Ingrid Macio

The infrequent use of office-based diagnostic tests for vaginitis

OBJECTIVE This study was undertaken to determine physician use of simple office-based tests in the evaluation of women with vulvovaginal symptoms. STUDY DESIGN A medical record review of 52 women seeking care at a referral-based vaginitis clinic was performed. The evaluation performed and the care management were recorded for 150 previous physician-provided office visits. RESULTS A microscopic assessment of vaginal fluid was not performed in 37% of office visits, and 42% of physicians did not perform microscopy as part of any evaluation of vaginitis. Whiff amine tests and measurement of vaginal pH were rarely performed (3% of office visits). Treatment without adequate evaluation of the etiology of the symptoms occurred in 54% of visits in which medication was prescribed. CONCLUSIONS In our study population the evaluation and care provided to women presenting for evaluation of vulvovaginal symptoms were suboptimal. The use of simple inexpensive office-based tests can optimize the assessment of vaginal infections and should be encouraged.

The Efficacy and Safety of Gentamicin Plus Azithromycin and Gemifloxacin Plus Azithromycin as Treatment of Uncomplicated Gonorrhea

BACKGROUND Ceftriaxone is the foundation of currently recommended gonorrhea treatment. There is an urgent need for backup treatment options for patients with cephalosporin allergy or infections due to suspected cephalosporin-resistant Neisseria gonorrhoeae. We evaluated the efficacy and tolerability of 2 combinations of existing noncephalosporin antimicrobials for treatment of patients with urogenital gonorrhea. METHODS We conducted a randomized, multisite, open-label, noncomparative trial in 5 outpatient sexually transmitted disease clinic sites in Alabama, California, Maryland, and Pennsylvania. Patients aged 15-60 years diagnosed with uncomplicated urogenital gonorrhea were randomly assigned to either gentamicin 240 mg intramuscularly plus azithromycin 2 g orally, or gemifloxacin 320 mg orally plus azithromycin 2 g orally. The primary outcome was microbiological cure of urogenital infections (negative follow-up culture) at 10-17 days after treatment among 401 participants in the per protocol population. RESULTS Microbiological cure was achieved by 100% (lower 1-sided exact 95% confidence interval [CI] bound, 98.5%) of 202 evaluable participants receiving gentamicin/azithromycin, and 99.5% (lower 1-sided exact 95% CI bound, 97.6%) of 199 evaluable participants receiving gemifloxacin/azithromycin. Gentamicin/azithromycin cured 10 of 10 pharyngeal infections and 1 of 1 rectal infection; gemifloxacin/azithromycin cured 15 of 15 pharyngeal and 5 of 5 rectal infections. Gastrointestinal adverse events were common in both arms. CONCLUSIONS Gentamicin/azithromycin and gemifloxacin/azithromycin were highly effective for treatment of urogenital gonorrhea. Gastrointestinal adverse events may limit routine use. These non-cephalosporin-based regimens may be useful alternative options for patients who cannot be treated with cephalosporin antimicrobials. Additional treatment options for gonorrhea are needed. Clinical Trials Registration. NCT00926796.

Use of Nucleic Acid Amplification Testing for Diagnosis of Anorectal Sexually Transmitted Infections

ABSTRACT Nucleic acid amplification testing (NAAT) has become the preferred method to detect Chlamydia trachomatis and Neisseria gonorrhoeae, but no commercial tests are cleared by the U.S. Food and Drug Administration for use with rectal swab samples. This study evaluated the performance of strand displacement amplification (SDA) and transcription-mediated amplification (TMA) to detect C. trachomatis and N. gonorrhoeae and to determine if TMA could also detect Mycoplasma genitalium and Trichomonas vaginalis in men and women reporting a history of receptive anal intercourse. Discordant results between the NAATs were reevaluated using the Aptima CT or Aptima GC assay, each of which targets primers other than those targeted by the Aptima Combo 2 (AC2) assay, as the confirmatory test. Of 497 evaluable participants, 41 (8.2%) were positive for C. trachomatis, 21 (4.2%) were positive for N. gonorrhoeae, 26 (5.2%) were positive for T. vaginalis, and 47 (9.5%) were positive for M. genitalium. The sensitivity and specificity of the C. trachomatis test were 100% and 99.8% for AC2 and 56.1% and 100% for SDA, respectively. The sensitivity and specificity of the N. gonorrhoeae test were 100% and 100% for AC2 and 76.2% and 100% for SDA, respectively, while culture was only 23.8% sensitive. Of the 114 participants who had a positive result for any of the four infectious agents, 16 were positive for two pathogens and 3 were positive for three pathogens. These data suggest that rectal infection is common and that the AC2 is superior to SDA for the detection of C. trachomatis and N. gonorrhoeae from rectal swab samples.

HIV-1 infection of female genital tract tissue for use in prevention studies.

Objective:Ex vivo HIV-1 challenge has been proposed as a bioindicator of microbicide product effectiveness. The objective of this study was to establish optimal parameters for use of female genital tract tissue in this model. Design:Ex vivo challenge involves in vivo product use, followed by tissue biopsy, and exposure of the tissue to HIV-1 in the laboratory. Methods:Paired ectocervical and vaginal biopsies were collected from 42 women, and 28 women had additional biopsies from each site collected after 5% lidocaine (n = 14) or chlorhexidine (n = 14) treatment. Tissues were transported immediately to the laboratory and exposed to HIV-1. HIV-1 infection was followed by p24 enzyme-linked immunosorbent assay on culture supernatants and at study end after weighing and fixing the tissue for immunohistochemistry to detect p24 expressing cells. Results:Although both tissue types were equally infected with HIV-1 based on the immunohistochemistry results, ectocervical tissues had significantly higher HIV-1 replication than vaginal tissues (P < 0.005). Lidocaine and chlorhexidine had minimal impact on HIV-1 infection and replication. Point estimates for p24 levels were defined for 95% probability of p24-positive tissues and were 3.43 log10 for ectocervical tissue and 2.50 log10 for vaginal tissue based on the weight-adjusted cumulative p24 end points. Conclusions:Although similar proportions of ectocervical and vaginal tissues support HIV-1 infection, higher levels of HIV-1 replication were observed in ectocervical tissues. Defining point estimates for HIV-1 infection in fresh ectocervical and vaginal tissues provides valuable information for the evaluation of HIV-1 preventative treatments during early clinical studies.

Pharmacokinetics and Placental Transfer of Single-Dose Tenofovir 1% Vaginal Gel in Term Pregnancy

UNLABELLED Tenofovir (TFV) 1% vaginal gel has been found to decrease sexual transmission of human immunodeficiency virus. To initiate investigations during pregnancy, 16 healthy pregnant women scheduled for cesarean delivery received a single application of TFV gel preoperatively. Maternal serum drug concentrations were determined and fetal cord blood, amniotic fluid, placental tissue, and endometrial tissue specimens were collected. The median maternal peak concentration and cord blood TFV concentrations were 4.3 and 1.9 ng/mL, respectively (∼100- and 40-fold lower than after TFV oral dosing, respectively). No adverse events were related to the use of TFV gel. These findings support ongoing and future investigations of TFV gel in pregnancy. CLINICAL TRIAL REGISTRATION NCT00572273. http://www.clinicaltrials.gov/ct2/show/NCT00540605?term=mtn-002&rank=1.

Patterns of Extragenital Chlamydia and Gonorrhea in Women and Men Who Have Sex With Men Reporting a History of Receptive Anal Intercourse.

Background Screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) in men who have sex with men is risk based. Despite high frequencies of oral and receptive anal intercourse (RAI) among women, extragenital screening is not recommended. Methods Women (n = 175) and men who have sex with men (n = 224) primarily recruited from a sexually transmitted infection clinic reporting a lifetime history of RAI completed a structured questionnaire and clinician-collected swab samples from the rectum, pharynx, vagina (women), and urine (men). CT and GC were detected using 2 commercial nucleic acid amplification tests (Aptima Combo 2; Hologic, Inc, Bedford, MA; Xpert CT/NG, Cepheid Innovation, Sunnyvale, CA). Results The median age of the population was 26 years, 62% were white, and 88% were enrolled from a sexually transmitted disease clinic. Men were more likely than women to have GC (22.8% vs. 3.4%) and CT (21.9% vs. 12.6%). In men versus women, GC was detected in 16.5% versus 2.3% of pharyngeal swabs, 11.6% versus 2.3% of rectal swabs, and 5.4% versus 2.9% of urine samples or vaginal swabs. C. trachomatis was detected in 2.2% versus 1.7% of pharyngeal swabs, 17.4% versus 11.4% of rectal swabs, and 4.5% versus 10.3% for urogenital sites in men versus women. Overall 79.6% of CT and 76.5% of GC in men and 18.2% of CT and 16.7% of GC in women were detected only in the pharynx or rectum. Conclusion Reliance on urogenital screening alone misses most of GC and CT in men and more than 15% of infections in women reporting RAI.

O01.4 Blood Transcriptional Profiling of Women with Chlamydia Trachomatis Identifies a Pelvic Inflammatory Disease (PID) Signature

Objective Most women with Chlamydia trachomatis (CT) infection are asymptomatic, while ∼3% progress to pelvic inflammatory disease (PID) within two weeks of untreated infection. The identification of biomarkers that predict development of PID would aid in identification of women at risk for complications of infertility and ectopic pregnancy. The specific aim of this study was to identify a whole blood transcript signature for acute PID due to chlamydial infection. Methods We performed gene expression microarrays using whole blood from 79 women who had a gynecologic exam, and cervical and endometrial microbiologic testing. Samples were divided into five groups: Group 1, women with acute PID who were CT+ at endometrium (PID+, CT+, and E+); Group 2, asymptomatic women who were CT+ at endometrium (PID-, CT+, E+); Group 3, asymptomatic women who were CT+ at cervix (PID-, CT+, E-); Group 4, asymptomatic women who were CT- at cervix and endometrium (PID-, CT-, E-); Group 5, women with symptoms of PID who were negative for CT or other sexually transmitted pathogens (PID+, STI-, E-). Results We identified a transcript signature that discriminated women with chlamydial PID from all other groups. Pathway analysis revealed that the chlamydial PID signature contained genes from interferon response pathways. Gene transcription in a subset of women with chlamydial endometrial infection clustered with women with chlamydial PID. Conclusions Our study raises the possibility that transcriptional biomarkers with potential as diagnostic and prognostic tools can be identified to combat chlamydial reproductive tract disease in women.

O04.6 Mycoplasma Genitalium- Is It a Pathogen in Acute Pelvic Inflammatory Disease (PID)?

Background PID is a polymicrobial infectious condition of the female upper genital tract. Neisseria gonorrhoeae (GC) and Chlamydia trachomatis(CT), long considered the predominant organisms involved in the pathogenesis of PID, are identified in fewer than half of U.S women diagnosed with acute PID. Mycoplasma genitalium (MG) is associated with male urethritis and some evidence suggests an association with other STD syndromes including cervicitis and PID. Our objective was to examine the association between MG and acute PID. Methods The ACE Trial is a randomised double-blind study evaluating the value of anaerobic therapy for acute PID. At enrollment, specimens were collected from the cervix and endometrium for testing for GC, CT and MG by transcription-mediated amplification. Histology was performed on endometrial tissue. Identification of cervical and endometrial organisms was correlated with endometritis. Results Among the 125 women diagnosed with acute PID, twenty two percent (n = 27) tested positive for M. genitalium, while CT, GC and bacterial vaginosis were present in 14%, 7% and 54%, respectively. Forty six women (37%) had histologic endometritis. Histologic endometritis was more common among those having cervical infections with GC, CT or MG than uninfected women (66% vs. 24%, p < 0.001). Among women with endometritis, GC, CT and MG were present in 17%, 30% and 36%, respectively. Endometritis was present in 71% (20/28) of women with endometrial GC, CT or MG. Endometrial identification of GC (100% vs. 34%, p < 0.05), CT (77% vs. 32%, p < 0.01) and MG (64% vs. 33%, p < 0.05) were each independently associated with endometritis. Conclusion Mycoplasma genitalium is identified in 22% of women diagnosed with acute PID. Similar to CT and GC ,the presence of MG in the endometrium is highly associated with endometritis among women diagnosed with PID. This study suggests that M. genitalium may play an important role in the pathogenesis of PID.

Impact of metronidazole on clearance of anaerobes in women with acute pelvic inflammatory disease: the ACE trial

1 Impact of metronidazole on clearance of anaerobes in women with acute pelvic inflammatory disease: the ACE trial H. Wiesenfeld, S. Hillier, L. Meyn, L. Rabe, I. Macio, C. Priest, T. Darville University of Pittsburgh and Magee-Womens Research Institute, Pittsburgh, PA, University of North Carolina, Chapel Hill, NC OBJECTIVES: Anaerobic organisms are associated with endometritis, yet the current CDC recommended outpatient antibiotic regimen for PID has limited activity against anaerobes. The objective of this randomized, placebo controlled study was to assess the impact of standard therapy to standard therapy plus metronidazole on clinical outcomes and eradication of anaerobes from the endometrium. METHODS: Women 14-40 years old meeting CDC criteria for acute PID were eligible for participation. Those requiring hospitalization, allergic to study medication, or were pregnant were excluded. All women underwent an exam and STD testing. An endometrial sample was submitted for aerobic/anaerobic culture, NAAT for gonorrhea (GC), chlamydia (CT) and Mycoplasma genitalium (MG), and histology. All women were treated with ceftriaxone 250 mg IM X1 and doxycycline 100 mg orally BID x 14 days, and were randomized to either metronidazole 500 mg orally BID for 14 days (n1⁄4116) or matching placebo(n1⁄4117) . Clinical and microbiologic assessments were repeated at 30 days. RESULTS: We enrolled 233 womenthe mean age was 23, 59% were black, 28% were white, and 15% had private insurance. Clinical presentations (e.g. pain, tenderness) and prevalence of CT (15%), GC (7%), MG (18%), bacterial vaginosis (55%) and T. vaginalis (8.9%) in the lower genital tract were similar between groups at enrollment. Among endometrial anaerobes, Atopobium vaginae, anaerobic gramnegative rods (GNR) and anaerobic gram-positive cocci (GPC) were associated with histologic endometritis. At 30 days, pelvic tenderness was less frequent among women receiving metronidazole (8.0% v 22.3%, p<0.01). Clearance of anaerobic organisms from the endometrium was more frequent in the metronidazole arm [94.7% (18/19) vs 68.2 % (15/22), p1⁄40.05]. All women treated with metronidazole had clearance of A. vaginae, anaerobic GNRs and anaerobic GPC (16/ 16), while clearance of these organisms was less common in the placebo arm (12/18, 66.7%, p<0.05). Medication adherence and GI side effects were similar between groups. CONCLUSIONS: Addition of metronidazole to ceftriaxone/doxycycline for the treatment of women with acute PID is associated with improved clinical outcome and clearance of anaerobic organisms from the endometrium. These results support a change in CDC recommendations to include metronidazole for all women receiving ceftriaxone/doxycycline for outpatient treatment of PID.

Heterogeneity of HIV-1 replication in ectocervical and vaginal tissue ex vivo

In clinical trials evaluating HIV-1 prevention products, ex vivo exposure of mucosal tissue to HIV-1 is performed to inform drug levels needed to suppress viral infection. Understanding assay and participant variables that influence HIV-1 replication will help with assay implementation. Demographic and behavioral data were obtained from 61 healthy women aged 21-45. Paired cervical tissue (CT) and vaginal tissue (VT) biopsies were collected and treated with HIV-1BaL or HIV-1JR-CSF, washed, and cultured. On days 3, 7, and/or 11, culture supernatant was collected, and viral replication was monitored by p24 ELISA. Tissue was extracted at study end, and HIV-1 relative RNA copies were determined by polymerase chain reaction. Cumulative p24 and RNA were log-transformed and analyzed using a linear mixed model, t-test, and an intraclass correlation coefficient (ICC). HIV replication was similar between CT and VT for each virus, but HIV-1BaL had 1.5 log10 and 0.9 log10 higher levels of p24 than HIV-1JR-CSF in CT and VT, respectively (p < .001), which correlated with HIV-1 relative RNA copies. Cumulative p24 and RNA copies in both tissues demonstrated low intraperson correlation for both viruses (ICC ≤0.513 HIV-1BaL; ICC ≤0.419 HIV-1JR-CSF). Enrollment into previous clinical studies in which genital biopsies were collected modestly decreased the HIV-1BaL cumulative p24 for CT, but not for VT. To improve the ex vivo challenge assay, viruses should be evaluated for replication in mucosal tissue before study implementation, baseline mucosal tissue is not needed if a placebo/no treatment group is included within the clinical trial, and previous biopsy sites should be avoided.