Patricia A Totten

University of Washington Seattle, Seattle, Washington, United States

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Publications (97)498.01 Total impact

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    ABSTRACT: Mycoplasma genitalium is a sexually transmitted pathogen and is associated with reproductive tract disease that can be chronic in nature despite the induction of a strong antibody response. Persistent infection exacerbates the likelihood of transmission, increases the risk of ascension to the upper tract, and suggests that M. genitalium may possess immune evasion mechanism(s). Antibodies from infected patients predominantly target the MgpB adhesin, which is encoded by a gene that recombines with homologous donor sequences, thereby generating sequence variation within and among strains. We have previously characterized mgpB heterogeneity over the course of persistent infection and have correlated the induction of variant-specific antibodies with the loss of that particular variant from the infected host. In the current study, we examined the membrane topology, antibody accessibility, distribution of amino acid diversity, and the location of functional and antigenic epitopes within the MgpB adhesin. Our results indicate that MgpB contains a single transmembrane domain, that the majority of the protein is surface exposed and antibody accessible, and that the attachment domain is located within the extracellular C-terminus. Not unexpectedly, amino acid diversity was concentrated within and around the three previously defined variable regions (B, EF, and G) of MgpB; while nonsynonymous mutations were twice as frequent as synonymous mutations in regions B and G, region EF had equal numbers of nonsynonymous and synonymous mutations. Interestingly, antibodies produced during persistent infection reacted predominantly with the conserved C-terminus and variable region B. In contrast, infection-induced antibodies reacted poorly with the N-terminus, variable regions EF and G, and intervening conserved regions despite the presence of predicted B cell epitopes. Overall, this study provides an important foundation to define how different segments of the MgpB adhesin contribute to functionality, variability, and immunogenicity during persistent M. genitalium infection.
    Preview · Article · Sep 2015 · PLoS ONE
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    ABSTRACT: Ureaplasma urealyticum biovar 2 (UU-2), but not Ureaplasma parvum (UP), has been associated with non-gonococcal urethritis (NGU), but little is known about species-specific responses to standard therapies. We examined species-specific treatment outcomes and followed men with treatment failure for 9 weeks. From May 2007 to July 2011, men aged ≥16 attending a sexually transmitted disease (STD) clinic in Seattle, Washington, with NGU (urethral discharge or urethral symptoms plus ≥5 polymorphonuclear leucocytes /high-powered field) enrolled in a double-blind, randomised trial. Participants received active azithromycin (1 g) + placebo doxycycline or active doxycycline (100 mg twice a day ×7 days) + placebo azithromycin. Ureaplasma were detected in culture followed by species-specific PCR. Outcomes were assessed at 3, 6 and 9 weeks. At 3 weeks, men with persistent Ureaplasma detection received 'reverse therapy' (eg, active doxycycline if they first received active azithromycin). At 6 weeks, persistently positive men received moxifloxacin (400 mg×7 days). Of 490 men, 107 (22%) and 60 (12%) were infected with UU-2 and UP, respectively, and returned at 3 weeks. Persistent detection was similar for UU-2-infected men initially treated with azithromycin or doxycycline (25% vs 31%; p=0.53), but differed somewhat for men with UP (45% vs 24%; p=0.11). At 6 weeks, 57% of UU-2-infected and 63% of UP-infected men who received both drugs had persistent detection. Failure after moxifloxacin occurred in 30% and 36%, respectively. Persistent detection of UU-2 or UP was not associated with signs/symptoms of NGU. Persistent detection after treatment with doxycycline, azithromycin and moxifloxacin was common for UU and UP, but not associated with persistent urethritis. NCT00358462. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to
    No preview · Article · Jan 2015 · Sexually Transmitted Infections
  • Raul Burgos · Patricia A. Totten
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    ABSTRACT: The human pathogen Mycoplasma genitalium employs homologous recombination to generate antigenic diversity in the immunodominant MgpB and MgpC proteins. Only recently, some of the molecular factors involved in this process have been characterized, but nothing is known about its regulation. Here, we show that M. genitalium expresses N-terminally truncated RecA isoforms via alternative translation initiation, but only the full-length protein is essential for gene variation. We also demonstrate that overexpression of MG428 positively regulates the expression of recombination genes, including recA, ruvA, ruvB and ORF2, a gene of unknown function co-transcribed with ruvAB. The coordinated induction of these genes correlated with an increase of mgpBC gene variation. In contrast, cells lacking MG428 were unable to generate variants despite expressing normal levels of RecA. Similarly, deletion analyses of the recA upstream region defined sequences required for gene variation without abolishing RecA expression. The requirement of these sequences is consistent with the presence of promoter elements associated with MG428-dependent recA induction. Sequences upstream of recA also influence the relative abundance of RecA isoforms, possibly through translational regulation. Overall, these results suggest that MG428 is a positive regulator of recombination and that precise control of recA expression is required to initiate mgpBC variation.
    No preview · Article · Aug 2014 · Molecular Microbiology
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    Raul Burgos · Patricia A Totten
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    ABSTRACT: Mycoplasma genitalium is an emerging sexually transmitted pathogen associated with reproductive tract disease in men and women, and it can persist for months to years despite the development of a robust antibody response. Mechanisms that may contribute to persistence in vivo include phase and antigenic variation of the MgpB and MgpC adhesins. These processes occur by segmental recombination between discrete variable regions within mgpB and mgpC and multiple archived donor sequences termed MgPa repeats (MgPars). The molecular factors governing mgpB and mgpC variation are poorly understood and obscured by the paucity of recombination genes conserved in the M. genitalium genome. Recently, we demonstrated the requirement for RecA using a quantitative PCR (qPCR) assay developed to measure recombination between the mgpB and mgpC genes and MgPars. Here, we expand these studies by examining the roles of M. genitalium ruvA and ruvB homologs. Deletion of ruvA and ruvB impaired the ability to generate mgpB and mgpC phase and sequence variants, and these deficiencies could be complemented with wild-type copies, including the ruvA gene from Mycoplasma pneumoniae. In contrast, ruvA and ruvB deletions did not affect the sensitivity to UV irradiation, reinforcing our previous findings that the recombinational repair pathway plays a minor role in M. genitalium. Reverse transcription-PCR (RT-PCR) and primer extension analyses also revealed a complex transcriptional organization of the RuvAB system of M. genitalium, which is cotranscribed with two novel open reading frames (ORFs) (termed ORF1 and ORF2 herein) conserved only in M. pneumoniae. These findings suggest that these novel ORFs may play a role in recombination in these two closely related bacteria.
    Preview · Article · Feb 2014 · Journal of bacteriology
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    ABSTRACT: Doxycycline, one of two recommended therapies for non-gonococcal urethritis (NGU), consists of a 7-day course of therapy (100 mg BID). Since suboptimal adherence may contribute to poor treatment outcomes, we examined the association between self-reported imperfect adherence to doxycycline and clinical and microbiologic failure among men with NGU. Men aged ≥16 years with NGU attending a Seattle, WA, sexually transmitted diseases clinic were enrolled in a double-blind, parallel-group superiority trial from January 2007 to July 2011. Men were randomised to active doxycycline/placebo azithromycin or placebo doxycycline/active azithromycin. Imperfect adherence was defined as missing ≥1 dose in 7 days. Urine was tested for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), and Ureaplasma urealyticum-biovar 2 (UU-2) using nucleic acid amplification tests. Clinical failure (symptoms and ≥5 PMNs/HPF or discharge) and microbiologic failure (positive tests for CT, MG, and/or UU-2) were determined after 3 weeks. 184 men with NGU were randomised to active doxycycline and provided data on adherence. Baseline prevalence of CT, MG and UU-2 was 26%, 13% and 27%, respectively. 28% of men reported imperfect adherence, and this was associated with microbiologic failure among men with CT (aRR=9.33; 95% CI 1.00 to 89.2) and UU-2 (aRR=3.08; 95% CI 1.31 to 7.26) but not MG. Imperfect adherence was not significantly associated with clinical failure overall or for any specific pathogens, but it was more common among imperfectly adherent men with CT (aRR=2.63; 0.93-7.41, p=0.07). Adherence may be important for microbiologic cure of select pathogens. Factors other than adherence should be considered for CT-negative men with persistent NGU.
    Preview · Article · Oct 2013 · Sexually transmitted infections
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    ABSTRACT: Background Antibiotic resistance profiles of recent Mycoplasma genitalium (MG) isolates have not been extensively evaluated nor correlated with treatment outcomes for NGU. Urine specimens from men with NGU enrolled in a treatment trial in Seattle, WA were used to culture MG strains and assess the association of their susceptibility to azithromycin and doxycycline with treatment outcomes. Methods Urines from all MG-positive (by PCR) men were co-cultured with VERO cells. MG growth was detected by an increase in genomes using an MG-specific quantitative PCR (qPCR); minimum inhibitory concentrations (MICs) were defined by the antibiotic concentration that resulted in 99% growth inhibition. MICs were measured at baseline (V1), 3-week (V2) and 6-week follow-up (V3). Clinical cure (V2, V3) was defined < 5 PMNs/HPF, no urethral discharge or symptoms; microbiologic cure was defined by a negative MG-specific PCR result. Results Viable MG strains were recovered from 141 (92%) of 153 MG PCR-positive specimens; MICs were determined on 103 isolates. Azithromycin MICs were clearly bimodal; 46% (48/103) were ≤ 0.001–0.5 μg/ml, considered susceptible, and 54% (55/103) were ≥ 8 μg/ml considered resistant. Except for two strains with MICs of ≥ 8 μg/ml doxycycline, MICs were < 0.125–2 μg/ml. Doxycycline MICs did not correlate with treatment outcomes. At baseline, 33/57 (57.9%) of isolates had azithromycin MICs that were resistant. Of men in the azithromycin arm with MIC data and treatment outcomes at V2, 11/13 clinical failures (84.6%) and 16/20 microbiologic failures (80.0%) had azithromycin resistant isolates at baseline. After receiving azithromycin, 9/10 V2 clinical failures (90%) and 12/13 microbiologic failures (92.3%) had V2 azithromycin resistant MICs. All V3 clinical (7/7) and microbiologic (10/10) failures had V3 azithromycin resistant MICs. Conclusion Approximately 60% of MG strains were resistant to azithromycin at baseline; azithromycin treatment failures occurred in 90–100% of men who received azithromycin. Development of new antimicrobial therapies for MG is essential.
    Preview · Article · Jul 2013 · Sexually Transmitted Infections
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    ABSTRACT: Background Recent treatment trials have demonstrated low efficacy of doxycycline against Mycoplasma genitalium (MG) and increasing resistance to azithromycin. Treatment with azithromycin is recommended for persistent NGU if not used for the initial episode. We evaluated microbiologic cure rates for men with NGU and persistent detection of MG. Methods English-speaking men aged 16 years attending the STD clinic in Seattle, WA with NGU (urethral discharge or urethral symptoms plus ≥ 5 PMNs/HPF) were enrolled in a randomised trial of NGU therapy between January 2007 and July 2011. Urine was tested for MG by PCR. Men received 1g azithromycin plus placebo doxycycline or doxycycline (100mg bid x 7d) plus placebo azithromycin. Treatment failures after 3 weeks received ‘reverse therapy’ (active doxycycline if they first received active azithromycin and vice versa). Persistent failures after 6 weeks received moxifloxacin (400mg x 7d). After September 2010, microbiologic failures at 3 weeks received moxifloxacin. Results Of 606 enrolled men, 65 were positive for MG at enrollment and returned after 3 weeks. Microbiologic failure (positive MG test) occurred in 23/38 (60.5%) who received azithromycin and 19/27 (70.4%) who received doxycycline (p = 0.41). Of the 37 men with microbiologic treatment failure who received ‘reverse therapy’ and returned after 6 weeks, 19 (51.4%) had persistent detection of MG, including 14/20 (70.0%) retreated with doxycycline and 5/17 (29.4%) retreated with azithromycin (p = 0.02). All 19 men were prescribed moxifloxacin; 16 returned at 9 weeks and 2 (12.5%) had microbiologic failure, despite clinical cure. Four men received moxifloxacin after initial failure; 1 had microbiologic failure at 6 weeks, was retreated with moxifloxacin and microbiologically cured at 9 weeks. Conclusion One half of MG-positive men retreated with a second standard NGU treatment regimen experienced microbiologic treatment failure. Moxifloxacin treatment failure, while not common, did occur, suggesting antimicrobial susceptibility in MG merits careful monitoring.
    Preview · Article · Jul 2013 · Sexually Transmitted Infections
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    ABSTRACT: Background U. urealyticum (UU) but not U. parvum (UP) is associated with non-gonococcal urethritis (NGU), while UP may be associated with adverse pregnancy outcomes. Treatment failure may differ byspecies; therefore, we examined the efficacy of CDC-recommended therapies for NGU against UU and UP separately. Methods From May 2007 to July 2011, men aged ≥ 16 years attending an STD clinic in Seattle, Washington with NGU (urethral discharge or urethral symptoms plus ≥ 5 PMNs/HPF) were enrolled in a randomised treatment trial. Participants received active azithromycin (1g) and placebo doxycycline or active doxycycline (100 mg bid × 7d) and placebo azithromycin. Ureaplasma species were detected in broth urine culture followed by species-specific PCR. Microbiologic failure (detected by PCR) was determined at 3, 6, and 9 weeks. At 3 weeks, men who failed initial treatment received the alternate therapy (active doxycycline if they first received active azithromycin and vice versa). Persistent failures received moxifloxacin at 6 weeks. Results Of 479 enrolled men, 107 (22.3%) and 59 (12.3%) were infected with UU and UP, respectively, and returned at 3 weeks. Among men who received azithromycin, microbiologic failure at 3 weeks occurred in 46.7% (14/30) of UP-infected men and 25.0% (13/52) of UU-infected men (P = 0.04). Among doxycycline-treated men, failure occurred in 24.1% (7/29) and 30.9% (17/55), respectively (P = 0.64). At 6 weeks, 80% (4/5) of UP and 58% (7/12) of UU-infected men originally treated with doxycycline and re-treated with azithromycin were failures; failure among men originally treated with azithromycin and re-treated with doxycycline was 57% (8/14) and 55% (6/11), respectively. At 9 weeks, failure after treatment with moxifloxacin occurred in 27.3% (3/11) of UP and 36.4% (4/11) of UU-infected men. Conclusion Azithromycin was less effective against UP than UU. Failure after re-treatment with alternate therapy and moxifloxacin was common for both UU and UP.
    Preview · Article · Jul 2013 · Sexually Transmitted Infections
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    ABSTRACT: Mycoplasma genitalium is a sexually transmitted pathogen associated with several acute and chronic reproductive tract disease syndromes in men and women. To evaluate the suitability of a pigtailed macaque model of M. genitalium infection, we inoculated a pilot animal with M. genitalium strain G37 in the uterine cervix and in salpingeal pockets generated by transplanting autologous Fallopian tube tissue subcutaneously. Viable organisms were recovered throughout the eight-week experiment in cervicovaginal specimens and up to two weeks post-infection in salpingeal pockets. Humoral and cervicovaginal antibodies reacting to MgpB were induced post-inoculation and persisted throughout the infection. The immunodominance of the MgpB adhesin and the accumulation of mgpB sequence diversity previously observed in persistent human infections prompted us to evaluate sequence variation in this animal model. We found that after eight weeks of infection, sequences within mgpB variable region B were replaced by novel sequences generated by reciprocal recombination with an archived variant sequence located elsewhere on the chromosome. In contrast, mgpB region B of the same inoculum propagated for eight weeks in vitro remained unchanged. Notably, serum IgG reacted strongly with a recombinant protein spanning MgpB region B of the inoculum, while reactivity to a recombinant protein representing the Week 8 variant was reduced, suggesting antibodies were involved in the clearance of bacteria expressing the original infecting sequence. Together these results suggest that the pigtailed macaque is a suitable model to study M. genitalium pathogenesis, antibody-mediated selection of antigenic variants in vivo, and immune escape.
    Full-text · Article · Jun 2013 · Infection and immunity
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    ABSTRACT: Background: Azithromycin or doxycycline is recommended for nongonococcal urethritis (NGU); recent evidence suggests their efficacy has declined. We compared azithromycin and doxycycline in men with NGU, hypothesizing that azithromycin was more effective than doxycycline. Methods: From January 2007 to July 2011, English-speaking males ≥16 years, attending a sexually transmitted diseases clinic in Seattle, Washington, with NGU (visible urethral discharge or ≥5 polymorphonuclear leukocytes per high-power field [PMNs/HPF]) were eligible for this double-blind, parallel-group superiority trial. Participants received active azithromycin (1 g) + placebo doxycycline or active doxycycline (100 mg twice daily for 7 days) + placebo azithromycin. Urine was tested for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), Ureaplasma urealyticum biovar 2 (UU-2), and Trichomonas vaginalis (TV) using nucleic acid amplification tests. Clinical cure (<5 PMNs/HPF with or without urethral symptoms and absence of discharge) and microbiologic cure (negative tests for CT, MG, and/or UU-2) were determined after 3 weeks. Results: Of 606 men, 304 were randomized to azithromycin and 302 to doxycycline; CT, MG, TV, and UU-2 were detected in 24%, 13%, 2%, and 23%, respectively. In modified intent-to-treat analyses, 172 of 216 (80%; 95% confidence interval [CI], 74%-85%) receiving azithromycin and 157 of 206 (76%; 95% CI, 70%-82%) receiving doxycycline experienced clinical cure (P = .40). In pathogen-specific analyses, clinical cure did not differ by arm, nor did microbiologic cure differ for CT (86% vs 90%, P = .56), MG (40% vs 30%, P = .41), or UU-2 (75% vs 70%, P = .50). No unexpected adverse events occurred. Conclusions: Clinical and microbiologic cure rates for NGU were somewhat low and there was no significant difference between azithromycin and doxycycline. Mycoplasma genitalium treatment failure was extremely common. Clinical Trials Registration.NCT00358462.
    Preview · Article · Dec 2012 · Clinical Infectious Diseases
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    ABSTRACT: An international multilaboratory collaborative study was conducted to develop standard media and consensus methods for the performance and quality control of antimicrobial susceptibility testing of Mycoplasma pneumoniae, Mycoplasma hominis, and Ureaplasma urealyticum using broth microdilution and agar dilution techniques. A reference strain from the American Type Culture Collection was designated for each species, which was to be used for quality control purposes. Repeat testing of replicate samples of each reference strain by participating laboratories utilizing both methods and different lots of media enabled a 3- to 4-dilution MIC range to be established for drugs in several different classes, including tetracyclines, macrolides, ketolides, lincosamides, and fluoroquinolones. This represents the first multilaboratory collaboration to standardize susceptibility testing methods and to designate quality control parameters to ensure accurate and reliable assay results for mycoplasmas and ureaplasmas that infect humans.
    Full-text · Article · Aug 2012 · Journal of clinical microbiology
  • Raul Burgos · Gwendolyn E Wood · Lei Young · John I Glass · Patricia A Totten
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    ABSTRACT: Mycoplasma genitalium, a sexually transmitted human pathogen, encodes MgpB and MgpC adhesins that undergo phase and antigenic variation through recombination with archived 'MgPar' donor sequences. The mechanism and molecular factors required for this genetic variation are poorly understood. In this study, we estimate that sequence variation at the mgpB/C locus occurs in vitro at a frequency of > 1.25 × 10(-4) events per genome per generation using a quantitative anchored PCR assay. This rate was dramatically reduced in a recA deletion mutant and increased in a complemented strain overexpressing RecA. Similarly, the frequency of haemadsorption-deficient phase variants was reduced in the recA mutant, but restored by complementation. Unlike Escherichia coli, inactivation of recA in M. genitalium had a minimal effect on survival after exposure to mitomycin C or UV irradiation. In contrast, a deletion mutant for the predicted nucleotide excision repair uvrC gene showed growth defects and was exquisitely sensitive to DNA damage. We conclude that M. genitalium RecA has a primary role in mgpB/C-MgPar recombination leading to antigenic and phase variation, yet plays a minor role in DNA repair. Our results also suggest that M. genitalium possesses an active nucleotide excision repair system, possibly representing the main DNA repair pathway in this minimal bacterium.
    No preview · Article · Jun 2012 · Molecular Microbiology
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    ABSTRACT: Ureaplasmas have been inconsistently associated with nongonococcal urethritis (NGU). We evaluated the association of the newly differentiated species Ureaplasma urealyticum (UU) and Ureaplasma parvum (UP) with NGU using 2 separate control groups. Case patients were men who attended a sexually transmitted disease (STD) clinic in Seattle, Washington, during the period 2007-2009 with NGU (defined as visible urethral discharge and/or ≥5 polymorphonuclear neutrophils per high-powered field; n = 329). Control subjects were STD clinic attendees (n = 191) and emergency department (ED) attendees (n = 193) without NGU. Polymerase chain reaction assays detected UU and UP in ureaplasma culture-positive urine. Multivariable logistic regression was used to assess the associations of UU and UP with NGU. UU was only marginally associated with NGU in aggregate multivariable analyses, irrespective of control group (adjusted odds ratio [aOR](STD-control), 1.6 [95% confidence interval {CI}, 0.9-2.8]; aOR(ED-control), 1.7 [95% CI, 0.97-3.0]). This association was significantly stronger when analyses were restricted to men with fewer lifetime sex partners (<10 vaginal partners: aOR(STD-control), 2.9 [95% CI, 1.2-6.7]; aOR(ED-control), 3.2 [95% CI, 1.3-7.6]; <5 vaginal partners: aOR(STD-control), 6.2 [95% CI, 1.8-21.0]; aOR(ED-control), 5.2 [95% CI, 1.3-20.2]). UP was not positively associated with NGU overall or among subgroups. The absence of an association of UU with NGU among men with more lifetime sex partners suggests that adaptive immunity may attenuate the clinical manifestation of UU infection. Similar relationships were not observed with UP, which suggests that it is not a urethral pathogen.
    Preview · Article · Oct 2011 · The Journal of Infectious Diseases
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    Stefanie L Iverson-Cabral · Lisa E Manhart · Patricia A Totten
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    ABSTRACT: Mycoplasma genitalium-reactive cervicovaginal IgA and IgG antibodies were detected in 51.9% and 70.4% of 27 infected women and 22.2% and 18.5% of 27 uninfected controls, respectively. The predominance of MgpB- and MgpC-reactive antibodies at the site of infection is consistent with their hypothesized role in selecting antigenic variants during persistent infection.
    Full-text · Article · Aug 2011 · Clinical and vaccine Immunology: CVI
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    ABSTRACT: Background Mycoplasma genitalium (MG) is a newly recognised pathogen associated with acute and persistent reproductive tract infection in men and women. Understanding of the disease mechanisms, persistence and immune avoidance of this organism is hampered by the lack of a suitable animal model. Methods Female pigtail macaques (Macaca nemestrina) were inoculated cervically with ∼109 genome equivalents (∼108 ccu's) of MG strain G37, then assessed at intervals over 8 weeks for the persistence of MG in lower tract specimens. Fallopian tube biopsies were collected via laparotomy at Weeks 4 and 8. Specimens were assessed for the presence of MG DNA by qPCR and for viable MG by growth in H broth and Vero cell co-cultures. Serum collected at intervals was evaluated by immunoblot and ELISA for reactivity to MG antigens. Finally the variable regions of the immunodominant surface antigens, MgpB and MgpC, were analysed by PCR cloning and sequencing to evaluate sequence variation during infection. Results Of the five primates inoculated cervically with MG, three were infected throughout the 8 weeks of the study, one maintained infection for 4 weeks and one resisted infection. Recovery of viable MG from lower reproductive tract sites was improved by co-culture in Vero cells followed by qPCR to measure an increase in MG genomes during culture. Growth in H broth, as determined by colour change proved an unreliable indicator of the presence of viable MG in the specimen possibly due to the presence of primate microorganisms that inhibit the growth of MG. No viable MG or MG DNA was detected in upper tract tissues in any of the primates perhaps suggesting that longer infection times or repeated inoculations are needed to achieve ascension in this model. Analysis of mgpB variable regions B and G indicated that after 8 weeks of infection the predominant expressed sequence changed from that of the G37C inoculum to 1 to 5 novel sequences consistent with recombination between the expression site and the MgPars. In contrast, no sequence variation was observed in the inoculum grown in vitro for a similar duration. Antibodies reactive with MG antigens, including the variable regions of MgpB and MgpC, were detected by immunoblot and ELISA in serum and cervical exudates. Conclusions The cervical inoculation model of pigtail macaques results in long-term infection and can be used to study the persistence of MG, development of antibodies and antigenic variation.
    Preview · Article · Jul 2011 · Sexually Transmitted Infections
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    ABSTRACT: Background Up to half of men with nongonoccocal urethritis (NGU) have no known aetiology, yet still receive syndromic treatment. Identifying characteristics associated with clinical treatment failure may aid in determining the aetiology of these cases. Methods From 1 January 2007 to 31 December 2010, 553 men entered a randomised double-blind treatment trial for NGU at the Public Health Seattle & King County STD clinic in Washington. Eligible men had visible urethral discharge or ≥5 PMNs/high power field on a Gram stained slide of urethral exudates. Men were randomised to either 1 g single dose azithromycin or 100 mg doxycycline twice daily for 7 days. Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis were assessed by TMA (Gen-Probe, Inc., San Diego, CA); Mycoplasma genitalium was assessed by an in-house PCR assay. Ureaplasmas were detected by culture and speciated by a Ureaplasma urealyticum-biovar two specific PCR. Men negative for all pathogens were considered idiopathic and invited to return 2–5 weeks after enrolment. Clinical treatment failure was defined as visible urethral discharge or ≥5 PMNs. We evaluated baseline demographic and clinical characteristics, self-reported sexual history at enrolment, sexual practices between visits and depression as potential correlates of clinical treatment failure using log binomial regression. Results Of the 430 (81%) men with NGU who returned for follow-up, 202 (47%) were considered idiopathic at baseline. Enrollees were 68% white and 27% black. Age ranged from 19 to 62. Fifty-one men (25%) with idiopathic NGU experienced clinical failure. In multivariate analyses, purulent discharge at enrolment more than doubled the risk of failure (ARR=2.5, 95% CI: 1.4% to 4.4%) and black men were nearly twice as likely as non-blacks to have treatment failure (ARR=1.8, 1.1 to 2.8). Age, socioeconomic status, number of partners in last 2 months, sexual orientation, sexual behaviour (anal/vaginal sex, unprotected sex between visits), depression, and other baseline clinical characteristics were not associated with treatment failure see Abstract O3-S4.06 table 1. Conclusions Treatment failure was common among men with idiopathic NGU and associated with black race and purulent discharge at enrolment. The association with purulent discharge suggests an etiologic agent that evokes a robust immune response. Insofar as race defines sexual networks, an etiologic agent present in the network may explain the observed differential risk of persistent NGU.
    Full-text · Article · Jul 2011 · Sexually Transmitted Infections
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    ABSTRACT: Nongonococcal urethritis (NGU) is common, yet up to 50% of cases have no defined etiology. The extent to which risk profiles and clinical presentations of pathogen-associated and idiopathic cases differ is largely unknown. Urethral swabs and urine specimens were collected from 370 NGU treatment trial participants who sought care at a sexually transmitted disease clinic in Seattle, WA from 2007 to 2009 and had a visible urethral discharge and/or microscopic evidence of urethral inflammation assessed by Gram-stain (≥5 polymorphonuclear leukocytes per high-powered field [PMNs/HPF]). Neisseria gonorrhoeae, Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), Trichomonas vaginalis (TV), and Ureaplasma urealyticum (UU) were detected in urine, using nucleic acid amplification tests. Cases negative for all assessed pathogens were considered idiopathic. Bivariate and multivariate analyses identified clinical, sociodemographic, and behavioral factors associated with detection of specific pathogens. After excluding 3 participants with gonococcal infection, pathogens were detected in only 50.7% of the 367 eligible cases: CT in 22.3%, MG in 12.5%, TV in 2.5%, and UU in 24.0%, with multiple pathogens detected in 9.5%. In all, 3.5% of cases were negative for CT, MG, and TV but lacked speciated ureaplasma results. The remaining cases (45.8%) were considered idiopathic. Pathogen detection was associated with young age, black race, risky sexual behaviors, cloudy or purulent discharge, and visible discharge plus≥5 PMNs/HPF. In contrast, idiopathic cases were more likely to report prior NGU, were older and less likely to be black, or have an abnormal urethral discharge on examination, compared to all other cases. These cases were not associated with any high risk behaviors. NGU is a heterogeneous condition. Pathogen detection was associated with a variety of traditional risk factors and clinical features; whereas, idiopathic cases tended to be diagnosed among lower-risk men.
    No preview · Article · Mar 2011 · Sexually transmitted diseases
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    ABSTRACT: Neisseria gonorrhoeae and Chlamydia trachomatis are characterized by different risk factors, thus control strategies for each also differ. In contrast, risk factors for Mycoplasma genitalium have not been well characterized. Between 2000 and 2006, 1090 women ages 14 to 45 attending the Public Health-Seattle & King County Sexually Transmitted Diseases Clinic in Seattle, WA, underwent clinical examination and computer-assisted survey interview. M. genitalium was detected by transcription mediated amplification from self-obtained vaginal swab specimens. C. trachomatis and N. gonorrhoeae were detected by culture from cervical swab specimens. Prevalent M. genitalium infection was detected in 84 women (7.7%), C. trachomatis in 63 (5.8%), and N. gonorrhoeae in 26 (2.4%). Age <20 and nonwhite race were associated with increased risk for all 3 organisms. In addition, risk for M. genitalium was higher for women with a black partner (adjusted odds ratio [AOR]: 3.4; 95% confidence interval = 1.83-6.29), those never married (AOR: 2.6; 1.08-6.25), using Depo-Provera (AOR: 2.3; 1.19-4.46), and smoking (AOR: 1.7; 1.03-2.83). Drug use, history of STI in the past year, ≤high school education, meeting and having intercourse the same day, anal sex, douching, and hormonal contraception were associated with N. gonorrhoeae or C. trachomatis, but not with M. genitalium. Number of partners was not associated with any of the 3 organisms. The limited number of risk factors for prevalent infection common to all 3 pathogens suggests that M. genitalium may circulate in different sexual networks than N. gonorrhoeae or C. trachomatis. The predominance of sociodemographic risk factors for M. genitalium, rather than high-risk sexual behaviors, suggests broad-based testing may be the most effective control strategy.
    No preview · Article · Dec 2010 · Sexually transmitted diseases
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    ABSTRACT: To assess the role of Ureaplasma urealyticum and Ureaplasma parvum in patients with non-gonococcal urethritis (NGU) using specimens from a previously reported study of NGU. Species-specific PCR assays for U urealyticum and U parvum were used to detect these organisms in specimens from men enrolled in a case-control study based in a Seattle STD clinic in order to evaluate their association with NGU. Urethritis was defined by clinical examination and the presence of inflammation on Gram stained smear. Controls had normal examination findings and no evidence of inflammation on Gram stain smear or by the leucocyte esterase test. U urealyticum was detected in 26% (31/119) of cases and 16% (19/117) of controls, resulting in an association with NGU (adjusted odds ratio (aOR)=2.3, 95% CI 1.04 to 4.9) after adjusting for age, race, history of prior urethritis and other NGU pathogens (Chlamydia trachomatis, Mycoplasma genitalium). The association of U urealyticum and NGU was strongest in white men <28 years of age (OR=5.4, 95% CI 1.3 to 22.2). U parvum was detected in 14% (17/119) cases and 31% (36/117 controls) and thus was negatively associated with NGU (aOR=0.4, 95% CI 0.2 to 0.8). The prevalence of U urealyticum (16%) in controls was higher than that of C trachomatis (3.4%) or M genitalium (4.3%, p<0.05, each comparison). Unlike U parvum, U urealyticum was associated with urethritis. The strong effect in younger white men and high rates in controls may suggest variability in virulence among U urealyticum strains or in host innate or acquired immunity.
    No preview · Article · May 2010 · Sexually transmitted infections
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    ABSTRACT: Mycoplasma genitalium is associated with cervicitis and pelvic inflammatory disease in nonpregnant women. We investigated associations between cervical M genitalium, demographic and behavioral risk factors for sexually transmitted infection and preterm birth among low-income Peruvian women. This case-control study, conducted at the Instituto Nacional Materno Perinatal, Lima, Peru, included 661 cases with a spontaneous preterm birth at <37 weeks and 667 controls who delivered at >or=37 weeks. Within 48 hours after delivery, subjects underwent interviews, medical record review, and collection of cervicovaginal specimens for M. genitalium, Chlamydia trachomatis, and Neisseria gonorrhoeae by nucleic acid amplification testing, and Trichomonas vaginalis by culture. Odds ratios and 95% confidence intervals were calculated for associations between M. genitalium, other genital infections and risk factors, and preterm birth. Multivariable logistic regression was used to adjust for potential confounders. Cervical M. genitalium was detected in 3% of subjects and was significantly associated with C. trachomatis infection (P < 0.001) and preterm birth (4% vs. 2%; adjusted odds ratio: 2.5, 95% confidence interval: 1.2-5.0, P = 0.014), and marginally associated with T. vaginalis (P = 0.05). M. genitalium detection was also associated with younger maternal age (P = 0.003) but not with other risk factors for preterm birth. The association between cervical M. genitalium detection and preterm birth remained significant after adjustment for maternal age and coinfection with C. trachomatis or T. vaginalis. Cervical M. genitalium detection was independently associated with younger maternal age and preterm birth, suggesting that this organism may be an infectious correlate of spontaneous preterm birth.
    No preview · Article · Feb 2010 · Sexually transmitted diseases

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  • 1983-2015
    • University of Washington Seattle
      • • Department of Medicine
      • • Division of Allergy and Infectious Diseases
      • • Department of Microbiology
      Seattle, Washington, United States
  • 2006
    • CSU Mentor
      Long Beach, California, United States
  • 2005
    • University of California, San Francisco
      • Department of Obstetrics, Gynecology and Reproductive Sciences
      San Francisco, California, United States
  • 1994-2001
    • Swedish Medical Center Seattle
      Seattle, Washington, United States
  • 1998
    • Centers for Disease Control and Prevention
      • Division for Heart Disease and Stroke Prevention
      Atlanta, Michigan, United States
  • 1991
    • University of Florida
      • Department of Medicine
      Gainesville, Florida, United States
  • 1985
    • Penn State Hershey Medical Center and Penn State College of Medicine
      • Pediatrics
      هرشي، بنسيلفانيا, Pennsylvania, United States
    • Uniformed Services University of the Health Sciences
      • Department of Preventive Medicine & Biometrics
      베서스다, Maryland, United States
  • 1984
    • University of Texas MD Anderson Cancer Center
      Houston, Texas, United States
    • Institute Of Tropical Medicine
      Antwerpen, Flanders, Belgium
  • 1979
    • University of Missouri
      Columbia, Missouri, United States
  • 1978
    • University of Georgia
      Атина, Georgia, United States