PID Normal Human Fallopian Tube Tissue C. trachomatis Infection (PID) Bakteriaalne põletik (tegelikult immunoloogiline vastureaktsioon sellele) põhjustab armistumise ja ripsepiteeli ripsmete hävimise, kleepumise

C. trachomatis infection in men Urethritis Majority (>50%) asymptomatic Symptoms/signs if present: mucoid or clear urethral discharge, dysuria Incubation period unknown (probably 5-10 days in symptomatic infection)

Chlamydia during pregnancy or infants Associated: – premature birth – low birth weight – stillbirths • During delivery ~50% of infants get infected: – Conjuctivitis (5-12 days after birth) – Pneumonia (subacute, afebrile pneumonia (1– 3 months after birth) Prenatal screening and treatment of pregnant women can prevent chlamydial infection among neonates. Pregnant women aged <25 years are at high risk for infection. C. trachomatis infection of neonates results from perinatal exposure to the mother’s infected cervix. Although neonatal ocular prophylaxis with silver nitrate solution or antibiotic ointments does not prevent perinatal transmission of C. trachomatis from mother to infant, ocular prophylaxis with these agents does prevent gonococcal ophthalmia and therefore should be administered (see Ophthalmia Neonatorum Prophylaxis). Initial C. trachomatis perinatal infection involves the mucous membranes of the eye, oropharynx, urogenital tract, and rectum, although infection might be asymptomatic in these locations. Instead, C. trachomatis infection in neonates is most frequently recognized by conjunctivitis that develops 5–12 days after birth. C. trachomatis also can cause a subacute, afebrile pneumonia with onset at ages 1–3 months. Although C. trachomatis has been the most frequent identifiable infectious cause of ophthalmia neonatorum, perinatal chlamydial infections (including ophthalmia and pneumonia) have occurred less frequently because of the institution of widespread prenatal screening and treatment of pregnant women.

Laboratory testing diagnostics

Diagnostic opportunities Culture Non-culture Nucleic Acid Amplification Tests (NAATs) - PCR (polymerase chain reaction) Non-Nucleic Acid Amplification Tests (Non-NAATs) Direct fluorescence antibody (DFA) (visualization against elementary bodies) Enzyme immunoassay (EIA) (against chlamydial lipopolysaccharide) Serology NAATs – teatud osa tekitaja genoomist amplifitseeritakse ehk mitmekorditakse selleks, et seda saaks lihtsalt tuvastada. Tekitaja ehk antigeeni direktne määramine proovis.

Culture Historically the “gold standard” Variable sensitivity (50%-80%) High specificity Use in legal investigations Not suitable for widespread screening

Non-NAATs Direct fluorescent antibody (DFA)- sensitivity 70% Enzyme immunoassay (EIA) Nucleic acid hybridization (NA probe=NAP) C.trachomatise ja N.gonorrhoeae DNA or RNA C. Trachimatis inclusions Miks DFA võib kasutada endotservikaalse materjali kvaliteedi hindamiseks?

NAATs NAATs amplify and detect organism-specific genomic or plasmid DNA or rRNA FDA cleared for urethral swabs from men/women, cervical swabs from women, and urine from both

Serology Rarely used for uncomplicated infections (results difficult to interpret) Criteria used in LGV diagnosis Complement fixation titers >1:64 suggestive Complement fixation titers > 1:256 diagnostic Complement fixation titers < 1:32 rule out

Sensitivity % Specificity % Culture 40-70 >99 DFA 50-70 95-99 EIA 60-70 95-99 PCR 95-98 >99 DNA amplified testing is most sensitive, New gold standard, can be used to test urine. Particularly important for screening males. PCR – new gold standard!

Women Vaginal swab vs cervical swab ??? Self-sampling or clinican??? Urine Vaginal (self) Vaginal (clinician) Cervical Sensitivity 81 % 93% 93% 91% Schachter et al, Vaginal swabs are appropriate specimens for diagnosis of genital tract infection with Chlamydia trachomatis. J Clin Microbiol, aug 2003.

Patient vs clinician collecting sample ** Schoeman SA, Stewart CM, Booth RA, Smith SD, Wilcox MH, Wils. Assessment of best single sample for finding chlamydia in women with and without symptoms: a diagnostic test study. BMJ. 2012 Dec 12;345:e8013. OBJECTIVE: To compare vulvovaginal swabs with endocervical swabs as optimal diagnostic sample for detection of Chlamydia trachomatis infection. DESIGN: A diagnostic test study. SETTING: An urban sexual health centre. PARTICIPANTS: 3973 women aged ≥ 16 years requesting testing for sexually transmitted infections. INTERVENTIONS: Participants took a vulvovaginal swab before routine examination, and clinicians took an endocervical swab during examination. MAIN OUTCOME MEASURE: Diagnosis of chlamydia infection with samples analysed using the Aptima Combo-2 assay; positive results confirmed with the Aptima CT assay. RESULTS: Of the 3973 participants, 410 (10.3%) were infected with C trachomatis. Infected women were significantly younger (22 v 25 years, P<0.0001) and more likely to have symptoms suggestive of a bacterial sexually transmitted infection (53% v 41%, odds ratio 1.63 (95% CI 1.30 to 2.04)), be a contact of someone with a sexually transmitted infection (25% v 5%, odds ratio 6.18 (4.61 to 8.30)), clinically diagnosed with cervicitis (17% v 4%, odds ratio 4.92 (3.50 to 6.91)), and have pelvic inflammatory disease (9% v 3%, odds ratio 2.85 (1.87 to 4.33)). When women co-infected with gonorrhoea were included in the analysis, there was an association with mixed ethnicity (10% v 7%, odds ratio 1.53 (1.07 to 2.17)); but when those with gonorrhoea were removed, women of white ethnicity were significantly more likely to have chlamydia (85% v 80%, odds ratio 1.40 (1.03 to 1.91)). On analysis of complete paired results, vulvovaginal swabs were significantly more sensitive than endocervical swabs (97% (95% CI 95% to 98%) v 88% (85% to 91%), P<0.00001); corresponding specificities were 99.9% and 100%. In women with symptoms suggestive of a bacterial sexually transmitted infection, vulvovaginal swabs were significantly more sensitive than endocervical swabs (97% (93% to 98%) v 88% (83% to 92%), P=0.0008), as they were in women without symptoms (97% (94% to 99%) v 89% (84% to 93%), P=0.002). CONCLUSIONS: Vulvovaginal swabs are significantly better than endocervical swabs at detecting chlamydia in women with and without symptoms suggestive of sexually transmitted infections. In those with symptoms, using endocervical samples rather than vulvovaginal swabs would have missed 9% of infections, or 1 in every 11 cases of chlamydia. TRIAL REGISTRATION: ISRCTN42867448. Palju kirjandust – ise kogumine vähemalt sama hea kui arsti kogutu ** Schachter J, Chernesky MA, Willis DE, Fine PM, Martin DH, Fuller D, Jordan JA, Janda W, Hook EW 3rd. Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis. 2005 Dec;32(12):725-8. ** Cook RL, Hutchison SL, Østergaard L, Braithwaite RS, Ness RB. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. 2005 Jun 7;142(11):914-25. Schoeman SA BMJ 2012

Urine Urethral swab Men Urine vs urethral swab??? Sensitivity 96-99% 97.5-99.5% Chernesky at al, Ability of New APTIMA CT and APTIMA GC Assays To Detect Chlamydia trachomatis and Neisseria gonorrhoeae in Male Urine and Urethral Swabs. J Clin Microbiol 2005. Urethral swab discomfort

Practical recommendations Sampling: Women: vaginal swab Men: urine (2-4 h before urination) Patient vs clinician sampling- no difference! Sample collection for testing during GP visit

How to collect a sample Vaginal swab: sampling from vagina with dry sterile swab, 10-15 turns C. trachomatis urogenital infection in women can be diagnosed by testing urine or by collecting swab specimens from the endocervix or vagina. Diagnosis of C. trachomatis urethral infection in men can be made by testing a urethral swab or urine specimen. Rectal C. trachomatis infections in persons that engage in receptive anal intercourse can be diagnosed by testing a rectal swab specimen. NAATs, cell culture, direct immunofluorescence, EIA, and nucleic acid hybridization tests are available for the detection of C. trachomatis on endocervical specimens and urethral swab specimens from men (197). NAATs are the most sensitive tests for these specimens and are FDA-cleared for use with urine. Some NAATs are cleared for use with vaginal swab specimens, which can be collected by a provider or self-collected by a patient. Self-collected vaginal swab specimens perform at least as well as with other approved specimens using NAATs (276,277), and women find this screening strategy highly acceptable. Rectal and oropharyngeal C. trachomatis infection in persons engaging in receptive anal or oral intercourse can be diagnosed by testing at the anatomic site of exposure. Most tests, including NAAT and nucleic acid hybridization tests, are not FDA-cleared for use with rectal or oropharyngeal swab specimens, and chlamydia culture is not widely available for this purpose. However, NAATs have demonstrated improved sensitivity and specificity compared with culture for the detection of C. trachomatis at rectal sites (278–280) and at oropharyngeal sites among men (278–281). Some laboratories have met CLIA requirements and have validated NAAT testing on rectal swab specimens for C. trachomatis. Recent evidence suggests that the liquid-based cytology specimens collected for Pap smears might be acceptable specimens for NAAT testing, although test sensitivity using these specimens might be lower than those resulting from the use of cervical swab specimens (282); regardless, certain NAATs have been FDA-cleared for use on liquid-based cytology specimens. Persons who undergo testing and are diagnosed with chlamydia should be tested for other STDs. NB! Essential to get epithelium cells not mucus

How to collect a sample Urethral swab: take speciment with dry tampon 2–4 cm deep, rotating the swab for 3-5 seconds. Urine: 15–30 ml first-void urine to sterile container.

STI guidelines in Estonia

Partner management Sex partners should be evaluated, tested, and treated if they had sexual contact with the patient during the 60 days preceding the onset of symptoms or diagnosis of chlamydia. The most recent sex partner should be evaluated and treated even if the time of the last sexual contact was >60 days before symptom onset or diagnosis. Patients should be instructed to refer their sex partners for evaluation, testing, and treatment if they had sexual contact with the patient during the 60 days preceding onset of the patient’s symptoms or chlamydia diagnosis. Although the exposure intervals defined for the identification of at-risk sex partners are based on limited evaluation, the most recent sex partner should be evaluated and treated, even if the time of the last sexual contact was >60 days before symptom onset or diagnosis. Among heterosexual patients, if concerns exist that sex partners who are referred to evaluation and treatment will not seek these services (or if other management strategies are impractical or unsuccessful), patient delivery of antibiotic therapy to their partners can be considered (see Partner Management). Compared with standard partner referral, this approach, which involves delivering a prescription or the medication itself, has been associated with a trend toward a decrease in rates of persistent or recurrent chlamydia (68,69,71). Patients must also inform their partners of their infection and provide them with written materials about the importance of seeking evaluation for any symptoms suggestive of complications (e.g., testicular pain in men and pelvic or abdominal pain in women). Patient-delivered partner therapy is not routinely recommended for MSM because of a high risk for coexisting infections, especially undiagnosed HIV infection, in their partners. Patients should be instructed to abstain from sexual intercourse until they and their sex partners have completed treatment. Abstinence should be continued until 7 days after a single-dose regimen or after completion of a multiple-dose regimen. Timely treatment of sex partners is essential for decreasing the risk for reinfecting the index patient.

Why to screen chlamydia? Most infections are asymptomatic High prevalence in selected population groups Preventing sequelae (incl newborn infections) Screening can reduce the incidence of PID for about 35%

Chlamydia screening in Estonia Repeat screening of women 3-4 months after treatment for C. trachomatis infection (Estonian guideline). http://www.eusti.ee/STI_ravijuhis_2011.pdf

Chlamydia screening in Estonia Screen all pregnant women at the first prenatal visit Antenatal guidelines http://www.ens.ee/

Reporting Chlamydia is reportable STI Chlamydia should be reported to Health Board (NAKIS) Control and prevention of infectious disease law (https://www.riigiteataja.ee/akt/12769931)

Prevention counceling Nature of the infection Chlamydia is commonly asymptomatic in men and women. In women, there is an increased risk of upper reproductive tract damage with re-infection Transmission issues Effective treatment of chlamydia may reduce HIV transmission and acquisition. Abstain from sexual intercourse until partners are treated and for 7 days after a single dose of azithromycin or until completion of a 7-day regimen.

Prevention counceling Risk reduction The clinician should: Assess the patient’s behavior-change potential. Discuss prevention strategies (abstinence, monogamy, condoms, limit number of sex partners, etc.). Latex condoms, when used consistently and correctly, can reduce the risk of transmission of chlamydia. Develop individualized risk-reduction plans.

Case study Suzy Jones: 17-year-old college student who presents to the Student Health Center seeking advice about contraception Shy talking about her sexual practices Has never had a pelvic exam Has had 2 sex partners in past 6 months Does not use condoms or any other contraceptives Her periods have been regular, but she has recently noted some spotting between periods. Last menstrual period was 4 weeks ago. Denies vaginal discharge, dyspareunia, genital lesions, or sores

Physical exam Vital signs: blood pressure 118/68, pulse 74, respiration 18, temperature 37.1° C Breast, thyroid, and abdominal exam within normal limits Genital exam reveals normal vulva and vagina The cervix appears inflamed, bleeds easily, with a purulent discharge coming from the cervical os. Bimanual exam is normal without cervical motion pain, uterine or adnexal tenderness

What is the initial clinical diagnosis? Questions? What is the initial clinical diagnosis? What are the possible etiologic agents associated with the clinical findings? What is the most likely microbiologic diagnosis? Which laboratory tests should be ordered or performed?

Lab results NAAT for Chlamydia trachomatis: positive NAAT for Neisseria gonorrhoeae: negative RPR: negative Wet mount: pH 4.2, no clue cells or trichomonads but numerous WBCs KOH preparation: negative for “whiff test” HIV antibody test: negative Pap smear: ASC-US Pregnancy test: negative

5. What is the final diagnosis? Questions? 5. What is the final diagnosis? What is the appropriate treatment at the initial visit? What are the appropriate prevention and counseling messages for Suzy? Who is responsible for reporting this case to the local health department?

Partner management Suzy’s sex partners from the past year: John – Last sexual exposure 5 weeks ago Tom – Last sexual exposure 7 months ago Michael – Last sexual exposure 2 weeks ago 9. Which sex partners should be evaluated, tested, and treated?

Follow-up Suzy returned for a follow-up visit at 4 months. Her repeat Pap test came back normal. Her repeat chlamydia test returned positive. Suzy stated that her partner, Michael, went to get tested, but the test result was negative so he was not treated. 10. What is the appropriate treatment at the 4-month follow-up visit?

Conclusion Chlamydia is most common STI Usually asymptomatic Sample collection for testing is easy Effective treatment Treatment prevents complications

References CDC (USA) Sexually Transmitted Diseases (STDs) training resources (incl www2a.cdc.gov/stdtraining/ready-to-use/Manuals/Chlamydia/chlamydia-slides-2010.pdf) ECDC. Sexually transmitted infections in Europe. 2011, 2012. Www.sharininhealth.ca A.Uusküla et al. The prevalence of chlamydial infection in Estonia: a population-based survey. Int J STD AIDS 2008; 19(7): 455—58. www.cdc.gov Schachter et al. Vaginal swabs are appropriate speciments for diagnosis of genital tract infection with Chlamydia trachomatis. J Clin Microbiol 2003; 41(8): 3784—9. Schoeman et al. Assessment of best single sample for finding chlamydia in women with and without symptoms: a diagnostic test study. BMJ 2012; 345 e8013. STI guidelines in Estonia. http://www.eusti.ee/STI_ravijuhis_2011.pdf Antenatal guidelines in Estonia. http://www.ens.ee Health Board. www.terviseamet.ee Control and prevention of infectious disease law. www.riigiteataja.ee/akt/12769931