Which women should be tested for Chlamydia trachomatis?

Screening for Chlamydia trachomatis infection among infertile women in Saudi Arabia

BACKGROUND

Chlamydia trachomatis infection is a worldwide-distributed sexually transmitted infection that may lead to infertility.

OBJECTIVES

This study aims to report the prevalence of Chlamydia trachomatis infection among infertile women in Saudi Arabia.

PATIENTS AND METHODS

A community-based study carried out at the obstetrics and gynecology clinic at Jazan General Hospital, Saudi Arabia. The study group included 640 Saudi infertile women who were aged between 18 and 40 years and who attended the gynecology clinic for infertility examination throughout 1 year of study (from July 1, 2011 to June 30, 2012). The randomized control group included 100 Saudi fertile women who attended the obstetrics clinic for routine antenatal care. All recruited women were screened for chlamydia infection by enzyme-linked immunosorbent assay (ELISA) for detection of serum-specific antibodies and then retested by the McCoy cell culture technique.

RESULTS

The prevalence of Chlamydia trachomatis infection among infertile women was high, at 15.0%. The rate of chlamydia infection detected by ELISA was 9.84%, and it was 12.03% by the culture method (P = 0.2443).

CONCLUSION

The high prevalence of Chlamydia trachomatis infection among Saudi infertile women demands a national screening program for early detection among infertile couples. ELISA is available as a simple screening test alternative to the culture method.

Chlamydia in colposcopy clinics: to screen or not to screen?

The objective of the study was to assess the prevalence of Chlamydia trachomatis in our colposcopy clinic. A total of 337 consecutive patients newly referred to the colposcopy clinic between May and November 2003 were screened for chlamydia trachomatis. All our patients were referred by their GPs and none of the patients had had a recent chlamydia test performed. Four patients screened positive, overall giving a prevalence of 1.2% [95% CI 0.04-2.36%]. Three of those with positive results were in the 21 - 30 year age group (139 in the group, which equals 2.2% prevalence [95% CI 0 - 4.6%]). The fourth positive result was in the group over the age of 60. None of those screened in the other age groups was positive (< or =20, 31 - 40, 41 - 50, 51 - 60 years). Numbers screened in each of those groups were: 14, 115, 53 and 12, consecutively. Our study, though small in sample size, supports the view that the prevalence of chlamydia is not high in all colposcopy clinic attenders. Women younger than 30 years old are more likely to be infected than older women; hence opportunistic screening should target this age group. The prevalence rate may be low due to the enzyme linked immunosorbent assay giving a poor detection rate for chlamydia screening.

Chlamydia prevalence and correlates among female adolescents in Hungary

PURPOSE

To evaluate the prevalence and the behavioral and historical determinants of genital chlamydial infection among adolescent females in Hungary.

METHODS

A total of 214 consecutive, unselected, self-referred, sexually active, nonpregnant female individuals aged 16-20 years were evaluated by polymerase chain reaction through the use of questionnaires.

RESULTS

The prevalence of chlamydial infection within this population was 7.9%. We find that the most important correlates of chlamydial infection were at least three lifetime sexual partners (p < .005), two or more sexual partners in the preceding 3 months (p < .05), and symptoms of vaginitis (p = .002).

CONCLUSIONS

The high prevalence of chlamydia in this study population may justify universal testing in Hungary.

Chlamydia screening and treatment in patients undergoing evacuation of retained products of conception or vaginal termination of pregnancy: an audit of the Royal College of Obstetricians and Gynaecologists' Guidelines in practice

OBJECTIVE

To assess compliance with the Royal College of Obstetricians and Gynaecologists Guidelines regarding screening for and treatment of Chlamydia trachomatis before vaginal termination of pregnancy (VTOP) and surgical evacuation of retained products of conception (ERPC).

METHODS

Case notes of women undergoing VTOP and ERPC in the authors' department were examined for evidence of the presence of C. trachomatis infection and identification of chlamydia risk factors, and for evidence of curative treatment for women with confirmed infection or prophylactic treatment for women at risk.

RESULTS

In the VTOP group (n = 30) screening and treatment was carried out satisfactorily, aided by an assessment proforma. In the ERPC group (n = 30) there were weaknesses in the identification and treatment of patients at risk.

CONCLUSIONS

We conclude that the use of a proforma helps to achieve effective screening. Adequate risk assessment of women undergoing ERPC seems to be difficult to achieve and so universal administration of prophylactic antibiotics might be a safe and efficient option until the National Chlamydia Screening Programme is established in our area.

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.

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.

An evaluation of economics and acceptability of screening for Chlamydia trachomatis infection, in women attending antenatal, abortion, colposcopy and family planning clinics in Scotland, UK

OBJECTIVE

The aims of this study were to determine cost effectiveness of screening for Chlamydia trachomatis in hospital-based antenatal and gynaecology clinics, and community-based family planning clinics. Additionally, women's views of screening were determined in the hospital-based clinics.

DESIGN

Cost effectiveness based on decision model. Model probabilities were generated for a hypothetical sample of 250 women in each age group in each setting, based on prevalence studies, published data and expert opinion. A prospective observational study was used to generate data on prevalence and acceptability.

SETTING

Antenatal, gynaecology and family planning clinics in Aberdeen, Edinburgh and Glasgow.

SAMPLE

Prevalence was estimated in 2817 women. Acceptability was determined in 484 women.

METHODS

An economic evaluation was performed using prevalence data from this and a previous study, and using outcome data from the literature and observational work. Incremental cost effectiveness ratios were estimated for each age group and clinical setting. Sensitivity analyses were performed to determine the robustness of incremental cost effectiveness ratios to changes in the incidence of long term sequelae and costs. The prevalence of infection was determined by nucleic acid amplification of urine samples or endocervical swabs. Knowledge of C. trachomatis and women's views of screening were determined using structured questionnaires.

MAIN OUTCOME MEASURES

Direct health service costs of screening, incidence and costs associated with adverse sequelae, women's views of screening and prevalence of infection.

RESULTS

The estimated cost of screening 250 women in each age group in each the four sample populations (total population of 3750) is 49,367 UK pounds, while preventing 64 major sequelae. This represents a net cost of 771.36 UK pounds in preventing one major sequela. Selective screening of all women under 20 years and all patients attending abortion clinics were shown to be the most cost effective strategies. These results were relatively insensitive to changes in estimated parameters, such as uptake rate, probabilities and unit costs of all major sequelae averted. Prevalence (95% CI) of infection in the highest risk groups (those aged under 20 in both antenatal and abortion clinics) was 12.1% (8.6-16.7) and 12.7% (7.3-21.2), respectively. The majority (>95%) of women agreed with a policy of regular screening for C. trachomatis, and screening in the settings employed in this study was largely acceptable.

CONCLUSIONS

A single episode of screening for C. trachomatis does not result in net cost savings. Currently recommended strategies of screening for C. trachomatis in women under 25 years of age in abortion clinics are supported by our data on prevalence and acceptability. These data also suggest that hospital-based screening strategies should be further extended to include younger women attending antenatal clinics and all women of reproductive age attending colposcopy clinics.

Chlamydia trachomatis in the United Kingdom: a systematic review and analysis of prevalence studies

OBJECTIVES

To undertake a systematic review to obtain estimates of genital Chlamydia trachomatis prevalence in various populations in the United Kingdom and Ireland; to determine which populations have the highest rates of infection; and to explore the most important determinants of infection.

METHODS

Electronic databases were searched using the keywords "chlamydia" and "England," "Wales," "UK," "Scotland," "Ireland," or "Britain." Additional unpublished data and references were solicited from experts. Studies were included in the analysis if C trachomatis prevalence was reported, and if they met inclusion criteria. Nine variables identified as potentially important descriptors of chlamydia prevalence were extracted from each study and analysed using various logistic regression models. Only studies reporting prevalence in female populations were included in the models, because there were few data from males.

RESULTS

357 studies were identified using the search methods, 90 of which met inclusion criteria, and 19 of which contributed to the final model. The most influential variables on prevalence were age and setting of the population tested. In general practice surgeries, the under 20 year old age group had an estimated prevalence of 8.1% (95% CI 6.5 to 9.9), 20-24 year olds 5.2% (95% CI 4.3 to 6.3), 25-29 year olds 2.6% (95% CI 2.0 to 3.3), decreasing to 1.4% (95% CI 1.0 to 1.9) in those aged over 30 years. Overall, healthcare settings had higher prevalence estimates than population based studies. For example, among under 20 year olds, estimates were 17.3% (95% CI 13.6 to 21.8) in genitourinary medicine clinics, 12.6% (95% CI 6.4 to 23.2) in antenatal clinics, 12.3% (95% CI 9.8 to 15.3) in termination of pregnancy clinics, 10.7% (95% CI 8.3 to 13.8) in youth clinics, 10.0% (95% CI 8.7 to 11.5) in family planning clinics, and 8.1% (95% CI 6.5 to 9.9) in general practice, compared to 5.0% (95% CI 3.2 to 7.6) in population based studies. The type of test, specimen used, date, and location of test were not strongly associated with chlamydia prevalence.

CONCLUSION

The chlamydia prevalence estimates by age and setting from the model may be used to inform chlamydia screening strategies. The systematic review revealed much heterogeneity in the studies identified, but with clear patterns of prevalence. It also indicated gaps in the knowledge about chlamydia prevalence in certain subgroups such as men and the general population.

Opportunistic screening for genital Chlamydia trachomatis infection and partner follow-up in family planning clinics in three Scottish cities

Three large urban family planning clinics (FPCs) in Scotland participated in a study to examine the implications of opportunistically offering urine testing for genital Chlamydia trachomatis infection and FPC follow-up of positive women and of their male partners. Ninety-eight percent (3029) of women accepted the test. The prevalence of infection was 5.2% and this decreased significantly with age. There was no significant difference in prevalence between centres. Ninety-one percent of positive women intended to inform at least one partner about their infection status. Pretest counselling took about 10 minutes per woman while management (excluding full screening for sexually transmitted infections) of positive women took an additional 10 minutes. Screening in the FPC is acceptable to many women and to some of their male partners. Training and resources for administration and staffing are required if opportunistic screening is to be implemented.

Parallel observation of four methods for screening women under 25 years of age for genital infection with Chlamydia trachomatis

OBJECTIVES

To compare four methods of screening women for Chlamydia trachomatis in an obstetrics and gynaecology department.

STUDY DESIGN

A total of 303 healthy women under 25 years were recruited from antenatal, induced abortion, and family planning clinics. Each underwent parallel testing of endocervical specimens by enzyme immunoassay (EIA) and ligase chain reaction (LCR), vulval swabs by LCR, and urine by LCR. Outcome measures included sensitivity, specificity, acceptability of each method, and the influence of pregnancy.

RESULTS

Overall prevalence (95% CI) was 9.9% (6.8-14%). All methods had a high rate of detection (75-100%), not affected by pregnancy. Urine was most acceptable, followed by vulval swabbing.

CONCLUSIONS

Opportunistic screening of women under 25 years attending obstetric and gynaecology affiliated clinics found high rates of C. trachomatis infection. Both urine and vulval swab methods were highly sensitive, acceptable, and not affected by pregnancy status. Due to pragmatic issues surrounding the urine method, screening by vulval swabs deserves wider recognition.

Opportunistic screening for genital chlamydial infection. II: prevalence among healthcare attenders, outcome, and evaluation of positive cases

OBJECTIVES

To determine the prevalence and treatment outcomes among young women screened opportunistically for genital Chlamydia trachomatis and to evaluate the impact of screening in those participating.

DESIGN

An opportunistic screening programme (1 September 1999 to 31 August 2000) using urine samples, tested by ligase chain reaction (LCR). In-depth interviews were used for programme evaluation.

SETTING

Screening was offered in two health authorities at general practice, family planning, genitourinary medicine (GUM), adolescent sexual health, termination of pregnancy clinics and women's services in hospitals (antenatal, colposcopy, gynaecology and infertility clinics). Main participants: Sexually active women (16-24 years) attending for any reason.

MAIN OUTCOME MEASURES

Screening data: prevalence of infection by age and healthcare setting; proportion of positive patients attending for treatment. Evaluation data: participants' attitudes and views towards screening and follow up.

RESULTS

In total, 16 930 women (16-24 years) were screened. Prevalence was higher in younger women (16-20) than those aged 21-24 years and was highly variable at different healthcare settings (range 3.4%-17.6%). Prevalence was approximately 9% in general practice. The role of the project health advisers in managing results and coordinating treatment of positive individuals was essential; the vast majority of all positives were known to be treated. Women felt that screening was beneficial. Improving awareness and education about sexually transmitted infections is required to alleviate negative reactions associated with testing positive for infection.

CONCLUSIONS

Prevalence of infection outside GUM clinics is substantial and opportunistic screening using urine samples is an acceptable method of reaching individuals with infection who do not normally present at specialist clinics.

Should all sexually active young women in Hungary be screened for Chlamydia trachomatis?

OBJECTIVE

Cost-effectiveness analysis was carried out to develop screening strategy for Chlamydia trachomatis to assess the possibility of preventing pelvic inflammatory disease and its sequelae.

STUDY DESIGN

An 18 months epidemiological study of prevalence of chlamydial infection among pregnant women was carried out in Hungary.

RESULTS

The policy of testing and treating was less cost-effective than neither testing nor treating, unless the cost of the diagnostic test were less than or equal to US$ 10, or the prevalence of infection in women were greater than 8.3.

CONCLUSIONS

Since the prevalence of chlamydial infection amongst 15-24 years old women in this study was 8.0%, the cost of screening in Hungary only barely outweighs the benefit in economic terms. Given the undesirable potential consequences of the infection, it is thus recommended that Hungarian clinicians should screen all young, sexually active women for C. trachomatis at the same time as they perform routine pelvic examinations.

Clinical characteristics of Chlamydia trachomatis infections in a general outpatient department of obstetrics and gynaecology in the Netherlands

OBJECTIVE

Evaluation of prevalence and risk factors of Chlamydia trachomatis infections in an outpatient obstetric and gynaecological population.

METHODS

A prospective, observational study was performed at an inner city hospital in The Hague, Netherlands. 1368 women attending the outpatient department of obstetrics and gynaecology participated in the study. For detection of C trachomatis infections we used amplification of CT rRNA in urine samples (Gen Probe/AMPLIFIED-CT) and DNA probe for detection of CT rRNA from a urethral, endocervical and anal swab (Gen Probe/PACE 2).

RESULTS

The overall prevalence of C trachomatis infections in our general obstetric and gynaecological population was 4.5%. The prevalence in women under 30 years of age was 8. 1%. We found age and postcoital bleeding to be significant risk factors. We did not find significant differences between women from different ethnic origin or between women using different kinds of contraceptives. 12 (19.4%) patients with C trachomatis infections were found positive by urine test only, and 15 (24.2%) only by DNA probe.

CONCLUSIONS

Age is the most important risk factor in our population (overall prevalence 4.5%, prevalence in women under 20 years of age 15.8%). Analyses of urine and of endocervical specimens are complementary for the determination of the prevalence of C trachomatis infections in women. Cost effectiveness analysis is needed to determine to what extent age based screening and/or antibiotic prophylaxis before intrauterine manipulations is indicated.

[Is extrauterine pregnancy a complication of chlamydial infection?]

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Screening for Chlamydia trachomatis infection is indicated for women under 30 using emergency contraception

A total of 838 women attending a large family planning clinic in Scotland for emergency contraception were offered screening for Chlamydia trachomatis infection. 569 were screened using ligase chain reaction test in first void urine at the time of presenting for emergency contraception and were retested 1 or 2 weeks later. Women aged under 20 and over 30 years were significantly more likely to decline to be tested than women aged 20 to 30. The prevalence of chlamydia was 7.6% in woman aged 24 or less, 5.3% in women aged 25 to 29, and 1.2% in women aged 30 or more. Only two women (< 1%) who tested negative at the time of using EC were positive 1 or 2 weeks later. Women under age 30 who use EC should be offered screening for chlamydia infection and testing at the time they attend for EC is adequate to detect the great majority of infected women.

Chlamydia trachomatis in subfertile women undergoing uterine instrumentation. The clinician's role

Most women attending a fertility clinic will undergo uterine instrumentation either diagnostically and/or therapeutically. This places them at potential risk of chlamydial pelvic inflammatory disease. Clinicians remain unclear about the roles of screening, serology and prophylactic antibiotics. A review of the evidence suggests that women <25 years and those older with risk factors, men with risk factors and gamete donors should have their lower genital tract screened for Chlamydia trachomatis by a sensitive test. More information is required before screening men by age can be recommended. Serology in its present form cannot be advocated as a screening tool. Those women with a past history of chlamydial morbidity or a diagnosis of tubal pathology should, in addition to screening, be covered with prophylactic antibiotics when undergoing uterine instrumentation. The partner should be screened for sexually transmitted infections. Non-selective use of prophylactic antibiotics serves only to increase the problem of antibiotic resistance and maintain the bacterial load of chlamydia in the community.

Chlamydia screening in primary care: is it useful, affordable and universal?

Genital chlamydial infection, with its possible long-term morbidity, is a serious public health problem. The number of new diagnoses is rising rapidly and, in the UK, recent evidence suggests that the infection rate in young women exceeds 10%. Screening programmes can reduce the population prevalence of infection, but uncertainty remains as to the ideal screening model. This may prove to be opportunistic screening of sexually active young women, less than 25 years of age, in primary care settings, and contact tracing of the partners of those with chlamydia. Recent literature on the practicalities of genital chlamydia screening is reviewed.

Chlamydia during pregnancy: implications and impact on perinatal and neonatal outcomes

Chlamydia is the most prevalent sexually transmitted disease in the United States, with an estimated 3 million cases occurring annually. Untreated Chlamydia can cause severe, costly reproductive and other health problems with both short- and long-term consequences. When Chlamydia coexists with pregnancy, it can have negative consequences for the woman, the pregnancy, and the newborn. Nurses are in important positions to ensure safe health care practices for all pregnant women. Awareness of the perinatal implications and routine screening for Chlamydia in pregnant women will provide safer health care for the mother and her baby.