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Zhang Y, Vodstrcil LA, Htaik K, Plummer EL, De Petra V, Sen MG, Williamson DA, Owlad M, Murray G, Chow EP, Fairley CK, Bradshaw CS, Ong JJ. Economic evaluation alongside a clinical trial of near-to-patient testing for sexually transmitted infections. J Infect Public Health 2024; 17:102447. [PMID: 38824739 DOI: 10.1016/j.jiph.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 04/30/2024] [Accepted: 05/05/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Current clinical care for common bacterial STIs (Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Mycoplasma genitalium (MG)) involves empiric antimicrobial therapy when clients are symptomatic, or if asymptomatic, waiting for laboratory testing and recall if indicated. Near-to-patient testing (NPT) can improve pathogen-specific prescribing and reduce unnecessary or inappropriate antibiotic use in treating sexually transmitted infections (STI) by providing same-day delivery of results and treatment. METHODS We compared the economic cost of NPT to current clinic practice for managing clients with suspected proctitis, non-gonococcal urethritis (NGU), or as an STI contact, from a health provider's perspective. With a microsimulation of 1000 clients, we calculated the cost per client tested and per STI- and pathogen- detected for each testing strategy. Sensitivity analyses were conducted to assess the robustness of the main outcomes. Costs are reported as Australian dollars (2023). RESULTS In the standard care arm, cost per client tested for proctitis, NGU in men who have sex with men (MSM) and heterosexual men were the highest at $247.96 (95% Prediction Interval (PI): 246.77-249.15), $204.23 (95% PI: 202.70-205.75) and $195.01 (95% PI: 193.81-196.21) respectively. Comparatively, in the NPT arm, it costs $162.36 (95% PI: 161.43-163.28), $158.39 (95% PI: 157.62-159.15) and $149.17 (95% PI: 148.62-149.73), respectively. Using NPT resulted in cost savings of 34.52%, 22.45% and 23.51%, respectively. Among all the testing strategies, substantial difference in cost per client tested between the standard care arm and the NPT arm was observed for contacts of CT or NG, varying from 27.37% to 35.28%. CONCLUSION We found that NPT is cost-saving compared with standard clinical care for individuals with STI symptoms and sexual contacts of CT, NG, and MG.
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Affiliation(s)
- Ying Zhang
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Lenka A Vodstrcil
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kay Htaik
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Erica L Plummer
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Vesna De Petra
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity at The University of Melbourne, Melbourne, Victoria, Australia
| | - Melodi G Sen
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity at The University of Melbourne, Melbourne, Victoria, Australia
| | - Deborah A Williamson
- Department of Infectious Diseases, The University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia; Victorian Infectious Diseases Reference Laboratory, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Monica Owlad
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Gerald Murray
- Murdoch Children's Research Institute, Parkville, Victoria, Australia; Women's Centre for Infectious Diseases, The Royal Women's Hospital, Parkville, Victoria, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
| | - Eric Pf Chow
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher K Fairley
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Catriona S Bradshaw
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jason J Ong
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.
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Wong A, Applegate T, Boettiger DC, Varma R, Guy R, Medland N. Unnecessary antibiotic use in men who have sex with men (MSM) with anogenital symptoms attending a sexual health clinic: a retrospective analysis. Sex Transm Infect 2024:sextrans-2024-056120. [PMID: 38871452 DOI: 10.1136/sextrans-2024-056120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 05/29/2024] [Indexed: 06/15/2024] Open
Abstract
OBJECTIVES To quantify the amount of unnecessary antibiotics, in particular ceftriaxone, given to men who have sex with men (MSM) with anogenital symptoms as part of presumptive management in an urban sexual health clinic and examine factors associated with unnecessary ceftriaxone. METHODS This is a retrospective cross-sectional analysis of electronic records from all visits involving MSM reporting symptoms of bacterial sexually transmitted infection (STI) and who received presumptive antibiotics at Sydney Sexual Health Centre. The following variables were extracted: demographic and sexual behaviour data, presenting symptoms, prior STI diagnoses, use of anoscopy, use of point-of-care microscopy, prescriptions of antibiotics and subsequent nucleic acid amplification testing (NAAT) results for chlamydia and gonorrhoea in all anatomical sites (urethra, pharynx and rectum). We defined unnecessary antibiotic as an agent prescribed to treat an STI organism that was subsequently not detected. RESULTS Among 1061 visits in this analysis, 41.8% yielded negative NAAT results for both chlamydia and gonorrhoea in all anatomical sites. There were 44.3% of visits which had positive gonorrhoea NAAT result in at least one anatomical site. There were 187 courses of ceftriaxone prescribed in patients who tested negative for gonorrhoea in all anatomical sites and therefore were unnecessary. Unnecessary ceftriaxone prescribing occurred in 50.2% of visits with anorectal symptoms, 19.6% of scrotal symptoms and 7.3% of urethral symptoms. Microscopy was associated with significantly less unnecessary ceftriaxone in urethral but not anorectal or scrotal presentations. In multivariable analysis, the following factors were associated with a higher likelihood of unnecessary ceftriaxone use: anorectal symptoms, scrotal symptoms, gonorrhoea in the preceding year, contact of a bacterial STI and living with HIV. CONCLUSIONS This study highlights the significant amount of unnecessary ceftriaxone used for STI symptoms in MSM. A new pathway incorporating rapid point-of-care molecular testing in symptomatic patients may improve the precision of antibiotic prescribing and reduce unnecessary use.
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Affiliation(s)
- Arthur Wong
- Sydney Sexual Health Centre, Sydney, New South Wales, Australia
- The Kirby Institute, Kensington, New South Wales, Australia
| | | | | | - Rick Varma
- Sydney Sexual Health Centre, Sydney, New South Wales, Australia
- The Kirby Institute, Kensington, New South Wales, Australia
| | - Rebecca Guy
- The Kirby Institute, Kensington, New South Wales, Australia
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Gleeson B, Piton J, Mazzola L, McHugh S, Bender J, Lear M, Gavrikova T, Van Der Pol B, Daniels B, Osborn J, Dailey P, Ferreyra C. Development of a Novel Fluorescent-Based Lateral Flow Assay for the Detection of Neisseria gonorrhoeae at the Point of Care. Sex Transm Dis 2024; 51:186-191. [PMID: 38412465 DOI: 10.1097/olq.0000000000001913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Neisseria gonorrhoeae (NG) has acquired significant resistance, primarily due to extensive and unwarranted antibiotic utilization over several decades. This resistance has largely been associated with the syndromic management of sexually transmitted infections, particularly in low- and middle-income countries where affordable point of care tests are unavailable. To address this diagnostic gap, FIND has developed a low-cost lateral flow assay for the detection of NG at the point of care. METHODS The early performance of the lateral flow assay was evaluated using frozen clinical samples. Limit of detection, inclusivity, and exclusivity studies were performed using well-characterized NG strains, common commensal genital microorganisms, and other Neisseria bacteria. Subsequently, clinical performance was evaluated at 2 sexual health clinics in Birmingham, Alabama. RESULTS The observed limit of detection with reference NG strains was 5 × 103 CFU/mL. Inclusivity was demonstrated for 31 NG strains. Exclusivity testing showed no cross-reactivity with 28 non-Neisseria and nongonococcal Neisseria species; cross-reactivity was observed with Neisseria meningitidis, Neisseria lactamica, and Neisseria polysaccharea. The lateral flow assay demonstrated clinical sensitivity and specificity of 78.6% and 100% in female vaginal swabs and 100% and 89.7% in male urine, respectively. CONCLUSIONS FIND has developed a lateral flow assay that aligns with the majority of the World Health Organization Target Product Profile criteria for confirming or excluding NG infection at the point of care. The NG lateral flow assay has now achieved design freeze (final device optimization) and is ready for technology transfer to a manufacturing partner. This test has the potential to support the shift in patient management from a syndromic to an etiological approach.
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Affiliation(s)
| | | | | | | | | | | | - Tatyana Gavrikova
- UAB Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Barbara Van Der Pol
- UAB Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Brice Daniels
- UAB Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
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Grebely J, Matthews S, Causer LM, Feld JJ, Cunningham P, Dore GJ, Applegate TL. We have reached single-visit testing, diagnosis, and treatment for hepatitis C infection, now what? Expert Rev Mol Diagn 2024; 24:177-191. [PMID: 38173401 DOI: 10.1080/14737159.2023.2292645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Progress toward hepatitis C virus (HCV) elimination is impeded by low testing and treatment due to the current diagnostic pathway requiring multiple visits leading to loss to follow-up. Point-of-care testing technologies capable of detecting current HCV infection in one hour are a 'game-changer.' These tests enable diagnosis and treatment in a single visit, overcoming the barrier of multiple visits that frequently leads to loss to follow-up. Combining point-of-care HCV antibody and RNA tests should improve cost-effectiveness, patient/provider acceptability, and testing efficiency. However, implementing HCV point-of-care testing programs at scale requires multiple considerations. AREAS COVERED This commentary explores the need for point-of-care HCV tests, diagnostic strategies to improve HCV testing, key considerations for implementing point-of-care HCV testing programs, and remaining challenges for point-of-care testing (including operator training, quality management, connectivity and reporting systems, regulatory approval processes, and the need for more efficient tests). EXPERT OPINION It is exciting that single-visit testing, diagnosis, and treatment for HCV infection have been achieved. Innovations afforded through COVID-19 should facilitate the accelerated development of low-cost, rapid, and accurate tests to improve HCV testing. The next challenge will be to address barriers and facilitators for implementing point-of-care testing to deliver them at scale.
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Affiliation(s)
- Jason Grebely
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
| | - Susan Matthews
- Flinders University International Centre for Point-of-Care Testing, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia
| | - Louise M Causer
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
| | - Philip Cunningham
- Flinders University International Centre for Point-of-Care Testing, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
| | - Tanya L Applegate
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
- NSW State Reference Laboratory for HIV, St Vincent's Centre for Applied Medical Research, Sydney, New South Wales, Australia
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Riegler AN, Larsen N, Amerson-Brown MH. Point-of-Care Testing for Sexually Transmitted Infections. Clin Lab Med 2023; 43:189-207. [PMID: 37169442 DOI: 10.1016/j.cll.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Point-of-care testing for sexually transmitted infections is essential for controlling transmission and preventing sequelae in high-risk populations. Since the World Health Organization published the ASSURED criteria, point-of-care testing has improved for use in large population screening and rapid testing that prevents loss of clinical follow-up. Recent advancements have been advantageous for low-resource areas allowing testing at a minimal cost without reliable electricity or refrigeration. Point-of-care nucleic acid detection and amplification techniques are recommended, but are often inaccessible in low-resource areas. Future advancements in point-of-care diagnostic testing should focus on improving antibody-based assays, monitoring viral loads, and detecting antimicrobial resistance.
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Affiliation(s)
- Ashleigh N Riegler
- Department of Pathology, The University of Alabama at Birmingham, Marnix E. Heersink School of Medicine, 619 East 19th Street South, WP240J, Birmingham, AL 35249-7331, USA
| | - Natalie Larsen
- Department of Pathology, The University of Alabama at Birmingham, Marnix E. Heersink School of Medicine, 619 East 19th Street South, WP240J, Birmingham, AL 35249-7331, USA
| | - Megan H Amerson-Brown
- Department of Pathology, The University of Alabama at Birmingham, Marnix E. Heersink School of Medicine, 619 East 19th Street South, WP240J, Birmingham, AL 35249-7331, USA.
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Abstract
Sexually transmitted infections (STIs) are caused by various pathogens, many of which have common symptoms. Diagnostic tests are critical to supporting clinical evaluations in making patient management decisions. Molecular diagnostics are the preferred test type when available, especially in asymptomatic patients for many STIs. However, for some infections, serology offers the best insight into infectious status. Clinicians should be aware of the performance characteristics of the available STI diagnostic tests and understand how to use them. Point-of-care tests are helpful to implement rapid and accurate treatment responses, which are particularly helpful in certain at-risk populations.
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Kairu A, Masson L, Passmore JAS, Cunnama L, Sinanovic E. Rapid Point-of-Care Testing for Genital Tract Inflammatory Cytokine Biomarkers to Diagnose Asymptomatic Sexually Transmitted Infections and Bacterial Vaginosis in Women: Cost Estimation and Budget Impact Analysis. Sex Transm Dis 2022; 49:237-243. [PMID: 34596633 PMCID: PMC8820766 DOI: 10.1097/olq.0000000000001565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/10/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Screening for genital inflammation can reveal asymptomatic cases of sexually transmitted infections (STIs) and bacterial vaginosis (BV), useful in settings where only syndromic management is available. This study aimed to estimate the incremental cost of screening using a new cytokine biomarker rapid test and determine the budget impact of providing this service in primary health facilities in South Africa. METHODS Costs of adding genital inflammation screening to existing family planning services were estimated for women (15-49 years) attending 3 different family planning clinics in US $2016. The predicted unit cost per patient screened from a provider's perspective was calculated using bottom-up and top-down approaches and was used to analyze the budget impact of scaling up and providing this service in primary health facilities countrywide. Univariate sensitivity analyses tested the robustness of the findings. RESULTS The incremental cost per woman screened for genital inflammation ranged between US $3.19 and US $4.79. The scaled-up costs ranged between US $7,245,775 and US $22,212,636 countrywide, annually. This was based on the number of women of reproductive age currently seeking contraceptive care at all primary health care facilities, as a proxy for those most susceptible to asymptomatic STIs/BV. The cost estimates were sensitive to changes in personnel costs, utilization rate, and population coverage rates. CONCLUSIONS This screening tool is likely to increase case detection, contributing to better STI/BV management and control, in addition to reducing women's risk of HIV acquisition. The incremental cost estimates could make implementation affordable.
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Affiliation(s)
- Angela Kairu
- From the Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town
| | - Lindi Masson
- Division of Medical Virology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town Medical School
| | - Jo-Ann S. Passmore
- Division of Medical Virology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town Medical School
- National Health Laboratory Service, Cape Town, South Africa
| | - Lucy Cunnama
- From the Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town
| | - Edina Sinanovic
- From the Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town
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Gaydos CA, Manabe YC, Melendez JH. A Narrative Review of Where We Are With Point-of-Care Sexually Transmitted Infection Testing in the United States. Sex Transm Dis 2021; 48:S71-S77. [PMID: 34110728 PMCID: PMC8284360 DOI: 10.1097/olq.0000000000001457] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/29/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Point-of-care (POC) tests enable immediate diagnosis and targeted treatment of sexually transmitted infections (STIs), which could accelerate control of ongoing epidemics. Although older nucleic acid amplification tests have improved the accuracy of laboratory-based tests for STIs, newer POC tests can facilitate control efforts. We sought to review the performance and time to result of POC assays for STIs in the last 10 years. METHODS The authors performed a PubMed, US National Library of Medicine, National Center for Biotechnology Information search for POC tests for STIs or sexually transmitted diseases. RESULTS Diagnostic technology for POC assays for STIs has achieved high sensitivity and specificity (>90%) using recent molecular advances in the last 10 years. Three POC tests for chlamydia and gonorrhea and 2 for trichomonas have been cleared by the Food and Drug Administration and can provide rapid results during the clinical encounter. Two POC assays for syphilis are now cleared by the Food and Drug Administration. Other similar POC assays are in development. These "fast followers" have faster time to result and will extend the diagnostic armamentarium at POC. CONCLUSIONS New technology has improved the performance accuracy of STI POC diagnostics. Innovation in device format has resulted in accurate POC assays, which can decrease the time to result and accelerate the detection and treatment of STIs during the clinical encounter. The full implementation potential of these newer tests will depend on the ability of these tests to achieve Clinical Laboratory Improvement Amendments-waived status so they can be performed by nonlaboratorians with no previous training.
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Development of an Immunochromatographic Strip Using Conjugated Gold Nanoparticles for the Rapid Detection of Klebsiella pneumoniae Causing Neonatal Sepsis. Pharmaceutics 2021; 13:pharmaceutics13081141. [PMID: 34452099 PMCID: PMC8401635 DOI: 10.3390/pharmaceutics13081141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/09/2021] [Accepted: 07/22/2021] [Indexed: 11/16/2022] Open
Abstract
Neonatal sepsis is a leading cause of death among newborns and infants, especially in the developing world. The problem is compounded by the delays in pinpointing the causative agent of the infection. This is reflected in increasing mortality associated with these cases and the spread of multi-drug-resistant bacteria. In this work, we deployed bioinformatics and proteomics analyses to determine a promising target that could be used for the identification of a major neonatal sepsis causative agent, Klebsiella pneumoniae. A 19 amino acid peptide from a hypothetical outer membrane was found to be very specific to the species, well conserved among its strains, surface exposed, and expressed in conditions simulating infection. Antibodies against the selected peptide were conjugated to gold nanoparticles and incorporated into an immunochromatographic strip. The developed strip was able to detect as low as 105 CFU/mL of K. pneumoniae. Regarding specificity, it showed negative results with both Escherichia coli and Enterobacter cloacae. More importantly, in a pilot study using neonatal sepsis cases blood specimens, the developed strip selectively gave positive results within 20 min with those infected with K. pneumoniae without prior sample processing. However, it gave negative results in cases infected with other bacterial species.
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Abstract
INTRODUCTION Point-of-care (POC) tests for Neisseria gonorrhoeae (Ng) are urgently needed to control the gonorrhea epidemic, so patients can receive immediate diagnoses and treatment. While the advent of nucleic acid amplification tests (NAATs) has improved the accuracy of Ng identification, very few POC assays are able to provide results of such tests at the clinical visit. Additionally, antimicrobial resistance (AMR) presents a unique treatment challenge for Ng. AREAS COVERED This review notes that older POC tests have lower sensitivity for Ng, compared to the currently-available NAATs, and are not adequate for the current demand for high sensitivity. Promising newer assays, which can be used at the POC are covered. This review also includes data about clinicians' and patients' acceptability and expectations of POC tests for Ng, testing of extragenital specimens, pooling studies, as well as their impact clinically, and use in low-resource settings. EXPERT OPINION The ability to use POC tests to identify and immediately treat Ng infections at the patient encounter offers many benefits and opportunities. POC tests for Ng are currently available, but not widely used especially in low-resource settings. Further development of POC tests with AMR testing capacity is needed to help guide antimicrobial stewardship.
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Affiliation(s)
- Charlotte A Gaydos
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University , Baltimore, Maryland, USA
| | - Johan H Melendez
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University , Baltimore, Maryland, USA
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Abstract
The bacterium Neisseria gonorrhoeae causes the sexually transmitted infection (STI) gonorrhoea, which has an estimated global annual incidence of 86.9 million adults. Gonorrhoea can present as urethritis in men, cervicitis or urethritis in women, and in extragenital sites (pharynx, rectum, conjunctiva and, rarely, systemically) in both sexes. Confirmation of diagnosis requires microscopy of Gram-stained samples, bacterial culture or nucleic acid amplification tests. As no gonococcal vaccine is available, prevention relies on promoting safe sexual behaviours and reducing STI-associated stigma, which hinders timely diagnosis and treatment thereby increasing transmission. Single-dose systemic therapy (usually injectable ceftriaxone plus oral azithromycin) is the recommended first-line treatment. However, a major public health concern globally is that N. gonorrhoeae is evolving high levels of antimicrobial resistance (AMR), which threatens the effectiveness of the available gonorrhoea treatments. Improved global surveillance of the emergence, evolution, fitness, and geographical and temporal spread of AMR in N. gonorrhoeae, and improved understanding of the pharmacokinetics and pharmacodynamics for current and future antimicrobials in the treatment of urogenital and extragenital gonorrhoea, are essential to inform treatment guidelines. Key priorities for gonorrhoea control include strengthening prevention, early diagnosis, and treatment of patients and their partners; decreasing stigma; expanding surveillance of AMR and treatment failures; and promoting responsible antimicrobial use and stewardship. To achieve these goals, the development of rapid and affordable point-of-care diagnostic tests that can simultaneously detect AMR, novel therapeutic antimicrobials and gonococcal vaccine(s) in particular is crucial.
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Evaluation of a Hydrogel-Based Diagnostic Approach for the Point-of-Care Based Detection of Neisseria gonorrhoeae. Antibiotics (Basel) 2018; 7:antibiotics7030070. [PMID: 30081551 PMCID: PMC6164196 DOI: 10.3390/antibiotics7030070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 11/18/2022] Open
Abstract
Eleven primer pairs were developed for the identification of Neisseria gonorrhoeae. The sensitivity and specificity of these primers were evaluated by Real Time (RT)-PCR melt curve analyses with DNA from 145 N. gonorrhoeae isolates and 40 other Neisseria or non-Neisseria species. Three primer pairs were further evaluated in a hydrogel-based RT-PCR detection platform, using DNA extracted from 50 N. gonorrhoeae cultures. We observed 100% sensitivity and specificity in the hydrogel assay, confirming its potential as a point-of-care test (POCT) for N. gonorrhoeae diagnosis.
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Masson L, Barnabas S, Deese J, Lennard K, Dabee S, Gamieldien H, Jaumdally SZ, Williamson AL, Little F, Van Damme L, Ahmed K, Crucitti T, Abdellati S, Bekker LG, Gray G, Dietrich J, Jaspan H, Passmore JAS. Inflammatory cytokine biomarkers of asymptomatic sexually transmitted infections and vaginal dysbiosis: a multicentre validation study. Sex Transm Infect 2018; 95:5-12. [PMID: 30018088 DOI: 10.1136/sextrans-2017-053506] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 05/11/2018] [Accepted: 06/15/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Vaginal dysbiosis and STIs are important drivers of the HIV epidemic and reproductive complications. These conditions remain prevalent, partly because most cases are asymptomatic. We have shown that inflammatory cytokines interleukin (IL)-1α, IL-1β and interferon-γ-induced protein (IP)-10 are biomarkers for detecting asymptomatic STIs and vaginal dysbiosis (bacterial vaginosis (BV) or intermediate microbiota). This study aimed to validate the performance of these biomarkers in African women recruited regardless of symptoms. METHODS IL-1α, IL-1β and IP-10 were measured in menstrual cup secretions, endocervical, lateral vaginal wall and vulvovaginal swabs from 550 women from Pretoria, Soweto and Cape Town, South Africa and Bondo, Kenya using Luminex and ELISA. STIs were assessed by PCR, BV by Nugent scoring and vaginal microbiota by 16S rRNA sequencing. RESULTS Across four study populations and four types of genital specimens, the performance of IL-1α, IL-1β and IP-10 for identification of women with STIs, BV or intermediate microbiota was consistent. Of the genital samples assessed, biomarkers measured in lateral vaginal wall swabs performed best, correctly classifying 76%(95% CI 70% to 81%) of women according to STI, BV or intermediate microbiota status (sensitivity 77%, specificity 71%) and were more accurate than clinical symptoms (sensitivity 41%, specificity 57%) (p=0.0003). Women incorrectly classified as STI/BV positive using the biomarkers had more abundant dysbiosis-associated bacteria, including Prevotella bivia and Gardnerella sp, detected by 16S rRNA sequencing, but not Nugent scoring. Including vaginal pH with the cytokine biomarkers improved the accuracy of the test (82% (95% CI 75% to 88%) correctly classified), although pH alone had poor specificity (61%). CONCLUSIONS An inexpensive, point-of-care screening test including IL-1α, IL-1β and IP-10 (and potentially pH) could be used in resource-limited settings to identify women with asymptomatic STIs and dysbiosis. These women could then be referred for aetiological testing, followed by specific treatment.
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Affiliation(s)
- Lindi Masson
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Shaun Barnabas
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Jennifer Deese
- Contraceptive Technology and Innovation Department, Family Health International 360, Durham, North Carolina, USA.,Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Katie Lennard
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Smritee Dabee
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Hoyam Gamieldien
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Shameem Z Jaumdally
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Anna-Lise Williamson
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Lut Van Damme
- The Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | | | - Tania Crucitti
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Saïd Abdellati
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Linda-Gail Bekker
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Glenda Gray
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa.,South African Medical Research Council, Cape Town, South Africa
| | - Janan Dietrich
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Heather Jaspan
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Seattle Children's Research Institute, University of Washington, Seattle, Washington, USA
| | - Jo-Ann S Passmore
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,National Health Laboratory Service, Johannesburg, South Africa
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14
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Guy RJ, Causer LM, Klausner JD, Unemo M, Toskin I, Azzini AM, Peeling RW. Performance and operational characteristics of point-of-care tests for the diagnosis of urogenital gonococcal infections. Sex Transm Infect 2018; 93:S16-S21. [PMID: 29223959 DOI: 10.1136/sextrans-2017-053192] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/30/2017] [Accepted: 08/08/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In 2012, there was an estimated 78 million new cases of gonorrhoea globally. Untreated infection may lead to reproductive and neonatal morbidity and facilitate HIV transmission. Diagnosis and treatment are a priority for control and prevention, yet use of point-of-care tests (POCTs) for Neisseria gonorrhoeae (NG) is limited. OBJECTIVES To review the performance and operational characteristics of NG POCTs for diagnosis of urogenital gonorrhoea. METHODS We compiled and synthesised findings from two separate systematic reviews which included evaluations published until August 2015. RESULTS Six tests were included: five were immunochromatographic tests (ICTs) or optical immunoassay (OIAs) based on antigen detection; with 5-7 steps and results in 25-40 min, and one (GeneXpert CT/NG) was a 'near-patient test' based on nucleic acid amplification technique (NAAT); with three steps, electricity required, and results in 90 min. When compared with laboratory-based NAATs as the reference tests, sensitivities of ICT and OIA-based POCTs ranged from 12.5% to 70% when cervical/vaginal swabs were tested. Specificities ranged from 89% to 99.8%. The near-patient NAAT had sensitivities of >95% and specificities of >99.8% consistently across all specimen types (urine, cervical and vaginal swabs). CONCLUSIONS Based on a limited number of evaluations, antigen detection POCTs for NG lacked sufficient sensitivity to be used for screening. A near-patient NAAT has acceptable performance, only involved a few steps, but needs electricity, a temperature-controlled environment and has a 90 min run time. To achieve wider scale up of NG POCTs, we need strong evidence of cost-effectiveness, which should inform guidelines and ultimately increase test development, demand and reduce costs.
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Affiliation(s)
- Rebecca J Guy
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Louise M Causer
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Jeffrey D Klausner
- Department of Global Health, University of California at Los Angeles, San Francisco, USA
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and other STIs, Örebro University Hospital, Örebro, Sweden
| | - Igor Toskin
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Rosanna W Peeling
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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15
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Grebely J, Applegate TL, Cunningham P, Feld JJ. Hepatitis C point-of-care diagnostics: in search of a single visit diagnosis. Expert Rev Mol Diagn 2017; 17:1109-1115. [DOI: 10.1080/14737159.2017.1400385] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jason Grebely
- Viral Hepatitis Clinical Research Program, The Kirby Institute, UNSW Sydney, Sydney, Australia
| | - Tanya L. Applegate
- Viral Hepatitis Clinical Research Program, The Kirby Institute, UNSW Sydney, Sydney, Australia
| | - Philip Cunningham
- St Vincent’s Centre for Applied Medical Research, Darlinghurst, Sydney, Australia
| | - Jordan J. Feld
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Health, University of Toronto, Toronto, Canada
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16
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Perera SR, Khan NH, Martin I, Taheri A, Parti RP, Levett PN, Horsman GB, Kusalik A, Dillon JAR. Multiplex Real-Time PCR Assay for Simultaneous Identification of Neisseria gonorrhoeae and Its Ciprofloxacin Susceptibility Status. J Clin Microbiol 2017; 55:3201-3209. [PMID: 28814585 PMCID: PMC5654903 DOI: 10.1128/jcm.00855-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/06/2017] [Indexed: 01/18/2023] Open
Abstract
A real-time PCR (RT-PCR) assay was designed for the simultaneous identification of Neisseria gonorrhoeae and its ciprofloxacin susceptibility status. A SYBR green-based multiplex RT-PCR format was used; it comprised two different forward primers and a common reverse primer to detect single nucleotide polymorphisms (SNPs) in gyrA of N. gonorrhoeae The primer pairs were evaluated for their sensitivity and specificity using genomic DNA from 254 N. gonorrhoeae isolates (82 were ciprofloxacin susceptible and 172 were ciprofloxacin resistant) and 23 non-N. gonorrhoeae species isolates. The performance of the primers was validated using genomic DNA from 100 different N. gonorrhoeae isolates (46 were ciprofloxacin susceptible and 54 were ciprofloxacin resistant) and 52 non-N. gonorrhoeae isolates. The latter panel was revalidated by testing 99 (46 isolates were ciprofloxacin susceptible and 53 isolates were ciprofloxacin resistant) of the N. gonorrhoeae isolates and 23 non-N. gonorrhoeae isolates. These primers detected N. gonorrhoeae and its ciprofloxacin susceptibility status with over 99% sensitivity and specificity for all panels tested. This assay has the potential to be an inexpensive and rapid test for the simultaneous identification of N. gonorrhoeae and its ciprofloxacin susceptibility status.
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Affiliation(s)
- Sumudu R Perera
- Vaccine and Infectious Disease Organization-International Vaccine Centre, University of Saskatchewan, Saskatoon, SK, Canada
- Department of Microbiology and Immunology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Nurul H Khan
- Vaccine and Infectious Disease Organization-International Vaccine Centre, University of Saskatchewan, Saskatoon, SK, Canada
| | - Irene Martin
- National Microbiology Laboratory, Streptococcus and STI Unit, Public Health Agency of Canada, Winnipeg, MB, Canada
| | - Ali Taheri
- Vaccine and Infectious Disease Organization-International Vaccine Centre, University of Saskatchewan, Saskatoon, SK, Canada
| | - Rajinder P Parti
- Vaccine and Infectious Disease Organization-International Vaccine Centre, University of Saskatchewan, Saskatoon, SK, Canada
| | - Paul N Levett
- Government of Saskatchewan, Saskatchewan Disease Control Laboratory, Regina, SK, Canada
| | - Greg B Horsman
- Government of Saskatchewan, Saskatchewan Disease Control Laboratory, Regina, SK, Canada
| | - Anthony Kusalik
- Department of Computer Science, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jo-Anne R Dillon
- Vaccine and Infectious Disease Organization-International Vaccine Centre, University of Saskatchewan, Saskatoon, SK, Canada
- Department of Microbiology and Immunology, University of Saskatchewan, Saskatoon, SK, Canada
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17
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Arboleda VA, Garner OB. Ensuring the Quality of Point-of-Care Testing in a Large and Decentralized Ambulatory Care Setting. Am J Clin Pathol 2017; 148:336-344. [PMID: 28967953 DOI: 10.1093/ajcp/aqx081] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES In this project, we assessed the breadth, quality, trends, and outcomes of point-of-care (POC) testing and regulatory compliance in 200 University of California, Los Angeles (UCLA) Health system outpatient clinics. METHODS We retrospectively extracted clinic POC test orders, results, and e-prescription data from the UCLA electronic health record over a 1-year period. RESULTS Over 100,000 total tests were performed, encompassing 10 POC tests. Initially, 40% of clinics did not have complete licensure, but after implementation of the POC team, this metric improved to 100% licensure within 6 months. Most clinics used two or fewer POC tests, resulted fewer than 200 tests per year, and performed little to no external quality control measures. Our data analytics approach showed that peak POC testing occurred in January 2015, driven by influenza and urinalysis testing, and that both the testing and resulting clinical decision making do not routinely follow society guidelines. CONCLUSIONS This decentralization of laboratory testing presents challenges to ensuring quality POC testing. Optimization and analysis of informatics data allow for the identification of POC test utilization trends, areas of improvement for clinical workflows, and increased education on national guidelines.
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Affiliation(s)
- Valerie A Arboleda
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA
| | - Omai B Garner
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA
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18
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Mensforth S, Thorley N, Radcliffe K. Auditing the use and assessing the clinical utility of microscopy as a point-of-care test for Neisseria gonorrhoeae in a Sexual Health clinic. Int J STD AIDS 2017; 29:157-163. [PMID: 28705094 DOI: 10.1177/0956462417721062] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We assessed whether urethral microscopy was performed as per clinic protocol for male clinic attendees reporting contact with Neisseria gonorrhoeae (GC), urethral symptoms or given a diagnosis of epididymo-orchitis (EO) over a 12-month period (9732 patients). Prevalence of gonorrhoea in the contacts, urethral symptoms and EO groups was 50, 12.7 and 1.6%, respectively. Microscopy was performed reliably for contacts (96%), those with discharge/dysuria with evidence of urethritis on examination (98%), but not those with EO (43%). We explored the clinical utility of microscopy as a point-of-care test for identifying urethral GC in each subgroup, using the APTIMA Combo 2 CT/GC nucleic acid amplification test as the comparator (1710 patients). Sensitivity of microscopy for each subgroup was good; there was no statistical difference between subgroup sensitivity using Fisher's exact test. Microscopy is valuable to ensure prompt diagnosis and contact tracing. All GC contacts were treated 'epidemiologically'; however, half of GC contacts did not have GC. Microscopy identified the majority of GC cases, including amongst contacts (71% of heterosexual contacts, 66% of contacts reporting sex with men). We propose that epidemiological treatment for GC contacts should be reconsidered on the grounds of antibiotic stewardship, favouring use of microscopy to guide treatment decisions.
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Affiliation(s)
- Sarah Mensforth
- Department of Sexual Health, Whittall Street Clinic, University Hospitals Birmingham, Birmingham, UK
| | - Nicola Thorley
- Department of Sexual Health, Whittall Street Clinic, University Hospitals Birmingham, Birmingham, UK
| | - Keith Radcliffe
- Department of Sexual Health, Whittall Street Clinic, University Hospitals Birmingham, Birmingham, UK
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19
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Bartelsman M, de Vries HJC, Schim van der Loeff MF, Sabajo LOA, van der Helm JJ. Leucocyte esterase dip-stick test as a point-of-care diagnostic for urogenital chlamydia in male patients: A multi-center evaluation in two STI outpatient clinics in Paramaribo and Amsterdam. BMC Infect Dis 2016; 16:625. [PMID: 27809795 PMCID: PMC5093983 DOI: 10.1186/s12879-016-1946-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 10/20/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Point-of-care (POC) tests are an important strategy to address the epidemic of sexually transmitted infections (STIs). The leucocyte esterase test (LET) can be used as a POC test for chlamydia. The aim of this study was to determine the diagnostic accuracy of the LET to detect urogenital chlamydia among men at STI clinics in Paramaribo, Suriname and Amsterdam, the Netherlands. METHODS Recruitment of patients took place in 2008-2010 in Suriname and in 2009-2010 in the Netherlands. Urine of patients was examined with the LET. The reference test was a nucleic acid amplification test (NAAT). RESULTS We included 412 patients in Suriname and 645 in the Netherlands. Prevalence of chlamydia in Suriname and the Netherlands was respectively 22.8 and 13.6 %. The sensitivity of the LET was 92.6 % (95 % CI = 85.3-97.0) and 77.3 % (95 % CI = 67.1-85.5) respectively, the specificity was 38.1 % (95 % CI = 32.7-43.6 %) and 58.1 % (95 % CI = 53.9-62.3) respectively. The positive predictive value was 30.6 % (95 % CI = 27.3-36.4) and 22.6 % (95 % CI = 18.0-27.7) respectively and the negative predictive value was 94.5 % (95 % CI = 89.1-97.8) and 94.2 % (95 % CI = 91.1-96.4) respectively. The kappa was respectively 0.179 and 0.176. CONCLUSIONS To diagnose urogenital chlamydia in men the LET performs poorly. It has a high negative but low positive predictive value. If the LET result is negative, chlamydia is accurately excluded, yet a positive result has a low predictive value. Whether the advantages of direct management based on LET outweigh the disadvantages of overtreatment is a subject for further studies.
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Affiliation(s)
- Menne Bartelsman
- Department of Infectious Diseases, STI Outpatient Clinic, Public Health Service of Amsterdam (GGD Amsterdam), Weesperplein 1, 1018, XA, Amsterdam, The Netherlands.
| | - Henry J C de Vries
- Department of Infectious Diseases, STI Outpatient Clinic, Public Health Service of Amsterdam (GGD Amsterdam), Weesperplein 1, 1018, XA, Amsterdam, The Netherlands.,Center for Infection and Immunology Amsterdam (CINIMA), Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands.,Department of Dermatology, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten F Schim van der Loeff
- Center for Infection and Immunology Amsterdam (CINIMA), Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands.,Department of Research, Public Health Service of Amsterdam (GGD Amsterdam), Nieuwe Achtergracht 100, 1018, WT, Amsterdam, The Netherlands
| | - Leslie O A Sabajo
- Dermatological Service, Ministry of Health Suriname, Tourtonnelaan 5, Paramaribo, Suriname
| | - Jannie J van der Helm
- Department of Infectious Diseases, STI Outpatient Clinic, Public Health Service of Amsterdam (GGD Amsterdam), Weesperplein 1, 1018, XA, Amsterdam, The Netherlands.,Department of Research, Public Health Service of Amsterdam (GGD Amsterdam), Nieuwe Achtergracht 100, 1018, WT, Amsterdam, The Netherlands
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20
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A Systematic Review of Point of Care Testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Infect Dis Obstet Gynecol 2016; 2016:4386127. [PMID: 27313440 PMCID: PMC4899593 DOI: 10.1155/2016/4386127] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/07/2016] [Indexed: 11/17/2022] Open
Abstract
Objectives. Systematic review of point of care (POC) diagnostic tests for sexually transmitted infections: Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV). Methods. Literature search on PubMed for articles from January 2010 to August 2015, including original research in English on POC diagnostics for sexually transmitted CT, NG, and/or TV. Results. We identified 33 publications with original research on POC diagnostics for CT, NG, and/or TV. Thirteen articles evaluated test performance, yielding at least one test for each infection with sensitivity and specificity ≥90%. Each infection also had currently available tests with sensitivities <60%. Three articles analyzed cost effectiveness, and five publications discussed acceptability and feasibility. POC testing was acceptable to both providers and patients and was also demonstrated to be cost effective. Fourteen proof of concept articles introduced new tests. Conclusions. Highly sensitive and specific POC tests are available for CT, NG, and TV, but improvement is possible. Future research should focus on acceptability, feasibility, and cost of POC testing. While pregnant women specifically have not been studied, the results available in nonpregnant populations are encouraging for the ability to test and treat women in antenatal care to prevent adverse pregnancy and neonatal outcomes.
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21
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Hui BB, Wilson DP, Ward JS, Guy RJ, Kaldor JM, Law MG, Hocking JS, Regan DG. The potential impact of new generation molecular point-of-care tests on gonorrhoea and chlamydia in a setting of high endemic prevalence. Sex Health 2016; 10:348-56. [PMID: 23806149 DOI: 10.1071/sh13026] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 05/04/2013] [Indexed: 11/23/2022]
Abstract
UNLABELLED Background Despite the availability of testing and treatment, bacterial sexually transmissible infections (STIs) continue to occur at endemic levels in many remote Indigenous communities in Australia. New generation molecular point-of-care (POC) tests have high sensitivity, comparable with conventional diagnostic tests, and have the potential to increase the impact of STI screening. METHODS We developed mathematical models of gonorrhoea (Neisseria gonorrhoeae) and chlamydia (Chlamydia trachomatis) transmission in remote Indigenous communities in Australia to evaluate screening and treatment strategies that utilise POC tests. RESULTS The introduction of POC testing with 95% sensitivity could reduce the prevalence of gonorrhoea and chlamydia from 7.1% and 11.9% to 5.7% and 8.9%, respectively, under baseline screening coverage of 44% per year. If screening coverage is increased to 60% per year, prevalence is predicted to be reduced to 3.6% and 6.7%, respectively, under conventional testing, and further reduced to 1.8% and 3.1% with the introduction of POC testing. Increasing screening coverage to 80% per year will result in a reduction in the prevalence of gonorrhoea and chlamydia to 0.6% and 1.5%, respectively, and the virtual elimination of both STIs if POC testing is introduced. CONCLUSIONS Modelling suggests that molecular POC tests of high sensitivity have great promise as a public health strategy for controlling chlamydia and gonorrhoea. However, evaluation of the cost-effectiveness of POC testing needs to be made before widespread implementation of this technology can be considered.
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Affiliation(s)
- Ben B Hui
- The Kirby Institute, University of New South Wales, Sydney, NSW 2052, Australia
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22
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Masson L, Arnold KB, Little F, Mlisana K, Lewis DA, Mkhize N, Gamieldien H, Ngcapu S, Johnson L, Lauffenburger DA, Abdool Karim Q, Abdool Karim SS, Passmore JAS. Inflammatory cytokine biomarkers to identify women with asymptomatic sexually transmitted infections and bacterial vaginosis who are at high risk of HIV infection. Sex Transm Infect 2015; 92:186-93. [PMID: 26511781 DOI: 10.1136/sextrans-2015-052072] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 09/26/2015] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Untreated sexually transmitted infections (STIs) and bacterial vaginosis (BV) cause genital inflammation and increase the risk of HIV infection. WHO-recommended syndromic STI and BV management is severely limited as many women with asymptomatic infections go untreated. The purpose of this cross-sectional study was to evaluate genital cytokine profiles as a biomarker of STIs and BV to identify women with asymptomatic, treatable infections. METHODS Concentrations of 42 cytokines in cervicovaginal lavages from 227 HIV-uninfected women were measured using Luminex. All women were screened for BV by microscopy and STIs using molecular assays. Multivariate analyses were used to identify cytokine profiles associated with STIs/BV. RESULTS A multivariate profile of seven cytokines (interleukin (IL)-1α, IL-1β, tumour necrosis factor-β, IL-4, fractalkine, macrophage-derived chemokine, and interferon-γ) most accurately predicted the presence of a treatable genital condition, with 77% classification accuracy and 75% cross-validation accuracy (sensitivity 72%; specificity 81%, positive predictive value (PPV) 86%, negative predictive value (NPV) 64%). Concomitant increased IL-1β and decreased IP-10 concentrations predicted the presence of a treatable genital condition without a substantial reduction in predictive value (sensitivity 77%, specificity 72%, PPV 82% and NPV 65%), correctly classifying 75% of the women. This approach performed substantially better than clinical signs (sensitivity 19%, specificity 92%, PPV 79% and NPV 40%). CONCLUSIONS Supplementing syndromic management with an assessment of IL-1β and IP-10 as biomarkers of genital inflammation may improve STI/BV management for women, enabling more effective treatment of asymptomatic infections and potentially reducing their risk of HIV infection.
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Affiliation(s)
- Lindi Masson
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town Medical School, Cape Town, South Africa Centre for the AIDS Programme of Research in South Africa, University of KwaZulu Natal, Durban, South Africa
| | - Kelly B Arnold
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Koleka Mlisana
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu Natal, Durban, South Africa School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal
| | - David A Lewis
- Western Sydney Sexual Health Centre, Parramatta, Australia Centre for Infectious Diseases and Microbiology & Marie Bashir Institute for Infectious Diseases and Biosecurity, Westmead Clinical School, University of Sydney, Sydney, Australia National Institute for Communicable Diseases, Sandringham, Johannesburg, South Africa
| | - Nonhlanhla Mkhize
- National Institute for Communicable Diseases, Sandringham, Johannesburg, South Africa
| | - Hoyam Gamieldien
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town Medical School, Cape Town, South Africa
| | - Sinaye Ngcapu
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu Natal, Durban, South Africa
| | - Leigh Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Douglas A Lauffenburger
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu Natal, Durban, South Africa Columbia University, New York, New York, USA
| | - Salim S Abdool Karim
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu Natal, Durban, South Africa Columbia University, New York, New York, USA
| | - Jo-Ann S Passmore
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town Medical School, Cape Town, South Africa Centre for the AIDS Programme of Research in South Africa, University of KwaZulu Natal, Durban, South Africa National Health Laboratory Services, South Africa
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23
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Brook G. The performance of non-NAAT point-of-care (POC) tests and rapid NAAT tests for chlamydia and gonorrhoea infections. An assessment of currently available assays. Sex Transm Infect 2015; 91:539-44. [PMID: 25935930 DOI: 10.1136/sextrans-2014-051997] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 04/16/2015] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To identify point-of-care (POC) and rapid nucleic acid amplification techniques (NAATs) for the diagnosis of chlamydia and gonorrhoea and assess their utility. METHODS Literature search for available POC and rapid NAATs. The performance from the best-performing assays were applied hypothetically to patients in the clinic in which 100 consecutive patients with chlamydia and 100 with gonorrhoea were diagnosed in 1737 and 4575 patients respectively, with 44/100 and 54/100 treated at first attendance, respectively. RESULTS 11 POC and 1 rapid NAAT were identified. Published performances for the best POC for chlamydia (CRT) were: sensitivity 41%-87%, specificity 89%-99.6%. Our data suggest that if this assay was used instead of our current NAAT, for every 100 patients diagnosed currently, 23-46 extra patients would be treated at first attendance; 10-35 would go undiagnosed with 7-191 false-positives. Best chlamydia rapid NAAT (GeneXpert): sensitivity 97.5%-98.7%, specificity 99.4%-99.9%. Anticipated performance for every 100 patients diagnosed currently: 0 extra patients treated at first attendance, 1-3 undiagnosed, 0-2 false-positives. Best POC for gonorrhoea (GC Check): sensitivity 54%-70%, specificity 97%-98%. Anticipated performance for every 100 patients diagnosed currently: 14-18 extra patients treated at first attendance, 28-32 undiagnosed, 92-137 false-positives. Best rapid NAAT for gonorrhoea (GeneXpert): sensitivity 96%-100%, specificity 99.9%-100%. Anticipated performance for every 100 patients diagnosed currently: 0 extra patients treated at first attendance, 0-4 undiagnosed, 0-5 false-positives. Rapid NAAT would reduce time to treatment by 4 days for initially untreated patients. CONCLUSIONS POC assays would need to be used in conjunction with a NAAT, increasing early treatment rates expense and false-positive results. The rapid NAAT could be used alone, with a reduction in average time-to-treat and a small reduction in sensitivity and specificity.
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24
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Causer LM, Hengel B, Natoli L, Tangey A, Badman SG, Tabrizi SN, Whiley D, Ward J, Kaldor JM, Guy RJ. A field evaluation of a new molecular-based point-of-care test for chlamydia and gonorrhoea in remote Aboriginal health services in Australia. Sex Health 2015; 12:27-33. [PMID: 25426655 DOI: 10.1071/sh14158] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 10/21/2014] [Indexed: 11/23/2022]
Abstract
UNLABELLED Background Point-of-care (POC) tests could be important public health tools in settings with treatment delays and high rates of sexually transmissible infections (STIs). Use is limited due to suboptimal performance. The performance and ease-of-use of a new molecular-based POC test for simultaneous detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) was assessed, alongside two single-organism immunochromatographic tests (ICT). METHODS The evaluation occurred between May 2012 and March 2013 during community STI screens in two remote Aboriginal health services. Urine was tested with the GeneXpert(®)CT/NG and if sufficient volume, also with Diaquick CT and Gonorrhoea Card. The gold standard comparison was laboratory nucleic acid amplification testing (NAAT). Operational characteristics were also assessed. RESULTS Among 198 samples, GeneXpert CT sensitivity and specificity was 100% [95% confidence intervals (CI): 75.9-100] and 99.5% (95% CI: 96.5-100), and NG was 100% (95% CI: 96.5-100) and 100% (95% CI: 97.5-100), respectively. Among a sample subset, Diaquick CT (n=104) sensitivity and specificity was 27.3% (95% CI: 7.3-60.7) and 66.7% (95% CI: 12.5-98.2), and Gonorrhoea Card (n=29), was 66.7% (95% CI: 12.5-98.2) and 76.9% (95% CI: 56.0-90.2), respectively. GeneXpert required 1mL of urine, four steps, 1min specimen preparation and 90min to result. ICTs required 15mL of urine, eight steps, 18min preparation and 10-15min to result. CONCLUSION The accuracy and operational benefits of GeneXpert CT/NG make it very suitable in these settings where delays to treatment are encountered.
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Affiliation(s)
- Louise M Causer
- The Kirby Institute, Wallace Wurth Building, UNSW Australia, Sydney, NSW 2052, Australia
| | - Belinda Hengel
- The Kirby Institute, Wallace Wurth Building, UNSW Australia, Sydney, NSW 2052, Australia
| | - Lisa Natoli
- The Kirby Institute, Wallace Wurth Building, UNSW Australia, Sydney, NSW 2052, Australia
| | - Annie Tangey
- The Kirby Institute, Wallace Wurth Building, UNSW Australia, Sydney, NSW 2052, Australia
| | - Steven G Badman
- The Kirby Institute, Wallace Wurth Building, UNSW Australia, Sydney, NSW 2052, Australia
| | - Sepehr N Tabrizi
- Department of Microbiology, Division of Laboratory Services, The Royal Children's Hospital, 50 Flemington Road, Parkville, Vic 3052, Australia
| | - David Whiley
- Queensland Paediatric Infectious Diseases (QPID) Laboratory, Queensland Children's Medical Research Institute, The University of Queensland, Herston, Qld 4029, Australia
| | - James Ward
- The Kirby Institute, Wallace Wurth Building, UNSW Australia, Sydney, NSW 2052, Australia
| | - John M Kaldor
- The Kirby Institute, Wallace Wurth Building, UNSW Australia, Sydney, NSW 2052, Australia
| | - Rebecca J Guy
- The Kirby Institute, Wallace Wurth Building, UNSW Australia, Sydney, NSW 2052, Australia
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Natoli L, Guy RJ, Shephard M, Donovan B, Fairley CK, Ward J, Regan DG, Hengel B, Maher L. Chlamydia and gonorrhoea point-of-care testing in Australia: where should it be used? Sex Health 2015; 12:51-8. [DOI: 10.1071/sh14213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 12/05/2014] [Indexed: 11/23/2022]
Abstract
Background Diagnoses of chlamydia and gonorrhoea have increased steadily in Australia over the past decade. Testing and treatment is central to prevention and control but in some settings treatment may be delayed. Testing at the point of care has the potential to reduce these delays. We explored the potential utility of newly available accurate point-of-care tests in various clinical settings in Australia. Methods: In-depth qualitative interviews were conducted with a purposively selected group of 18 key informants with sexual health, primary care, remote Aboriginal health and laboratory expertise. Results: Participants reported that point-of-care testing would have greatest benefit in remote Aboriginal communities where prevalence of sexually transmissible infections is high and treatment delays are common. Some suggested that point-of-care testing could be useful in juvenile justice services where young Aboriginal people are over-represented and detention periods may be brief. Other suggested settings included outreach (where populations may be homeless, mobile or hard to access, such as sex workers in the unregulated sex industry and services that see gay, bisexual and other men who have sex with men). Point-of-care testing could also improve the consumer experience and facilitate increased testing for sexually transmissible infections among people with HIV infection between routine HIV-management visits. Some participants disagreed with the idea of introducing point-of-care testing to urban services with easy access to pathology facilities. Conclusions: Participants felt that point-of-care testing may enhance pathology service delivery in priority populations and in particular service settings. Further research is needed to assess test performance, cost, acceptability and impact.
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Adams EJ, Ehrlich A, Turner KME, Shah K, Macleod J, Goldenberg S, Meray RK, Pearce V, Horner P. Mapping patient pathways and estimating resource use for point of care versus standard testing and treatment of chlamydia and gonorrhoea in genitourinary medicine clinics in the UK. BMJ Open 2014; 4:e005322. [PMID: 25056977 PMCID: PMC4120370 DOI: 10.1136/bmjopen-2014-005322] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Revised: 07/02/2014] [Accepted: 07/03/2014] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES We aimed to explore patient pathways using a chlamydia/gonorrhoea point-of-care (POC) nucleic acid amplification test (NAAT), and estimate and compare the costs of the proposed POC pathways with the current pathways using standard laboratory-based NAAT testing. DESIGN/PARTICIPANTS Workshops were conducted with healthcare professionals at four sexual health clinics representing diverse models of care in the UK. They mapped out current pathways that used chlamydia/gonorrhoea tests, and constructed new pathways using a POC NAAT. Healthcare professionals' time was assessed in each pathway. OUTCOME MEASURE The proposed POC pathways were then priced using a model built in Microsoft Excel, and compared to previously published costs for pathways using standard NAAT-based testing in an off-site laboratory. RESULTS Pathways using a POC NAAT for asymptomatic and symptomatic patients and chlamydia/gonorrhoea-only tests were shorter and less expensive than most of the current pathways. Notably, we estimate that POC testing as part of a sexual health screen for symptomatic patients, or as stand-alone chlamydia/gonorrhoea testing, could reduce costs per patient by as much as £16 or £6, respectively. In both cases, healthcare professionals' time would be reduced by approximately 10 min per patient. CONCLUSIONS POC testing for chlamydia/gonorrhoea in a clinical setting may reduce costs and clinician time, and may lead to more appropriate and quicker care for patients. Further study is warranted on how to best implement POC testing in clinics, and on the broader clinical and cost implications of this technology.
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Affiliation(s)
- Elisabeth J Adams
- Aquarius Population Health Limited, Bristol, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | | | - Kunj Shah
- Aquarius Population Health Limited, Bristol, UK
| | - John Macleod
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Simon Goldenberg
- Centre for Clinical Infection & Diagnostics Research, Guy's & St Thomas’ NHS Foundation Trust and King's College, London, UK
| | | | | | - Patrick Horner
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- Department of Genitourinary Medicine, NHS Bristol, Bristol, UK
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Natoli L, Maher L, Shephard M, Hengel B, Tangey A, Badman SG, Ward J, Guy RJ. Point-of-care testing for chlamydia and gonorrhoea: implications for clinical practice. PLoS One 2014; 9:e100518. [PMID: 24956111 PMCID: PMC4067364 DOI: 10.1371/journal.pone.0100518] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 05/28/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Point-of-care (POC) testing for chlamydia (CT) and gonorrhoea (NG) offers a new approach to the diagnosis and management of these sexually transmitted infections (STIs) in remote Australian communities and other similar settings. Diagnosis of STIs in remote communities is typically symptom driven, and for those who are asymptomatic, treatment is generally delayed until specimens can be transported to the reference laboratory, results returned and the patient recalled. The objective of this study was to explore the clinical implications of using CT/NG POC tests in routine clinical care in remote settings. METHODS In-depth qualitative interviews were conducted with a purposively selected group of 18 key informants with a range of sexual health and laboratory expertise. RESULTS Participants highlighted the potential impact POC testing would have on different stages of the current STI management pathway in remote Aboriginal communities and how the pathway would change. They identified implications for offering a POC test, specimen collection, conducting the POC test, syndromic management of STIs, pelvic inflammatory disease diagnosis and management, interpretation and delivery of POC results, provision of treatment, contact tracing, management of client flow and wait time, and re-testing at 3 months after infection. CONCLUSIONS The introduction of POC testing to improve STI service delivery requires careful consideration of both its advantages and limitations. The findings of this study will inform protocols for the implementation of CT/NG POC testing, and also STI testing and management guidelines.
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Affiliation(s)
- Lisa Natoli
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- The Burnet Institute, Melbourne, Victoria, Australia
- * E-mail:
| | - Lisa Maher
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark Shephard
- Flinders University International Centre for Point of-Care Testing, Flinders University, Adelaide, South Australia, Australia
| | - Belinda Hengel
- Apunipima Cape York Health Council, Cairns, Queensland, Australia
| | - Annie Tangey
- Ngaanyatjarra Health Service, Alice Springs, Northern Territory, Australia
| | - Steven G. Badman
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - James Ward
- Baker IDI, Alice Springs, Northern Territory, Australia
| | - Rebecca J. Guy
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
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Samarawickrama A, Cheserem E, Graver M, Wade J, Alexander S, Ison C. Pilot study of use of the BioStar Optical ImmunoAssay GC point-of-care test for diagnosing gonorrhoea in men attending a genitourinary medicine clinic. J Med Microbiol 2014; 63:1111-1112. [PMID: 24907352 DOI: 10.1099/jmm.0.071852-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Amanda Samarawickrama
- Department of Sexual Health and HIV, Caldecot Centre, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Emily Cheserem
- Department of Sexual Health and HIV, Caldecot Centre, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Michelle Graver
- Department of Microbiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Jim Wade
- Department of Microbiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Sarah Alexander
- Sexually Transmitted Bacteria Reference Unit, Microbiological Services, Public Health England, 61 Colindale Avenue, London NW9 5HT, UK
| | - Catherine Ison
- Sexually Transmitted Bacteria Reference Unit, Microbiological Services, Public Health England, 61 Colindale Avenue, London NW9 5HT, UK
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Gaydos C, Hardick J. Point of care diagnostics for sexually transmitted infections: perspectives and advances. Expert Rev Anti Infect Ther 2014; 12:657-72. [PMID: 24484215 PMCID: PMC4065592 DOI: 10.1586/14787210.2014.880651] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Accurate and inexpensive point-of-care (POC) tests are urgently needed to control sexually transmitted infection epidemics, so that patients can receive immediate diagnoses and treatment. Current POC assays for Chlamydia trachomatis and Neisseria gonorrhoeae perform inadequately and require better assays. Diagnostics for Trichomonas vaginalis rely on wet preparation, with some notable advances. Serological POC assays for syphilis can impact resource-poor settings, with many assays available, but only one available in the U.S. HIV POC diagnostics demonstrate the best performance, with excellent assays available. There is a rapid assay for HSV lesion detection; but no POC serological assays are available. Despite the inadequacy of POC assays for treatable bacterial infections, application of technological advances offers the promise of advancing POC diagnostics for all sexually transmitted infections.
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Affiliation(s)
- Charlotte Gaydos
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Justin Hardick
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Turner KME, Round J, Horner P, Macleod J, Goldenberg S, Deol A, Adams EJ. An early evaluation of clinical and economic costs and benefits of implementing point of care NAAT tests for Chlamydia trachomatis and Neisseria gonorrhoea in genitourinary medicine clinics in England. Sex Transm Infect 2013; 90:104-11. [PMID: 24273127 PMCID: PMC3932743 DOI: 10.1136/sextrans-2013-051147] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives To estimate the costs and benefits of clinical pathways incorporating a point of care (POC) nucleic acid amplification test (NAAT) for chlamydia and gonorrhoea in genitourinary medicine (GUM) clinics compared with standard off-site laboratory testing. Method We simulated 1.2 million GUM clinic attendees in England. A simulation in Microsoft Excel was developed to compare existing standard pathways of management for chlamydia and gonorrhoea with a POC NAAT. We conducted scenario analyses to evaluate the robustness of the model findings. The primary outcome was the incremental cost-effectiveness ratio. Secondary outcomes included the number of inappropriate treatments, complications and transmissions averted. Results The baseline cost of using the point of POC NAAT was £103.9 million compared with £115.6 million for standard care. The POC NAAT was also associated with a small increase of 46 quality adjusted life years, making the new test both more effective and cheaper. Over 95 000 inappropriate treatments might be avoided by using a POC NAAT. Patients receive diagnosis and treatment on the same day as testing, which may also prevent 189 cases of pelvic inflammatory disease and 17 561 onward transmissions annually. Discussion Replacing standard laboratory tests for chlamydia and gonorrhoea with a POC test could be cost saving and patients would benefit from more accurate diagnosis and less unnecessary treatment. Overtreatment currently accounts for about a tenth of the reported treatments for chlamydia and gonorrhoea and POC NAATs would effectively eliminate the need for presumptive treatment.
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Guy RJ, Natoli L, Ward J, Causer L, Hengel B, Whiley D, Tabrizi SN, Donovan B, Fairley CK, Badman SB, Tangey A, Wand H, Shephard M, Regan DG, Wilson D, Anderson D, Kaldor JM. A randomised trial of point-of-care tests for chlamydia and gonorrhoea infections in remote Aboriginal communities: Test, Treat ANd GO- the "TTANGO" trial protocol. BMC Infect Dis 2013; 13:485. [PMID: 24138699 PMCID: PMC4231474 DOI: 10.1186/1471-2334-13-485] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 10/14/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND High prevalence rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) have been reported in Aboriginal people in remote and regional areas of Australia for well over two decades, and repeat positivity rates are high. To interrupt disease transmission and reduce the risk of complications, early diagnosis and treatment is important. However in many remote and regional areas there are long delays between testing for these curable sexually transmissible infections and providing treatment, due to both physical distance from laboratories and difficulties when recalling patients for subsequent management once results are available. Point-of-care (POC) tests have the potential to provide more timely diagnosis, to increase treatment and contact tracing, and in turn reduce CT and NG infection rates. METHODS/DESIGN TTANGO (Test, Treat, ANd GO) is a cross-over cluster randomised controlled trial in 12 regional or remote Australian health services, which predominantly provide clinical services to Aboriginal people. The overall aim of TTANGO is to measure the clinical effectiveness, cost-effectiveness and cultural and operational acceptability of molecular POC testing for CT and NG infection. The primary outcome is repeat positivity at three months after treatment of an initial CT or NG infection. Participating health services will undertake the clinical management of CT and NG under two different modalities for one year each. In the first year, six health services will be randomly assigned to manage these infections under current diagnostic guidelines. The other six will supplement current diagnostic guidelines with POC testing, whereby diagnosis is made and subsequent treatment for those with positive POC tests is offered at the initial consultation. In the second year, the health services will cross over to the opposite management modality. TTANGO will be conducted over four years; 1.5 years of trial initiation and community consultation, 2 years of trial conditions and evaluation, and 6 months of data analysis and feedback. DISCUSSION TTANGO is the first cluster randomised trial of POC testing for CT and NG internationally. The results of this trial will provide crucial information to guide sexual health clinical practice in remote Aboriginal communities and other high prevalence settings. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ACTRN12613000808741.
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Affiliation(s)
- Rebecca J Guy
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Lisa Natoli
- The Kirby Institute, University of New South Wales, Sydney, Australia
- The Burnet Institute, Melbourne, Australia
| | - James Ward
- The Kirby Institute, University of New South Wales, Sydney, Australia
- Baker IDI, Alice Springs, Northern Territory, Alice Springs, Northern Territory, Australia
| | - Louise Causer
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Belinda Hengel
- Apunipima Cape York Health Council, Cairns, Queensland, Australia
| | - David Whiley
- Queensland Paediatric Infectious Diseases (QPID) Laboratory, Queensland Children’s Medical Research Institute, The University of Queensland, Queensland, Australia
| | - Sepehr N Tabrizi
- Department of Microbiology and Infectious Diseases, The Royal Women’s Hospital, Parkville, Victoria, Australia
- Department of Obstetrics and Gynaecology, The Royal Women’s Hospital and Murdoch Childrens Research Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Basil Donovan
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Christopher K Fairley
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, Melbourne, Victoria, Australia
| | - Steven B Badman
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Annie Tangey
- Ngaanyatjarra Health Service, Alice Springs, Northern Territory, Australia
| | - Handan Wand
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Mark Shephard
- Flinders University International Centre for Point of-Care Testing, Flinders University, Adelaide, South Australia, Australia
| | - David G Regan
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - David Wilson
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | | | - John M Kaldor
- The Kirby Institute, University of New South Wales, Sydney, Australia
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Cassell JA. Highlights from this issue. Br J Vener Dis 2013. [DOI: 10.1136/sextrans-2013-051188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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