Urethritis
Conditions
Keywords
NGU, M genitalium, Ureaplasma, azithromycin, doxycycline
Brief summary
The purpose of this study is to find out which of 2 different antibiotics, doxycycline or azithromycin, works best against germs that may cause nongonococcal urethritis. Study participants will include approximately 1200 men, 16 years of age or older, attending a sexually transmitted diseases clinic in Seattle, Washington with clinical signs of urethral inflammation (\>=5PMNs/HPF on a Gram-stained slide prepared from urethral exudates and/or a visible urethral discharge upon examination). Urine specimens will be collected and tested for Mycoplasma genitalium and Ureaplasmas. Each participant will receive a blinded packet of study medication. Participants will answer an enrollment questionnaire and will also receive a log to complete between visits to record information about treatment adherence, side effects, symptoms, and sexual activity. All subjects will be asked to return for evaluation 3 weeks after the initial clinic visit. Subjects who test positive for M. genitalium and/or Ureaplasmas at the initial clinic visit will also be asked to return for a third study visit, 6 weeks following the initial clinic visit. During follow-up visits, participants will answer a follow-up questionnaire and will be re-evaluated for signs of urethritis. Those who were initially positive for M. genitalium and/or Ureaplasmas will be re-tested for these organisms. Study participants with signs and/or symptoms of urethritis or who test positive for M. genitalium or Ureaplasmas at the follow-up study visit will receive another blinded treatment packet containing the alternate medication. Those who require additional treatment at the 6-week visit will be asked to return for a fourth follow-up study visit at 9-10 weeks. Study participants who did not test positive for M. genitalium or Ureaplasmas at the initial clinic visit, but who continue to demonstrate signs and/or symptoms of infection at their single follow-up study visit will treated according to clinic standard of care (after the study clinician unblinds their randomly-assigned treatment regimen).
Detailed description
OBJECTIVES The primary objective of this study is to determine the relative effectiveness of azithromycin and doxycycline in eradicating Mycoplasma genitalium and Ureaplasmas among men with nongonococcal urethritis (NGU). Secondary objectives of this study are to: * determine the sensitivity of persisting organisms to azithromycin and doxycycline by performing minimum inhibitory concentration (MIC) testing * determine the relationship between persistence/recurrence of clinical signs and persistent/recurrent detection of M. genitalium and Ureaplasmas among men with NGU treated with azithromycin or doxycycline, measured by follow-up clinical exams and repeated assays performed on specimens collected at follow-up study visits STUDY DESCRIPTION 1200 men with NGU, ages 16 and older, will be enrolled in a randomized double-blinded treatment trial. Urine samples, oral swabs, and urethral swabs will be obtained from each subject at the initial clinic visit. Urine specimens will be tested for M. genitalium and Ureaplasma. Study participants will be randomly assigned to receive one of two pre-packaged treatments: active doxycycline plus placebo azithromycin or active azithromycin plus placebo doxycycline. Subjects will complete a questionnaire, and will be given a simple standardized log in which they will be asked to keep track of adherence to the study drug, record solicited adverse events, note when symptoms disappear and/or reappear, and document sexual activity between study visits. Subjects who test positive for M. genitalium or Ureaplasmas at the initial clinic visit will be asked to return for at least two follow-up study visits: at approximately 3 and 6 weeks following the initial clinic visit. During follow-up visits, participants will answer a follow-up questionnaire and will be re-evaluated for signs of urethritis and re-tested for M. genitalium and Ureaplasmas. Study participants with signs and/or symptoms of urethritis or who test positive for M. genitalium or Ureaplasmas at the follow-up study visits will receive a blinded treatment packet containing the alternate medication, or will be offered open-label moxifloxacin if the alternate treatment regimen was administered at the prior follow-up study visit. If additional treatment is administered at the 6-week follow-up study visit, a fourth study visit will be scheduled to occur approximately 9 or 10 weeks following the initial clinic visit. Study participants who were negative for M. genitalium and Ureaplasma at enrollment will be asked to return for evaluation for a single follow-up study visit, approximately 3 weeks after the initial clinic visit. At this visit they will complete the follow-up questionnaire and provide specimens for future testing.
Interventions
DRUGAzithromycin
two 500mg tablets or four 250mg tablets administered as a single dose
DRUGDoxycycline
one 100mg capsule administered twice daily for seven days
Sponsors
National Institute of Allergy and Infectious Diseases (NIAID)
University of Washington
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
MALE
Age
16 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Has a visible urethral discharge or greater than or equal to 5 polymorphonuclear leukocytes (PMNs) per high power field on a Gram-stained slide of a urethral swab sample * Possesses and is willing to disclose valid contact information for follow-up * English-speaking * Gives informed consent * Exhibits understanding of study procedures * Exhibits ability to comply with study procedures for the entire length of the study
Exclusion criteria
* Has previously participated in this study * Has taken antibiotics within the prior month * Has known allergies to tetracyclines or azithromycin * Is being treated with any of the following: warfarin, ergot derivatives, pimozide (Orap), propafenone (Rytmonorm, Rythmol), disopyramide (Norpace, Rythmodan), rifampin, digoxin, isotretinoin, or methotrexate * Has received a kidney, heart, or lung transplant. * Is undertaking concomitant systemic steroid therapy
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| mITT Analysis of Eradication of M. Genitalium at First Follow-up Study Visit | approximately 3 weeks after initial study visit (allowable window is 2-5 weeks after initial study visit) | Microbiologic cure of M. genitalium at first follow-up visit (defined as a negative in-house PCR test performed on urine) |
| mITT Analysis of Eradication of U. Urealyticum at First Follow-up Visit | 3 weeks (allowable window 2-5) | Microbiologic cure, defined as negative PCR for U. urealyticum (if cultured), or negative culture at first follow-up visit |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Minimum Inhibitory Concentrations (MIC) of M. Genitalium for Azithromycin | baseline | In vitro susceptibiities of M. genitalium to azithromycin |
| Minimum Inhibitory Concentrations (MIC) of M. Genitalium for Doxycycline | baseline | In vitro susceptibilities of M. genitalium to doxycycline |
| Clinical Cure Among Case Subjects Who Were Positive for M. Genitalium at the Initial Study Visit | approximately 3 weeks after initial study visit (allowable window is 2-5 weeks after initial study visit) | Proportion of men with M. genitalium at the initial study visit who had clinical cure, defined as \<5 PMNs/HPF (with or without urethral symptoms) on a urethral Gram stain and absence of urethral discharge at follow-up. |
| Minimum Inhibitory Concentrations (MIC) of U. Parvum | baseline | In vitro susceptibilities of U. parvum |
| Minimum Inhibitory Concentrations (MIC) of U. Ureaplasma Biovar 2 | baseline | In vitro susceptibilities of U. urealyticum biovar 2 |
| Clinical Cure Among Case Subjects Who Were Positive for Ureaplasmas at the Initial Study Visit | approximately 3 weeks after initial study visit (allowable window is 2-5 weeks after initial study visit) | Proportion of men with Ureaplasma urealyticum at the initial study visit who had clinical cure, defined as \<5 PMNs/HPF (with or without urethral symptoms) on a urethral Gram stain and absence of urethral discharge at follow-up. |
Countries
United States
Participant flow
Recruitment details
Men were recruited from a sexually transmitted diseases clinic in Seattle, Washington from January 2007 to July 2011
Participants by arm
| Arm | Count |
|---|---|
| Active Azithromycin + Placebo Doxycycline Azithromycin : two 500mg tablets or four 250mg tablets administered as a single dose | 304 |
| Active Doxycycline + Placebo Azithromycin Doxycycline : one 100mg capsule administered twice daily for seven days | 302 |
| Total | 606 |
Baseline characteristics
| Characteristic | Active Azithromycin + Placebo Doxycycline | Active Doxycycline + Placebo Azithromycin | Total |
|---|---|---|---|
| Age, Continuous | 34.1 years STANDARD_DEVIATION 9.8 | 33.3 years STANDARD_DEVIATION 10.1 | 33.7 years STANDARD_DEVIATION 10 |
| Region of Enrollment United States | 304 participants | 302 participants | 606 participants |
| Sex: Female, Male Female | 0 Participants | 0 Participants | 0 Participants |
| Sex: Female, Male Male | 304 Participants | 302 Participants | 606 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 53 / 304 | 56 / 302 |
| serious Total, serious adverse events | 1 / 304 | 3 / 302 |
Outcome results
Primary
mITT Analysis of Eradication of M. Genitalium at First Follow-up Study Visit
Microbiologic cure of M. genitalium at first follow-up visit (defined as a negative in-house PCR test performed on urine)
Time frame: approximately 3 weeks after initial study visit (allowable window is 2-5 weeks after initial study visit)
Population: mITT population (defined as urethral symptoms or visible discharge plus \>=5PMNs/HPF at baseline) who tested positive for M. genitalium at baseline
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Active Azithromycin + Placebo Doxycycline | mITT Analysis of Eradication of M. Genitalium at First Follow-up Study Visit | 15 participants |
| Active Doxycycline + Placebo Azithromycin | mITT Analysis of Eradication of M. Genitalium at First Follow-up Study Visit | 8 participants |
Primary
mITT Analysis of Eradication of U. Urealyticum at First Follow-up Visit
Microbiologic cure, defined as negative PCR for U. urealyticum (if cultured), or negative culture at first follow-up visit
Time frame: 3 weeks (allowable window 2-5)
Population: mITT population (defined as urethral symptoms or visible discharge plus \>=5PMNs/HPF at baseline) who tested positive for U. urealyticum at baseline
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Active Azithromycin + Placebo Doxycycline | mITT Analysis of Eradication of U. Urealyticum at First Follow-up Visit | 39 participants |
| Active Doxycycline + Placebo Azithromycin | mITT Analysis of Eradication of U. Urealyticum at First Follow-up Visit | 38 participants |
Secondary
Clinical Cure Among Case Subjects Who Were Positive for M. Genitalium at the Initial Study Visit
Proportion of men with M. genitalium at the initial study visit who had clinical cure, defined as \<5 PMNs/HPF (with or without urethral symptoms) on a urethral Gram stain and absence of urethral discharge at follow-up.
Time frame: approximately 3 weeks after initial study visit (allowable window is 2-5 weeks after initial study visit)
Population: mITT population
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Active Azithromycin + Placebo Doxycycline | Clinical Cure Among Case Subjects Who Were Positive for M. Genitalium at the Initial Study Visit | 24 participants |
| Active Doxycycline + Placebo Azithromycin | Clinical Cure Among Case Subjects Who Were Positive for M. Genitalium at the Initial Study Visit | 13 participants |
Secondary
Clinical Cure Among Case Subjects Who Were Positive for Ureaplasmas at the Initial Study Visit
Proportion of men with Ureaplasma urealyticum at the initial study visit who had clinical cure, defined as \<5 PMNs/HPF (with or without urethral symptoms) on a urethral Gram stain and absence of urethral discharge at follow-up.
Time frame: approximately 3 weeks after initial study visit (allowable window is 2-5 weeks after initial study visit)
Population: mITT population
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Active Azithromycin + Placebo Doxycycline | Clinical Cure Among Case Subjects Who Were Positive for Ureaplasmas at the Initial Study Visit | 43 participants |
| Active Doxycycline + Placebo Azithromycin | Clinical Cure Among Case Subjects Who Were Positive for Ureaplasmas at the Initial Study Visit | 40 participants |
Secondary
Minimum Inhibitory Concentrations (MIC) of M. Genitalium for Azithromycin
In vitro susceptibiities of M. genitalium to azithromycin
Time frame: baseline
Population: Participants with recovered isolates that successfully underwent in vitro assessment of antibiotic susceptibilities
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Active Azithromycin + Placebo Doxycycline | Minimum Inhibitory Concentrations (MIC) of M. Genitalium for Azithromycin | MIC range <=0.001 - 0.004 ug/ml | 31 Participants |
| Active Azithromycin + Placebo Doxycycline | Minimum Inhibitory Concentrations (MIC) of M. Genitalium for Azithromycin | MIC range >8 ug/ml | 25 Participants |
Secondary
Minimum Inhibitory Concentrations (MIC) of M. Genitalium for Doxycycline
In vitro susceptibilities of M. genitalium to doxycycline
Time frame: baseline
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Active Azithromycin + Placebo Doxycycline | Minimum Inhibitory Concentrations (MIC) of M. Genitalium for Doxycycline | 0.5 MIC (ug/mL) |
Secondary
Minimum Inhibitory Concentrations (MIC) of U. Parvum
In vitro susceptibilities of U. parvum
Time frame: baseline
Population: isolates
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Active Azithromycin + Placebo Doxycycline | Minimum Inhibitory Concentrations (MIC) of U. Parvum | 0.5 MIC (ug/mL) |
| Active Doxycycline + Placebo Azithromycin | Minimum Inhibitory Concentrations (MIC) of U. Parvum | 0.25 MIC (ug/mL) |
| Moxifloxacin | Minimum Inhibitory Concentrations (MIC) of U. Parvum | 0.25 MIC (ug/mL) |
Secondary
Minimum Inhibitory Concentrations (MIC) of U. Ureaplasma Biovar 2
In vitro susceptibilities of U. urealyticum biovar 2
Time frame: baseline
Population: isolates
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Active Azithromycin + Placebo Doxycycline | Minimum Inhibitory Concentrations (MIC) of U. Ureaplasma Biovar 2 | 1.00 MIC (ug/mL) |
| Active Doxycycline + Placebo Azithromycin | Minimum Inhibitory Concentrations (MIC) of U. Ureaplasma Biovar 2 | 0.5 MIC (ug/mL) |
| Moxifloxacin | Minimum Inhibitory Concentrations (MIC) of U. Ureaplasma Biovar 2 | 0.5 MIC (ug/mL) |