Prevalence of Chlamydia trachomatis in the general population in Germany - a triangulation of data from two population-based health surveys and a laboratory sentinel system.

BACKGROUND: Chlamydia trachomatis (chlamydia) is a common, frequently asymptomatic, sexually transmitted infection. It can result in severe sequelae, such as ectopic pregnancy and infertility. In Germany, chlamydia is not notifiable. An opportunistic screening program for women < 25 years was introduced in 2008. The aim of this research was to triangulate different data sources to describe the epidemiological situation of chlamydia in Germany and to investigate whether the current target group of the chlamydia screening program aligns with these findings. METHODS: Urine specimens from participants from population-based health examination surveys of children (2014-17) and adults (2008-11) were tested for chlamydia, using nucleic acid amplification testing. These data were used to generate weighted chlamydia prevalence estimates by age group and sex. Data from a nationwide chlamydia laboratory sentinel system (2014-16) were used to calculate the positive proportion among individuals tested for chlamydia by age, sex and test reason. RESULTS: Using data from the population-based surveys, we found a chlamydia prevalence estimate of 2.8% (95% confidence interval (CI) 1.0-7.5%) among all 15- to 17-year-old girls and of 9.6% (95% CI 0.0-23) among those reporting to be sexually active. In adult women, we found the highest prevalence among 18- to 24-year-olds (all: 2.3%; 95% CI 1.0-5.3%; sexually active: 3.1%; 95% CI 1.3-7.0%). In adult men, we found the highest prevalence among 25- to 29-year-olds (all: 3.5%; 95% CI 1.6-7.7%; sexually active: 3.3%; 95% CI 1.3-7.8%). Data from the chlamydia laboratory sentinel showed the highest positive proportion among those opportunistically screened in 19-year-old women (6.1%; 95%- CI 5.9-6.4%), among those screened due to pregnancy in 15-year-old girls (10%; 95% CI 8.5-12%), and among those tested due to symptoms or a positive partner in 19-year-old women (10%; 95% CI 9.8-11%) and 19-year-old men (24%; 95% CI 22-26%). CONCLUSIONS: Chlamydia seems to mainly affect adolescents and young adults in Germany, with similar overall prevalence in men and women, but with slightly different age distributions. Women at highest risk of chlamydia are covered by the current screening program but given the on-going discussions in high-income countries on cost-effectiveness and benefit-to-harm ratio of these programs, the program-aim needs reconsideration.

Not again! Effect of previous test results, age group and reason for testing on (re-)infection with Chlamydia trachomatis in Germany.

BACKGROUND: Infection with Chlamydia trachomatis (Ct) is the most commonly reported sexually transmitted infection in Europe. In Germany, Ct screening is offered free of charge to pregnant women since 1995 and to women < 25 years of age since 2008. For symptomatic individuals, testing is covered by statutory health insurance. Study results have shown that repeat Ct infection occurs in 10-20% of previously infected women and men. Our aim was to describe persons tested for Ct and to investigate the determinants of (repeat) Ct infection in women and men in Germany. METHODS: We analysed Ct test results from men and women tested between 2008 and 2014 in laboratories participating in the German Chlamydia trachomatis Laboratory Sentinel surveillance. Reinfection was defined as at least 2 positive laboratory tests within more than 30 days. We performed logistic regression stratified by sex and, for women, reason for testing to determine the effect of previous test results and age group on subsequent test results. RESULTS: In total, 2,574,635 Ct tests could be attributed to 1,815,494 women and 123,033 men. 5% of women and 14% of men tested positive at least once. 15-19- and 20-24-year-old women tested positive at least once respectively in 6.8 and 6.0%, while men respectively in 16.6 and 21.2%. Altogether, 23.1% of tested women and 11.9% of tested men were tested repeatedly between 2008 and 2014. Among those who previously tested positive, reinfection occurred in 2.0% of women and 6.6% of men. Likelihood to be tested Ct positive was higher in women and men with a positive Ct test in the past compared to previously tested Ct negative, odds ratios 4.7 and 2.6 (p < 0.01) respectively. Odds ratios ranged by age group and test reason. CONCLUSION: A history of Ct infection increased the likelihood of infection with Ct in women and men taking into account the result of the previous test. Health education, safer sex and treatment of partners are necessary for women and men who have tested positive to prevent reinfection and complications and to interrupt the chain of transmission. To identify potential reinfection repeat testing after treatment should be performed.

Antimicrobial resistance of Neisseria gonorrhoeae in Germany: low levels of cephalosporin resistance, but high azithromycin resistance.

BACKGROUND: The widespread antimicrobial resistance of Neisseria gonorrhoeae is a serious problem for the treatment and control of gonorrhoea. Many of the previously effective therapeutic agents are no longer viable. Because N. gonorrhoeae infections are not reportable in Germany, only limited data on disease epidemiology and antimicrobial susceptibility patterns are available. The Gonococcal Resistance Network (GORENET) is a surveillance project to monitor trends in the antimicrobial susceptibility of N. gonorrhoeae in Germany in order to guide treatment algorithms and target future prevention strategies. METHODS: Between April 2014 and December 2015, data on patient-related information were collected from laboratories nationwide, and susceptibility testing was performed on 537 N. gonorrhoeae isolates forwarded from the network laboratories to the Conciliar Laboratory for gonococci. Susceptibility results for cefixime, ceftriaxone, azithromycin, ciprofloxacin and penicillin were defined according to EUCAST 4.0 standards. Percentages, medians and interquartile ranges (IQR) were calculated. RESULTS: Altogether, 90% of isolates were from men. The median age was 32 (IQR 25-44) years for men and 25 (IQR 22-40) years for women (p-value < 0.001). The most frequently tested materials among men were urethral (96.1%) and rectal swabs (1.7%), and among women, it was mainly endocervical and vaginal swabs (84.3%). None of the isolates were resistant to ceftriaxone. Furthermore, 1.9% (in 2014) and 1.4% (in 2015) of the isolates were resistant to cefixime, 11.9% and 9.8% showed resistance against azithromycin, 72.0% and 58.3% were resistant to ciprofloxacin, and 29.1% and 18.8% were resistant to penicillin. CONCLUSIONS: Resistance to ceftriaxone was not detected, and the percentage of isolates with resistance to cefixime was low, whereas azithromycin resistance showed high levels during the observation period. The rates of ciprofloxacin resistance and penicillin resistance were very high across Germany. Continued surveillance of antimicrobial drug susceptibilities for N. gonorrhoeae remains highly important to ensure efficient disease management.

Establishment of a voluntary electronic Chlamydia trachomatis laboratory surveillance system in Germany, 2008 to 2014.

Chlamydia trachomatis (CT) infections are not reportable in Germany and limited data on prevalence are available. CT screening has been offered free of charge to pregnant women since 1995 and to all women under 25 years since 2008. For symptomatic women and men, diagnostic testing is covered by statutory health insurance. We describe the establishment of a nationwide, laboratory-based, voluntary sentinel that electronically collects information on all performed CT tests with test results, test reason and patient information. The sentinel represents one third of all performed CT tests in Germany. In the period from 2008 to 2014, 3,877,588 CT tests were reported, 93% in women. Women aged 20-24 years and men aged 25-29 years were the most frequently tested age groups. The overall proportion of positive tests (PPT) among women was 3.9% and among men 11.0%. The highest PPT among women was in the age groups 15-19 (6.8%) and 20-24 years (5.9%), and among men in the age groups 20-24 (19.2%), 15-19 (15.4%) and 25-29 years (14.8%). The PPT for CT was high among women and men younger than 25 years. Prevention is urgently needed. Monitoring of CT infection in Germany should be continued.

Prevalence of pharyngeal and rectal Chlamydia trachomatis and Neisseria gonorrhoeae infections among men who have sex with men in Germany.

OBJECTIVES: To determine the prevalence of pharyngeal and rectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections among men who have sex with men (MSM) in Germany and describe associations between these infections, sexual practices and other factors to provide an evidence base for screening recommendations. METHODS: We conducted a cross-sectional study in 22 sentinel sites of sexually transmitted infections across Germany. Pharyngeal and rectal swabs were collected and tested for CT and NG with a nucleic acid amplification test (NAAT). Information on HIV status, number of sex partners and sexual practices was collected and linked to NAAT results. RESULTS: Overall, 2247 MSM were screened for pharyngeal or rectal CT and NG infections; median age was 34 years (range 16-83). Prevalence of CT was 1.5% in pharyngeal and 8.0% in rectal specimens. Prevalence of NG was 5.5% in pharyngeal and 4.6% in rectal specimens. Local symptoms were reported in 5.1% of pharyngeal and 11.9% of rectal infections. Altogether 90.8% of rectal or pharyngeal infections would remain undetected if only symptomatic cases were tested. Rectal infection was significantly more likely in men reporting multiple partners (2-5 partners, OR=1.85; 6-10 partners, OR=2.10; >11 partners, OR=2.95), men diagnosed with HIV (OR=1.60) and men practising receptive anal intercourse without a condom (OR=1.54). Pharyngeal infection was more likely in men reporting multiple partners (6-10 partners, OR=2.88; >11 partners, OR=4.96), and men diagnosed with HIV (OR=1.78). CONCLUSIONS: Pharyngeal and rectal infections in sexually active MSM can remain undetected and thus transmissible if swabbing is not offered routinely. Screening should be offered particularly to MSM diagnosed with HIV and MSM reporting multiple partners.

Lymphogranuloma venereum in men screened for pharyngeal and rectal infection, Germany.

To determine prevalence of lymphogranuloma venereum among men who have sex with men in Germany, we conducted a multicenter study during 2009-2010 and found high rates of rectal and pharyngeal infection in men positive for the causative agent, Chlamydia trachomatis. Many infections were asymptomatic. An adjusted C. trachomatis screening policy is justified in Germany.