1. Chlamydial Infection and its Effect on Reproduction 2004. 9. 8. 수 차 선 화

2. Content Introduction Biology Immunopathology Chlamydial infection in women Diagnosis Treatment Screening and Prevention

3. The most prevalent sexually transmitted bacterial infection According to the WHO, 90 million chlamydial infections are annually worldwide detected (Gerbase et al., 1998). Prevalence of C. trachomatis infections - 14% among adolescents. ( Lechner et al. 2002) - 35.9% in men and 38.0% in women. ( Gdoura et al. 2001) - from 2 to 26% in pregnant women in the USA. - 65% of babies born from infected mothers during vaginal delivery. ( Betl et al. 1987) - about 21.0% in women having spontaneous abortions. (Vigil et al., 2002). Introduction

4. approximately 70–80% of women and 50% of men infected do not have any symptom Recurrent infections are common ( only partially protective immunity following inf.)

5. Biology Nonmotile, G(-) bacteria Obligate intracellular parasite Unique biphasic growth cycle - elementary body (EB) ; extracellular, metabolically inactive, contagious form - reticulate body (RB) ; intracellular, metabolically active, reproducing form visible as inclusion bodies on light microscope Whole cycle takes 48~72 hours

6. Biology 1.EB attachment 2.Phagocytosis 3.Reorganization of EB into RB 4.multiplication 6. Lysis of cells 5.Convert back to EB 24 hours 48 hours

7. Transmission ►Mechanisms for transmission of Chlamydiae Sexual intercourse of an infected partner of a sexually active couple Eggert-Kruse et al. (1997) Mother to child at delivery Fenton (2000) Family cluster infections Thompson et al. (2001) Extragenital infection (mechanical deposition, flies, dirty fingers, towels and bad hygienic conditions) Emerson et al. (1999) ►Subjects at risk for chlamydial infection With higher number of sexual partners Offspring of infected couples Direct nonsexual family contamination Personnel who deals with patients at hospitals and clinics Clinical laboratory technicians

8. Immunopathology Activation of Th1 Control of extracelluar inf Damage to tissues IFN suspends replication of RB TH1 response to C trachomatis - both protective and pathogenic. Fallopian tube cell IFN-γ Th1 Matrix metalloproteinase

9. Chlamydial infection in women and delivery Tubal factor – silent salpingitis Acute pelvic inflammatory disease Ectopic pregnancy Female infertility Recurrent spontaneous abortion Premature rupture of membranes Low birth weight Stillbrith Postpartum endometritis-salpingitis Conjunctivitis in newborn Pneumonia in newborn

10. The value of Chlamydia trachomatis antibody testing as part of routine infertility investigations Titre No. of patients Primary Infertility HSGLaparoscopy Tubal damage 1 in 325627 (48)46 (82)14 (25)3 (5) 1 in 1283216 (50)17 (53)16 (50)8 (25) 1 in 51216 8 (50) 9 (56) 8 (50)5 (31) 1 in 20487 0 (0) 3 (43) 5 (71) 1 in 81922 2 (100) 0 (0) 2 (100) ► Patients positive for Chlamydia trachomatis antibodies(MIF, Ig G) grouped according to the titre - K. Thomas et al. 2000 In those patients with a low titre (<1 in 128) ; combination of HSG and C. trachomatis antibody titres will give a false negative rate of approximately 5% (Meikle et al., 1994 ) In patients with a higher titre, a laparoscopy would be the better procedure as there is a significantly higher incidence of tubal disease.

11. First-trimester pregnancy loss and active Chlamydia trachomatis infection 1) Autoimmune reaction  immunity against the conserved epitopes of a hsp60 and subsequent immunity to a person’s own hsp60 - Witkin(1999) 2) infected zygote  Ct-infected spermatozoon would directly transmit the organism to the oocyte  or the early embryo would become infected with Ct on its way down the oviduct or inside the uterus.  result in lysis of the zygote or early embryo.  Ct infection (%) Women with abortion (n=259) Women without abortion (n=66) Men with abortion (n=32) Men without abortion (n=17) Couples with abortion (n=32) Couples without abortion (n=17) * P < 0.01 ** P < 0.001 - P. Vigil et al. ANDROLOGIA 2002 -

12. Inclusion vesicle in oolemma EB

13. Diagnosis 1.Culture methods 2. Nonculture methods 1) antigen detection methods ; DFA test, EIA, Rapid test 2) nucleic acid detection methods ; DNA hybridization probe, nucleic acid amplification tests - PCR, LCR, TMA 3) direct cytologic exam 4) Leukocyte esterase test 3. Serologic tests – not useful 1) CF test 2) MIF test 3) EIA for chlamydial antibodis

14. Diagnostic tests CultureDFAEIARapid testsNNANAA Commercial name Microtrak DFAChlamydia- zyme, Microtrak EIA Clearview, TestPack, SureCell PACE2Amplicor(PCR), Abbott(LCR) Sensitivity (%) 40-8550-9043-9252-8567-9687-98 Specificity (%) 10098-9992-100>9596-10098-100 Sites for use Cervix, urethra, pharynx, rectum Cervix, urethra, urine Cervix, urethra Cervix, urethra, urine, vulvovaginal notesAcceptable for medicolegal purposes Time-consuming; can’t be done in large quantities. Used as confirmatory test Automatio n possible Should be considered presumptiv e Automation possible, concurrentl y test for gonorrhea Automation possible DFA-direct fluorescent antibody, EIA-enzyme immunoassays, NNA-non-amplified nucleic acid, NAA-nucleic acid amplification, PCR-polymerase chain reaction, LCR-ligase chain reaction

15. BLACK et al, 1997

16. Diagnostic tests EIA vs PCR - Chan et al. 2000 EIA (%)PCR (%) Urine aloneUrine + cervical cells Sensitivity7592.298.5 Specificity100 Positive predictive value100 Negative predictive value96.198.899.8 Conventional assays - Complicated - time consuming - labour intensive - Lack of sensitivit y and specificity NAA-based technology : PCR & LCR - Rapid - more sensitive and specific - Comparatively cost effective

17. Viral Quantitation Gene Expression Array Verification Drug Therapy DNA Damage Quality Control Pathogen detection Genotyping “real-time PCR” is sequence detection in a closed-tube

18. Diagnostic test in Samsung Cheil Hospital NPositiveBorderlinePositive Rate(%) 20017033905.5 20027496528.9 200310253413.4 20047574025.5 Total398324376.3 1) Methods - Chlamydial antigen detection by ELFA (VIDAS) 2) Positive Rates Samsung Cheil Hospital

19. Preliminary data at Samsung Cheil Hospital Data from patients samples by Real-Time PCR C(T)copies Patient 117.087142,411 Patient 223.3362470.57 Patient 326.177391.083 1,000 100 10

20. Specimen Collection should be to include the host cells that harbor the organism. Endocervix - Swabs with wooden shafts must be avoided. - inserted into the cervical os past the squamocolumnar junction, about 1 to 2 cm deep, rotated for 15 to 30 s, and removed without touching the vaginal mucosa. - following the removal of secretions and discharge from cervix ; decreases bacterial contamination, toxicity for culture - Pap smears be collected first Urethral swab - inserted 1 cm into the female urethra, rotated once prior urine specimens - collected as first catch, - of appropriate volume - obtained within no less than 1 to 2 h of previous urination.

21. Treatment Abstain from sexual intercourse - for 7 days after single-dose therapy - until completion of a 7-day regimen - until all of their sex partners are treated. rescreened 3–4 months after treatment. refer their sex partners for evaluation,testing, and treatment. Presumptive treatment of coinfection with gonococcal infection CDC Recommendation 2002

22. Doxycycline and ofloxacin are contraindicated azithromycin is safe and effective ( Adair et al, 1998) Repeat testing (preferably by culture) 3 weeks after completion of therapy Erythromycin estolate is contraindicated because of drug-related hepatotoxicity. Treatment Pregnancy

23. Chlamydial Infections Among Children Sexual abuse in preadolescent children Diagnostic Considerations ; Nonculture tests for chlamydia (e.g., non- amplified probes [EIA and DFA]) should not be used because of the possibility of false-positive test results.

24. Screening ► Routine screening vs selective screening ? ► Screening Criteria recommended by CDC - women with mucopurulent cervicitis - sexually active women < 20 years old - women 20-24 years old or over ; inconsistent use of barrier contraception ; new or more than one sexual partner during the last 3 months ; prior history of STD ► Screening interval ; 6-12 months for high-risks ► Methods ; less expensive and more sensitive DNA or RNA test - endocervical or urethral swab and urine specimens

25. ► Chlamydia trachomatis in subfertile women undergoing uterine instrumentation (e.g. HSG, laparoscopy with hydrotubation, induced abortion) Women <25 years, those older with risk factors - concurrent sexual partners - partners working in STI endemic regions - those with a current or past history of STI, PID, EP or TFI men with risk factors and gamete donors  should have their LGT screened by a sensitive test.  prophylactic antibiotics when undergoing uterine instrumentation.  The partner should be screened for STIs. Prevention

26. Conclusion Most common bacterial STD Asymptomatic infection Associated with significant sequelae Diagnosis – DNA amplification methods Treatment – Doxycycline, Azithromycin Tx for sexual partner Screening and prevention for high risks

27. Thank you for your attention!

29. Chlamydia trachomatis – the organism

30. Guidelines for diagnosis of infections with non-LGV strains of C. trachomatisa ► Definitive (requires 1 or 2) 1. Isolation and confirmed identification of C. trachomatis in tissue culture from cervical, rectal, or urethral exudate and identification of characteristic intracellular inclusions 2. Identification of C. trachomatis by one of the following methods and confirmation by a second culture or nonculture test method a. Identification of the organism by DFA test of exudate b. Detection of antigen by EIA of exudate c. Detection of nucleic acid from exudate by DNA probe or DNA amplification technique ► Presumptive (requires 1 and 2) 1. Presence or absence of clinical symptoms (e.g., mucopurulent cervicitis, urethritis, epididymitis, PID) 2. Detection of C. trachomatis by a nonculture test ► Suggestive (requires 1 and either 2 or 3) 1. Clinical symptoms (e.g., mucopurulent cervicitis, urethritis, epididymitis, PID) 2. Exclusion of other causes of discharge or exudate (e.g., gonorrhea) 3. Sexual exposure to a person infected with C. trachomatis or recently diagnosed with nongonococcal urethritis, mucopurulent cervicitis, or PID

31. Guidelines for diagnosis of infections with non-LGV strains of C. trachomatisa