Isolation of Chlamydia from women attending a clinic for sexually transmitted disease

Chlamydia trachomatis and oral contraceptive use: a quantitative review

OBJECTIVES

Chlamydia trachomatis is now recognised as a major sexually transmitted disease; oral contraceptive use is rapidly increasing particularly in developing countries. There are thus important public health implications of the many reports that isolation of C trachomatis is more frequent among users of oral contraceptives. The aim of this analysis was to assess the strength and consistency of this association by summarising published studies between 1972 and 1990.

DESIGN

Studies identified were grouped according to whether they were prospective or case-control studies. Data were extracted and pooled estimates of the unadjusted odds ratios were made for all studies, as well as for sub-groups defined by an index of study quality, background prevalence of C trachomatis, and the contraceptive comparison being made.

LOCATION

Studies in the analysis were mainly conducted in Europe and North America; the meta-analysis was done at the Harvard School of Public Health, Boston, MA, USA.

RESULTS

The pooled estimated unadjusted odds ratio for 29 case-control studies examined was 1.93 (95% CI, 1.77-2.11), indicating an almost twofold increased risk of chlamydial infection for oral contraceptive users. Neither study quality nor prevalence of C trachomatis modified this risk. When compared to the use of barrier contraceptives, however, the risk of infection for women using oral contraceptives increased to 2.91 (95% CI, 1.86-4.55). The pooled estimated protective effect of barrier methods in these studies was 0.34 (95% CI, 0.22-0.54).

CONCLUSIONS

Cross-study comparisons of the relationship between oral contraceptive use and chlamydial infection are limited by the design and analysis of many component studies which did not control for confounding factors such as sexual behaviour and age. The almost twofold risk of increased chlamydial infection for oral contraceptive users, supported by the findings of two prospective studies, however, points to the importance of considering the risks and benefits of oral contraceptive use in women who are likely to be exposed to C trachomatis and other STDs. The protective effect of barrier methods emphasizes the continued need for promoting barrier methods of contraception.

Prostitution in Sheffield: differences between prostitutes

This study to assess differences between street walking prostitutes and sauna girls who attended this clinic in 1986 and 1987 showed that fewer street walkers used barrier methods for disease prevention with clients or accepted tests for antibody to human immunodeficiency virus (HIV) when offered and more street walkers practised their profession in both Sheffield and London. They therefore represent a potential pathway for the heterosexual spread of HIV to the region. Trichomonas vaginalis was the only organism more commonly isolated from street walkers. Other sexually transmitted diseases diagnosed, and the sources of acquisition of gonococcal cervicitis, were similar in both groups of prostitutes. Prostitutes rarely used barrier methods with their regular consorts, who were found to be responsible for most cases of gonorrhoea in both groups. As 11 out of 58 prostitutes attending were found to have dysplasia on routine cervical cytological examination, we suggest that all prostitutes be advised to undergo cytology yearly.

Clinical acute cholecystitis and the Curtis-Fitz-Hugh syndrome

When patients are admitted with clinically diagnosed acute cholecystitis, no cause will be found for their pain in 9-13% (4.5). Our retrospective study shows that women between 15-35 years are most likely to be in this group. Our prospective study of all patients in the 15-35 year age group admitted with clinical 'acute cholecystitis', showed that in 6 out of 7 patients with 'undiagnosed' pain, the Curtis-Fitz-Hugh syndrome was the cause. We suggest that screening for the Curtis-Fitz-Hugh syndrome is performed in all patients with right upper quadrant pain who have a normal ultrasound scan.

Prevalence of Chlamydia trachomatis and other micro-organisms in women seeking abortions in Pittsburgh, Pennsylvania, United States of America

The prevalence of Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, group B streptococcus, herpes simplex virus, and Neisseria gonorrhoeae from cervical cultures obtained from 210 women seeking abortion in Pittsburgh, Pennsylvania, United States of America was 9.3%, 72.9%, 25.2%, 4.3%, 0.9%, and 0.9% respectively. Cultures from 40/203 (19.7%) patients failed to produce any of these organisms. C trachomatis isolation was not associated with age, race, marital status, average family income, number of sexual partners, history of gonorrhoea or syphilis, or previous pregnancies, live births, or abortions, and 82.4% of women with chlamydial infections had had no urogenital symptoms in the preceding six months. The highest concentration of U urealyticum was 10(5) colour changing units (ccu)/ml, and about half of the positive ureaplasma cultures produced less than 10(3) ccu/ml of this organism. Screening for C trachomatis, is encouraged to prevent neonatal morbidity and the common complication of pelvic inflammatory disease after abortion.

Chlamydial cervicitis: a research study from general practice

Chlamydia trachomatis was isolated from the cervix in five out of 294 women at routine cervical cytology screening. Significant sera antibody titres were obtained from six out of 115 isolate-negative women similarly screened. The antibody response increased in proportion to the past frequency and severity of cervical pathology and sexually transmitted disease.It is suggested that the true incidence of chlamydial genital infection in general practice will be five times as high as the current cervical isolation rate.

Prevalence of chlamydial infection in promiscuous women

Chlamydia trachomatis was isolated from the cervix of 18 (33%) of 55 women who admitted to two or more casual sexual contacts to one (3%) of 32 women who admitted to one casual contact in the preceding month. The chlamydial infections did not produce characteristic clinical features. Since promiscuous women are at high risk of acquiring chlamydial infection, they should be regarded as a priority group when resources for chlamydial isolation are limited.

Chlamydial screening of pregnant women in a sexually transmitted diseases clinic

Fifty-three consecutive pregnant women seen over six months were screened for chlamydial infection, syphilis, gonorrhoea, trichomoniasis, and candidosis. Chlamydia trachomatis was isolated in 20 (37.7%) patients, of whom six were sexual partners of known cases of non-gonococcal urethritis (NGU) (two had associated gonorrhoea or candidosis) and six had gonorrhoea (three had associated trichomoniasis and candidosis). If treatment is given to contacts of NGU 14 patients with other presenting conditions would not have been treated unless chlamydial cultures had been performed. This may lead to potentially serious complications of chlamydial infection in both mothers and neonates.

Chlamydia trachomatis in women attending a gynaecological outpatient clinic with lower genital tract infection

In a study of 3794 consecutive women attending a gynaecological outpatient clinic with symptoms of lower genital tract infection (LGTI) 350 (9.2%) harboured Chlamydia trachomatis and 83 (2.2%) Neisseria gonorrhoeae. One hundred and ninety-five patients who were later found to have acute salpingitis and 109 other women in whom the chlamydial cultures were spoiled were excluded from the series. Of the remaining 3490 women, 281 were infected with C trachomatis, 42 with N gonorrhoeae, and 17 with both. Of the 3150 women who were infected with neither organism, 146 were randomly selected as controls. The chlamydia-positive patients were younger (P less than 0.001), did not complain of pelvic discomfort or pain (P less than 0.01), and used oral contraceptives (P less than 0.001) more frequently than did the controls; intrauterine devices were used more often (P less than 0.01) by the controls. Increased vaginal discharge was reported significantly more often in chlamydia-positive patients than in the controls (P less than 0.05). Of 266 women harbouring C trachomatis the organism was still present in 22 (8.3%) when they were followed up from two to more than eight weeks after finishing treatment with doxycycline. Of 91 male consorts of chlamydia-positive women, 53 (58.2%) were infected with C trachomatis.

Oral contraceptive use and prevalence of infection with Chlamydia trachomatis in women

One thousand eight non-pregnant women aged 16-34 years, presenting for the first time at a clinic for sexually transmitted diseases (STD), were examined and screened for infection with Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Candida species. The respective prevalence rates were 21.1%, 20.7%, 13.4%, and 27.8%. Isolation rates for C trachomatis, either occurring alone or in association with other genital infections, were significantly greater in women using oral contraceptive agents. This was not because oral contraceptive users were more promiscuous. The findings strengthen the case for providing a routine chlamydial culture service for women attending STD clinics. They also indicate that the likelihood of chlamydial infection in women taking oral contraceptives is increased.

Epidemiology of infection by serotypes D to K of chlamydia trachomatis

Non-specific urethritis (NSU) is a sexually transmitted disease; 50% of cases are due to Chlamydia trachomatis, so that this is the commonest sexually transmitted infection in the developed world. Chlamydial infection is now readily diagnosable and the evidence increasingly suggests that it is underdiagnosed. Chlamydial conjunctivitis (in the newborn baby or the adult) in the developed world is a complication of sexually transmitted genital infection by C trachomatis and it indicates a large reservoir of such infections. Because of the association of sexually transmitted diseases, systemic treatment for such chlamydial conjunctivitis should not be given until full genital and serological investigators have been carried out. Chlamydial infection causes serious complications (that were formerly often thought to be gonococcal), such as epididymitis in young men and salpingitis on young women. It may cause local complications in the eye of the newborn baby and even pneumonia in babies and fatal endocarditis in adults. The diagnosis of NSU should lead to the correct treatment of the male patient and of his sexual partners. It is the promiscuous woman, who does not have a regular sexual partner to report back to her that he has NSU, who is at particular risk of undiagnosed chlamydial infection. Routine genital investigations for chlamydia are particularly indicated in her case. Following the parallel of gonorrhoea, it seems that the use of contact tracers may be an effective method for controlling chlamydial infection.

Colonisation of pregnant and puerperal women and neonates with Chlamydia trachomatis

Chlamydia trachomatis was cultured from cervical specimens of 14 (16.1%) of 231 women applying for legal abortion and from 23 (8.7%) of 273 puerperal women. The chlamydial isolation rate was related to the women's age. Of the pregnant and puerperal women under 20 years C trachomatis was isolated in 10% and 24% respectively; in those aged between 20 and 24 years the rates were 8.7% and 10.2% respectively whereas in those over 24 years the rates were 4.2% in both groups. Chlamydia were isolated more frequently from cervical specimens than from urethral specimens. However, if a cervical specimen alone had been examined the diagnosis would have been missed in three (17%) of 18 women. IgG antichlamydial antibodies (titre greater than or equal to 1/32) were detected by a micro-immunofluorescence test in samples of cord blood from 35 (25%) of 139 infants of the puerperal women. Of the 23 infants born to mothers harbouring chlamydia in the cervix C trachomatis was isolated from the conjuntival folds in five (22.5%). The chlamydial isolation rate from the eyes of the neonates was related to the time of sampling. None of the 108 infants examined between 6 and 7 days old was chlamydia-positive whereas chlamydia could be recovered from the conjunctival folds of four of them when re-examined from three to 23 days later.

Value and feasibility of screening women attending STD clinics for cervical chlamydial infections

A chlamydial screening service was provided in Bristol over a three-month period for women attending the sexually transmitted disease (STD) clinic either for the first time or with a new complaint. Isolation of Chlamydia trachomatis was attempted in cytochalasin-treated McCoy cells. Of 919 specimens, valid results were obtained in 796. Chlamydial infections were identified and treated in 154 (19%) of these 796 women. Chlamydia were isolated from 52 (37%) of 152 female partners of men with nongonococcal urethritis (NGU); these patients already routinely receive treatment with tetracylcines in this clinic. The remaining 102 infections (34 (48%) of 71 women with gonorrhoea and 68 (12%) of the other 573 women) would have been unrecognised and usually untreated without chlamydial isolation studies. These figures confirm the need to provide chlamydial diagnostic services for selected STD clinic attenders.

The rôle of Chlamydia trachomatis in genital-tract and associated diseases

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Chlamydial infection of the cervix in contacts of men with nongonococcal urethritis

An investigation of chlamydial infection in sexual contacts of patients with nongonococcal urethritis (NGU) was carried out to determine the clinical signs of infection in the cervix, and their response to chemotherapy, and the incidence of cervical infection in the presence of ectopy and oral contraception. In 202 consecutive female contacts of NGU the isolation rate of Chlamydia trachomatis was 35%. Hypertrophic ectopy and endocervical mucopus were present in 19% and 37% of chlamydia-positive patients respectively and, in all but one, resolved after treatment. Only 14% of those followed up after treatment developed yeast infections. The chlamydial isolation rate was significantly higher in patients with hypertrophic ectopy and endocervical mucopus. Cervical ectopy and oral contraceptives acted additively, each producing a significant effect on the chlamydial isolation rate in the presence of the other but not when present alone.

Vaginal oxytetracycline concentrations

Although tetracycline preparations are widely used in departments of genitourinary medicine, or sexually transmitted diseases clinics, little is known of the concentrations of these preparations in genital secretions. For this reason a microbiological method was used for estimating oxytetracycline concentrations in vaginal secretions. These concentrations varied from 0.6 to 6.5 microgram/ml in 19 women who had had sexual contact with a man with non-specific urethritis and who were taking oxytetracycline dihydrate 250 mg four times daily. They were well in excess of the minimum inhibitory concentration of oxytetracycline (0.2 microgram/ml) for the strains of Chlamydia trachomatis isolated from the patients with positive culture results. Thus, oxytetracycline 250 mg four times daily appears to be a satisfactory regimen for the treatment of chlamydial genital infection in women.

The need for a chlamydial culture service

In a prospective study of unselected, female patients attending a sexually transmitted disease clinic one in eight patients would have been errouneously declared free of infection in the absence of a chlamydial culture service. Chlamydia trachomatis is now accepted as a causative organism of non-specific urethritis and post-gonococcal urethritis in men and non-specific genital infection in women. Thus, facilities for isolation of C. trachomatis should be an essential aid in the management of women attending STD clinics. Male patients would also benefit if such facilities were readily available.

Diagnostic, treatment, and reporting criteria for non-specific genital infection in sexually transmitted disease clinics in England and Wales. 1: Diagnosis

The current methods of diagnosis for non-specific genital infection (NSGI) in clinics in England and Wales are described. In most clinics (92%) microscopical findings were used by consultants to establish the diagnosis of non-specific urethritis (NSU) in male patients. However, the microscopical criteria that they used in reaching a diagnosis varied between clinics. The most commonly applied criterion was that of less than five leucocytes per high power field. NSGI in female patients and non-specific proctitis in passive homosexuals were recognised as distincy in 60% of clinics and the latter in 57%. Among those who recognised these conditions the diagnostic criteria varied. The establishment of acceptable and uniform criteria for diagnosis are discussed.

Rapid diagnosis of chlamydial infection of the cervix

A rapid serodiagnostic test for the presumptive diagnosis of chlamydial infection of the cervix has been developed. The method used in based on the modified micro-immunofluorescence test using pooled chlamydial antigens and the detection of different immunoglobulin classes of chlamydial antibody in sera and cervical secretions. The presence of IgG chlamydial antibody at a level of 1/64, or IgM antibody at a level of 1/8 or greater, or both in sera and IgG or IgA antibody at a level of 1/8 or more or both in cervical secretions was closely associated with the isolation of Chlamydia trachomatis and non-specific genital infection. In general, serodiagnosis was three to nine times more sensitive than cultural methods, and the detection of IgG chlamydial antibody in cervical secretions alone provided the most sensitive of the serological tests. This sensitive, low-cost, rapid, and simple serodiagnostic test for the presumptive diagnosis of chlamydial infection of the cervix, coupled with transportation of specimens by post, offers advantages over conventional isolation techniques for the routine diagnosis and management of chlamydial genital infections.

A microbiological study of neonatal conjunctivae and conjunctivitis

To investigate the importance of chlamydiae, ureaplasmas, Mycoplasma hominis, and anaerobic bacteria in the pathogenesis of neonatal conjunctivitis in the Harrow population conjunctival specimens from 104 infants with conjunctivitis and 104 similar healthy neonates were examined. The incidence of neonatal conjunctivitis was 8-2%, and no case of neomycin-resistant disease occurred during the study. Staphylococcus aureus, viridans Streptococci, and Escherichia coli were the only micro-organisms isolated significantly more frequently from affected than from control eyes, which suggests that these bacteria may be a cause of the conjunctivitis. All cultures for chlamydiae, M. hominis, Neisseria gonorrhoeae, and anaerobic bacteria were negative. The mother's race, social status, illness, and obstetric events were found to have no effect on the incidence, time of onset of conjunctivitis, or micro-organisms isolated. The clinical characteristics of conjunctivitis were also not related to the micro-organisms isolated. No potential pathogens were isolated from 63-5% of the eyes showing conjunctivitis. The results suggest that some of these cases may be caused by chemical irritation, and the possibility of an infectious aetiology is also discussed.

Chlamydial infection of the urogenital tract in promiscuous and non-promiscuous women

Chlamydia trachomatis infection of the urogenital tract of women presumed to be non-promiscuous, and in presumably promiscuous women attending a Special Clinic in Manchester was studied. Two hundred female members of hospital staff, who formed the non-promiscuous group, were found to have a 1% incidence of chlamydial infection. This compared with an incidence of 26% among 200 women attending the clinic. Among the clinic patients, chlamydial infection was significantly linked with the presence of gonorrhoea, mixed infections, and other sexually transmissible diseases--such as, trichomoniasis. No correlation could be made be made between the incidence of chlamydial infection and the use of oral contraceptives.

Triple tetracycline (Deteclo) in the treatment of chlamydial infection of the female genital tract

The efficacy of treating genital Chlamydia in women using Deteclo 300 mg twice daily for seven and 21 days has been studied. Forty-four patients were treated for seven days and 20 for 21 days. Seven days of treatment was as effective in eliminating Chlamydia trachomatis from the female genital tract as 21 days. The reproducibility of the technique of isolation of C. trachomatis was assessed by delaying treatment in 10 patients for up to 156 days and find C. trachomatis still present.

Isolation of Chlamydia trachomatis from the male urethra

Chlamydia trachomatis was isolated from 26% of urethral swabs taken from 509 men with urethritis. The highest yield of 68% was obtained from a selected group of men with nonspecific urethritis (NSU) who had a frank urethral discharge. This is a higher than in previous reports, and is significantly higher than the isolation of C. trachomatis from men with less severe urethritis. The higher yield was similar to C. trachomatis isolation rates reported among patients with severe trachoma in hyperendemic areas. Men with a previous history of NSU had low isolation rates. Overall, 30% of 385 men with NSU had positive chlamydial culture results, 7% of 59 men with gonococcal urethritis alone were Chlamydia-positive, 15% of 59 men with gonorrhoea followed by NSU (post-gonococcal urethritis) were Chlamydia-positive, and only 3% of 61 men without urethritis harboured Chlamydia. Swabs taken from the cervical os of 28 of 108 female contacts of men with NSU had a positive result for C. trachomatis. Significantly more pairs of sexual partners had the same chlamydial culture result than had different results. The chlamydial isolation rate was higher among men admitting a casual sexual contact than in men claiming only regular partnerships. The findings provide further evidence for the sexual transmission of C. trachomatis and for its aetiological role in NSU.

Significance of leucocytes in smears taken from the female urethral meatus

A prospective study of 86 women attending the clinic for the first time showed that nine patients had more than 10 leucocytes per highpower microscope field (HPF) in smears taken from the urethral meatus, even though six of them had micturated less than two hours before examination. Six of these patients had urethral gonorrhoea, one had trichomoniasis, and two were contacts of men with non-specific urethritis. It is concluded that women with more than 10 leucocytes per HPF of urethral secretion at their first visit and in whom a diagnosis has not been made, should strongly be urged to return for further assessment.

Isolation of Chlamydia trachomatis from women attending a clinic for sexually transmitted diseases

Attempts were made to isolate Chlamydia trachomatis from the cervix of 300 women attending a clinic for sexually transmitted diseases in Leeds. The women were divided into four groups; (1) 130 were consorts of men suffering from non-specific urethritis; (2) 66 were suffering from gonorrhoea, or were consorts of men suffering from this disease; (3) 56 were suffering from other sexually transmitted diseases; (4) 48 had no evidence of STD. The overall isolation rate of Chlamydia trachomatis was 20%. Positive results were obtained in 30%. of Group 1, in 27-3%. of Group 2, in 3-6%. of Group 3, and in 2-1%. of Group 4. No pathogenic sign or symptom of Chlamydia trachomatis infection of the cervix was detected.

Cervical cytology in genital infection

Papanicolaou-stained cervical smears taken from 203 female patients with either gonorrhoea, trichomoniasis, or candidosis were examined for the degree of inflammatory change. The results from these patients were compared with the results of smears taken from women who had no evidence of sexually-acquired infection after full assessment in the clinic. Gonorrhoea and trichomoniasis were associated with inflammatory changes but these were less marked in patients with candidosis. It is concluded that, before cytological inflammatory changes are attributed to non-specific genital infection, it is important to exclude gonorrhoea, trichomoniasis, and, to a lesser extent, candidosis.