Concurrent gonococcal and chlamydial infections among men attending a sexually transmitted diseases clinic

Using Self-Reported Sexual Positioning as an Indicator for Rectal Chlamydia and Gonorrhea Screening Among Men Who Have Sex With Men in China: A Missed Opportunity

BACKGROUND

Rectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections among men who have sex with men (MSM) are escalating public health concerns. This study aimed to explore (1) the reliability of self-reported sexual positioning as an indicator for rectal CT and NG screening, and (2) factors associated with rectal CT and NG infections in Shenzhen, China.

METHODS

A cross-sectional study was conducted in 2 settings in Shenzhen, China, from April 1, 2021, to March 31, 2022. Data on sociodemographic characteristics, sexual behaviors, and basic CT knowledge were collected. Urine and self-collected rectal swabs were collected for CT and NG testing.

RESULTS

In total, 195 MSM participated in the study, and 5.1% tested positive for urogenital CT, 29.2% for rectal CT, 1.0% for urogenital NG, and 8.2% for rectal NG. Among those who reported exclusively insertive anal sex, 69.2% of CT infections and 85.7% of NG infections would have remained undetected with urine testing alone. Risk factors for rectal CT infection included engaging in both insertive and receptive anal sex, with a significant association found for coinfection with rectal NG.

CONCLUSIONS

Self-reported sexual positioning was found to be an unreliable indicator for CT and NG screening, as a substantial proportion of infections would have remained undetected. The findings suggest that CT and NG screening in China should be offered to all MSM regardless of self-reported sexual positioning, and that the dual CT/NG testing is recommended.

Screening for chlamydia and/or gonorrhea in primary health care: systematic reviews on effectiveness and patient preferences

BACKGROUND

We conducted systematic reviews on the benefits and harms of screening compared with no screening or alternative screening approaches for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in non-pregnant sexually active individuals, and on the relative importance patients' place on the relevant outcomes. Findings will inform recommendations by the Canadian Task Force on Preventive Health Care.

METHODS

We searched five databases (to January 24, 2020), trial registries, conference proceedings, and reference lists for English and French literature published since 1996. Screening, study selection, and risk of bias assessments were independently undertaken by two reviewers, with consensus for final decisions. Data extraction was conducted by one reviewer and checked by another for accuracy and completeness. Meta-analysis was conducted where appropriate. We used the GRADE approach to rate the certainty of the evidence. The Task Force and content experts provided input on determining thresholds for important effect sizes and on interpretation of findings.

RESULTS

Of 41 included studies, 17 and 11 reported on benefits and harms of screening, respectively, and 14 reported on patient preferences. Universal screening for CT in general populations 16 to 29 years of age, using population-based or opportunistic approaches achieving low screening rates, may make little-to-no difference for a female's risk of pelvic inflammatory disease (PID) (2 RCTs, n=141,362; 0.3 more in 1000 [7.6 fewer to 11 more]) or ectopic pregnancy (1 RCT, n=15,459; 0.20 more per 1000 [2.2 fewer to 3.9 more]). It may also not make a difference for CT transmission (3 RCTs, n=41,709; 3 fewer per 1000 [11.5 fewer to 6.9 more]). However, benefits may be achieved for reducing PID if screening rates are increased (2 trials, n=30,652; 5.7 fewer per 1000 [10.8 fewer to 1.1 more]), and for reducing CT and NG transmission when intensely screening high-prevalence female populations (2 trials, n=6127; 34.3 fewer per 1000 [4 to 58 fewer]; NNS 29 [17 to 250]). Evidence on infertility in females from CT screening and on transmission of NG in males and both sexes from screening for CT and NG is very uncertain. No evidence was found for cervicitis, chronic pelvic pain, or infertility in males from CT screening, or on any clinical outcomes from NG screening. Undergoing screening, or having a diagnosis of CT, may cause a small-to-moderate number of people to experience some degree of harm, mainly due to feelings of stigmatization and anxiety about future infertility risk. The number of individuals affected in the entire screening-eligible population is likely smaller. Screening may make little-to-no difference for general anxiety, self-esteem, or relationship break-up. Evidence on transmission from studies comparing home versus clinic screening is very uncertain. Four studies on patient preferences found that although utility values for the different consequences of CT and NG infections are probably quite similar, when considering the duration of the health state experiences, infertility and chronic pelvic pain are probably valued much more than PID, ectopic pregnancy, and cervicitis. How patients weigh the potential benefits versus harms of screening is very uncertain (1 survey, 10 qualitative studies); risks to reproductive health and transmission appear to be more important than the (often transient) psychosocial harms.

DISCUSSION

Most of the evidence on screening for CT and/or NG offers low or very low certainty about the benefits and harms. Indirectness from use of comparison groups receiving some screening, incomplete outcome ascertainment, and use of outreach settings was a major contributor to uncertainty. Patient preferences indicate that the potential benefits from screening appear to outweigh the possible harms. Direct evidence about which screening strategies and intervals to use, which age to start and stop screening, and whether screening males in addition to females is necessary to prevent clinical outcomes is scarce, and further research in these areas would be informative. Apart from the evidence in this review, information on factors related to equity, acceptability, implementation, cost/resources, and feasibility will support recommendations made by the Task Force.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42018100733 .

Spontaneous clearance of genital and extragenital Neisseria gonorrhoeae: data from GToG

OBJECTIVES

Neisseria gonorrhoeae (NG) infection can resolve without antibiotic treatment, however the literature describing the frequency of clearance at individual sites, how rapidly it occurs and potential predictive factors is limited. In this analysis of a subpopulation identified from a large multicentre UK cohort, we describe the overall rate of spontaneous clearance of infection and explore factors associated with this.

METHODS

Data from the Gentamicin compared with Ceftriaxone for the Treatment of Gonorrhoea randomised controlled trial consisting of 720 patients with NG were analysed. A subgroup of individuals had both a pretrial test sample and a trial enrolment sample taken. Those who had cleared NG between initial presentation and subsequent entry into the trial without antibiotic treatment were deemed to have spontaneously cleared. Sociodemographic characteristics, sexual history and sites of infection for those who spontaneously cleared infection were compared with that of those who did not. We also estimated the time interval to clearance.

RESULTS

Overall, the proportion who had spontaneous clearance was 20.5% (83/405). Clearance of infection occurred over a median of 10 days (IQR 7-15 days). The cohort who spontaneously cleared were similar to those who did not in terms of age, gender, sexual orientation, HIV status and previous NG infection. Chlamydia coinfection was more frequent in the 'no spontaneous clearance group' (11.1% (9/83) cf 22.0% (69/322)) (p=0.029). Dysuria was reported more often in the 'no spontaneous clearance group' (4.8% (4/83) cf 13.0% (42/322)) (p=0.035).

CONCLUSION

We present data from a large cohort of NG-infected individuals, of whom a significant proportion had spontaneous clearance of infection. This is consistent with previous smaller studies. If this is indicative of cure, point-of-care testing prior to treatment has the potential to reduce unnecessary exposure to antimicrobials. Further work to assess the importance of bacterial load, genotype and host immune response on spontaneous clearance of infection is required.

TRIAL REGISTRATION NUMBER

ISRCTN51783227.

Coinfection of Chlamydiae and other Bacteria in Reactive Arthritis and Spondyloarthritis: Need for Future Research

Reactive (inflammatory) arthritis has been known for many years to follow genital infection with the intracellular bacterial pathogen Chlamydia trachomatis in some individuals. Recent studies from several groups have demonstrated that a related bacterium, the respiratory pathogen Chlamydia pneumoniae, can elicit a similar arthritis. Studies of these organisms, and of a set of gastrointestinal pathogens also associated with engendering inflammatory arthritis, have been relatively extensive. However, reports focusing on coinfections with these and/or other organisms, and the effects of such coinfections on the host immune and other systems, have been rare. In this article, we review the extant data regarding infections by multiple pathogens in the joint as they relate to engendering arthritis, and we suggest a number of research areas that must be given a high priority if we are to understand, and therefore to treat in an effective manner, such arthritides.

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.

HIV, rectal chlamydia, and rectal gonorrhea in men who have sex with men attending a sexually transmitted disease clinic in a midwestern US city

BACKGROUND

Men who have sex with men (MSM) who report receptive anal intercourse (RAI) are currently recommended to undergo at least annual screening for rectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infection.

METHODS

Using standard culture methods, we assessed the prevalence of rectal GC/CT among MSM who reported RAI in the last year (n = 326) at an urban sexually transmitted disease (STD) clinic in a midwestern US city. A subset (n = 125) also underwent rectal GC/CT screening via nucleic acid amplification testing. We examined the associations between HIV status and prevalence of rectal GC and rectal CT using unadjusted and adjusted logistic regression models.

RESULTS

The prevalence of rectal GC, rectal CT, and either rectal infection was 9%, 9%, and 15% by culture and 24%, 23%, and 38% by nucleic acid amplification testing, respectively. HIV was not associated with rectal GC prevalence in unadjusted or adjusted analyses. HIV-positive status was significantly associated with increased rectal CT prevalence in unadjusted models (odds ratio, 2.18; 95% confidence interval, 1.04-4.60); this association increased after multivariable adjustment (odds ratio, 3.14; 95% confidence interval, 1.37-7.19).

CONCLUSIONS

Men who have sex with men reporting RAI had a high prevalence of rectal GC and rectal CT. HIV-positive status was significantly associated with prevalent rectal CT but not with prevalent rectal GC.

Risk of coinfection with Chlamydia trachomatis and Neisseria gonorrhoeae in Nova Scotia

BACKGROUND

The frequency of Chlamydia trachomatis and Neisseria gonorrhoeae coinfection can vary depending on their individual incidence and prevalence rates.

OBJECTIVE

To determine the frequency of C trachomatis and N gonorrhoeae coinfections by evaluating the results of testing in 2007 and 2008 to better inform testing and treatment decisions.

METHODS

Specimens from the same patient submitted on the same day served as the basis for the present study. The age, sex and the source of the specimen were also linked to the accession number. Infection and coinfection rates were analyzed in both males and females.

RESULTS

Concurrent testing was performed on 41,567 female specimens and 1827 male specimens, of which, 1495 female samples (3.6%) tested positive for C trachomatis infection and 88 (0.2%) tested positive for N gonorrhoeae infections. Only 31 females were coinfected; however, for those between 11 and 25 years of age, 25 of 61 females (40.1%) with N gonorrhoeae infection also tested positive for C trachomatis infection; conversely, 25 of 1248 females (2.0%) with C trachomatis infection also tested positive for N gonorrhoeae infection. For males, 213 (11.7%) tested positive for C trachomatis infection, and 59 (3.2%) tested positive for N gonorrhoeae infection. In 30 males with N gonorrhoeae between 11 and 25 years of age, and 149 males with C trachomatis, eight coinfections were observed (26.7% and 5.3%, respectively). Of those older than 25 years of age, only five of 905 men and six of 19,465 women were coinfected. None of the 10,935 women who were 30 years of age or older had coinfections.

CONCLUSION

The N gonorrhoeae coinfection rate in males with C trachomatis may justify empirical antimicrobials; however, in females, the proportion of coinfected may not justify empirical treatment for N gonorrhoeae infection when the C trachomatis test is positive and N gonorrhoeae testing has not been performed.

A review on infection with Chlamydia trachomatis

Infection with Chlamydia trachomatis accounts for the most common bacterial sexually transmitted infection in the UK. Men between 20 and 24 years and women between 16 and 19 years have the highest prevalence of chlamydial infection. Because the majority of women with chlamydial infection are asymptomatic, a proportion remains untreated and eventually develops pelvic inflammatory disease (PID). PID can result in ectopic pregnancy, infertility and chronic pelvic pain. Screening for chlamydial infection might reduce the incidence of complications of PID. The advent of nucleic acid amplification tests and single-dose therapy for chlamydial infection has made home testing and easy treatment possible.

Screening for chlamydia and gonorrhoea in men who have sex with men in clinical and non-clinical settings

Background: There are few published data on the rate of chlamydia and gonorrhoea infection in men who have sex with men (MSM). Our aim was to determine the rate of positive chlamydia and gonorrhoea tests in this population in the Australian Capital Territory (ACT). Methods: Results of all chlamydia and gonorrhoea tests generated by Canberra Sexual Health Centre between June 2001 and September 2003, including those from outreach clinics, were reviewed (audit one). Between September 2003 and April 2004, Canberra Sexual Health Centre outreach program staff and a general practitioner with a high caseload of MSM offered screening of the throat, urethra and rectum to all MSM, irrespective of their reported participation in unprotected anal intercourse. Chlamydia and gonorrhoea test results generated during this period were reviewed (audit two). Results: In the first audit, 1086 specimens from 314 individuals were tested and 30/314 (9.6%, 95% CI 6.6–13.4) men were positive for chlamydia in one or more anatomical site. A total of 306 specimens from 118 individuals were tested for gonorrhoea. Of these, eight (6.8%, 95% CI 3.0–12.9) individuals tested positive. In the second audit, 16 of 157 men (10.2%, 95% CI 9.5–16.0) tested positive for chlamydia and 4/155 (2.6%, 95% CI 0.7–6.5) tested positive for gonorrhoea. The rectum was the most commonly infected anatomical site for both infections. The overall proportions of positive chlamydia and gonorrhoea tests were 36/471 (7.6%, 95% CI 5.4–10.4) and 12/273 (4.4%, 95% CI 2.2–7.6) respectively. Conclusions: These data, collected in a range of settings, indicate high rates of chlamydia and gonorrhoea in MSM in the ACT and provide support for annual testing, particularly of the rectum, in this population.