Chlamydia trachomatis and Mycoplasma genitalium prevalence and associated factors among women presenting to a pregnancy termination and contraception clinic, 2009-2019

BACKGROUND

Risk of pelvic inflammatory disease associated with Chlamydia trachomatis and Mycoplasma genitalium is increased after termination of pregnancy (TOP) and may be increased after insertion of intrauterine devices (IUDs). Screening prior to these procedures is recommended only for C. trachomatis. We examined C. trachomatis and M. genitalium prevalence and associated factors among women presenting to a pregnancy termination and contraception service over 10 years.

METHODS

Retrospective analysis of clinical data collected from 17 573 women aged 15-45 years in 2009-2019 and for 266 M. genitalium positive women tested for macrolide resistance-associated mutations in 2016-2019.

RESULTS

C. trachomatis and M. genitalium prevalence was 3.7% and 3.4%, respectively. In multivariable analyses, shared risk factors were younger age (p<0.001, for both C. trachomatis and M. genitalium), socioeconomic disadvantage (p=0.045 and p=0.008, respectively) and coinfection (p<0.001, for both sexually transmitted infections), with 10.1% of C. trachomatis positive women also positive for M. genitalium. Additional risk factors were earlier year of visit (p=0.001) for C. trachomatis and for M. genitalium residing outside a major city (p=0.013). The proportion of M. genitalium infections tested between 2016 and 2019 with macrolide resistance-associated mutations was 32.7%.

CONCLUSIONS

Given the high level of antimicrobial resistance and the prevalence of coinfection, testing C. trachomatis positive women for M. genitalium could be considered in this setting to prevent further spread of resistant infections. Further research is required into the causal link between M. genitalium and pelvic inflammatory disease in women undergoing TOP and IUD insertion.

Asymptomatic and symptomatic urethral gonorrhoea in men who have sex with men attending a sexual health service

OBJECTIVES

Guidelines regarding whether men who have sex with men (MSM) without symptoms of urethritis should be screened for urethral gonorrhoea differ between countries. We examined the rate of asymptomatic urethral gonorrhoea in MSM using sensitive nucleic acid amplification testing.

METHODS

This study was conducted on consecutive MSM attending the Melbourne Sexual Health Centre between July 2015 and May 2016 for sexually transmitted infections screening. Gonorrhoea testing with the Aptima Combo 2 (AC2) assay was performed on all urine specimens obtained from MSM, whether symptoms of urethritis were present or not. Men were classified as having: typical discharge if they reported symptoms suggesting purulent discharge; other symptoms if they reported other symptoms of urethritis; and no symptoms if they reported no urethral symptoms.

RESULTS

During the study period, there were 7941 clinic visits by 5947 individual MSM with 7090 urine specimens obtained from 5497 individual MSM tested with the AC2 assay. Urethral gonorrhoea was detected in 242 urine specimens from 228 individual MSM. The majority (189/242, 78%, 95% CI 73-83) reported typical discharge, 27/242 (11%, 95% CI 8-16) reported other urethral symptoms, and 26/242 (11%, 95% CI 7-15) reported no symptoms on the day of presentation and testing. Among men with urethral gonorrhoea, the proportions with concurrent pharyngeal or rectal gonorrhoea were 32% (134/210) and 64% (74/235), respectively. The mean interval between last reported sexual contact and onset of typical urethral discharge, where present, was 3.9 days.

CONCLUSION

The findings from our study lend support to guidelines that recommend screening asymptomatic MSM for urethral gonorrhoea.

The potential of metatranscriptomics for identifying screening targets for bacterial vaginosis

BACKGROUND

The ribosomal RNA content of a sample collected from a woman with bacterial vaginosis (BV) was analysed to determine the active microbial community, and to identify potential targets for further screening.

METHODOLOGY/PRINCIPAL FINDINGS

The sample from the BV patient underwent total RNA extraction, followed by physical subtraction of human rRNA and whole transcriptome amplification. The metatranscriptome was sequenced using Roche 454 titanium chemistry. The bioinformatics pipeline MG-RAST and desktop DNA analysis platforms were utilised to analyse results. Bacteria of the genus Prevotella (predominately P. amnii) constituted 36% of the 16S rRNA reads, followed by Megasphaera (19%), Leptotrichia/Sneathia (8%) and Fusobacterium (8%). Comparison of the abundances of several bacteria to quantitative PCR (qPCR) screening of extracted DNA revealed comparable relative abundances. This suggests a correlation between what was present and transcriptionally active in this sample: however distinct differences were seen when compared to the microbiome determined by 16S rRNA gene amplicon sequencing. To assess the presence of P. amnii in a larger pool of samples, 90 sexually active women were screened using qPCR. This bacterium was found to be strongly associated with BV (P<0.001, OR 23.3 (95%CI:2.9-190.7)) among the 90 women.

CONCLUSIONS/SIGNIFICANCE

This study highlighted the potential of metatranscriptomics as a tool for characterising metabolically active microbiota and identifying targets for further screening. Prevotella amnii was chosen as an example target, being the most metabolically active species present in the single patient with BV, and was found to be detected at a high concentration by qPCR in 31% of cohort with BV, with an association with both oral and penile-vaginal sex.

Bacterial vaginosis (BV) candidate bacteria: associations with BV and behavioural practices in sexually-experienced and inexperienced women

Background

In recent years several new fastidious bacteria have been identified that display a high specificity for BV; however no previous studies have comprehensively assessed the behavioural risk associations of these bacterial vaginosis-candidate organisms (BV-COs).

Methods

We examined the associations between 8 key previously described BV-COs and BV status established by Nugent's score (NS). We also examined the sexual practices associated with each BV-CO. We incorporated 2 study populations: 193 from a sexually-inexperienced university population and 146 from a highly sexually-active clinic population. Detailed behavioural data was collected by questionnaire and vaginal smears were scored by the Nugent method. Stored samples were tested by quantitative PCR assays for the 8 BV-COs: Atopobium vaginae, Gardnerella vaginalis, Leptotrichia spp., Megasphaera type I, Sneathia spp., and the Clostridia-like bacteria BVAB1, BVAB2 and BVAB3. Associations between BV-COs and BV and behaviours were examined by univariate and multivariable analyses.

Results

On univariate analysis, all BV-COs were more common in BV compared to normal flora. However, only Megasphaera type I, BVAB2, A. vaginae and G. vaginalis were significantly independently associated with BV by multivariable analysis. Six of the eight BV-COs (Megasphaera type I, BVAB2, BVAB3, Sneathia, Leptotrichia and G. vaginalis) were rare or absent in sexually-unexposed women, and demonstrated increasing odds of detection with increasing levels of sexual activity and/or numbers of lifetime sexual partners. Only G. vaginalis and A. vaginae were commonly detected in sexually-unexposed women. Megasphaera type I was independently associated with women-who-have-sex-with women (WSW) and lifetime sexual partner numbers, while unprotected penile-vaginal-sex was associated with BVAB2 detection by multivariate analysis.

Conclusions

Four of eight key BV-COs were significantly associated with BV after adjusting for the presence of other BV-COs. The majority of BV-COs were absent or rare in sexually-unexposed women, and associated with increasing sexual exposure, suggesting potential sexual transmission of BV-COs.

Opting off the New South Wales Pap Test Register in a sexual health setting

OBJECTIVES

To determine the proportion of women having a Pap smear at Sydney Sexual Health Centre (SSHC) who opted off the NSW Pap Test Register (PTR) and to establish the characteristics of these women.

DESIGN

Retrospective cross sectional study involving three time periods during 1996 and 1997.

SETTING

A public sexual health centre in Sydney.

PARTICIPANTS

985 women who had a Pap smear at SSHC.

MAIN OUTCOME MEASURES

The participant's decision to opt on or off, and the demographic and behavioural characteristics associated with opting off the PTR.

RESULTS

590 (59.9%) women opted off the PTR. Using logistic regression, young age (p=0.005), birth outside Australia and New Zealand (p=0.0001), not speaking English at home (p=0.005) and being a commercial sex worker (CSW) (p=0.0001) were variables associated with opting off the PTR. Women from countries outside of Australia and New Zealand were more likely to opt off, whether or not they were a CSW and CSWs were more likely to opt off the PTR irrespective of their country of birth (p=0.013).

CONCLUSION

The majority of women (60%) attending the SSHC opted off the PTR. Studies to evaluate culturally appropriate health promotion material particularly for CSWs and women with poor English skills living in Australia are needed and if successful may improve uptake on the PTR.

Sexually transmitted infections and risk behaviours in women who have sex with women

OBJECTIVES

To assess the prevalence of sexually transmitted infections (STIs) and blood borne viruses, risk behaviours, and demographics in women who have sex with women (WSW).

METHODS

Retrospective cross sectional study using a multivariate model. Demographic, behavioural, and morbidity data were analysed from standardised medical records of patients attending a public STI and HIV service in Sydney between March 1991 and December 1998. All women with any history of sex with a woman were compared with women who denied ever having sex with another woman (controls).

RESULTS

1408 WSW and 1423 controls were included in the study. Bacterial vaginosis (BV) was significantly more common among WSW (OR 1.7, p < 0.001). Abnormalities on cervical cytology were equally prevalent in both groups, except for the higher cytological BV detection rate in WSW (OR 5.3, p = 0.003). Genital herpes and genital warts were common in both groups, although warts were significantly less common in WSW (OR 0.7, p = 0.001). Prevalence of gonorrhoea and chlamydia were low and there were no differences between the groups. The prevalence of hepatitis C was significantly greater in WSW (OR 7.7, p < 0.001), consistent with the more frequent history of injecting drug use in this group (OR 8.0, p < 0.001). WSW were more likely to report previous sexual contact with a homo/bisexual man (OR 3.4, p < 0.001), or with an injecting drug user (OR 4.2, p < 0.001). Only 7% of the WSW reported never having had sexual contact with a male.

CONCLUSION

We demonstrated a higher prevalence of BV, hepatitis C, and HIV risk behaviours in WSW compared with controls. A similar prevalence of cervical cytology abnormalities was found in both groups. Measures are required to improve our understanding of STI/HIV transmission dynamics in WSW, to facilitate better health service provision and targeted education initiatives.

Management of women with recurrent genital herpes in pregnancy in Australia

OBJECTIVE

To document clinical practice for the management of recurrent genital herpes in pregnant women in Australia.

DESIGN AND PARTICIPANTS

A questionnaire to all doctors associated with the Royal Australian College of Obstetricians and Gynaecologists.

MAIN OUTCOME MEASURES

Policies for antenatal herpes screening, circumstances in which delivery by caesarean section was considered appropriate, and the use of aciclovir during pregnancy. The results were analysed by college status, sex, and whether the doctor worked in a public or private facility.

RESULTS

2855 (67.3%) obstetricians returned questionnaires. 696 (34.3%) stated that their hospital had a policy for managing recurrent genital herpes in pregnancy: 44.5% examined the genitalia and 33.8% took cultures during pregnancy. Fellows were more likely to examine the genitalia (87% v 37%, p < 0.001), and more likely to perform antenatal viral cultures than members (75% v 30%, p < 0.001). Doctors working at private hospitals were significantly more likely to take viral cultures than doctors in public hospitals (39% v 33% p < 0.05). Doctors were asked to consider five scenarios and judge whether caesarean section would be appropriate. 96% considered that a caesarean section was appropriate in women with active herpes at the onset of labour. In the case of a recurrence of genital HSV at the time of presentation with ruptured membranes longer than 4 hours, diplomats (79%) were significantly more likely to recommend a caesarean section than fellows (64%), members (63%), or trainees (49%) (all p < or = 0.001). Where there were positive viral cultures before the onset of labour fellows (45%) were more likely than members (29%) (p = 0.005), males (62%) were more likely than females (55%) (p = 0.03), and doctors working in private hospitals (69%) were more likely than those in the public sector (54%) (p < 0.001) to recommend caesarean section.

CONCLUSION

There is considerable divergence of opinion regarding the appropriate management of recurrent genital herpes in pregnancy. The implementation of management guidelines would provide consistency of care.