Chlamydia trachomatis lower respiratory tract infection in infants

Evaluating the diagnosis and treatment of Chlamydia trachomatis and Neisseria gonorrhoeae in pregnant women to prevent adverse neonatal consequences in Gaborone, Botswana: protocol for the Maduo study

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are extremely common sexually transmitted infections (STIs) that are associated with adverse birth and neonatal outcomes, and the risk of vertical transmission of CT and NG during delivery is high. The majority of CT and NG infections are asymptomatic and missed by the standard of care in most countries (treatment based on symptoms). Thus, it is likely that missed maternal CT and NG infections contribute to preventable adverse health outcomes among women and children globally. This study aims to assess the effectiveness of CT and NG testing for asymptomatic pregnant women to prevent adverse neonatal outcomes, understand the inflammatory response linking CT and NG infections to adverse neonatal outcomes, and conduct an economic analysis of the CT and NG testing intervention.

METHODS

The Maduo ("results" in Setswana) is a prospective, cluster-controlled trial in Gaborone, Botswana to compare a near point-of-care CT and NG testing and treatment intervention implemented in "study clinics" with standard antenatal care (World Health Organization-endorsed "syndromic management" strategy based on signs and symptoms without laboratory confirmation) implemented in "standard of care clinics" among asymptomatic pregnant women. The primary outcome is vertical transmission of CT/NG infection. Secondary outcomes include preterm birth (delivery < 37 completed weeks of gestation) and/or low birth weight (< 2500 g). The trial will also evaluate immunological and inflammatory markers of adverse neonatal outcomes, as well as the costs and cost-effectiveness of the intervention compared with standard care.

DISCUSSION

The Maduo study will improve our understanding of the effectiveness and cost-effectiveness of CT and NG testing among asymptomatic pregnant women. It will also increase knowledge about the CT/NG-related immune responses that might drive adverse neonatal outcomes. Further, results from this study could encourage expansion of STI testing during antenatal care in low resource settings and improve maternal and neonatal health globally.

TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov (Identifier NCT04955717, First posted: July 9, 2021)).

Chlamydiae in febrile children with respiratory tract symptoms and age-matched controls, Ghana

Members of the Chlamydiales order are obligate intracellular pathogens causing acute and chronic infectious diseases. Chlamydiaceae are established agents of community- and zoonotically acquired respiratory tract infections, and emerging pathogens among the Chlamydia-related bacteria have been implicated in airway infections. The role of both in airway infections in Africa is underexplored. We performed a case -control study on the prevalence of Chlamydiaceae and Chlamydia-related emerging pathogens in children with febrile respiratory tract infections in West Africa, Ghana. Using a pan-Chlamydiales broad-range real-time PCR, we detected chlamydial DNA in 11 (1.9%) of 572 hospitalized febrile children with respiratory tract symptoms and in 24 (4.3%) of 560 asymptomatic age-matched controls (p 0.03). Chlamydiaceae were found to be common among both symptomatic and healthy Ghanaian children, with Chlamydia pneumoniae being the most prevalent species. Parachlamydiaceae were detected in two children without symptoms but not in the symptomatic group. We identified neither Chlamydia psittaci nor Simkania negevensis but a member of a new chlamydial family that shared 90.2% sequence identity with the 16S rRNA gene of the zoonotic pathogen Chlamydia pecorum. In addition, we found a new Chlamydia-related species that belonged to a novel family sharing 91.3% 16S rRNA sequence identity with Candidatus Syngnamydia venezia. The prevalence and spectrum of chlamydial species differed from previous results obtained from children of other geographic regions and our study indicates that both, Chlamydiaceae and Chlamydia-related bacteria, are not clearly linked to clinical symptoms in Ghanaian children.

Neonatal chlamydial infections: prevention and treatment

Neonatal chlamydial infection, which manifests principally as ophthalmia neonatorum (ON) or pneumonia, is a significant cause of neonatal morbidity. Widespread use of silver nitrate drops resulted in a dramatic decline in the incidence of gonococcal ophthalmia but had much less impact on the incidence of neonatal chlamydial infection. Chlamydia trachomatis has become the most common infectious cause of ON in developed countries.A number of prophylactic antibiotic or antiseptic agents have been used to prevent ON. Prophylaxis with 1% silver nitrate ophthalmic drops, 0.5% erythromycin ophthalmic ointment, or 1% tetracycline ointment has comparable efficacy for the prevention of chlamydial ophthalmia but does not offer protection against nasopharyngeal colonization or the development of pneumonia. Erythromycin or tetracycline topically have been used as prophylactic agents because of their allegedly superior activity for the prevention of ON and because they produced less chemical conjunctivitis compared with silver nitrate. However, the relative efficacy of these agents for chlamydial infection and the emergence of beta-lactamase-producing Neisseria gonorrheae has raised questions regarding their effectiveness when applied topically for prophylaxis of ON. Compared with these agents, a 2.5% povidone-iodine ophthalmic solution has been found to have greater efficacy for the prevention of ON generally, and chlamydial ophthalmia specifically. In countries where the incidence of ON is very low, an alternative strategy is to institute prenatal screening and treatment of infected mothers, forgo routine neonatal prophylaxis, and follow-up infants after birth for the possible development of infection. For the treatment of chlamydial ophthalmia or pneumonia, oral erythromycin for 2 weeks is recommended; additional topical therapy is unnecessary. However, in approximately 20-30% of infants, therapy will not eradicate the organism and the infant may require a repeat oral course of antibiotics. The few published studies on the use of the new oral macrolide antibiotics, such as azithromycin, roxithromycin, or clarithromycin for chlamydial infections in neonates suggest that these agents may be effective; however, more data on their tolerability and efficacy in this patient group are warranted.

[Respiratory infection due to Chlamydia trachomatis in infants. Clinical presentation and outcome in 18 patients]

BACKGROUND

Among other diseases, Chlamydia trachomatis causes epididymitis and prostatitis in men and urethritis, cervicitis and pelvic inflammatory disease in women. In children, it most usually causes conjunctivitis and is also responsible for lower respiratory tract disease, occasionally requiring hospital admission.

OBJECTIVE

To draw attention to this disease, which is usually overlooked and which can be potentially serious.

METHODS

We retrospectively reviewed the medical records of infants aged less than 6 months with symptoms of lower respiratory tract disease in whom C. trachomatis antigen was detected by enzyme immunoassay.

RESULTS

We identified 18 patients with C. trachomatis between 1993 and 2002. Of these, 17 patients required hospital admission and five required monitoring in the pediatric intensive care unit. The mean length of hospital stay was 9.6 days. Three patients were immigrants. The mean age at admission was 6.6 weeks. Apnea occurred in five infants. Chest x-ray showed interstitial infiltrates in five infants. Sixteen patients were treated with erythromycin and all made a complete recovery.

CONCLUSIONS

Although lower respiratory tract disease caused by C. trachomatis is usually managed on an outpatient basis, it sometimes requires hospital admission or even management in the intensive care unit. Therefore, C. trachomatis infection should be ruled out in infants aged less than 6 months with clinical symptoms of lower respiratory tract disease for which no other pathogen can be found.