Population prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in the Netherlands. Should asymptomatic persons be tested during population-based Chlamydia screening also for gonorrhoea or only if chlamydial infection is found?

Use of the mtrR Gene for Rapid Molecular Diagnosis of Neisseria gonorrhoeae and Identification of the Reduction of Susceptibility to Antibiotics in Endocervical Swabs

BACKGROUND

Neisseria gonorrhoeae is one of the main etiological agents of sexually transmitted diseases. The asymptomatic course of the infection and its resistance to antibiotics can lead to pelvic inflammatory disease and infertility.

OBJECTIVES

We developed a polymerase chain reaction (PCR) test using the methyltetrahydrofolate homocysteine methyltransferase reductase (mtrR) gene to identify N. gonorrhoeae and detect reduced susceptibility to antibiotics.

MATERIAL AND METHODS

We analysed 250 samples of endocervical exudate from infertile women with a negative diagnosis of N. gonorrhoeae. We designed NGmtr primers to detect N. gonorrhoeae and identify the antibiotic-resistant strain.

RESULTS

Of the 250 samples, 60 (24%) tested positive for N. gonorrhoeae using real-time PCR. Our study was validated using the HO primers and the Seeplex STD6 ACE System, with a 100% correlation. Furthermore, the NGmtr primers are specific for N. gonorrhoeae and not for other species. Additionally, the curves generated by real-time PCR differed between wild and variant strains (10.93%). The dissociation temperatures for the wild and variant strains were 86.5 and 89 °C, respectively.

CONCLUSIONS

The NGmtr primers enabled us to identify N. gonorrhoeae strains with or without reduction of susceptibility to antibiotics. Therefore, this work constitutes a tool that will facilitate the diagnosis of this infection for a low cost and improve patient quality of life.

High-risk human papillomavirus seroprevalence in men and women of six different ethnicities in Amsterdam, the Netherlands: The HELIUS study

Background

Ethnic variations in the (sero)prevalence of Human Papillomavirus (HPV) and HPV related diseases have been observed previously. We explored if high-risk HPV (hrHPV) seropositivity indeed differs among 6 ethnic groups in Amsterdam the Netherlands and assessed if hrHPV seroprevalence is higher among women than men within each ethnic group, both after adjustment for confounders.

Methods

From the multi-ethnic HEalthy Life In an Urban Setting (HELIUS) study in Amsterdam (the Netherlands) we randomly selected 4637 men and women aged 18–44 years with a Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Moroccan, or Turkish ethnicity. Blood samples were tested for HPV-16,−18,−31,−33,−45,−52, and −58 antibodies using a validated Luminex-based multiplex serology assay. We assessed the association of both ethnicity and gender with hrHPV seropositivity using logistic regression models with generalised estimating equations.

Results

The hrHPV seroprevalence in Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Moroccan, and Turkish participants was 18%, 12%, 23%, 19%, 17%, and 15% in men, and 30%, 22%, 34%, 31%, 14%, and 15% in women, respectively. HrHPV seroprevalence of non-Dutch men did not differ significantly from Dutch men. HrHPV seroprevalence was significantly higher among African Surinamese women, and significantly lower among Moroccan and Turkish women when compared to Dutch women. These differences were not significant anymore after adjustment for demographic, health, and sexual behavioural differences between ethnicities. HrHPV seroprevalence varied by age, age of sexual debut, and lifetime sexual partners among women but not among men. Seroprevalence of hrHPV was higher among women than among men, except in the Turkish group.

Conclusion

Among women hrHPV seroprevalence differed by ethnicity, yet among men no pronounced differences were observed across ethnicities.

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Women have a higher hrHPV seroprevalence than men, except in the Turkish group.

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Seroprevalence of hrHPV varies by ethnicity among women in Amsterdam.

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Among men no pronounced differences in hrHPV seroprevalence by ethnicity are observed.

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Differences by ethnicity in women are attributable to differences in sexual behaviour.

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HPV serology is not a useful indicator of sexual exposure among heterosexual men.

Coinfection of Chlamydiae and other Bacteria in Reactive Arthritis and Spondyloarthritis: Need for Future Research

Reactive (inflammatory) arthritis has been known for many years to follow genital infection with the intracellular bacterial pathogen Chlamydia trachomatis in some individuals. Recent studies from several groups have demonstrated that a related bacterium, the respiratory pathogen Chlamydia pneumoniae, can elicit a similar arthritis. Studies of these organisms, and of a set of gastrointestinal pathogens also associated with engendering inflammatory arthritis, have been relatively extensive. However, reports focusing on coinfections with these and/or other organisms, and the effects of such coinfections on the host immune and other systems, have been rare. In this article, we review the extant data regarding infections by multiple pathogens in the joint as they relate to engendering arthritis, and we suggest a number of research areas that must be given a high priority if we are to understand, and therefore to treat in an effective manner, such arthritides.

"Hidden" sexually transmitted infections among women in primary care health services, Amazonas, Brazil

This study describes the prevalence of infection by Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis in a female population in Amazonas, Brazil. We collected cervical samples from 361 women examined at 10 primary care health services in the city of Coari, Amazonas, Brazil. The women were interviewed about socio-economic data, clinical history and sexual behaviour. Pelvic examinations were performed and cervical specimens were collected for detection of pathogens by PCR. The prevalence of infection was: 12.7% for Trichomonas vaginalis, 6.4% for Chlamydia trachomatis and 1.4% for Neisseria gonorrhoeae. There were no statistically significant associations between infections by any of the pathogens nor by any pathogen alone with any clinical variable, socio-demographic data or sexual behaviour. This study draws attention to the need for surveillance and possible need for screening for Chlamydia trachomatis, which often progresses asymptomatically. For the significant prevalence found, attention should also be given to asymptomatic infection by Trichomonas vaginalis, since this pathogen has recently been implicated as a risk factor for HIV infection.

Higher Chlamydia trachomatis prevalence in ethnic minorities does not always reflect higher sexual risk behaviour

Background

In affluent countries, the prevalence of Chlamydia trachomatis (CT) is often higher in certain ethnic minorities than in the majority population. In the Netherlands, we examined why CT prevalence is higher in Surinamese/Antilleans, the largest minority in the country.

Methods

Heterosexuals were recruited for a cross-sectional survey from May through August 2010 at the sexually transmitted infections (STI) clinic in Amsterdam. Participants completed a questionnaire and were tested for STI. A causal directed acyclic graph was assumed to investigate whether the association between ethnicity and CT could be explained by differences in sexual risk behaviour and socio-economic status.

Results

Subjects included 1044 with Dutch background and 335 with Surinamese/Antillean background. Median age for the combined population was 25 (IQR 22-30) years, and 55.4% was female. Sexual risk behaviour did not differ significantly between the two groups. CT was diagnosed in 17.9% of Surinamese/Antilleans and in 11.4% of Dutch. Surinamese/Antilleans were significantly more likely to have CT (OR 1.70; 95% CI 1.21-2.38). The association between ethnicity and CT remained statistically significant after adjusting for sexual risk behaviour, age, sex, and ethnic mixing (aOR 1.48; 95% CI 1.00-2.18), but not after adjusting for education and neighbourhood, markers of socio-economic status (aOR 1.08; 95% CI 0.71-1.64).

Conclusion

The difference in CT prevalence between the minority and majority groups was not explained by differences in sexual risk behaviour. The higher CT prevalence found among Surinamese/Antilleans appeared to reflect their lower educational level and neighbourhood, two markers of lower socio-economic status. We hypothesise that the effect results from lower health-seeking behaviour.

Effects of population based screening for Chlamydia infections in the Netherlands limited by declining participation rates

Background

A large trial to investigate the effectiveness of population based screening for chlamydia infections was conducted in the Netherlands in 2008–2012. The trial was register based and consisted of four rounds of screening of women and men in the age groups 16–29 years in three regions in the Netherlands. Data were collected on participation rates and positivity rates per round. A modeling study was conducted to project screening effects for various screening strategies into the future.

Methods and Findings

We used a stochastic network simulation model incorporating partnership formation and dissolution, aging and a sexual life course perspective. Trends in baseline rates of chlamydia testing and treatment were used to describe the epidemiological situation before the start of the screening program. Data on participation rates was used to describe screening uptake in rural and urban areas. Simulations were used to project the effectiveness of screening on chlamydia prevalence for a time period of 10 years. In addition, we tested alternative screening strategies, such as including only women, targeting different age groups, and biennial screening. Screening reduced prevalence by about 1% in the first two screening rounds and leveled off after that. Extrapolating observed participation rates into the future indicated very low participation in the long run. Alternative strategies only marginally changed the effectiveness of screening. Higher participation rates as originally foreseen in the program would have succeeded in reducing chlamydia prevalence to very low levels in the long run.

Conclusions

Decreasing participation rates over time profoundly impact the effectiveness of population based screening for chlamydia infections. Using data from several consecutive rounds of screening in a simulation model enabled us to assess the future effectiveness of screening on prevalence. If participation rates cannot be kept at a sufficient level, the effectiveness of screening on prevalence will remain limited.

A case of fitz-hugh-curtis syndrome complicated by appendicitis conservatively treated with antibiotics

A 27-year-old woman developed a low grade fever and increased vaginal discharge that persisted for 2 weeks. Intermittent abdominal pain in the right upper quadrant had been experienced over the previous few days. Due to her clinical manifestations and typical abdominal computed tomography (CT) findings, including hepatic capsular enhancement and hepatomegaly, a diagnosis of Fitz-Hugh-Curtis syndrome was made. The early empirical use of antibiotics, azithromycin and levofloxacin, partially improved her symptoms. However, the low grade fever persisted and additional abdominal pain developed in the right lower quadrant. Based on the radiological evidence of an enlarged appendix with wall thickening, a diagnosis of appendicitis was additionally made, which was thought to occur secondarily to the genital tract infection. Following the administration of antibiotics ceftriaxone and cefditoren pivoxil, her symptoms were completely resolved without the need for any surgical intervention. Here, we report the first case of Fitz-Hugh-Curtis syndrome complicated by appendicitis, which was conservatively managed with antibiotic treatment alone. In this case, the overgrowth of pathogens within the genital tract and their direct penetration into the appendix was thought to be responsible for the development of appendicitis.

Chlamydia trachomatis infections of the female genital tract: state of the art

Chlamydia trachomatis (CT) is the most common bacterial cause of sexually transmitted infections. CT infections are strongly associated with risk-taking behavior. Recommendations for testing have been implemented in many countries. The effectiveness of the screening programs has been questioned since chlamydia rates have increased. However, the complication rates including pelvic inflammatory disease, tubal factor infertility, and tubal pregnancy have been decreasing, which is good news. The complication rates associated with CT infection have clearly been over-estimated. Genetic predisposition and host immune response play important roles in the pathogenesis of long-term complications. CT plays a co-factor role in the development of cervical neoplasia caused by high-risk human papillomavirus (HPV) types. The evidence linking CT and other adverse pregnancy outcomes is weak. The current nucleic acid amplification tests perform well. A new genetic variant of CT was discovered in Sweden but has only rarely been detected elsewhere. Single-dose azithromycin remains effective against CT. Secondary prevention by screening is still the most important intervention to limit the adverse effects of CT on reproductive health.

The first simultaneous study of the prevalence of Neisseria gonorrhoeae and Chlamydia trachomatis infections by polymerase chain reaction and standard methods

BACKGROUND

Neisseria gonorrhoeae and Chlamydia trachomatis are important sexually transmissible pathogens. The aim of the present study was to determine their prevalence in symptomatic and asymptomatic people.

METHODS

Polymerase chain reaction (PCR) and standard methods were tested for 413 specimens.

RESULTS

The registered prevalence with PCR was N. gonorrhoeae 2.66% and C. trachomatis 0.73%. One man showed co-infection. Standard methods demonstrated lower sensitivity in finding N. gonorrhoeae and C. trachomatis in comparison with the PCR.

CONCLUSIONS

This is the first simultaneous study in Bulgaria for detection of N. gonorrhoeae and C. trachomatis by PCR and standard methods. N. gonorrhoeae was found to be a more frequent infection. Further investigations are needed.

Risk of coinfection with Chlamydia trachomatis and Neisseria gonorrhoeae in Nova Scotia

BACKGROUND

The frequency of Chlamydia trachomatis and Neisseria gonorrhoeae coinfection can vary depending on their individual incidence and prevalence rates.

OBJECTIVE

To determine the frequency of C trachomatis and N gonorrhoeae coinfections by evaluating the results of testing in 2007 and 2008 to better inform testing and treatment decisions.

METHODS

Specimens from the same patient submitted on the same day served as the basis for the present study. The age, sex and the source of the specimen were also linked to the accession number. Infection and coinfection rates were analyzed in both males and females.

RESULTS

Concurrent testing was performed on 41,567 female specimens and 1827 male specimens, of which, 1495 female samples (3.6%) tested positive for C trachomatis infection and 88 (0.2%) tested positive for N gonorrhoeae infections. Only 31 females were coinfected; however, for those between 11 and 25 years of age, 25 of 61 females (40.1%) with N gonorrhoeae infection also tested positive for C trachomatis infection; conversely, 25 of 1248 females (2.0%) with C trachomatis infection also tested positive for N gonorrhoeae infection. For males, 213 (11.7%) tested positive for C trachomatis infection, and 59 (3.2%) tested positive for N gonorrhoeae infection. In 30 males with N gonorrhoeae between 11 and 25 years of age, and 149 males with C trachomatis, eight coinfections were observed (26.7% and 5.3%, respectively). Of those older than 25 years of age, only five of 905 men and six of 19,465 women were coinfected. None of the 10,935 women who were 30 years of age or older had coinfections.

CONCLUSION

The N gonorrhoeae coinfection rate in males with C trachomatis may justify empirical antimicrobials; however, in females, the proportion of coinfected may not justify empirical treatment for N gonorrhoeae infection when the C trachomatis test is positive and N gonorrhoeae testing has not been performed.

Aptima Combo 2 testing detected additional cases of Neisseria gonorrhoeae infection in men and women in community settings

Aptima Combo 2 (AC2) Neisseria gonorrhoeae testing of 81,405 patients who were tested by culture and 14,666 who were AC2 tested for Chlamydia trachomatis detected 142 extra infections and confirmed 106 culture-positive samples (the positivity rate increased from 0.13 in testing by culture to 0.26 in testing by AC2). Retrievable AC2 positive samples were confirmed (98.5%) by an alternate AGC test.

Risk of Chlamydia trachomatis infection during pregnancy: effectiveness of guidelines-based screening in identifying cases

Our goal was to define the risk factors for Chlamydia trachomatis (CT) infection among pregnant women at a large urban medical centre. In a retrospective study, clinical records at a US maternity unit from July 2005 through February 2008 were reviewed. The study population included all pregnant women with a singleton newborn of at least 20 weeks gestation and antenatal care information. Logistic regression was used to analyse the association between a positive CT test and demographic, behavioural and prenatal care variables. A total of 2127 women were included in this analysis. The prevalence of CT infection was 4.7%. Cases were more likely to be younger, black and single. Other risk factors included tobacco use and Neisseria gonorrhoeae infection. Our findings suggest that factors other than age may impact upon the diagnosis of CT in pregnant women and that a more comprehensive testing strategy should be considered.

Epidemiology of Chlamydia trachomatis infection in women and the cost-effectiveness of screening

BACKGROUND

The majority of Chlamydia trachomatis infections in women are asymptomatic, but may give rise to pelvic inflammatory disease (PID) and tubal infertility. Screening programmes aim at reducing morbidity in individuals by early detection and treatment, and at decreasing the overall prevalence of infection in the population. A number of modelling studies have tried to calculate the threshold prevalence of chlamydia lower genital tract infection above which screening becomes cost-effective. There is considerable debate over the exact complication rates after chlamydia infections, and more precise estimates of PID and tubal infertility are needed, for instance to be inserted in economic models.

METHODS

With reference to key studies and systematic reviews, an overview is provided focusing on the epidemiology of chlamydia infection and the risk-estimates of its late complications.

RESULTS

In the literature, the generally assumed risk of developing PID after lower genital tract chlamydia infection varies considerably, and is up to 30%. For developing tubal infertility after PID the risks are 10-20%. This implies that the risk of test-positive women of developing tubal infertility would range between 0.1 and 6%. We included chlamydia IgG antibody testing in a model and estimated a risk of tubal infertility up to 4.6%.

CONCLUSION

The risk of developing late complications after chlamydia lower genital tract infection appears low. High quality RCTs dealing with the transition from cervicitis to infertility are needed to broaden the evidence. In screening programmes, chlamydia antibody testing, as an intermediate marker for potential adverse sequelae, might enable more precise estimates.