No abstract

Mycoplasma genitalium infection contributes to 10-35% of non-chlamydial non-gonococcal urethritis in men. In women, M. genitalium is associated with cervicitis and pelvic inflammatory disease (PID). Transmission of M. genitalium occurs through direct mucosal contact. Asymptomatic infections are frequent. In women, symptoms include vaginal discharge, dysuria or symptoms of PID -abdominal pain and dyspareunia. In men, urethritis, dysuria and discharge predominates.Besides symptoms, indication for laboratory test is a high-risk sexual behaviour. Diagnosis is achievable only through nucleic acid amplification testing (NAAT). If available, NAAT diagnosis should be followed with an assay for macrolide resistance. Therapy for M. genitalium is indicated if M. genitalium is detected or on an epidemiological basis. Doxycycline has a low cure rate of 30-40%, but does not increase resistance. Azithromycin has a cure rate of 85-95% in macrolide susceptible infections. An extended course appears to have a higher cure rate. An increasing prevalence of macrolide resistance, most likely due to widespread use of azithromycin 1 g single dose without test of cure, is drastically decreasing the cure rate. Moxifloxacin can be used as second-line therapy, but resistance is increasing. Uncomplicated M. genitalium infection should be treated with azithromycin 500 mg on day one, then 250 mg on days 2-5 (oral), or josamycin 500 mg three times daily for 10 days (oral). Second line treatment and treatment for uncomplicated macrolide resistant M. genitalium infection is moxifloxacin 400 mg od for 7-10 days (oral). For third line treatment of persistent M. genitalium infection after azithromycin and moxifloxacin doxycycline 100 mg two times daily for 14 days can be tried and may cure 30%. Pristinamycin 1 g four times daily for 10 days (oral) has a cure rate of app. 90%. Complicated M.genitalium infection (PID, epididymitis) is treated with moxifloxacin 400 mg od for 14 days.

At present, we have no evidence that we are doing more good than harm detecting and subsequently treating Mycoplasma hominis, Ureaplasma parvum and Ureaplasma urealyticum colonizations/infections. Consequently, routine testing and treatment of asymptomatic or symptomatic men and women for M. hominis, U. urealyticum and U. parvum are not recommended. Asymptomatic carriage of these bacteria is common, and the majority of individuals do not develop any disease. Although U. urealyticum has been associated with urethritis in men, it is probably not causal unless a high load is present (likely carriage in 40-80% of detected cases). The extensive testing, detection and subsequent antimicrobial treatment of these bacteria performed in some settings may result in the selection of antimicrobial resistance, in these bacteria, 'true' STI agents, as well as in the general microbiota, and substantial economic cost for society and individuals, particularly women. The commercialization of many particularly multiplex PCR assays detecting traditional non-viral STIs together with M. hominis, U. parvum and/or U. urealyticum has worsened this situation. Thus, routine screening of asymptomatic men and women or routine testing of symptomatic individuals for M. hominis, U. urealyticum and U. parvum is not recommended. If testing of men with symptomatic urethritis is undertaken, traditional STI urethritis agents such as Neisseria gonorrhoeae, Chlamydia trachomatis, M. genitalium and, in settings where relevant, Trichomonas vaginalis should be excluded prior to U. urealyticum testing and quantitative species-specific molecular diagnostic tests should be used. Only men with high U. urealyticum load should be considered for treatment; however, appropriate evidence for effective treatment regimens is lacking. In symptomatic women, bacterial vaginosis (BV) should always be tested for and treated if detected.

The novel coronavirus SARS-CoV-2/COVID-19 is rapidly and dramatically spreading throughout the world. We describe the clinical and histopathological features of 3 Italian patients with different cutaneous presentations of COVID-19 infection, observed and followed at the University of Milan. CASE REPORTSCase 1. A 59-year-old woman was admitted to the intensive care unit (ICU) at the University of Milan with bilateral interstitial pneumonia. Three days after admission, she developed widespread erythematous macules on arms, trunk and lower limbs (Fig. 1 A-C) that spontaneously improved within 5 days. C-reactive protein was 12 mg/l. Reverse transcriptase (RT)-PCR for COVID-19 virus was positive. Treatment was started with lopinavir-ritonavir, heparin and levofloxacin. She is currently recovering. Case 2. An 89-year-old woman was suffering from fever and cough of one-week duration. An exanthem on the trunk and arms was observed on admission at ICU (Fig. 1 D,E). Laboratory tests revealed mild increase in fibrinogen and transaminases. RT-PCR was positive for COVID-19 virus. Ceftriaxone and azithromycin were started. The exanthem improved spontaneously 8 days later. Case 3. A 57-year-old man in good general health acutely developed a widespread pruritic eruption of erythematous macules and papules (Fig. 1 F,G), followed two days later by fever, headache, cough and arthralgias. RT-PCR for COVID-19 virus was positive. Treatment with levofloxacin and hydroxychloroquine was started.

Gonorrhoea is a major public health concern globally. Increasing incidence and sporadic ceftriaxone-resistant cases, including treatment failures, are growing concerns. The 2020 European gonorrhoea guideline provides up-to-date evidence-based guidance regarding the diagnosis and treatment of gonorrhoea. The updates and recommendations emphasize significantly increasing gonorrhoea incidence; broad indications for increased testing with validated and quality-assured nucleic acid amplification tests and culture; dual antimicrobial therapy including high-dose ceftriaxone and azithromycin (ceftriaxone 1 g plus azithromycin 2 g) OR ceftriaxone 1 g monotherapy (ONLY in well-controlled settings, see guideline for details) for uncomplicated gonorrhoea when the antimicrobial susceptibility is unknown; recommendation of test of cure (TOC) in all gonorrhoea cases to ensure eradication of infection and identify resistance; and enhanced surveillance of treatment failures when recommended treatment regimens have been used. Improvements in access to appropriate testing, test performance, diagnostics, antimicrobial susceptibility surveillance and treatment, and follow-up of gonorrhoea patients are essential in controlling gonorrhoea and to mitigate the emergence and/or spread of ceftriaxone resistance and multidrug-resistant and extensively drug-resistant gonorrhoea. For detailed background, evidence base and discussions, see the background review for the present 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults (Unemo M, et al. Int J STD AIDS. 2020).

Mycoplasma genitalium infection contributes to 10–35% of non‐chlamydial non‐gonococcal urethritis in men. In women, M. genitalium is associated with cervicitis and pelvic inflammatory disease (PID) in 10–25%. Transmission of M. genitalium occurs through direct mucosal contact. Clinical features and diagnostic tests Asymptomatic infections are frequent. In men, urethritis, dysuria and discharge predominate. In women, symptoms include vaginal discharge, dysuria or symptoms of PID – abdominal pain and dyspareunia. Symptoms are the main indication for diagnostic testing. Diagnosis is achievable only through nucleic acid amplification testing and must include investigation for macrolide resistance mutations. Therapy Therapy for M .genitalium is indicated if M. genitalium is detected. Doxycycline has a cure rate of 30–40%, but resistance is not increasing. Azithromycin has a cure rate of 85–95% in macrolide‐susceptible infections. An extended course of azithromycin appears to have a higher cure rate, and pre‐treatment with doxycycline may decrease organism load and the risk of macrolide resistance selection. Moxifloxacin can be used as second‐line therapy but resistance is increasing. Recommended treatment Uncomplicated M. genitalium infection without macrolide resistance mutations or resistance testing:Azithromycin 500 mg on day one, then 250 mg on days 2–5 (oral). Second‐line treatment and treatment for uncomplicated macrolide‐resistant M. genitalium infection:Moxifloxacin 400 mg od for 7 days (oral). Third‐line treatment for persistent M. genitalium infection after azithromycin and moxifloxacin:Doxycycline or minocycline 100 mg bid for 14 days (oral) may cure 40–70%.Pristinamycin 1 g qid for 10 days (oral) has a cure rate of around 75%. Complicated M. genitalium infection (PID, epididymitis):Moxifloxacin 400 mg od for 14 days. Main changes from the 2016 European M. genitalium guideline Due to increasing antimicrobial resistance and warnings against moxifloxacin use, indications for testing and treatment have been narrowed to primarily involve symptomatic patients. The importance of macrolide resistance‐guided therapy is emphasised.

Human herpesvirus-8 (HHV-8) variants have been found heterogeneously distributed among human populations living in diverse geographic regions, but their differential pathogenicity in Kaposi's sarcoma development remains controversial. In the present study, HHV-8 variant distribution has been analyzed in classic, iatrogenic, endemic as well as epidemic Kaposi's sarcoma (KS) during pre-AIDS and AIDS period (1971-2008) in countries with different KS incidence rate. DNA samples from cutaneous KS lesions of 68 patients living in Africa (n=23, Cameroon, Kenya and Uganda), Europe (n=34, Greece and Italy) and North America (n=11) have been subjected to PCR amplification of HHV-8 ORF 26, T0.7, K1 and K14.1/15, followed by direct nucleotide sequencing and phylogenetic analysis. Among the 23 African samples, the majority of HHV-8 ORF 26 variants clustered with the subtype R (n=12) and B (n=5). Conversely, the viral sequences obtained from 45 European and North European tumors belonged mainly to subtype A/C (n=36). In general, HHV-8 and K1 variant clustering paralleled that of ORF 26 and T0.7. Genotyping of the K14.1/15 loci revealed a large predominance of P subtype in all tumors. In conclusion, comparison of the HHV-8 sequences from classic or endemic versus AIDS-associated KS showed a strong linkage of the HHV-8 variants with specific populations, which has not changed during AIDS epidemic.

The European guideline for the management of pelvic inflammatory disease includes evidence-based advice on the investigation and treatment of pelvic inflammatory disease (PID). It has been updated to acknowledge the role of Mycoplasma genitalium as an important cause of PID with testing now recommended for women presenting with possible PID and for the male partners of women with confirmed M. genitalium infection. Recent evidence suggests that serious adverse events are uncommon when using moxifloxacin and its use is now recommended as a first-line therapy, especially in those women with M. genitalium PID. The potential utility of MRI scanning of the pelvis in excluding differential diagnoses has been highlighted. The use of doxycycline is now suggested as empirical treatment for male partners of women with PID to reduce exposure to macrolide antibiotics, which has been associated with increased resistance in M. genitalium.