We aim to characterize sexual behavioral aspects of heterosexual Neisseria gonorrhoea (NG) acquisition in two Sexually Transmitted Diseases clinics in Sydney, Australia, in 2008–2012. Of 167 NG cases, 102 were heterosexually acquired with a trend of increasing NG prevalence in heterosexuals from 1.1% (95% CI 0.6–2.1) in 2008 to 3.0% (95% CI 2.0–4.0) in 2012 ( ). Of heterosexual male cases, unprotected fellatio was the likely sexual activity for NG acquisition in 21/69 (30.4%) and commercial sex work (CSW) contact the likely source in 28/69 (40.6%). NG prevalence overall in CSW (2.2%) was not significantly higher than in non-CSW (1.2%) ( ), but in 2012 there was a significant increase in NG prevalence in CSW (8.6%) compared to non-CSW (1.6%) ( ). Pharyngeal NG was found in 9/33 (27.3%) female cases. Decreased susceptibility to ceftriaxone (MIC ≥ 0.03？mg/L) occurred in 2.5% NG isolates, none heterosexually acquired. All were azithromycin susceptible. A significant trend of increasing prevalence of heterosexual gonorrhoea in an urban Australian STD clinic setting is reported. We advocate maintenance of NG screening in women, including pharyngeal screening in all women with partner change who report fellatio, as pharyngeal NG may be an important reservoir for heterosexual transmission. Outreach to CSW should be enhanced. 1. Introduction Latest surveillance indicates rising rates of Neisseria gonorrhoea (NG) in New South Wales, Australia [1]. The risk of HIV transmission is significantly enhanced by coinfection with NG [2, 3], and so the control of NG particularly in light of increasing minimum inhibitory concentration (MIC) values to ceftriaxone is a major public health concern [4, 5]. The predominance of gonorrhoea amongst Australian urban men who have sex with men (MSM) is well documented [1, 6] but heterosexual gonorrhoea in urban settings is less well characterised. NG is a notifiable disease in Australia but data is only collected by age, sex, and region of diagnosis and so heterosexual trends are poorly defined. Trends of increasing prevalence of heterosexually acquired NG and acquisition from fellatio and commercial sex worker (CSW) contact were noted in our suburban STD services in 2009, prompting this investigation specifically aimed at examining sexual behavioral aspects of heterosexual NG acquisition. 2. Methods A case series was conducted from patient records at two STD services in South Eastern Sydney over a 5-year period, January 1, 2008 to December 31, 2012. Data was collected prospectively from late 2009 when the study started but
References
[1]
South Eastern Sydney Local Health District Public Health Unit, “Chlamydia, Gonorrhoea and Syphilis in South Eastern Sydney and Illawarra Shoalhaven Local Health Districts 2008–2012,” Midyear Report, August 2012.
[2]
H. Grosskurth, F. Mosha, J. Todd et al., “Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial,” The Lancet, vol. 346, no. 8974, pp. 530–536, 1995.
[3]
C. R. Cohen, F. A. Plummer, N. Mugo et al., “Increased interleukin-10 in the endocervical secretions of women with non-ulcerative sexually transmitted diseases: a mechanism for enhanced HIV-1 transmission?” AIDS, vol. 13, no. 3, pp. 327–332, 1999.
[4]
M. M. Lahra, “Annual report of the Australian gonococcal surveillance programme,” Communicable Diseases Intelligence, vol. 36, 2012.
[5]
D. M. Whiley, N. Goire, M. M. Lahra, et al., “The ticking time bomb: escalating antibiotic resistance in Neisseria gonorrhoeae is a public health disaster in waiting,” Journal of Antimicrobial Chemotherapy, vol. 67, no. 9, pp. 2059–2061, 2012.
[6]
B. Donovan, N. J. Bodsworth, R. Rohrsheim, A. McNulty, and J. W. Tapsall, “Increasing gonorrhoea reports–not only in London,” The Lancet, vol. 355, no. 9218, article 1908, 2000.
[7]
“Second National Sexually Transmissible Infections Strategy 2010-2013,” Commonwealth Department of Health and Ageing, Australia, 2012.
D. W. Smith, J. W. Tapsall, and G. Lum, “Guidelines for the use and interpretation of nucleic acid detection tests for Neisseria gonorrhoeae in Australia: a position paper on behalf of the Public Health Laboratory Network,” Communicable Diseases Intelligence, vol. 29, no. 4, pp. 358–365, 2005.
[10]
A. McDonald, Ed., HIV, Viral Hepatitis and Sexually Transmissible Infections in Australia, Annual Surveillance Report, National Centre in HIV Epidemiology and Clinical Research, 2011.
[11]
H. Weinstock and K. A. Workowski, “Pharyngeal gonorrhea: an important reservoir of infection?” Clinical Infectious Diseases, vol. 49, no. 12, pp. 1798–1800, 2009.
[12]
G. Kinghorn, “Pharyngeal gonorrhoea: a silent cause for concern,” Sexually Transmitted Infections, vol. 86, no. 6, pp. 413–414, 2010.
[13]
S. A. Sanders, B. J. Hill, W. L. Yarber, C. A. Graham, R. A. Crosby, and R. R. Milhausen, “Misclassification bias: diversity in conceptualisations about having had sex,” Sexual Health, vol. 7, no. 1, pp. 31–34, 2010.
[14]
J. Schachter, J. Moncada, S. Liska, C. Shayevich, and J. D. Klausner, “Nucleic acid amplification tests in the diagnosis of chlamydial and gonococcal infections of the oropharynx and rectum in men who have sex with men,” Sexually Transmitted Diseases, vol. 35, no. 7, pp. 637–642, 2008.
[15]
N. Bell and R. Drayton, “Pharyngeal gonorrhoea in heterosexual women:an unrecognised reservoir of infection?” International Journal of STD and AIDS, supplement 1, no. 24, 2013.
[16]
B. Donovan, C. Harcourt, S. Egger, and C. K. Fairley, “Improving the health of sex workers in NSW: maintaining success,” New South Wales Public Health Bulletin, vol. 21, no. 3-4, pp. 74–77, 2010.
[17]
P. J. Read, H. Wand, R. Guy, et al., “Unprotected fellatio between female sex workers and their clients in Sydney, Australia,” Sexually Transmitted Infections, vol. 88, pp. 581–584, 2012.
[18]
G. A. Bolan, P. F. Sparling, and J. N. Wasserheit, “The emerging threat of untreatable gonococcal infection,” New England Journal of Medicine, vol. 366, no. 6, pp. 485–487, 2012.
