Distribution and resistance patterns of male urethritis pathogens from a private South African laboratory.

PURPOSE: To assess the microbial aetiology and antimicrobial resistance patterns in male urethritis syndrome by analysing private laboratory urethral swab and urine specimens. The study also compared diagnostic performance between nucleic acid amplification testing and culture and evaluated the relevance of syndromic management. This is the first large-scale South African private sector analysis of male urethritis syndrome pathogen profiles and antimicrobial resistance using nucleic acid amplification testing and culture, providing critical evidence for diagnostic and management policy updates. METHODS: A retrospective cross-sectional study was performed using laboratory data from 2012 to 2023, comprising over 61 000 samples. Organism prevalence and antimicrobial resistance rates were assessed. Diagnostic sensitivity and specificity of nucleic acid amplification testing versus culture for Neisseria gonorrhoeae were calculated in matched samples. RESULTS: NG and Chlamydia trachomatis were the most prevalent pathogens. Nucleic acid amplification testing demonstrated superior sensitivity, while culture yielded essential antimicrobial resistance data. NG showed elevated resistance patterns, but susceptibility to first-line antimicrobials remained high. Culture sensitivity and specificity relative to nucleic acid amplification testing were 56% and 98.6%, respectively. Ureaplasma urealyticum showed elevated resistance versus global averages. The first cases of extensively drug-resistant NG in South Africa were identified. CONCLUSION: Nucleic acid amplification testing improves male urethritis syndrome detection, while culture remains vital for antimicrobial resistance surveillance. Syndromic management remains effective but rising resistance and extensively drug-resistant NG emergence warrants urgent attention.