Rationale for review International travel facilitates the spread of drug-resistant infections, including sexually transmitted infections (STIs). In 2016, the World Health Organization highlighted the global burden of ‘curable’ STIs, estimating 376 million new infections of gonorrhoea, chlamydia, syphilis and trichomoniasis annually, with considerable geographic variation in both the burden of disease and prevalence of resistance. Travelers’ risk of contracting and transmitting drug-resistant STIs depends in part on their geographic exposure. In this review, we describe the epidemiology of antimicrobial resistance (AMR) and the management of these four common STIs and Mycoplasma genitalium, an increasingly recognized cause of non-gonococcal urethritis. Key findings Multi-drug and extensively drug resistant gonorrhoea strains have been associated with international spread, particularly in travelers returning from Southeast Asia. Chlamydia is the most common bacterial STI worldwide. Although in vitro resistance has been reported, surveillance data suggest that clinically significant resistance to macrolides and tetracyclines is rare. Macrolide resistance in syphilis is now endemic in much of the world but there is no documented penicillin resistance, which remains first-line therapy. Trichomoniasis is the most common non-viral STI worldwide. Although clinical failure after treatment occurs, resistance to metronidazole is thought to be uncommon. Mycoplasma genitalium exhibits intrinsic resistance to many antibiotics, and the prevalence of resistance to both first- and second-line regimens (macrolides and fluoroquinolones) is increasing worldwide, with limited alternative therapeutic options. Recommendations International travelers are at risk for acquiring resistant STIs with limited therapeutic options. Improved diagnostics are urgently needed to improve AMR surveillance and the management of infected patients. As no vaccinations are currently available for these STIs, and pre-exposure prophylaxis is an area of active study with limited data, condom use is critical for prevention. Travel medicine providers should incorporate STI risk reduction counselling, with an emphasis on condom use, into the routine pre-travel consultation.

Background Using published data, we sought to compare outcomes in patients transitioned to either oral fluoroquinolones (FQs) or trimethoprim-sulfamethoxazole (TMP-SMX) vs ß-lactams (BLs) after an initial intravenous (IV) course for gram-negative rod (GNR) bacteremia. Methods We conducted a systematic review of PubMed and EMBASE and published IDWeek abstracts. We included studies that reported all-cause mortality and/or infection recurrence in patients transitioned to oral FQ/TMP-SMX and BLs. Results Eight retrospective studies met inclusion criteria with data for 2289 patients, of whom 65% were transitioned to oral FQs, 7.7% to TMP-SMX, and 27.2% to BLs. Follow-up periods ranged from 21 to 90 days. All-cause mortality was not significantly different between patients transitioned to either FQ/TMP-SMX or BLs (odds ratio [OR], 1.13; 95% confidence interval [CI], 0.69–1.87). Overall recurrence of infection, either bacteremia or the primary site, occurred more frequently in patients transitioned to oral BLs vs FQs (OR, 2.05; 95% CI, 1.17–3.61). Analysis limited to recurrent bacteremia was similarly suggestive, although limited by small numbers (OR, 2.15; 95% CI, 0.93–4.99). However, based on known pharmacokinetics/pharmacodynamics, prescribed ß-lactam dosing regimens were frequently suboptimal. Conclusions In the step-down IV to oral treatment of GNR bacteremia, we found insufficient data regarding outcomes after oral TMP-SMX; however, selection of an FQ over commonly utilized ß-lactam regimens may reduce chances of infection recurrence. Although this may be a class effect, it may simply be the result of inadequate dosing of ß-lactams. Additional investigations are warranted to determine outcomes with TMP-SMX and optimized oral ß-lactam dosing regimens.

To the Editor-The need for studies on coronavirus disease 2019 (COVID-19) superinfections that can inform rational antimicrobial treatment and stewardship strategies has been recognized. 1 In a recent review from our institution, 2 we found that up to 71% of patients admitted with COVID-19 received antibiotics. Anti-methicillin-resistant Staphylococcus aureus (anti-MRSA) agents, particularly vancomycin, are important stewardship targets, and they are included in the 2019 World Health Organization (WHO) Watch List of Antibiotics. Recently, guidance was published on the treatment of possible concomitant community-acquired bacterial pneumonia (CAP) for patients admitted with COVID-19. 3 The authors recommend selective use of anti-MRSA therapy, as for any other patient with CAP, and the utility of the MRSA nares PCR is not addressed. However, the empiric use of these agents for admitted COVID-19 patients remains prevalent, driven by several factors. For one, staphylococcal superinfection is a common complication of other viral pneumonias, such as influenza, 4 and the 2018 Infectious Diseases Society of America (IDSA) guidelines on influenza treatment state that "agents with activity against MRSA should be included in the empiric regimen for critically ill patients." 5 Additionally, the real-world treatment of patients with COVID-19 is complicated by recurrent fevers, fluctuating oxygen requirements, prolonged hospitalization and/or ventilation, blurring the line between community-acquired versus hospital-acquired pneumonia. Therefore, we sought to determine the prevalence of MRSA in respiratory cultures of patients admitted with COVID-19, and we evaluated the diagnostic performance of the MRSA nares PCR test, a valuable stewardship tool for ruling out MRSA pneumonia in low-prevalence settings, 6 in this cohort.