.7-98.0) and doxycycline-moxifloxacin was 92.0%(88.1-94.6). De novo macrolide-resistance was detected in 4.6% of cases. Combining doxycycline-azithromycin data with our prior RGT study (n=186) yielded a pooled cure of 95.7% (91.6-97.8). ParC mutations implicated in moxifloxacin failure were present in 15-22% of macrolide-resistant cases at baseline. CONCLUSION These findings support the inclusion of moxifloxacin in resistance-guided strategies and extend the evidence for use of 2.5g azithromycin, and presumptive use of doxycycline. These data provide an evidence-base for current UK, Australian and European guidelines for the treatment of MG, an STI which is increasingly challenging to cure.

Background Mycoplasma genitalium resistance to antibiotic treatments is increasing, with very limited treatment alternatives on the horizon. Surveillance via sequencing of multiple M. genitalium loci would allow: monitoring of known antibiotic resistance mutations, associations between resistance/treatment failure and specific mutations, and strain typing for epidemiological purposes. In this study we assessed the performance of a custom amplicon sequencing approach, which negates the cost of library preparation for next generation sequencing. Methods Fifty-two M. genitalium positive samples (cervical, vaginal, anal and rectal swabs, and urine) were used. Three regions associated with M. genitalium antibiotic resistance (23S rRNA, parC and gyrA genes) were targeted, in conjunction with a locus used for differentiation of sequence types in the mgpB gene, and findings compared to Sanger sequencing. Results Amplicon sequencing provided adequate sequence read coverage (>30×) for the majority of samples for 23S rRNA gene (96%) and mgpB (97%), parC (78%) and gyrA (75%). Single nucleotide polymorphisms (SNPs) were characterised in samples for 23S rRNA gene (94%), parC (56%) and gyrA (4%). Unlike Sanger sequencing, mixed mutations could be identified by the amplicon sequencing method, and ratios of mutation types determined. All results, with one exception, were concordant to Sanger sequence results. Sequence diversity in the mgpB region was represented by 15 sequence types, 4 being observed in multiple samples. Conclusions We have demonstrated the utility of this custom amplicon sequencing approach for generating highly informative datasets with the capacity to identify and determine ratios of mixed sequences. The use of this customisable amplicon sequencing method enables cost effective, scalable amplicon sequencing of multiple target regions of interest in M. genitalium.

Introduction. Mycoplasma genitalium is a sexually transmitted organism with high levels of resistance to the recommended first-line therapy, azithromycin. The ResistancePlus MG test concurrently detects M. genitalium, and the presence of macrolide-resistance mutations (MRM). European, UK and Australian guidelines recommend a diagnostic test that reports MRM to optimize treatment through resistance-guided therapy. Hence, for samples collected for use on other platforms, reflex testing using the ResistancePlus MG test would be beneficial.Aim. To validate the ResistancePlus MG assay using samples collected in Aptima buffer for testing on the Hologic Panther.Methodology. Positive (n=99) and negative (n=229) clinical samples collected in Aptima buffer were extracted on the MagNA Pure 96 (Roche Diagnostics), and tested with the ResistancePlus MG test on the LightCycler 480 II (Roche Diagnostics). Results were compared to matched samples collected using standard sample collection (urine or swab resuspended in PBS), with positive percent agreement (PPA), negative percent agreement (NPA) and Cohen's Kappa statistic.Results. The ResistancePlus MG test had high performance with a 200 µl input volume (PPA/NPA for M. genitalium detection, 92.9 % [95 % confidence interval (CI): 85.5-96.9]/100 % [95 % CI: 97.9-100], MRM detection, 96.9 % [95 % CI: 88.2-99.5]/85.7 % [95 % CI: 66.4-95.3]) and for 1 ml input volume (PPA/NPA for M. genitalium detection, 95.9%/96.6%, MRM detection, 98.4%/90.3%). Samples remained positive after storage at room temperature beyond the manufacturer-recommended storage of <60 days (mean storage time for 1 ml extraction: 129 days).Conclusion. Samples collected using Aptima collection kits are suitable for reflex testing using the ResistancePlus MG test, allowing detection of macrolide resistance.

Objective To systematically review and appraise published data, to determine the prevalence of Mycoplasma genitalium (MG) in men who have sex with men (MSM) tested at each anatomical site, that is, at the urethra, rectum and/or pharynx. Design Systematic review and meta-analysis. Data sources Ovid Medline, PubMed, Embase were searched for articles from 1st January 1981 (the year MG was first identified) to 1st June 2018. Review methods Studies were eligible for inclusion if they reported MG prevalence in MSM tested at the urethra, rectum and/or pharynx, in at least 50 MSM, using nucleic acid amplification testing. Data were extracted by anatomical site, symptom and HIV status. Summary estimates (95% CIs) were calculated using random-effects meta-analysis. Subgroup analyses were performed to assess heterogeneity between studies. Results Forty-six studies met inclusion criteria, with 34 reporting estimates of MG prevalence at the urethra (13 753 samples), 25 at the rectum (8629 samples) and 7 at the pharynx (1871 samples). MG prevalence was 5.0% (95% CI 3.5 to 6.8; I-2=94.0) at the urethra; 6.2% (95% CI 4.6 to 8.1; I-2=88.1) at the rectum and 1.0% (95% CI 0.0 to 5.1; I-2=96.0) at the pharynx. The prevalence of MG was significantly higher at urethral and rectal sites in symptomatic versus asymptomatic MSM (7.1% vs 2.2%, p<0.001; and 16.1% vs 7.5%, p=0.039, respectively). MG prevalence at the urethra was significantly higher in HIV-positive compared with HIV-negative MSM (7.0% vs 3.4%, p=0.006). Conclusion MG was common in MSM, particularly at urethral and rectal sites (5% to 6%). MG was more commonly detected in symptomatic men at both sites, and more common in HIV-positive men at the urethra. MG was uncommonly detected in the pharynx. Site-specific estimates are similar to those for chlamydia and will be helpful in informing testing practices in MSM. PROSPERO registration number CRD42017058326.

Background There has been a rapid increase in the resistance of Mycoplasma genitalium to first line (azithromycin) and second line (fluoroquinolone) therapy, particularly in the Asia-Pacific region. While mutations conferring resistance to azithromycin are well established, this is not the case for fluoroquinolones. We aimed to define mutations associated with fluoroquinolone failure to inform next generation resistance assays. Methods Samples from patients undergoing resistance-guided therapy with either moxifloxacin (Apr-2017–Jun-2018, 202 cases: 21 moxifloxacin failures) or sitafloxacin (Jun-2016–May-2017, 125 cases:12 sitafloxacin failures) were sequenced for key regions of parC and gyrA genes. Chi-square or Fisher’s exact tests were used to examine prevalence of each mutation and treatment outcome. Results In an interim analysis the most common parC mutations were G248T (amino acid change S83I; 16%), G259A (D87N; 4%), G248A (S83N; 1%) and mutations effecting S83R (1%). G248T (S83I) mutation was more common among patients that failed moxifloxacin [15/21 failures (71%) vs 11/181 cures (6%), p<0.001] and sitafloxacin [6/12 failures (50%) vs 19/113 cures (17%), p=0.0063]. Notably, sitafloxacin cured a higher proportion of infections carrying the S83I mutation than moxifloxacin (76% vs 42%; p=0.015). ParC D87N was not associated with failure of moxifloxacin [1/21 failures (5%) vs 11/181 cures (6%)]. The most common gyrA mutations were G285A (M95I; 5%) and G295T (D99Y; 1%). An infection with an S83I mutation was more likely to fail treatment when combined with a gyrA mutation (M95I or D99N) (4/6 sitafloxacin failures with parC S83I also had gyrA mutation, compared to 1/16 cures; p=0.0093), suggesting an additive effect. Conclusion This study provides compelling evidence that parC G248T (S83I) mutations contribute to failure of moxifloxacin and sitafloxacin used for macrolide-resistant M. genitalium. These data will inform the development of quinolone resistance assays needed to ensure optimal selection of antimicrobials in M. genitalium. Disclosure No significant relationships.

Background Macrolide-resistance in Mycoplasma genitalium (MG) exceeds 50% in many nations and increasing quinolone-resistance is reported. Recent data showed resistance-guided therapy (RGT) using doxycycline then sitafloxacin for macrolide-resistant MG cured 92% of infections and doxycycline-azithromycin for macrolide-susceptible MG cured 95%. As sitafloxacin is not widely available, we undertook a study of RGT to evaluate the efficacy of moxifloxacin in RGT to provide data that is relevant to international guidelines and to assess the efficacy of this alternative approach in a population with 15–20% quinolone-resistance (ParC mutations). Methods Patients attending Melbourne Sexual Health Centre between April 2017-June 2018 with urethritis, cervicitis or proctitis were treated with doxycycline (7 days)and recalled if positive for MG. Macrolide-susceptible cases received azithromycin (1g, then 500 mg daily 3 days)and resistant-cases received moxifloxacin (400 mg daily, 7 days). Patients attended for test of cure (TOC) following treatment. Adherence and side effects were recorded. Patients were included in the efficacy analysis if they were treated in accordance with RGT protocol, were not at high risk of reinfection and had a 14–90 day TOC. Results 382 participants (80 female/106 heterosexual male/196 MSM) were included: 109 (28.5%) had macrolide-susceptible MG and 273(71.5%) macrolide-resistant MG. Doxycycline-azithromycin cure was 95.4% (95%CI 89.7–98%) and doxycycline-moxifloxacin cure was 91.9% (95%CI 88.1–94.6%). Median time to TOC was 27 days (IQR=22–35). Doxycycline-azithromycin data was combined with our prior RGT study and the pooled estimate of cure (n=186) was 95.2% (95%CI 91.1–97.4%). Analysis of selected macrolide resistance is underway but will not exceed 4.3% (95%CI 2.2–8.6%). Conclusion Despite 15–20% quinolone resistance in Melbourne the sequential strategy of doxycycline-moxifloxacin achieved unexpectedly high cure (92%), and did not differ to doxycycline-sitafloxacin, a more effective quinolone, suggesting preceding doxycycline may improve cure through reducing pre-treatment load. Doxycycline followed by azithromycin for susceptible infections consistently achieves 95% cure and low levels of selected resistance (<5%). Disclosure No significant relationships.

Background While the contribution of Mycoplasma genitalium (MG) to symptoms in men is well described, less is known about its clinical presentation in women. Data support an association with cervicitis, but an association with pelvic inflammatory disease is contentious. We undertook a study of 1200 symptomatic and asymptomatic women to determine the prevalence of MG and macrolide resistance, and to determine its association with common genital symptoms in women to inform indications for testing. Methods Women attending Melbourne Sexual Health Centre from 18th April 2017 (in progress) were tested for MG and macrolide resistance (ResistancePlusMG SpeeDx, Sydney), chlamydia and gonorrhoea (Aptima Combo 2, Hologic), trichomonasis (microscopy and culture), bacterial vaginosis (BV) and candida (microscopy). Women underwent examination and completed a questionnaire on symptoms. The prevalence of MG, macrolide-resistance, STIs and coinfection, and association with genital symptoms and signs, was determined by univariate and multivariable analysis. Results Of 1054 women enrolled to date (968 symptomatic and 86 asymptomatic), 62 women (6%, 95%CI 5–7%) tested positive for MG, with macrolide-resistance detected in 54% (95%CI 41–67%). Chlamydia and gonorrhoea were detected in 8% (95%CI 6–9%) and 1% (95%CI 1–2%) of the 1054 women respectively. Of the 62 women infected with MG, 42% (95%CI 30–55) also had BV, 26% (95%CI 16–38) candida, 6% (95%CI 2–16) chlamydia and 2% (95%CI 0–9) gonorrhoea. MG prevalence did not differ between symptomatic and asymptomatic women (6% vs 5%, p=0.614). No specific genital symptoms or signs were significantly associated with MG, in contrast to chlamydia, which was associated with post-coital bleeding (OR 1.7, p=0.04) and cervicitis (OR 2.3, p=0.014). Conclusion MG was as common as chlamydia in our clinic population but in contrast to chlamydia was not associated with any specific clinical features that would inform testing practices. Macrolide resistance was detected in half of cases and coinfection with BV was particularly common. Disclosure No significant relationships.

Objectives There are limited data on the prevalence of Mycoplasma genitalium (Mgen) coinfection with rectal chlamydia (Chlamydia trachomatis (CT)) and rectal gonorrhoea (Neisseria gonorrhoeae (NG)) infections and few studies examining the prevalence of pharyngeal Mgen in men who have sex with men (MSM). Using transcription-mediated amplification assay, this study aimed to determine the proportion of rectal CT and rectal NG infections in MSM who are coinfected with rectal Mgen, and the proportion of MSM with Mgen detected in the pharynx in order to inform clinical practice. Methods This was a cross-sectional study conducted at Melbourne Sexual Health Centre in Australia. Consecutively collected rectal swabs from MSM that tested positive for CT (n=212) or NG (n=212), and consecutively collected pharyngeal samples (n=480) from MSM were tested for Mgen using the Aptima Mycoplasma genitalium Assay (Hologic, San Diego). Samples were linked to demographic data and symptom status. Results Rectal Mgen was codetected in 27 of 212 rectal CT (13%, 95% CI 9 to 18) and in 29 of 212 rectal NG (14%, 95% CI 9 to 19) samples, with no difference in the proportion positive for Mgen. MSM with rectal CT/Mgen coinfection had more sexual partners than those with rectal CT monoinfection (mean 6 vs 11, p=0.06). MSM with rectal NG/Mgen coinfection were more likely to be HIV-positive than those with rectal NG monoinfection (OR=2.96, 95% CI 1.21 to 7.26, p=0.023). MSM with rectal CT/Mgen coinfection were more likely to be using pre-exposure prophylaxis than MSM with rectal NG/Mgen coinfection (OR 0.25, 95% CI 0.10 to 0.65, p=0.002). Pharyngeal Mgen was uncommon and detected in 8 of 464 samples (2%, 95% CI 1% to 3%). Pharyngeal Mgen was associated with having a rectal STI (OR=10.61, 95% CI 2.30 to 48.87, p=0.002), and there was a borderline association with being HIV-positive (p=0.079). Conclusion These data indicate one in seven MSM treated for rectal CT or rectal NG will have undiagnosed Mgen that is potentially exposed to azithromycin during treatment of these STIs. Rectal Mgen coinfection was associated with specific risk factors which may inform testing practices. Pharyngeal Mgen was uncommon.

OBJECTIVES:Reports of rising herpes simplex virus type 1 (HSV-1) genital infections relative to HSV-2 have been published up to 2006 in Australia. These changes have been attributed to declining childhood immunity to HSV-1. We described the temporal trends of HSV-1 and HSV-2 up to 2017 in Melbourne, Australia, to determine if the earlier trend is continuing.METHODS:We conducted a retrospective review of the medical records of 4517 patients who were diagnosed with first episode of anogenital HSV infection at the Melbourne Sexual Health Centre, Australia, between January 2004 and December 2017. HSV-1 and HSV-2 were calculated as a proportion of all first episode of anogenital HSV infections. The change in the proportions of HSV-1 and HSV-2 over time was assessed by a χ2 trend test. Risk factors associated with HSV-1 were examined using a multivariable logistic regression model.RESULTS:The proportion of first episode of anogenital herpes due to HSV-1 increased significantly over time in women (from 45% to 61%; ptrend<0.001) and heterosexual men (from 38% to 41%; ptrend=0.01) but not in men who have sex with men (MSM) (ptrend=0.21). After adjusting for condom use, partner number and age, the annual increase remained significant only in women (OR 1.08, 95% CI 1.03 to 1.13, p<0.001). In MSM, HSV-1 caused up to two-thirds of anogenital herpes in most years and HSV-1 was more likely to be diagnosed at an anal site than genital site (OR 1.69, 95% CI 1.23 to 2.32, p<0.001). Younger age (<28 years) was an independent risk factor for HSV-1 in all groups.CONCLUSIONS:The proportion of first-episode anogenital herpes due to HSV-1 has been rising in women since 2004. HSV-1 has become the leading cause of anogenital herpes in younger populations, women and MSM.

OBJECTIVE:PRONTO!, a peer-led rapid HIV-testing service in Melbourne, Australia, opened to improve HIV testing among gay and bisexual men (GBM). We compared client characteristics and return testing among GBM testing at PRONTO! with GBM testing at Melbourne Sexual Health Centre (MSHC).METHODS:All GBM attending PRONTO! and MSHC for HIV testing between August 2013 and April 2016 were included. We describe the number of tests, percentage of clients who returned during follow-up, the mean number of tests and median time between tests at the two services.RESULTS:At PRONTO!, 33% of 3,102 GBM and at MSHC 50% of 9,836 GBM returned for a further HIV test at least once. The mean number of tests per client was 1.7 and 2.5 at PRONTO! and MSHC (p<0.01), respectively. A majority of clients at both services reported behaviours that would recommend up to quarterly testing, however, the median time between tests was 20.0 and 17.0 weeks at PRONTO! and MSHC (p<0.01), respectively.CONCLUSIONS:A greater proportion of clients returned and returned frequently at MSHC compared to PRONTO!, however, at both services HIV testing frequency was suboptimal. Implications for public health: Novel HIV testing services should provide convenient and comprehensive sexual health services.

Aims Mycoplasma genitalium causes a common, sexually transmitted bacterial infection. This study assessed the detection of M. genitalium in stored urine samples to understand the impact of sample storage on M. genitalium detection. Methods Aliquots of M. genitalium-positive urine (n = 20 patients) were stored at either room temperature (22 degrees C) or 4 degrees C, without a preservative. At weekly intervals, samples were tested using the commercial test ResistancePlus MG (R) (SpeeDx (R), Australia). We report the analysis at 1 week, an acceptable collection-to-test turnaround time, with further analysis over 5 weeks to illustrate degradation trends. Results After storing at 4 degrees C, the proportion of specimens that remained positive for M. genitalium was 100% after 1 week and 95% after 4 weeks. Storage at 22 degrees C led to more rapid decline in detection in the first 4 weeks, with 95% detected after 1 week and 85% at 2 weeks onwards. At 5 weeks, samples stored at both temperatures had an 85% M. genitalium detection rate, with increase in crossing points (Cq) of 0 center dot 72 (95% confidence interval (CI) 0 center dot 01-1 center dot 43; P-trend = 0 center dot 027) at 4 degrees C, and 1 center dot 75 ((95% CI 0 center dot 79-2 center dot 71), P-trend <0 center dot 001) at 22 degrees C. Conclusions Urine samples stored without preservative, and unfrozen, retained high M. genitalium detection levels over the short term (up to 5 weeks). To minimize degradation, storing at 4 degrees C is recommended. Significance and Impact of the Study There is little known about the stability of clinical samples for M. genitalium detection. This study found that a high proportion (85-100%) of samples are still suitable for M. genitalium detection after storage for up to 5 weeks.

During 2016-2017, we tested asymptomatic men who have sex with men (MSM) in Melbourne, Australia, for Mycoplasma genitalium and macrolide resistance mutations in urine and anorectal swab specimens by using PCR. We compared M. genitalium detection rates for those asymptomatic men to those for MSM with proctitis and nongonococcal urethritis (NGU) over the same period. Of 1,001 asymptomatic MSM, 95 had M. genitalium; 84.2% were macrolide resistant, and 17% were co-infected with Neisseria gonorrhoeae or Chlamydia trachomatis. Rectal positivity for M. genitalium was 7.0% and urine positivity was 2.7%. M. genitalium was not more commonly detected in the rectums of MSM (n = 355, 5.6%) with symptoms of proctitis over the same period but was more commonly detected in MSM (n = 1,019, 8.1%) with NGU. M. genitalium is common and predominantly macrolide-resistant in asymptomatic MSM. M. genitalium is not associated with proctitis in this population.

Objectives A mathematical model suggested that a significant proportion of oropharyngeal gonorrhoea cases are acquired via oropharynx-to-oropharynx transmission (ie, tongue-kissing), but to date, no empirical study has investigated this. This study aimed to examine the association between kissing and oropharyngeal gonorrhoea among gay and bisexual men who have sex with men (MSM). Methods MSM attending a public sexual health centre in Melbourne, Australia, between March 2016 and February 2017 were invited to participate in a brief survey that collected data on their number of male partners in the last 3 months, in three distinct categories: kissing-only (ie, no sex including no oral and/or anal sex), sex-only (ie, any sex without kissing), and kissing-with-sex (ie, kissing with any sex). Univariable and multivariable logistic regression analyses were performed to examine associations between oropharyngeal gonorrhoea positivity by nucleic acid amplification tests and the three distinct partner categories. Results A total of 3677 men completed the survey and were tested for oropharyngeal gonorrhoea. Their median age was 30 (IQR 25–37) and 6.2% (n=229) had oropharyngeal gonorrhoea. Men had a mean number of 4.3 kissing-only, 1.4 sex-only, and 5.0 kissing-with-sex partners in the last 3 months. Kissing-only and kissing-with-sex were associated with oropharyngeal gonorrhoea, but sex-only was not. The adjusted odds for having oropharyngeal gonorrhoea were 1.46-fold (95% CI 1.04 to 2.06) for men with ≥4 kissing-only partners and 1.81-fold (95% CI 1.17 to 2.79) for men with ≥4 kissing-with-sex partners. Conclusions These data suggest that kissing may be associated with transmission of oropharyngeal gonorrhoea in MSM, irrespective of whether sex also occurs.

Background Receptive condomless anal sex is a known risk factor for anorectal chlamydia, but it remains unclear whether oroanal sex practices also contribute. We aimed to determine whether oroanal sex (rimming), fingering, or the use of saliva as anal lubricant are risk factors for anorectal chlamydia among men who have sex with men (MSM). Methods This cross-sectional study was conducted at Melbourne Sexual Health Centre from July 2014 to June 2015. Routinely collected computer-assisted self-interview data included demographics, number of sexual partners, and condom use. We added questions on receptive rimming, receptive fingering or penis dipping, and the use of a partner's saliva as anal lubricant. Results A total of 1691 MSM completed the questionnaire and tested for anorectal chlamydia. In univariable analyses, anorectal chlamydia was associated with using a partner's saliva as lubricant (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.26-3.09), receptive rimming (OR 1.59; 95% CI 1.04-2.45), and receptive fingering or dipping (OR 1.90; 95% CI 1.06-3.43). In multivariable analysis, anorectal chlamydia was not associated with these sexual practices, after adjusting for number of sexual partners, HIV status, known contact with chlamydia, and condom use. However, collinearity between sexual practices likely obscured associations with anorectal chlamydia, and further analyses suggested weak associations between these sexual practices and anorectal chlamydia. Conclusions The use of a partner's saliva during receptive anal sex practices such as rimming, fingering, or penis dipping were weak risk factor for anorectal chlamydia in MSM. This contrasts with our previously reported findings that the use of saliva as anal lubricant is more strongly associated with anorectal gonorrhea.

High levels of macrolide resistance and increasing fluoroquinolone resistance are found in Mycoplasma genitalium in many countries. We evaluated pristinamycin for macrolide-resistant M. genitalium in a sexual health center in Australia. Microbiologic cure was determined by M. genitalium-specific 16S PCR 14-90 days after treatment began. Of 114 persons treated with pristinamycin, infection was cured in 85 (75%). This percentage did not change when pristinamycin was given at daily doses of 2 g or 4 g or at 3 g combined with 200 mg doxycycline. In infections with higher pretreatment bacterial load, treatment was twice as likely to fail for each 1 log10 increase in bacterial load. Gastrointestinal side effects occurred in 7% of patients. Pristinamycin at maximum oral dose, or combined with doxycycline, cured 75% of macrolide-resistant M. genitalium infections. Pristinamycin is well-tolerated and remains an option where fluoroquinolones have failed or cannot be used.

Treating Mycoplasma genitalium with a sequence of first doxycycline to reduce bacterial load, and then using a resistance assay to choose either high-dose azithromycin or sitafloxacin, cured >92% of infections in a population with high levels of antibiotic resistance.