High co-occurrence of anorectal chlamydia with urogenital chlamydia in women visiting an STI clinic revealed by routine universal testing in an observational study; a recommendation towards a better anorectal chlamydia control in women

Familiar Infections in Novel Anatomy: Patient Reports of Sexually Transmitted Infections After Gender-Affirming Penile Reconstruction

BACKGROUND

Sexually transmitted infections (STIs) after penile reconstruction in transgender, nonbinary, and other gender expansive (T/GE) populations have not previously been described, despite known risk factors in the population. After T/GE penile reconstruction, care providers may underdiagnose STI without anatomically appropriate guidelines.

METHODS

A detailed anonymous online survey of experiences of T/GE penile reconstruction patients was constructed with community input. Respondents were recruited from online support groups.

RESULTS

A total of 128 T/GE people with experience of penile reconstruction responded to an anonymous survey posted in online support groups from January to May 2020. Seven respondents (5.5%) self-reported 1 or more of the listed STIs at any point after penile reconstruction. All respondents with neourethras were diagnosed with localized STIs in nonurethral (extrapenile) locations only, and lack of vaginectomy was correlated with STI (P = 0.002). Sexually transmitted infections were correlated with reporting sex with cisgender men (P = 0.001), transgender men (P = 0.009), and transgender women (P = 0.012). Of health care access variables, only receiving health care at a community health center was correlated with STI history (P = 0.003).

CONCLUSIONS

This exploratory survey indicates that STI occurs after penile reconstruction in T/GE patients. Clinical confirmation is needed to identify specific risk factors and relative susceptibility of postreconstruction anatomy to STIs. Given no previous surveillance recommendations for this population and the correlation of health care provider location with STI prevalence, underdiagnoses are likely. Based on the authors' clinical experience, we describe a urogenital screening algorithm after gender-affirming penile reconstruction.

High rates of anorectal chlamydia in women: Cross-sectional study in general practice

BACKGROUND

Genital and anorectal Chlamydia trachomatis frequently present together in sexually transmitted infection clinics.

AIM

This study aimed to investigate the prevalence of co-occurrent genital and anorectal chlamydia infection, and to study whether sexual behavior is associated with anorectal infection.

DESIGN & SETTING

A cross-sectional study in general practices in the north of the Netherlands.

METHOD

Women attending general practice with an indication for genital chlamydia testing were included and asked to complete a structured questionnaire on sexual behaviour. Anorectal infection prevalence was compared according to testing indications: standard vs experimental (ie, based on questionnaire answers). Variables associated with anorectal chlamydia were analysed by univariate and multivariate logistic regression analyses.

RESULTS

Data could be analysed for 497 of 515 included women. Overall, 17.8% (87/490) were positive for C. trachomatis; of these, 72.4% (63/87) had co-occurrent genital and anorectal infection, 13.8% (12/87) had genital infection only, and 12.6% (11/87) had anorectal infection only. Rectal infection was missed in 69.3% of cases using the standard indication alone, while adding the sexual history still missed 20.0%. Age was the only variable significantly associated with anorectal infection.

CONCLUSIONS

The prevalence of anorectal disease is high among women who visit their general practitioner with an indication for genital C. trachomatis testing. Many anorectal infections are missed despite taking comprehensive sexual histories, meaning that standard treatment of genital infection with azithromycin may result in rectal persistence. Performing anorectal testing in all women with an indication for genital C. trachomatis testing is therefore recommended.

Feasibility of anorectal chlamydia testing in women: a cross-sectional survey among general practitioners

BACKGROUND

Anorectal Chlamydia trachomatis (CT) may be clinically relevant for women in general practice. Although anorectal CT testing in this setting may prevent underdiagnosis and undertreatment, its feasibility is questioned as GPs currently rarely order anorectal CT tests, for yet unknown reasons.

OBJECTIVE

To explore the feasibility of anorectal CT testing in women in general practice.

METHODS

GPs across the Netherlands were invited directly (n = 1481) and by snowball sampling (n = 330) to join an online cross-sectional survey that asked about the acceptability of and barriers for (standard) anorectal testing in women during CT-related consultations. Data were analysed with univariable and multivariable logistic regression models.

RESULTS

The questionnaire was opened by 514 respondents (28%, 514/1811) and 394 fully completed it. GPs' acceptability of anorectal testing by either self-sampling or provider-sampling was high (86%). Twenty-eight percent of GPs felt neutral, and 43% felt accepting towards standard anorectal testing. Nevertheless, 40% of GPs had never tested for anorectal CT in women, which was associated with a reported difficulty in asking about anal sex (odds ratio [OR]: 3.07, 95% confidence interval [CI]: 1.21-7.80), infrequency of anal sexual history taking (OR: 11.50, 95% CI: 6.39-20.72), low frequency of urogenital CT testing (OR 3.44, 95%-CI: 1.86-6.38) and with practicing in a non-urban area (OR: 2.27, 95% CI: 1.48-3.48). Acceptability of anorectal testing was not associated with the studied factors.

CONCLUSION

This quantitative survey shows that anorectal CT testing is feasible based on its acceptability, but is likely hindered by a lower awareness of (anorectal) CT in GPs.

Swab-yourself Trial With Economic Monitoring and Testing for Infections Collectively (SYSTEMATIC): Part 1. A Diagnostic Accuracy and Cost-effectiveness Study Comparing Clinician-taken vs Self-taken Rectal and Pharyngeal Samples for the Diagnosis of Gonorrhea and Chlamydia

BACKGROUND

Urogenital testing misses extragenital Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT). Extragenital self-sampling is frequently undertaken despite no robust randomized, controlled trial evidence of efficacy. We compared clinician-taken rectal and pharyngeal samples with self-taken samples for diagnostic accuracy and cost in men who have sex with men (MSM) and in females.

METHODS

This was a prospective convenience sample from a UK sexual health clinic. We randomized the order of clinician- and self-taken samples from the pharynx and rectum, plus first catch urine (MSM) and vulvovaginal swabs (females), for NG/CT detection.

RESULTS

Of 1793 participants (1284 females, 509 MSM), 116 had NG detected (75 urogenital, 83 rectum, 72 pharynx); 9.4% infected females and 67.3% MSM were urogenital-negative. A total of 276 had CT detected (217 urogenital, 249 rectum, 63 pharynx); 13.1% infected females and 71.8% MSM were urogenital-negative. Sexual history did not identify those with rectal infections. There was no difference in diagnostic accuracy between clinician- and self-taken samples from the rectum or pharynx. Clinicians took swabs more quickly than participants, so costs were lower. However, in asymptomatic people, nonqualified clinicians would oversee self-swabbing making these costs lower.

CONCLUSIONS

There was no difference in the diagnostic accuracy of clinician-taken compared with self-taken extragenital samples. Sexual history did not identify those with rectal infections, so individuals should have extragenital clinician- or self-taken samples. Clinician-taken swabs cost less than self-taken swabs; however, in asymptomatic people or those who perform home testing, the costs would be lower than for clinician-taken swabs.

CLINICAL TRIALS REGISTRATION

NCT02371109.

Vaginal and Anal Microbiome during Chlamydia trachomatis Infections

Background.Chlamydia trachomatis (CT) is the agent of the most common bacterial sexually transmitted infection worldwide, with a significant impact on women's health. Despite the increasing number of studies about the vaginal microbiome in women with CT infections, information about the composition of the anal microbiome is still lacking. Here, we assessed the bacterial community profiles of vaginal and anal ecosystems associated or not with CT infection in a cohort of Caucasian young women. Methods. A total of 26 women, including 10 with a contemporary vaginal and ano-rectal CT infection, were enrolled. Composition of vaginal and anal microbiome was studied by 16S rRNA gene profiling. Co-occurrence networks of bacterial communities and metagenome metabolic functions were determined. Results. In case of CT infection, both vaginal and anal environments were characterized by a degree of dysbiosis. Indeed, the vaginal microbiome of CT-positive women were depleted in lactobacilli, with a significant increase in dysbiosis-associated bacteria (e.g., Sneathia, Parvimonas, Megasphaera), whereas the anal microbiota of CT-infected women was characterized by higher levels of Parvimonas and Pseudomonas and lower levels of Escherichia. Interestingly, the microbiome of anus and vagina had numerous bacterial taxa in common, reflecting a significant microbial 'sharing' between the two sites. In the vaginal environment, CT positively correlated with Ezakiella spp. while Gardnerella vaginalis co-occurred with several dysbiosis-related microbes, regardless of CT vaginal infection. The vaginal microbiome of CT-positive females exhibited a higher involvement of chorismate and aromatic amino acid biosynthesis, as well as an increase in mixed acid fermentation. Conclusions. These data could be useful to set up new diagnostic/prognostic tools, offering new perspectives for the control of chlamydial infections.

Increased risk of subsequent chlamydia infection among women not tested at the anorectal anatomical location

BACKGROUND

Universal anorectal testing for Chlamydia trachomatis (chlamydia) among women is not recommended in many countries, while anorectal chlamydia infections are common. Missed anorectal infections might cause sequelae at the genital site if autoinoculation from the anorectum is possible, but evidence is limited. This study investigates the association between potentially missed anorectal infections and subsequent genital chlamydia infections in women, using not being tested at the anorectal site as a proxy for having a potentially missed anorectal infection.

METHODS

We included all women with a repeat chlamydia test within 1 year (with at least a genital test) from the Dutch sexual health centre surveillance between 2014 and 2019. Multilevel logistic regression analyses were used to identify determinants of genital chlamydia infection at the repeat test, with anorectal testing at the previous chlamydia test as the main determinant.

RESULTS

A total of 40 217 women were included in the analyses, of whom 15.4% tested chlamydia-positive genitally at their second test. Not being tested anorectally at the first test was an independent risk factor for genital chlamydia infection at the repeat test (adjusted OR 1.24, 95% CI 1.15 to 1.33). This association was in the same range as most other significant risk factors in the model: low education level, no condom use, STI symptoms and previous STI diagnosis. Young age (<20 years) (2.67, 2.39-2.98) and those who received partner notification (3.11, 2.91-3.31) showed stronger associations. The findings were robust; correcting for interactions and a sensitivity analysis stratifying by chlamydia infection at first visit did not show significant differences in the adjusted OR of not being tested anorectally at first test.

CONCLUSION

The results are suggestive of an autoinoculation process from the anorectal to the genital anatomical site in women. To enhance chlamydia control, future studies on the role of extragenital testing and autoinoculation in chlamydia transmission are needed.

Evidence supporting the standardisation of extragenital gonorrhoea and chlamydia screenings for women

OBJECTIVE

Current guidelines for women do not include extragenital screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) and do not mention anal sex behaviour. The objective of this cross-sectional study was to determine the number of potentially missed CT and NG cases by relying on urogenital screening and self-reported anal sex behaviour among women.

METHODS

Demographic and clinical data of 4658 women attending a community health centre in Los Angeles, California, USA from 2015 to 2018 were examined. CT and NG were detected using nucleic acid amplification test (APTIMA Combo 2, Hologic Gen-Probe, San Diego, California). Demographic and behavioural factors were also examined to assess potentially missed NG/CT cases. Multivariable regression analyses were used to determine whether reported anal sex behaviour predicts NG/CT rectal infection.

RESULTS

A total of 193 NG cases and 552 CT cases were identified; however, 53.9% of NG cases and 25.5% of CT cases were identified exclusively through extragenital screening. Of all positive cases of rectal CT, 87.0% did not report anal sex without a condom and 91.3% did not report any anal sex with their last sexual partner. Of all positive cases of rectal NG, 78.9% did not report anal sex without a condom and 76.3% did not report any anal sex with their last sexual partner. Anal sex with last partner was not predictive of NG/CT rectal infection.

CONCLUSIONS

Relying solely on urogenital screening and reported behaviour misses NG/CT cases. Extragenital NG/CT screening should be conducted in all women regardless of reported anal sex behaviour.

A Genital Infection-Attenuated Chlamydia muridarum Mutant Infects the Gastrointestinal Tract and Protects against Genital Tract Challenge

Chlamydia spp. productively infect mucosal epithelial cells of multiple anatomical sites, including the conjunctiva, lungs, gastrointestinal (GI) tract, and urogenital tract. We, and others, previously established that chlamydial GI tropism is mediated by distinct chromosomal and plasmid factors. In this study, we describe a genital infection-attenuated Chlamydia muridarum mutant (GIAM-1) that is profoundly and specifically attenuated in the murine genital tract. GIAM-1 infected the murine GI tract similarly to wild-type (WT) Chlamydia muridarum but did not productively infect the lower genital tract of female mice, ascend to infect the upper genital tract, or cause hydrosalpinx. However, GI infection of mice with GIAM-1 elicited a transmucosal immune response that protected against subsequent genital challenge with WT Chlamydia muridarum Collectively, our results demonstrate that chlamydia mutants that are profoundly attenuated for specific organ tissues can be derived and demonstrate that live-attenuated vaccine strains that infect the GI tract, but do not elicit genital tract disease, could be used to protect against chlamydia genital tract infection and disease.IMPORTANCE Chlamydia is the most common sexually transmitted bacterial infection in the United States. Most chlamydia genital infections resolve without serious consequences; however, untreated infection in women can cause pelvic inflammatory disease and infertility. Antibiotics are very effective in treating chlamydia, but most genital infections in both men and women are asymptomatic and go undiagnosed. Therefore, there is a critical need for an effective vaccine. In this work, we show that a mutant chlamydia strain, having substantially reduced virulence for genital infection, colonizes the gastrointestinal tract and produces robust immunity to genital challenge with fully virulent wild-type chlamydia. These results are an important advance in understanding chlamydial virulence and provide compelling evidence that safe and effective live-attenuated chlamydia vaccines may be feasible.

Gonorrhea and Chlamydia Specimen Positivity Rate by Polymerase Chain Reaction at a Regional Veteran Affairs Medical Center

OBJECTIVE

Sexually transmitted infections because of Neisseria gonorrhoeae (NG) and/or Chlamydia trachomatis (CT) remain a major public health problem. Although the literature describes the population-based epidemiology of CT/NG, it does not appear to contain reference points for the statistical analyses of specimen positivity rates by nucleic acid testing (NAT) with polymerase chain reaction (PCR) that would be collected by a laboratory following best laboratory and regulatory practice. For facilities that diagnose NG and CT by a real-time PCR assay, an understanding of the expected specimen positivity rate of gonorrhea and chlamydia would be helpful for monitoring the assay for quality assurance. Therefore, on behalf of the Michael J. Crescenz Veteran Affairs Medical Center (VAMC), we present this novel quality assurance study on its CT/NG specimen positivity rates conducted by NAT with PCR.

METHODS

Quality assurance/improvement quarterly data from April 1, 2012 to September 30, 2019 were reviewed to obtain both the test volume of PCR for CT/NG and the number of positive test results at the VAMC to collate and perform statistical analyses. Testing had been performed using the Abbott m2000 RealTime System (Abbott Park, IL).

RESULTS

A total of 22,709 PCR tests for CT/NG had been performed on the veteran population; of these, 502 tests were positive for NG and 744 were positive for CT. Quarterly percentage rates ranged from 1.67% to 5.30% for CT and from 1.00% to 3.25% for NG, with average rates of 3.35% and 2.22% for CT and NG, respectively.

CONCLUSION

The establishment of an expected rate of specimen positivity of CT/NG by NAT with PCR at the VAMC is a significant novel reference point in the quality assurance (QA) literature and provides a benchmark that aids tremendously in QA for the microbiology/molecular laboratory.

Detection of Rectal Chlamydia trachomatis in Heterosexual Men Who Report Cunnilingus

BACKGROUND

Rectal infection with Chlamydia trachomatis (CT) is frequent in women who deny receptive anal sex and is thought to arise from autoinoculation of the rectum from vaginal secretions. An alternate hypothesis is that oral sex inoculates and establishes gastrointestinal tract infection. Distinguishing these hypotheses is difficult in women. In men, autoinoculation is unlikely and heterosexual men frequently perform oral sex, but rarely participate in receptive anal exposure behaviors.

METHODS

We enrolled high-risk men with and without nongonococcal urethritis who presented to a sexually transmitted infection clinic in Indianapolis, Indiana. Urine and rectal swabs were collected and tested for urogenital and rectal CT, Neisseria gonorrhoeae (NG), and Mycoplasma genitalium (MG). Men completed surveys concerning symptoms, sexual orientation, and detailed recent and lifetime oral and anal sexual behaviors.

RESULTS

Rectal CT was detected in 2/84 (2.4%) heterosexual men who reported cunnilingus, but no lifetime receptive anal behaviors. All of the men who denied receptive anal behaviors were negative for rectal NG and MG. In homosexual and bisexual men, rectal CT prevalence was high (9.7%), and rectal NG (4.8%) and MG (4.8%) were also detected.

CONCLUSIONS

We detected rectal CT infections in heterosexual men who reported cunnilingus but denied receptive anal behaviors. Oral sex may be a risk factor for rectal CT infection via oral inoculation of the gastrointestinal tract.

A longitudinal study to investigate previous Chlamydia trachomatis infection as a risk factor for subsequent anorectal infection in men who have sex with men (MSM) and women visiting STI clinics in the Netherlands

Although anorectal Chlamydia trachomatis (CT) infections are frequently diagnosed in men who have sex with men (MSM) and women, the reason for this infection often remains unexplained, as anal sex is not always reported. Oropharyngeal infections inoculating the gastrointestinal (GI) tract may contribute to anorectal-CT infections, as evidence in animals suggests that chlamydia bacteria undergo GI passage; however, no evidence exists in humans. Longitudinal patient clinic-registry data from MSM (n = 17 125) and women (n = 4120) from two Dutch sexually transmitted infection clinics were analysed. When adjusting for confounding socio-demographics, co-infections and risk behaviour, previous (from 3 weeks up to 24 months) oropharyngeal CT was not a risk factor for subsequent anorectal CT in women (odds ratio (OR) 0.46; 95% confidence interval (CI) 0.18–1.18; P = 0.11) and MSM (OR 1.33; 95% CI 0.86–2.07; P = 0.204). Despite the large dataset, the numbers did not allow for the estimation of risk in specific subgroups of interest. The role of the GI tract cannot be excluded with this epidemiological study, but the impact of preceding oropharyngeal CT on anorectal-CT infection is likely limited.

Infrequent Testing of Women for Rectal Chlamydia and Gonorrhea in the United States

Background

Anal sex is a common sexual behavior among women that increases their risk of acquiring rectal infection with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC).

Methods

We estimated the frequency and positivity of rectal CT and GC tests for women aged 15-60 years performed by a large US commercial laboratory between November 2012 and September 2015. We also estimated the frequency and positivity of pharyngeal and genital specimens also performed on the same date. Among women with a positive CT or GC result, we estimated the frequency and positivity of recommended repeat testing within 12 months.

Results

Of 5499 women who had rectal CT and GC tests, positivity was 10.8%. On the same date, approximately 80% also had genital CT tests, genital GC tests, and pharyngeal GC tests, while 40% had pharyngeal CT tests. Rectal CT or GC infection was associated with genital CT or GC infection, but 46.5% of rectal CT and GC infections would not have been identified with genital testing alone. Among women with a rectal CT or GC infection, only 20.0% had a recommended repeat rectal test. Of those who had a repeat test, 17.7% were positive.

Conclusions

Testing women for rectal CT and GC was infrequent, but positive tests were often found in women with negative genital tests. Most women with positive rectal tests were not retested. Interventions are needed to increase extragenital CT and GC testing of at-risk women.

Rectal Chlamydia trachomatis and Neisseria gonorrhoeae Infections Among Women Reporting Anal Intercourse

OBJECTIVE

To examine the prevalence and treatment of rectal Chlamydia trachomatis and Neisseria gonorrhoeae infections among women reporting receptive anal intercourse in a network of sexually transmitted disease or sexual health clinics and estimate the proportion of missed infections if women were tested at the genital site only.

METHODS

We conducted a cross-sectional analysis of C trachomatis and N gonorrhoeae test results from female patients reporting receptive anal intercourse in the preceding 3 months during visits to 24 sexually transmitted disease clinics from 2015 to 2016. Primary outcomes of interest were 1) anatomic site-specific C trachomatis and N gonorrhoeae testing and positivity among women attending selected U.S. sexually transmitted disease clinics who reported receptive anal intercourse and 2) the proportion of rectal infections that would have remained undetected if only genital sites were tested.

RESULTS

Overall, 7.4% (3,743/50,785) of women reported receptive anal intercourse during the 2 years. Of the 2,818 women tested at both the genital and rectal sites for C trachomatis, 292 women were positive (61 genital only, 60 rectal only, and 171 at both sites). Of the 2,829 women tested at both the genital and rectal sites for N gonorrhoeae, 128 women were positive (31 genital only, 23 rectal only, and 74 at both sites). Among women tested at both anatomic sites, the proportion of missed C trachomatis infections would have been 20.5% and for N gonorrhoeae infections, 18.0%.

CONCLUSION

Genital testing alone misses approximately one fifth of C trachomatis and N gonorrhoeae infections in women reporting receptive anal intercourse in our study population. Missed rectal infections may result in ongoing transmission to other sexual partners and reinfection.

Genital and anal Chlamydia trachomatis bacterial load in concurrently infected women: a cross-sectional study

OBJECTIVES

Most international STI guidelines recommend Chlamydia trachomatis anorectal testing in women after self-reported sexual exposure or symptoms in women. However, it has been shown that the prevalence of anorectal C. trachomatis is as high (7%-17 %) in women who do not report anorectal intercourse (AI) as in women who do. This study assessed the correlation between the genital and anorectal C. trachomatis load in concurrently infected women for increased microbiological insight.

METHODS

A convenience sample of 105 women with a concurrent (genital and anorectal) C. trachomatis infection was included from the STI clinic in South Limburg, the Netherlands. Women provided self-collected vaginal and anorectal swabs. The C. trachomatis load was quantified with qPCR and the human cell load was assessed to ensure sample adequacy. Genital and anorectal C. trachomatis loads were divided into tertiles for comparison. The χ² test and linear regression were used to compare genital and anorectal C. trachomatis loads and identify determinants associated with load.

RESULTS

The overall median C. trachomatis load was higher in genital (median 5.3 log₁₀ C. trachomatis/ml) than anorectal samples (median 3.4, p ≤ 0.001), but both loads were within the same range. The genital and anal load categories were not related within one woman (p = 0.99), both in women with and without AI. The anorectal C. trachomatis load was in the same or higher load category than the genital load in 56% of women without AI, and 79% of women with AI.

CONCLUSIONS

Although no cut-off for clinical relevance is known, an anorectal C. trachomatis load in the same or higher load category than the genital C. trachomatis load is likely to be clinically relevant. Other measurements should also be taken into account, such as leucocytes or bacterial viability to distinguish infection from contamination or exposure.

Chlamydia trachomatis bacterial load, estimated by Cq values, in urogenital samples from men and women visiting the general practice, hospital or STI clinic

Background

The bacterial load of Chlamydia trachomatis (CT) is assumed to play a role in transmission and sequelae. We assessed urogenital CT cycle quantification (Cq) values, as an indicator for CT load, of men and women diagnosed by general practitioners (GPs), hospital physicians and the STI clinic.

Methods

Urogenital CT-positive samples (n = 2,055 vaginal swabs, n = 77 cervical swabs, n = 1,519 urine samples and n = 19 urethral swabs) diagnosed by GPs, hospital physicians and the STI clinic from the Maastricht Medical Microbiology Laboratory were included (2012–2016). The outcome measure ‘urogenital Cq values’ was used as an inversely proportional measure for CT load. Among all patients, multivariate linear regression analyses were used to assess primary determinants for mean urogenital Cq values, stratified by sex. Additional clinical determinants were assessed among STI clinic patients.

Results

In men, mean urogenital Cq values were similar between GPs, hospital physicians and the STI clinic (32.7 and 33.5 vs. 32.7; p>0.05). Women visiting the GP had lower urogenital Cq values than women visiting the STI clinic (30.2 vs. 30.9; p = <0.001). Women visiting the hospital had higher urogenital Cq values than women visiting the STI clinic (32.4 vs. 30.9; p = <0.001). Among STI clinic women, urogenital Cq values were lower in women with concurrent anorectal CT and in rectally untested women compared to anorectal CT-negative women (30.7 and 30.6 vs. 33.9; p = <0.001).

Conclusion

Men visiting different STI care providers had similar urogenital Cq values, which could be an indicator for similar CT loads. The lower Cq values of women visiting the GP compared to women visiting the STI clinic could be an indicator for higher CT loads and likely higher transmission potential. Notably, urogenital Cq values of STI clinic women were much lower (>3 Cq) when STI clinic women also had anorectal CT. This finding could indicate higher urogenital CT loads and likely higher chances of transmission and sequelae.

Spontaneous clearance of urogenital, anorectal and oropharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae in women, MSM and heterosexual men visiting the STI clinic: a prospective cohort study

OBJECTIVE

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections can clear without treatment. Despite high prevalence of anorectal infections in men who have sex with men (MSM) and women, studies on anorectal clearance are scarce. Moreover it is unknown whether bacterial load affects urogenital/anorectal CT clearance. In this prospective cohort study, CT and NG clearance is assessed at three anatomical sites of men and women.

METHODS

CT-positive and NG-positive MSM, heterosexual men and women ≥18 years of age visiting our STI clinic between 2011 and 2013 underwent a repeat test when returning for treatment (n=482). The primary outcome was clearance, defined as a positive nucleic acid amplification test (NAAT) at screening-consultation, followed by a negative NAAT at treatment-consultation. Sociodemographics, sexual risk behaviour and CT bacterial load (inhouse quantitative PCR) were tested as determinants for clearance using multivariable logistic regression for CT and Fisher's exact test for NG.

RESULTS

CT clearance was 9.1% (10/110) for urine, 6.8% (20/292) for vaginal swabs, 12.7% (8/63) for anorectal swabs (ie, 4.0% [1/25] in MSM and 18.4% [7/38] in women) and 57.1% (4/7) for oropharyngeal swabs. For NG this was 33.3% (2/6), 28.6% (2/7), 20.0% (2/10) and 27.3% (6/22), respectively. The number of days between tests (median 10, IQR 7-14) was not associated with clearance. Lower bacterial load at screening was the only predictor for CT clearance (urine mean 1.2 vs 2.6 log CT/mL, p=0.001; vaginal swabs mean 2.1 vs 5.2 log CT/mL p<0.0001; anorectal swabs mean 2.0 vs 3.7 log CT/mL, p=0.002). None of the tested determinants were associated with NG clearance.

CONCLUSIONS

This study reports the largest number of anorectal infections tested for CT and NG clearance to date. Clearance in all sample types was substantial: between 7% and 57% for CT, and between 20% and 33% for NG (notwithstanding low absolute numbers). CT clearance was associated with a lower load at screening. However, not all individuals with low bacterial CT load cleared the infection, hampering STI guideline change.

Randomized, open-label, multicenter study of azithromycin compared with doxycycline for treating anorectal Chlamydia trachomatis infection concomitant to a vaginal infection (CHLAZIDOXY study)

BACKGROUND

Chlamydia trachomatis can lead to a persistent infection in the lower gastrointestinal tract, suggesting a potential role of autoinoculation of cervical chlamydial infection from the rectal site, contributing to repeat infections. Moreover, around 75% of women with urogenital C. trachomatis have concurrent anorectal infection. Current treatment guidelines for urogenital C. trachomatis infection recommend either a single 1 g dose of azithromycin or doxycycline 100 mg twice daily for 7 days. Doxycycline appears to be more effective in treating anorectal infections as suggested in a population of men who have sex with men, but no randomized controlled trial (RCT) had directly compared azithromycin with doxycycline for the treatment of rectal infections. We propose an open-label RCT to compare the microbial cure obtained with a single 1 g dose of azithromycin versus 100 mg of doxycycline twice daily for 7 days, for the treatment of anorectal C. trachomatis infection concurrent to urogenital infection in women.

METHODS AND STUDY DESIGN

A total of 460 women with C. trachomatis urogenital infection will be enrolled in the study. Women will be asked to provide self-collected anorectal swabs and will be randomized to receive either a 1 g single dose of azithromycin or doxycycline 100 mg twice daily for 7 days. Clinical and biological data will be collected and patients will complete questionnaires about their sexual behavior. The primary outcome is the microbial cure rate, defined as a C. trachomatis negative nucleic acid amplification test (NAAT) result in the anorectal specimens 6 weeks after treatment initiation among women with a C. trachomatis positive urogenital and anorectal NAAT result at the baseline. The secondary outcome is autoinoculation from the rectum to the vagina, which will be evaluated based on the number of women with the same C. trachomatis genotype profile that will be identified in an anorectal-positive specimen obtained 6 weeks after treatment initiation and in a vaginal-positive specimen obtained four months after treatment.

DISCUSSION

The results of this trial will establish which treatment is more efficacious against anorectal infection and could affect recommendations for the treatment of urogenital C. trachomatis infection, taking into account concurrent anorectal infection.

TRIAL REGISTRATION NUMBERS

EudraCT number: 2017-002595-15. CLINICALTRIALS.

GOV IDENTIFIER

NCT03532464. Date of registration: May 31, 2018.

WORLD HEALTH ORGANISATION INTERNATIONAL CLINICAL TRIALS REGISTRY

NTC03532464. Secondary ID: CHUBX 2016/26. Date of registration: May 09, 2018.

Chlamydiae in human intestinal biopsy samples

Chlamydia trachomatis is frequently detected in anorectal specimens from men and women. A recent hypothesis suggests that C. trachomatis is a natural commensal organism asymptomatically colonizing the gastrointestinal tract. In this study, we investigated the presence of chlamydial DNA and antigen in intestinal biopsy samples taken during colonoscopy. Cases (n = 32) were patients whose histopathology reports included the term ‘chlamydia’, suggesting a possible history of infection. Control patients (n = 234) did not have chlamydia mentioned in their histopathology report and all tested negative for Chlamydiaceae DNA by 23S ribosomal RNA-based real-time PCR. Amongst the cases, C. trachomatis DNA was detected in the appendix and colon of two female and one male patients. Chlamydia abortus DNA was present in the colon of a fourth female patient. Thus, chlamydial DNA could be demonstrated in intestinal biopsy samples proximal to the anorectal site and inclusions were identified in rectum or appendix of two of these patients by immunohistochemistry. However, the findings in two cases were compatible with sexually acquired C. trachomatis. The identification of C. trachomatis DNA/antigen does not prove the presence of active infection with replicating bacteria. Larger prospective studies on fresh tissue samples are required to confirm the data obtained in this study.

Sexually transmitted infections: Need for extragenital screening

Extragenital infections can occur concurrently with simultaneous urogenital infections. Extragenital sites are believed to serve as hidden reservoirs and play a critical role in their transmission. The etiological relationship of the most widespread Sexually transmitted diseases (STD) pathogen to reproductive tract has long been established, but the distribution to extragenital sites appears to be infrequent and its correlation with the sexual practice still requires to be investigated. Optimal-screening strategies for extragenital infections are largely unknown. However, there is a lack of data on clinical outcomes and optimal treatment regimens for rectal and pharyngeal extragenital infections. Further studies are needed in settings other than reproductive health and STD clinics, especially in primary care clinics and resource-limited settings.

Growth characteristics of Chlamydia trachomatis in human intestinal epithelial Caco-2 cells

Chlamydia trachomatis is an obligate intracellular bacterium causing infections of the eyes, urogenital and respiratory tracts. Asymptomatic, repeat and chronic infections with C. trachomatis are common in the urogenital tract potentially causing severe reproductive pathology. Animal models of infection and epidemiological studies suggested the gastrointestinal tract as a reservoir of chlamydiae and as a source of repeat urogenital infections. Thus, we investigated the growth characteristics of C. trachomatis in human intestinal epithelial Caco-2 cells and the infection-induced defensin production. Immunofluorescence staining and transmission electron microscopy showed the presence of chlamydial inclusions in the cells. Chlamydial DNA and viable C. trachomatis were recovered from Caco-2 cells in similar quantity compared to that detected in the usual in vitro host cell of this bacterium. The kinetics of expression of selected C. trachomatis genes in Caco-2 cells indicated prolonged replication with persisting high expression level of late genes and of heat shock protein gene groEL. Replication of C. trachomatis induced moderate level of β-defensin-2 production by Caco-2 cells, which might contribute to avoidance of immune recognition in the intestine. According to our results, Caco-2 cells support C. trachomatis replication, suggesting that the gastrointestinal tract is a site of residence for these bacteria.

Detection of Chlamydia trachomatis in rectal specimens in women and its association with anal intercourse: a systematic review and meta-analysis

OBJECTIVES

Chlamydia trachomatis is the most commonly diagnosed bacterial STI. Lack of prevalence and risk factor data for rectal chlamydia in women has testing and treatment implications, as azithromycin (a first-line urogenital chlamydia treatment) may be less effective for rectal chlamydia. We conducted a systematic review of studies on women in high-income countries to estimate rectal chlamydia prevalence, concurrency with urogenital chlamydia and associations with reported anal intercourse (AI).

DESIGN

Systematic review and four meta-analyses conducted using random-effects modelling.

DATA SOURCES

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and the Cochrane Database were searched for articles published between January 1997 and October 2017.

ELIGIBILITY CRITERIA

Studies reporting rectal chlamydia positivity in heterosexual women aged ≥15 years old in high-income countries were included. Studies must have used nucleic acid amplification tests and reported both the total number of women tested for rectal chlamydia and the number of rectal chlamydia infections detected. Conference abstracts, case reports and studies with self-reported diagnoses were excluded. Data extracted included setting, rectal and urogenital chlamydia testing results, AI history, and demographics.

RESULTS

Fourteen eligible studies were identified, all among diverse populations attending sexual health services. Among routine clinic-attending women, summary rectal chlamydia positivity was 6.0% (95% CI 3.2% to 8.9%); summary concurrent rectal chlamydia infection was 68.1% in those who tested positive for urogenital chlamydia (95% CI 56.6% to 79.6%); and of those who tested negative for urogenital chlamydia, 2.2% (95% CI 0% to 5.2%) were positive for rectal chlamydia. Reported AI was not associated with rectal chlamydia (summary risk ratio 0.90; 95% CI 0.75 to 1.10).

CONCLUSIONS

High levels of rectal chlamydia infection have been shown in women with urogenital chlamydia infection. The absence of association between reported AI and rectal chlamydia suggests AI is not an adequate indicator for rectal testing. Further work is needed to determine policy and practice for routine rectal testing in women.

Review of Chlamydia trachomatis viability methods: assessing the clinical diagnostic impact of NAAT positive results

INTRODUCTION

Chlamydia trachomatis (chlamydia) is the most commonly diagnosed bacterial sexually transmitted infection (STI) worldwide. The advancement of molecular techniques has made chlamydia diagnostics infinitely easier. However, molecular techniques lack the information on chlamydia viability. Where in routine diagnostics the detection of chlamydia DNA or RNA might suffice, in other patient scenarios, information on the viability of chlamydia might be essential. Areas covered: In this review, the authors discuss the specific strengths and limitations of currently available methods to evaluate chlamydia viability: conventional cell culture, messenger RNA (mRNA) detection and viability-PCR (V-PCR). PubMed and Google Scholar were searched with the following terms: Chlamydia trachomatis, Treatment failure, Anal chlamydia, Microbial viability, Culture, Viability-PCR, Messenger RNA, and Molecular diagnostics Expert commentary: Several techniques are currently available to determine chlamydia viability and thus the clinical relevance of a positive test result in clinical samples. Depending on the underlying research question, all three discussed techniques have their merits when testing for viability. However, mRNA methods show the most promise in determining the presence of a true infection, in case the chlamydia reticulate body can be specifically detected. Further research is needed to understand how to best apply viability testing in current chlamydia diagnostics.

High Proportion of Anorectal Chlamydia trachomatis and Neisseria gonorrhoeae After Routine Universal Urogenital and Anorectal Screening in Women Visiting the Sexually Transmitted Infection Clinic

Background.

Testing on indication of self-reported anal sex or symptoms is used to manage anorectal Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhea) infections in women. Little is known about the impact of another testing strategy, routine universal anorectal screening with respect to chlamydia and gonorrhea prevalence and risk factors.

Methods.

All women (n = 1012) aged ≥16 years attending our sexually transmitted infection clinic in 2015 were offered routine universal screening. In total, 19.5% (n = 185) of women had an indication (reported anal sex or symptoms), 72.5% (n = 689) did not have an indication, and 8.0% (n = 76) had missing information on indication. Logistic regression analyses were used to identify determinants associated with anorectal chlamydia and gonorrhea.

Results.

Of all women who visited our clinic, 94% (n = 950) participated in the study. Overall anorectal chlamydia/gonorrhea positivity was 13.4% (n = 127)/1.3% (n = 12). Self-reported anal sex and anal symptoms were independently associated with anorectal gonorrhea (odds ratios [ORs], 3.3 [95% confidence interval {CI}, 1.01-10.7] and 14.5 [95% CI, 2.8-75.0], respectively), but not with anorectal chlamydia. Of all anorectal chlamydia/gonorrhea cases, 72% (n = 92)/33% (n = 4) were diagnosed in women without an indication, of which 19% (n = 19)/0% (n = 0) were anorectal only. For women with missing indication, this was 7% (n = 9)/8% (n = 1) and 44% (n = 4)/100% (n = 1).

Conclusions.

Anorectal screening in women without an indication is feasible and highly acceptable. Selective testing on indication could be an appropriate control strategy for anorectal gonorrhea, as few infections would be missed. In contrast, selective testing is a suboptimal control strategy for anorectal chlamydia, as we found a high prevalence in women both with and without indication for anorectal testing, along with a substantial amount of anorectal-only infections.

Repeat Chlamydia trachomatis testing among heterosexual STI outpatient clinic visitors in the Netherlands: a longitudinal study

BACKGROUND

Chlamydia infections are common in both men and women, are often asymptomatic and can cause serious complications. Repeat testing in high-risk groups is therefore indicated. In the Netherlands, guidelines on repeat chlamydia testing differ between testing facilities, and knowledge on repeat testing behaviour is limited. Here, we analyse the current repeat testing behaviour of heterosexual STI clinic visitors, and aim to identify groups for which repeat testing advice could be advantageous.

METHODS

Longitudinal surveillance data from all Dutch STI outpatient clinics were used, which included all STI clinic consultations carried out among heterosexual men and women between June 2014 and December 2015. Repeat testing was defined as returning to the same STI clinic between 35 days and 12 months after initial consultation. We calculated chlamydia positivity at repeat test stratified by initial test result and time between consultations. Logistic regression analyses were used to identify predictors of repeat testing, and predictors of having a chlamydia positive repeat test.

RESULTS

In total, 140,486 consultations in 75,487 women and 46,286 men were available for analyses. Overall, 15.4% of women and 11.1% of men returned to the STI clinic within the study period. Highest chlamydia positivity at repeat test was seen 3-5 months after initial positive test. Among both women and men, repeat testing was associated with non-Western ethnicity, having had more than two sex partners in the past 6 months, reporting STI symptoms, having a history of STI, and having a chlamydia positive initial test. Among repeat testers, chlamydia positive repeat test was most strongly associated with younger age, followed by a chlamydia positive initial test.

CONCLUSIONS

Repeat testing most often resulted in a positive test result among young heterosexuals (<25) and heterosexuals of any age with a chlamydia infection at the initial consultation. Further efforts are needed to determine optimal repeat testing strategies.

Sexually transmitted infections of the lower gastrointestinal tract

The World Health Organization estimates that there is greater than one million new cases of sexually transmitted infections (STIs) every day. In many countries, STIs are at an unprecedented high, including the USA, where nearly 20 million new cases were reported in 2016. Although morbidity associated with STIs is usually seen in the context of genitourinary disease, these pathogens may also affect the gastrointestinal tract and cause anal pain, abdominal pain, or diarrhea. It is important to recognize patterns of injury associated with these pathogens, especially those that may mimic other gastrointestinal diseases, such as idiopathic inflammatory bowel disease (IBD). This review focuses upon STIs of the lower gastrointestinal tract, organized by the most common site of involvement: the anus, rectum, and colon.

Monitoring therapy success of urogenital Chlamydia trachomatis infections in women: A prospective observational cohort study

INTRODUCTION

The use of a nucleic acid amplification test (NAAT) as a test of cure after treatment is subject to discussion, as the presence of C. trachomatis nucleic acids after treatment may be prolonged and intermittent without presence of infectious bacteria. We used cell culture to assess if a positive RNA- or DNA-based NAAT after treatment indicates the presence of viable C. trachomatis.

METHODS

We included women with asymptomatic urogenital C. trachomatis infection visiting the Amsterdam STI clinic from September 2015 through June 2016. Endocervical swabs were collected prior to treatment with azithromycin, and during three follow-up visits 7, 21 and 49 days after treatment. Collected swabs were subjected to C. trachomatis culture and a RNA- and DNA-based NAAT. High-resolution multilocus sequence typing (hr-MLST) was used to further differentiate potential re-infections.

RESULTS

We included 90 women with a positive RNA-test prior to receiving treatment of whom 81 (90%) were also DNA-positive, and 69 (76.7%) culture-positive. Prolonged and intermittent positive RNA and DNA results over time were observed. Three women had culture positive results at the second visit, but all were negative at the third visit. Five women had NAAT-positive results at the fourth visit of whom three women were also culture-positive indicating a viable infection. All five women reported unprotected sexual contact since the first visit. From 2, hr-MLST sequence types were obtained. One had a different sequence type indicating a new infection the other was identical to the previously found indicating a potentially persisting infection.

CONCLUSION

Most RNA- or DNA-positive results after treatment of urogenital C. trachomatis may be caused by non-viable molecular remnants since they cannot be confirmed by culture. In a minority viable C. trachomatis was found in culture at the second visit, indicating that patients may remain infectious at least 7 days after treatment.

High-Throughput Testing of Urogenital and Extragenital Specimens for Detection of Chlamydia Trachomatis and Neisseria Gonorrhoeae with Cobas® CT/NG

We compared the analytical and clinical performance of cobas^® CT/NG for use on the Cobas^® 6800/8800 Systems with the Cobas^® 4800 CT/NG Test from urogenital and extragenital specimens in over 12,000 specimens from both male and female subjects in Germany and the United States. The analytical sensitivity was ≤40 EB/ml for Chlamydia trachomatis (CT) and ≤1 CFU/ml for Neisseria gonorrhoeae (NG). Using clinical specimens, the overall percent agreement with the Cobas^® 4800 CT/NG Test was >98.5%. Across urogenital specimens, there were 93 discrepant specimens; 76 (93.8%) of 81 CT discrepant specimens were 6800+/4800– and 10 (83.3%) of 12 NG discrepant specimens were 6800+/4800–. Sequencing verified CT results for 45 (61.6%) of 73 samples positive by 6800 and 1 (20%) of 5 positive by 4800. Similarly, 7 (70.0%) of 10 NG samples positive by 6800 and 1 of 2 positive by 4800 were confirmed by sequencing. Among discrepant extragenital specimens (all 6800+/4800–), 7 (50%) of 14 oropharyngeal and 23 (76.7%) of 30 anorectal CT discordant samples were confirmed as CT positive by sequencing; all 8 anorectal and 20 (90.9%) of 22 oropharyngeal NG discordant results were also confirmed as NG positive. In conclusion, Cobas^® CT/NG for use on the Cobas^® 6800/8800 Systems provides high-throughput automated solutions for sexually transmitted infection (STI) screening programs.

What explains anorectal chlamydia infection in women? Implications of a mathematical model for test and treatment strategies

OBJECTIVES

Female anorectal Chlamydia trachomatis (chlamydia) infections are common irrespective of recent anal sex. We explored the role of anorectal infections in chlamydia transmission and estimated the impact of interventions aimed at improved detection and treatment of anorectal infections.

METHODS

We developed a pair compartmental model of heterosexuals aged 15-29 years attending STI clinics, in which women can be susceptible to or infected with chlamydia urogenitally and/or anorectally and men urogenitally. Transmission probabilities per vaginal and anal sex act, together with an autoinoculation probability, were estimated by fitting to anatomic site-specific prevalence data (14% urogenital; 11% anorectal prevalence). We investigated the 10-year reduction in female chlamydia prevalence of interventions (universal anorectal testing of female STI clinic attendees or doxycycline use for urogenital chlamydia) relative to continued current care (anorectal testing on indication and doxycycline for anorectal and azithromycin for urogenital chlamydia).

RESULTS

The transmission probability per anal sex act was 5.8% (IQR 3.0-8.3%), per vaginal sex act 2.0% (IQR 1.7-2.2%) and the daily autoinoculation probability was 0.7% (IQR 0.5-1.0%). More anorectal chlamydia infections were caused by autoinoculation than by recent anal sex. Universal anorectal testing reduced population prevalence modestly with 8.7% (IQR 7.6-9.7%), yet the reduction was double that of doxycycline use for urogenital infections (4.3% (IQR 3.5-5.3%)) relative to continued current care.

CONCLUSIONS

Autoinoculation between anatomic sites in women might play a role in sustaining high chlamydia prevalence. A shift to more anorectal testing of female STI clinic attendees may be considered for its (albeit modest) impact on reducing prevalence.

Anorectal swabs as a marker of male-to-male sexual exposure in STI surveillance systems

Identification of priority populations such as men who have sex with men (MSM) is important in surveillance systems to monitor trends of sexually transmitted infections (STIs). We explored using routinely collected non-behavioural data as a means to establish MSM status in surveillance by assessing anorectal swab as a marker of male-to-male sexual exposure. We used chlamydia testing data from a sexual health clinic, 2007-2012. Men reporting any male sexual partner(s) in the previous 12 months were considered MSM. The dataset was split into development and validation samples to develop a univariate predictive model and assess the model fit. The dataset included 30 358 individual men and 48 554 episodes of STI testing; 45% were among reported MSM and an anorectal swab was performed in 40% of testing episodes. Anorectal swabbing had good diagnostic performance as a marker for MSM status (sensitivity = 87%, specificity = 99%, positive predictive value = 98·6%, negative predictive value = 90·3%). The model showed good fit against the internal validation sample (area under the curve = 0·93). Anorectal swabs are a valid marker of MSM behaviour in surveillance data from sexual health clinics, and they are likely to be particularly useful for monitoring STI trends among MSM with higher risk behaviour.

Anogenital infection by Chlamydia trachomatis and Neisseria gonorrhoeae in HIV-infected men and women in Salvador, Brazil

Background

Infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae are the most common bacterial sexually transmitted infections throughout the world. These sexually transmitted infections are a growing problem in people living with HIV/AIDS. However, the presence of these agents in extra genital sites, remains poorly studied in our country. The objective of this study was to estimate the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae anal and genital infection in people living with HIV/AIDS followed in a reference center in Salvador, Brazil.

Methods

Cross-sectional study, from June 2013 to June 2015. Proven HIV-infected people attending this reference center were invited. Clinical and epidemiological data were obtained through interview with standardized form. Chlamydia trachomatis and Neisseria gonorrhoeae screening was performed using qPCR (COBAS 4800^® Roche).

Results

The frequency of positive cases of Chlamydia trachomatis and Neisseria gonorrhoeae was 12.3% in total, 9.2% cases amongst women and 17.1% amongst men. We found 14.0% of positive cases in anus and 3.1% in genital region in men, while 5.6% and 3.6%, in women, respectively. Among men, anal infection was associated with age <29 years (p = 0.033), report of anal intercourse (p = 0.029), pain during anal intercourse (p = 0.028). On the other hand, no association between genital infection and other variables were detected in bivariate analysis. Among women, we detected an association between Chlamydia trachomatis genital infection and age <29 years (p < 0.001), younger age at first sexual intercourse (p = 0.048), pregnancy (p < 0.001), viral load >50 copies/mL (p = 0.020), and no antiretroviral use (p = 0.008). Anal infection in women was associated with age <29 years old (p < 0.001) and pregnancy (p = 0.023), and was not associated with report of anal intercourse (p = 0.485).

Conclusion

Missed opportunities for diagnosis in extra genital sites could impact on HIV transmission. The extra genital sites need to be considered to break the HIV and bacterial sexually transmitted infections chain-of-transmission.

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.

Design of the FemCure study: prospective multicentre study on the transmission of genital and extra-genital Chlamydia trachomatis infections in women receiving routine care

Background

In women, anorectal infections with Chlamydia trachomatis (CT) are about as common as genital CT, yet the anorectal site remains largely untested in routine care. Anorectal CT frequently co-occurs with genital CT and may thus often be treated co-incidentally. Nevertheless, post-treatment detection of CT at both anatomic sites has been demonstrated. It is unknown whether anorectal CT may play a role in post-treatment transmission. This study, called FemCure, in women who receive routine treatment (either azithromycin or doxycycline) aims to understand the post-treatment transmission of anorectal CT infections, i.e., from their male sexual partner(s) and from and to the genital region of the same woman. The secondary objective is to evaluate other reasons for CT detection by nucleic acid amplification techniques (NAAT) such as treatment failure, in order to inform guidelines to optimize CT control.

Methods

A multicentre prospective cohort study (FemCure) is set up in which genital and/or anorectal CT positive women (n = 400) will be recruited at three large Dutch STI clinics located in South Limburg, Amsterdam and Rotterdam. The women self-collect anorectal and vaginal swabs before treatment, and at the end of weeks 1, 2, 4, 6, 8, 10, and 12. Samples are tested for presence of CT-DNA (by NAAT), load (by quantitative polymerase chain reaction -PCR), viability (by culture and viability PCR) and CT type (by multilocus sequence typing). Sexual exposure is assessed by online self-administered questionnaires and by testing samples for Y chromosomal DNA. Using logistic regression models, the impact of two key factors (i.e., sexual exposure and alternate anatomic site of infection) on detection of anorectal and genital CT will be assessed.

Discussion

The FemCure study will provide insight in the role of anorectal chlamydia infection in maintaining the CT burden in the context of treatment, and it will provide practical recommendations to reduce avoidable transmission. Implications will improve care strategies that take account of anorectal CT.

Trial registration

ClinicalTrials.gov Identifier: NCT02694497.

Extragenital Infections Caused by Chlamydia trachomatis and Neisseria gonorrhoeae: A Review of the Literature

In the United States, sexually transmitted diseases due to Chlamydia trachomatis and Neisseria gonorrhoeae continue to be a major public health burden. Screening of extragenital sites including the oropharynx and rectum is an emerging practice based on recent studies highlighting the prevalence of infection at these sites. We reviewed studies reporting the prevalence of extragenital infections in women, men who have sex with men (MSM), and men who have sex only with women (MSW), including distribution by anatomical site. Among women, prevalence was found to be 0.6–35.8% for rectal gonorrhea (median reported prevalence 1.9%), 0–29.6% for pharyngeal gonorrhea (median 2.1%), 2.0–77.3% for rectal chlamydia (median 8.7%), and 0.2–3.2% for pharyngeal chlamydia (median 1.7%). Among MSM, prevalence was found to be 0.2–24.0% for rectal gonorrhea (median 5.9%), 0.5–16.5% for pharyngeal gonorrhea (median 4.6%), 2.1–23.0% for rectal chlamydia (median 8.9%), and 0–3.6% for pharyngeal chlamydia (median 1.7%). Among MSW, the prevalence was found to be 0–5.7% for rectal gonorrhea (median 3.4%), 0.4–15.5% for pharyngeal gonorrhea (median 2.2%), 0–11.8% for rectal chlamydia (median 7.7%), and 0–22.0% for pharyngeal chlamydia (median 1.6%). Extragenital infections are often asymptomatic and found in the absence of reported risk behaviors, such as receptive anal and oral intercourse. We discuss current clinical recommendations and future directions for research.

Chlamydia trachomatis infection prevalence and serovar distribution in a high-density urban area in the north of Italy

The aim of this study was to assess Chlamydia trachomatis (CT) infection prevalence and serovar distribution in a high-density urban area in the north of Italy, by comparing different groups of subjects divided on the basis of the type of care provider they referred to (STI Clinic, gynaecologists or general practitioners). From January 2011 to May 2014, all the specimens submitted to the Microbiology Laboratory of St Orsola Hospital in Bologna for CT detection were tested by PCR assay. For positive specimens, molecular genotyping based on RFLP analysis was performed. Total prevalence of CT infection was 8.1 %, with significant differences between subgroups (P<0.01) but stable during the study period. The STI Clinic was mainly responsible for CT diagnosis, whereas the lowest infection prevalence was detected in gynaecological clinics, despite the high number of tests performed. Extra-genital samples were almost exclusively collected from males at the STI Clinic. Interestingly, 13.3 % of patients providing extra-genital specimens were positive for CT on rectal and/or pharyngeal swabs, and 4.4 % of cases would have been missed if extra-genital sites had not been tested. The most common serovar was E, and serovar distribution was influenced by gender (P<0.01), age (P<0.01), care provider (P=0.01) and anatomical site (P<0.01). The L2 serovar was detected only in extra-genital samples from males at the STI Clinic. Knowledge about care providers' contributions in CT testing and diagnosis is essential for infection control. CT typing is crucial for appropriate management of specific infections, such as lymphogranuloma venereum in extra-genital samples of high-risk populations.

Penicillin G-Induced Chlamydial Stress Response in a Porcine Strain of Chlamydia pecorum

Chlamydia pecorum causes asymptomatic infection and pathology in ruminants, pigs, and koalas. We characterized the antichlamydial effect of the beta lactam penicillin G on Chlamydia pecorum strain 1710S (porcine abortion isolate). Penicillin-exposed and mock-exposed infected host cells showed equivalent inclusions numbers. Penicillin-exposed inclusions contained aberrant bacterial forms and exhibited reduced infectivity, while mock-exposed inclusions contained normal bacterial forms and exhibited robust infectivity. Infectious bacteria production increased upon discontinuation of penicillin exposure, compared to continued exposure. Chlamydia-induced cell death occurred in mock-exposed controls; cell survival was improved in penicillin-exposed infected groups. Similar results were obtained both in the presence and in the absence of the eukaryotic protein translation inhibitor cycloheximide and at different times of initiation of penicillin exposure. These data demonstrate that penicillin G induces the chlamydial stress response (persistence) and is not bactericidal, for this chlamydial species/strain in vitro, regardless of host cell de novo protein synthesis.

Chlamydial Antibiotic Resistance and Treatment Failure in Veterinary and Human Medicine

The Chlamydiaceae are widespread pathogens of both humans and animals. Chlamydia trachomatis infection causes blinding trachoma and reproductive complications in humans. Chlamydia pneumoniae causes human respiratory tract infections and atypical pneumonia. Chlamydia suis infection is associated with conjunctivitis, diarrhea, and failure to gain weight in domestic swine. Chlamydial infections in humans and domesticated animals are generally controlled by antibiotic treatment—particularly macrolides (usually azithromycin) and tetracyclines (tetracycline and doxycycline). Tetracycline-containing feed has also been used to limit infections and promote growth in livestock populations, although its use has decreased because of growing concerns about antimicrobial resistance development. Because Sandoz and Rockey published an elegant review of chlamydial anti-microbial resistance in 2010, we will review the following: (i) antibiotic resistance in C. suis, (ii) recent evidence for acquired resistance in human chlamydial infections, and (iii) recent non-genetic mechanisms of antibiotic resistance that may contribute to treatment failure.

The effect of introducing routine self-taken extra-genital swabs in a genitourinary medicine clinic cohort: a before and after study

Starting July 2013, all patients attending a sexual health clinic who reported risk of extra-genital infection were offered self-taken extra-genital swabs. The study aim was to assess the detection rate of extra-genital infection since self-taken swabs were introduced. We compared patients diagnosed with chlamydia and gonorrhoea in six-month periods before (February-July 2012) and after (February-July 2014) the introduction of self-taken extra-genital swabs. There were 408 (98 gonorrhoea, 310 chlamydia) detected infections in the 2012 period and 404 (121 gonorrhoea, 283 chlamydia) in 2014. The rate of extra-genital chlamydia/gonorrhoea increased fourfold from 18/408, 4.4% to 77/404 19% (P < 0.0001). The rise was seen in both rectal (8/408, 2% vs. 40/404, 9.9%, P < 0.0001) and pharyngeal infection (10/408, 2.5% vs. 48/404, 11.8% P < 0.0001). Significant rises were seen in men who have sex with men in rectal (5/408, 1.2% vs. 28/404, 6.9% P = 0.001) and pharyngeal infection (10/408, 2.5% vs. 20/404, 5%, P = 0.02) and for women in rectal (3/408, 0.7% vs. 12/404, 3% P = 0.03) and pharyngeal infection (0/408, 0% vs. 20/404, 5%, P < 0.0001). In 100 consecutive patients having extra-genital swabs in each study period, self-swabbing rose from 0% (0/100) to 89% (89/100) P < 0.0001. The introduction of routine self-taken extra-genital swabs has led to a large rise in detected extra-genital chlamydia and/or gonorrhoea infection in men who have sex with men and women.

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).

What is needed to guide testing for anorectal and pharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae in women and men? Evidence and opinion

Background

Anorectal and pharyngeal infections with Chlamydia trachomatis (CT) and Neisseria gonorrheae (NG) are commonly observed in men who have sex with men (MSM). There is increasing evidence that such infections at extra-genital sites are also common in women. In both sexes, these infections are largely overlooked as they are not routinely tested for in regular care. Testing based on sexual behavior or symptoms would only detect half of these extra-genital infections. This paper elucidates the differences and similarities between women and MSM, regarding the epidemiology of extra-genital CT and NG. It discusses the clinical and public health impact of untested extra-genital infections, how this may impact management strategies, and thereby identifies key research areas.

Discussion

Extra-genital CT is as common in women as it is in MSM; NG in women is as common at their extra-genital sites as it is at their genital sites. The substantial numbers of extra-genital CT and NG being missed in women and MSM indicate a need to test and treat more patients and perhaps different choices in treatment and partner management strategies. Doing so will likely contribute to reduced morbidity and transmission in both sexes. However, in our opinion, it is clear that there are several knowledge gaps in understanding the clinical and public health impact of extra-genital CT and NG. Key research areas that need to be addressed concern associated morbidity (anorectal and reproductive morbidity due to extra-genital infections), ‘the best’ management strategies, including testing and treatment for extra-genital CT, extra-genital treatment resistance, transmission probabilities between partners and between anatomic sites in a woman, and impact on transmission of other infections. Data are also lacking on cost-effectiveness of pharyngeal testing, and of NG testing and anorectal CT testing in women. Gaps in the management of extra-genital CT and NG may also apply for other STIs, such Mycoplasma genitalium.

Summary

Current management strategies, including testing, to address extra-genital CT and NG in both sexes are suboptimal. Comparative data on several identified key themes in women and MSM are lacking and urgently needed to guide better management of extra-genital infections.

2015 UK national guideline for the management of infection with Chlamydia trachomatis

This guideline offers recommendations on the diagnostic tests, treatment regimens and health promotion principles needed for the effective management of Chlamydia trachomatis genital infection. It covers the management of the initial presentation, as well the prevention of transmission and future infection. The guideline is aimed at individuals aged 16 years and older presenting to healthcare professionals working in departments offering Level 3 care in sexually transmitted infections management within the UK. However, the principles of the recommendations should be adopted across all levels, using local care pathways where appropriate.

Prevalence of and Factors Associated with Rectal-Only Chlamydia and Gonorrhoea in Women and in Men Who Have Sex with Men

BACKGROUND

Both anorectal Chlamydia trachomatis (CT) and Neisseria gonorrhoea (NG) can occur as a rectal-only infection or concurrently with simultaneous urogenital infection with the same pathogen. Characterising the target groups in which rectal-only infections occur may improve the efficacy of screening practices.

METHODS

We analysed data from two Dutch outpatient sexually transmitted infection (STI) clinics between 2011 and 2012. We included all men who have sex with men (MSM) (n = 9549) and women (n = 11113), ≥18 years, who had been tested for anorectal and urogenital CT and/or NG (either as a result of reporting anal sex/symptoms or via routine universal testing). Factors associated with rectal-only CT and NG infections were assessed using univariable and multivariable logistic regression.

RESULTS

In MSM, anorectal CT prevalence was 9.8% (693/7094), anorectal NG prevalence was 4.2% (397/9534). In women this was 9.5% overall (439/4597) and 0.9% (96/10972) respectively. Anorectal CT prevalence among women who were routinely universally tested was 10.4% (20/192), for selective testing this was 9.5% (419/4405) (p = 0.68). Anorectal NG infections were not detected among women who were routinely universally tested (p = 0.19). Among CT or NG positive MSM, rectal-only CT infections were found in 85.9% (595/693), for NG this was 85.6% (340/397) respectively. In positive women these figures were 22.1% (97/439)for CT and 20.8% (20/96) for NG, respectively. In MSM, independent factors associated with rectal-only CT were: being a sex worker (OR0.4,CI0.2-1.0), exclusively having sex with men (OR3.4,CI1.7-6.8), and absence of urogenital symptoms (OR0.2,CI0.2-0.4). In women, these factors were: older age (OR2.3, CI1.3-4.0) and non-Western nationality (OR1.8, CI1.0-3.5). Factors associated with rectal-only NG in MSM were: having been warned for STIs by an (ex) partner (OR2.9,CI1.1-7.5), oropharyngeal NG infection (OR2.4,CI1.0-5.3), and absence of urogenital symptoms (OR0.02,CI0.01-0.04), while in women no significant factors were identified.

CONCLUSIONS

The prevalence of anorectal CT and NG was substantial in MSM and prevalence of anorectal CT was also substantial in women. Anorectal infections occurred mostly as rectal-only infections in MSM and mostly concurrent with other infections in women. Given the lack of useful indicators for rectal-only infections, selective screening based on a priori patient characteristics will have low discriminatory power both in relation to MSM and women.

Who tests whom? A comprehensive overview of Chlamydia trachomatis test practices in a Dutch region among different STI care providers for urogenital, anorectal and oropharyngeal sites in young people: a cross-sectional study

OBJECTIVES

To evaluate and compare Chlamydia trachomatis (CT) diagnostic test practices of different sexually transmitted infection (STI) care providers in 16-29 year olds from one defined geographic Dutch region (280,000 inhabitants). Both number and proportion of positive CT tests (ie, test positivity) were assessed, and factors associated with these outcomes.

METHODS

Data on laboratory testing and diagnosis of urogenital, anorectal and oropharyngeal CT between 2006 and 2010 were retrieved from general practitioners (GPs), gynaecologists, an STI clinic and a population-based chlamydia screening programme. Multivariable regression analyses explored associations between age, sex, test year, socio-economic status (SES) and STI care provider and the outcomes being the number of tests and test positivity.

RESULTS

Overall, 22,831 tests were performed (1868 positive; 8.2%). Extragenital (ie, anorectal and oropharyngeal) tests accounted for 4% of all tests (7.5% positive) and were almost exclusively (99%) performed by the STI clinic. STI clinics tested most men (37.2% of all tested men), whereas GPs tested most women (29.9% of all tested women). GPs and STI clinics accounted for 73.3% (1326/1808) of urogenital CT diagnoses. In women, the number of tests increased with age, whereas test positivity decreased for all STI care providers. Lower SES was associated with higher test positivity in GP and gynaecology patients.

CONCLUSIONS

STI clinics performed most CT tests in men, whereas GPs performed most CT tests in women. GPs and STI clinics accounted for the majority of positives. Extragenital CT testing is rarely performed outside the STI clinic and needs to be promoted, especially in men who have sex with men.

Anorectal Chlamydia trachomatis Load Is Similar in Men Who Have Sex with Men and Women Reporting Anal Sex

BACKGROUND

Anorectal Chlamydia trachomatis (chlamydia) is frequently diagnosed in men who have sex with men (MSM) and in women, but it is unknown whether these infections are comparable in clinical impact and transmission potential. Quantifying bacterial load and identifying determinants associated with high bacterial load could provide more insight.

METHODS

We selected a convenience sample of MSM who reported anal sex (n = 90) and women with concurrent urogenital/anorectal chlamydia who reported anal sex (n = 51) or did not report anal sex (n = 61) from the South Limburg Public Health Service's STI unit. Bacterial load (Chlamydia/ml) was quantified for all samples and log transformed for analyses. Samples with an unquantifiable human leukocyte antigen (n = 9) were excluded from analyses, as they were deemed inadequately sampled.

RESULTS

The mean log anorectal chlamydia load (3.50) was similar for MSM and women who reported having anal sex (3.80, P = 0.21). The anorectal chlamydia load was significantly higher in these groups than in women who did not report having anal sex (2.76, P = 0.001). Detectable load values ranged from 1.81-6.32 chlamydia/ml for MSM, 1.74-7.33 chlamydia/ml for women who reported having anal sex and 1.84-6.31 chlamydia/ml for women who did not report having anal sex. Symptoms and several other determinants were not associated with anorectal chlamydia load.

CONCLUSIONS

Women who did not report anal sex had lower anorectal loads, but they were within a similar range to the other two groups. Anorectal chlamydia load was comparable between MSM and women who reported anal sex, suggesting similar transmission potential.

Acceptance of Home-Based Chlamydia Genital and Anorectal Testing Using Short Message Service (SMS) in Previously Tested Young People and Their Social and Sexual Networks

Background

Control strategies for Chlamydia trachomatis (CT) are most effective when targeting people at highest risk. We assessed test acceptance of home-collection test kits offered by short messaging services (SMS) texts, in high-risk young people, i.e. those who had previously tested CT positive (positive indices), or negative reporting more than 3 sex partners (negative indices), and their sexual and social networks.

Methods

Young (16 to 25 years old) heterosexuals who previously tested positive (n=536) or negative (n=536) in our STI clinic received, 3 to 20 months after their initial screening, an SMS inviting them to re-test. They were offered a free home-collection test kit including a genital (men and women) and anorectal (women only) test, and a test kit to pass on to a friend or sex partner (peer). SMS reminders were sent in case of non-response. We assessed proportions of tests requested and returned, peers tested, and positivity. Associations with the individual’s initial screening result and other factors were explored using logistic regression.

Results

Of 1072 people invited to retest, 34.4% (n=369) requested a test. Of these, 55.8% (n=206) retested. Overall, retest participation was higher in positive (22%) than in negative indices (16%) (p<0.001); it was also higher in women and in those aged >22 years. Positivity was 13% and 7% in positive and negative indices, respectively. One in 3 retesters also had a peer tested. Of tested peers (n=87), 84% were friends, 31% were first-time testers, and 7% tested positive.

Conclusion

Acceptance of a relatively low-cost strategy for genital and anorectal testing, i.e. using SMS and home-collection test kits, was highest in individuals who previously tested CT positive suggesting that implementation for this group may be considered. By further including a peer-led testing component, undetected CT positives can be identified in the social networks surrounding a high-risk individual.

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.

Rectal chlamydia infection in women at high risk of chlamydia attending Canberra Sexual Health Centre

Chlamydia is the most commonly notified sexually transmitted infection in Australia. Australian guidelines recommend urogenital screening in asymptomatic men and women, and rectal screening in men who have sex with men or women reporting anal sex/symptoms. International studies describe a rectal chlamydia prevalence in women of 5% to 21%. We found that in women at high risk of chlamydia, 57% (32/56) tested positive for rectal chlamydia. Of these, 97% (31/32) had concurrent urogenital chlamydia. Women with urogenital chlamydia were significantly more likely to have a positive rectal result (χ(2), p = 0.000). Neither anal symptoms nor reported anal sex were associated with a positive rectal chlamydia test. The recommended treatment of rectal chlamydia differs substantially from that of urogenital chlamydia, raising the possibility that Australian women are being regularly undertreated due to a lack of rectal testing. Untreated rectal chlamydia may increase the risk of persistent infection, reproductive tract reinfection, complications and transmission. Further work is needed to determine the optimal management of chlamydia in women.