Chlamydial cervicitis and urethritis: single dose treatment compared with doxycycline for seven days in community based practises

Urogenital chlamydia trachomatis treatment failure with azithromycin: A meta-analysis

Background

Chlamydia Trachomatis is one of the most common pathogens transmitted through the genital tract in humans that leads to urogenital infection.

Objective

Given the high prevalence of chlamydia infection and its adverse effects on the health of women and men, the present meta-analysis was conducted to determine the rate of treatment failure with azithromycin.

Materials and Methods

Databases including MEDLINE, ISI - Web of Science, PubMed, EMBASE, Scopus, ProQuest, and Science Direct were searched for articles published between 1991 and 2018. The quality of the selected articles was assessed using the Cochrane risk of bias assessment tool. Heterogeneity was determined using the I2 and Cochrane Q-Test. Subgroup analysis and meta-regression were used to compare the prevalence rates on different levels of the variables.

Results

A total of 21 articles that met the inclusion criteria were ultimately assessed. The pooled estimate of azithromycin failure rate was 11.23% (CI 95%: 8.23%-14.24%). Also, the azithromycin failure rate was 15.87% (CI 95%: 10.20%-21.54%) for the treatment of urethritis, 7.41% (CI 95%: 0.60%-14.22%) for cervicitis, and 7.14% (CI 95%: 10.90%-3.39%) for genital chlamydia. The pooled estimate of failure rate difference was 2.37% (CI 95%: 0.68%-4.06%), which shows that azithromycin has a higher failure rate in the treatment of chlamydia compared to doxycycline and other examined medications. The meta-regression results showed that the patient's age contributes significantly to the heterogeneity for azithromycin treatment failure rate (β░=░0.826; p░=░0.017).

Conclusion

Azithromycin has a higher failure rate than doxycycline and other studied medications in treating urogenital chlamydia infections.

Antibiotics for treating urogenital Chlamydia trachomatis infection in men and non-pregnant women

BACKGROUND

The genital infection caused by Chlamydia trachomatis (CT) is a common sexually transmitted infection (STI) globally. The infection is mainly asymptomatic in women, thus it can produce infertility and chronic pelvic pain. In men infection is mainly symptomatic, but can evolve to prostatitis. Clinical practice guidelines for CT urogenital infections do not give any specific recommendation about which antibiotic use as first option OBJECTIVES: To assess the efficacy and safety of antibiotic treatment for CT genital infection in men and non-pregnant women.

SEARCH METHODS

The Cochrane Sexually Transmitted Infections' (STI) Information Specialist developed the electronic searches in electronic databases (CENTRAL, MEDLINE, Embase and LILACS), and trials registers. We searched studies published from inception to June 2018.

SELECTION CRITERIA

We included parallel, randomised controlled trials (RCTs) of men, and sexually-active, non-pregnant women with CT infection (urethritis or uterine cervicitis or asymptomatic), diagnosed by cell culture for CT, nucleic acid amplification tests (NAAT) or antigen-based detection methods, who had been treated with any of the antibiotic regimens recommended by any of the updated to 2013 CT Guidelines.

DATA COLLECTION AND ANALYSIS

Four review authors screened evidence according to selection criteria and independently extracted data and assessed risk of bias. Two authors developed the 'Summary of findings' tables. We used a fixed-effect meta-analysis model for combining data where it was reasonable to assume that studies were estimating the same underlying treatment effect. We estimated the pooled risk ratio in order to establish the effects of the comparisons. Our primary outcomes were microbiological failure and adverse events, and our secondary outcomes were clinical failure, antimicrobial resistance and reinfection.

MAIN RESULTS

We selected 14 studies ( 2715 participants: 2147 (79.08%) men and 568 (20.92%) women). The studies were conducted mainly at STD clinics. Sample sizes ranged from 71 to 606 participants; follow-up was 29.7 days on average.For the comparison: azithromycin single dose versus doxycycline once or twice daily for 7 days, in men treated for CT, the risk of microbiological failure was higher in the azithromycin group (RR 2.45, 95% CI 1.36 to 4.41; participants = 821; studies = 9; moderate-quality evidence), but regarding clinical failure, the results showed that the effect is uncertain (RR 0.94, 95% CI 0.43 to 2,05; I² = 55%; participants = 525; studies = 3; low-quality evidence). Regarding adverse events (AE) in men there could be little or no difference between the antibiotics (RR 0.83, 95% CI 0.67 to 1.02; participants = 1424; studies = 6; low-quality evidence). About women treated for CT, the effect on microbiological failure was uncertain (RR = 1.71, 95% CI 0.48 to 6.16; participants = 338; studies = 5; very low-quality evidence). There were no studies assessing clinical failure or adverse events in women, however, we found that azithromycin probably has fewer adverse events in both genders (RR 0.83, 95% CI 0.71 to 0.98; I² = 0%; participants = 2261; studies = 9; moderate-quality evidence).For the second comparison: doxycycline compared to ofloxacin, for men treated for CT the effect on microbiological failure was uncertain (RR 8.53, 95% CI 0.43 to 167.38, I² not applicable; participants = 80; studies = 2; very low-quality evidence), as also it was on clinical failure (RR 0.85, 95% CI 0.28 to 2.62; participants = 36; studies = 1; very low-quality evidence). The effect of in women on clinical failure was uncertain (RR 0.94, 95% CI 0.39 to 2.25; I² = 39%; participants = 127; studies = 2; very low-quality evidence).Regarding adverse events, the effect in both men and women was uncertain (RR 1.02 95% CI 0.66 to 1.55; participants = 339 studies = 3; very low-quality evidence). The effect on microbiological failure in women and in men and women together, the effect on microbiological failure was not estimable. The most frequently AE reported were not serious and of gastrointestinal origin.No studies assessed antimicrobial resistance or reinfection in either comparison.

AUTHORS' CONCLUSIONS

In men, regimens with azithromycin are probably less effective than doxycycline for microbiological failure, however, there might be little or no difference for clinical failure. For women, we are uncertain whether azithromycin compared to doxycycline increases the risk of microbiological failure. Azithromycin probably slightly reduces adverse events compared to doxycycline in men and women together but may have little difference in men alone. We are uncertain whether doxycycline compared to ofloxacin reduces microbiological failure in men or women alone, or men and women together, nor if it reduces clinical failure or adverse events in men or women.Based on the fact that women suffer mainly asymptomatic infections, and in order to test the effectiveness and safety of the current recommendations (azithromycin, doxycycline and ofloxacin), for CT infection, especially in low and middle income countries, future RCTs should be designed and conducted to include a large enough sample size of women, and with low risk of bias. It is also important that future RCTs include adherence, CT resistance to antibiotic regimens, and risk of reinfection as outcomes to be measured. In addition, it is important to conduct a network meta-analysis in order to evaluate all those studies that included in one arm only the current antibiotic treatments for CT infection that are recommended by the updated clinical practice guidelines.

Efficacy of Genital Chlamidiae Trachomatis Treatment in Women of Reproductive Age

Cervicitis is inflammation of the cervix, and the causes of such inflammation may include infection from certain sexually transmitted diseases (STDs), injury to the cervix from a foreign body inserted into the vagina (for example, birth control devices such as a cervical cap or diaphragm), or cervical cancer, whose course can be subacute or chronic. Our research aimed to test the efficacy of the proposed treatment protocol for chlamydia trachomatis distal genital infections in reproductive women. This single-centre, randomized, quasi-experimental prospective study was conducted among 40 women with diagnosed Chlamydia Trachomatis (CT) cervical infections who were diagnosed and treated at the Clinic of Obstetrics and Gynaecology in the Clinical Center Kragujevac in Serbia from December 2014 to January 2015. Patients were divided into two groups according to the treatment method: the tetracycline group (n=20), with doxiciclyn (Dovicin®) given at a dose of 100 mg twice per day for 10 days and 100 mg per day for the next 10 days, and the macrolides group (n=20), with azithromycin (Hemomycin®) at a dose of 1000 mg per day, divided into four doses or a single dose per day. Treatment with doxycycline proved to be statistically more effective compared to treatment with azithromycin. Our results confirm that the outcome of infections caused by C. trachomatis depends solely on the applied therapy and management, but extensive prospective studies in a female cohort that includes more parameters, such as potential age related, dose-dependent and adherence variability, are necessary to determine and confirm the best choice for treatment of CT cervicitis.

A Population-Based Study to Compare Treatment Outcomes Among Women With Urogenital Chlamydial Infection in Washington State, 1992 to 2015

BACKGROUND

United States guidelines recommend azithromycin or doxycycline for chlamydia (Chlamydia trachomatis [CT]) treatment. These therapies are similarly efficacious for urogenital infections when outcomes are measured 7 to 42 days after treatment, although doxycycline may be superior for rectal infections. Some investigators have suggested that persistent rectal infections may lead to autoinfection of the urogenital tract, potentially resulting in higher rates of recurrent infection in azithromycin-treated women.

METHODS

We used Washington State surveillance data to identify women 14 years or older with urogenital CT (1992-2015) treated with azithromycin or doxycycline. We defined persistent/recurrent CT as a repeat positive CT test result 14 to 180 days after treatment of the initial infection. We used log binomial regression to estimate the adjusted relative risk (aRR) of persistent/recurrent infection associated with treatment with azithromycin versus doxycycline.

RESULTS

From 1992 to 2015, there were 268,596 reported cases of urogenital CT, including 168,301 (63%) who received azithromycin and 66,432 (25%) who received doxycycline. The risk of persistent/recurrent urogenital CT was 6.7% and 4.7% in azithromycin- and doxycycline-treated cases, respectively (P < 0.001). Adjusting for age, race/ethnicity, year, pregnancy status, jurisdiction reporting, reason for examination, and gonorrhea coinfection, azithromycin-treated women were significantly more likely to have persistent/recurrent urogenital CT than doxycycline-treated women (aRR, 1.24; 95% confidence interval [CI], 1.19-1.30). Adjusting the retesting window to 21 to 180 days (aRR, 1.24; 95% CI, 1.19-1.30) and 28 to 180 days (aRR, 1.25; 95% CI, 1.19-1.30) did not alter our primary findings.

CONCLUSIONS

Persistent/recurrent urogenital CT may be more common among women treated with azithromycin than with doxycycline. The reason for this difference is uncertain and is an important area of future investigation.

Enrofloxacin and macrolides alone or in combination with rifampicin as antimicrobial treatment in a bovine model of acute Chlamydia psittaci infection

Chlamydia psittaci is a zoonotic bacterium with a wide host range that can cause respiratory disease in humans and cattle. In the present study, effects of treatment with macrolides and quinolones applied alone or in combination with rifampicin were tested in a previously established bovine model of respiratory C. psittaci infection. Fifty animals were inoculated intrabronchially at the age of 6-8 weeks. Seven served as untreated controls, the others were assigned to seven treatment groups: (i) rifampicin, (ii) enrofloxacin, (iii) enrofloxacin + rifampicin, (iv) azithromycin, (v) azithromycin + rifampicin, (vi) erythromycin, and (vii) erythromycin + rifampicin. Treatment started 30 hours after inoculation and continued until 14 days after inoculation (dpi), when all animals were necropsied. The infection was successful in all animals and sufficient antibiotic levels were detected in blood plasma and tissue of the treated animals. Reisolation of the pathogen was achieved more often from untreated animals than from other groups. Nevertheless, pathogen detection by PCR was possible to the same extent in all animals and there were no significant differences between treated and untreated animals in terms of local (i.e., cell count and differentiation of BALF-cells) and systemic inflammation (i.e. white blood cells and concentration of acute phase protein LBP), clinical signs, and pathological findings at necropsy. Regardless of the reduced reisolation rate in treated animals, the treatment of experimentally induced respiratory C. psittaci infection with enrofloxacin, azithromycin or erythromycin alone or in combination with rifampicin was without obvious benefit for the host, since no significant differences in clinical and pathological findings or inflammatory parameters were detected and all animals recovered clinically within two weeks.

The efficacy of oral azithromycin in clearing ocular chlamydia: mathematical modeling from a community-randomized trachoma trial

Mass oral azithromycin distributions have dramatically reduced the prevalence of the ocular strains of chlamydia that cause trachoma. Assessing efficacy of the antibiotic in an individual is important in planning trachoma elimination. However, the efficacy is difficult to estimate, because post-treatment laboratory testing may be complicated by nonviable organisms or reinfection. Here, we monitored ocular chlamydial infection twice a year in pre-school children in 32 communities as part of a cluster-randomized clinical trial in Tanzania (prevalence in children was lowered from 22.0% to 4.7% after 3-year of annual treatment). We used a mathematical transmission model to estimate the prevalence of infection immediately after treatment, and found the effective field efficacy of antibiotic in an individual to be 67.6% (95% CI: 56.5–75.1%) in this setting. Sensitivity analyses suggested that these results were not dependent on specific assumptions about the duration of infection. We found no evidence of decreased efficacy during the course of the trial. We estimated an 89% chance of elimination after 10 years of annual treatment with 95% coverage.

Differential susceptibilities to azithromycin treatment of chlamydial infection in the gastrointestinal tract and cervix

Evidence from animal studies suggests that chlamydiae may persist in the gastrointestinal tract (GI) and be a reservoir for reinfection of the genital tract. We hypothesize that there may be a differential susceptibility of organisms in the GI and genital tracts. To determine the effect of azithromycin on persistent chlamydial gut infection, C57BL/6 and BALB/c mice were infected orally and genitally and treated with azithromycin (Az) orally (20, 40, or 80 mg/kg of body weight), and the numbers of chlamydiae were determined from cervix and cecal tissues. The Az concentration in the cecum and cervix was measured by high-performance liquid chromatography with electrochemical detection (HPLC-ECD). Az treatment cleared genital infection in both C57BL/6 and BALB/c mice; however, GI infection was not cleared with the same doses. HPLC data showed the presence of Az at both sites of infection, and significant amounts of Az were measured in treatment groups. However, no significant difference in Az levels between the cecum and the cervix was observed, indicating similar levels of Az reaching both sites of infection. These data indicate that antibiotic levels that are sufficient to cure genital infection are ineffectual against GI infection. The results suggest a reevaluation of antibiotic therapy for chlamydial infection.

Macrolides: A Canadian Infectious Disease Society position paper

Since the introduction of erythromycin in 1965, no new compounds from the macrolide antimicrobial class were licensed in Canada until the 1990s. Clarithromycin and azithromycin, since their introduction, have become important agents for treating a number of common and uncommon infectious diseases. They have become prime agents in the treatment of respiratory tract infections, and have revolutionized the management of both genital chlamydial infections, by the use of single-dose therapy with azithromycin, and nontuberculous mycobacterial infections, by the use of clarithromycin. The improvement of clarithromycin and azithromycin over the gastrointestinal intolerability of erythromycin has led to supplanting the use of the latter for many primary care physicians. Unfortunately, the use of these agents has also increased the likelihood for misuse and has raised concerns about a resultant increase in the rates of macrolide resistance in many important pathogens, such as Streptococcus pneumoniae. This paper reviews the pharmacology and evidence for the current indications for use of these newer agents, and provides recommendations for appropriate use.

Practical recommendations for the drug treatment of bacterial infections of the male genital tract including urethritis, epididymitis and prostatitis

Bacterial infections of the male genital tract in young men (<35 years old) are primarily caused by sexually transmissible bacteria like Chlamydia trachomatis, Neisseria gonorrhoeae but also Mycoplasma or Haemophilus spp. In men aged over 35 years, Enterobacteriaceae are more frequently involved in urethritis, epididymitis and prostatitis. The traditional treatments suggested like tetracyclines or erythromycin are less effective since bacterial resistance is increasingly frequent, particularly in N. gonorrhoeae. Moreover, patient compliance with these drug treatments are frequently not well observed. New therapies including short term therapy with fluoroquinolones or azalides (e.g. azithromycin) are very effective and easy to use and thus eliminate any problem of compliance. However, we have to be vigilant for the emergence of resistant strains to these agents.

Epidemiology of genital Chlamydia trachomatis in England and Wales

OBJECTIVE

To describe the recent epidemiology of genital Chlamydia trachomatis infection in England and Wales.

DESIGN

Retrospective study of routinely available surveillance datasets and ad hoc prevalence studies.

METHODS

Numbers of new cases of genital C trachomatis infection, obtained from the Department of Health and Welsh Office, were combined with the estimated mid-year resident population of England and Wales. Rates were analysed for trend over time using a log linear age period model in GLIM4. Ad hoc prevalence and case finding studies carried out over the past 20 years were critically assessed in terms of study design and testing methodologies.

RESULTS

Attendance rates at genitourinary medicine (GUM) clinics were higher for women than men over the period 1989 to 1994 as were the number of laboratory reports. The highest rate of attendance (GUM clinic data) was for women aged 16 to 19 years. There was an overall significant linear decrease in the attendance rates over time for both men (p = 0.0172) and women (p = 0.0000) between 1989 and 1994. There was considerable variation in the prevalence of genital C trachomatis infection detected within different clinical settings, together with a substantial level of asymptomatic infection.

CONCLUSIONS

Genital C trachomatis infection is broadly distributed throughout the sexually active population, with a substantial reservoir of asymptomatic infection among those generally perceived to be at low risk of a sexually transmitted infection. Young people, particularly women aged 16 to 19 years, are at highest risk of genital C trachomatis infection. This is of concern since younger women are more susceptible than older women to developing complications of chlamydial infection, such as pelvic inflammatory disease. The broad distribution of infection across all sexually active health service attenders and the high level of asymptomatic infection suggest that a new, screening based, approach to the control of genital C trachomatis infection is required. Recommendations are made as to the epidemiological research required to guide such work.