Chlamydia trachomatis infection in Sydney women

The Performance of the Vaginal Discharge Syndromic Management in Treating Vaginal and Cervical Infection: A Systematic Review and Meta-Analysis

Background

This review aimed to synthesize and analyze the diagnostic accuracy and the likelihood of providing correct treatment of the syndromic approach Vaginal Discharge Flowchart in managing cervical infections caused by Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT), and vaginal infections caused by Trichomonas vaginalis (TV) and Bacterial vaginosis (BV) and Candida albicans. This review will inform updating the WHO 2003 guidelines on Vaginal Discharge syndromic case management.

Methods

A systematic review was conducted on published studies from 01-01-2000 to 30-03-2015 in multiple databases. Studies evaluating the diagnostic accuracy and validation of the WHO Vaginal Discharge Flowchart were included. Validation parameters including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) and the 95% confidence intervals for the different types of the flowchart were taken as outcomes, re-calculated, and analysed using a fixed model meta-analysis for data pooling. The level of agreement between the index and reference test were determined by the Cohen’s Kappa co-efficiency test. Each individual study was assessed on quality using the QUADAS-2 tool.

Findings

The search yielded 2,845 studies of which 16 met the eligibility criteria for final analysis. The diagnostic performance to identify cervical infections was low and resulted in a high proportion of over and missed treatment. The four flowcharts had a sensitivity between 27.37% in history and risk assessment and 90.13% with microscopy, with the inverse in specificity rates. The treatment performances between the flowcharts were inconsistent. The same applies to the use of vaginal discharge flowchart for treating vaginal infections. For vaginal infections the vaginal discharge flowchart had a good performance in flowchart 3 with 91.68% of sensitivity; 99.97% specificity; 99.93% PPV and 0.02% who missed their treatment and 8.32% of women who were over treated by the vaginal discharge flowchart

Conclusion

The vaginal discharge flowchart should focus on management of vaginal infection. It could be used as an intermediate approach for cervical infections for sex workers until a point of care test is available in resource poor settings.

Chlamydia infection in individuals reporting contact with sexual partners with chlamydia: a cross-sectional study of sexual health clinic attendees

OBJECTIVES

We aimed to ascertain the proportion of positive, and predictive factors of chlamydia infection among females, heterosexual males and men who have sex with men (MSM) presenting to a sexual health service reporting contact with a chlamydia infected sexual partner.

METHODS

A cross-sectional analysis of patients attending the Melbourne Sexual Health Centre from October 2010 to September 2013. Behavioural data obtained using computer assisted self-interview were analysed to determine factors predictive of chlamydia.

RESULTS

Of the 491 female, 808 heterosexual male, and 268 MSM chlamydia contacts, the proportion diagnosed with chlamydia were 39.9% (95% CI 35.7% to 44.3%), 36.1% (95% CI 32.9% to 39.9%) and 23.5% (95% CI 18.8% to 29.0%), respectively. Female chlamydia contacts were more likely to have chlamydia if age <25 (adjusted OR (AOR) 1.86, 95% CI 1.12 to 3.10) or if they reported inconsistent condom use during vaginal sex with a regular male partner (AOR 2.5, 95% CI 1.12 to 6.14). Heterosexual male contacts were more likely to have chlamydia if age <25 (AOR 1.69, 95% CI 1.25 to 2.28) or if they had a regular female sexual partner (AOR 1.38, 95% CI 1.03 to 1.85). In MSM urethral chlamydia was diagnosed in 8.8%, rectal chlamydia in 20.2%, and 3.9% at both sites. MSM were more likely to have chlamydia if they had a regular male sexual partner (OR 2.12, 95% CI 1.18 to 3.81).

CONCLUSIONS

This study of female, heterosexual male, and MSM presentations with self-reported chlamydia contact provides insight into the likelihood and predictive factors of infection. The data may inform policy and individual clinical decision making regarding presumptive treatment of chlamydia contacts.

Predictors identifying those at increased risk for STDs: a theory-guided review of empirical literature and clinical guidelines

SummarySexually transmitted diseases (STDs) are leading causes of substantial morbidity worldwide. Identification of risk factors for estimating STD risk provides opportunities for optimising service delivery in clinical settings, including improving case finding accuracy and increasing cost-efficiency by limiting the testing of low-risk individuals. The current study was undertaken to synthesise the evidence supporting commonly cited chlamydia and gonorrhoea risk factors. The level of empirical support for the following predictors was strong/moderate: age, race/ethnicity, multiple lifetime sexual partners, sex with symptomatic partners and concurrent STD diagnosis. The following predictors had weak evidence: socio-economic status, transactional sex, drug/alcohol use, condom use and history of STD diagnosis. The most frequently listed predictors among nine clinical guidelines were younger age and multiple sexual partners; the least consistently listed predictor was inconsistent condom use. We found reasonably good concordance between risk factors consistently listed in the recommendations and predictors found to have strong empirical support in the literature. There is a need to continue building the evidence base to explicate the mechanisms and pathways of STD acquisition. We recommend periodic reviews of the level of support of predictors included in clinical guidelines to ensure that they are in accordance with empirical evidence.

Chlamydia trends in men who have sex with men attending sexual health services in Australia, 2004-2008

BACKGROUND

In most Australian settings, chlamydia notifications do not contain information on the gender of sexual partners. We assessed trends and predictors of chlamydia testing and positivity among men who have sex with men (MSM), attending sexual health services in Australia.

METHODS

The Australian Collaboration for Chlamydia Enhanced Sentinel Surveillance (ACCESS) program was established in 2008 to collate demographic and chlamydia testing information from 25 sexual health services. We calculated the proportion tested and chlamydia positivity among MSM and assessed trends from 2004 to 2008 using a χ2 test and predictors using logistic regression.

RESULTS

In the 5-year period, 11,777 MSM attended as new patients (first visit ever to the service) and the proportion tested for chlamydia increased significantly from 71% in 2004 to 79% in 2008 (P < 0.01). Independent predictors of chlamydia testing were younger age, residing in a metropolitan area (adjusted prevalence ratio [APR] = 1.23; 95% confidence interval [CI]: 1.19, 1.27), being Australian-born (APR = 1.03; 95% CI: 1.01, 1.06), being a traveler or migrant (APR = 1.09; 95% CI: 1.06, 1.12), and sex overseas in the past year (APR = 1.05; 95% CI: 1.03, 1.07). Overall chlamydia positivity was 8.6% (95% CI: 8.0%-9.2%). There was no significant trend in chlamydia positivity between 2004 and 2008. Independent predictors of chlamydia positivity were younger age, being a traveler or migrant (APR = 1.52; 95% CI: 1.26-1.84), and exclusive same-sex contact (APR = 1.28; 95% CI: 1.05-1.55).

CONCLUSIONS

This new national surveillance program demonstrates that the majority of MSM attending sexual health services was offered chlamydia testing and testing has increased over time. The MSM at highest risk of chlamydia were more likely to be tested. Chlamydia transmission was frequent but stable among MSM accessing clinical services.

Correlates of Chlamydia trachomatis infection in a primary care sentinel surveillance network

Background Chlamydia is the most commonly notified infection in Australia. Prevention strategies should be informed by routine data on at-risk populations. Methods: We calculated chlamydia positivity and correlates of infection using multivariable logistic regression for data collected between April 2006 and June 2009. Results: Chlamydia positivity was 5.6% in 12 233 females, 7.7% in 10 316 heterosexual males and 6.2% in 7872 men who have sex with men (MSM). Correlates of chlamydia positivity among females included younger age (odds ratio (OR) 2.27, 95% confidence interval (CI) 1.92–2.69), being born overseas (OR 1.50, 95% CI 1.25–1.82), multiple sex partners in the past year (OR 1.72, 95% CI 1.40–2.11) and inconsistent condom use with regular sex partners (OR 3.44 ,95% CI 1.65–7.20). Sex work was protective for females (OR 0.68, 95% CI 0.53–0.86). Among heterosexual males, correlates of positivity were younger age (OR 1.87, 95% CI 1.62–2.17), being born overseas (OR 1.35, 95% CI 1.16–1.58), symptoms at the time of testing (OR 1.64, 95% CI 1.40–1.92) and multiple sex partners in the past year (OR 1.83, 95% CI 1.46–2.30). Correlates of positivity among MSM were being born overseas (OR 1.23, 95% CI 1.00–1.51), being HIV-positive (OR 1.80, 95%CI 1.32–2.47), and reporting six or more anal sex partners in the past 6 months (OR 4.45, 95% CI 1.37–14.5). Conclusions: Our analysis identified subgroups at the highest risk of chlamydia in Victoria. These estimates will provide important baseline information to measure the impact of chlamydia control strategies.

Trichomonas vaginalis infection among women in a low prevalence setting

Objectives: Trichomonas vaginalis has become rare in Australian cities but remains endemic in some remote regions. We describe the prevalence and associations of infection among women attending an urban Australian sexual health clinic. Methods: A retrospective case control study was conducted with women diagnosed with T. vaginalis at Sydney Sexual Health Centre between January 1992 and December 2006. Proforma medical records for all women were reviewed to extract demographic, behavioural and diagnostic variables using a predefined data collection instrument. Results: Over the 15-year period, 123 cases of T. vaginalis were diagnosed, with a prevalence of 0.40%. Factors independently associated with infection were older age, vaginitis symptoms (adjusted odds ratio (AOR) 6.47; 95% confidence interval (CI), 3.29–12.7), sex with a partner from outside Australia (AOR 2.33; 95% CI, 1.18–4.62), a concurrent (AOR 3.65; 95% CI, 1.23–10.8) or past (AOR 2.67; 95% CI, 1.28–5.57) sexually transmissible infection, injecting drugs (AOR 7.27; 95% CI, 1.43–36.8), and never having had a Papanicolaou smear (AOR 7.22; 95% CI, 2.81–18.9). Conclusions: T. vaginalis infection was rare in women attending our urban clinic. Rarity, combined with an association with sex outside Australia, points to imported infections accounting for a large proportion of T. vaginalis infections in an urban population. The association with never having had cervical cancer screening, along with injecting drug use, likely reflects an increased prevalence in those with reduced access to health services or poor health seeking behaviours.

Chlamydia at an inner metropolitan sexual health service in Sydney, NSW: Australian Collaboration for Chlamydia Enhanced Sentinel Surveillance (ACCESS) Project

Background: Australia has a widely dispersed network of public sexual health services that test large numbers of people from high prevalence populations for genital Chlamydia trachomatis infection. These populations include young sexually active heterosexuals, men who have sex with men, sex workers and Aboriginal and Torres Strait Islander people. The Australian Collaboration for Chlamydia Enhanced Sentinel Surveillance (ACCESS) Project was established to monitor chlamydia testing rates and positivity rates at a national level, which in turn will help interpret trends in chlamydia diagnoses reported through passive surveillance. The ACCESS Project is the first time that chlamydia-related data including priority population and testing denominators has been collated at a national level. The present paper reports on chlamydia testing and positivity rates in a sexual health service in the inner west of Sydney between 2004 and 2008 and compares these to published national data from the ACCESS Project in sexual health services. Methods: Chlamydia positivity and testing rates at an inner western Sydney sexual health service were compared with aggregate data from the ACCESS Project obtained from 14 sexual health services across Australia. Using a standardised extraction program, retrospective de-identified line-listed demographic and chlamydia testing data on all patients were extracted from patient management systems. Results: Over the 5-year period, 5145 new patients attended the inner-west sexual health service. Almost 66% had a chlamydia test at first visit and there was no significant difference in this testing rate when compared with the ACCESS Project national rate for sexual health services (67.0%; odds ratio [OR] 0.94, 95% confidence intervals 0.88–1.00). The testing rate increased over time from 61% in 2004 to 70% in 2008. There were 281 chlamydia diagnoses at this service, giving an overall chlamydia positivity rate of 9.3%, significantly higher than the ACCESS Project national rate of 8.2% (OR 1.16, 95% confidence intervals 1.02–1.32). Discussion: Testing rates were similar and positivity rates for Chlamydia trachomatis were higher in this sexual health service in Sydney than national trends.

Postcoital bleeding: a study of the current practice amongst consultants in the United Kingdom

OBJECTIVES

To measure the variations amongst consultant gynaecologists all over the UK in managing women with postcoital bleeding (PCB).

STUDY DESIGN

A questionnaire was sent to 1020 consultant gynaecologists in the UK, using the database of The Royal College of Obstetricians and Gynaecologists, enquiring about their opinions and the details of practice.

RESULTS

Six hundred and fourteen (60%) replies were received. Three hundred and thirty-seven (59.8%) of the respondents agree that PCB is a significant clinical issue that requires developing national guidelines for management, 452 (80.1%) do not have local guidelines in their departments, 336 (59.6%) agree with The Department of Health guidelines for referral. Two hundred and eighty-one (49.8%) respondents see women in gynaecology clinic, 94 (16.7%) in colposcopy clinic, while 163 (28.9%) see them in either clinics depending on the workload. Only 275 (48.8%) respondents repeat the cervical smear for those with negative smear history who are still within the national screening interval. Chlamydia testing is performed by 450 (79.8%) respondents, whereas 68 (12.1%) consider investigating the endometrium in selected cases.

CONCLUSION

The results highlight the wide variations in managing women with PCB. Given the well-reported association with serious pathology, it may be prudent to standardise the management in the UK based on the best available evidence.

Auditing the Use of Colposcopy Versus General Gynecology Clinics to Investigate Women With Postcoital or Intermenstrual Bleeding

OBJECTIVE

The aim of this audit was to determine whether initial referral to a general gynecology clinic (GOPD) or a colposcopy clinic is the most efficient means of managing women with postcoital (PCB) or intermenstrual (IMB) bleeding.

MATERIALS AND METHODS

A prospective audit of women with PCB or IMB was conducted. Sixty referrals from primary care were note-logged and alternatively allocated to either clinic. Data were collected by case note review.

RESULTS

Sixty women were referred for abnormal bleeding, 33 (55%) of which were seen at the GOPD and 27 (45%) at the colposcopy clinic. Investigations included Chlamydia testing, which was deficient in both settings, whereas ultrasound scans and hysteroscopies were performed in 9% of patients attending the GOPD compared with none in the colposcopy clinic. The most common finding at the GOPD was cervical ectopy in 14 (42%) patients. No abnormality was found in 9 (28%) patients. At colposcopy, 14 (52%) had no abnormality detected, whereas 8 (30%) had cervical ectopy and 3 (11%) had cervical intraepithelial neoplasia. There were no cases of malignancy found in this study.

CONCLUSION

Most patients with PCB and IMB will not have a serious abnormality. Our study proposes that a new PCB/IMB outpatient service can improve the efficiency of treatment of these women by providing appropriate guidelines to standardize their care.