Frequency and risk factors for incident and redetected Chlamydia trachomatis infection in sexually active, young, multi-ethnic women: a community based cohort study

Alarming incidence of reinfections after treatment for Chlamydia trachomatis and gonorrhoea: Can we predict and prevent them?

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections are a public health problem, worsened by frequent reinfections, whose incidence rate is not known in Spain. The objective of this study is to estimate in patients diagnosed with NG, CT or mixed infection (NG and CT): (1) the incidence of reinfections by the same microorganism, (2) the total incidence of Sexually Transmitted Infections (STI), both by the same microorganism and by infections other than the initial one, and (3) to identify predictors of reinfection.

METHODS

Observational prospective case series involving 986 patients with CT and/or NG at specialized STI clinics in Biscay (Spain) between 2016 and 2019.

RESULTS

The six month cumulative incidence of reinfection by the same microorganism was 17.24% (CI95%: 14.9-19.7) and 24.65% (CI95%: 21.9-27.4) for any STI (reinfection or other). Being an immigrant (OR=1.8; CI95%: 1.3-2.6), men who have sex with men (OR=1.8; CI95%: 1.3-2.6), number of sexual partners (OR=4.3; CI95%: 2.7-6.8 for more than 5 partners), having a new partner (OR=1.7; CI95%: 1.08-2.6), not always using a condom (OR=1.4; CI95%: 1.02-1.9) and consumption of alcohol prior to sex (OR=3.8; CI95%: 1.5-9.5) were associated with reinfection by any STI.

CONCLUSION

These characteristics allow doctors to identify patients in whom to prioritize short-term rescreening for repeated infections with any STIs after initial treatment for NG or CT.

The role of the genital microbiota in the acquisition and pathogenesis of sexually transmitted infections

PURPOSE OF REVIEW

There are an estimated 374 million new sexually transmitted infections (STIs) worldwide every year. Our review article examines the current evidence of how STI acquisition, transmission, and pathogenesis is impacted upon by the genital microbiota, with a focus on epidemiological, biochemical, and immunological features.

RECENT FINDINGS

At least in women, a genital microbiota dominated by lactobacilli has long been considered optimal for reproductive health, while depletion of lactobacilli may lead to a genital microenvironment dominated by anaerobic pathogens, which can manifest clinically as bacterial vaginosis. Recent research efforts have characterized genital microbiota composition in greater resolution, sometimes at species-level, using proteomics, metabolomics, and deep sequencing. This has enhanced our understanding of how specific microbiota members influence acquisition or clinical manifestation of STI pathogen infection. Other advances include a steady, though still slow, increase in the number of studies that sought to determine the genital (penile or urethral) microbiota of males and how it may impact that of their female partners' genital microbiota and risk of STI acquisition. Altogether, these data enabled us to explore the concept that genital microbiota may be sexually transmitted and influence pathogenesis and clinical presentation of other STI.

SUMMARY

With STI infection rates increasing worldwide, it is important now more than ever to find novel STI prevention strategies. Understanding if and how the genital microbiota is a modifiable risk factor for STI transmission, acquisition, and clinical manifestation may prove to be an important strategy in our efforts to curb morbidity in at risk populations.

Factors Associated With Incidence and Spontaneous Clearance of Molecular-Bacterial Vaginosis: Results From a Longitudinal Frequent-Sampling Observational Study

BACKGROUND

We sought to assess time-independent and time-varying factors associated with incidence and spontaneous clearance of molecular-bacterial vaginosis (BV; without treatment).

METHODS

Midvaginal samples were self-collected daily by 100 participants recruited at the University of Alabama Birmingham for 10 weeks (4778 samples). Vaginal microbiota was characterized by 16S rRNA gene amplicon sequencing and clustered into community state types (CSTs). A low-Lactobacillus CST defined the molecular-BV outcome in this study. Factors associated with molecular-BV incidence and spontaneous clearance were modeled using Andersen-Gill recurrent event Cox models. Community class identified the predominant CST of a participant during follow-up.

RESULTS

Menstruations (adjusted odds ratio [aHR], 2.09 [95% confidence interval, 1.51-2.89] in the prior 24 hours) and CST III (Lactobacillus iners dominated) at the previous sample (aHR, 2.25 [1.48-3.40]) were associated with increased molecular-BV incidence. Participants with a majority of L. iners-dominated samples longitudinally (community class LI) displayed less stable patterns of vaginal microbiota. In LI participants, reduced molecular-BV spontaneous clearance was observed in African American participants (aHR, 0.44 [0.26-0.75]) compared with White participants, older participants (age, 40-49 years [aHR, 0.38; 0.23-0.61]; age, 30-39 years [aHR, 0.48; 0.28-0.83]) compared with participants aged 18 to 29 years, and after douching (0.45 [0.28-0.73] within prior 72 hours).

CONCLUSIONS

Although it is now well documented that vaginal microbiota are dynamic, there are few available data on factors associated with spontaneous clearance of molecular-BV. Lactobacillus iners-dominated vaginal microbiota are more likely to be dynamic and associated with different risk factors for incidence and clearance of BV. Among L. iners-dominated participants, age, race, and douching were linked to reduced clearance. Most transitions to molecular-BV during menstruations were short-lived.

A systematic review of the prevalence of selected sexually transmitted infections in young people in Latin America

Objective

To estimate the burden of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Treponema pallidum (TP), and human papillomavirus (HPV) infections among people aged 10 to 25 in Latin America and the Caribbean.

Methods

The MEDLINE, EMBASE, and LILACS databases were searched, as well as documents from regional organizations or national health Institutions. Population-based studies that reported prevalence or incidence of CT, NG, TP, and HPV detected through confirmatory tests in adolescents and young people were included. Two reviewers independently selected studies and extracted data. The quality of studies was assessed using the Newcastle-Ottawa Scale. Pooled estimators were calculated in cases where heterogeneity was <70%; when not feasible, prevalence ranges were reported.

Results

Out of a total of 3 583 references, 15 prevalence studies complied with the inclusion criteria. Due to substantial heterogeneity (>70%), it was not possible to pool frequency estimators. Among the general population, the prevalence of CT infection ranged between 2.1% and 30.1% (9 studies, 5 670 participants); for NG, prevalence ranged between 0% and 2.9% (8 studies, 5 855 participants); for TP, prevalence varied between 0% and 0.7% (3 studies, 11 208 participants), and for HPV infection, prevalence ranged between 25.1% and 55.6% (8 studies, 3 831 participants).

Conclusions

Reliable, population-based data on sexually transmitted infections (STIs) in adolescents and youth in Latin America and the Caribbean are limited. Additional studies are needed to better understand the burden of STIs in this population. However, given the substantial prevalence of STIs detected, countries need public health policies for prevention, early diagnosis, and treatment of STIs in young people.

Diagnosis and Management of Uncomplicated Chlamydia trachomatis Infections in Adolescents and Adults: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines

To prepare for the development of the 2021 Centers for Disease Control and Prevention (CDC) sexually transmitted infections treatment guidelines, the CDC convened a committee of expert consultants in June 2019 to discuss recent abstracts and published literature on the epidemiology, diagnosis, and management of sexually transmitted infections.This paper summarizes the key questions, evidence, and recommendations for the diagnosis and management of uncomplicated Chlamydia trachomatis (CT) infections in adolescents and adults that were reviewed and discussed for consideration in developing the guidelines. The evidence reviewed mostly focused on efficacy of doxycycline and azithromycin for urogenital, rectal, and oropharyngeal CT infection, CT risk factors in women, performance of CT nucleic acid amplification tests on self-collected meatal specimens in men, and performance of newer CT point-of-care tests.

Female urogenital chlamydia: Epidemiology, chlamydia on pregnancy, current diagnosis, and treatment

Female urogenital chlamydia is a disease caused by Chlamydia trachomatis infection in the female urogenital tract. It is a common bacterial sexually transmitted disease. The bacteria is transmitted through sexual contact with an infected partner or from mother to newborn during vaginal delivery. The prevalence varies among studies and the number is possibly higher due to the lack of massive screening. Many patients were asymptomatic and still be able to transmit the disease. The undiagnosed and untreated disease could cause pelvic inflammatory disease, which leads to infertility, ectopic pregnancy, and chronic pelvic pain. The prevalence among pregnant women is similar to non-pregnant women, therefore chlamydia screening in pregnant women is highly recommended. The nucleic acid amplification test is the most reliable method for the diagnosis due to high sensitivity. The current treatment is given by prescribing antibiotics.

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Female urogenital chlamydia is caused by Chlamydia trachomatis.

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Urogenital chlamydia affects young and sexually active women.

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Female urogenital chlamydia is diagnosed through indirect methods (serology-based tests) and direct methods (culture).

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Treatment of chlamydia consists of antibiotics with doxycycline being the first-line choice.

Vaginal Microbiota of the Sexually Transmitted Infections Caused by Chlamydia trachomatis and Trichomonas vaginalis in Women with Vaginitis in Taiwan

The three most common sexually transmitted infections (STIs) are Chlamydia trachomatis (CT), Neisseria gonorrhoeae (GC) and Trichomonas vaginalis (TV). The prevalence of these STIs in Taiwan remains largely unknown and the risk of STI acquisition affected by the vaginal microbiota is also elusive. In this study, a total of 327 vaginal swabs collected from women with vaginitis were analyzed to determine the presence of STIs and the associated microorganisms by using the BD Max CT/GC/TV molecular assay, microbial cultures, and 16S rRNA sequencing. The prevalence of CT, TV, and GC was 10.8%, 2.2% and 0.6%, respectively. A culture-dependent method identified that Escherichia coli and Streptococcus agalactiae (GBS) were more likely to be associated with CT and TV infections. In CT-positive patients, the vaginal microbiota was dominated by L. iners, and the relative abundance of Gardnerella vaginalis (12.46%) was also higher than that in TV-positive patients and the non-STIs group. However, Lactobacillus spp. was significantly lower in TV-positive patients, while GBS (10.11%), Prevotella bivia (6.19%), Sneathia sanguinegens (12.75%), and Gemella asaccharolytica (5.31%) were significantly enriched. Using an in vitro co-culture assay, we demonstrated that the growth of L. iners was suppressed in the initial interaction with TV, but it may adapt and survive after longer exposure to TV. Additionally, it is noteworthy that TV was able to promote GBS growth. Our study highlights the vaginal microbiota composition associated with the common STIs and the crosstalk between TV and the associated bacteria, paving the way for future development of health interventions targeting the specific vaginal bacterial taxa to reduce the risk of common STIs.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

The Female Vaginal Microbiome in Health and Bacterial Vaginosis

The vaginal microbiome is an intricate and dynamic microecosystem that constantly undergoes fluctuations during the female menstrual cycle and the woman's entire life. A healthy vaginal microbiome is dominated by Lactobacillus which produce various antimicrobial compounds. Bacterial vaginosis (BV) is characterized by the loss or sharp decline in the total number of Lactobacillus and a corresponding marked increase in the concentration of anaerobic microbes. BV is a highly prevalent disorder of the vaginal microbiota among women of reproductive age globally. BV is confirmed to be associated with adverse gynecologic and obstetric outcomes, such as sexually transmitted infections, pelvic inflammatory disease, and preterm birth. Gardnerella vaginalis is the most common microorganism identified from BV. It is the predominant microbe in polymicrobial biofilms that could shelter G. vaginalis and other BV-associated microbes from adverse host environments. Many efforts have been made to increase our understanding of the vaginal microbiome in health and BV. Thus, improved novel and accurate diagnosis and therapeutic strategies for BV have been developed. This review covers the features of vaginal microbiome, BV, BV-associated diseases, and various strategies of diagnosis and treatment of BV, with an emphasis on recent research progresses.

[Update of Chlamydia trachomatis infection]

Chlamydia trachomatis (CT) is the most common sexually transmitted bacterial infection worldwide. It is asymptomatic in most cases and mainly affects young women, with potential long term sequelae (pelvic inflammatory disease, tubal infertility, obstetric complications). The impact on male fertility is controversial. Screening methods as well as antibiotics use have recently been reassessed due to resistance phenomena and the negative effect on the urogenital microbiota. Positive CT serology may be indicative of tuboperitoneal pathology, which may not be noticed on hysterosalpingography. New research on single-nucleotide polymorphisms (SNPs) aims to establish a patient profile at higher risk of infectious tubal damage due to CT. CT seropositivity is also associated with decreased spontaneous pregnancy rates and is a predictive factor for obstetrical complications.

Nonoptimal Vaginal Microbiota After Azithromycin Treatment for Chlamydia trachomatis Infection

We characterized the composition and structure of the vaginal microbiota in a cohort of 149 women with genital Chlamydia trachomatis infection at baseline who were followed quarterly for 9 months after antibiotic treatment. At time of diagnosis, the vaginal microbiota was dominated by Lactobacillus iners or a diverse array of bacterial vaginosis–associated bacteria including Gardnerella vaginalis. Interestingly, L. iners–dominated communities were most common after azithromycin treatment (1 g monodose), consistent with the observed relative resistance of L. iners to azithromycin. Lactobacillus iners–dominated communities have been associated with increased risk of C. trachomatis infection, suggesting that the impact of antibiotic treatment on the vaginal microbiota could favor reinfections. These results provide support for the dual need to account for the potential perturbing effect(s) of antibiotic treatment on the vaginal microbiota, and to develop strategies to protect and restore optimal vaginal microbiota.

Smoking increases the risk of infectious diseases: A narrative review

Smoking is relevant to infectious diseases resulting in increased prevalence and mortality. In this article, we aim to provide an overview of the effects of smoking in various infections and to explain the potential mechanisms. We searched PubMed and other relevant databases for scientific studies that explored the relationship between smoking and infection. The mechanisms of susceptibility to infection in smokers may include alteration of the structural, functional and immunologic host defences. Smoking is one of the main risk factors for infections in the respiratory tract, digestive tract, reproductive tract, and other systems in humans, increasing the prevalence of HIV, tuberculosis, SARS-CoV, and the current SARS-CoV-2. Smoking cessation can reduce the risk of infection. Smoking increases the incidence of infections and aggravates the progress and prognosis of infectious diseases in a dose-dependent manner. Smoking cessation promotion and education are the most practical and economical preventive measures to reduce aggravation of disease infection owing to tobacco use.

Chlamydia Infection Among Digital Daters and Nondigital Daters

OBJECTIVES

The aim of the study was to investigate whether the use of dating apps is a risk factor for acquiring Chlamydia trachomatis (CT) infections.

METHODS

Patients attending the drop-in facility at the STI clinic at Umeå University Hospital between April 2016 and November 2017 were asked to fill in a survey about their sexual preferences and behaviors, including dating app use.

RESULTS

Of 943 participants, 80 (8.5%) received a CT diagnosis (34 women and 46 men). Dating app users did not seem to have an increased risk of CT infection. Having 3 or more sex partners within the last year was a risk factor for CT only among those not using a dating app. Alcohol use before sex and unprotected sex with a new partner were risk factors for CT infection in the univariate but not in the multivariate analysis.

CONCLUSIONS

Dating app users did not seem to have an increased risk of acquiring CT and for dating app users the seemingly well-established risk factor of having many partners was not valid.

Simultaneous profiling of sexually transmitted bacterial pathogens, microbiome, and concordant host response in cervical samples using whole transcriptome sequencing analysis

Pelvic inflammatory disease (PID) is a female upper genital tract inflammatory disorder that arises after sexually transmitted bacterial infections (STI). Factors modulating risk for reproductive sequelae include co-infection, microbiota, host genetics and physiology. In a pilot study of cervical samples obtained from women at high risk for STIs, we examined the potential for unbiased characterization of host, pathogen and microbiome interactions using whole transcriptome sequencing analysis of ribosomal RNA-depleted total RNAs (Total RNA-Seq). Only samples from women with STI infection contained pathogen-specific sequences (3 to 38% transcriptome coverage). Simultaneously, we identified and quantified their active microbial communities. After integration with host-derived reads from the same data, we detected clustering of host transcriptional profiles that reflected microbiome differences and STI infection. Together, our study suggests that total RNA profiling will advance understanding of the interplay of pathogen, host and microbiota during natural infection and may reveal novel, outcome-relevant biomarkers.

A Review of Sexually Transmitted Infections in Australia - Considerations in 2018

Sexually transmitted infections (STIs) bear a high burden of disease and, subsequently, high health costs globally. Chlamydia, gonorrhoea, syphilis, and trichomoniasis contribute to nearly one million infections every day worldwide. Sexually transmitted infections continue to be the most frequently notified condition to the Australian National Notifiable Diseases Surveillance System and the numbers continue to increase. Australia has achieved several significant successes in reducing STIs and blood-borne viruses (BBV) including the significant decrease in genital warts in those less than 30 years old since 2007 following the launch of human papillomavirus vaccines in women, the virtual elimination of mother to child transmission of HIV, and the increased uptake of successful hepatitis C treatment following the availability of direct acting antiviral treatment on the Pharmaceutical Benefits Scheme. However, several challenges remain, including the ongoing rise of chlamydia, gonorrhoea, and syphilis over the last five years; the emergence of antibiotic resistance; and the increasing disparity in the prevalence of STIs and BBV in men who have sex with men, young people, and Aboriginal and Torres Strait Islander people, and challenges in the delivery of services to rural and remote Australia. In this paper, we aim to provide a snapshot of the current landscape and challenges for chlamydia, gonorrhoea, mycoplasma, syphilis and HIV infections in Australia.

Relationship Status and Sexual Behaviors in Post-Pelvic Inflammatory Disease (PID) Affected Urban Young Women: A Sub-Study of a Randomized Controlled Trial

Adolescent and young adult women disproportionately experience Pelvic Inflammatory Disease (PID) as a complication of Sexually Transmitted Infections (STIs). This study seeks to understand the relationship context, changes in sexual behavior, and impact of partner sexual behavior on recurrent STI diagnoses at 3-months post-diagnosis. Adolescents and young adult women 13–25 were recruited from an outpatient disposition from an outpatient clinic, and pediatric and adult emergency rooms. Participants received treatment at baseline and follow-up at 2-weeks, 1-month and 3-month post-diagnosis, including interviews about personal and partner sexual behaviors and STI screening (n = 94). At the 2-week interview, 53% of participants (50/94) believed they could acquire an STI from their current partner if they did not use a condom. However, at 3-month follow-up only 35% reported condom usage at last sex. At 3-month follow-up, 55% (50/91) of participants were still in a sexual relationship with the previously reported partner and 38% of participants who reported they could get an STI from their partner were diagnosed with an STI; compared with 25% of participants who predicted that they could not get an STI (OR 1.85; 95% CI: 0.67–5.30). There was no association between maintaining the same partner and having an STI at 3-months (OR 0.5; 95% CI: 0.27–1.96). Most young women diagnosed with PID report exclusive relationships, but are simultaneously aware of their risk for recurrent STIs. Given the short-term stability of many relationships, couples interventions are an unexplored opportunity for prevention of recurrent STIs after PID.

'Test n Treat (TnT)'- Rapid testing and same-day, on-site treatment to reduce rates of chlamydia in sexually active further education college students: study protocol for a cluster randomised feasibility trial

BACKGROUND

Sexually active young people attending London further education (FE) colleges have high rates of chlamydia, but screening rates are low. We will conduct a cluster randomised feasibility trial of frequent, rapid, on-site chlamydia testing and same-day treatment (Test and Treat (TnT)) in six FE colleges (with parallel qualitative and economic assessments) to assess the feasibility of conducting a future trial to investigate if TnT reduces chlamydia rates.

METHODS

We will recruit 80 sexually active students aged 16-24 years from public areas at each of six colleges. All participants (total n = 480) will be asked to provide samples (urine for males, self-taken vaginal swabs for females) and complete questionnaires on sexual lifestyle and healthcare use at baseline and after 7 months. Participants will be informed that baseline samples will not be tested for 7 months and be advised to get screened separately. Colleges will be randomly allocated to the intervention (TnT) or the control group (no TnT). One and 4 months after recruitment, participants at each intervention college (n = 3) will be texted and invited for on-site chlamydia tests using the 90-min Cepheid GeneXpert system. Students with positive results will be asked to see a visiting nurse health adviser for same-day treatment and partner notification, (backed by genitourinary medicine follow-up). Participants in control colleges (n = 3) will receive 'thank you' texts 1 and 4 months after recruitment. Seven months after recruitment, participants from both groups will be invited to complete questionnaires and provide samples for TnT. All samples will be tested, and same-day treatment offered to students with positive results. Acceptability of TnT will be assessed by qualitative interviews of purposively sampled students (n = 30) and college staff (n = 12). We will collect data on costs of TnT and usual healthcare.

DISCUSSION

Findings will provide key values to inform feasibility, sample size and timescales of a future definitive trial of TnT in FE colleges, including: Recruitment rates TnT uptake rates Follow-up rates Prevalence of chlamydia in participants at baseline and 7 months Acceptability of TnT to students and college staff Estimate of the cost per person screened/treated in TnT versus usual care TRIAL REGISTRATION: International Standard Randomised Controlled Trials Registry, ID: ISRCTN58038795 , Registered on 31 August 2016.

'Test n Treat (TnT)': a cluster-randomised feasibility trial of frequent, rapid-testing and same-day, on-site treatment to reduce rates of chlamydia in high-risk further education college students: statistical analysis plan

BACKGROUND

There are high rates of sexually transmitted infections (STIs) in ethnically diverse, sexually active students aged 16-24 years attending London further education (FE) colleges. However, uptake of chlamydia screening remains low. The TnT study aims to assess the feasibility of conducting a future trial in FE colleges to investigate if frequent, rapid, on-site testing and treatment (TnT) reduces chlamydia rates. This article presents the statistical analysis plan for the main study publication as approved and signed off by the Trial Management Group prior to the first data extraction for the final report.

METHODS/DESIGN

TnT is a cluster-randomised feasibility trial conducted over 7 months with parallel qualitative and economic assessments. Colleges will be randomly allocated into the intervention (TnT) or the control group (no TnT). Six FE colleges in London will be included. At each college for 2 days, 80 consecutive sexually active students aged 16-24 years (total 480 students across all six colleges) will be recruited from public areas and asked to provide baseline samples. One and 4 months after recruitment intervention colleges will be visited on two consecutive days by the TnT team where participating students will be texted and invited to come for same-day, on-site, rapid chlamydia testing and, if positive, treatment. Participants in the control colleges will receive 'thank you' texts 1 and 4 months after recruitment. Seven months after recruitment, participants from both groups will be invited to complete questionnaires and provide samples for TnT. All samples will be tested, and same-day treatment offered to participants with positive results. Key feasibility outcomes include: recruitment rates, testing and treatment uptake rates (at 1 and 4 months) and follow-up rates (at 7 months).

TRIAL REGISTRATION

ISRCTN 58038795 . Registered on 31 August 2016.

Chlamydia trachomatis Incidence Using Self-Reports and Serology by Gender, Age Period, and Sexual Behavior in a Birth Cohort

BACKGROUND

Although understanding chlamydia incidence assists prevention and control, analyses based on diagnosed infections may distort the findings. Therefore, we determined incidence and examined risks in a birth cohort based on self-reports and serology.

METHODS

Self-reported chlamydia and behavior data were collected from a cohort born in New Zealand in 1972/3 on several occasions to age 38 years. Sera drawn at ages 26, 32, and 38 years were tested for antibodies to Chlamydia trachomatis Pgp3 antigen using a recently developed assay, more sensitive in women (82.9%) than men (54.4%). Chlamydia incidence by age period (first coitus to age 26, 26-32, and 32-38 years) was calculated combining self-reports and serostatus and risk factors investigated by Poisson regression.

RESULTS

By age 38 years, 32.7% of women and 20.9% of men had seroconverted or self-reported a diagnosis. The highest incidence rate was to age 26, 32.7 and 18.4 years per 1000 person-years for women and men, respectively. Incidence rates increased substantially with increasing number of sexual partners. After adjusting age period incidence rates for partner numbers, a relationship with age was not detected until 32 to 38 years, and then only for women.

CONCLUSIONS

Chlamydia was common in this cohort by age 38, despite the moderate incidence rates by age period. The strongest risk factor for incident infection was the number of sexual partners. Age, up to 32 years, was not an independent factor after accounting for partner numbers, and then only for women. Behavior is more important than age when considering prevention strategies.

A 30-Min Nucleic Acid Amplification Point-of-Care Test for Genital Chlamydia trachomatis Infection in Women: A Prospective, Multi-center Study of Diagnostic Accuracy

Background

Rapid Point-Of-Care Tests for Chlamydia trachomatis (CT) may reduce onward transmission and reproductive sexual health (RSH) sequelae by reducing turnaround times between diagnosis and treatment. The io® single module system (Atlas Genetics Ltd.) runs clinical samples through a nucleic acid amplification test (NAAT)-based CT cartridge, delivering results in 30 min.

Methods

Prospective diagnostic accuracy study of the io® CT-assay in four UK Genito-Urinary Medicine (GUM)/RSH clinics on additional-to-routine self-collected vulvovaginal swabs. Samples were tested “fresh” within 10 days of collection, or “frozen” at − 80 °C for later testing. Participant characteristics were collected to assess risk factors associated with CT infection.

Results

CT prevalence was 7.2% (51/709) overall. Sensitivity, specificity, positive and negative predictive values of the io® CT assay were, respectively, 96.1% (95% Confidence Interval (CI): 86.5–99.5), 97.7% (95%CI: 96.3–98.7), 76.6% (95%CI: 64.3–86.2) and 99.7% (95%CI: 98.9–100). The only risk factor associated with CT infection was being a sexual contact of an individual with CT.

Conclusions

The io® CT-assay is a 30-min, fully automated, high-performing NAAT currently CE-marked for CT diagnosis in women, making it a highly promising diagnostic to enable specific treatment, initiation of partner notification and appropriately intensive health promotion at the point of care.

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The io® CT assay's sensitivity is comparable to that of laboratory-based assays commonly used for Chlamydia detection.

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The specificity as shown is this study is at the lower end of the range reported for laboratory-based assays.

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The resulting positive predictive value, in this population, indicates that a targeted testing approach may be optimal.

Until now, there have been no ≤ 30-min point-of-care test (POCT) nucleic acid amplification tests (NAATs) on the market for detecting Chlamydia trachomatis (CT), despite cost-effectiveness analyses demonstrating they may improve Genito-Urinary Medicine (GUM)/Reproductive and Sexual Health (RSH) clinical care pathway efficiencies and patient outcomes. Our evaluation of the 30-min Atlas Genetics io® CT NAAT POCT, on vaginal swabs from women attending four GUM/RSH clinics in England, shows that the test's sensitivity (accurately detecting CT-positive infections) is similar to that of laboratory-based NAATs, and its specificity (accurately detecting CT-negative infections) is at the lower end of the laboratory-based NAAT range.

Examining sociodemographic risk factors for Chlamydia trachomatis infection: a population-based cohort study

AIM

Chlamydia trachomatis is the most prevalent bacterial sexually transmitted infection in developed nations and is an important public health concern. We aimed to assess the factors associated with testing and positivity of C. trachomatis in a large population.

METHODS

A retrospective study of a large Canadian health region was undertaken using 2011 census and laboratory data. Demographic and socioeconomic data from the national household survey were linked to microbiologic data for C. trachomatis. Multivariable generalized estimating equation models were constructed to examine relative risk for C. trachomatis testing and positivity.

RESULTS

For testing and positivity, female sex and younger age groups were associated with increased risk. University education and South Asian ethnicity were associated with lower risk of positivity.

CONCLUSION

Incorporating socio-demographic factors will be critical to the success of future sexually transmitted infection public health programs.

Impact of antiseptics on Chlamydia trachomatis growth

Bacterial vaginosis is a frequent dysbiosis, where the normal lactobacillus-dominated flora is replaced by an anaerob/aerob polymicrobial flora. Bacterial vaginosis increases the risk of acquiring sexually transmitted infections (STI) including the most frequent Chlamydia trachomatis infections. Intravaginal antiseptics are part of the bacterial vaginosis treatment, and ideally they should also inhibit the bacterial vaginosis-related STI. Therefore, we tested the antichlamydial activity of four antiseptics: iodine aqueous solution, povidone-iodine, chlorhexidine and borax. First, we measured the impact of antiseptics on the viability of the HeLa cervical epithelial cells, and calculated the maximum nontoxic concentrations. Next, we infected the cells with C. trachomatis preincubated for 1 h with the particular antiseptic. The chlamydial growth was measured by direct quantitative PCR (qPCR) of the infected cells. The minimal inhibitory concentrations (MIC) of chlorhexidine and povidone-iodine were 3·91 and 97 μg ml(-1) respectively; however, the MIC of chlorhexidine was close to its maximum nontoxic concentration. The iodine aqueous solution and the borax showed no antichlamydial activity. Our in vitro studies showed that chlorhexidine and particularly povidone-iodine are potentially able to limit the bacterial vaginosis-related C. trachomatis infection.

SIGNIFICANCE AND IMPACT OF THE STUDY

We measured the antichlamydial effects of various antiseptics. These antiseptics are being used for the treatment of bacterial vaginosis, but their effect on the bacterial vaginosis-related sexually transmitted infections, particularly the most frequent Chlamydia trachomatis (C. trachomatis) infections has not been investigated. We showed that povidone-iodine (Betadine) inhibited the chlamydial growth in concentrations that was not toxic to the epithelial cells. We concluded that due to its additional antichlamydial effect, povidone-iodine could be a preferable antiseptic in bacterial vaginosis treatment.

Adolescent Sexuality: Updates to the Sexually Transmitted Infection Guidelines

Adolescents are at high risk for acquisition and transmission of sexually transmitted infections (STI) secondary to both cognitive and biological susceptibility. The prevention, diagnosis, and treatment of STIs are a critical part of adolescent health care. This article discusses the most common bacterial, parasitic, and viral STIs encountered in this age group with an emphasis on new guidelines for screening and management.

Lifetime Sexual Assault and Sexually Transmitted Infections Among Women Veterans

OBJECTIVE

Women veterans report a high prevalence of sexual assault. Unfortunately, there are limited data on the reproductive health sequelae faced by these women. Our objective was to evaluate the association between completed lifetime sexual assault (LSA) and sexually transmitted infections (STIs) among a cohort of women veterans, adjusting for sexual risk behaviors.

MATERIALS AND METHODS

We conducted a retrospective study among women veterans aged 51 years or younger who enrolled for care at two Veterans Administration (VA) healthcare sites between 2000 and 2008. Participants completed a telephone interview assessing reproductive health and sexual violence history. We compared the frequencies of past STI diagnoses among those who had and had not experienced LSA. We used logistic regression to assess the effect of sexual assault with history of an STI diagnosis after adjusting for age, sexual risk behaviors, and substance abuse treatment.

RESULTS

Among 996 women veterans, a history of STIs was reported by 32%, including a lifetime history of gonorrhea (5%), chlamydia (15%), genital herpes infection (8%), and human papillomavirus infection (15%), not mutually exclusive; 51% reported LSA. Women with a history of LSA were significantly more likely to report a history of STIs (unadjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.45-2.50; adjusted OR 1.49, 95% CI 1.07-2.08).

CONCLUSIONS

Women veterans who have experienced LSA are at increased risk for lifetime STI diagnoses. To adequately address the reproductive health needs of the growing population of women veterans, STI risk assessments should include queries of military service and LSA histories.

Risk Factors for Incident and Redetected Chlamydia trachomatis Infection in Women: Results of a Population-Based Cohort Study

OBJECTIVES

To investigate risk factors for incident and redetected Chlamydia trachomatis (CT) infection in women, including the role of high-risk human papillomavirus (HPV).

METHODS

In this population-based, prospective cohort study conducted in Copenhagen, Denmark, 10,729 women aged 20 to 29 years were tested for CT and HPV DNA and provided information on sexual and health behavior at baseline. Of these, 7998 (74.5%) participated in a follow-up visit 2 years later with identical data collection. We used logistic regression to investigate risk factors for incident and redetected CT infection at follow-up.

RESULTS

Among CT DNA negative women at baseline (n = 7529), 106 (1.4%) were CT DNA positive at follow-up (incident infection). Increasing number of sexual partners during follow-up (odds ratio [OR], 1.07 per partner; 95% confidence interval (CI), 1.02-1.11), low educational level (OR, 1.69; 95% CI, 1.11-2.56; for basic education vs. high school or higher), and high-risk HPV positivity at baseline (OR, 1.66; 95% CI, 1.06-2.58) were risk factors for incident infection, whereas older age (OR, 0.86 per year increase; 95% CI, 0.80-0.93) and condom use (OR, 0.60; 95% CI, 0.38-0.94) were associated with reduced risk. Among CT DNA positive women at baseline (n = 469), 108 (23.0%) tested positive at follow-up (redetected infection). We found no statistically significant associations between age, educational level, sexual behavior, smoking, or high-risk HPV status and the risk for redetected CT.

CONCLUSION

Young age, low educational level, high number of sexual partners, failure to use condoms, and high-risk HPV positivity are associated with increased risk for incident CT infection. These findings may guide the development of targeted CT prevention strategies, including screening and information campaigns.

Chlamydia trachomatis re-infection in Spain: A STI clinic-based cohort study

BACKGROUND

Chlamydia trachomatis (C. trachomatis) is the most frequently reported sexually transmitted infection (STI) in developed countries, but there is a lack data on its incidence and population dynamics in Spain. The objectives of this study were to estimate the incidence of C. trachomatis in patients seeking medical attention in an STI clinic with a defined population catchment area, to identify factors associated with this infection, and to explore differences between factors associated with new infections and re-infections.

METHODS

A retrospective study was conducted on a cohort of patients from a STI clinic who underwent chlamydia testing at least twice between 2007 and 2015.

RESULTS

Of the 2633 patients who met study selection criteria, 795 (30.2%) tested positive for C. trachomatis at baseline (baseline Chlamydia). The overall incidence was 7.97/100 person-years (95% CI: 7.2-8.8): 5.9/100 person-years (95% CI: 5.2-6.7) among patients testing negative for C. trachomatis at baseline, and 18.3 person-years (95% CI: 15.6-21.5) among those testing positive at baseline. In multivariate analysis, the factors independently associated with overall incidence were a history of infection with C. trachomatis in the previous 6 months (hazard ratio=3.6; 95% CI: 2.3-5.4), younger age (HR <20 vs ≥35 years=5.5; 95% CI: 3.2-9.5), male sex, 2 or more sexual partners in the previous month and year, and inconsistent condom use.

CONCLUSIONS

Guidelines should be established for C. trachomatis in Spain, including recommendations on the need for follow-up and re-testing, independently of age. Though data concerning the optimal timing of re-testing are inconclusive, our findings support the establishment of a 3-6 month interval.

Chlamydia trachomatis Genital Infections

Etiology, transmission and protection: Chlamydia trachomatis is the leading cause of bacterial sexually transmitted infection (STI) globally. However, C. trachomatis also causes trachoma in endemic areas, mostly Africa and the Middle East, and is a leading cause of preventable blindness worldwide. Epidemiology, incidence and prevalence: The World Health Organization estimates 131 million new cases of C. trachomatis genital infection occur annually. Globally, infection is most prevalent in young women and men (14-25 years), likely driven by asymptomatic infection, inadequate partner treatment and delayed development of protective immunity. Pathology/Symptomatology: C. trachomatis infects susceptible squamocolumnar or transitional epithelial cells, leading to cervicitis in women and urethritis in men. Symptoms are often mild or absent but ascending infection in some women may lead to Pelvic Inflammatory Disease (PID), resulting in reproductive sequelae such as ectopic pregnancy, infertility and chronic pelvic pain. Complications of infection in men include epididymitis and reactive arthritis. Molecular mechanisms of infection: Chlamydiae manipulate an array of host processes to support their obligate intracellular developmental cycle. This leads to activation of signaling pathways resulting in disproportionate influx of innate cells and the release of tissue damaging proteins and pro-inflammatory cytokines. Treatment and curability: Uncomplicated urogenital infection is treated with azithromycin (1 g, single dose) or doxycycline (100 mg twice daily x 7 days). However, antimicrobial treatment does not ameliorate established disease. Drug resistance is rare but treatment failures have been described. Development of an effective vaccine that protects against upper tract disease or that limits transmission remains an important goal.

Sexual and testing behaviour associated with Chlamydia trachomatis infection: a cohort study in an STI clinic in Sweden

BACKGROUND

Genital chlamydia infection (chlamydia) is the most commonly reported sexually transmitted infection (STI) in Sweden. To guide prevention needs, we aimed to investigate factors associated with chlamydia.

METHODS

A cohort of visitors aged 20-40 years at an urban STI clinic in Sweden was recruited. Behavioural data were collected using a self-administered questionnaire. Self-sampled specimens were tested for chlamydia by a DNA amplification assay. Statistically significant (p<0.05) and epidemiologically relevant covariates were entered in a multivariate Poisson model adjusted for potential confounders (age and gender). Backward stepwise elimination produced a final model. Multiple imputation was used to account for missing values.

RESULTS

Out of 2814 respondents, 1436 were men with a chlamydia positivity rate of 12.6% vs 8.9% in women. Lifetime testing for chlamydia and HIV was high (82% and 60%, respectively). Factors significantly associated with chlamydia were: 20-24 years old (adjusted risk ratio (ARR)=2.10, 95% CI 1.21 to 3.65); testing reason: contact with a chlamydia case (ARR=6.55, 95% CI 4.77 to 8.98) and having symptoms (ARR=2.19, 95% CI 1.48 to 3.24); 6-10 sexual partners (ARR=1.53, 95% CI 1.06 to 2.21); last sexual activity 'vaginal sex and oral sex and anal sex and petting' (ARR=1.84, 95% CI 1.09 to 3.10); alcohol use before sex (ARR=1.98, 95% CI 1.10 to 3.57); men with symptoms (ARR=2.09, 95% CI 1.38 to 3.18); tested for chlamydia (ARR=0.72, 95% CI 0.55 to 0.94).

CONCLUSIONS

Risk factors associated with chlamydia were consistent with previous reports in similar settings and suggest no major changes over time. Increased risk for chlamydia infection associated with high-risk behaviour (eg, alcohol use, increased number of sexual partners) supports the need for behavioural interventions in this population such as promotion of safer sex behaviour (condom use) and testing.

Bacterial vaginosis: a critical analysis of current knowledge

Bacterial vaginosis (BV), the change from a Lactobacillus-dominant vaginal microbiota to an anaerobic and facultative bacterial dominance, is associated with pathological sequelae. In many BV-positive women their microbiota is in fact normal and unrelated to pathology. Whether or not the dominance of BV-associated bacteria persists depends upon interactions between host and bacterial factors. Inconsistencies in diagnosis and erroneous associations with pathology may be due to a failure to differentiate between sub-populations of women. It is only in those women with a BV diagnosis in which the identified bacteria are atypical and persist that BV may be a clinical problem requiring intervention.

TWEETABLE ABSTRACT

Improved diagnosis of bacterial vaginosis is needed to accurately determine its role in pathology.

Which sexually active young female students are most at risk of pelvic inflammatory disease? A prospective study

OBJECTIVE

To identify risk factors for pelvic inflammatory disease (PID) in female students.

METHODS

We performed a prospective study set in 11 universities and 9 further education colleges in London. In 2004-2006, 2529 sexually experienced, multiethnic, female students, mean age 20.8 years, provided self-taken vaginal samples and completed questionnaires at recruitment to the Prevention of Pelvic Infection chlamydia screening trial. After 12 months, they were followed up by questionnaire backed by medical record search and assessed for PID by blinded genitourinary medicine physicians.

RESULTS

Of 2004 (79%) participants who reported numbers of sexual partners during follow-up, 32 (1.6%, 95% CI 1.1% to 2.2%) were diagnosed with PID. The strongest predictor of PID was baseline Chlamydia trachomatis (relative risk (RR) 5.7, 95% CI 2.6 to 15.6). After adjustment for baseline C. trachomatis, significant predictors of PID were ≥2 sexual partners or a new sexual partner during follow-up (RR 4.0, 95% CI 1.8 to 8.5; RR 2.8, 95% CI 1.3 to 6.3), age <20 years (RR 3.3, 95% CI 1.5 to 7.0), recruitment from a further education college rather than a university (RR 2.6, 95% CI 1.3 to 5.3) and history at baseline of vaginal discharge (RR 2.7, 95% CI 1.2 to 5.8) or pelvic pain (RR 4.1, 95% CI 2.0 to 8.3) in the previous six months. Bacterial vaginosis and Mycoplasma genitalium infection were no longer significantly associated with PID after adjustment for baseline C. trachomatis.

CONCLUSIONS

Multiple or new partners in the last 12 months, age <20 years and attending a further education college rather than a university were risk factors for PID after adjustment for baseline C. trachomatis infection. Sexual health education and screening programmes could be targeted at these high-risk groups.

TRIAL REGISTRATION NUMBER

(ClinicalTrials.gov NCT00115388).

Background review for the '2015 European guideline on the management of Chlamydia trachomatis infections'

SummaryChlamydia trachomatis infections are major public health concerns globally. Of particular grave concern is that the majority of persons with anogenital Chlamydia trachomatis infections are asymptomatic and accordingly not aware of their infection, and this silent infection can subsequently result in severe reproductive tract complications and sequelae. The current review paper provides all background, evidence base and discussions for the 2015 European guideline on the management of Chlamydia trachomatis infections (Lanjouw E, et al. Int J STD AIDS 2015). Comprehensive information and recommendations are included regarding the diagnosis, treatment and prevention of anogenital, pharyngeal and conjunctival Chlamydia trachomatis infections in European countries. However, Chlamydia trachomatis also causes the eye infection trachoma, which is not a sexually transmitted infection. The 2015 European Chlamydia trachomatis guideline provides up-to-date guidance regarding broader indications for testing and treatment of Chlamydia trachomatis infections; clearer recommendation of using validated nucleic acid amplification tests only for diagnosis; advice on (repeated) Chlamydia trachomatis testing; recommendation of increased testing to reduce the incidence of pelvic inflammatory disease and prevent exposure to infection and recommendations to identify, verify and report Chlamydia trachomatis variants. Improvement of access to testing, test performance, diagnostics, antimicrobial treatment and follow-up of Chlamydia trachomatis patients are crucial to control its spread.

2015 European guideline on the management of Chlamydia trachomatis infections

Chlamydia trachomatis infections, which most frequently are asymptomatic, are major public health concerns globally. The 2015 European C. trachomatis guideline provides: up-to-date guidance regarding broader indications for testing and treatment of C. trachomatis infections; a clearer recommendation of using exclusively-validated nucleic acid amplification tests for diagnosis; advice on (repeated) C. trachomatis testing; the recommendation of increased testing to reduce the incidence of pelvic inflammatory disease and prevent exposure to infection; and recommendations to identify, verify and report C. trachomatis variants. Improvement of access to testing, test performance, diagnostics, antimicrobial treatment and follow-up of C. trachomatis patients are crucial to control its spread. For detailed background, evidence base and discussions, see the background review for the present 2015 European guideline on the management of Chlamydia trachomatis infections (Lanjouw E, et al. Int J STD AIDS. 2015).

Analysis of Factors Driving Incident and Ascending Infection and the Role of Serum Antibody in Chlamydia trachomatis Genital Tract Infection

BACKGROUND

Chlamydia trachomatis genital tract infection is a major cause of female reproductive morbidity. Risk factors for ascending infection are unknown, and the role for antibody in protection is not well established.

METHODS

We recruited 225 women from urban outpatient clinics and followed them for a median of 12 months. We performed a cross-sectional analysis of serum anti-chlamydial immunoglobulin G (IgG), behavioral factors, and microbiological factors associated with endometrial infection at enrollment, and a longitudinal analysis of factors associated with incident infection.

RESULTS

Oral contraceptives (adjusted relative risk [RR], 2.02 [95% confidence interval {CI}, 1.38-2.97]) and gonorrhea (adjusted RR, 1.66 [95% CI, 1.07-2.60]) were associated with endometrial infection. Gonorrhea (adjusted hazard ratio [HR], 3.09 [95% CI, 1.41-6.78]), cervical infection at enrollment (adjusted HR, 2.33 [95% CI, 1.07-5.11]), and exposure to uncircumcised partners (adjusted HR, 2.65 [95% CI, 1.21-5.82]) or infected partners (adjusted HR, 4.99 [95% CI, 2.66-9.39]) significantly increased the risk of incident infection. Seropositivity was associated with a reduced cervical burden (P < .05) but no differences in rates of ascending infection (adjusted RR, 1.24 [95% CI, .71-2.19]) or incident infection (adjusted HR, 0.94 [95% CI, .52-1.69]).

CONCLUSIONS

Serum anti-chlamydial IgG is not associated with a lowered rate of ascending or repeat infection. Identification of factors associated with ascending infection and increased risk of incident infection provide guidance for targeted screening of women at increased risk for sequelae.

Distribution of human papillomavirus (HPV) genotypes and bacterial vaginosis presence in cervical samples from Paraguayan indigenous

OBJECTIVE

To determine the frequency of human papillomavirus (HPV) types and to assess bacterial vaginosis (BV) possible associations with cervical infections in indigenous Paraguayan women of the Department of Presidente Hayes.

METHODS

This study included 181 sexually active women without cervical lesions. HPV typing was performed by polymerase chain reaction with primers PGMY 09/11 followed by reverse line hybridization. BV was diagnosed by the Nugent criteria using the results from a Gram stain smear.

RESULTS

Sixteen percent of women were positive for at least one high risk HPV type (HR-HPV). The most frequent genotypes were HPV 16 (4.4%), followed by HPV 58 (3.3%), HPV 45 (3.3%), HPV 53 (2.8%) and HPV 11 (2.8%). A significant association between HR-HPV and BV was observed (p=0.01). In addition, women with BV had a higher frequency of Chlamydia trachomatis (p=0.0007), Trichomonas vaginalis (p=0.00009), Mycoplasma hominis (p=0.001).

CONCLUSIONS

A large variety of HPV genotypes was detected and showed a slightly different pattern from previous studies on urban women in Paraguay, with the predominance of HR-HPV. Furthermore, the information of co-infections involved in BV could be useful for the improvement of national prevention programs, as well as for laboratory surveillance of these genital infections.

Treatment challenges for urogenital and anorectal Chlamydia trachomatis

While true antimicrobial resistance to Chlamydia trachomatis is a rare occurrence, repeat chlamydia infections continue to be reported following treatment with a single 1 g dose of azithromycin or week long doxycycline - with considerable more concern about azithromycin treatment failure. While most repeat positive cases are likely to be reinfections, emerging evidence indicates treatment failure may play a role. Current data suggests that there may are differences in the efficacy of the drugs between rectal and non-rectal sites of infection and factors such as immune response, drug pharmacokinetics, organism load, auto-inoculation from rectum to cervix in women and the genital microbiome may play a role in treatment failure. Other possible reasons for repeat infection include the low discriminatory power of NAAT tests to differentiate between viable and nonviable organisms and failure to detect LGV infection. This review will present the current evidence regarding the management challenges for urogenital and anorectal chlamydia infections and provide some suggestions for where future research efforts are needed to address important knowledge gaps in this area and provide stronger evidence for the development of robust treatment guidelines.