Geneviève A. F. S. van Liere

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

BackgroundSymptom- and sexual history-based testing i.e., testing on indication, for anorectal sexually transmitted infections (STIs) in women is common. Yet, it is unknown whether this strategy is effective. Moreover, little is known about alternative transmission routes i.e. by fingers/toys. This study assesses anorectal STI prevalence and infections missed by current testing practice, thereby informing the optimal control strategy for anorectal STIs in women.MethodsWomen (n = 663) attending our STI-clinic between May 2012-July 2013 were offered routine testing for anorectal and urogenital Chlamydia trachomatis and Neisseria gonorrhoeae. Data were collected on demographics, sexual behaviour and symptoms. Women were assigned to one of the categories: indication (reported anal sex/symptoms), fingers/toys (only reported use of fingers/toys), or without indication.ResultsOf women, 92% (n = 654) participated. There were 203 reports (31.0%) of anal sex and/or symptoms (indication), 48 reports (7.3%) of only using fingers/toys (fingers/toys), and 403 reports (61.6%) of no anal symptoms, no anal sex and no anal use of fingers/toys (without indication). The overall prevalence was 11.2% (73/654) for urogenital chlamydia and 8.4% (55/654) for anorectal chlamydia. Gonorrhoea infections were not observed. Prevalence of anorectal chlamydia was 7.9% (16/203) for women with indication and 8.6% (39/451) for all other women (P = 0.74). Two-thirds (39/55) of anorectal infections were diagnosed in women without indication. Isolated anorectal chlamydia was rare (n = 3): of all women with an anorectal infection, 94.5% (52/55) also had co-occurrence of urogenital chlamydia. Of all women with urogenital chlamydia, 71.2% (52/73) also had anorectal chlamydia.ConclusionsCurrent selective testing on indication of symptoms and sexual history is not an appropriate control strategy for anorectal chlamydia in women visiting an STI clinic. Routine universal anorectal testing is feasible and may be a possible control strategy in women. Yet costs may be a problem. When more restricted control measures are preferred, possible alternatives include (1) anorectal testing only in women with urogenital chlamydia (problem: treatment delay or loss to follow up), and (2) direct treatment for urogenital chlamydia that is effective for anorectal chlamydia as well.

Standard Symptom- and Sexual History-Based Testing Misses Anorectal Chlamydia trachomatis and Neisseria gonorrhoeae Infections in Swingers and Men Who Have Sex With Men

Background Currently, individuals at risk for sexually transmitted diseases (STDs) are tested extragenitally only if indicated, most often when there is a history of self-reported symptoms or self-reported anal sex. The sensitivity of such selective symptom- and sexual history–based testing for detection of anorectal STD has not been determined. Methods All men having sex with men (MSM) and swingers (heterosexual couples who have sex with other heterosexual couples and their self-identified heterosexual sex partners) attending our STD clinic (consults: n = 1690) from January 2010 until February 2011 were universally tested for urogenital, anorectal, and oropharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae infections (STD). We compared STD prevalence at anorectal site based on universal versus selective testing. Results Sensitivity of selective symptom- and sexual history–based testing for anorectal STD was 52% for homosexual MSM, 40% for bisexual MSM, 43% for bisexual male swingers, 40% for heterosexual male swingers, and 47% for female swingers. Conclusions Universal testing of STD clinic clients who were MSM and swingers yielded more than half of all anorectal STD infections and is more sensitive for identifying anorectal STD infections compared with selective testing. Universal testing may be a more effective strategy for interrupting the ongoing transmission in high-risk sexual networks.

Evaluation of the anatomical site distribution of chlamydia and gonorrhoea in men who have sex with men and in high-risk women by routine testing: cross-sectional study revealing missed opportunities for treatment strategies

Objectives Current strategies for controlling non-urogenital chlamydia and gonorrhoea are not uniform. It is assumed that present anorectal/oropharyngeal infections are coincidentally treated with urogenital infections. However, it is not clear whether this control strategy is effective. To inform current debate, we evaluated the anatomical site distribution of chlamydia and gonorrhoea by routine testing in men who have sex with men (hereafter men) and in high-risk women (prostitutes and swingers, hereafter women). Methods Between January 2010 and November 2012, all men (n=2436) and women (n=1321) attending our sexually transmitted infection clinic were routinely tested for anorectal, oropharyngeal and urogenital Chlamydia trachomatis and Neisseria gonorrhoeae. Data were collected on demographics and sexual behaviour. Results Overall chlamydia positivity was 10.4% (254/2436) in men and 7.0% (92/1321) in women, for gonorrhoea this was 6.3% (154/2436) and 3.1% (41/1321), respectively. Isolated non-urogenital infections amounted to 76% of all infections in men and for up to 59% of all infections in women. For combined urogenital and anorectal infections, this amounted to 14% for men and up to 54% for women. Conclusions Testing only for non-urogenital infections is insufficient, as it overlooks many infections. The use of coincidental treatment is therefore a suboptimal control strategy in high-risk groups for halting complications and transmission. There is an urgent need to optimise the testing guidelines for chlamydia and gonorrhoea at different anatomical sites.

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

BackgroundAnorectal 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.DiscussionExtra-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.SummaryCurrent 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.

Re-screening Chlamydia trachomatis positive subjects: a comparison of practices between an STI clinic, general practitioners and gynaecologists

Objectives Re-screening after an initial positive test is a highly effective strategy to identify new Chlamydia trachomatis positive cases. Here, we evaluate adherence to international re-screening guidelines and the re-screening positive rates among sexual healthcare providers. Methods Passive retrospective cohort data were obtained from our STI clinic (South Limburg, Netherlands) and from the public laboratory that performs the majority of C trachomatis tests (September 2006–September 2010) conducted in the eastern South Limburg area. We assessed trends in re-screening after 3–12 months among young (16–25-year-old) and older women and men and evaluated differences between providers using multivariate regression analyses. Results The positive rates in C trachomatis screening varied from 2–9% depending on the type of provider. At the STI clinic, subsequent re-screening was performed in 33% (382/1144) of patients, and 19% of re-screening cases were positive (74/382). Similar rates were observed for gynaecologists (re-screening 30%, 54/178; re-screening positive rate 15%, 8/51); re-screening rates were lower for general practitioners (23%, 144/625, p<0.01), but the positive rate in re-screening was similar (17%, 25/144). At the STI clinic, the re-screening rate was higher for older females (p<0.01) and older males (p<0.01) than for young females. The re-screening rate for young male patients increased over time (p=0.04). General practitioners re-screened young women more often than young (p<0.01) and older (p<0.01) men. Conclusions Positive rates were high for all care providers when re-screening patients. However, re-screening practices are suboptimal and differ between providers, arguing for improved adherence to current C trachomatis control guidelines.

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.

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.

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.

Antibiotic Use before Chlamydia and Gonorrhea Genital and Extragenital Screening in the Sexually Transmitted Infection Clinical Setting

ABSTRACT Background antibiotic use (i.e., administration of antibiotics not directly related to Chlamydia trachomatis or Neisseria gonorrhoeae infections) has been associated with a lower prevalence of genital C. trachomatis infection in a clinical setting. Associations with specific antibiotic types or with N. gonorrhoeae are lacking. Here, we assessed the prevalence of antibiotic use, the different classes and agents used, and their association with a subsequent sexually transmitted infection (STI) clinic C. trachomatis and N. gonorrhoeae test result. At our STI clinic, we systematically registered whether antibiotics were used in the past month (in 29% of the cases, the specific antibiotic agent was named). Patients were screened for urogenital C. trachomatis and N. gonorrhoeae; a third of them were also screened for anorectal and oropharyngeal C. trachomatis and N. gonorrhoeae. The proportion of antibiotics used and their association with C. trachomatis and N. gonorrhoeae prevalence were assessed for heterosexual men, men who have sex with men (MSM), and women. During 14,775 clinic consultations, antibiotic use was reported by 12.2% (95% confidence interval [CI], 11.7% to 12.7%), i.e., 14.8% of women, 8.6% of heterosexual men, and 11.6% of MSM. The most reported antibiotics were penicillins, tetracyclines, and macrolides, respectively. The prevalence was 11.0% (95% CI, 10.3% to 11.3%) for C. trachomatis and 1.9% (95% CI, 1.7% to 2.1%) for N. gonorrhoeae. Only tetracycline use was associated with a lower C. trachomatis prevalence (3%). Overall antibiotic use was associated with lower anorectal C. trachomatis prevalence in MSM only (odds ratio, 0.4; 95% CI, 0.2 to 0.8). STI clinic visitors commonly report recent antibiotic use. Even in a country with low antibiotic consumption, tetracycline use impacted C. trachomatis prevalence, while there was a notable absence of association with azithromycin.

The added value of chlamydia screening between 2008-2010 in reaching young people in addition to chlamydia testing in regular care; an observational study

BackgroundInternet-based Chlamydia Screening Implementation (chlamydia screening programme) was introduced in the Netherlands in 2008-2010 to detect and treat asymptomatic infections and to limit ongoing transmission through annual testing and treatment of Chlamydia trachomatis in young people (16-29 years). This population-based screening may be less effective when addressing individuals who are already covered by regular care, instead of addressing a hidden key population without chlamydia testing experience in regular care. This study had two aims: (1) to assess the rate and determinants of newly reached (i.e. not previously tested in 2006-2010) participants in the chlamydia screening programme, and (2) to assess the chlamydia positivity in these newly reached participants.MethodsThis observational matching study included all chlamydia tests performed in subjects aged 16-29 years in eastern South Limburg in the Netherlands (population 16-29 years:41,000) between 2006-2010. Testing was conducted during the systematic chlamydia screening programme (2008-2010), at a sexually transmitted infections clinic (STI clinic), by general practitioners (GPs), and by medical specialists as reported by the medical laboratory serving the region. Data were matched between testing services on individual level. The study population included all participants who were tested at least once for chlamydia by the chlamydia screening programme. Participants were included at their first chlamydia screening participation.ResultsIn the chlamydia screening programme, 80.7% (4298/5323) of participants were newly reached, others were previously tested by the STI clinic (5.7%, n=304), GPs (6.2%, n=328), medical specialists (3.5%, n=187) or a combination of providers (3.9%, n=206). Chlamydia prevalence was similar in newly reached participants (4.8%, 204/4298) and participants previously tested (4.5%, 46/1025, P=0.82). Independent determinants for being a newly reached participant were male gender (men OR 2.9; 95% CI 2.5-3.4) and young age <21 years (versus 25-29 years OR 1.8; 95% CI 1.5-2.2).ConclusionsThe majority of the chlamydia screening programme participants have not been tested by regular care, and show similar chlamydia prevalence as those previously tested. Thereby population-based chlamydia screening adds to the existing regular care by testing young individuals hidden to current regular care.