Treatment Rates for Chlamydia trachomatis and Neisseria gonorrhoeae in a Metropolitan Area: Observational Cohort Analysis

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the 2 most common sexually transmitted infections (STIs) in the United States. The Centers for Disease Control and Prevention regularly publishes and updates STI Treatment Guidelines. The purpose of this study was to measure and compare treatment rates for CT and GC among public and private providers.

METHODS

Data from multiple sources, including electronic health records and Medicaid claims, were linked and integrated. Cases observed during 2016-2020 were defined based on positive laboratory results. We calculated descriptive statistics and odd ratios based on characteristics of providers and patients, stratifying by public versus private providers. Univariate logistic regression models were used to examine the factors associated with recommended treatment.

RESULTS

Overall, we found that 82.2% and 63.0% of initial CT and GC episodes, respectively, received Centers for Disease Control and Prevention-recommended treatment. The public STI clinic treated more than 90% of CT and GC cases consistently across the 5-year period. Private providers were significantly less likely to treat first episodes for CT (79.6%) and GC (53.3%; P < 0.01). Other factors associated with a higher likelihood of recommended treatment included being male, being HIV positive, and identifying as Black or multiracial. Among GC cases, 10.8% received nonrecommended treatment; all CT cases with treatment occurred per guidelines.

CONCLUSIONS

Although these treatment rates are higher than previous studies, there remain significant gaps in STI treatment that require intervention from public health.

Chlamydia trachomatis seroassays used in epidemiologic research: a narrative review and practical considerations

Chlamydia trachomatis (CT) is a sexually transmitted infection that can lead to adverse reproductive health outcomes. CT prevalence estimates are primarily derived from screening using nucleic acid amplification tests (NAATs). However, screening guidelines in the United States only include particular subpopulations, and NAATs only detect current infections. In contrast, seroassays identify past CT infections which are important for understanding the public health impacts of CT, including pelvic inflammatory disease and tubal factor infertility. Older seroassays have been plagued by low sensitivity and specificity and have not been validated using a consistent reference measure, making it challenging to compare studies, define the epidemiology of CT and determine the effectiveness of control programs. Newer seroassays have better performance characteristics. This narrative review summarizes the "state of the science" for CT seroassays that have been applied in epidemiologic studies and provides practical considerations for interpreting the literature and employing seroassays in future research.

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.

Analysis of Patient Adherence to Filling Emergency Department Discharge Prescriptions for Empiric Treatment of Chlamydia

PURPOSE

Sexually transmitted infections (STIs) represent an enormous public health burden in the United States. Emergency departments (EDs) are a significant source of medical care, particularly for vulnerable patient populations. Guidelines for the treatment of Chlamydia trachomatis have evolved and now recommend doxycycline 100 mg orally twice daily for 7 days as the primary regimen for adults. However, the single-dose azithromycin regimen can be given during the ED visit, while the new regimen has nonadherence hurdles. The purpose of this study will be determining the rate of ED discharge prescription pick ups of doxycycline for Chlamydia trachomatis infection at two discharge pharmacies.

METHODS

This is a retrospective chart review of information contained in the electronic medical record (EMR) from August 1st, 2021 - July 31st, 2022. Adult patients who present to the two EDs in the healthcare system and those who received empiric antibiotic treatment for Chlamydia trachomatis infection prior to, or at, ED discharge will be included. Patients who are pregnant, less than 18 years old, those without a Chlamydia trachomatis nucleic acid amplification test during their ED visit, or patients whose antibiotic treatment prescription was sent to a pharmacy other than the two primary discharge pharmacies at the respective medical centers will be excluded. The primary outcome of this study will be determining the rate of emergency department (ED) discharge prescription pick ups of doxycycline for empiric treatment of Chlamydia trachomatis infection at two discharge pharmacies. The secondary outcomes will include the incidence of repeat positive tests between four weeks and 90 days, risk of repeat positive tests in those who do not fill doxycycline, number of positive and negative test results, rate of prescribing adherence to 2021 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infections Treatment Guidelines regimens for empiric treatment, and insurance status at the time of discharge fill.

RESULTS

Seven hundred and thirty patients were pulled from the EMR. One hundred of the patients were excluded from the study as they did not receive empiric antibiotic treatment for Chlamydia trachomatis infection prior to, or at, ED discharge leaving 630 participants. Among this group, 369 patients were excluded as their discharge prescription was not sent to the discharge pharmacies within the medical system, leaving 261 individuals in the study. Per chart review, 215 of the patients picked up their doxycycline prescription (82.4%) and 46 (17.6%) patients failed to pick up their prescription. Additionally, 43 (16.5) of the patients who were prescribed empiric therapy had a positive chlamydia trachomatis test, while 209 (83.5%) of those had a negative test. This study also showed 188 (72%) patients received treatment according to the current CDC recommendations.

CONCLUSION

Majority of patients who received prescriptions from the in-hospital discharge pharmacy picked up their prescriptions.

Trichomoniasis and retesting in Durham County, North Carolina, United States, 2021 - 2022

BACKGROUND

The Centers for Disease Control and Prevention recommends universal retesting within 3 months after treatment of Trichomonas vaginalis infection given high rates of persistent infection or reinfection, or if this is not possible, within 12 months following treatment. Data is lacking on how often this is actually done.

METHODS

We analyzed the demographic and clinical characteristics, rate of return for the recommended retesting, concordance between wet prep and nucleic acid amplification testing, and percent positivity for T. vaginalis on repeat vaginal specimens at a local public health department in Durham, North Carolina, United States.

RESULTS

Of 193 females treated for trichomoniasis between March 1, 2021 - May 31, 2022, 83% were Black or African American and 44% between the ages of 20 and 29 years. Of these individuals, 32% had retesting performed within 3 months and 50% within 365 days after treatment. Females between the ages of 20 and 29 years were more likely to return for retesting than those between the ages of 30 and 39 years. Of those who returned for retesting, 10% were positive on repeat testing.

CONCLUSION

In this study, 50% of females diagnosed with trichomoniasis completed retesting within 365 days. Improved scheduling of clients at the time of trichomoniasis treatment and improved identification in our electronic health record of individuals diagnosed with trichomoniasis within the prior year would likely improve retesting rates. Given the high prevalence of trichomoniasis, expanded screening of asymptomatic females in settings where this is feasible may be warranted.

Results of a Community-Based Screening Program for Chlamydia trachomatis Genital Infection in Young People Aged 18-25 Years

Introduction and aim Chlamydia trachomatis (CT) cases have increased in the last decade. The aim of the study was to assess the prevalence of CT genital infection in asymptomatic, sexually active young people and determine whether a community screening program would be effective in reducing the number of cases. Methods A descriptive cross-sectional studyof consecutive inclusion of asymptomatic people aged 18-25 years between September 2021 and May 2022. Community interventions in high schools, universities, and cultural events were planned to realize the screening. Sociodemographic variables of gender, age, country of origin, and educational level, as well as sexual habits, were recorded for each patient. CT was detected via urine samples. An estimate of the prevalence of CT genital infection and its 95% confidence interval (CI) was made based on the exact binomial distribution, assuming that the sample is representative of the study population. Results A total of 628 subjects participated in the study, of whom 33 had a CT infection, giving a prevalence of 5.2% (95% CI: 3.6%, 7.3%). 93.9% of subjects with CT infection were female (p≤0.019) and 85% of the participants were Spanish nationals. Among vocational training students, the prevalence was 8.1%. Having had four or more sexual partners in the last month and in the previous year was significantly associated with CT infection (p<0.001). Conclusion Screening for CT genital infection in young sexually active women should be implemented in our country, as recommended by the various guidelines.

Preferences for Rectal Sexually Transmitted Infection Sample Collection and Sexual Behaviors Among Adolescent and Young Adult Women Accessing Primary Care Services

BACKGROUND

High prevalence of asymptomatic rectal chlamydia and gonorrhea among women is increasingly recognized. Screening is controversial because of lack of natural history data. Barriers to screening may include reluctance to discuss anal sex and collect rectal samples. This study describes the prevalence of sexual contact exposing adolescent and young adult women to extragenital sexually transmitted infections and acceptability of self-collection and clinician collection of rectal samples, preference for self- versus clinician-collected rectal samples, and preference for home or doctor's office for sample collection.

METHODS

Participants were recruited from a primary care office and completed structured interviews assessing types of sexual contact and attitudes about rectal sampling. Differences were tested using χ2 and 2-sided Fisher exact test.

RESULTS

Of 110 cisgender women (aged 14-22 years) enrolled, the average age was 18.4 years (SD, 1.7 years), 83% reported a history of extragenital contact, 22% reported history of receptive anal intercourse. A majority of participants reported self- and clinician-collected rectal samples to be acceptable (86% and 73%, respectively), with preferences for self-collection (71%) over clinician collection (29%, P < 0.001) and collection at the doctor's office (85%) over home (15%, P < 0.001).

CONCLUSIONS

Adolescent and young adult (AYA) women engage in behaviors that increase the risk of rectal sexually transmitted infection (STI). Self- and clinician-collected rectal samples were acceptable. A majority of AYA women preferred to collect rectal samples in the doctor's office rather than at home. This may reduce adolescents' access to direct-to-consumer STI services. Offering in-clinic, self-collected rectal samples may improve uptake of rectal STI screening in adolescent girls.

The Relationship Between Directly Observed Therapy for Chlamydia Infections and Retesting Rates in an Adolescent Population

BACKGROUND

Chlamydia trachomatis is the most common reportable sexually transmitted infection in the United States, with >60% of reported cases occurring in individuals aged 15 to 24 years. US practice guidelines recommend directly observed therapy (DOT) for the treatment of chlamydia in adolescents, but almost no research has been done to evaluate whether DOT results in improved outcomes.

METHODS

We conducted a retrospective cohort study of adolescents who sought care at 1 of 3 clinics within a large academic pediatric health system for a chlamydia infection. The study outcome was return for retesting within 6 months. Unadjusted analyses were performed using χ2 , Mann-Whitney U , and t tests, and adjusted analyses were performed using multivariable logistic regression.

RESULTS

Of the 1970 individuals included in the analysis, 1660 (84.3%) received DOT and 310 (15.7%) had a prescription sent to a pharmacy. The population was primarily Black/African American (95.7%) and female (78.2%). After controlling for confounders, individuals who had a prescription sent to a pharmacy were 49% (95% confidence interval, 31%-62%) less likely than individuals who received DOT to return for retesting within 6 months.

CONCLUSIONS

Despite clinical guidelines recommending the use of DOT for chlamydia treatment in adolescents, this is the first study to describe the association between DOT and an increase in the number of adolescents and young adults who return for sexually transmitted infection retesting within 6 months. Further research is needed to confirm this finding in diverse populations and explore nontraditional settings for the provision of DOT.

Prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium among Patients with Urogenital Symptoms in Istanbul

Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium are the three most commonly reported sexually transmitted bacteria. The present study aimed to investigate the presence of C. trachomatis, N. gonorrhoeae, and M. genitalium in urogenital samples collected from 18-68-year-old Turkish patients who were admitted to the hospital with various urogenital symptoms. A total of 360 patients with symptoms of STD were included in the study. Following DNA extraction by QIAamp Mini Kit, the presence of C. trachomatis, N. gonorrhoeae, and M. genitalium were investigated using multiplex real-time PCR. Causative organisms were identified in 68 (18.9%) of 360 patients. C. trachomatis, N. gonorrhoeae, and M. genitalium were detected in 40 (11.1%), 14 (3.9%), and 28 (7.8%) of the patients, respectively. Patients 21-30 years of age represented more than one-third (37.8%) of positive patients. Of all patients, dual infections of C. trachomatis-M. genitalium, N. gonorrhoeae-C. trachomatis, N. gonorrhoeae-M. genitalium, and triple infection of C. trachomatis-N. gonorrhoeae-M. genitalium were determined in 1.6% (6/360), 1.3% (5/360), 0.2% (1/360), and 0.2% (1/360) of the patients, respectively. In CT-, NG-, and MG-positive patients, different STI agents were also found such as HIV, HBV, HPV, HSV2, T. pallidum, and T. vaginalis. In conclusion, among C. trachomatis, N. gonorrhoeae, and M. genitalium, CT was the most frequently detected bacterial cause of STDs in our hospital at Istanbul. Co-infections, which comprise more than one-fifth of the cases, should not be underestimated. Regular screening and following up of STD agents using multiplex real-time PCR-based diagnostic methods enabling the immediate detection of co-infections are essential for the treatment and primary prevention of STDs.

Management of Pelvic Inflammatory Disease in Clinical Practice

Pelvic inflammatory disease (PID) is a common reproductive health disorder among women of reproductive age. The treatment of PID has slowly evolved, reflecting changing antibiotic susceptibility and advancements in therapeutics and research; however, it has been largely unchanged over the last several decades. The most recent treatment recommendations consider the severity of infection, clinical presentation, and the polymicrobial nature of the disease. In addition, the role of novel organisms like Mycoplasma genitalium in PID is of emerging significance. PID treatment guidance offers oral and parenteral treatment options based on the patient's clinical status; however, deviations from the published guidelines are a general concern. Point of care (POC) testing for precision care, provision of adherence support, optimizing self-management and prevention strategies, and other alternative or synergistic approaches that maximize treatment outcomes will be instrumental for addressing the current challenges in PID diagnosis and management.

Not only monkeypox infection: Keratoderma blenorrhagicum

We report the case of a 18-year-old boy affected by keratoderma blenorrhagicum mimicking monkeypox infection. PCR test in urine and urethral swab positive for chlamydia trachomatis and a biopsy performed on a lesion of the palm of the hand led to the correct diagnosis. The current monkeypox outbreak is an evolving situation, thus a better understanding of morphological, clinical and temporal features could help in prompt diagnosis of this infection.

Effectiveness of chlamydia Test and Treat strategy in preventing adverse pregnancy outcomes: protocol for a randomized controlled trial

Introduction

Chlamydia trachomatis is one of the most common bacterial sexually transmitted infections worldwide, and is associated with an increased risk of adverse pregnancy outcomes. However, whether providing chlamydia screening and treatment during the first trimester of pregnancy could reduce adverse pregnancy outcomes is still not clear. This study reports a randomized controlled trial (RCT) protocol to evaluate the effectiveness of chlamydia Test and Treat during early pregnancy in preventing adverse pregnancy outcomes in China.

Methods and analysis

This trial is a multi-center two-arm RCT targeting 7,500 pregnant women in early pregnancy (6-20 weeks). The inclusion criteria included: 18-39 years old, on their first antenatal visit, in the first trimester, and plan to deliver in the study cities. Following a block randomization procedure, every block of twenty women will be randomly assigned in a 1:1 ratio into two arms: (1) a Test and Treat arm in which women receive free chlamydia testing immediately after enrollment and people tested as chlamydia positive will receive standardized treatment and partner treatment; (2) a control arm in which women receive regular prenatal care without receiving testing during the pregnancy period, but collect urine samples and test them after delivery or indicating a chlamydia-related complication during pregnancy happens. The primary outcome is a composite of eight adverse events rate at delivery between two arms, including stillbirth, infant death, spontaneous abortion, preterm labor, low birth weight, premature rupture of membranes, postpartum endometritis, and ectopic pregnancy. Secondary outcomes include the cost-effectiveness of the intervention, the proportion of people tested with chlamydia infection, the proportion of tested-positive patients that received treatment, and the proportion of people who were cured 1 month after the treatment initiation. Urine specimens will be collected and tested for chlamydia by using Nucleic Acid Amplification Test. Data will be analyzed according to the intention-to-treat principle.

Discussion

This trial will test the hypothesis that early testing and treating of chlamydia can reduce the risk for adverse pregnancy outcomes and may help in developing chlamydia screening guidelines in China and other countries with a similar prevalence of chlamydia infection.

Trial registration

Chinese Clinical Trials Registry, ChiCTR2000031549. Registered on April 4, 2020.

Interactions between microbiota and cervical epithelial, immune, and mucus barrier

The female reproductive tract harbours hundreds of bacterial species and produces numerous metabolites. The uterine cervix is located between the upper and lower parts of the female genital tract. It allows sperm and birth passage and hinders the upward movement of microorganisms into a relatively sterile uterus. It is also the predicted site for sexually transmitted infection (STI), such as Chlamydia, human papilloma virus (HPV), and human immunodeficiency virus (HIV). The healthy cervicovaginal microbiota maintains cervical epithelial barrier integrity and modulates the mucosal immune system. Perturbations of the microbiota composition accompany changes in microbial metabolites that induce local inflammation, damage the cervical epithelial and immune barrier, and increase susceptibility to STI infection and relative disease progression. This review examined the intimate interactions between the cervicovaginal microbiota, relative metabolites, and the cervical epithelial-, immune-, and mucus barrier, and the potent effect of the host-microbiota interaction on specific STI infection. An improved understanding of cervicovaginal microbiota regulation on cervical microenvironment homeostasis might promote advances in diagnostic and therapeutic approaches for various STI diseases.

Chitosan particle stabilized Pickering emulsion/interleukin-12 adjuvant system for Pgp3 subunit vaccine elicits immune protection against genital chlamydial infection in mice

Considering the shortcomings in current chlamydia infection control strategies, a major challenge in curtailing infection is the implementation of an effective vaccine. The immune response induced by C. trachomatis plasmid encoded Pgp3 was insufficient against C. trachomatis infection, which requires adjuvant applications to achieve the robust immune response induced by Pgp3. There is increasing promising in developing adjuvant systems relying on the delivery potential of Pickering emulsions and the immunomodulatory effects of interleukin (IL)-12. Here, owing to the polycationic nature, chitosan particles tended to absorb on the oil/water interphase to prepare the optimized chitosan particle-stabilized Pickering emulsion (CSPE), which was designed as a delivery system for Pgp3 protein and IL-12. Our results showed that the average droplets size of CSPE was 789.47 ± 44.26 nm after a series of optimizations and about 90% antigens may be absorbed by CSPE owing to the positively charged surface (33.2 ± 3mV), and CSPE promoted FITC-BSA proteins uptake by macrophages. Furthermore, as demonstrated by Pgp3-specific antibody production and cytokine secretion, CSPE/IL-12 system enhanced significantly higher levels of Pgp3-specific IgG, IgG1, IgG2a, sIgA and significant cytokines secretion of IFN-γ, IL-2, TNF-α, IL-4. Similarly, vaginal chlamydial shedding and hydrosalpinx pathologies were markedly reduced in mice immunized with Pgp3/CSPE/IL-12. Collectively, vaccination with Pgp3/CSPE/IL-12 regimen elicited robust cellular and humoral immune response in mice resulting in an obvious reduction of live chlamydia load in the vaginal and inflammatory pathologies in the oviduct, which further propells the development of vaccines against C. trachomatis infection.

Prevalence, Anatomic Distribution, and Correlates of Chlamydia trachomatis and Neisseria gonorrhoeae Infections Among a Cohort of Men Who Have Sex With Men in Hanoi, Vietnam

BACKGROUND

Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) disproportionately affect men who have sex with men (MSM). Data on the prevalence, anatomical distribution, and correlates of NG and CT infections among MSM in Vietnam are limited.

METHODS

Between July 2017 and April 2019, MSM 16 years or older without HIV were enrolled into an observational cohort study. Baseline data, including sociodemographics, sexual behavior, and HIV status, were collected. Testing for NG and CT were performed on urine, rectal, and pharyngeal specimens. Multivariate logistic regression models identified factors associated with NG and CT infections at baseline.

RESULTS

In total, 1489 participants underwent NG/CT testing. The median age was 22 years (interquartile range, 20-26 years). There were 424 (28.5%) NG or CT infections: 322 (21.6%) with CT and 173 (11.6%) with NG. Rectal infections were most common for CT (73.9%), whereas pharyngeal infections were most common for NG (70.5%). Independent risk factors for CT or NG infection included ≥2 sex partners in the prior month (adjusted odds ratio [aOR], 2.04; 95% confidence interval [CI], 1.44-2.91), condomless anal sex (aOR, 1.44; 95% CI, 1.12-1.86), and meeting sex partners online (aOR, 1.35; 95% CI, 1.03-1.76). Recent genitourinary or rectal symptoms were not associated with infections.

CONCLUSIONS

The overall and extragenital prevalences of NG and CT infections were high within this sample of young MSM without HIV in Hanoi. Testing limited to urethral specimens would have missed nearly three-quarters of CT and NG infections, supporting the need for routine testing at multiple anatomic sites.

Etiology of cervicitis: Are there new agents in play?

Background

Considering the changing causative and resistance pattern of agents implicated in sexually transmitted infections (STIs), etiological diagnosis is imperative, especially in countries practicing syndromic management. This study was designed to identify etiological agents associated with cervicitis and to analyze their association with clinical and behavioral profile.

Materials and Methods

Female STI clinic attendees presenting with cervico-vaginal discharge were examined for the presence of cervicitis. Endocervical swabs were collected for gram staining and real-time polymerase chain reaction was performed for various bacterial and viral STI agents in patients presenting with cervical discharge. A vaginal swab was also evaluated for bacterial vaginosis by Nugent's criteria.

Results

Of 64 patients with vaginal discharge, 26.6% and 12.5% patients complained of genital itching and lower abdominal pain, respectively. Mean of 36.6 pus cells/hpf were observed, appreciably greater number in patients with Neisseria gonorrhoeae and Chlamydia trachomatis infections (P = 0.0063 and 0.0032, respectively). Pus cells were high (mean 68 pus cells/hpf) in patients with Ureaplasma urealyticum, though this may be attributed to coexisting N. gonorrhoeae. Agents isolated from endocervix were N. gonorrhoeae, 17 (26.6%), Trichomonas vaginalis, 4 (6.3%), HSV1 and C. trachomatis, 1 each (1.6%), HSV2, 9 (14.1%), U. urealyticum 5 (7.8%), Ureaplasma parvum 26 (40.6%), Mycoplasma genitalium (0%), and Mycoplasma hominis 11 (17.2%). Bacterial vaginosis was diagnosed in 14 (21.9%) patients. Multiple agents were isolated in 10 (two), 6 (three), 6 (four), and 1 (five) patients. Isolation of M. hominis and U. parvum was significantly associated with bacterial vaginosis (P = 0.04 and 0.003, respectively). Nonusage of condoms and mental stress predisposed to cervicitis.

Conclusion

We concluded that there are changing etiological patterns of cervicitis. There is need to use tests that detect wider array of organisms, and can replace standard culture methods with molecular assays, to increase the ability to diagnose more number of organisms implicated in cervicitis.

Prevalence of nonviral reproductive tract infections/sexually transmitted infections in female patients with cervicovaginal discharge: Excerpts from a regional reference center in North India

Background

To study the prevalence of common nonviral reproductive tract infections/sexually transmitted infections (RTI/STI) prevailing among females who presented to our regional STI reference center and to ascertain the association of various symptoms with different RTI/STIs.

Materials and Methods

A retrospective analysis of female patients presenting to our STI Regional center located in the Department of Medical Microbiology in PGIMER, Chandigarh, was done between April 2018 and December 2019 for patients presenting with cervico-vaginal discharge. Two to three swabs were collected from each patient. The first swab was subjected to wet mount, gram stain, Potassium hydroxide (KOH) test, and culture on blood agar, the colonies obtained were identified by matrix-assisted laser desorption time of flight mass spectrometer (MALDI TOF-MS). Second swab was used for DNA extraction and detection of Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV), and Chlamydia trachomatis (CT) by polymerase chain reaction. The third swab, when available, was inoculated onto pleuropneumonia-like organisms (PPLO) broth.

Results

One thousand and thirteenth of 1472 (69%) female patients were symptomatic and the most common presenting symptoms were vaginal discharge (707/1013 [69.8%]), infertility (266/1013 [26.2%]), genital itching (60/1013 [5.9%]), lower abdomen pain (47/1013 [4.6%]) and burning micturition (16/1013 [1.6%]). The most prevalent RTI/STI was bacterial vaginosis (BV) 18.2% (269/1472), followed by vulvovaginal candidiasis (VVC) 6.8% (100/1472) and trichomoniasis (TV) 1.9% (28/1472). Five cases each of Mycoplasma genitalium and Ureaplasma urealyticum, three of NG and one of CT were also identified. Coinfections were seen in 40 (2.7%) cases. The most common causative agent responsible for VVC in our study was Candida albicans (65%).

Conclusion

RTI/STIs were common among women and 69% were symptomatic. BV was the most common STI present in 18.2%, followed by VVC (6.8%) and trichomoniasis (1.9%).

Cross-sectional assessment of determinants of STIs among men who have sex with men and transgender women in Kigali, Rwanda

BACKGROUND

STIs among men who have sex with men (MSM) and transgender women (TGW) continue to increase. In Rwanda, STI management relies on syndromic management with limited empirical data characterising the burden of specific STIs among MSM/TGW. This study evaluated the prevalence of syphilis, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) and associated factors among MSM/TGW in Kigali.

METHODS

From March to August 2018, 737 MSM/TGW >18 years were enrolled using respondent-driven sampling (RDS). Structured interviews and HIV/STI screening were conducted. Syphilis was screened with rapid plasma reagin confirmed by Treponema pallidum hemagglutination assay. CT/NG were tested by Cepheid GeneXpert. RDS-adjusted multivariable Poisson regression models with robust variance estimation were used to evaluate factors associated with any STI, and determinants of urethral and rectal STIs separately.

RESULTS

Prevalence of any STI was 20% (RDS adjusted: 16.7% (95% CI: 13.2% to 20.2%)). Syphilis was 5.7% (RDS adjusted: 6.8% (95% CI: 4.3% to 9.4%)). CT was 9.1% (RDS adjusted: 6.1% (95% CI: 3.9% to 8.4%)) and NG was 8.8% (RDS adjusted: 7.1% (95% CI: 4.9% to 9.2%)). STIs were more common among older MSM and those with HIV (p<0.05). Of CT infections, 67% were urethral, 27% rectal and 6% were dual site. For NG infections, 52% were rectal, 29% urethral and 19% were dual site. Overall, 25.8% (23 of 89) of those with confirmed STI and returned for their results were symptomatic at time of testing.STI symptoms in the previous year (adjusted prevalence ratio (aPR): 1.94 (95% CI: 1.26 to 2.98)) were positively associated with any STI. Being circumcised was negatively associated with any STI (aPR: 0.47 (95% CI: 0.31 to 0.73)). HIV was positively associated with rectal STIs (aPR: 3.50 (95% CI: 1.09 to 11.21)) but negatively associated with urethral STIs.

CONCLUSION

MSM/TGW, especially those living with HIV, are at high risk of STIs in Rwanda with the vast majority being asymptomatic. These data suggest the potential utility of active STI surveillance strategies using highly sensitive laboratory methods among those at high risk given the anatomical distribution and limited symptomatology of STIs observed among Rwandan MSM/TGW.

Chlamydia trachomatis: quest for an eye-opening vaccine breakthrough

INTRODUCTION

Chlamydia trachomatis, commonly referred to as chlamydia (a bacterium), is a common sexually transmitted infection, and if attended to early, it can be treatable. However, if left untreated it can lead to serious consequences. C. trachomatis infects both females and males although its occurrence in females is more common, and it can spread to the eyes causing disease and in some case blindness.

AREA COVERED

With ongoing attempts in the most impoverished regions of the country, trachoma will be eradicated as a blinding disease by the year 2022. A prophylactic vaccine candidate with established safety and efficacy is a cogent tool to achieve this goal. This manuscript covers the vaccine development programs for chlamydial infection.

EXPERT OPINION

Currently, the Surgery Antibiotics Facial Environmental (SAFE) program is being implemented in endemic countries in order to reduce transmission and control of the disease. Vaccines have been shown over the years to protect against infectious diseases. Charge variant-based adjuvant can also be used for the successful delivery of chlamydial specific antigen for efficient vaccine delivery through nano delivery platform. Thus, a vaccine against C. trachomatis would be of great public health benefit.

Incidence of sexually transmitted INFECTIONS is lower among kidney transplant recipients compared to the general population- a nationwide cohort study

AIM

The burden of sexually transmitted infections (STI) among solid-organ transplant recipients is currently unknown. We studied the risk of STIs among kidney transplant recipients compared with the general population in a nationwide cohort.

METHODS

Between 2002 and 2019, all microbiological findings of Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum (syphilis), and human immunodeficiency virus among kidney transplant recipients <65 years and transplanted between 1995 and 2017 in our country were captured from statutory national registries. Data from the general population of Finland, population 5.5 million, were used for comparisons. Incidence of STIs and age and sex-adjusted standardized incidence ratios (SIR) were calculated.

RESULTS

Altogether 3612 transplantations, with a total follow-up of 27 069 person-years were included. A total of 30 STIs microbiological findings of STI were confirmed in 25 patients: C. trachomatis (N = 27), N. gonorrhoeae (N = 2), and syphilis (N = 1). No hospitalizations associated with STIs were detected. The risk of STI after kidney transplantation was significantly lower compared to the general population (SIR, 0.57, 95% CI 0.39-0.80). The lower risk of STIs was more pronounced in female patients (SIR 0.40, 95% CI 0.20-0.74), whereas in male patients the difference was statistically not significant (SIR 0.69, 95% CI 0.44-1.04)). Of the confirmed STI cases, 30% were detected in patients who received their transplants during adolescence.

CONCLUSIONS

Within the Finnish kidney transplant population, the age and sex-adjusted incidence of sexually transmitted infections is not higher compared to the general population. Highest frequency of infections was seen among patients transplanted during adolescence. This article is protected by copyright. All rights reserved.

Gynaecological infections in paediatric and adolescent gynaecology: a review of recommendations

Inflammation within the genital organs in women is an important problem in gynaecology and venereology. Understanding the factors contributing to the inflammatory process and the role of defence mechanisms against their occurrence is important in terms of prevention and treatment. It is especially visible in paediatric gynaecology, where inflammatory diseases of the vulva, dermatoses, injuries and the effects of possible sexual harassment may overlap.

High prevalence of Chlamydia trachomatis infection among women attending STD and gynecology clinics in Jiangsu province, China: A cross-sectional survey

Epidemics of Chlamydia trachomatis (CT) infection among women are major global public health concerns. This study examined the prevalence of CT infection and associated factors among women attending sexually transmitted disease (STD) and gynecology clinics in Jiangsu province, China.A cross-sectional survey was conducted among women attending STD and gynecology clinics in the province during 2018 to 2019. Socio-demographic and behavioral information were collected through face-to-face questionnaire survey. Cervical swab specimens were collected to test for CT. Chi square tests were used to compare differences in CT prevalence between subgroups of characteristics. Multivariate logistic regression analysis was used to identify factors associated with CT infection.A total of 2664 participants were enrolled. The prevalence of CT infection was 16.6% (95% confidence interval: 15.0%-18.1%). Of those, CT prevalence among participants from STD clinics (19.4%) and South Jiangsu (18.5%) were higher. Female outpatients who were service personnel (adjusted odds ratio [aOR] = 1.667, P = .004) or farmers (aOR = 1.593, P = .039), lived in South Jiangsu (aOR = 1.796, P = .004), and were from STD clinics (aOR = 1.608, P = .022) were more likely to infect CT.Our study showed a high prevalence of CT infection among women attending STD and gynecology clinics in Jiangsu province, China. CT screening, surveillance and treatment promotion should therefore be of top priority on the CT prevention agenda.

The Performance of Pooled 3 Anatomic Site Testing for Chlamydia trachomatis and Neisseria gonorrhoeae Among Men Who Have Sex With Men and Transgender Women

BACKGROUND

Although molecular testing for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) is highly sensitive, the cost can be prohibitive. Those high costs are amplified when the recommended screening approach is used, which requires separate testing of specimens from 3 anatomic sites (rectal, pharyngeal and urogenital). Although individual molecular testing is standard of care, pooled testing may offer a cost-saving alternative.

METHODS

Using the Xpert® CT/NG assay (Cepheid, Sunnyvale, CA) we tested urine, rectal and pharyngeal swabs for CT and NG in a high-risk cohort of participants assigned male at birth who reported sex with other persons who were assigned male at birth. Remnant specimens (0.34 mL from each anatomic site) were combined to perform a single 'pooled' test. We calculated positive and negative percent agreement between the pooled testing results with standard of care Xpert CT/NG test results as the reference.

RESULTS

We conducted 644 pooled tests. Of those, 598 (92.3%) gave CT and NG results. The CT-positive and -negative percent agreement were 90.1% (95% confidence interval [CI], 80.7-95.9%) and 99.2% (98.1-99.8%), respectively. The NG-positive and -negative percent agreement were 96.2% (95% CI, 86.8-99.5%) and 99.8% (95% CI, 99.0-100%), respectively. Pooled testing identified 4 CT and 1 NG infections that were negative at all anatomic sites by individual testing.

CONCLUSIONS

Three-site pooled CT and NG testing performs similarly to single anatomic site testing among tests providing a valid result. Future cost analyses should evaluate the cost effectiveness of pooled 3-site testing to determine if such a strategy improves the feasibility and accessibility of molecular sexually transmitted infection testing.

Brazilian Protocol for Sexually Transmitted Infections, 2020: infections that cause urethral discharge

This article approaches infections that cause urethral discharge. This theme is part of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Ministry of Health of Brazil in 2020. These guidelines were prepared based on scientific evidence and validated in discussions with experts. Urethritis can cause severe and even irreversible health damage when not properly treated, or when the microorganism develops antimicrobial resistance. It is noteworthy that the high levels of antimicrobial resistance grown by pathogens that cause urethritis comprises a global emergency in public health. This article presents epidemiological and clinical aspects, recommendations on diagnostic and treatment, and strategies for surveillance, prevention, and control actions for infections that cause urethral discharge, to contribute to managers' and health professionals' care qualification. Associated factors with urethritis are: young age, low socioeconomic level, multiple partnerships or new sexual partnership, history of STI, irregular use of condoms, and lack of access to adequate diagnosis and treatment.

Chlamydia trachomatis and Mycoplasma genitalium prevalence and associated factors among women presenting to a pregnancy termination and contraception clinic, 2009-2019

BACKGROUND

Risk of pelvic inflammatory disease associated with Chlamydia trachomatis and Mycoplasma genitalium is increased after termination of pregnancy (TOP) and may be increased after insertion of intrauterine devices (IUDs). Screening prior to these procedures is recommended only for C. trachomatis. We examined C. trachomatis and M. genitalium prevalence and associated factors among women presenting to a pregnancy termination and contraception service over 10 years.

METHODS

Retrospective analysis of clinical data collected from 17 573 women aged 15-45 years in 2009-2019 and for 266 M. genitalium positive women tested for macrolide resistance-associated mutations in 2016-2019.

RESULTS

C. trachomatis and M. genitalium prevalence was 3.7% and 3.4%, respectively. In multivariable analyses, shared risk factors were younger age (p<0.001, for both C. trachomatis and M. genitalium), socioeconomic disadvantage (p=0.045 and p=0.008, respectively) and coinfection (p<0.001, for both sexually transmitted infections), with 10.1% of C. trachomatis positive women also positive for M. genitalium. Additional risk factors were earlier year of visit (p=0.001) for C. trachomatis and for M. genitalium residing outside a major city (p=0.013). The proportion of M. genitalium infections tested between 2016 and 2019 with macrolide resistance-associated mutations was 32.7%.

CONCLUSIONS

Given the high level of antimicrobial resistance and the prevalence of coinfection, testing C. trachomatis positive women for M. genitalium could be considered in this setting to prevent further spread of resistant infections. Further research is required into the causal link between M. genitalium and pelvic inflammatory disease in women undergoing TOP and IUD insertion.

Should Screening for Chlamydia Trachomatis Be Performed on Asymptomatic Young Adults as well as on the Victims of Sexual Assault?

In recent years, chlamydia trachomatis (CT) screening has been discussed among different scientific boards. However, in Spain, chlamydia screening is offered to women who attend a hospital after sexual assault. We found that 5.1% of 59 cases attending our hospital after sexual assault between January 2017 and December 2019 tested positive for chlamydia infection. The mean age of the cases was 23.3 years. In comparison, screening asymptomatic patients of similar age attending hospital for other reasons have revealed a prevalence of CT of 7%. Hence, since CT is common in asymptomatic individuals as well as victims of sexual assault, we believe that chlamydia screening should also be a priority in asymptomatic patients.

The Prevalence of Bacteriospermia in Infertile Men and Association with Semen Quality in Southwestern Iran

INTRODUCTION

Infertility considered as a social and public health issue and estimated that most of these infertile couples are residents of developing countries. Infectious diseases including the history of Sexually Transmitted Infections (STIs) may impact on male reproductive function. Therefore, the present study aimed to investigate the prevalence of bacterial contaminants of semen and probable association with sperm quality of infertile men in Iranian population.

METHODS

The study population consisted of 200 infertile men and 150 fertile men attending an infertility Center in southwestern Iran during the study period in 2015. The assessment of sperm parameters was according to the World Health Organization (WHO) guidelines. The presumptive pathogens were identified using standard microbiology tests and confirmed by specific PCR primers.

RESULTS

The prevalence of bacteriospermia in the semen of the infertile group was significantly higher than that in the fertile group (48% vs. 26.7%, P <0.001). The microbiological analysis of samples showed that the most abundant species of bacteria in semen of infertile men were Chlamydia trachomatis (12.5%) followed by Neisseria gonorrhoeae (11%). On the other hand, in the control group, Lactobacillus spp. (17.3%) was the most isolated pathogen. Results showed that the presence of N. gonorrhoeae, C. trachomatis, Mycoplasma genitalium, Haemophilus, and Klebsiella was significantly associated with sperm abnormality.

CONCLUSIONS

Based on our findings, it seems that bacteriospermia is associated with alterations in the properties of semen which may lead to a decrease in the fertilization potential of sperm. Therefore, immediate and appropriate treatment is necessary before investigating every other possible cause of infertility.

Discovery of Spilanthol Endoperoxide as a Redox Natural Compound Active against Mammalian Prx3 and Chlamydia trachomatis Infection

Chlamydia trachomatis (Ct) is a bacterial intracellular pathogen responsible for a plethora of diseases ranging from blindness to pelvic inflammatory diseases and cervical cancer. Although this disease is effectively treated with antibiotics, concerns for development of resistance prompt the need for new low-cost treatments. Here we report the activity of spilanthol (SPL), a natural compound with demonstrated anti-inflammatory properties, against Ct infections. Using chemical probes selective for imaging mitochondrial protein sulfenylation and complementary assays, we identify an increase in mitochondrial oxidative state by SPL as the underlying mechanism leading to disruption of host cell F-actin cytoskeletal organization and inhibition of chlamydial infection. The peroxidation product of SPL (SPL endoperoxide, SPL^E), envisioned to be the active compound in the cellular milieu, was chemically synthesized and showed more potent anti-chlamydial activity. Comparison of SPL and SPL^E reactivity with mammalian peroxiredoxins, demonstrated preferred reactivity of SPL^E with Prx3, and virtual lack of SPL reaction with any of the reduced Prx isoforms investigated. Cumulatively, these findings support the function of SPL as a pro-drug, which is converted to SPL^E in the cellular milieu leading to inhibition of Prx3, increased mitochondrial oxidation and disruption of F-actin network, and inhibition of Ct infection.

Sexually transmitted infections among women randomised to depot medroxyprogesterone acetate, a copper intrauterine device or a levonorgestrel implant

Objectives

Reproductive aged women are at risk of pregnancy and sexually transmitted infections (STI). Understanding drivers of STI acquisition, including any association with widely used contraceptives, could help us to reduce STI prevalence and comorbidities. We compared the risk of STI among women randomised to three contraceptive methods.

Methods

We conducted a secondary analysis to assess the risk of chlamydia and gonorrhoea in a clinical trial evaluating HIV risk among 7829 women aged 16–35 randomised to intramuscular depot medroxyprogesterone acetate (DMPA-IM), a copper intrauterine device (IUD) or a levonorgestrel (LNG) implant. We estimated chlamydia and gonorrhoea prevalences by contraceptive group and prevalence ratios (PR) using log-binomial regression.

Results

At baseline, chlamydia and gonorrhoea prevalences were 18% and 5%, respectively. Final visit chlamydia prevalence did not differ significantly between DMPA-IM and copper IUD groups or between copper IUD and LNG implant groups. The DMPA-IM group had significantly lower risk of chlamydia compared with the LNG implant group (PR 0.83, 95% CI 0.72 to 0.95). Final visit gonorrhoea prevalence differed significantly only between the DMPA-IM and the copper IUD groups (PR 0.67, 95% CI 0.52 to 0.87).

Conclusions

The findings suggest that chlamydia and gonorrhoea risk may vary with contraceptive method use. Further investigation is warranted to better understand the mechanisms of chlamydia and gonorrhoea susceptibility in the context of contraceptive use.

Descriptive Evaluation of Male Emergency Department Patients in the United States With Gonorrhea and Chlamydia

Introduction

Sexually transmitted infections are commonly tested for in the emergency department (ED), but diagnostic test results are often unavailable during the clinical encounter.

Methods

We retrospectively reviewed health records of 3,132 men ≥18 years that had an emergency department visit in northeast Ohio between April 18, 2014 and March 7, 2017. All subjects underwent testing for Neisseria gonorrhoeae and Chlamydia trachomatis. Independent t-tests and chi-square analyses were performed as well as multivariable regression analysis.

Results

On univariable analysis, men with N gonorrhoeae and/or C trachomatis, compared with uninfected men, were younger (25.9 vs 32.4 years), more likely to be of Black race (91.7% vs 85.6%), less likely to be married (3.7% vs 10.2%), less likely to arrive to the ED by ambulance or police (1.7% vs 4.1%), and more likely to be diagnosed with a urinary tract infection (8.3% vs 3.7%), to be treated for gonorrhea and chlamydia in the ED (84.6% vs 54.9%), and to have higher emergency severity index (ESI) scores (3.8 vs 3.6) (P ≤ .03 for all). On urinalysis, men infected with N gonorrhoeae and/or C trachomatis had significantly more white blood cells (55.1 vs 20.9); more mucus (1.3 vs 1.2); higher leukocyte esterase (1.5 vs .4); fewer squamous epithelial cells (.6 vs 1.4); higher urobilinogen (1.1 vs .8); higher bilirubin (.09 vs .05); and more protein (.4 vs .3) (P ≤ .04).

Conclusions

Demographic and urinalysis findings can be associated with an increased odds of men being infected with N gonorrhoeae and/or C trachomatis.

Azithromycin in the treatment of rectogenital Chlamydia trachomatis infections: end of an era?

INTRODUCTION

Azithromycin was recommended as the first-line therapeutic regimen for treatment of genital infections in men and women by the Centers for Disease Control in 1998. A series of studies of azithromycin for treatment of rectal chlamydial infection in men who have sex with men (MSM) found that azithromycin was significantly less effective than doxycycline.

AREAS COVERED

Literature on treatment of rectal C. trachomatis from 2000 through May 2020 was searched using PubMed. Retrospective and observational studies were identified documenting the frequency and treatment of rectal chlamydial infection in MSM, heterosexual men and women that reported lower efficacy of single-dose azithromycin compared to doxycycline. Literature on possible reasons for the lower efficacy were also reviewed including studies of antibiotic resistance, impact of organism load, and persistent infection in rectal specimens and pharmacokinetics and pharmacodynamics of azithromycin in rectal tissue.

EXPERT OPINION

The available data suggests that single-dose azithromycin is not as effective as azithromycin for the treatment of rectal infection in MSM and women. Most of these data have been retrospective or from observational studies. Final recommendations will depend on the outcome of prospective, randomized, treatment studies. We may also need to examine other dosage regimens for azithromycin.

Sexual risk-taking among young Swedish men testing for STI

OBJECTIVES

This study investigates sexual risk-taking among young men testing for sexually transmitted infections (STI).

SAMPLING METHOD

452 participants (aged 18-30) completed surveys concerning their backgrounds, sexual risk-taking, and experience with STI.

RESULTS

Over one-third had used alcohol during their last sexual encounter, one-fifth were reluctant to use condoms due to concerns about erection difficulties, 14.7% had experienced sexual coercion and one-fifth reported having had contracted the most common STI, chlamydia trachomatis (CT). Older participants (aged 25-30) were more reluctant to use condoms because of erection worries and to report having had CT. Immigrant men reported more unprotected sex while men who have sex with men (MSM) were more exposed to sexual coercion than others, but less likely to use alcohol when having sex.

CONCLUSIONS

There are important differences in sexual risk-taking within the group of young men testing for sexually transmitted infections which need to be taken into account in developing effective counselling and promotion strategies in sexual and reproductive health care. Further research on young men's sexual risk-taking is needed to broaden understanding of factors associated with young men's sexual health.

Pregnancy and fertility-related adverse outcomes associated with Chlamydia trachomatis infection: a global systematic review and meta-analysis

BACKGROUND

Genital chlamydia infection in women is often asymptomatic, but may result in adverse outcomes before and during pregnancy. The purpose of this study was to examine the strength of the relationships between chlamydia infection and different reproductive health outcomes and to assess the certainty of the evidence.

METHODS

This review was registered and followed the Cochrane guidelines. We searched three databases to quantitatively examine adverse outcomes associated with chlamydia infection. We included pregnancy and fertility-related outcomes. We performed meta-analyses on different study designs for various adverse outcomes using unadjusted and adjusted analyses.

RESULTS

We identified 4730 unique citations and included 107 studies reporting 12 pregnancy and fertility-related outcomes. Sixty-eight studies were conducted in high-income countries, 37 studies were conducted in low-income or middle-income countries, and 2 studies were conducted in both high-income and low-income countries. Chlamydia infection was positively associated with almost all of the 12 included pregnancy and fertility-related adverse outcomes in unadjusted analyses, including stillbirth (OR=5.05, 95% CI 2.95 to 8.65 for case-control studies and risk ratio=1.28, 95% CI 1.09 to 1.51 for cohort studies) and spontaneous abortion (OR=1.30, 95% CI 1.14 to 1.49 for case-control studies and risk ratio=1.47, 95% CI 1.16 to 1.85 for cohort studies). However, there were biases in the design and conduct of individual studies, affecting the certainty of the overall body of evidence. The risk of adverse outcomes associated with chlamydia is higher in low-income and middle-income countries compared with high-income countries.

CONCLUSION

Chlamydia is associated with an increased risk of several pregnancy and fertility-related adverse outcomes in unadjusted analyses, especially in low-income and middle-income countries. Further research on how to prevent the sequelae of chlamydia in pregnant women is needed.

TRIAL REGISTRATION NUMBER

CRD42017056818.

Mucosal Vaccination with UV-Inactivated Chlamydia suis in Pre-Exposed Outbred Pigs Decreases Pathogen Load and Induces CD4 T-Cell Maturation into IFN-γ+ Effector Memory Cells

Chlamydia trachomatis (Ct) infections are the most frequent bacterial sexually transmitted disease, and they can lead to ectopic pregnancy and infertility. Despite these detrimental long-term sequelae, a vaccine is not available. Success in preclinical animal studies is essential for vaccines to move to human clinical trials. Pigs are the natural host to Chlamydia suis (Cs)-a chlamydia species closely related to Ct, and are susceptible to Ct, making them a valuable animal model for Ct vaccine development. Before making it onto market, Ct vaccine candidates must show efficacy in a high-risk human population. The high prevalence of human Ct infection combined with the fact that natural infection does not result in sterilizing immunity, results in people at risk likely having been pre-exposed, and thus having some level of underlying non-protective immunity. Like human Ct, Cs is highly prevalent in outbred pigs. Therefore, the goal of this study was to model a trial in pre-exposed humans, and to determine the immunogenicity and efficacy of intranasal Cs vaccination in pre-exposed outbred pigs. The vaccine candidates consisted of UV-inactivated Cs particles in the presence or absence of an adjuvant (TriAdj). In this study, both groups of vaccinated pigs had a lower Cs burden compared to the non-vaccinated group; especially the TriAdj group induced the differentiation of CD4⁺ cells into tissue-trafficking CCR7^- IFN-γ-producing effector memory T cells. These results indicate that Cs vaccination of pre-exposed pigs effectively boosts a non-protective immune response induced by natural infection; moreover, they suggest that a similar approach could be applied to human vaccine trials.

Prevalence of lymphogranuloma venereum among anorectal Chlamydia trachomatis-positive MSM using pre-exposure prophylaxis for HIV

OBJECTIVES

We evaluated the prevalence of lymphogranuloma venereum (LGV) in anorectal Chlamydia trachomatis-positive French men who have sex with men (MSM) using pre-exposure prophylaxis (PrEP) for HIV. Here, we describe the clinical, biological and behavioural characteristics of these patients.

METHODS

Laboratories throughout French metropolitan areas performing routine testing for C. trachomatis sent positive anorectal specimens to the National Reference Centre for bacterial STIs for LGV real-time PCR targeting the pmpH gene. Identification of the C. trachomatis genovar was performed by ompA gene sequencing. For each patient, clinical, biological and sexual behaviour data were collected after obtaining written informed consent.

RESULTS

In 2017, 486 anorectal C. trachomatis-positive specimens from MSM PrEP users were analysed. A strain of genovar L was detected in 91 cases (18.7%). Patients with LGV were significantly more symptomatic, had more sexual partners and more concurrent syphilis compared with their non-LGV counterparts. OmpA gene sequencing, successful in two-thirds of anorectal C. trachomatis-positive specimens, showed that the LGV cases were mainly of variant L2b (n=33), followed by genovar L2 (n=27) and genetic L2b ompA variants (n=16). In 11 cases, the results indicated the occurrence of genetic exchange between L and non-L genovars.

CONCLUSIONS

LGV was diagnosed in 18.7% of anorectal C. trachomatis-positive specimens from French MSM using PrEP. LGV testing should be carried out for MSM diagnosed with chlamydia and with a large number of sexual partners, high-risk practices and anorectal symptoms. These patients should be presumptively treated as having LGV. This is the first surveillance study of LGV among MSM PrEP users and monitoring should continue.

Spontaneous clearance of Chlamydia trachomatis accounting for bacterial viability in vaginally or rectally infected women (FemCure)

OBJECTIVES

Spontaneous clearance of Chlamydia trachomatis (CT) infections can occur between diagnosis and treatment. We followed CT patients to assess clearance using a conventional definition (no total CT-DNA, assessed by routine quantitative PCR methods) and a definition accounting for viability, assessed by viability PCR testing.

METHODS

Three outpatient STI clinics included CT-diagnosed women (The Netherlands, 2016-2017, FemCure study); participants had vaginal CT (vCT) and rectal CT (rCT) (group A: n=155), vCT and were rectally untested (group B: n=351), single vCT (group C: n=25) or single rCT (group D: n=29). Follow-up (median interval 9 days) vaginal and rectal samples underwent quantitative PCR testing (detecting total CT-DNA). When PCR positive, samples underwent V-PCR testing to detect 'viable CT' (CT-DNA from intact CT organisms; V-PCR positive). 'Clearance' was the proportion PCR-negative patients and 'clearance of viable CT' was the proportion of patients testing PCR negative or PCR positive but V-PCR negative. We used multivariable logistic regression analyses to assess diagnosis group (A-D), age, days since initial CT test (diagnosis) and study site (STI clinic) in relation to clearance and clearance of viable CT.

RESULTS

Clearance and clearance of viable CT at both anatomic sites were for (A) 0.6% and 3.9%; (B) 5.4% and 9.4%; (C) 32.0% and 52.0% and (D) 27.6% and 41.4%, respectively. In multivariate analyses, women with single infections (groups C and D) had higher likelihood of clearance than women concurrently infected with vCT and rCT (p<0.001).Of rectally untested women (group B), 76.9% had total CT-DNA and 46.7% had viable CT (V-PCR positive) at the rectal site.

CONCLUSIONS

Of untreated female vCT patients who had CT also at the rectal site, or who were rectally untested, only a small proportion cleared CT (in fact many had viable CT) at their follow-up visit (median 9 days). Among single site infected women clearance was much higher.

TRIAL REGISTRATION NUMBER

NCT02694497.

Rapid point of care test for detecting urogenital Chlamydia trachomatis infection in nonpregnant women and men at reproductive age

BACKGROUND

Chlamydia trachomatis (C trachomatis) is one of the most frequent sexually transmitted infections and a source of deleterious effects on the reproductive health of men and women. Because this infection is likely asymptomatic and is associated with subfertility, ectopic pregnancy, and chronic pain, its presence needs to be confirmed. Technologies available for the diagnosis of C trachomatis infection can be classified into tests performed in a laboratory and rapid tests at the point of care (POC tests). Laboratory-based tests include culture, nucleic acid amplification tests, enzyme immunoassays (EIA), direct fluorescent antibody, nucleic acid hybridization, and transformation tests. Rapid tests include solid-phase EIA and solid-phase optical immunoassay. POC tests can be performed within 30 minutes without the need for expensive or sophisticated equipment. The principal advantage of this technology is the immediate presentation of results with the subsequent possibility to start the treatment of infected patients immediately.

OBJECTIVES

To determine the diagnostic accuracy of rapid point-of-care (POC) testing for detecting urogenital C trachomatis infection in nonpregnant women and men of reproductive age, as verified with nucleic acid amplification tests (NAATs) as the reference standard.

SEARCH METHODS

In November 2019 we searched CENTRAL, MEDLINE, Embase and LILACS. We also searched Web of Science, two trials registries and an abstract database. We screened reference lists of included studies for additional references.

SELECTION CRITERIA

We included diagnostic accuracy studies of symptomatic or asymptomatic nonpregnant women and men reproductive age. Included trials should have prospectively enrolled participants without previous diagnostic testing, co-infections or complications and consecutively or through random sampling at primary or secondary care facilities. Only studies reporting that all participants received the index test and the reference standard and presenting 2 x 2 data were eligible for inclusion. We excluded diagnostic case-control studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance. Two review authors independently, and in duplicate, assessed eligibility, extracted data, and carried out quality assessment. We resolved differences through consensus or by involving a third review author. We assessed studies for methodological quality using QUADAS-2 and used meta-analysis to combine the results of studies using the bivariate approach to estimate the expected sensitivity and specificity values. We assessed the quality of the evidence using GRADE criteria and explored sources of heterogeneity.

MAIN RESULTS

We included a total of 19 studies, with 13,676 participants, that assessed the diagnostic accuracy of POC tests for C trachomatis infection in nonpregnant women and men of reproductive age, as verified with NAATs as the reference standard. Rapid tests were provided by the distributors in nine studies. Seven studies recruited a predominantly high risk or symptomatic population; the studies were conducted in America, Asia, Africa, Europe and Oceania, with a median prevalence of 10% (range 8% to 28%); nine different brands were assessed. The mean sensitivity for rapid tests for detecting urogenital infection was 0.48 (95% confidence interval (CI) 0.39 to 0.58; low-quality evidence) with a mean specificity of 0.98 (95% CI 0.97 to 0.99; moderate-quality evidence). We explored sources of heterogeneity by looking into differences in diagnostic accuracy according to the specimen (endocervical versus urine or vaginal), symptoms among participants (symptomatic versus asymptomatic), and setting (low/middle-income versus high-income countries). Likelihood ratio tests were not significantly different in terms of sensitivity or specificity by specimen (P = 0.27) or setting (P = 0.28); for this reason, these covariates do not appear to explain the observed variability. Included studies did not provide enough information to assess the 'presence of symptoms' covariate. We downgraded the quality of evidence because of some limitations in applicability and heterogeneity.

AUTHORS' CONCLUSIONS

Based on the results of this systematic review, the POC test based on antigen detection has suboptimal sensitivity but good specificity. Performance of this test translates, on average, to a 52% chance of mistakenly indicating absence of infection and a 2% chance of mistakenly pointing to the presence of this condition. Because of its deleterious consequences for reproductive health, and considering the current availability of safe and effective interventions to treat C trachomatis infection, the POC screening strategy should not be based on a rapid diagnostic test for antigen detection. Research in this topic should focus on different technologies.

Structures of glyceraldehyde 3-phosphate dehydrogenase in Neisseria gonorrhoeae and Chlamydia trachomatis

Neisseria gonorrhoeae (Ng) and Chlamydia trachomatis (Ct) are the most commonly reported sexually transmitted bacteria worldwide and usually present as co-infections. Increasing resistance of Ng to currently recommended dual therapy of azithromycin and ceftriaxone presents therapeutic challenges for syndromic management of Ng-Ct co-infections. Development of a safe, effective, and inexpensive dual therapy for Ng-Ct co-infections is an effective strategy for the global control and prevention of these two most prevalent bacterial sexually transmitted infections. Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) is a validated drug target with two approved drugs for indications other than antibacterials. Nonetheless, any new drugs targeting GAPDH in Ng and Ct must be specific inhibitors of bacterial GAPDH that do not inhibit human GAPDH, and structural information of Ng and Ct GAPDH will aid in finding such selective inhibitors. Here, we report the X-ray crystal structures of Ng and Ct GAPDH. Analysis of the structures demonstrates significant differences in amino acid residues in the active sites of human GAPDH from those of the two bacterial enzymes suggesting design of compounds to selectively inhibit Ng and Ct is possible. We also describe an efficient in vitro assay of recombinant GAPDH enzyme activity amenable to high-throughput drug screening to aid in identifying inhibitory compounds and begin to address selectivity.

Internet-based self-sampling for Chlamydia trachomatis testing: a national evaluation in Sweden

OBJECTIVE

Internet-based testing for Chlamydia trachomatis (CT) with self-sampling at home has gradually been implemented in Sweden since 2006 as a free-of-charge service within the public healthcare system. This study evaluated the national diagnostic outcome of this service.

METHODS

Requests for data on both self-sampling at home and clinic-based sampling for CT testing were sent to the laboratories in 18 of 21 counties. Four laboratories were also asked to provide data on testing patterns at the individual level for the years 2013-2017.

RESULTS

The proportion of self-sampling increased gradually from 2013, comprising 22.0% of all CT tests in Sweden in 2017. In an analysis of 14 counties (representing 83% of the population), self-sampling increased by 115% between 2013 and 2017 for women, compared with 71% for men, while test volumes for clinic-based sampling were fairly constant for both sexes (1.8% increase for women, 15% increase for men). In 2017 self-sampling accounted for 20.3% of all detected CT cases, and the detection rate was higher than, but similar to, clinic-based testing (5.5% vs 5.1%). The proportion of self-sampling men was also higher, but similar (33.7% vs 30.8%). Analysis of individual testing patterns in four counties over 5 years showed a higher proportion of men using self-sampling only (67%, n=10 533) compared with women (40%, n=8885).

CONCLUSIONS

Self-sampling has increased substantially in recent years, especially among women. This service is at least as beneficial as clinic-based screening for detection of CT, and self-sampling reaches men more than clinic-based testing.

Relation of Chlamydia trachomatis infections to ectopic pregnancy: A meta-analysis and systematic review

BACKGROUND

In a multitude of previous studies, Chlamydia trachomatis (CT) plays an important role in the occurrence of ectopic pregnancy (EP). However, the predictive value of CT infections in the occurrence of EP has not been estimated worldwide. We thus evaluated, by means of a meta-analysis, the current status of the association between CT infections with EP and the potential predictive value of CT infections in EP.

METHODS

We evaluated studies performed between the database construction time and August 2018 published in PubMed, the Cochrane Library, EMBASE, and the Web of Science (SCI). The relationship between CT and EP was calculated based upon the predetermined entry criteria for control group selection and the original data. The related articles were analyzed using a random-effects model, and the heterogeneity of the studies was assessed using the I index. Data were analyzed with the STATA 12.0 software.

RESULTS

Twenty-five studies that recruited 11960 patients were included in the present meta-analysis, and the relation of CT infections with EP were assessed. The association between CT infections and EP risk showed an odds ratio (OR) of 3.03, with a 95% confidence interval (CI) of 2.37 to 3.89. Our results showed that there was a statistically significant difference between the intervention and control groups. The prevalence of CT infections in EP was then calculated by a subgroup analysis: African (OR, 2.22; 95% CI, 1.14-4.31), European (OR, 3.16; 95% CI, 2.10-4.47), North American (OR, 3.07; 95% CI, 1.78-5.31), and Asian (OR, 3.39; 95% CI, 1.95-5.90).

CONCLUSIONS

From the results of numerous studies conducted on different continents, this meta-analysis showed a clear association between EP and prior CT infections, that is, CT infections increase the risk of EP occurrence.

History, Physical Examination, and Laboratory Findings Associated with Infection and the Empiric Treatment of Gonorrhea and Chlamydia of Women in the Emergency Department

Background Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) are common sexually transmitted infections (STIs) treated in the emergency department (ED). Objectives To assess the history, physical examination, and laboratory findings associated with NG and CT infection and the decision to administer empiric antibiotic treatment for the diseases in the ED. Methods A retrospective review of 566 clinical encounters of adult female patients tested for STIs between January 1, 2013 and December 31, 2014. An analysis of patient- and provider-level variables was assessed to determine the characteristics associated with empiric antibiotic treatment in the ED and post-discharge laboratory confirmed NG or CT. Results Younger age and the presence of TV on vaginal wet prep had a higher association with being infected with NG or CT (p < 0.05). Subjective exam findings, such as vaginal discharge, abdominal pain, urinary urgency, urinary frequency, dysuria, objective vaginal discharge, cervical motion tenderness, adnexal tenderness, vaginal bleeding, as well as positive leukocyte esterase and nitrites on urinalysis were all not associated with NG or CT infection (p > 0.05). ED providers were more likely to treat subjects in the ED for NG and CT when there was subjective and objective vaginal discharge, cervical motion tenderness, adnexal tenderness, and vaginal bleeding, TV on wet prep, and leukocyte esterase on urinalysis (p < 0.05). Conclusions Only younger age women and the presence of TV on vaginal wet prep were associated with NG or CT infection. ED providers empirically over-treated with antibiotics ~20 patients uninfected with NG and CT by laboratory confirmation, for every one patient with a laboratory confirmed infection.

Sirenomelia and maternal chlamydia trachomatis infection: a case report and review

Background: Sirenomelia is a lethal congenital anomaly, presenting with fusion of lower extremities and malformed perineum. The pathogenesis is unclear, and "defective blastogenesis" is the proposed mechanism. Chlamydia trachomatis (CT) is an obligate intracellular pathogen which reportedly invades placenta and may result in fetal demise. It has documented cytopathogenic effects, specifically, cellular disruption, tissue dysgenesis, and genomic instability.Case report: An infant with sirenomelia was born as a product of 30 weeks of pregnancy, which was normal except for a persistent maternal CT infection. The infant expired shortly after birth.Conclusion: Fetal invasion by CT, conceivably, may induce structural anomalies, such as sirenomelia by virtue of its cytopathic effects. We intend to draw attention to such a possibility by reporting this case. This association, however, is speculative and more cases of sirenomelia with CT positive mothers need to be described in order to make definite conclusions about such a relationship.

Aetiology and prevalence of mixed-infections and mono-infections in non-gonococcal urethritis in men: a case-control study

OBJECTIVES

Chlamydia trachomatis (CT) and Mycoplasma genitalium (MG) cause the majority of non-gonococcal urethritis (NGU). The role of Ureaplasma urealyticum (UU) in NGU is unclear. Prior case-control studies that examined the association of UU and NGU may have been confounded by mixed infections and less stringent criteria for controls. The objective of this case-control study was to determine the prevalence and aetiology of mixed infections in men and assess if UU monoinfection is associated with NGU.

METHODS

We identified 155 men with NGU and 103 controls. Behavioural and clinical information was obtained and men were tested for Neisseria gonorrhoeae and CT, MG, UU and Trichomonas vaginalis (TV). Men who were five-pathogen negative were classified as idiopathic urethritis (IU).

RESULTS

Twelve per cent of NGU cases in which a pathogen was identified had mixed infections, mostly UU coinfections with MG or CT; 27% had IU. In monoinfected NGU cases, 34% had CT, 17% had MG, 11% had UU and 2% had TV. In controls, pathogens were rarely identified, except for UU, which was present in 20%. Comparing cases and controls, NGU was associated with CT and MG monoinfections and mixed infections. UU monoinfection was not associated with NGU and was almost twice as prevalent in controls. Men in both the case and control groups who were younger and who reported no prior NGU diagnosis were more likely to have UU (OR 0.97 per year of age, 95% CI 0.94 to 0.998 and OR 6.3, 95% CI 1.4 to 28.5, respectively).

CONCLUSIONS

Mixed infections are common in men with NGU and most of these are UU coinfections with other pathogens that are well-established causes of NGU. UU monoinfections are not associated with NGU and are common in younger men and men who have never previously had NGU. Almost half of NGU cases are idiopathic.

Police killings of Black people and rates of sexually transmitted infections: a cross-sectional analysis of 75 large US metropolitan areas, 2016

OBJECTIVES

Emerging literature shows that racialised police brutality, a form of structural racism, significantly affects health and well-being of racial/ethnic minorities in the USA. While public health research suggests that structural racism is a distal determinant of sexually transmitted infections (STIs) among Black people, no studies have empirically linked police violence to STIs. To address this gap, our study measures associations between police killings and rates of STIs among Black residents of US metropolitan statistical areas (MSAs).

METHODS

This cross-sectional ecological analysis assessed associations between the number of Black people killed by police in 2015 and rates of primary and secondary syphilis, gonorrhoea and chlamydia per 100 000 Black residents of all ages in 2016 in 75 large MSAs. Multivariable models controlled for MSA-level demographic and socioeconomic characteristics, police expenditures, violent crime, arrest and incarceration rates, insurance rates and healthcare funding.

RESULTS

In 2015, the median number of Black people killed by police per MSA was 1.0. In multivariable models, police killings were positively and significantly associated with syphilis and gonorrhoea rates among Black residents. Each additional police killing in 2015 was associated with syphilis rates that were 7.5% higher and gonorrhoea rates that were 4.0% higher in 2016.

CONCLUSIONS

Police killings of Black people may increase MSA-level risk of STI infections among Black residents. If future longitudinal analyses support these findings, efforts to reduce STIs among Black people should include reducing police brutality and addressing mechanisms linking this violence to STIs.

Assessment of rectal Chlamydia trachomatis viable load in women by viability-PCR

OBJECTIVES

In recent years, studies have demonstrated frequent rectal Chlamydia trachomatis (CT) detection in women, irrespective of reported anal sex or rectal symptoms. However, the clinical relevance and public health implication of rectal CT detection in women remain under debate. Therefore, evaluating CT viability may provide more insight into the relevance of standard routine nucleic acid amplification test (NAAT)-positive results.

METHODS

In this cross-sectional explorative study, a convenience sample of female patients at our STI clinic aged 18 years or older, diagnosed with vaginal and/or rectal CT, were invited to participate. On return for treatment, rectal CT-diagnosed women were instructed to self-collect rectal swab samples before being treated. Standard COBAS 4800 CT/NG routine NAAT testing was applied for CT diagnosis. Rectal viable CT load was evaluated by using viability-PCR (V-PCR).

RESULTS

53 women with rectal CT were included in this study; 86.8% (46/53) had a quantifiable rectal total CT load. Of women with quantifiable samples, 52.2% (24/46) had viable CT detected from rectal swabs by V-PCR, with a mean rectal viable CT load of 3.31 log₁₀ CT/mL (range 1.16-6.22). No statistically significant difference (p=0.73) was observed in the mean rectal viable CT load of women with an indication for rectal testing (n=9) and without (n=15), 3.20 log₁₀ CT/mL (range 2.06-4.36) and 3.38 log₁₀ CT/mL (range 1.16-6.22), respectively. CT culture yielded positive test results from rectal swabs in 22.6% (12/53) of rectal CT NAAT-diagnosed women. Of women with viable rectal CT by V-PCR (n=24), 50% (12/24) were positive by CT culture.

CONCLUSIONS

Overall, the detection of high rectal viable CT loads in this study indicates that rectal CT in some women might represent a currently ongoing infection rather than just the presence of remnant DNA from dead bacteria or only contamination from an active vaginal CT infection.

Prevalence and persistence of Chlamydia trachomatis-specific antibodies after occasional and recurrent infections

OBJECTIVES

Population-based Chlamydia trachomatis seroepidemiological studies help to identify trends in chlamydia infection. However, an improved understanding of the antibody response to infection is required when using serology to estimate cumulative incidence. Thus, the objectives of this longitudinal, retrospective, biobank-based study were to assess the appearance and persistence of C. trachomatis major outer membrane protein (MOMP)-specific serum IgG antibodies after infection and to evaluate the role of antibodies in providing protective immunity against recurrent infection.

METHODS

Data of notified C. trachomatis infections in Finland were obtained from the National Infectious Diseases Register. Serum samples were acquired from the Finnish Maternity Cohort. 411 women with single chlamydia infection and 62 women with recurrent infections, and for whom suitable paired serum samples were available, were included in the study. Antibody appearance, persistence after infection and the impact of recurrent infections were evaluated. IgG antibodies specific for MOMP were measured from serum using an ELISA method.

RESULTS

Anti-C. trachomatis MOMP-specific IgG antibodies were detected in 65.5% (269/411) of women within 3 months of notification of infection. In the absence of recurrent infection, seroprevalence declined to 34.5% (142/411) 3-10 years after the initial infection. The serum antibody levels at baseline correlated positively with seroprevalence at follow-up. Reinfection boosted the humoral immune response by increasing seroprevalence and the serum antibody levels. Seroprevalence within 3 months after first notification of infection was 65.5% (19/29) in women who were later diagnosed with recurrent infection, comparable with women with single notification of infection (65.5%, 269/411).

CONCLUSIONS

Approximately one-third of women with single notification of chlamydia infection remain seropositive 3-10 years after the initial infection. The concentration of antibodies remained stable during the follow-up. Recurrent infection boosted the humoral immune response, but reinfection occurred despite the presence of pre-existing antibodies.

Correlations of chlamydia and gonorrhoea among pharyngeal, rectal and urethral sites among Thai men who have sex with men: multicentre community-led test and treat cohort in Thailand

OBJECTIVE

Routine screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections in sexually exposed anatomical sites may be challenging in resource-limited settings. The objective of this study was to determine the proportion of missed CT/NG diagnoses if a single anatomical site screening was performed among men who have sex with men (MSM) by examining the pattern of anatomical sites of CT/NG infections.

METHODS

Thai MSM were enrolled to the community-led test and treat cohort. Screening for CT/NG infections was performed from pharyngeal swab, rectal swab and urine using nucleic acid amplification testing. The correlations of CT/NG among the three anatomical sites were analysed.

RESULTS

Among 1610 MSM included in the analysis, 21.7% had CT and 15.5% had NG infection at any anatomical site. Among those tested negative for CT or NG infection at either pharyngeal, rectal or urethral site, 8%-19% had CT infection and 7%-12% had NG infection at the remaining two sites. Of the total 349 CT infections, 85.9%, 30.6% and 67.8% would have been missed if only pharyngeal, rectal or urethral screening was performed, respectively. Of the total 249 NG infection, 55.7%, 39.6% and 77.4% would have been missed if only pharyngeal, rectal or urethral screening was performed, respectively. The majority of each anatomical site of CT/NG infection was isolated to their respective site, with rectal site having the highest proportion of isolation: 78.9% of rectal CT and 62.7% of rectal NG infection.

CONCLUSIONS

A high proportion of CT/NG infections would be missed if single anatomical site screening was performed among MSM. All-site screening is highly recommended, but if not feasible, rectal screening provides the highest yield of CT/NG diagnoses. Effort in lowering the cost of the CT/NG screening test or developing affordable molecular technologies for CT/NG detection is needed for MSM in resource-limited settings.

TRIAL REGISTRATION NUMBER

NCT03580512; Results.