Effect of treatment for Chlamydia trachomatis during pregnancy

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.

Sexually transmitted infection screening to prevent adverse birth and newborn outcomes: study protocol for a randomized-controlled hybrid-effectiveness trial

Background

Sexually transmitted infections (STIs) during pregnancy are associated with adverse birth outcomes, including preterm birth, low birth weight, perinatal death, and congenital infections such as increased mother-to-child HIV transmission. Prevalence of STIs among pregnant women in South Africa remains high, with most women being asymptomatic for their infection(s). Unfortunately, most STIs remain undetected and untreated due to standard practice syndromic management in accordance with World Health Organization (WHO) guidelines. Although lab-based and point-of-care molecular tests are available, optimal screening strategies during pregnancy, their health impact, and cost-effectiveness are unknown.

Methods

We will implement a 3-arm (1:1:1) type-1 hybrid effectiveness-implementation randomized-controlled trial (RCT). We will enroll 2500 pregnant women attending their first antenatal care (ANC) visit for their current pregnancy at participating health facilities in Buffalo City Metro District, Eastern Cape Province, South Africa. Participants allocated to arms 1 and 2 (intervention) will receive GeneXpert® point-of-care diagnostic testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis, with same-day treatment for detected infection(s). Arm 1 will additionally receive a test-of-cure 3 weeks post-treatment, while Arm 2 will receive a repeat test at 30–34 weeks’ gestation. Those allocated to Arm 3 will receive syndromic management (standard-of-care). The RE-AIM framework will be used to guide collection of implementation indicators to inform potential future scale up. Primary outcome measures include (1) frequency of adverse birth outcomes among study arms, defined by a composite measure of low birth weight and pre-term delivery, and (2) change in STI prevalence between baseline and birth outcome among intervention arms and compared to standard-of-care. Estimates and comparative costs of the different screening strategies relative to standard-of-care and the costs of managing adverse birth outcomes will be calculated. Cost-effectiveness will be assessed per STI and disability-adjusted life year averted.

Discussion

This trial is the first RCT designed to identify optimal, cost-effective screening strategies that decrease the burden of STIs during pregnancy and reduce adverse birth outcomes. Demonstrating the impact of diagnostic screening and treatment, compared to syndromic management, on birth outcomes will provide critical evidence to inform changes to WHO guidelines for syndromic management of STIs during pregnancy.

Trial registration

ClinicalTrials.gov NCT04446611. Registered on 25 June 2020.

The Impact of Syndromic Management of Vaginal Discharge Syndrome on Adverse Birth Outcomes in Botswana

Background

Vaginal discharge syndrome (VDS) is a common clinical diagnosis during pregnancy in Botswana; it is treated with broad-spectrum antibiotics using a syndromic approach. We evaluated associations between the syndromic management of VDS and adverse birth outcomes.

Methods

The Tsepamo Study performs birth outcomes surveillance at government hospitals throughout Botswana. Obstetric record data collected from August 2014 to March 2019 were analyzed. Chi-square tests were conducted to compare proportions of maternal characteristics and infant outcomes. To avoid immortal time bias, all analyses were conducted among women who presented to care before 24 weeks gestation, with VDS categorized as present or absent by 24 weeks gestation. Log-binomial regression models were generated to determine associations between treated VDS and infant outcomes.

Results

VDS was diagnosed in 36 731 (30.7%) pregnant women, of whom 33 328 (90.7%) received antibiotics. Adjusted analyses yielded a harmful association between treated VDS and very preterm delivery (adjusted risk ratio, 1.11; 95% CI, 1.02-1.21). This association remained when restricting to women with VDS who received the recommended antibiotic treatment regimen. Sensitivity analyses produced nonsignificant associations when women with treated VDS were compared with women without VDS who received antibiotics for other indications.

Conclusions

A clinical diagnosis of VDS is common among pregnant women in Botswana, and the majority receive antibiotics in pregnancy. Although analyses of VDS occurring later in pregnancy are precluded by immortal time bias, a modest association between treated VDS and very preterm delivery was observed among women diagnosed with VDS by 24 weeks gestation.

Chlamydia trachomatis Screening and Treatment in Pregnancy to Reduce Adverse Pregnancy and Neonatal Outcomes: A Review

Chlamydial trachomatis infection has been associated with adverse pregnancy and neonatal outcomes such as premature rupture of membranes, preterm birth, low birth weight, conjunctivitis, and pneumonia in infants. This review evaluates existing literature to determine potential benefits of antenatal screening and treatment of C. trachomatis in preventing adverse outcomes. A literature search revealed 1824 studies with 156 full-text articles reviewed. Fifteen studies were selected after fulfilling inclusion criteria. Eight studies focused on chlamydial screening and treatment to prevent adverse pregnancy outcomes such as premature rupture of membranes, preterm birth, low birth weight, growth restriction leading to small for gestational age infants, and neonatal death. Seven studies focused on the effects of chlamydial screening and treatment on adverse infant outcomes such as chlamydial infection including positive mucosal cultures, pneumonia, and conjunctivitis. Given the heterogeneity of those studies, this focused review was exclusively qualitative in nature. When viewed collectively, 13 of 15 studies provided some degree of support that antenatal chlamydial screening and treatment interventions may lead to decreased adverse pregnancy and infant outcomes. However, notable limitations of these individual studies also highlight the need for further, updated research in this area, particularly from low and middle-income settings.

Sexually transmitted infections in pregnancy - An update on Chlamydia trachomatis and Neisseria gonorrhoeae

Routine screening for Chlamydia and gonococcal infection in pregnancy is not widespread, especially in low- and middle-income countries (LMICs), despite their potential adverse consequences on pregnancy outcome. We conducted a systematic literature search of three major databases to review current literature surrounding Chlamydia trachomatis and Neisseria gonorrhoeae infections in pregnancy. We discuss the epidemiology and burden of both infections, detection methods, potential adverse feto-maternal and infant outcomes and provide an overview of treatment options. A total of 67 articles met the inclusion criteria. The prevalence of C. trachomatis and N. gonorrhoeae across all trimesters ranged between 1.0%-36.8% and 0-14.2% worldwide, respectively. The most common diagnostic method is the Nucleic acid amplification test (NAAT). In pregnancy, chlamydia is associated with preterm birth, spontaneous miscarriage, stillbirth and neonatal conjunctivitis, while gonorrhoea is mainly associated with preterm birth and stillbirth. Amoxicillin, erythromycin and azithromycin showed similar efficacy in the treatment of chlamydia in pregnancy, while ceftriaxone and cefixime were effective in treating gonorrhoea in pregnancy. Being largely asymptomatic infections in women, we opine that detection strategies with locally appropriate tools should be combined with the syndromic approach in LMICs, where there is a high burden of disease.

Detection of Chlamydia trachomatis infections by polymerase chain reaction in asymptomatic pregnant women with special reference to the utility of the pooling of urine specimens

BACKGROUND & OBJECTIVES

Genital Chlamydia trachomatis (CT) infections are one of the most prevalent sexually transmitted infections across the world. In pregnant women, if not detected and treated early, these may result in poor pregnancy outcomes and complications. The present study was aimed to screen CT infections from first void urine (FVU) samples of asymptomatic pregnant women using molecular methods. The secondary objective was to evaluate cost-effectiveness in pooling FVU samples for their diagnostic application.

METHODS

FVU samples were collected from 1000 asymptomatic pregnant women over a period of three years. Pooling was done by including five specimens in one pool in the amount of 10 μl and subjected to polymerase chain reaction (PCR) and further confirmed by direct fluorescent antibody assay (DFA).

RESULTS

The age of study participants ranged from 18 to 43 yr with the median±standard deviation of 26±3.84 yr. Majority of positive participants were younger than 25 years. A total of 200 pools were prepared and 20 of these were PCR positive. When individual specimen in 20 positive pools was tested, 20 PCR-positive specimens were identified from 19 pools, of which 16 were positive by DFA. Thus, CT was detected in 1.6 per cent asymptomatic pregnant women in India and pooling strategy resulted in 70 per cent reduction in a number of tests performed.

INTERPRETATION & CONCLUSIONS

Our study detected C. trachomatis infection in 1.6 per cent asymptomatic pregnant women, and pooling of FVU specimens for PCR testing was found to be a cost-saving strategy in comparison to testing individual samples. Further evaluation and studies on the bigger sample size are warranted to validate these results.

Prevalence of Curable Sexually Transmitted Infections in Pregnant Women in Low- and Middle-Income Countries From 2010 to 2015: A Systematic Review

BACKGROUND

Current literature comparing the prevalence rates of curable sexually transmitted infections (STIs) in pregnant women in various global regions is limited. As a result, antenatal screening practices for curable STIs in pregnant women, specifically Treponema pallidum (syphilis), Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) vary around the world, differing by country and particular STI.

METHODS

We conducted a systematic review of publications on STI prevalence among pregnant women in 30 different low- and middle-income countries. We searched PubMed for studies reporting prevalence of syphilis, CT, NG, and TV in pregnant women. English language studies published between January 1, 2010, and March 1, 2015, were included. The adjusted mean STI prevalence by region was calculated via multivariable linear regression adjusting for health care setting, women's mean age, study sample size, and sensitivity of diagnostic test.

RESULTS

We identified 75 studies that met inclusion criteria, providing 116 point prevalence estimates for curable STIs among 3,489,621 pregnant women. Adjusted mean prevalence for NG ranged from 1.2% (95% confidence interval [CI], 1.0-1.3) in Latin America to 4.6% (95% CI, 4.0-5.2) in Southern Africa; syphilis prevalence ranged from 1.1% (95% CI, 0.5-1.6) in Asia to 6.5% (95% CI, 4.7-6.3) in Southern Africa; CT ranged from 0.8% (95% CI, 0.4-1.1) in Asia to 11.2% (95% CI, 6.0-16.4) in Latin America; and TV ranged from 3.9% (95% CI, 2.2-5.6) in Latin America to 24.6% (95% CI, 17.9-31.4) in Southern Africa.

CONCLUSIONS

Although we observed a wide variation in STI burden in pregnancy after adjusting for age, test, and health care setting, further valid comparison may depend on adjustment for access to care and screening practices.

Pregnancy Outcomes in Association with STDs including genital HSV-2 shedding in a South African Cohort Study

OBJECTIVES

Genital herpes simplex virus-2 (HSV-2) shedding in pregnant women in association with neonatal herpes infection has been widely studied but there is limited evidence of its association with pregnancy outcomes.

METHODS

In this retrospective observational study, we included a subgroup of pregnant women who were enrolled in a randomized control behavioural intervention study that was conducted in South Africa in 2008-2010. In pregnancy, women had a HIV rapid test done and a genital swab taken to test for curable STIs and HSV-2 DNA. Subsequent visits were scheduled for 6, 10, 14 weeks and 9 months post-delivery. Pregnancy outcomes were documented at the 6-week or 10-week postpartum visit. Women were treated syndromically for curable STIs.

RESULTS

Among 615 women included in this data analysis, 36.6% (n=225) tested HIV positive and 8.3% (n=51) tested positive for genital HSV-2 shedding during pregnancy. Women <24 years and HIV-1 seropositive women were 1.5 and 2.5 times more likely to test positive for HSV-2 genital shedding respectively. STI treatment records were available for 158/205 (77.1%) women; all 87 women with symptomatic STIs were treated the same day, and 50/71 (70.4%) asymptomatic women received treatment at the subsequent visit. Remaining 21 (29.6%) asymptomatic women did not receive treatment because they failed to return for antenatal follow-up. In a multivariable regression analysis, genital HSV-2 shedding, HIV-1, Neisseria gonorrhoea, Chlamydia trachomatis and Trichomanas vaginalis were not associated with preterm deliveries, still births and low birth weight. However with stratification by treatment for a STI, asymptomatic women who were not treated were 3.3 times more likely to deliver prematurely (33.3%; n=6/18) when compared to women who were treated during pregnancy (13.2%; n=15/114) (p=0.042).

CONCLUSIONS

Genital HSV-2 shedding in pregnancy does not appear to alter pregnancy outcomes. Untreated curable STIs (T.vaginalis, C.trachomatis, N.gonorrhoea) were more likely associated with preterm births.

Cost-effectiveness analysis of Chlamydia trachomatis screening in Dutch pregnant women

Chlamydia trachomatis infections during pregnancy may have serious consequences for women and their offspring. Chlamydial infections are largely asymptomatic. Hence, prevention is based on screening. The objective of this study was to estimate the cost-effectiveness of C. trachomatis screening during pregnancy. We used a health-economic decision analysis model, which included potential health outcomes of C. trachomatis infection for women, partners and infants, and premature delivery. We estimated the cost-effectiveness from a societal perspective using recent prevalence data from a population-based prospective cohort study among pregnant women in the Netherlands. We calculated the averted costs by linking health outcomes with health care costs and productivity losses. Cost-effectiveness was expressed as net costs per major outcome prevented and was estimated in base-case analysis, sensitivity, and scenario analysis. In the base-case analysis, the costs to detect 1000 pregnant women with C. trachomatis were estimated at €527,900. Prevention of adverse health outcomes averted €626,800 in medical costs, resulting in net cost savings. Sensitivity analysis showed that net cost savings remained with test costs up to €22 (test price €19) for a broad range of variation in underlying assumptions. Scenario analysis showed even more cost savings with targeted screening for women less than 30 years of age or with first pregnancies only. Antenatal screening for C. trachomatis is a cost-saving intervention when testing all pregnant women in the Netherlands. Savings increase even further when testing women younger than 30 years of age or with pregnancies only.

Should All Pregnant Women be Screened for Syphilis?

In industrialized countries, the incidence of syphilis has decreased dramatically since the discovery of penicillin in the 1940s. However, syphilis and congenital syphilis are far from eradicated, especially in low- and middle-income countries. Syphilis in pregnant women is a cause of adverse pregnancy outcomes that can be prevented by screening for syphilis and early treatment in pregnancy. Several studies have found screening of pregnant women for syphilis to be a highly cost-effective intervention, even if the prevalence of syphilis is low. Obstacles to universal screening of pregnant women include low awareness of syphilis and low quality of antenatal care and healthcare in general in many low- and middle-income countries. For these settings, we need simpler and more reliable serological tests for syphilis, but we also need to strengthen health services in general to ensure sustainable antenatal care services to ensure sustainability of syphilis screening programmes.

Chlamydia trachomatis Infection in Pregnancy: The Global Challenge of Preventing Adverse Pregnancy and Infant Outcomes in Sub-Saharan Africa and Asia

Screening and treatment of sexually transmitted infections (STIs) in pregnancy represents an overlooked opportunity to improve the health outcomes of women and infants worldwide. Although Chlamydia trachomatis is the most common treatable bacterial STI, few countries have routine pregnancy screening and treatment programs. We reviewed the current literature surrounding Chlamydia trachomatis in pregnancy, particularly focusing on countries in sub-Saharan Africa and Asia. We discuss possible chlamydial adverse pregnancy and infant health outcomes (miscarriage, stillbirth, ectopic pregnancy, preterm birth, neonatal conjunctivitis, neonatal pneumonia, and other potential effects including HIV perinatal transmission) and review studies of chlamydial screening and treatment in pregnancy, while simultaneously highlighting research from resource-limited countries in sub-Saharan Africa and Asia.

Expression of prostaglandin receptors in Chlamydia trachomatis-infected recurrent spontaneous aborters

A study was undertaken to quantify the expression of prostaglandin (PG) receptors and find the effect of gestational age on expression of PG receptor genes in Chlamydia trachomatis-infected recurrent spontaneous aborters (RSA). Endometrial curettage tissue (ECT) was collected from 130 RSA (Group I) and 100 age-matched controls (Group II) at the Department of Obstetrics and Gynecology, Safdarjung Hospital, New Delhi (India). PCR was performed for diagnosis of C. trachomatis cryptic plasmid; mRNA expression of PG receptor genes was assessed by real-time PCR (q-PCR), while serum progesterone/estrogen levels were determined by respective commercial kits. Data were evaluated statistically. A total of 15.4 % RSA (GroupI) were diagnosed as C. trachomatis-positive (200 bp), whereas controls were uninfected. q-PCR showed significant upregulation (P<0.0001) of PGE2 (EP-1, EP-2, EP-3, EP-4), PGF2α (FP) and PGI2 (IP) receptors in Group I versus Group II. The expression of PG receptors increased significantly with advanced gestational age (P<0.002); however, only contractile receptors, EP-1, EP-3 and FP, were positively correlated with gestational age in Group-I. In infected RSA, mean serum progesterone level was significantly low (P<0.0001) while serum oestrogen was high (P<0.0001). Overall, the data suggest that increased expression of PG receptors, particularly contractile gene receptors (EP-1, EP-3, FP), with advanced gestational age and altered steroid levels could be a possible risk factor for abortion in Chlamydia-infected RSA.

Chlamydia trachomatis infection in HIV-infected women: need for screening by a sensitive and specific test

Reproductive tract infection (RTIs)/sexually transmitted infections (STIs) are recognized as a major public health problem, particularly due to their relationship with HIV infection. Early detection and treatment of Chlamydia trachomatis infection (CTI) among HIV-infected and HIV-uninfected women may impact heterosexual HIV transmission. A total of 120 participants were enrolled: 30 HIV seropositive women with symptoms of RTIs, 30 HIV seropositive women without symptoms of RTIs, 30 HIV seronegative women with symptoms of RTIs, and 30 HIV seronegative women without symptoms of RTIs. One endocervical swab was collected from all participants and CTI was detected by real-time PCR (COBAS TaqMan CT Test, v2.0). CTI was detected in 4 (6.67%) HIV-infected women and in 1 (1.67%) HIV-uninfected woman (OR 4.214; 95% CI 0.457–38.865). Vaginal discharge was present in almost half of HIV-infected and HIV-uninfected women; lower abdominal pain was present in 11 (18.3%) of HIV-infected and in 9 (15%) of HIV-uninfected women. This study showed that CTI is more prevalent among HIV-infected females as compared to HIV-uninfected females. As the use of real-time PCR is not feasible in most hospitals, efforts should be made to develop a simple, sensitive, and specific test to identify women with CTI for prevention of sequelae and HIV transmission.

Genitourinary pathogens and preterm birth

PURPOSE OF REVIEW

The aim is to describe and quantify the association between genitourinary tract infections and preterm birth.

RECENT FINDINGS

Recent studies confirm the importance of identifying and treating both asymptomatic and symptomatic bacteriuria in pregnancy, which is reflected in current antenatal screening guidelines. These guidelines do not recommend routine screening for other asymptomatic lower genital infections (bacterial vaginosis, trichomonas and gonorrhoea) reflecting inconsistent study results, which may reflect differences in study design, size, diagnostics and the timing of screening in pregnancy. Screening for group B Streptococcus (GBS) late in pregnancy is recognized to reduce neonatal disease, but there is a striking lack of robust studies, specifically randomized controlled trials (RCTs), considering the effect of GBS screening earlier in pregnancy on adverse pregnancy outcomes.

SUMMARY

The potential for screening and treatment of genitourinary tract infections in pregnancy to reduce preterm birth rates has been demonstrated in some RCTs. Current guidelines do not reflect these data because of inconsistencies across the body of evidence. There is a need for robust RCTs to confirm or refute earlier data, to inform the optimal timing for screening in pregnancy and to better quantify the contribution of individual infections to the burden of preterm birth.

Low prevalence of Chlamydia trachomatis infection in non-urban pregnant women in Vellore, S. India

Objective

To determine the prevalence and risk factors for Chlamydia trachomatis (CT) infection in pregnant women and the rate of transmission of CT to infants.

Methods

Pregnant women (≥28 weeks gestation) in Vellore, South India were approached for enrollment from April 2009 to January 2010. After informed consent was obtained, women completed a socio-demographic, prenatal, and sexual history questionnaire. Endocervical samples collected at delivery were examined for CT by a rapid enzyme test and nucleic acid amplification test (NAAT). Neonatal nasopharyngeal and conjunctival swabs were collected for NAAT testing.

Results

Overall, 1198 women were enrolled and 799 (67%) endocervical samples were collected at birth. Analyses were completed on 784 participants with available rapid and NAAT results. The mean age of women was 25.8 years (range 18–39 yrs) and 22% (95% CI: 19.7–24.4%) were primigravida. All women enrolled were married; one reported >one sexual partner; and six reported prior STI. We found 71 positive rapid CT tests and 1/784 (0.1%; 95% CI: 0–0.38%) true positive CT infection using NAAT.

Conclusions

To our knowledge, this is the largest study on CT prevalence amongst healthy pregnant mothers in southern India, and it documents a very low prevalence with NAAT. Many false positive results were noted using the rapid test. These data suggest that universal CT screening is not indicated in this population.

2010 European guideline for the management of Chlamydia trachomatis infections

This guideline aims to provide comprehensive information regarding the management of infections caused by Chlamydia trachomatis in European countries. The recommendations contain important information for physicians and laboratory staff working with sexually transmitted infections (STIs) and/or STI-related issues. Individual European countries may be required to make minor national adjustments to this guideline as some of the tests or specific local data may not be accessible, or because of specific laws.

[Chlamydia trachomatis infections in neonates--overview of current laboratory diagnostics]

Based on recent literature and their own laboratory experiences the author summarizes the clinical manifestations, diagnostic possibilities and the tools of prevention of neonatal Chlamydia trachomatis infection, where a potential or a verified role of this pathogen is present. Definitive diagnosis is complicated by the common phenomenon of asymptomatic, undiagnosed maternal infection, as well as by the need for adequate sample-collection and targetted screening techniques. There are only estimated data regarding the incidence of neonatal Chlamydia trachomatis infection; however we do have the diagnostic tests to identify the affected neonates, who may have generally only a mild-moderate manifestation of infection in case of an early treatment. Focussed screening efforts should be made to reduce the number of infected pregnant women and thereby the vertical rate of transmission.

Azithromycin-chloroquine and the intermittent preventive treatment of malaria in pregnancy

In the high malaria-transmission settings of sub-Saharan Africa, malaria in pregnancy is an important cause of maternal, perinatal and neonatal morbidity. Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) reduces the incidence of low birth-weight, pre-term delivery, intrauterine growth-retardation and maternal anaemia. However, the public health benefits of IPTp are declining due to SP resistance. The combination of azithromycin and chloroquine is a potential alternative to SP for IPTp. This review summarizes key in vitro and in vivo evidence of azithromycin and chloroquine activity against Plasmodium falciparum and Plasmodium vivax, as well as the anticipated secondary benefits that may result from their combined use in IPTp, including the cure and prevention of many sexually transmitted diseases. Drug costs and the necessity for external financing are discussed along with a range of issues related to drug resistance and surveillance. Several scientific and programmatic questions of interest to policymakers and programme managers are also presented that would need to be addressed before azithromycin-chloroquine could be adopted for use in IPTp.

Treating malaria in pregnancy in developing countries: priorities in clinical research and drug development

Reducing the burden of falciparum malaria in pregnancy is an urgent international public health priority but one that involves considerable challenges. The rapidly declining effectiveness of agents known to be safe in pregnancy, and the limited efficacy, safety and pharmacokinetic data available for many other antimalarial drugs, mean that current options for the treatment of both severe and uncomplicated falciparum malaria in pregnancy are limited. This report summarizes the literature on this subject and recommends drug combinations for evaluation in Phase II/III treatment trials in pregnancy.

Sexually transmitted infections among pregnant women attending an antenatal clinic in Fuzhou, China

OBJECTIVE

To determine the prevalence of sexually transmitted infections (STIs) among women attending an antenatal clinic in urban China and to show whether reported symptoms and findings on clinical examination predicted STIs in this population.

STUDY DESIGN

Cross-sectional descriptive study was conducted among 504 pregnant women attending an antenatal clinic in Fuzhou, China. Structured questionnaires were used to collect demographic and behavioral information, and clinical and gynecologic examinations were performed to detect clinical signs of STIs. Blood samples, vaginal swabs, and cervical swabs were collected, respectively, to test for antibodies to syphilis, culture Trichomonas vaginalis (T. vaginalis), and perform PCR to detect Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae).

RESULTS

C trachomatis was detected in 51 (10.1%), N gonorrhoeae in 4 (0.8%), T vaginalis in 16 (3.2%), and syphilis in 1 (0.2%) of the 504 pregnant women. Fifty-two (73%) of 71 women with any STI were asymptomatic. Multiple logistic regression analysis indicated that age <or=25 years (OR=2.72) and monthly income >RMB 2000 yuan (OR=3.57) were significant independent risk factors for chlamydial infection (P<0.05). The reported symptom of vaginal discharge or the clinical sign of either vaginal or cervical discharge poorly predicted infection with C trachomatis, N gonorrhoeae, or T vaginalis, with a positive predictive value <25% for each STI.

CONCLUSION

A substantial prevalence of STIs, including a large proportion of asymptomatic infections, was found among pregnant women in the study area. These results support a strategy of screening pregnant women for bacterial STIs (followed by treatment of infections), which could be integrated into routine pregnancy care in China.

Use of pooled urine samples and automated DNA isolation to achieve improved sensitivity and cost-effectiveness of large-scale testing for Chlamydia trachomatis in pregnant women

The success of large-scale screening for Chlamydia trachomatis depends on the availability of noninvasive samples, low costs, and high-quality testing. To evaluate C. trachomatis testing with pregnant women, first-void urine specimens from 750 consecutive asymptomatic pregnant women from the Rotterdam area (The Netherlands) were collected. Initially, we investigated the performance of three different DNA isolation methods with 350 of these urines and 70 pools of 5 of the same subset of urine samples. The routinely used COBAS AMPLICOR test was compared to the COBAS AMPLICOR test with prior DNA isolation by use of the MagNA Pure large-volume kit and the MagNA Pure bacterial DNA isolation kit. The latter combination provided the best DNA test for pooled urines, with a sensitivity twice that of the other methods. Next, using all 750 urines, the COBAS AMPLICOR performance for individual testing was compared to pooled testing with the standard COBAS AMPLICOR procedure and subsequently to pooled testing with COBAS AMPLICOR in combination with the MagNA Pure bacterial DNA isolation kit. The sensitivity of COBAS AMPLICOR was 65% on individual and 42% on pooled urines but improved to 92% on pooled urines with the MagNA Pure bacterial DNA isolation kit, making this combination the best screening method. The C. trachomatis prevalence in this population appeared to be 6.4%. Additionally, the cost of the combined MagNA Pure bacterial DNA isolation kit and COBAS AMPLICOR method on pooled urines was only 56% of the cost of the standard COBAS AMPLICOR test applied to individual urines. Costs per positive case detected in the combined method were 39% of standard costs.

Sexually transmitted infections in pregnancy: prevalence, impact on pregnancy outcomes, and approach to treatment in developing countries

Sexually transmitted infections (STIs) are common in the developing world. Management of STIs in pregnancy in many developing countries has, however, been complicated by the lack of simple and affordable diagnostic tests. This review examines the prevalence and impact on pregnancy outcome of STIs in developing countries and recommends approaches to management of STIs in pregnancy for resource poor settings.

Prevalence and risk factors of chlamydia and gonorrhea among rural Nepali women

OBJECTIVES

The epidemiology of sexually transmitted infections (STI) in rural, developing world populations is poorly understood. We estimated the prevalence and risk factors of Neisseria gonorrhoeae and Chlamydia trachomatis in a female population in rural Nepal.

METHODS

We conducted a cross sectional study in a sample of 1177 postpartum women participating in a micronutrient supplementation trial in Nepal. Urine samples were collected to test for the two infections using the ligase chain reaction (LCR).

RESULTS

C trachomatis was detected in 1.0% (95% confidence intervals (CI): 0.4 to 1.5) and N gonorrhoeae in 2.3% (95% CI: 1.2 to 3.4) of women. None of the women tested positive for both. Self report of all three symptoms of lower abdominal pain, pain and burning on urination, and vaginal discharge was associated with the presence of gonorrhoea (odds ratio (OR): 12.1, 95% CI: 1.3 to 115.0). Neonatal eye discharge was associated with maternal gonococcal infection (OR = 5.2, 95% CI: 1.1 to 24.9). Incidence of low birth weight was not related to these maternal infections, but very preterm delivery (<32 weeks) was higher among women positive for gonorrhoea (OR = 4.7, 95% CI: 1.0 to 22.0). In a multivariable analysis, low body mass index (<18.5) and cattle ownership were associated with gonorrhoea (p <0.05), whereas woman's literacy was associated with chlamydia (p = 0.06).

CONCLUSION

We found the rates of N gonorrhoeae and C trachomatis to be low among women in this rural population of Nepal.

Paediatric community-acquired pneumonia: current concept in pharmacological control

Community-acquired pneumonia (CAP) is one of the most frequent infections in childhood but it is not easy to establish a rational therapeutic approach for a number of reasons, including difficulties in identifying the aetiology, the fact that the most frequent bacterial pathogens become resistant to commonly used antibiotics and the lack of certain information concerning the possible preventive role of conjugate vaccines. This leads paediatricians to treat almost all cases of CAP with antibiotics, often using a combination of different antimicrobial classes. In order to avoid unnecessary antibiotic use and limit the spread of antibiotic resistance, consensus guidelines for the management of CAP in childhood should be developed and used by practitioners in their offices and hospitals.