Utility of antimicrobial susceptibility testing in Trichomonas vaginalis-infected women with clinical treatment failure.

BACKGROUND: Antimicrobial resistance is one of the causes of treatment failure in women after standard nitroimidazole therapy for Trichomonas vaginalis infections. The Centers for Disease Control and Prevention provides drug susceptibility testing and guidance for treatment failures but the efficacy of the alternate recommendations has not been assessed. METHODS: T. vaginalis isolates from women who had failed at least 2 courses of standard therapy for trichomoniasis were submitted to the Centers for Disease Control and Prevention for susceptibility testing. Alternative treatment recommendations were provided based on in vitro drug susceptibility results and clinical outcomes were collected. RESULTS: Drug susceptibility results were available for 175 women tested between January 2002 and January 2008. In vitro, 115 of the 175 isolates demonstrated metronidazole resistance. For all isolates resistant to metronidazole, in vitro resistance to tinidazole was similar or lower. Clinical treatment outcomes were available for 72 women. Of the women receiving an alternative recommended nitroimidazole regimen, 30 (83%) of 36 were cured compared with 8 (57%) of 14 women who received a lower dose than recommended. Clinical and microbiologic success was attained in 59 (82%) of 72 women whose follow-up information was available, with some women requiring multiple treatment courses. CONCLUSIONS: Clinical and microbiologic cure rates were higher for women who were treated in accordance with the recommendation provided after in vitro testing compared with those who received a lower dose or a different drug. Susceptibility testing leading to tailored treatment may have a beneficial role for management of women with persistent trichomoniasis.

Gonococcal, chlamydia, and syphilis infection positivity among MSM attending a large primary care clinic, Boston, 2003 to 2004.

BACKGROUND: In the past decade, increases in syphilis and rectal gonorrhea have been reported among men who have sex with men (MSM) in the United States; however, limited sexually transmitted disease (STD) positivity data are available on MSM who receive their healthcare from primary care or general medical clinics. The current study sought to elucidate STD positivity in asymptomatic MSM seen at the largest primary care clinic for MSM in New England and to describe STD test positivity by reason for STD testing. METHODS: As part of the Centers for Disease Control and Prevention's MSM Prevalence Monitoring Project, all medical visits between 2003 and 2004 (n = 21,927) among MSM attending Fenway Community Health (Boston) were reviewed. The prevalence of positive STD tests (chlamydia, gonorrhea, and syphilis reactivity) was determined and analyzed by demographic characteristics, HIV status, symptoms, and reason for testing. RESULTS: Overall, 23.4% of MSM visits included STD testing during the observation period. Their mean age was 39 years (range: 18-65 years); 84% were white, 5% were black, and 5% were Hispanic. Sixty-five percent of MSM tested were asymptomatic with 7% of asymptomatic MSM testing positive for at least one STD. STD prevalence varied by reason for STD testing: 4.4% of MSM routinely screened had at least one STD, compared to 6.9% of MSM who reported having high risk sex in the preceding 3 months, and 17% of MSM reporting an exposure to an STD. Among all asymptomatic MSM tested, 1.0% had urethral gonorrhea; 1.7% had pharyngeal gonorrhea; 5.6% had rectal gonorrhea; 2.2% had urethral chlamydia; and 4.3% were seroreactive for syphilis. CONCLUSIONS: Rectal gonorrhea and syphilis seropositivity were frequently diagnosed in asymptomatic MSM; STD prevalence was highest in MSM tested due to an STD exposure or reporting high-risk sex, underscoring the need to promote routine screening in high risk MSM populations.

Risk factors for prevalent and incident Trichomonas vaginalis among women attending three sexually transmitted disease clinics.

GOAL: Trichomonas vaginalis is the most common nonviral sexually transmitted infection in the United States and may be associated with adverse birth outcomes and may also increase susceptibility to or transmissibility of human immunodeficiency virus. The purpose of this analysis is to describe the epidemiology of T. vaginalis in Sexually Transmitted Disease clinics and characterize the risk factors associated with prevalent and incident T. vaginalis within the same population. METHODS: We analyzed data from visits occurring during February 1999-December 2001 from 3 sexually transmitted disease clinics in Newark, NJ; Long Beach, CA; and Denver, CO. Data were analyzed from 1462 women aged 15 to 39 years who were tested by culture at their initial visit for T. vaginalis, and for 1269 women with at least 1 follow-up visit. Risk factors for prevalent infections at baseline and incident infections among treated or previously uninfected women were assessed. RESULTS: At baseline, 13.0% of the women had a prevalent infection; risk factors included the following: older age (> or =20 years), black race, having less than 12 years of education, and having a concurrent chlamydial infection. At follow-up, 4.6% of women had an incident infection; risk factors included the following: older age (35-39 years), black race, having a concurrent chlamydial infection, having had multiple sexual partners in the 3 months before incident infection, and having had T. vaginalis at the visit before their incident infection. CONCLUSIONS: T. vaginalis incidence is high in women. Risk factors for prevalent and incident infection are similar. T. vaginalis was associated with older age in women, unlike other sexually transmitted infections.

Management of trichomonas vaginalis in women with suspected metronidazole hypersensitivity.

BACKGROUND/OBJECTIVE: Standard treatment for Trichomonas vaginalis is metronidazole or tinidazole. Hypersensitivity to these drugs has been documented but is poorly understood. Desensitization is an option described in limited reports of women with hypersensitivity to nitroimidazoles. The purpose of this analysis is to improve documentation of management for trichomonas infections among women with metronidazole hypersensitivity. STUDY DESIGN: Clinicians who consulted Centers for Disease Control and Prevention concerning patients with suspected hypersensitivity to metronidazole were provided with treatment options and asked to report outcomes. RESULTS: From September 2003-September 2006, complete information was obtained for 59 women. The most common reactions were urticaria (47%) and facial edema (11%). Fifteen of these women (25.4%) were treated with metronidazole desensitization and all had eradication of their infection. Seventeen women (28.8%) were treated with alternative intravaginal drugs, which were less successful; 5 of 17 infections (29.4%) were eradicated. CONCLUSION: Metronidazole desensitization was effective in the management of women with nitroimidazole hypersensitivity.

An ongoing burden: chlamydial infections among young American Indian women.

OBJECTIVES: Studies conducted in the 1980s, when there was limited chlamydia screening, showed high positivity, 23%-30%, among American Indian women. In the 1990 s, chlamydia screening and treatment programs were implemented in a variety of settings serving American Indian women including Indian Health Service (IHS) clinics. Yet, a 2000-2001 national survey documented a chlamydia prevalence of 13.3% among young American Indian women, five times higher than the prevalence among whites. The purpose of this analysis was to determine the chlamydia positivity and risk factors for chlamydia among women screened in Indian Health Service (IHS) clinics participating in the National Infertility Prevention Program in 2003. METHODS: Data were analyzed from 11,485 chlamydia tests performed among women universally screened in 23 IHS clinics in three states (Montana, North Dakota, South Dakota). Sexual risk history and clinical data were collected in the Montana IHS clinics and used to assess risk factors for chlamydial infection in a multivariate logistic regression model. RESULTS: Chlamydia positivity was highest among 15-19 year old women screened in IHS clinics (state range: 15.3%-18.6%). Positivity decreased with age but remained high even among women aged 30-34 years. Young age and having had multiple or new sex partners in the last 90 days were associated with an increased risk of chlamydia; however, chlamydia positivity was greater than 6.7% for women with no known risk factors. CONCLUSIONS: A greater emphasis on chlamydia screening and treatment should be a component of any program whose goal is to improve the reproductive health of American Indian women.

Within the hidden epidemic: sexually transmitted diseases and HIV/AIDS among American Indians and Alaska Natives.

OBJECTIVES: To review the epidemiology, research, and prevention programs for sexually transmitted diseases in American Indians and Alaska Natives (AI/ANs). STUDY DESIGN: We reviewed the current national and regional trends in sexually transmitted diseases (STDs) for AI/ANs from 1998-2004, peer-reviewed studies from January 1996, through May 2006, and reports, unpublished documents, and electronic resources addressing AI/AN STD prevention and control. RESULTS: STD prevalence among AI/ANs remains high. For example, the case rate of C. trachomatis in the North Central Plains AI/AN populations is 6 times the overall US rate. Trends for C. trachomatis also show sustained increases. Little research exists on STDs for this population, and most is focused on HIV/AIDS. Fear of compromised confidentiality, cultural taboos, and complex financial and service relationships inhibit effective surveillance, prevention, and management. CONCLUSIONS: Recommendations for STD control in this population include improved local surveillance and incorporation of existing frameworks of health and healing into prevention and intervention efforts. Research defining the parameters of cultural context and social epidemiology of STDs is necessary.

Testing for sexually transmitted diseases in U.S. Public health laboratories in 2004.

OBJECTIVE: Appropriate laboratory testing practices are a critical part of sexually transmitted disease (STD) control. GOAL: The goal of this study was to describe the type and volume of STD tests performed in public health laboratories in the United States in 2004. STUDY DESIGN: A web-based survey was made available to 144 members of the Association of Public Health Laboratories. RESULTS: One hundred fourteen laboratories responded (79%). Overall, 3,553,196 chlamydia tests and 3,461,151 gonorrhea tests were performed; 64.4% of chlamydia tests and 60.8% of gonorrhea tests were nucleic acid amplification tests. Ninety-four percent of laboratories performed syphilis testing. Few laboratories used type-specific tests for herpes simplex virus or used new tests for trichomoniasis, bacterial vaginosis, or human papillomavirus. CONCLUSIONS: This survey collected important data that can be used to monitor trends in STD testing practices in public health laboratories.

Prevalence of Chlamydia in young men in the United States from newly implemented universal screening in a national job training program.

OBJECTIVE: The objective of this study was to examine chlamydia prevalence and its risk factors from the first universal screening in socioeconomically disadvantaged young men. GOAL: The goal of this study was to evaluate the need for universal screening in young men. STUDY DESIGN: We calculated chlamydia prevalence by demographic and geographic characteristics from 51,478 men aged 16 to 24 years who were screened from July 2003 to December 2004. RESULTS: Overall, chlamydia prevalence was 8.2%. Only 2.4% of the young men had sexually transmitted disease symptoms. Blacks had the highest prevalence (13.0%), whereas non-Hispanic whites had the lowest (3.1%). Men who smoked marijuana had a significantly higher prevalence compared with those who did not (11.9% vs. 6.4%). Men who used cocaine or PCP also had a significantly higher chlamydia prevalence compared with those who did not. Men who lived in the southern region of the United States had the highest prevalence. CONCLUSIONS: Chlamydial infection is highly prevalent among socioeconomically disadvantaged young men. Young men entering the National Job Training Program represent an important population for screening.

Prevalence trends in chlamydial infections among young women entering the national job training program, 1998-2004.

OBJECTIVES: To assess the trends and risk factors of chlamydial infections in disadvantaged women aged 16 to 24 years entering a national job training program. GOAL: To assess the impact of chlamydia screening program on chlamydia trend. STUDY DESIGN: The authors calculated the prevalence of chlamydia by demographic and geographic characteristics from 106,377 women who were screened from 1998 through 2004. RESULTS: Chlamydia prevalence was inversely associated with age, decreasing from 12.7% in women aged 16 to 17 years to 6.6% in women aged 22 to 24 years. Blacks had the highest prevalence (13.1%). Chlamydia prevalence significantly decreased from 11.7% in 1998 to 10.0% in 2003 and then slightly increased to 10.3% in 2004. After direct standardization and adjustment for the laboratory test type, a similar trend was observed by age and race/ethnicities. CONCLUSIONS: Among disadvantaged women aged 16 to 24 years entering a national job training program, the chlamydia prevalence and racial disparities in prevalence were consistently high from 1998 to 2004, especially among younger black women.

Chlamydial infections among female adolescents screened in juvenile detention centers in Washington State, 1998-2002.

OBJECTIVE: The objective of this study was to assess trends in Chlamydia trachomatis positivity and associated risk factors among detained female adolescents. GOAL: The goal of this study was to determine trends in prevalence of chlamydia among detained female adolescents. STUDY DESIGN: We retrospectively reviewed risk factor data and chlamydia results collected by providers during 1998-2002 at four large juvenile detention centers in Washington State that routinely screen female adolescents for C. trachomatis. RESULTS: Of 3,593 tests, a total of 493 (13.7%) were positive for chlamydia. High chlamydia positivity was sustained throughout the 5-year period (range, 12.5-15.0%) with no statistically significant trends in positivity. Independent risk factors for chlamydial infection included report of more than one sex partner in the previous 60 days (adjusted odds ratio [OR] = 1.56, 95% confidence interval [CI] = 1.19-2.04) and previous chlamydial infection within 12 months (adjusted OR = 1.87, 95% CI = 1.45-2.40). CONCLUSIONS: Efforts are needed to promote chlamydia screening programs in juvenile detention centers because these sites have access to high-risk sexually active female adolescents.

Chlamydia trachomatis and Neisseria gonorrhoeae prevalence and coinfection in adolescents entering selected US juvenile detention centers, 1997-2002.

BACKGROUND: Juvenile detention centers offer public health practitioners an opportunity to gain access to large numbers of adolescents at risk for chlamydia and gonorrhea. GOAL: To describe the prevalence and coinfection of chlamydia and gonorrhea among adolescents in 14 US juvenile detention centers from 1997 to 2002. STUDY: We calculated the prevalence of chlamydia and gonorrhea in males and females, stratified by race/ethnicity, age group, and site. We also calculated the proportion of adolescents with chlamydia that were coinfected with gonorrhea and the proportion of those with gonorrhea that were coinfected with chlamydia. RESULTS: The prevalence of chlamydia was 15.6% in 33,619 females and 5.9% in 98,296 males; gonorrhea prevalence was 5.1% in females and 1.3% in males. Of females with gonorrhea, 54% were coinfected with chlamydia, and 51% of males with gonorrhea were coinfected with chlamydia. CONCLUSIONS: Chlamydia and gonorrhea prevalence was very high in females in all project sites. In males, chlamydia prevalence was high in some areas; however, gonorrhea prevalence was substantially lower. These prevalence data justify screening for chlamydia and gonorrhea among female adolescents in juvenile detention centers nationally.

Assessing a web-based approach to collect complex and sensitive surveillance data: the sexually transmitted diseases- laboratory tests methods survey.

The Centers for Disease Control and Prevention (CDC) is looking for improved ways to collect complex, and highly sensitive, public health surveillance data. The Sexually Transmitted Diseases - Laboratory Test Methods Survey (STD-LMS) was developed to replace the traditional STD mail survey. The web-based STD-LMS offered distinct advantages over the traditional mail survey technique including,reduced time and cost of conducting the survey and avoiding the often error prone and tedious task of data entry.

Indirect estimation of Chlamydia screening coverage using public health surveillance data.

Although routine screening of all sexually active adolescent females for Chlamydia trachomatis infection is recommended at least annually in the United States, no national or state-specific population-based estimates of chlamydia screening coverage are known to exist. Conclusions regarding screening coverage have often been based on surveys of health care provider or facility screening practices, but such surveys do not consider persons who do not seek care at these facilities or who seek care at more than one facility. The authors developed a method to estimate the proportion of sexually active females aged 15-19 years screened for chlamydia in 45 states and the District of Columbia by using national data on chlamydia positivity, estimates of sexual activity from the National Survey of Family Growth, and chlamydial infections reported to the Centers for Disease Control and Prevention. Because of uncertainty regarding these values and related assumptions, credibility intervals were calculated by using a Monte Carlo model. When this model was used, the median state-specific proportion of sexually active females aged 15-19 years screened in 2000 was 60% (90% credibility interval: 55, 66). These results and this method should be evaluated for their utility in guiding implementation of national and state chlamydia control programs.

Laboratory tests used in US public health laboratories for sexually transmitted diseases, 2000.

BACKGROUND AND OBJECTIVES: Public health laboratories are a critical component of sexually transmitted disease (STD) control in the United States. GOAL: The goal of this study was to describe the types and volume of STD tests performed in U.S. public health laboratories in 2000. STUDY DESIGN: A survey was mailed to 123 members of the Association of Public Health Laboratories. RESULTS: Eighty-one percent of 100 laboratories responded. Overall, 3294739 chlamydia tests and 3088142 gonorrhea tests were done; 62.4% of chlamydia tests and 63.6% of gonorrhea tests were DNA probes. Fifty-six percent of laboratories performed rapid plasma reagin (RPR) tests and 55% performed Venereal Disease Research Laboratory (VDRL) tests; the number of RPR tests performed was twice that of VDRL tests. Few laboratories used new technologies for bacterial vaginosis and trichomoniasis. Eighteen percent of laboratories performed herpes simplex virus serology; however, most used inaccurate tests. No laboratories performed human papillomavirus tests. CONCLUSIONS: This survey documents for the first time STD tests performed in U.S. public health laboratories.

Gonorrhea prevalence and coinfection with chlamydia in women in the United States, 2000.

BACKGROUND: No recent national data address the prevalence of gonorrhea. GOAL: The goal was to describe gonorrhea prevalence and chlamydial coinfection among women aged 15 to 24 years. STUDY DESIGN: Data were analyzed from tests for chlamydia and gonorrhea at family planning, STD, and prenatal clinics in 2000. Gonorrhea positivity, chlamydia positivity among women with gonorrhea, and the median and interquartile ranges (IQRs) were calculated. RESULTS: The median state-specific gonorrhea positivity among women aged 15 to 24 years was 0.9% (IQR, 0.7%-1.7%) in family planning clinics, 7.0% (IQR, 4.1%-10.4%) in STD clinics, and 1.0% (IQR, 0.8%-1.6%) in prenatal clinics. Gonorrhea positivity was higher among females aged 15 to 19 years than among those aged 20 to 24 years. Median chlamydia positivity for females infected with gonorrhea was highest among those aged 15 to 19 years (46%). CONCLUSIONS: Gonorrhea positivity was consistently highest among women aged 15 to 19 years; almost half of women aged 15 to 19 years with gonorrhea also had chlamydia.