Update on the treatment of sexually transmitted infections in pregnancy--1

Congenital syphilis in the 21st century

While the prevalence of congenital syphilis continues to be low throughout most of the developed world, there has been a slight resurgence of the disease in several European countries, including Spain. In this context, we need to become more familiar with the signs and symptoms of this disease and consider its diagnosis in patients with only mild clinical manifestations. A definitive diagnosis may be difficult or even impossible in patients whose diagnostic tests reveal low positive titers or inconsistent results. The cornerstone of congenital syphilis control is prenatal screening and the treatment of infected mothers with penicillin, an effective and economical intervention. Based on a review of the literature supplemented by data from our own clinical experience, this article provides a detailed description of the clinical manifestations of congenital syphilis as well as the various diagnostic methods and treatments available.

Correlates of syphilis seroreactivity among pregnant women: the HIVNET 024 Trial in Malawi, Tanzania, and Zambia

OBJECTIVES

The objectives of this cross-sectional study were to determine correlates of syphilis seroprevalence among HIV-infected and -uninfected antenatal attendees in an African multisite clinical trial, and to improve strategies for maternal syphilis prevention.

RESULTS

A total of 2,270 (86%) women were HIV-infected and 366 (14%) were HIV-uninfected. One hundred seventy-five (6.6%) were syphilis-seropositive (7.3% among HIV-infected and 2.6% HIV-uninfected women). Statistically significant correlates included geographic site (odds ratio [OR] = 4.5, Blantyre; OR = 3.2, Lilongwe; OR = 9.0, Lusaka vs. Dar es Salaam referent); HIV infection (OR = 3.3); age 20 to 24 years (OR = 2.5); being divorced, widowed, or separated (OR = 2.9); genital ulcer treatment in the last year (OR = 2.9); history of stillbirth (OR = 2.8, one stillbirth; OR = 4.3, 2-5 stillbirths); and history of preterm delivery (OR = 2.7, one preterm delivery).

CONCLUSION

Many women without identified risk factors were syphilis-seropositive. Younger HIV-infected women were at highest risk. Universal integrated antenatal HIV and syphilis screening and treatment is essential in sub-Saharan African settings.

Cost-effectiveness of universal screening for chlamydia and gonorrhea in US jails

Universal screening for the sexually transmitted diseases (STDs) of chlamydia and gonorrhea on intake in jails has been proposed as the most effective strategy to decrease morbidity in inmates and to reduce transmission risk in communities after release. Most inmates come from a population that is at elevated risk for STDs and has limited access to health care. However, limited resources and competing priorities force decision makers to consider the cost of screening programs in comparison to other needs. The costs and cost-effectiveness of universal screening in correctional settings have not been documented. We estimated the incremental cost-effectiveness of universal urine-based screening for chlamydia and gonorrhea among inmates on intake in US jails compared to the commonly used practice of presumptive treatment of symptomatic inmates without laboratory testing. Decision analysis models were developed to estimate the cost-effectiveness of screening alternatives and were applied to hypothetical cohorts of male and female inmates. For women, universal screening for chlamydia only was cost-saving to the health care system, averting more health care costs than were incurred in screening and treatment. However, for men universal chlamydia screening cost $4,856 more per case treated than presumptive treatment. Universal screening for both chlamydia and gonorrhea infection cost the health care system $3,690 more per case of pelvic inflammatory disease averted for women and $650 more per case of infection treated for men compared to universal screening for chlamydia only. Jails with a high prevalence of chlamydia and gonorrhea represent an operationally feasible and cost-effective setting to universally test and treat women at high risk for STDs and with limited access to care elsewhere.

Gender Differences in Bacterial STIs in Canada

HEALTH ISSUE: The incidence of bacterial sexually transmitted infections (STIs) is rising in Canada. If these curable infections were prevented and treated, serious long-term sequelae including infertility, and associated treatment costs, could be dramatically reduced. STIs pose a greater risk to women than men in many ways, and further gender differences exist in screening and diagnosis. KEY FINDINGS: Reported incidence rates of chlamydia, gonorrhea, and infectious syphilis declined until 1997, when the trend began to reverse. The reported rate of chlamydia is much higher among women than men, whereas the reverse is true for gonorrhea and infectious syphilis. Increases in high-risk sexual behaviour among men who have sex with men were observed after the introduction of potent HIV suppressive therapy in 1996, but behavioural changes in women await further research. DATA GAPS AND RECOMMENDATIONS: STI surveillance in Canada needs improvement. Reported rates underestimate the true incidence. Gender-specific behavioural changes must be monitored to enhance responsiveness to groups at highest risk, and more research is needed on effective strategies to promote safer sexual practices. Geographic and ethnic disparities, gaps, and needs must be addressed. Urine screening for chlamydia should be more widely available for women as well as men, particularly among high-risk men in order to prevent re-infections in their partners. As women are more likely to present for health examinations (e.g. Pap tests), these screening opportunities must be utilized. Female-controlled methods of STI prevention, such as safer topical microbicides, are urgently needed.

A randomized trial that compared oral cefixime and intramuscular ceftriaxone for the treatment of gonorrhea in pregnancy

OBJECTIVE

The purpose of this study was to evaluate prospectively the Centers for Disease Control recommendations for the treatment of gonococcal infection in pregnancy.

STUDY DESIGN

One hundred sixty-one women who were referred with probable endocervical gonorrhea underwent pretreatment endocervical, anal, and oral cultures for Neisseria gonorrhoeae. The women were randomly assigned to receive ceftriaxone 125 mg intramuscularly or cefixime 400 mg orally. Treatment was open and in a 1:1 distribution. There were 95 evaluable patients. The tests of cure cultures were performed 4 to 10 days after treatment.

RESULTS

Eighty-six women (91%) had endocervical infection; 39 women (41%) had anal infection, and 11 women (12%) had pharyngeal infection. Fifty of 95 women (53%) had concomitant endocervical chlamydial infection. The overall efficacy was 91 of 95 subjects (95.8%; 95% CI, 89.6%-98.8%). Ceftriaxone was effective in 41 of 43 cases (95%; 95% CI, 84.2%-99.4%), and cefixime was effective in 50 of 52 cases (96%; 95% CI, 86.8%-99.5%). No significant difference was noted in the overall efficacy or by site of infection. Three of the 4 women who experienced treatment failures admitted to unprotected intercourse before their test of cure culture.

CONCLUSION

Both intramuscular ceftriaxone 125 mg and oral cefixime 400 mg appear to be effective for the treatment of gonococcal infection in pregnancy.

Antibiotics for syphilis diagnosed during pregnancy

BACKGROUND

Congenital syphilis is an increasing problem in many developing countries and in the transitional economies of Eastern Europe and the former Soviet Union. In several countries this increase has been aggravated by HIV/AIDS. While the effectiveness of penicillin in the treatment of syphilis in pregnant women and the prevention of congenital syphilis was established shortly after the introduction of penicillin in the 1940s, there is uncertainty about the optimal treatment regimens.

OBJECTIVES

To identify the most effective antibiotic treatment regimen (in terms of dose, length of course and mode of administration) of syphilis with and without concomitant infection with HIV for pregnant women infected with syphilis.

SEARCH STRATEGY

MEDLINE 1966 to March 2000; EMBASE 1974 to March 2000, the Cochrane Controlled Trials Register (last searched March 2001), the Cochrane Pregnancy and Childbirth group trials register (last searched March 2001) and the references of traditional reviews were searched. Experts in specialist units were contacted.

SELECTION CRITERIA

It was planned that any trial in which an attempt is made to allocate treatment for syphilis during pregnancy by a random or quasi-random method would be included in this review.

DATA COLLECTION AND ANALYSIS

Information was extracted using a data extraction sheet and this included entry criteria, the source of controls, and whether the authors stratified by the stage of pregnancy when the diagnosis of syphilis was made.

MAIN RESULTS

Twenty six studies met the criteria for detailed scrutiny. However, none of these met the pre-determined criteria for comparative groups and none included comparisons between randomly allocated groups of pregnant women.

REVIEWER'S CONCLUSIONS

While there is no doubt that penicillin is effective in the treatment of syphilis in pregnancy and the prevention of congenital syphilis, uncertainty remains about what are the optimal treatment regimens. Further studies are needed to evaluate treatment failure cases with currently recommended regimens and this should include an assessment of the role of HIV infection in cases of prenatal syphilis treatment failure. The effectiveness of various antibiotic regimens for the treatment of primary and secondary syphilis in pregnant women need to be assessed using randomised controlled trials which compare them with existing recommendations.