Repeat infection with Chlamydia and gonorrhea among females: a systematic review of the literature

The MraY Inhibitor Muraymycin D2 and Its Derivatives Induce Enlarged Cells in Obligate Intracellular Chlamydia and Wolbachia and Break the Persistence Phenotype in Chlamydia

Chlamydial infections and diseases caused by filarial nematodes are global health concerns. However, treatment presents challenges due to treatment failures potentially caused by persisting Chlamydia and long regimens against filarial infections accompanied by low compliance. A new treatment strategy could be the targeting of the reduced peptidoglycan structures involved in cell division in the obligate intracellular bacteria Chlamydia and Wolbachia, the latter being obligate endosymbionts supporting filarial development, growth, and survival. Here, cell culture experiments with C. trachomatis and Wolbachia showed that the nucleoside antibiotics muraymycin and carbacaprazamycin interfere with bacterial cell division and induce enlarged, aberrant cells resembling the penicillin-induced persistence phenotype in Chlamydia. Enzymatic inhibition experiments with purified C. pneumoniae MraY revealed that muraymycin derivatives abolish the synthesis of the peptidoglycan precursor lipid I. Comparative in silico analyses of chlamydial and wolbachial MraY with the corresponding well-characterized enzyme in Aquifex aeolicus revealed a high degree of conservation, providing evidence for a similar mode of inhibition. Muraymycin D2 treatment eradicated persisting non-dividing C. trachomatis cells from an established penicillin-induced persistent infection. This finding indicates that nucleoside antibiotics may have additional properties that can break bacterial persistence.

Chlamydial and Gonococcal Infections and Adverse Reproductive Health Conditions Among Patients Assigned Female at Birth in the Veterans Health Administration

BACKGROUND

Reproductive age female individuals comprise the fastest-growing segment of Veterans Health Administration patients, but little is known about rates of reproductive health outcomes among those with chlamydia or gonorrhea infections. Our aim was to estimate the risk of pelvic inflammatory disease, ectopic pregnancy, infertility, and pelvic pain in female veterans tested for chlamydia or gonorrhea.

METHODS

We performed a retrospective cohort analysis of female veterans tested for chlamydia or gonorrhea between January 1, 2010, and December 31, 2020. We calculated rates of pelvic inflammatory disease, ectopic pregnancy, infertility, and pelvic pain per 100,000 person-years and used Cox proportional hazards regression models to estimate the risk of these reproductive health conditions according to infection status after adjustment for age, race, ethnicity, military sexual trauma, mental health diagnoses, and substance use disorder.

RESULTS

Of female veterans, 232,614 were tested at least once for chlamydia or gonorrhea, with a total of 1,665,786 person-years of follow-up. Of these, 12,971 had positive chlamydia or gonorrhea results (5.8%, 796 cases per 100,000 person-years). Compared with people who tested negative, those testing positive had double the risk of pelvic inflammatory disease (adjusted hazard ratio [aHR], 1.94; 95% confidence interval [CI], 1.81-2.07), 11% increased risk of infertility (aHR, 1.11; 95% CI, 1.04-1.18), 12% increased risk of pelvic pain (aHR, 1.12; 95% CI, 1.08-1.17), and 21% increased risk of any of these conditions (aHR, 1.21; 95% CI, 1.17-1.25). People with positive chlamydia or gonorrhea testing tended to have an increased risk of ectopic pregnancy (aHR, 1.14; 95% CI, 1.0-1.30). Among those with a positive test result, 2218 people (17.1%) had 1 or more additional positive test results. Compared with those with 1 positive test result, people with more than 1 positive test result had a significantly increased risk of pelvic inflammatory disease (aHR, 1.37; 95% CI, 1.18-1.58), infertility (aHR, 1.20; 95% CI, 1.04-1.39), and pelvic pain (aHR1.16; 95% CI, 1.05-1.28), but not ectopic pregnancy (aHR, 1.09; 95% CI, 0.80-1.47).

CONCLUSIONS

Female veterans with positive chlamydia or gonorrhea results experience a significantly higher risk of pelvic inflammatory disease, infertility, and pelvic pain, especially among those with repeat infection.

Sexually Transmitted Infections in the Emergency Department

As the United States faces a worsening epidemic of sexually transmitted infections (STIs), emergency departments (EDs) play a critical role in identifying and treating these infections. The growing health inequities in the distribution and disproportionate impact of STIs add to the urgency of providing high-quality sexual health care through the ED. Changes in population health are reflected in the new Centers for Disease Control recommendations on screening, diagnostic testing, and treatment of STIs. This review covers common, as well as and less common or emerging STIs, and discusses the state-of-the-art guidance on testing paradigms, extragenital sampling, and antimicrobial treatment and prevention of STIs.

Use of Expedited Partner Therapy for Pregnant Women Treated for Sexually Transmitted Infections in Gaborone, Botswana

BACKGROUND

Partner notification and treatment for sexually transmitted infections are critical to prevent reinfection and reduce transmission. However, partner treatment rates are low globally. Expedited partner therapy (EPT), in which the patient delivers treatment directly to their partner, may result in more partners treated. We assessed partner notification and treatment outcomes among pregnant women in Gaborone, Botswana, including EPT intent, uptake, and effectiveness.

METHODS

The Maduo study was a cluster-controlled trial evaluating the effect of antenatal Chlamydia trachomatis and Neisseria gonorrhoeae infection screening in pregnant women. The intervention arm received screening at first antenatal care (ANC), third-trimester, and postnatal care visits. The standard-of-care arm received screening postnatally. Participants screening positive were given options for partner treatment: contact slips, in-clinic treatment, or EPT. Self-reported partner notification and treatment outcomes were assessed at test-of-cure visit.

RESULTS

Of 51 women who screened positive for C. trachomatis / N. gonorrhoeae at first ANC and returned for test of cure, 100% reported notifying their partner and 48 (94.1%) reported their partner received treatment. At third trimester 100% (n = 5), reported partners were treated. Before testing, EPT intent was lower than EPT uptake at all time points (first ANC: 17.9% vs. 80.4%; third-trimester: 57.1% vs. 71.4%; postnatal care: 0% vs. 80.0%). Partner treatment success was 100% among EPT users compared with 70% among nonusers ( P = 0.006).

CONCLUSIONS

Partner notification and treatment success was high in this population. Despite low pretest intent to use EPT, uptake was high and associated with greater partner treatment success. Our findings suggest that EPT may be a successful partner treatment strategy to pursue in low- and middle-income countries.

Detection of High-Risk Human Papillomavirus Genotypes Among HIV-Infected Women in Four States in Nigeria

Introduction The World Health Organization states that almost all cervical cancer cases are linked to infection with high-risk human papillomaviruses transmitted through sexual contact. Implementing effective surveillance and preventive measures would enable the prevention of most cervical cancer cases, especially in HIV-infected women. Every year, about 12,000 women in Nigeria are diagnosed, with almost 8,000 deaths. HPV cervical cancer testing capacity is low in Nigeria. Testing scale-up and sensitization efforts across health facilities, including cervical tissue sample collection, are needed to reduce the cases of cervical cancer. This study aimed to assess the genotype-specific prevalence of clinically relevant high-risk HPV among women living with HIV in Nigeria. Methods A descriptive, cross-sectional study was conducted among adult HIV-infected women attending health facilities in four Nigerian states. From August to October 2022, cervical tissue was collected into PCR cell media, transported to the Nigerian Institute of Medical Research, and assayed for HPV presence and genotype using the Cobas 6800 System (Roche Diagnostics). Statistical analysis was conducted with Stata 2. Results A total of 4423 cervical swab samples were tested. The ages of women ranged from 18 to 72 years (mean 36.61±8.61). In our study, we found that 16.3% of participants tested positive for HPV. Among the high-risk HPV genotypes detected, HPV16 was present in 1.44% of participants, HPV18 in 1.29%, and other high-risk HPV (OHR-HPV) in 11.35%. Additionally, co-infections were observed, with 0.98% of participants testing positive for both HPV16 and OHR-HPV, 1.12% for HPV18 and OHR-HPV, and 0.12% for HPV16, HPV18, and OHR-HPV concurrently. However, 7.4% of the total results were deemed invalid. Conclusion OHR-HPV is prevalent among HIV-infected women across the north and west geopolitical zones of Nigeria. Policies and interventions geared towards curtailing the incidence of cervical cancer are fervently solicited.

A Narrative Review on Spontaneous Clearance of Urogenital Chlamydia trachomatis: Host, Microbiome, and Pathogen-Related Factors

ABSTRACT

Chlamydia trachomatis (CT) is the most commonly reported sexually transmitted infection in the United States. Untreated urogenital infection in women can result in adverse sequelae such as pelvic inflammatory disease and infertility. Despite national screening and treatment guidelines, rates continue to rise; because most infections are asymptomatic, the actual prevalence of CT infection is likely significantly higher than reported. Spontaneous clearance of CT in women (in the absence of antibiotic treatment) has been described in multiple epidemiologic studies. Given the serious consequences and high prevalence of CT infection, there is growing interest in understanding this phenomenon and factors that may promote CT clearance in women. Spontaneous CT clearance is likely the result of complex interactions between CT, the host immune system, and the vaginal microbiota (i.e., the communities of bacteria inhabiting the vagina), which has been implicated in CT acquisition. Herein, we briefly review current literature regarding the role of each of these factors in spontaneous CT clearance, identify knowledge gaps, and discuss future directions and possible implications for the development of novel interventions that may protect against CT infection, facilitate clearance, and prevent reproductive sequelae.

Expedited Partner Therapy: A Multicomponent Initiative to Boost Provider Counseling

BACKGROUND

Expedited partner therapy prescription remains low and highly variable throughout the United States, leading to frequent reinfections with Chlamydia trachomatis and Neisseria gonorrhoeae . We examined provider counseling on expedited partner therapy before and after an electronic smart tool-based initiative.

METHODS

In this quasi-experimental interrupted time-series study, we implemented an initiative of electronic smart tools and education for expedited partner therapy in March 2020. We reviewed the records of patients with chlamydia and/or gonorrhea at an urban, academic obstetrics and gynecology clinic in the preimplementation (March 2019-February 2020) and postimplementation (March 2020-February 2021) groups. Descriptive statistics and an interrupted time-series model were used to compare the percent of expedited partner therapy offered by clinicians to patients in each group.

RESULTS

A total of 287 patient encounters were analyzed, 155 preintervention and 132 postintervention. An increase in expedited partner therapy counseling of 13% (95% confidence interval [CI], 2%-24%) was observed before the intervention (27.1% [42 of 155]) versus after the intervention (40.2% [53 of 132]). Significant increases in provider counseling were seen for patients who were single (15%; 95% CI, 3%-26%), 25 years or older (21%; 95% CI, 6%-37%), receiving public insurance (15%; 95% CI, 3%-27%), seen by a registered nurse (18%; 95% CI, 4%-32%), or seen for an obstetrics indication (21%; 95% CI, 4%-39%). No difference was seen in patients' acceptance of expedited partner therapy ( P = 1.00).

CONCLUSIONS

A multicomponent initiative focused on electronic smart tools is effective at increasing provider counseling on expedited partner therapy. Further research to understand patient perceptions and acceptance of expedited partner therapy is critical.

Sexually Transmitted Infections and the Risk of Reinfection Within 12 Months: A Population-Based Cohort

BACKGROUND

Chlamydia, gonorrhea, and syphilis are common sexually transmitted infections that disproportionately affect specific groups in New Zealand (NZ). Predictors of reinfection are not well studied in NZ but could inform public health strategies to decrease sexually transmitted infection (STI) incidence.

METHODS

New Zealand-wide chlamydia, gonorrhea, and syphilis cases during 2019 were identified using nationally collected data. Cases were followed-up to identify reinfection with the same STI within 12 months of initial infections. Logistic regression models were used to identify predictors for each STI reinfection.

RESULTS

Determinants identified for increased odds of chlamydia reinfection were age groups 16-19 and 20-24 years, females, Māori and Pacific peoples, cases in the Northern region, and cases with at least one test before the initial infection. Age 40 years and older was associated with lower odds of gonorrhea reinfection, as was being of Asian ethnicity, living in Midland or Southern regions, and reporting heterosexual behavior. Region was the only statistically significant predictor for syphilis reinfection, with higher odds of reinfection for people living in the Central region.

CONCLUSIONS

Our findings reflect disproportionate STI rates for some groups in NZ, with younger age groups, Māori and Pacific peoples, men who have sex with men, and people living in the Northern region experiencing higher odds of reinfection. Groups identified with higher odds for reinfection require increased access to culturally responsive health services to treat, understand, and prevent possible reinfection. Changes to current public health strategies could include culturally specific behavioral counseling, and improvements to and adherence to effective contract tracing.

HLA-DQB1*06 and Select Neighboring HLA Variants Predict Chlamydia Reinfection Risk

Associations of HLA class II alleles with genital chlamydial infection outcomes have been reported, especially HLA DQB1*06. However, the potential role of DQB1*06 in influencing reinfection risk has still not been established. The purpose of this study was to determine whether the association of DQB1*06 with chlamydia reinfection was impacted by any other nearby HLA class II variants that were also associated with reinfection. We used next-generation sequencing to map HLA class II variants spanning the HLA-DQ and -DR loci. DQB1*06 as well as DQB1*04 were confirmed as significant predictors of chlamydia reinfection, when controlling for age and percent African ancestry. SKAT analysis revealed one region each in DRB1, DRB5, DQA2, and three intergenic regions that had variants associated with reinfection. Further analyses of these variants revealed that rs112651494 within DRB5 and an intergenic SNP rs617058 in DRB1:DQA1 were significantly associated with reinfection, but this did not impact the significance of the association of DQB1*06 or DQB1*04 with reinfection.

Alarming incidence of reinfections after treatment for Chlamydia trachomatis and gonorrhoea: Can we predict and prevent them?

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections are a public health problem, worsened by frequent reinfections, whose incidence rate is not known in Spain. The objective of this study is to estimate in patients diagnosed with NG, CT or mixed infection (NG and CT): (1) the incidence of reinfections by the same microorganism, (2) the total incidence of Sexually Transmitted Infections (STI), both by the same microorganism and by infections other than the initial one, and (3) to identify predictors of reinfection.

METHODS

Observational prospective case series involving 986 patients with CT and/or NG at specialized STI clinics in Biscay (Spain) between 2016 and 2019.

RESULTS

The six month cumulative incidence of reinfection by the same microorganism was 17.24% (CI95%: 14.9-19.7) and 24.65% (CI95%: 21.9-27.4) for any STI (reinfection or other). Being an immigrant (OR=1.8; CI95%: 1.3-2.6), men who have sex with men (OR=1.8; CI95%: 1.3-2.6), number of sexual partners (OR=4.3; CI95%: 2.7-6.8 for more than 5 partners), having a new partner (OR=1.7; CI95%: 1.08-2.6), not always using a condom (OR=1.4; CI95%: 1.02-1.9) and consumption of alcohol prior to sex (OR=3.8; CI95%: 1.5-9.5) were associated with reinfection by any STI.

CONCLUSION

These characteristics allow doctors to identify patients in whom to prioritize short-term rescreening for repeated infections with any STIs after initial treatment for NG or CT.

Trends in Follow-up Testing Among Patients Positive for Chlamydia and Gonorrhea in the Veterans Health Administration, 2013 to 2019

BACKGROUND

The Centers for Disease Control and Prevention (CDC) recommends testing patients with chlamydia (CT)/gonorrhea (GC) for other sexually transmitted infections (STIs) and repeating CT/GC testing 3 to 12 months later. We assessed repeat CT/GC testing and testing for HIV/syphilis in accordance with CDC guidelines in the US Veterans Health Administration.

METHODS

Molecular laboratory testing for CT/GC during January 1, 2013-December 31, 2020 was retrieved from Veterans Health Administration data sources. Patients were evaluated for syphilis, HIV, and repeat CT/GC testing within 1 year after a positive CT/GC test result. Differences of CT/GC-positive patients associated with receiving recommended testing were assessed using χ2 /Fisher exact tests.

RESULTS

A total of 41,630 of 1,005,761 CT (4.1%) and 17,649 of 1,013,198 GC (1.7%) results were positive. Median ages of positive CT/GC patients were 29 and 36 years, respectively. Repeat testing rates for CT/GC within 90 to 119 days were 3.9% and 2.9%, and rates within 90 to 365 days were 32.8% and 34.7%, with 8.6% and 15% being positive again, respectively. Guideline-compatible repeat testing in known HIV-positive patients nearly doubled (75.7% for CT and 67.8% for GC). The CDC-recommended HIV testing was performed for 72.4% and 65.5% CT and GC first positives, respectively, whereas syphilis testing was completed for 66.5% and 60.5% CT and GC, respectively. Compared with 25- to 34-year-old patients with CT or GC, those younger than 25 years had higher odds of guideline-discordant repeat testing but had lower odds of not receiving HIV/syphilis testing.

CONCLUSIONS

Nearly two-thirds of patients did not receive recommended repeat testing, and nearly one-third were not tested for HIV/syphilis. Veterans Health Administration providers may benefit from additional education on CDC-recommended sexually transmitted infection guidelines and testing recommendations.

Effects of azithromycin and doxycycline on the vaginal microbiota of women with urogenital Chlamydia trachomatis infection: a substudy of the Chlazidoxy randomized controlled trial

OBJECTIVES

Dysbiotic bacterial communities within the vagina are associated with Chlamydia trachomatis infection. We compared the effect of treatment with azithromycin and doxycycline on the vaginal microbiota in a cohort of women with a urogenital C. trachomatis infection randomly assigned to one of these treatments (Chlazidoxy trial).

METHODS

We analysed vaginal samples from 284 women (135 in the azithromycin group and 149 in the doxycycline group) collected at baseline and 6 weeks after treatment initiation. The vaginal microbiota was characterized using 16S rRNA gene sequencing and classified into community state types (CSTs).

RESULTS

At baseline, 75% (212/284) of the women had a high-risk microbiota (CST-III or CST-IV). A cross-sectional comparison 6 weeks after treatment showed that 15 phylotypes were differentially abundant, but this difference was not reflected at the CST (p=0.772) or diversity level (p=0.339). Between baseline and the 6-week visit, α-diversity (p=0.140) and transition probabilities between CSTs were not significantly different between the groups, and no phylotype was differentially abundant.

CONCLUSION

In women with urogenital C. trachomatis infection, the vaginal microbiota does not seem to be affected by azithromycin or doxycycline 6 weeks after treatment. Because the vaginal microbiota remains susceptible to C. trachomatis infection (with CST-III or CST-IV) following antibiotic treatment, women remain at risk of reinfection, which could originate from unprotected sexual intercourse or untreated anorectal C. trachomatis infection. This last consideration advocates for the use of doxycycline instead of azithromycin because of its higher anorectal microbiological cure rate.

Determinants and prediction of Chlamydia trachomatis re-testing and re-infection within 1 year among heterosexuals with chlamydia attending a sexual health clinic

Background

Chlamydia trachomatis (chlamydia) is one of the most common sexually transmitted infections (STI) globally, and re-infections are common. Current Australian guidelines recommend re-testing for chlamydia 3 months after treatment to identify possible re-infection. Patient-delivered partner therapy (PDPT) has been proposed to control chlamydia re-infection among heterosexuals. We aimed to identify determinants and the prediction of chlamydia re-testing and re-infection within 1 year among heterosexuals with chlamydia to identify potential PDPT candidates.

Methods

Our baseline data included 5,806 heterosexuals with chlamydia aged ≥18 years and 2,070 re-tested for chlamydia within 1 year of their chlamydia diagnosis at the Melbourne Sexual Health Center from January 2, 2015, to May 15, 2020. We used routinely collected electronic health record (EHR) variables and machine-learning models to predict chlamydia re-testing and re-infection events. We also used logistic regression to investigate factors associated with chlamydia re-testing and re-infection.

Results

About 2,070 (36%) of 5,806 heterosexuals with chlamydia were re-tested for chlamydia within 1 year. Among those retested, 307 (15%) were re-infected. Multivariable logistic regression analysis showed that older age (≥35 years old), female, living with HIV, being a current sex worker, patient-delivered partner therapy users, and higher numbers of sex partners were associated with an increased chlamydia re-testing within 1 year. Multivariable logistic regression analysis also showed that younger age (18-24 years), male gender, and living with HIV were associated with an increased chlamydia re-infection within 1 year. The XGBoost model was the best model for predicting chlamydia re-testing and re-infection within 1 year among heterosexuals with chlamydia; however, machine learning approaches and these self-reported answers from clients did not provide a good predictive value (AUC < 60.0%).

Conclusion

The low rate of chlamydia re-testing and high rate of chlamydia re-infection among heterosexuals with chlamydia highlights the need for further interventions. Better targeting of individuals more likely to be re-infected is needed to optimize the provision of PDPT and encourage the test of re-infection at 3 months.

Behavioural intervention to reduce sexually transmitted infections in people aged 16–24 years in the UK: the safetxt RCT

Background

The prevalence of genital chlamydia and gonorrhoea is higher in the 16–24 years age group than those in other age group. With users, we developed the theory-based safetxt intervention to reduce sexually transmitted infections.

Objectives

To establish the effect of the safetxt intervention on the incidence of chlamydia/gonorrhoea infection at 1  year.

Design

A parallel-group, individual-level, randomised superiority trial in which care providers and outcome assessors were blinded to allocation.

Setting

Recruitment was from 92 UK sexual health clinics.

Participants

Inclusion criteria were a positive chlamydia or gonorrhoea test result, diagnosis of non-specific urethritis or treatment started for chlamydia/gonorrhoea/non-specific urethritis in the last 2 weeks; owning a personal mobile phone; and being aged 16–24 years.

Allocation

Remote computer-based randomisation with an automated link to the messaging system delivering intervention or control group messages.

Intervention

The safetxt intervention was designed to reduce sexually transmitted infection by increasing partner notification, condom use and sexually transmitted infection testing before sex with new partners. It employed educational, enabling and incentivising content delivered by 42–79 text messages over 1 year, tailored according to type of infection, gender and sexuality.

Comparator

A monthly message regarding trial participation.

Main outcomes

The primary outcome was the incidence of chlamydia and gonorrhoea infection at 12 months, assessed using nucleic acid amplification tests. Secondary outcomes at 1 and 12 months included self-reported partner notification, condom use and sexually transmitted infection testing prior to sex with new partner(s).

Results

Between 1 April 2016 and 23 November 2018, we assessed 20,476 people for eligibility and consented and randomised 6248 participants, allocating 3123 to the safetxt intervention and 3125 to the control. Primary outcome data were available for 4675 (74.8%) participants. The incidence of chlamydia/gonorrhoea infection was 22.2% (693/3123) in the intervention group and 20.3% (633/3125) in the control group (odds ratio 1.13, 95% confidence interval 0.98 to 1.31). There was no evidence of heterogeneity in any of the prespecified subgroups. Partner notification was 85.6% in the intervention group and 84.0% in the control group (odds ratio 1.14, 95% confidence interval 0.99 to 1.33). At 12 months, condom use at last sex was 33.8% in the intervention group and 31.2% in the control group (odds ratio 1.14, 95% confidence interval 1.01 to 1.28) and condom use at first sex with most recent new partner was 54.4% in the intervention group and 48.7% in the control group (odds ratio 1.27, 95% confidence interval 1.11 to 1.45). Testing before sex with a new partner was 39.5% in the intervention group and 40.9% in the control group (odds ratio 0.95, 95% confidence interval 0.82 to 1.10). Having two or more partners since joining the trial was 56.9% in the intervention group and 54.8% in the control group (odds ratio 1.11, 95% confidence interval 1.00 to 1.24) and having sex with someone new since joining the trial was 69.7% in the intervention group and 67.4% in the control group (odds ratio 1.13, 95% confidence interval 1.00 to 1.28). There were no differences in safety outcomes. Additional sensitivity and per-protocol analyses showed similar results.

Limitations

Our understanding of the mechanism of action for the unanticipated effects is limited.

Conclusions

The safetxt intervention did not reduce chlamydia and gonorrhoea infections, with slightly more infections in the intervention group. The intervention increased condom use but also increased the number of partners and new partners. Randomised controlled trials are essential for evaluating health communication interventions, which can have unanticipated effects.

Future work

Randomised controlled trials evaluating novel interventions in this complex area are needed.

Trial registration

This trial is registered as ISRCTN64390461.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 11, No. 1. See the NIHR Journals Library website for further project information.

Check your assumptions: Further scrutiny of basic model frameworks of antimicrobial resistance

Since the mid-1990s, growing concerns over antimicrobial resistant (AMR) organisms has led to an increase in the use of mathematical models to explore the inter-host transmission of such infections. Previous work reviewing such models categorised them into generic frameworks based on their underlying assumptions. These assumptions dictated the coexistence between AMR and antimicrobial sensitive strains. We add to this work performing stability analyses of the frameworks, along with simulating them deterministically and stochastically. Stability analyses found that many of these assumptions lead to models having the same equilibria, but showed differences in the equilibria's stability between models. Deterministic simulations reveal that assuming replacement of one infecting strain by another leads to an unusual antimicrobial treatment threshold. Increasing beyond this threshold causes a discontinuous increase in disease burden. The cost of AMR to pathogen fitness (lowered transmission) dictates both the threshold of treatment that causes the discontinuous increase in disease burden and the size of that increase. It was also shown that Superinfection states can be biased against resident strains and so favour coexistence of both strains. Stochastic simulations demonstrated that differing scenario starting conditions can guide models to converge upon equilibria that they may not have under deterministic simulation. These findings highlight the importance of checking assumptions when modelling AMR and strain competition more widely.

Adherence to chlamydia and gonorrhea follow up testing in a college population

Objectives: To examine differences in compliance to follow-up for STD based on demographic, clinical and academic characteristics. Methods: Cross-sectional study examining associations between clinical, demographic and academic variables and compliance to follow-up for STDs in a college population. Participants: Chart review data collected at University Health Services (UHS) UW- Madison, where 449 cases were reported in 2017. Results: Final model includes sex, sex of partners and its interaction. It shows no significant difference in follow-up for males compared to females or for students having partners of the same sex nor students having partners of the same and different sex. Finally, when interactions are introduced, males having partners of a different sex were significantly associated with less compliant follow-up (AOR: 10.36; 95% CI= 1.57- 68.35). Conclusions: The effect of the sexual partners in noncompliance differs by sex. Males with partners of a different sex were 10 times more likely to noncompliance to follow up than females with partners of a different sex.

Chlamydia Trachomatis/Neisseria Gonorrhea Retesting Among Adolescents and Young Adults in a Primary Care Network

PURPOSE

Chlamydia trachomatis/Neisseria gonorrhea (CT/NG) retesting three months after diagnosis is a guideline-recommended strategy to detect re-infections. Adolescents and young adults are priority populations in the U.S. Sexually Transmitted Infections National Strategic Plan, but there is a lack of research examining CT/NG retesting among these populations. This study describes retesting following CT/NG diagnosis among adolescent and young adult patients at Title X and non-Title X clinics and measures the association of patient-level factors with CT/NG retesting.

METHODS

We evaluated electronic medical records from 2014 to 2020 from an academic urban-suburban primary care network. The primary outcome was retesting, defined as a diagnostic test for CT or NG ordered 8-16 weeks after index diagnosis. Mixed effects logistic regression modeling stratified by Title X funding was conducted to evaluate the association of patient-level factors with CT/NT retesting.

RESULTS

Overall, 23.5% (n = 731) of patients were retested within 8-16 weeks following index CT/NG diagnosis. A significantly greater proportion of Title X patients were retested compared to non-Title X patients. Males were significantly less likely to be retested compared to females, and the proportion of patients retested decreased significantly over the study period.

DISCUSSION

Guideline-recommended retesting following CT/NG diagnosis was low in this young primary care cohort, especially among male and non-Title X clinic patients. Decreases in CT/NG retesting over the study period may be contributing to worsening of the STI epidemic. Our results provide insights into CT/NG retesting that can inform efforts to end the STI epidemic.

New insights into Chlamydia pathogenesis: Role of leukemia inhibitory factor

Chlamydia trachomatis (Ct) is the leading cause of bacterial sexually transmitted infections worldwide. Since the symptoms of Ct infection are often subtle or absent, most people are unaware of their infection until they are tested or develop severe complications such as infertility. It is believed that the primary culprit of Ct-associated tissue damage is unresolved chronic inflammation, resulting in aberrant production of cytokines, chemokines, and growth factors, as well as dysregulated tissue influx of innate and adaptive immune cells. A member of the IL-6 cytokine family, leukemia inhibitory factor (LIF), is one of the cytokines induced by Ct infection but its role in Ct pathogenesis is unclear. In this article, we review the biology of LIF and LIF receptor (LIFR)-mediated signaling pathways, summarize the physiological role of LIF in the reproductive system, and discuss the impact of LIF in chronic inflammatory conditions and its implication in Ct pathogenesis. Under normal circumstances, LIF is produced to maintain epithelial homeostasis and tissue repair, including the aftermath of Ct infection. However, LIF/LIFR-mediated signaling – particularly prolonged strong signaling – can gradually transform the microenvironment of the fallopian tube by altering the fate of epithelial cells and the cellular composition of epithelium. This harmful transformation of epithelium may be a key process that leads to an enhanced risk of infertility, ectopic pregnancy and cancer following Ct infection.

Effectiveness of a behavioural intervention delivered by text messages (safetxt) on sexually transmitted reinfections in people aged 16-24 years: randomised controlled trial

OBJECTIVE

To quantify the effects of a series of text messages (safetxt) delivered in the community on incidence of chlamydia and gonorrhoea reinfection at one year in people aged 16-24 years.

DESIGN

Parallel group randomised controlled trial.

SETTING

92 sexual health clinics in the United Kingdom.

PARTICIPANTS

People aged 16-24 years with a diagnosis of, or treatment for, chlamydia, gonorrhoea, or non-specific urethritis in the past two weeks who owned a mobile phone.

INTERVENTIONS

3123 participants assigned to the safetxt intervention received a series of text messages to improve sex behaviours: four texts daily for days 1-3, one or two daily for days 4-28, two or three weekly for month 2, and 2-5 monthly for months 3-12. 3125 control participants received a monthly text message for one year asking for any change to postal or email address. It was hypothesised that safetxt would reduce the risk of chlamydia and gonorrhoea reinfection at one year by improving three key safer sex behaviours: partner notification at one month, condom use, and sexually transmitted infection testing before unprotected sex with a new partner. Care providers and outcome assessors were blind to allocation.

MAIN OUTCOME MEASURES

The primary outcome was the cumulative incidence of chlamydia or gonorrhoea reinfection at one year, assessed by nucleic acid amplification tests. Safety outcomes were self-reported road traffic incidents and partner violence. All analyses were by intention to treat.

RESULTS

6248 of 20 476 people assessed for eligibility between 1 April 2016 and 23 November 2018 were randomised. Primary outcome data were available for 4675/6248 (74.8%). At one year, the cumulative incidence of chlamydia or gonorrhoea reinfection was 22.2% (693/3123) in the safetxt arm versus 20.3% (633/3125) in the control arm (odds ratio 1.13, 95% confidence interval 0.98 to 1.31). The number needed to harm was 64 (95% confidence interval number needed to benefit 334 to ∞ to number needed to harm 24) The risk of road traffic incidents and partner violence was similar between the groups.

CONCLUSIONS

The safetxt intervention did not reduce chlamydia and gonorrhoea reinfections at one year in people aged 16-24 years. More reinfections occurred in the safetxt group. The results highlight the need for rigorous evaluation of health communication interventions.

TRIAL REGISTRATION

ISRCTN registry ISRCTN64390461.

Chlamydia trachomatis Infection and Seropositivity in Women Reporting Sexual Contact to a Chlamydia-Infected Partner

ABSTRACT

Among 73 women presenting to a sexually transmitted infection (STI) clinic in Birmingham, Alabama for reported sexual contact to a chlamydia-infected partner, Chlamydia trachomatis was detected in genital specimens in 24 (32.8%), less often in women reporting prior chlamydial infection ( P = 0.001). Most women (93.2%) were C. trachomatis seropositive.

Management of Neisseria gonorrhoeae in the United States: Summary of Evidence From the Development of the 2020 Gonorrhea Treatment Recommendations and the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infection Treatment Guidelines

INTRODUCTION

Neisseria gonorrhoeae has developed resistance to all first-line recommended therapies, making gonococcal antimicrobial resistance a major public health concern given limited antibiotic options currently and an even smaller antimicrobial development pipeline. Since the release of the Centers for Disease Control and Prevention (CDC) 2015 STD Treatment Guidelines, azithromycin, part of the 2015 dual-drug treatment regimen, has had a rapid rise in resistance. The 2020 CDC Gonorrhea Treatment Recommendations and the 2021 Sexually Transmitted Infections (STI) Treatment Guidelines were developed weighing the priorities of treating the individual, protecting the population, and preventing antimicrobial resistance.

METHODS

Gonorrhea subject matter experts (SME) generated 8 key questions and conducted a literature review of updated data from 2013 to 2019 on gonorrhea antimicrobial resistance, treatment failures, clinical trials, and other key topics. More than 2200 abstracts were assessed, and 248 clinically relevant articles were thoroughly reviewed. SMEs also evaluated N gonorrhoeae antimicrobial resistance data from the Gonococcal Isolate Surveillance Project (GISP).

EVIDENCE

Although there have been reports of ceftriaxone treatment failures internationally, GISP data suggest that ceftriaxone minimal inhibitory concentrations (MICs) have remained stable in the United States, with < 0.1% exhibiting an "alert value" MIC (> 0.25 mcg/mL). However, GISP documented a rapid rise in the proportion of isolates with an elevated MIC (≥ 2.0 mcg/mL) to azithromycin-nearly 5% in 2018. At the same time, new pharmacokinetic/pharmacodynamic data are available, and there is greater recognition of the need for antimicrobial stewardship.

SUMMARY

The 2021 CDC STI Treatment Guidelines now recommend 500mg ceftriaxone intramuscularly once for the treatment of uncomplicated gonorrhea at all anatomic sites. If coinfection with chlamydia has not been excluded, cotreatment with doxycycline 100mg twice daily for 7 days should be added. Few alternative therapies exist for persons with cephalosporin allergies; there are no recommended alternative therapies for N gonorrhoeae infection of the throat.

Patterns of sexual behaviour associated with repeated chlamydia testing and infection in men and women: a latent class analysis

BACKGROUND

Adolescents and young adults are at higher risk of acquiring Chlamydia trachomatis infection (chlamydia), so testing is promoted in these populations. Studies have shown that re-testing for chlamydia is common amongst them. We investigated how sexual risk behaviour profiles are associated with repeated testing for chlamydia.

METHODS

We used baseline data from a cohort of 2814 individuals recruited at an urban STI -clinic. We applied latent class (LC) analysis using 9 manifest variables on sexual behaviour and substance use self-reported by the study participants. We fitted ordered logistic regression to investigate the association of LC membership with the outcomes repeated testing during the past 12 months and lifetime repeated testing for chlamydia. Models were fit separately for men and women.

RESULTS

We identified four LCs for men and three LCs for women with increasing gradient of risky sexual behaviour. The two classes with the highest risk among men were associated with lifetime repeated testing for chlamydia: adjOR = 2.26 (95%CI: 1.50-3.40) and adjOR = 3.03 (95%CI: 1.93-4.74) as compared with the class with lowest risk. In women, the class with the highest risk was associated with increased odds of repeated lifetime testing (adjOR =1.85 (95%CI: 1.24-2.76)) and repeated testing during past 12 months (adjOR = 1.72 (95%CI: 1.16-2.54)). An association with chlamydia positive test at the time of the study and during the participant's lifetime was only found in the male highest risk classes.

CONCLUSION

Prevention messages with regard to testing for chlamydia after unprotected sexual contact with new/casual partners seem to reach individuals in highest risk behaviour classes who are more likely to test repeatedly. Further prevention efforts should involve potentially more tailored sex-specific interventions taking into consideration risk behaviour patterns.

Whole-genome sequencing of Chlamydia trachomatis isolates from persistently infected patients

BACKGROUND

Current understanding of the causes of treatment failure in Chlamydia trachomatis is poor and antimicrobial susceptibility data are lacking. We used genome sequencing to seek evidence of antimicrobial resistance in isolates sourced from patients who were persistently infected.

METHODS

Genomic DNA was extracted from C. trachomatis isolates cultured in McCoy cell monolayers. Sequencing libraries were prepared using the SureSelect^XT Illumina paired-end protocol. Paired reads were mapped against a reference genome and single nucleotide variants (SNVs) were identified.

RESULTS

Seven isolates from persistently infected patients and five isolates from successfully treated patients were sequenced. No previously reported SNVs associated with antimicrobial resistance were found. A unique SNV was identified in the gyrA gene of one treatment failure isolate but was located outside of the quinolone resistance determining region; this SNV has been previously reported in other members of the Chlamydiaceae family.

CONCLUSION

No genomic evidence was found to explain the differences in clinical outcome for our two groups of patients. A mutation unrelated to antimicrobial susceptibility was found in an isolate from a persistently infected patient. The cause of these persistent infections with C. trachomatis remains unclear.

Public health detailing to increase expedited partner therapy for chlamydia and gonorrhea in Maryland: Changes in awareness and implementation among prescribing community providers

The objective of this evaluation was to assess the use of public health detailing in a pilot program to increase Expedited Partner Therapy (EPT) uptake among community-based providers in two Maryland jurisdictions. Public health detailing is a method designed to raise awareness and increase implementation of evidence-based clinical practices by delivering educational content via one-on-one meetings with providers. EPT is a voluntary clinical practice of treating all sexual partners of patients diagnosed with STIs by prescribing medications without the provider first examining said sexual partners. The aim of EPT is to prevent STI reinfection and reduce further transmission. From April 2017 to March 2019, detailers visited community-based health care practice sites to conduct EPT detailing with providers. The effectiveness of this program was evaluated by comparing provider responses from pre- to post-detailing surveys, administered six months after detailing. Survey responses assessed EPT awareness and practices, barriers to implementation, and satisfaction with detailing. The proportion of providers (170) aware of EPT for treating chlamydia and gonorrhea increased from 61.7% (114) to 99.4% (169) (p-value < 0.001). The proportion who reported prescribing EPT increased from 63.2% (72) to 86.4% (146) (p-value < 0.001). Providers reporting no barriers to prescribing EPT increased from 30.6% (52) to 55.9% (95) (p-value < 0.001). Most providers were satisfied with detailing, 95.5% (164), and 95.3% (162) preferred this method to communicate about public health measures. Detailing appears to be a strategy to improve provider awareness of EPT, increase EPT implementation, and reduce barriers to prescribing EPT.

Impact of an Electronic Medical Record Best Practice Alert on Expedited Partner Therapy for Chlamydia Infection and Reinfection

Background

Atrius Health implemented a best practice alert (BPA) to encourage clinicians to provide expedited partner therapy (EPT) in October 2014. We assessed (1) the impact of the BPA on EPT provision and chlamydial reinfection and (2) the impact of EPT on testing for chlamydia reinfection and reinfection rates.

Methods

We included patients ≥15 years with ≥1 positive chlamydia test between January 2013 and March 2019. Tests-of-reinfection were defined as chlamydia tests 28–120 days after initial infection, and corresponding positive results were considered evidence of reinfection. We used interrupted time series analyses to identify changes in (1) frequency of EPT, (2) tests-of-reinfection, and (3) reinfections after the BPA was released. Log-binomial regression models, with generalized estimating equation methods, assessed associations between (1) EPT and tests-of-reinfection and (2) EPT and reinfection.

Results

Among 7267 chlamydia infections, EPT was given to 1475 (20%) patients. Expedited partner therapy frequency increased from 15% to 22% of infections between January 2013 and September 2014 (β = 0.003, P = .03). After the BPA was released, EPT frequency declined to 19% of infections by March 2019 (β = −0.004, P = .008). On average, 35% of chlamydia infections received a test-of-reinfection and 7% were reinfected; there were no significant changes in these percentages after BPA implementation. Patients given EPT were more likely to receive tests-of-reinfection (prevalence ratio [PR] 1.09; 95% confidence interval [CI], 1.01–1.16) but without change in reinfections (PR 0.88; 95% CI, 0.66–1.17).

Conclusions

Best practice alerts in electronic medical record systems may not be effective at increasing EPT prescribing and decreasing chlamydial reinfection. However, patients given EPT were more likely to receive a test of chlamydia reinfection.

Women's knowledge and hypothetical acceptance of expedited partner therapy for chlamydia

Background Expedited partner therapy (EPT) for chlamydia can be an important public health tool to treat the sex partners of newly diagnosed individuals, especially when those sex partners are women of reproductive ages. Untreated and repeat chlamydia infections increase a woman's risk for subfertility. This study aimed to determine the knowledge of EPT, and the factors associated with EPT knowledge, among reproductive-aged women. Methods Women aged 18-40 years were recruited for a community sample from a large state fair; 871 women completed a questionnaire for this study. Women reported on their knowledge of sexually transmitted infections, and about their knowledge and attitudes toward EPT. Using a hypothetical example, women were asked if they would accept EPT. Results This community sample of reproductive-aged women found overwhelming hypothetical support for chlamydia testing, partner notification, and partner treatment. However, only 12% of women reported having heard of EPT prior to the survey; once EPT was described, there were high levels of support for EPT and the belief that EPT could reduce chlamydia rates. Half of the women strongly agreed that EPT could reduce chlamydia rates, and 48% supported the state law allowing for EPT. Working in the healthcare field was the only independent determinant of prior EPT knowledge, increasing the odds of hearing about EPT by more than 2.5-fold. Conclusions Despite overwhelming support of the tenets of EPT, our results indicate that prior knowledge of EPT is low among women, meaning that education about EPT is needed for those outside of the healthcare field.

Cost-Effectiveness Analysis of Michigan's School-Wide Sexually Transmitted Disease Screening Program in Four Detroit High Schools

PURPOSE

The Michigan Department of Health and Human Services, in collaboration with St. John Providence Health System, initiated voluntary school-wide sexually transmitted disease (STD) screenings in four Detroit public high schools. We sought to assess the cost-effectiveness of the STD screening program from 2010 to 2015, with a focus on chlamydia.

METHODS

The costs and effectiveness of the school-based screening were compared with those of a "no school screening" scenario using a healthcare system perspective. A decision tree model was constructed to project cases of chlamydia, epididymitis, and pelvic inflammatory disease (PID) in each of the two scenarios among students tested positive and their partners. Health effects were measured as cases of PID prevented, and quality-adjusted life-years (QALYs) gained. Cost estimates included program costs, chlamydia testing/treatment costs in the absence of school screening, and treatment costs for epididymitis, PID, and PID sequelae. The incremental cost-effectiveness ratio (ICER) was measured as cost/QALY gained. Multivariate sensitivity analyses were conducted on key parameter estimates and assumptions used.

RESULTS

Under base-case assumptions, at a total program cost of $333,848 over 5 years, the program prevented an estimated 1.9 cases of epididymitis and 17.3 cases of PID, resulting in an ICER of $38,235/QALY gained (yearly ICER ranging from $27,417 to $50,945/QALY). Of 10,000 Monte Carlo simulation runs, the yearly ICER remained ≤$50,000/QALY in 64%-98% of the simulation runs.

CONCLUSIONS

We found favorable cost-effectiveness ratios for Michigan's school-wide STD screening program in Detroit. School-based STD screening programs of this type warrant careful considerations by policy makers and program planners.

Predicting the Probability of Chlamydia Reinfection in African American Women Using Immunologic and Genetic Determinants in a Bayesian Model

BACKGROUND

African Americans have the highest rates of Chlamydia trachomatis (CT) infection in the United States and also high reinfection rates. The primary objective of this study was to develop a Bayesian model to predict the probability of CT reinfection in African American women using immunogenetic data.

METHODS

We analyzed data from a cohort of CT-infected African American women enrolled at the time they returned to a clinic in Birmingham, AL, for the treatment of a positive routine CT test result. We modeled the probability of CT reinfection within 6 months after treatment using logistic regression in a Bayesian framework. Predictors of interest were presence or absence of an HLA-DQB1*06 allele and CT-specific CD4+ IFN-γ response, both of which we had previously reported were independently associated with CT reinfection risk.

RESULTS

Among 99 participants evaluated, the probability of reinfection for those with a CT-specific CD4+ IFN-γ response and no HLA-DQB1*06 alleles was 14.1% (95% credible interval [CI], 3.0%-45.0%), whereas the probability of reinfection for those without a CT-specific CD4+ IFN-γ response and at least one HLA-DQB1*06 allele was 61.5% (95% CI, 23.1%-89.7%).

CONCLUSIONS

Our model demonstrated that presence or absence of an HLA-DQB1*06 allele and CT-specific CD4+ IFN-γ response can have an impact on the predictive probability of CT reinfection in African American women.

Effect of Previous Adverse Reproductive Health Outcomes on Young Women's Engagement in a Health Coaching Intervention to Improve Contraceptive Continuation

STUDY OBJECTIVE

Nonadherence in sexual risk reduction interventions might be common among adolescents. We compared intervention completion rates among adolescent and young adult women with and without a previous pregnancy or sexually transmitted infection (STI) participating in a program to improve contraceptive continuation.

DESIGN

Secondary data analysis from a feasibility study of a health-coaching intervention to improve contraceptive continuation.

SETTING

Three urban pediatric clinics in Philadelphia.

PARTICIPANTS

Women ages 14-22 years who were English-speaking, sexually active in the past year, not desiring pregnancy in the next year, and starting a new contraceptive method.

INTERVENTIONS

At baseline, participants completed a sociodemographic questionnaire and semistructured interview, followed by 5 monthly coaching sessions. Interviews and coaching sessions were audio-recorded, transcribed, and coded for thematic content.

MAIN OUTCOME MEASURES

Intervention completion was defined as the number of completed coaching sessions. Secondary outcomes were qualitatively explored group differences in reproductive knowledge, attitudes, and risk perception.

RESULTS

Participants with a previous adverse outcome (a previous STI and/or a previous pregnancy) completed fewer coaching sessions than those without such history (median: 2 vs 4; P = .03). Both groups had low HIV/STI knowledge, negative attitudes toward pregnancy, and low HIV/STI risk perception. Those with a previous adverse reproductive outcome held more negative attitudes toward condoms.

CONCLUSION

Despite similar reproductive knowledge, attitudes, and risk perception, young women who have experienced an adverse reproductive outcome might be less likely to fully engage in sexual risk reduction interventions. Future studies should confirm these findings and consider strategies to optimize the intervention's reach for vulnerable youth.

Chlamydia and Gonorrhea

Gonorrhea and chlamydia rates have risen to record-high levels in the United States over the past decade. Because these infections are often asymptomatic, effective clinical management relies on screening of asymptomatic patients, particularly women younger than 25 years and men who have sex with men. If undetected and untreated, gonorrhea and chlamydia can lead to infertility, ectopic pregnancy, and chronic pelvic pain and can facilitate HIV acquisition and transmission. Primary care providers need to be aware of recent changes in recommended treatments for both infections.

A Pilot Evaluation of Expedited Partner Treatment and Partner Human Immunodeficiency Virus Self-Testing Among Adolescent Girls and Young Women Diagnosed With Chlamydia trachomatis and Neisseria gonorrhoeae in Kisumu, Kenya

BACKGROUND

Expedited partner treatment (EPT) is effective for preventing sexually transmitted infection recurrence, but concerns about intimate partner violence and missed opportunities for human immunology virus (HIV) testing have limited its use in African settings.

METHODS

We conducted a pilot prospective evaluation of EPT among adolescent girls and young women (AGYW) accessing HIV preexposure prophylaxis in an implementation project in Kisumu, Kenya. Those with etiologic diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae were treated and given the option of delivering sexually transmitted infection medication and HIV self-test kits to their current sexual partner(s). At enrollment, we assessed their reasons for declining. Three months after they delivered medication and kits to the partner(s), we assessed their reasons for failing to deliver medication and kits to their partner and reported partner's reactions.

RESULTS

Between September 2018 and March 2020, 63 AGYW were enrolled. The majority (59/63 [94%]) accepted EPT, and 50 (79%) of 63 partner HIV self-testing (HIVST). Three quarters (46/59) of those accepting EPT returned for the assessment visit with 41 (89%) of 46 successfully delivering medication to 54 partners, of whom 49 (91%) used it. Seventy percent (35/50) who took partner HIVST kits returned for the assessment, with 80% (28/35) reporting providing kits to 40 partners, of whom 38 (95%) used it. Reported barriers to EPT and partner HIVST uptake among women who declined included anticipated fear that their partner could become angry or violent and loss of relationship.

CONCLUSIONS

Both EPT and partner HIVST were acceptable despite noted barriers among Kenyan AGYW with etiologic diagnosis of Chlamydia trachomatis/Neisseria gonorrhoeae and their partners.

Effectiveness of Chlamydia trachomatis expedited partner therapy in pregnancy

BACKGROUND

Expedited partner therapy for Chlamydia trachomatis has had mixed efficacy in different populations, but limited data exist on the efficacy of the therapy in a pregnant population.

OBJECTIVE

This study aimed to evaluate the real-world effectiveness of establishing a prenatal expedited partner therapy program in eradicating chlamydia before delivery and to examine the maternal and neonatal outcomes between women who received expedited partner therapy for chlamydia and women who received standard partner referral testing and treatment during pregnancy.

STUDY DESIGN

An expedited partner therapy program was implemented on August 21, 2019, at a public hospital in a county with high chlamydia prevalence. Pregnant women were provided with single-dose packets of azithromycin to treat partners following a diagnosis of chlamydia infection. We prospectively observed pregnant women treated in the expedited partner therapy program who delivered at our institution in the same year and compared the outcomes with a historic cohort from the previous year that had traditional partner referral testing and treatment. We excluded women with concurrent gonorrhea, HIV, syphilis, or current intimate partner violence. The primary outcome was chlamydia reinfection or no-cure rates at repeat testing in 4 to 6 weeks following treatment or at the 36-week prenatal care screening. Secondary outcomes included obstetrical, maternal, and neonatal outcomes, including premature rupture of membranes, chorioamnionitis, endometritis, neonatal intensive care unit admission, neonatal sepsis, pneumonia, and conjunctivitis.

RESULTS

The rate of chlamydia infection was 3.6% over a 2-year period in our delivered population. In the year following the implementation of the expedited partner therapy, compared with 419 women (mean±standard deviation, 23.4±5.5 years) who were diagnosed with chlamydia infection in the previous year, 471 women (mean±standard deviation age, 23.8±5.3 years) who delivered at our institution were diagnosed with chlamydia infection. There was no difference in race, parity, prenatal care attendance, or concomitant sexually transmitted infections. Compared with the pre-expedited partner therapy group, the rate of reinfection in the post-expedited partner therapy group was not statistically different (60/471 [13%] vs 61/419 [15%]; odds ratio, 0.86 [95% confidence interval 0.58-1.26]). In a per-protocol analysis, 72 women (17%) in the pre-expedited partner therapy group and 389 women (83%) in post-expedited partner therapy group received expedited partner therapy; reinfection was not statistically different between groups (P=.47). There was no difference in secondary outcomes, although a trend toward improved rates of endometritis was noted in the post-expedited partner therapy group (odds ratio, 0.13; 95% confidence interval, 0.02-1.02).

CONCLUSION

The implementation of a prenatal expedited partner therapy program did not affect the rate of chlamydia reinfection before delivery. Treatment of chlamydia in an inner-city population has multiple factors that lead to successful treatment. Future efforts to reduce sexually transmitted infection and chlamydia reinfection rates in an at-risk population should include exploring patient education and safe sex practices beyond expedited partner therapy alone during pregnancy.

EVO100 prevents chlamydia and gonorrhea in women at high risk of infection

BACKGROUND

According to the Centers for Disease Control and Prevention, rates of infection for Chlamydia trachomatis and Neisseria gonorrhoeae are increasing in the United States. EVO100 is an investigational antimicrobial, pH-modulating, vaginal gel with active ingredients L-lactic acid, citric acid, and potassium bitartrate that is being evaluated for the prevention of sexually transmitted infections.

OBJECTIVE

The objective of this phase 2B/3 study was to assess the efficacy and safety of EVO100 for the prevention of chlamydia and gonorrhea.

STUDY DESIGN

AMPREVENCE was a double-blinded, placebo-controlled, multicenter study based in the United States conducted over approximately 16 weeks in women at the age of 18 to 45 years who were at risk of urogenital chlamydia and gonorrhea infection. Enrolled women had been diagnosed as having and treated for chlamydia or gonorrhea ≤16 weeks before enrollment. Women received either EVO100 or placebo vaginal gel and were instructed to apply the study drug immediately before or up to 1 hour before each act of vaginal sexual intercourse. The primary and secondary endpoints were the prevention of urogenital chlamydia and gonorrhea, respectively. Exploratory outcomes include women's overall satisfaction with EVO100.

RESULTS

In total, 860 women were randomized 1:1 to receive EVO100 (n=426) or placebo (n=434), and 764 women (EVO100, n=376; placebo, n=388) were documented as using the study drug at least once. Baseline characteristics were similar between treatment arms. Overall, women had a mean age of 27.7 years (standard deviation, 6.9) and body mass index of 28.9 kg/m² (standard deviation, 8.0). Most women were of White (54.3% [467 of 860]) or African American (41.6% [358 of 860]) race and of non-Hispanic/Latina ethnicity (67.1% [577 of 860]). The chlamydia infection rate in EVO100 users was 4.8% (14 of 289) compared with 9.7% (28 of 290) among placebo users (P=.0256), representing a relative risk reduction of 50%. For gonorrhea, the infection rate was 0.7% (2 of 280) in the EVO100 arm compared with 3.2% (9 of 277) in the placebo arm (P=.0316), representing a relative risk reduction of 78%. Increased efficacy was observed with increased adherence, and chlamydia infection rates were significantly reduced with increased adherence in the EVO100 group compared with placebo. Across both arms, there were similar rates of all-cause adverse events (EVO100, 21.3% [80 of 376]; placebo, 20.4% [79 of 388]) and treatment-related adverse events (EVO100, 7.2% [27 of 376]; placebo, 7.5% [29 of 388]). The most common adverse events in the EVO100 arm were vulvovaginal candidiasis (5.1% [19 of 376]), vaginal discharge (3.2% [12 of 376]), and urinary tract infection (3.2% [12 of 376]) and, in the placebo arm, bacterial vaginosis (4.6% [18 of 388]), urinary tract infection (2.6% [10 of 388]), and vaginal discharge (2.6% [10 of 388]). Few women discontinued owing to adverse events in either arm (EVO100, 1.1% [4 of 376]; placebo, 1.5% [6 of 388]). No treatment-related serious adverse events were reported. Most EVO100 users (88%) were satisfied or very satisfied with EVO100 after 16 weeks of use.

CONCLUSION

EVO100 significantly reduced the risk of chlamydia and gonorrhea infections in women at high risk of Chlamydia trachomatis and Neisseria gonorrhoeae infection and was well tolerated, with observed adverse events consistent with its known safety profile.

Prevalence of Chlamydia trachomatis Infection in Young Women and Associated Predictors

BACKGROUND

Chlamydia trachomatis (CT) infection remains highly prevalent, and young women are disproportionately affected. Most CT-infected women are asymptomatic, and their infection often goes unrecognized and untreated. We hypothesized that testing for active CT infection with molecular diagnostics and obtaining a reported history of CT infection underestimate the prevalence of current and past CT infection, and incorporating serum CT antibody testing in addition to these other prevalence measures would generate more accurate estimates of the prevalence of CT infection in asymptomatic young women.

METHODS

We enrolled 362 asymptomatic women aged 16 to 29 years at 4 different clinical settings in Birmingham, AL, between August 2016 and January 2020 and determined the prevalence of CT infection based on having 1 or more of the following prevalence measures: an active urogenital CT infection based on molecular testing, reported prior CT infection, and/or being CT seropositive. Multivariable regression analysis was used to determine predictors of the prevalence of CT infection after adjustment for participant characteristics.

RESULTS

The prevalence of CT infection was 67.7% (95% confidence interval, 62.6%-72.5%). Addition of CT antibody testing to the other individual prevalence measures more than doubled the CT infection prevalence. Non-Hispanic Black race, reported prior gonorrhea, and reported prior trichomoniasis predicted a higher prevalence of CT infection.

CONCLUSIONS

More than half of women were unaware of ever having CT infection, suggesting many were at risk for CT-associated reproductive complications. These data reinforce the need to adhere to chlamydia screening guidelines and to increase screening coverage in those at risk.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Who Is Practicing Expedited Partner Therapy and Why? Insights From Providers Working in Specialties With High Volumes of Sexually Transmitted Infections

BACKGROUND

Expedited partner therapy (EPT), the practice of prescribing antibiotics for sexual partners of patients, is underutilized in Georgia. This qualitative study in a large urban institution aimed to (1) characterize the clinical specialties that predominantly treat sexually transmitted infections (STIs), (2) identify perceived barriers to EPT, and (3) describe strategies to advance routine EPT use.

METHODS

Providers in obstetrics/gynecology (OB/GYN), infectious disease (ID), and emergency medicine (EM) were interviewed using a structured discussion guide. Transcripts were double-coded and iteratively analyzed using qualitative content analysis. Barriers and strategies were summarized and supported with quotes from providers (n = 23).

RESULTS

Perceived EPT barriers overlapped across OB/GYN, ID, and EM, yet the settings were diverse in their patient populations, resources, and concerns. Providers in OB/GYN were the only ones practicing EPT, yet there was a lack of standardization. Providers in ID noted that an EPT prescription from an ID provider could inadvertently disclose the HIV status of a patient to a sexual partner, posing an ethical dilemma. Providers in EM exhibited readiness for EPT, although routine empiric treatment for index patients in EM (estimated at 90%) gave some providers pause in prescribing for partners: "I do not know what I'm treating." Point-of-care testing could increase providers' confidence in prescribing EPT, yet some worried it could contribute to overutilization of the emergency department as a sexually transmitted infection clinic. All settings prioritized setting-specific training and protocols.

CONCLUSIONS

Providers in OB/GYN, ID, and EM report unique hurdles, specific to their settings and patient populations; tailored EPT implementation strategies, particularly provider training, are urgently needed to improve patient/partner outcomes.

Systematic Development of an Intervention to Promote Self-Sampling for HIV and Sexually Transmitted Infections for Men Who Have Sex With Men: An Intervention Mapping Approach

Sexual healthcare aims to reduce HIV and sexually transmitted infections (STIs) by promoting testing and prevention. To better reach men who have sex with men (MSM), additional strategies are needed. Here, we describe development of an intervention, which is part of a broader HIV/STI home-care program, targeted to reach MSM and motivate them to use self-sampling tests. Self-sampling includes blood sampling (finger prick) for HIV, hepatitis B, and syphilis, and a urine sample and oral and anorectal swab samples for chlamydia and gonorrhea. Intervention mapping, a systematic six-step approach, was used to guide the development process: (1) needs assessment including interviews with MSM, (2) create a matrix of change, (3) selection of theory-based methods and practical strategies, (4) intervention development, (5) implementation plan, and (6) evaluation (not included in this paper). Stakeholders were involved to increase program support and feasibility. The needs assessment revealed that testing barriers among MSM related to stigma, time, and privacy concerns. Barriers among healthcare providers related to time, competing priorities, lack of expertise, and guideline restrictions. Included intervention components are designed to overcome these barriers, e.g., engaging role models, with a website with a role model story, and providing tailored information. Methods to reach MSM were a variety of information channels (posters, flyers, and audio-visual displays) and delivery modes, such as advertisements on websites and invitational cards (online and paper) distributed by healthcare providers and MSM themselves (social network testing/peer testing). Our intervention aims to encourage MSM to engage in testing, re-testing, and providing a test to peer MSM. Evidence-based methods to overcome barriers were included to reach and motivate an increased number of MSM. Using intervention mapping stimulated systematic evidence-based decision making and adapting the intervention to the target audience and setting. The next step (step 6) is to implement and evaluate the intervention.

Evaluation of Text Message Reminders to Encourage Retesting for Chlamydia and Gonorrhea Among Female Patients at the Municipal Sexually Transmitted Disease Clinic in Seattle, Washington

BACKGROUND

United States guidelines recommend retesting for chlamydia (CT) and gonorrhea (GC) approximately 3 months after treatment, but adherence to these guidelines is poor.

METHODS

In May 2016, the municipal sexually transmitted disease (STD) Clinic in Seattle, WA, integrated opt-in short message system (SMS) (text message) retesting reminders for female patients into our clinic's routine electronic intake. Women were asked if they wanted to receive an SMS reminder for retesting for GC/CT in 3 months. We used Fisher exact tests to compare the proportion who returned to the clinic for retesting and the proportion who retested GC/CT positive 3 to 6 months after their initial diagnosis. We used sexually transmitted disease surveillance data to ascertain repeat GC/CT diagnoses.

RESULTS

From May 2016 to December 2017, 743 (36%) of 2067 women opted to receive an SMS reminder. Overall, 95 of these women tested positive for GC or CT and provided a valid phone number; 31 (33%) had opted into SMS reminders. The percentage of women who returned to the clinic 3 to 6 months after their initial GC/CT diagnosis did not significantly differ for women who did and did not opt in to receive SMS reminders (23% vs 9%; P = 0.11). Repeat GC/CT diagnosis 3 to 6 months after the initial GC/CT diagnosis was not significantly different between women who did and did not opt in (7% vs 3%; P = 0.58).

CONCLUSIONS

Uptake of automated SMS reminders among women was low, and most women who received reminders did not return for retesting. Despite this, SMS reminders integrated into an existing clinic infrastructure may somewhat increase retesting among women with GC/CT.

Do Prescriptions for Expedited Partner Therapy for Chlamydia Get Filled? Findings From a Multi-Jurisdictional Evaluation, United States, 2017-2019

BACKGROUND

Expedited partner therapy (EPT) is commonly provided by prescription; however, the efficacy of this modality is unknown. We examined whether EPT prescriptions are filled when the cost barrier is removed.

METHODS

To track EPT prescription fill rates, we used single-use pharmacy vouchers that covered the cost of azithromycin, 1 g (chlamydia treatment). We recruited clinical sites to distribute vouchers to patients with chlamydia who would receive an EPT prescription under clinic policies. When distributing vouchers, sites recorded and retained: voucher unique identifier, sex and age of index patient, distribution date, and whether partner name was written on the EPT prescription. Pharmacists receiving vouchers entered the identifier, sex and age of presenting person, and redemption date into a standard pharmacy claim transmission system. Data for redeemed vouchers were retrieved from an industry portal and linked with data retained at clinical sites.

RESULTS

Thirty-two clinical sites distributed 931 vouchers during September 2017 to January 2019; 382 (41%) were redeemed. Vouchers distributed to patients 18 years or younger (49 [30%] of 163) were less likely to be redeemed compared with those distributed to patients older than 18 years (322 [44%] of 736; P = 0.001). Just over half of vouchers were redeemed the same day (196 [56%] of 352) and 1 mile or less from the clinical site (188 [54%] of 349). After excluding an outlier site, vouchers accompanied by EPT prescriptions including a partner name (15 [56%] of 27) were more likely to be redeemed than those lacking a name (83 [34%] of 244; P = 0.03).

CONCLUSIONS

Less than half of EPT prescriptions were filled, even when medication was free. Whenever possible, EPT should be provided as drug-in-hand.

Facilitators and Barriers to Expedited Partner Therapy: Results From a Survey of Family Physicians

BACKGROUND

Expedited partner therapy (EPT) can prevent transmission of sexually transmitted infections (STIs) and reinfection of the index patient. We surveyed family physicians (FPs) in British Columbia to understand their perceptions of barriers and facilitators to EPT use and explored how perceptions varied by demographic and practice characteristics.

METHODS

Survey participants were recruited through the Divisions of Family Practice, which include greater than 90% of FPs in British Columbia. Common barriers and facilitators for EPT were identified using descriptive statistics. The association between each EPT barrier and facilitator and demographic and practice characteristics were tested using χ test.

RESULTS

One hundred eighty-one FPs started the survey, of which 146 (80.7%) answered 10 questions or more and were analyzed. Overall, inaccurate information about sex partners (88 [60.3%] of 146) and medicolegal concerns (87 [59.6%] of 146) were the most common barriers reported. Family physicians in nonurban settings were more likely to identify insufficient time as a barrier compared with FPs in urban settings (P < 0.01). The most common facilitators were having a health care professional for follow-up after prescribing EPT (110 [75.3%] of 146), improved remuneration (93 [63.7%] of 146), clear clinical guidelines around EPT (87/146, 59.6%), and having a legal framework (92 [63.0%] of 146). Family physicians practicing for less than 9 years (the median) were more likely to identify the latter as facilitating EPT compared with FPs practicing for 9 years or longer (P < 0.05).

CONCLUSIONS

Ensuring patients have access to a health care professional for follow-up, improved remuneration, and development of clinical guidelines and a legal framework can support the implementation of EPT. Tools catered to different practice types and contexts may help increase EPT use.

Screening for chlamydia and/or gonorrhea in primary health care: systematic reviews on effectiveness and patient preferences

BACKGROUND

We conducted systematic reviews on the benefits and harms of screening compared with no screening or alternative screening approaches for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in non-pregnant sexually active individuals, and on the relative importance patients' place on the relevant outcomes. Findings will inform recommendations by the Canadian Task Force on Preventive Health Care.

METHODS

We searched five databases (to January 24, 2020), trial registries, conference proceedings, and reference lists for English and French literature published since 1996. Screening, study selection, and risk of bias assessments were independently undertaken by two reviewers, with consensus for final decisions. Data extraction was conducted by one reviewer and checked by another for accuracy and completeness. Meta-analysis was conducted where appropriate. We used the GRADE approach to rate the certainty of the evidence. The Task Force and content experts provided input on determining thresholds for important effect sizes and on interpretation of findings.

RESULTS

Of 41 included studies, 17 and 11 reported on benefits and harms of screening, respectively, and 14 reported on patient preferences. Universal screening for CT in general populations 16 to 29 years of age, using population-based or opportunistic approaches achieving low screening rates, may make little-to-no difference for a female's risk of pelvic inflammatory disease (PID) (2 RCTs, n=141,362; 0.3 more in 1000 [7.6 fewer to 11 more]) or ectopic pregnancy (1 RCT, n=15,459; 0.20 more per 1000 [2.2 fewer to 3.9 more]). It may also not make a difference for CT transmission (3 RCTs, n=41,709; 3 fewer per 1000 [11.5 fewer to 6.9 more]). However, benefits may be achieved for reducing PID if screening rates are increased (2 trials, n=30,652; 5.7 fewer per 1000 [10.8 fewer to 1.1 more]), and for reducing CT and NG transmission when intensely screening high-prevalence female populations (2 trials, n=6127; 34.3 fewer per 1000 [4 to 58 fewer]; NNS 29 [17 to 250]). Evidence on infertility in females from CT screening and on transmission of NG in males and both sexes from screening for CT and NG is very uncertain. No evidence was found for cervicitis, chronic pelvic pain, or infertility in males from CT screening, or on any clinical outcomes from NG screening. Undergoing screening, or having a diagnosis of CT, may cause a small-to-moderate number of people to experience some degree of harm, mainly due to feelings of stigmatization and anxiety about future infertility risk. The number of individuals affected in the entire screening-eligible population is likely smaller. Screening may make little-to-no difference for general anxiety, self-esteem, or relationship break-up. Evidence on transmission from studies comparing home versus clinic screening is very uncertain. Four studies on patient preferences found that although utility values for the different consequences of CT and NG infections are probably quite similar, when considering the duration of the health state experiences, infertility and chronic pelvic pain are probably valued much more than PID, ectopic pregnancy, and cervicitis. How patients weigh the potential benefits versus harms of screening is very uncertain (1 survey, 10 qualitative studies); risks to reproductive health and transmission appear to be more important than the (often transient) psychosocial harms.

DISCUSSION

Most of the evidence on screening for CT and/or NG offers low or very low certainty about the benefits and harms. Indirectness from use of comparison groups receiving some screening, incomplete outcome ascertainment, and use of outreach settings was a major contributor to uncertainty. Patient preferences indicate that the potential benefits from screening appear to outweigh the possible harms. Direct evidence about which screening strategies and intervals to use, which age to start and stop screening, and whether screening males in addition to females is necessary to prevent clinical outcomes is scarce, and further research in these areas would be informative. Apart from the evidence in this review, information on factors related to equity, acceptability, implementation, cost/resources, and feasibility will support recommendations made by the Task Force.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42018100733 .

Men and Women Repeatedly Infected With Chlamydia trachomatis Have a Lower Urogenital Bacterial Load

We assessed whether patients repeatedly infected with Chlamydia trachomatis (CT) have a lower urogenital or anorectal CT load. A CT-positive retest was independently associated with higher vaginal and higher urine Cq values (P<0.01). Partial immunity could play a role in repeat urogenital infections, potentially not in anorectal infections.

T cell responses to Chlamydia

Chlamydia trachomatis is the most commonly reported sexually transmitted infection in the United States. The high prevalence of infection and lack of a vaccine indicate a critical knowledge gap surrounding the host's response to infection and how to effectively generate protective immunity. The immune response to C. trachomatis is complex, with cells of the adaptive immune system playing a crucial role in bacterial clearance. Here, we discuss the CD4+ and CD8+ T cell response to Chlamydia, the importance of antigen specificity and the role of memory T cells during the recall response. Ultimately, a deeper understanding of protective immune responses is necessary to develop a vaccine that prevents the inflammatory diseases associated with Chlamydia infection.

Gonorrhea and Chlamydia Rates Among 12- to 24-Year-Old Patients in an Urban Health System

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infection rates continue to rise. Screening guidelines have largely focused on sexually active female individuals and men who have sex with men populations. Health care system testing and infection rates, particularly among heterosexual male individuals, are poorly understood. Our aim was to evaluate CT and GC testing and prevalence among 12- to 24-year-old patients in an urban federally qualified health center system.

METHODS

This retrospective study analyzed electronic health record data from 2017 to 2019 in a large system of federally qualified health centers in Denver, CO. Abstracted data included demographics, sexual activity, sexual orientation, and laboratory results. χ2 Tests were used to evaluate differences between groups.

RESULTS

Of the 44,021 patients included, 37.6% were tested, 15.0% were positive for CT, and 3.4% were positive for GC. Heterosexual male patients had a testing rate of 22.8% and positivity rates of CT and GC at 13.1% and 3.0%, respectively. Among tested patients documented as not sexually active, 7.5% were positive for CT. Multiple or reinfections were detected in 29% of patients.

CONCLUSIONS

This study shows low testing rates and high rates of CT and GC infections among all patients, including heterosexual male patients and those documented as not sexually active. Improved screening of these populations in the primary care setting may be key to combating the sexually transmitted disease epidemic.

Nonviral sexually transmitted infections in pregnancy: current controversies and new challenges

PURPOSE OF REVIEW

This review provides an update of nonviral, curable sexually transmitted infections (STIs) in pregnancy and summarizes our understanding of the current issues and controversies surrounding risk factors, screening, and treatment of STIs in pregnancy primarily in high-income countries (using the United States and the United Kingdom as examples). The infections covered in this review are syphilis, gonorrhea, chlamydia, trichomoniasis, and Mycoplasma genitalium infections.

RECENT FINDINGS

Overall, limited modern data is available to update researchers and clinicians on the epidemiology and care of STIs in pregnancy. Though common risk factors can be identified among these STIs, like socioeconomic status and inadequate antenatal care, specific screening and treatment challenges vary by geography and pathogen. Wherever available, surveillance data and research evidence are often limited to nonpregnant patients, leading to imperfect pregnancy-specific risk estimates and obstetric lags in the development and adoption of new guidelines. We have identified three areas of opportunity that may enhance the effectiveness of current approaches and inform new ones: improved data collection and evidence-based screening practices; prompt and comprehensive therapy, including partner services, and evaluations of new treatment modalities; and equitable antenatal and sexual healthcare for all pregnant persons and their partners.

SUMMARY

These findings highlight the need to revisit standards of screening and management of STIs in pregnancy in high-income countries.