By: Madison Davis MPH Candidate, Brown University School of Public Health

Background

       The monkeypox virus (MPV) was first reported in 1958 in a Copenhagen research facility containing monkeys¹. However, the first human infection was not until 1970 when a nine-month-old child in the Democratic Republic of the Congo was diagnosed^1,2. Although the virus has been primarily concentrated in African countries, it has recently spread to other regions². MPV is transmitted via contact with animals who have infected lesions, body fluids, or respiratory droplets. The median age of those diagnosed ranges from 4-21 years of age². The fatality rate is ~8.7%; however, there are marked differences between regions². The escalation in MPV cases is believed to be due to a decrease in smallpox vaccination, which provides cross-protection, and new mutations in the virus^1,2.

Signs & Symptoms

The symptoms of MPV include^3,4:

• Fever
• Headache
• Muscle aches and backache
• Swollen lymph nodes
• Chills
• Exhaustion
• Respiratory symptoms (sore throat, nasal congestion, and cough)
• An itchy and painful rash located on or near the genitals, hands, feet, chest, face, or mouth
  • The rash will progress through stages prior to healing
  • The rash will appear like pimples or blisters

       The majority of people who are diagnosed with MPV will experience a rash that developed 1-4 days after flu-like symptoms³. The symptoms will usually appear within 3 weeks of exposure and last 2-4 weeks³. Anyone can get MPV, so it is important to be vigilant of developing symptoms and new or worsening rashes.

Current Outbreak

       According to the Centers for Disease Control and Prevention website, between January 1, 2022, and July 29^th, 2022, there have been 22,485 confirmed cases across 79 countries³. The United States, Spain, Germany, and the UK have reported the highest cases at 5,186, 4,298, 2,595, and 2,546 cases respectively³. In the United States, New York, California, and Illinois have the highest confirmed case numbers, reporting 1,345, 799, and 419 cases respectively³. Belgium was the first country to implement a 21-day quarantine for those infected¹. The infections are reported to be both caused by human-to-human transmission and animal-to-human transmission¹.

       The CDC is working to collaborate with other countries who are also experiencing a marked increase in MPV cases to expand testing and track the evolution of the virus³.

Spread, Testing & Prevention

       MPV can spread through contact with infectious rash or bodily fluids, respiratory droplets during prolonged face-to-face contact, touching objects or fabrics that infectious rash or fluids have touched, or being scratched or bitten by an infected animal³. The infection can be spread from the time that symptoms start to when the rash has fully healed³.

       If a person is experiencing symptoms of MPV, a lesion swab can be conducted in order to test for the presence of the MPV⁴. Ideally, there should be more than one specimen taken from two separate lesions on different parts of the body⁵. The lesion should be “unroofed” to properly sample the secretions⁵.

       Prevent close, skin-to-skin contact with people who have a rash associated with MPV and  avoid objects an infected person has used such as utensils, cups, bedding, or clothing³. Furthermore, washing your hands frequency with soap and warm water and consistently using an alcohol-based hand sanitizer can help prevent infection³.

Recommendations for Providers

       The CDC, Health Alert Network (HAN), and Clinician Outreach and Communication Activity (COCA) ask providers to be alert to patients who are experiencing a new rash and have other associated MPV symptoms³. Providers can also conduct testing through the Laboratory Response Network, advise patients on health monitoring, and track confirmed cases³. Additionally, providers can subscribe to the COCA Now email updates and Health Alert Network messages to receive information on testing options. Lastly, providers are able to educate patients on and distribute vaccines to individuals who may be diagnosed or a part of a high risk population³.

       When treating patients with known or suspected MPV, it is recommended that providers don PPE for contact precautions including eye protection, a fit-tested N-95 or equivalent, gown, and gloves⁵. Furthermore, surfaces should be decontaminated, and the patient should be isolated⁵.

       Given the similarity in genetic makeup of the smallpox virus and MPV, it is believed that the antivirals and vaccines that aid with smallpox treatment will also help with MPV³. The CDC recommends antiviral treatment (tecovirimat (TPOXX), cidofovir, and brincidofovir)  for severely ill and immunocompromised patients³. These medications can be accessed through the CDC by submitting a request to the state and territorial health departments⁵. Furthermore, PEP vaccines, ACAM2000 or JYNNEOS, are recommended for intermediate to high-risk individuals who have been exposed via unprotected contact with an infected rash or being less than six feet from an unmasked person for more than three hours without wearing a surgical mask⁴. Supportive care is also recommended as treatment, including fluid maintenance, supplemental oxygen, and treatment of bacterial skin lesions where applicable⁵.

       Given the potentially stigmatizing nature of MPV, the CDC has released a report on how to effectively communicate MPV information without using stigmatizing language or marginalizing specific groups. 

More Resources

       Given the evolving and novel nature of MPV, it is important to educate ourselves as providers to ensure we are implementing best practices for our patients. Here are some additional sources for reference:

Monkeypox vaccines in pregnancy

The use of JYNNEOS as a PEP vaccine

Overview of monkeypox biology

Monkeypox transmission in healthcare facilities

Social consideration for monkeypox response

References

1. 1. pathobiology of the monkeypox virus. Journal of Autoimmunity. 2022:102855.
   2. Bunge EM, Hoet B, Chen L, et al. The changing epidemiology of human monkeypox—A potential threat? A systematic review. PLoS neglected tropical diseases. 2022;16(2):e0010141.
   3. Monkeypox. 2022; https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html.
   4. Minhaj FS, Ogale YP, Whitehill F, et al. Monkeypox outbreak—nine states, May 2022. Morbidity and Mortality Weekly Report. 2022;71(23):764.
   5. Titanji BK, Tegomoh B, Nematollahi S, Konomos M, Kulkarni PA. Monkeypox: A Contemporary Review for Healthcare Professionals. Paper presented at: Open Forum Infectious Diseases2022.

By: Madison Davis MPH Candidate, Brown University School of Public Health

Background: Human Papillomavirus

       The human papillomavirus (HPV) is associated with cervical, anus, penile, vagina, vulva, and oropharynx cancers and is the most common sexually transmitted infection in the United States as of 2015^1-3. The virus is associated with a wide range of anogenital cancers due to its wide range of genotypes¹. Cervical cancer specifically is the fourth most common cancer among women making it a significant health burden¹. Furthermore, the HPV virus accounts for approximately 70% of cervical cancers and is also responsible for the majority of vaginal and vulvar cancer diagnosis among women.

       Given that cervical cancer is a major public health issue, it is often the disease that is most commonly associated with HPV; however, the HPV virus is significantly associated with other types of cancers found in both men and women. The HPV virus is attributed to 95% of anal cancer cases among men and women which have an incidence rate that has increased by more than 50% in the United States⁴, Scotland⁵, Denmark⁶, and Australia^7-9. Furthermore, men who have sex with men have higher rates of HPV infection and HPV-associated anal cancer¹⁰. Additionally, the incidence rate of HPV-associated penile cancer has also increased in developing countries where it makes up 10% of cancer diagnosis¹¹. 

HPV Vaccine for Women

       The FDA has approved three different HPV vaccines: quadrivalent vaccine for males and females, a bivalent vaccine for females, and a 9-valent vaccine for males and females¹². A study of over 17,000 women between the ages of 15 and 26 showed 100% efficacy in preventing HPV-associated cervical intraepithelial neoplasia 2 and 3, and cervical adenocarcinoma¹³. 

HPV Vaccine for Men

       Despite targeted marketing toward female patients, the rate of HPV infection is nearly the same among men and women¹⁴. Furthermore, the prophylactic HPV vaccine shows significant protection from anogenital infection and external genital lesions associated with HPV among men between 16 and 26 years of age². Specifically, the vaccine showed 60.2% efficacy against HPV infection in a 2011 study of 4065 heterosexual men and men who have sex with men². An additional study in 2019 showed an 83.3% efficacy rate after six months¹⁵. To further support this, a 10-year longitudinal study also found an 85.6% efficacy rate at preventing HPV infection among men¹⁶. Although the efficacy rate of the vaccine is higher in women, the confidence intervals overlap which suggests that the vaccine is effective for both populations².

Implementation Into Practice

       The development of screening programs has been a pivotal change in the approach to treating cancer. Like many other cancers, the stage at which cervical cancer is detected is one of the best prognostic factors for survival¹. Although screening measures have been important in diagnosing cancer early, and thus reducing the mortality rate, there has been little change in the incidence rate of cancer in areas that have strong screening programs thus highlighting the need for increased vaccination¹.

       The HPV vaccine has been shown to be effective in both men and women at preventing devastating cancers with little to no reported side effects thus it should be marketed to both populations. The previous argument for only vaccinating women was that if herd immunity was reach among the female population, then it would limit transmission to the male population; however, this excludes men who have sex with men, a vulnerable population to HPV infection¹⁷. Therefore, vaccination of both men and women is the best way to reach all vulnerable populations and limit the spread of HPV. In your own practice, consider speaking with both your male and female patients about the HPV vaccine to determine if partaking in the immunization series would be best for them.

References

1. Wakeham K, Kavanagh K. The burden of HPV-associated anogenital cancers. Current oncology reports. 2014;16(9):1-11.
2. Giuliano AR, Palefsky JM, Goldstone S, et al. Efficacy of quadrivalent HPV vaccine against HPV Infection and disease in males. New England Journal of Medicine. 2011;364(5):401-411.
3. Hariri S, Unger ER, Sternberg M, et al. Prevalence of genital human papillomavirus among females in the United States, the National Health and Nutrition Examination Survey, 2003–2006. Journal of Infectious Diseases. 2011;204(4):566-573.
4. Johnson LG, Madeleine MM, Newcomer LM, Schwartz SM, Daling JR. Anal cancer incidence and survival: the surveillance, epidemiology, and end results experience, 1973–2000. Cancer. 2004;101(2):281-288.
5. Brewster D, Bhatti L. Increasing incidence of squamous cell carcinoma of the anus in Scotland, 1975–2002. British journal of cancer. 2006;95(1):87-90.
6. Frisch M, Melbye M, Møller H. Trends in incidence of anal cancer in Denmark. British Medical Journal. 1993;306(6875):419-422.
7. Daling JR, Madeleine MM, Johnson LG, et al. Human papillomavirus, smoking, and sexual practices in the etiology of anal cancer. Cancer. 2004;101(2):270-280.
8. Jin F, Stein AN, Conway EL, et al. Trends in anal cancer in Australia, 1982–2005. Vaccine. 2011;29(12):2322-2327.
9. Baricevic I, He X, Chakrabarty B, et al. High-sensitivity human papilloma virus genotyping reveals near universal positivity in anal squamous cell carcinoma: different implications for vaccine prevention and prognosis. European journal of cancer. 2015;51(6):776-785.
10. Palefsky J. Human papillomavirus and anal neoplasia. Current HIV/AIDS Reports. 2008;5(2):78-85.
11. Ornellas AA. Management of penile cancer. In. Vol 972008:199-200.
12. Food U, Administration D. Vaccines, blood, and biologics: human papillomavirus vaccine. In:2015.
13. Group FIS. Prophylactic efficacy of a quadrivalent human papillomavirus (HPV) vaccine in women with virological evidence of HPV infection. The Journal of infectious diseases. 2007;196(10):1438-1446.
14. Yoshida T, Ogawa T, Nakanome A, et al. Investigation of the diversity of human papillomavirus 16 variants and L1 antigenic regions relevant for the prevention of human papillomavirus-related oropharyngeal cancer in Japan. Auris Nasus Larynx. 2022.
15. Mikamo H, Yamagishi Y, Murata S, et al. Efficacy, safety, and immunogenicity of a quadrivalent HPV vaccine in Japanese men: a randomized, Phase 3, placebo-controlled study. Vaccine. 2019;37(12):1651-1658.
16. Goldstone S, Giuliano A, Palefsky J, Luxembourg A, team V-s. Long-term effectiveness and immunogenicity of quadrivalent HPV vaccine in young men: 10-year end-of study analysis. In: American Society of Clinical Oncology; 2018.
17. Spînu AD, Anghel RF, Marcu DR, Iorga DL, Cherciu A, Mischianu DLD. HPV vaccine for men: Where to? Experimental and Therapeutic Medicine. 2021;22(5):1-6.

By: Ellen Smith, MSN, MPH, NP-C, WHNP-BC, CIC, CPH 

       Given the COVID-19 pandemic over the past two years, many nurse practitioners may be unfamiliar with recent clinical practice updates and treatment options in other corners of the infection control field. As we celebrate the month of July as HIV Awareness Month, we turn our attention to developments in the field of HIV prevention, namely HIV PrEP (Pre-exposure prophylaxis). Pre-exposure prophylaxis consists of medications that are prescribed to people at risk for HIV acquisition (such as people who use IV drugs or have high-risk sex)1. When taken as prescribed, PrEP reduces the risk of acquiring HIV through sex by about 99% and reduces the risk of acquiring HIV through IV drug use by at least 74%1. Given that 1.7 million people are newly infected with HIV each year, PrEP has been a huge breakthrough in the HIV field2. However, it is dependent on prescribers being familiar with its use and effectively counseling people who may benefit.  

       The CDC now recommends talking about PrEP to all sexually active adolescents and adults and offering PrEP to all those who request it; including those who do not report a history of high-risk sexual activity or drug use3. Given the stigma that still surrounds HIV, this strategy helps patients overcome embarrassment or shame. In addition to stigma, another barrier that has prevented patients from seeking PrEP is the cost; however, as of July 2021, the federal government announced that nearly all health insurers are required to cover not only the cost of PrEP medications but associated lab tests and clinic visits as well4. A barrier to compliance is patient’s reluctance to take a daily pill, even if it can have such a positive benefit. A new injectable treatment option (Cabotegravir) has surmounted this obstacle. One injection of Cabotegravir prevents HIV infection for up to 2 months3. It was approved by the FDA in 2021 and may be particularly beneficial for patients who have a hard time taking oral medications as prescribed, have severe kidney disease, or simply prefer more infrequent medication administration3. The final obstacle to maximizing the utility of PrEP is prescriber and patient awareness.  

       This HIV Awareness Month, make it a point to talk about PrEP with your colleagues and friends. Also, get into the habit of discussing the benefits of PrEP with your patients. Given the wide availability of this effective tool, now is the time to step up our fight against HIV! For more prescriber information, visit the updated PrEP guideline from the CDC at www.cdc.gov/hiv/pdg/risk/prep/cdc-hiv-prep-guidelines-2021.pdf.  

References

1. 1. PrEP Effectiveness. Centers for Disease Control and Prevention. Updated May 13, 2021. Accessed May 16th, 2022. https://www.cdc.gov/hiv/basics/prep/prep-effectiveness.html 
   2. Global statistics. HIV.gov. Updated November 30th, 2021. Accessed May 16th, 2021. https://www.hiv.gov/hiv-basics/overview/data-and-trends/global-statistics 
   3. Clinicians’ Quick Guide. Centers for Disease Control and Prevention. Accessed May 16th, 2021. https://www.cdc.gov/hiv/pdf/clinicians/materials/cdc-hiv-FlyerPrEPUpdateProvider508.pdf
   4. Ryan, Benjamin. PrEP, the HIV prevention pill, must now be totally free under almost all insurance plans. NBC News. July 20th, 2021. Accessed May 16th, 2021. https://www.nbcnews.com/news/amp/rcna1470  

By: Madison Davis MPH Candidate, Brown University School of Public Health

Background

       Drowning can be defined as being unable to breathe as a result of being submerged in water. When a person is submerged underwater, they experience a laryngeal spasm reflex which closes off their airway and prevents oxygen from going to the brain¹. Accidental drowning is one of the leading causes of death among children in the United States². Specifically, drowning is the second leading cause of death among children between the ages of 1 and 14². As we approach warmer months, it is important to understand how to prevent and treat as numbers will be on the rise. On average, there are about 3,960 fatal and 8,080 nonfatal, accidental drownings per year^2,3. Even in the case on nonfatal accidental drownings, more than 40% of children treated in the emergency department subsequently require hospitalization or relocation for more intense care².

At Risk Population

       Children between the ages of 1 and 4 are most at risk². Drownings among children tend to occur in swimming pools³. Males are also more at risk than females for fatal, accidental drownings². This is often due to increased exposure to water, increased risk-taking behaviors, and alcohol use^4,5. Black children between 10 and 14 are 7.6 times more likely to die from accidental drowning than white children⁶.

Secondary Drowning

       Secondary drowning is when a water enters the lungs/airway of a child prior to the laryngeal spasm reflex¹. If excessive amounts of water enter the airway, lung damage can occur and become more serious 6-12 hours after the incident¹. The signs and symptoms of secondary drowning include¹:

• Change of skin color
• Heavy coughing
• High fever
• Loss of consciousness
• Shortness of breath
• Vomiting

Treatment

       The most important factor in treating someone who has experienced a drowning is ventilation⁷. Oxygenation, ventilation, and perfusion should be the top priority; thus, CPR should be administered as soon as possible⁷. A secondary factor in treating those who have experienced a drowning is the possible presence of primary or secondary hypothermia⁸. However, c-spine stabilization is not indicated unless there was trauma involved in the drowning incident⁷. Common trauma incidents include diving, water slides, signs of injury, or alcohol intoxication⁷. There is also not a need to remove small amount of aspirated water from the victim’s mouth or perform the abdominal thrusts or the Heimlich maneuver⁷.

       Pulling the victim from the water quickly is important⁷. Prompt ventilation via mouth-to-mouth or BVM is recommended: 2 rescue breathes should be administered once removed from water⁷. If the victim does not have a pulse, then chest compressions should subsequently begin⁷. Cycles of CPR should continue until a pulse is returned⁷. If an AED is present, that should be properly used on the patient if indicated⁷. If the patient vomits during CPR, then they should be rolled on their side and the vomit should be suctioned out or removed by the rescuer⁷.

       Some modifications to ACLS include the use of surfactant for fresh water-induced drownings and extracorporeal membrane oxygenation for cases of severe hypothermia^9-13. However, the use of barbiturates, steroid, nitric oxide, therapeutic hypothermia, or vasopressin are not supported^14-17.  

Prevention

       Many fatal, accidental drownings occur due to children who are unable to swim having access to water⁵. This could be due to ineffective fencing around pools, a lack of supervision and life jackets, or the consumption of drugs and alcohol⁵. However, the common location of drownings for each age varies. The highest risk of drowning for infants under 1 year is reported to occur in bathtubs; however, for children 1-4 years of age, drownings tend to occur in residential swimming pools³. Furthermore, for adolescents 15 years or older, the majority of drownings both fatal and nonfatal occur in natural bodies of water such as lakes, rivers, or oceans³.

       There are a few important precautions that can be taken to avoid a drowning incident. While in a natural body of water, look for steep drops, hazardous currents, or opaque water¹⁸. For at home pools, it is vital to have a safe perimeter to prevent accidents or unsupervised swimming¹⁸. In any body of water, if not a strong swimmer, swimming with friends, wearing a life jacket, having a dedicated watcher/constant supervision, and understanding basic first aid is important¹⁸. Furthermore, checking side effects of medications to ensure they do not make you drowsy or impaired and consulting a provider on medication use while swimming¹⁸.

References

1. ‘Dry Drowning’: Separating Fact From Fiction. Pediatrics 2020; https://health.clevelandclinic.org/dry-drowning-separating-fact-from-fiction/.
2. Web-based Injury Statistics Query and Reporting System (WISQARS). 2021; http://www.cdc.gov/injury/wisqars.
3. Wide-ranging Online Data for Epidemiologic Research (WONDER). 2021; https://wonder.cdc.gov/.
4. Lawes J, Ellis A, Daw S, Strasiotto L. Risky business: a 15-year analysis of fatal coastal drowning of young male adults in Australia. Injury prevention. 2020.
5. Denny S, Quan L, Gilchrist J, et al. Policy Statement – Prevention of Drowning American Academy of Pediatrics (AAP) – Council on Injury, Violence, and Poison Prevention. 2019;143(5).
6. Clemens T, Moreland B, Lee R. Persistent Racial/Ethnic Disparities in Fatal Unintentional Drowning Rates Among Persons Aged ≤29 Years – United States, 1999-2019. MMWR. 2021.
7. Part 10.3: Drowning. American Heart Association. 2005;112:133-135.
8. Quan L, Kinder D. Pediatric submersions: prehospital predictors of outcome. Pediatrics. 1992;90(6):909-913.
9. Bolte RG, Black PG, Bowers RS, Thorne JK, Corneli HM. The use of extracorporeal rewarming in a child submerged for 66 minutes. Jama. 1988;260(3):377-379.
10. Onarheim H, Vik V. Porcine surfactant (Curosurf) for acute respiratory failure after near‐drowning in 12 year old. Acta anaesthesiologica scandinavica. 2004;48(6):778-781.
11. Staudinger T, Bankier A, Strohmaier W, et al. Exogenous surfactant therapy in a patient with adult respiratory distress syndrome after near drowning. Resuscitation. 1997;35(2):179-182.
12. Suzuki H, Ohta T, Iwata K, Yamaguchi K, Sato T. Surfactant therapy for respiratory failure due to near-drowning. European journal of pediatrics. 1996;155(5):383-384.
13. Thalmann M, Trampitsch E, Haberfellner N, Eisendle E, Kraschl R, Kobinia G. Resuscitaton in near drowning with extracorporeal membrane oxygenation. The Annals of thoracic surgery. 2001;72(2):607-608.
14. Foex BA, Boyd R. Corticosteroids in the management of near-drowning. Emergency Medicine Journal. 2001;18(6):465-466.
15. Takano Y, Hirosako S, Yamaguchi T, et al. Nitric oxide inhalation as an effective therapy for acute respiratory distress syndrome due to near-drowning: a case report. Nihon Kokyuki Gakkai Zasshi= the Journal of the Japanese Respiratory Society. 1999;37(12):997-1002.
16. Williamson JP, Braude S, Illing R, Gertler P. Near-drowning treated with therapeutic hypothermia. The Medical Journal of Australia. 2004;181(9):500-501.
17. Sumann G, Krismer A, Wenzel V, et al. Cardiopulmonary resuscitation after near drowning and hypothermia: restoration of spontaneous circulation after vasopressin. Acta anaesthesiologica scandinavica. 2003;47(3):363-365.
18. Drowning data and facts. https://www.mass.gov/service-details/drowning-data-and-facts.

By: Casey N. Pinto PhD, CRNP, MPH, The Pennsylvania State University, Department of Public health Sciences

       Chlamydia was discovered in 1907 but was not associated with non-gonococcal urethritis (NGU) until the 1970s. In 1988 the CDC made chlamydia a nationally notifiable disease in the US. In 1990 there were 34,000 cases documented,^1,2 rising to nearly 1.6 million cases in 2020.³ Prevalence rates of chlamydia among the general population is 2.3%⁴ however, rates vary between 1.4% and 14% based on select social determinants and age.^2,5,6

       Mycoplasma genitalium (MG) was discovered in 1981 during a search for causative agents of NGU.^7,8 However, since the MG bacteria took six months to grow on very specific culture mediums, clinical diagnosis was limited to clinical suspicion. The first assay for MG was approved by the FDA in the US in 2019,⁹ allowing for improved diagnosis and prevalence estimates. Current prevalence of MG is 1% among the general US population⁴ with a range of 4-38% among select population groups.^10-14 Thus MG is more prevalent than gonorrhea (0.4%),⁴ and is quickly catching chlamydia, and surpassing in select populations.

       Initial symptoms of MG are mild (urethritis/cervicitis/proctitis) with limited information on long-term effects. Existing evidence is predominantly among women (endometritis, pelvic inflammatory disease, preterm birth, fetal demise, and infertility).^15-17 Among men it is theorized that infertility, epididymitis, and/or prostatitis are potential long-term effects.^18,19

       MG screening guidelines are continually adjusted based on new evidence. Currently, screening is limited to patients who are symptomatic and includes urine, vaginal, meatal, rectal, and endocervical sites as indicated.¹⁹ Asymptomatic screening should not include MG ¹⁹ unless clinical decision making justifies screening (i.e. partner positive and unable to clear infection). Symptomatic patients who test positive for MG require treatment. Asymptomatic patients with a positive MG test should be considered for treatment based on clinical judgement, especially since there is evidence that 93% of patients will clear an MG infection without any treatment at 12 months.²⁰

       Treatment for MG initially mirrored chlamydia treatment (azithromycin 1gm PO) however, increasing macrolide resistance has been documented among MG isolates (44%-90%).¹⁹ Due to the high rate of macrolide resistance, and the lack of resistance testing in the US (currently available in other countries),²¹ azithromycin should be avoided as a treatment for proven or suspected MG. The current recommendations are doxycycline 100mg PO BID x 7days followed by moxifloxacin 400mg PO daily x 7 days. Doxycycline alone will not adequately treat the infection but will decrease the bacteria burden. So moxifloxacin can successfully eradicate the infection without increasing the rate of resistance among fluoroquinolones.²² While the 7-day doxycycline treatment followed by moxifloxacin is cumbersome, it does allow time for MG testing results to determine if the second antibiotic is needed. Additionally, when resistance testing is available in the US, the 7-day doxycycline window will allow time to determine the appropriate second antibiotic.

       MG is not only likely to be the next chlamydia, but the high likelihood of developing resistance will complicate current and future treatment. Providers should be suspicious of MG in cases of NGU to ensure appropriate and timely treatment.

References

1. Taylor-Robinson D. The discovery of Chlamydia trachomatis. Sex Transm Infect. 2017;93:10.
2. Miller WC. Prevalence of Chlamydial and Gonococcal Infections Among Young Adults in the United States. JAMA. 2004;291(18):2229.
3. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2020. 2021.
4. Manhart LE, Holmes KK, Hughes JP, Houston LS, Totten PA. Mycoplasma genitalium Among Young Adults in the United States: An Emerging Sexually Transmitted Infection. American Journal of Public Health. 2007;97(6):1118-1125.
5. Torrone EAP, John; Weinstock, Hillard. Prevalence of Chlamydia trachomatis Genital Infection Among Persons Aged 14-39 years — United States, 2007-2012. Morbidity and Mortality Weekly Report. 2014;63(38):834-838.
6. Force USPST. Final Recommendation Statement: Chlamydia and Gonorrhea: Screening – US Preventive Services Task Force. In:2019.
7. Tully JG, Taylor-Robinson, David., Cole, Roger M., Rose, David L.,. A Newly Discovered Mycoplasma in the Human Urogenital Tract. The Lancet. 1981:1288-1291.
8. Taylor-Robinson D, Tully, J.G., Furr, P.M., Cole, R.M., Rose, D. L., Hanna, N.F.,. Urogenital mycoplasma infections of man: a review with ovservations on a recently discovered mycoplasma. Isr J Med Sci. 1981;17(7):524-530.
9. FDA permits marketing of first test to aid in the diagnosis of a sexually-transmitted infection known as Mycoplasma genitalium [press release]. 2019.
10. le Roux MCH, Anwar Ahmed. Quantitative Real-Time Polymerase Chain Reaction for the Diagnosis of Mycoplasma genitalium Infection in South African Men With and Without Symptoms of Urethritis. Sex Transm Dis. 2017;144:18-21.
11. Munson E, Wenten D, Jhansale S, et al. Expansion of Comprehensive Screening of Male Sexually Transmitted Infection Clinic Attendees with Mycoplasma genitalium and Trichomonas vaginalis Molecular Assessment: a Retrospective Analysis. Journal of Clinical Microbiology. 2017;55(1):321-325.
12. Getman DJ, A., O’Donnell, Meghan., Cohen, Seth. Mycoplasma genitalium Prevalence, Coinfection, and Macrolide Antibiotic Resistance Frequency in a Multicenter Clinical Study Cohort in the United States. J Clin Microbiol. 2016;54(9):2278-2283.
13. Seña AC, Lee JY, Schwebke J, et al. A Silent Epidemic: The Prevalence, Incidence and Persistence of Mycoplasma genitalium Among Young, Asymptomatic High-Risk Women in the United States. Clinical Infectious Diseases. 2018;67(1):73-79.
14. Hancock EB, Manhart LE, Nelson SJ, Kerani R, Wroblewski JKH, Totten PA. Comprehensive Assessment of Sociodemographic and Behavioral Risk Factors for Mycoplasma genitalium Infection in Women. Sexually Transmitted Diseases. 2010;37(12):777-783.
15. Frenzer C, Egli-Gany D, Vallely LM, Vallely AJ, Low N. Adverse pregnancy and perinatal outcomes associated with <i>Mycoplasma genitalium:</i> systematic review and meta-analysis. Sex Transm Infect. 2022;98(3):222-227.
16. Cazanave C, Manhart L. E., Bebear, C. Mycoplasma genitalium, an emerging sexually transmitted pathogen. Medecine et Maladies Infectieuses. 2012;42(9):381-392.
17. Vazquez F, Fernández J. Pelvic Inflammatory Disease Due to <i>Mycoplasma genitalium</i>: A Character in Search of an Author. Clinical Infectious Diseases. 2020;71(10):2723-2725.
18. Ahmadi MHM, Akbar; Gilani, Mohammad Ali Sadighi; Bahador, Abbas; Talebi, Malihe Improvement of semen parameters after antibiotic therapy in asymptomatic infertile men infected with Mycoplasma genitalium. Infection. 2018;46:31-38.
19. Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly Report. 2021;70(4):1-187.
20. Vandepitte J, Weiss HA, Kyakuwa N, et al. Natural history of Mycoplasma genitalium Infection in a Cohort of Female Sex Workers in Kampala, Uganda. Sexually Transmitted Diseases. 2013;40(5):422-427.
21. Manhart LE. Editorial Commentary: Diagnostic and Resistance Testing for Mycoplasma genitalium: What Will It Take? Clinical Infectious Diseases. 2014;59(1):31-33.
22. Pond MJ, Nori AV, Witney AA, Lopeman RC, Butcher PD, Sadiq ST. High Prevalence of Antibiotic-Resistant Mycoplasma genitalium in Nongonococcal Urethritis: The Need for Routine Testing and the Inadequacy of Current Treatment Options. Clinical Infectious Diseases. 2014;58(5):631-637.