Gonorrhoea diagnoses in a network of STI clinics in Spain during the period 2006-2010: differences by sex and transmission route

Clinic-based evaluation of the dual Xpert CT/NG assay on the GeneXpert System for screening for extragenital chlamydial and gonococcal infections amongst men who have sex with men

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections have increased globally. Asymptomatic infections represent a significant risk of long-term complications. Men who have sex with men (MSM) are disproportionally affected, underscoring the need to offer screening programmes to this population. CT/NG Point of Care Testing (POCT) constitutes a strategic tool to improve the continuum of STI care, however extensive real-life evaluations amongst at risk populations are lacking. The aim of this study is to estimate the GeneXpert CT/NG assay performance and usability for CT and NG at genital and extragenital sites for screening amongst MSM.

METHODS

This study was a multi-site sexual health clinic-based evaluation (Italy, Malta and Peru) with consecutive enrolment. A first void urine sample (divided in two aliquots), two oropharyngeal and two anorectal swabs were collected for each study participant. One specimen set (one for each anatomical site) was tested with the dual index test (Cepheid) at the clinics by the healthcare staff, the other set with FDA/CE approved Nucleic Acid Amplification Tests (NAATs) at the laboratory. Clinical sites and reference laboratories participated in an internal and external quality control programme. Sensitivity, specificity, positive and negative likelihood ratios, positive and negative predictive values for each anatomical site were estimated using a meta-analytic approach.

RESULTS

One thousand seven hundred two MSM were recruited across all clinical sites for a total of 5049 biological specimens. NG and CT were respectively detected in 274 and 287 of samples. Overall, the NG POCT sensitivity and specificity was 91.43% and 99.75% in urine (LR + 372.80, LR- 0.09), 89.68% and 99.55% in rectal specimens (LR + 197.30, LR- 0.10) and 75.87% and 98.77% at the pharynx respectively (LR + 61.94, LR- 0.24). The CT component of the POCT sensitivity was 84.82% and specificity 99.63% in urine (LR + 228.68, LR- 0.15), 78.07% and 99.19% respectively on rectal site (LR + 96.23, LR-0.22), 67.79% and 99.88% respectively at pharyngeal site (LR + 554.89, LR- 0.32). 95.95% of MSM reported to be willing to wait for POCT results and no provider reported difficulties in terms of performance or interpretation of the results of the Xpert CT/NG.

CONCLUSION

Rapid turnaround time, ease of use and high acceptability make the Xpert CT/NG testing system a strategic tool for increasing testing frequency, reaching those not yet tested and offering the possibility of immediate treatment if needed. The assay showed good negative likelihood ratios and confirms its use to rule out CT/NG infections. Sensitivity varied across sites and pathogens. Periodic staff training at the testing sites should be mandatory.

Epidemiological Characteristics and Factors Associated with Repeat Sexually Transmitted Infections in Barcelona, Spain Over a Decade

In the last few years, the frequency of sexually transmitted infections (STI) has increased, as has the number of people with multiple infections. The aim of our study was to describe the epidemiological characteristics of persons with repeated bacterial STI and to determine the risk factors for these episodes in persons living in Barcelona during the period 2007-2018. We studied all cases of bacterial STI included in the STI registry of Barcelona. Repeated STI were defined as a diagnosis of gonorrhea, syphilis, or lymphogranuloma venereum (LGV) after a first episode of one of these infections. Analysis was stratified by sex and place of birth. The factors associated with time to reinfection were determined by Kaplan-Meier estimates, while the factors associated with risk of infection were determined by a Cox proportional hazards model. Of 9927 persons with a diagnosis of bacterial STI, 1690 (17.0%) had at least two episodes of STI during the study period. On multivariate analysis, repeat STI were independently associated with male sex assigned at birth (HR: 3.45; 95%CI 2.22-5.36), age less than 34 years (HR: 1.22; 95%CI 1.10-1.35); gay, bisexual, and other men who have sex with men, and transgender o transsexual woman (GBSMS/Trans) (HR: 4.03; 95%CI 3.24-5.03), having gonorrhea as first diagnosis (HR:1.49, 95%CI 1.34-1.66) or LGV (HR:1.75; 95%CI 1.47-2.08) and coinfection with HIV (HR:1.98; 95%CI 1.78-2.21). Sexual health programs should be strengthened to prevent STI and reinfection in key populations.

Provider uptake of extragenital screening for gonorrhea and chlamydia in a cohort of Air Force members with incident HIV diagnosis

The prevalence of Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT) is higher at extragenital anatomic sites among men who have sex with men (MSM) with HIV infection. Although national guidelines recommend that all MSM with HIV infection undergo screening for extragenital sexually transmitted infections (EG-STIs), uptake is low in many primary care settings. We evaluated EG-STI screening by primary care providers (PCPs) for US Air Force (USAF) members with incident HIV infection. All USAF members with incident HIV infection who received initial HIV specialty care with Infectious Disease (ID) providers at Brooke Army Medical Center from 2016 to 2018 (n = 98) were included. A retrospective chart review was conducted to evaluate STI screening performed by PCPs within 1 week of HIV diagnosis compared to screening at entry into ID care. Demographic, clinical, laboratory and behavioral risk data were collected. STI screening included GC/CT EG-STIs, urethral GC/CT, syphilis, and hepatitis B and C. Patients were predominantly male (98%) with a median age of 26 (IQR 23, 32) years at HIV diagnosis. A previous history of STIs was reported in 53 (54%) patients and the majority of males self-identified as MSM (66%) or bisexual (23%). The median time from HIV diagnosis to ID evaluation was 26 days (IQR 9, 33). PCPs performed any STI screening in 61 (62%) patients. EG-STI screening was conducted in 3 (3%) patients overall and in (3%) MSM/bisexuals. A total of 31 (32%) patients had missed STIs; the majority due to EG-STIs of the rectum (59%) and pharynx (19%). All EG-STIs would have been missed by urethral GC/CT screening alone. EG-STI screening uptake was low among PCPs evaluating USAF members with incident HIV infection. Underutilization of EG-STI screening can result in missed infections and forward transmission of GC/CT. Barriers to low uptake need to be explored.

[Map of sexually transmitted disease care in Spanish emergency departments]

OBJECTIVE

To determine the approaches used in Spanish emergency departments (EDs) in patients suspected of having sexually transmitted diseases (STD) analysed according to the size of the hospital, ED census and autonomous community.

METHODS

Questionnaire to the heads of 282 public EDs (7/24) related to emergency routines for patients with suspected STD. Results compared using odds-ratio (OR) and 95% confidence interval (95%CI) according to hospital size (large vs medium-small: ≥500 vs. <500 beds) and ED census (high vs. medium-low: ≥200 vs. <200 patients/day), by autonomous community.

RESULTS

A total of 250 EDs responded (89%). With protocol for STD 36% of EDs [>60% Catalonia, Vasque Country, more in large hospitals (LH), (OR=2.65, 95%CI=1.46-4.82) and high census (HCEN) EDs, (OR=3.49, 95%CI=2.03-5.98)]. 70% obtained exudate sampling (>80% Catalonia, Madrid, Castilla-La Mancha, Aragón, Navarra, Vasque Country), 44% STD serology (>60% Madrid) and 35% HIV serology [(>60% Navarra, Baleares; more in LH (OR=2.43, 95%CI=1.34-4.42) and HCEN EDs (OR=1.94, 95%CI=1.15-3.29)]. At discharge, follow-up in hospital outpatients clinics 53% of EDs [>60% Catalonia, Comunidad Valenciana, Murcia, Castilla-La Mancha, Vasque Country, Asturias; more in LH (OR=2.45, 95%CI=1.31-4.57) and HCEN EDs (OR=2.25, 95%CI=1.35-3.76)] and by primary care 28% (>80% Cantabria). In 55% of EDs, patients are discharged with a scheduled follow-up (>80% Extremadura, La Rioja, Navarra) and 32% visit next workday [>60% Vasque Country; more in LH (OR=3.43, 95%CI=1.87-6.30) and HCEN EDs (OR=3.63, 95%CI=2.08-6.37)].

CONCLUSIONS

The care of patients with suspected STD is not homogeneous in Spanish EDs. Areas of improvement were detected, especially the need for specific diagnostic and follow-up protocols.

Comparison of an in-house real-time duplex PCR assay with commercial HOLOGIC® APTIMA assays for the detection of Neisseria gonorrhoeae and Chlamydia trachomatis in urine and extra-genital specimens

BACKGROUND

Extra-genital Neisseria gonorrhoeae and Chlamydia trachomatis infections are mostly asymptomatic, and important reservoir sites of infection as they often go undetected and may be more difficult to eradicate with recommended therapeutic regimens. Commercial nucleic acid amplification tests (NAATs) have not received regulatory approval for the detection of N. gonorrhoeae and C. trachomatis in extra-genital specimens. The HOLOGIC® APTIMA Combo2 assay for N. gonorrhoeae and C. trachomatis has performed well in evaluations using extra-genital specimens.

METHODS

We assessed the performance of an in-house real-time duplex PCR assay for the detection of N. gonorrhoeae and C. trachomatis in urine and extra-genital specimens using the HOLOGIC® APTIMA assays as gold standard comparators. Urine, oropharyngeal and ano-rectal specimens were collected from each of 200 men-who-have-sex-with-men (MSM) between December 2011 and July 2012.

RESULTS

For N. gonorrhoeae detection, the in-house PCR assay showed 98.5-100% correlation agreement with the APTIMA assays, depending on specimen type. Sensitivity for N. gonorrhoeae detection was 82.4% for ano-rectal specimens, 83.3% for oropharyngeal specimens, and 85.7% for urine; and specificity was 100% with all specimen types. The positive predictive value (PPV) for N. gonorrhoeae detection was 100% and the negative predictive value (NPV) varied with sample type, ranging from 98.5-99.5%. For C. trachomatis detection, correlation between the assays was 100% for all specimen types. The sensitivity, specificity, PPV and NPV of the in-house PCR assay was 100% for C. trachomatis detection, irrespective of specimen type.

CONCLUSION

The in-house duplex real-time PCR assay showed acceptable performance characteristics in comparison with the APTIMA® assays for the detection of extra-genital N. gonorrhoeae and C. trachomatis.

Epidemiology and current control of sexually transmitted infections. The role of STI clinics

The burden of disease from sexually transmitted infections (STI) undermines sexual and reproductive health and the health of newborn infants. The presence of some STI facilitates the transmission of others, such as HIV, and cause cellular changes that precede some types of cancer. For all these reasons STIs are a first order uncontrolled public health problem. In Spain, gonococcal infection has been on rising since the beginning of 2000, while syphilis has remained stable at high levels since 2011. Both infections are more common in males. Chlamydia trachomatis is the most common STI, and principally affects females between the ages of of 20 and 40. STI units are an essential instrument to tackle this problem. They deal with populations that are particularly vulnerable to these infections and are essential for their control by means of interventions that reduce their transmission efficiency and infectivity duration. They are also the principal source of epidemiological information about these infections.

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.

Evolution of acute hepatitis C virus infection in a large European city: Trends and new patterns

The aims of this study were to describe the evolution of acute hepatitis C virus (HCV) infections since 2004 and to determine its associated factors. Acute HCV infections diagnosed in Barcelona from 2004 to 2015 were included. Incidence ratios (IR) were then estimated for sex and age groups. Cases were grouped between 2004-2005, 2006-2011 and 2012-2015, and their incidence rate ratios (IRR) were calculated. In addition, risk factors for acute HCV infection were identified using multinomial logistic regression for complete, available and multiple imputed data. 204 new HCV cases were identified. Two peaks of higher IR of acute HCV infection in 2005 and 2013 were observed. Men and those aged 35-54 had higher IR. IRR for men was 2.9 times greater than in women (95% confidence intervals (CI): 1.8 ‒ 4.7). Factors related to the period 2012-2015 (versus 2006-2011) were: a) sexual risk factor for transmission versus nosocomial (relative-risk ratio (RRR): 13.0; 95% CI: 2.3 ‒ 72.1), b) higher educated versus lower (RRR: 5.4; 95% CI: 1.6 ‒ 18.7), and c) HIV co-infected versus not HIV-infected (RRR: 53.1; 95% CI: 5.7 ‒ 492.6). This is one of the few studies showing IR and RRRs of acute HCV infections and the first focused on a large city in Spain. Sexual risk for transmission between men, higher educational level and HIV co-infection are important factors for understanding current HCV epidemic. There has been a partial shift in the pattern of the risk factor for transmission from nosocomial to sexual.

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.

Performance of the NG OligoGen kit for the diagnosis of Neisseria gonorrhoeae: comparison with cobas 4800 assay

PCR assays are nowadays between the most sensitive and reliable methods for screening and diagnosing sexually transmitted infections (STIs). The aim of this study was to analyze the reliability, accuracy, and usefulness of the new NG OligoGen kit in comparison with the cobas 4800 assay for the detection of Neisseria gonorrhoeae in clinical samples. A prospective study was designed for detection of N. gonorrhoeae including urine samples (n=152), rectal (n=80), endocervical (n=67), pharyngeal (n=41), and urethral swabs (n=5) that were sent from a regional STI clinic in Seville, Spain. Samples were collected from 255 (73.9%) men and 90 women. Sensitivity, specificity, positive and negative predicative values, and kappa value for N. gonorrhoeae detection using the NG OligoGen kit were 99.6%, 100%, 100%, 99.1%, and 0.99, respectively. Statistical data obtained in this study confirm the usefulness and reliable results of this new assay.

Can we rely on the antiretroviral treatment as the only means for human immunodeficiency virusprevention? A Public Health perspective

The evidence that supports the preventive effect of combination antiretroviral treatment (cART) in HIV sexual transmission suggested the so-called 'treatment as prevention' (TAP) strategy as a promising tool for slowing down HIV transmission. As the messages and attitudes towards condom use in the context of TAP appear to be somehow confusing, the aim here is to assess whether relying on cART alone to prevent HIV transmission can currently be recommended from the Public Health perspective. A review is made of the literature on the effects of TAP strategy on HIV transmission and the epidemiology of other sexual transmitted infections (STIs) in the cART era, and recommendations from Public Health institutions on the TAP as of February 2014. The evolution of HIV and other STIs in Barcelona from 2007 to 2012 has also been analysed. Given that the widespread use of cART has coincided with an increasing incidence of HIV and other STIs, mainly amongst men who have sex with men, a combination and diversified prevention methods should always be considered and recommended in counselling. An informed decision on whether to stop using condoms should only be made by partners within stable couples, and after receiving all the up-to-date information regarding TAP. From the public health perspective, primary prevention should be a priority; therefore relying on cART alone is not a sufficient strategy to prevent new HIV and other STIs.