Extragenital gonorrhea and chlamydia positivity and the potential for missed extragenital gonorrhea with concurrent urethral chlamydia among men who have sex with men attending STD clinics - STD Surveillance Network, 2015-2019.Sex Transm Dis. 2020 Mar 16 [Online ahead of print]ST
Extragenital gonorrhea (GC) and chlamydia (CT) are usually asymptomatic and only detected through screening. Ceftriaxone plus azithromycin is the recommended GC treatment; monotherapy (azithromycin or doxycycline) is recommended for CT. In urethral CT-positive/urethral GC-negative persons who are not screened extragenitally, CT monotherapy can lead to GC undertreatment and may foster the development of gonococcal antimicrobial resistance. We assessed urethral and extragenital GC and CT positivity among men who have sex with men (MSM) attending sexually transmitted disease (STD) clinics.
We included visit data for MSM tested for GC and CT at 30 STD clinics in 10 jurisdictions during 1/1/2015-6/30/2019. Using an inverse-variance random effects model to account for heterogeneity between jurisdictions, we calculated weighted test visit positivity estimates and 95% confidence intervals (CI) for GC and CT at urethral and extragenital sites, and extragenital GC among urethral CT-positive/GC-negative test visits.
Of 139,718 GC and CT test visits, we calculated overall positivity (GC=16.7% [95% CI=14.4-19.1]; CT=13.3% [95% CI=12.7-13.9]); urethral positivity (GC=7.5% [95% CI=5.7-9.3]; CT=5.2% [95% CI=4.6-5.8]); rectal positivity (GC=11.8% [95% CI=10.4-13.2]; CT=12.6% [95% CI=11.8-13.4]); and pharyngeal positivity (GC=9.1% [95% CI=7.9-10.3]; CT=1.8% [95% CI=1.6-2.0]). Of 4,566 urethral CT-positive/GC-negative test visits with extragenital testing, extragenital GC positivity was 12.5% (95% CI=10.9-14.1).
Extragenital GC and CT were common among MSM. Without extragenital screening of MSM with urethral CT, extragenital GC would have been undetected and undertreated in ~13% of these men. Undertreatment could potentially select for antimicrobial resistance. These findings underscore the importance of extragenital screening in MSM.