Looking for an asymptomatic infection: usefulness of screening for Chlamydia trachomatis and genital herpes.

Chlamydia trachomatis (CT) and Herpes simplex virus type 2 (HSV-2) genital infections are among the more frequent sexually transmissible infections with different prevalence by age, populations and geographical areas. Both are widespread, have an asymptomatic latent stage detectable only by laboratory and can have serious consequences such as tubal infertility and neonatal herpes. The direct isolation of CT in cervical or urethral discharge through Nucleic Acid Amplification Test (NAATs) allows to detect and to treat the infection with effective antibiotic medication. The screening of all women younger than 25 year old showed to be effective in reducing tubal complications but not in decreasing the incidence of the infection in the general population. Only a proactive screening of younger women, repeated yearly and associated with an effective partner notification could achieve a decrease of the incidence rate in the general population. The detection of type specific herpetic antibodies allows to identify persons with herpetic infection regardless of symptoms. While a population-based screening of general population cannot be proposed at the moment, a selective screening (attenders of STI clinic, HIV-positive patients, pregnant women) is a debated issue between those who consider it an effective means to detect persons with unrecognized symptoms who are infectious and those who think that preventive measures and antiviral medication are not effective enough to be proposed.

Clinical characteristics and response to prophylactic fluconazole of preterm VLBW neonates with baseline and acquired fungal colonisation in NICU: data from a multicentre RCT.

BACKGROUND: Fungal colonisation by Candida spp. affects a high proportion of VLBW neonates in NICU. However, few data are available on the clinical characteristics of colonisation in preterm infants who are colonised at baseline via vertical transmission, compared to preterms who become colonised during their stay in NICU via horizontal transmission. MATERIAL AND METHODS: We reviewed the database of a multicentre, randomised trial of prophylactic fluconazole in VLBW neonates conducted in 8 Italian NICUs in the years 2004 and 2005 (Manzoni et al., NEJM 2007;356(24):2483-95). Per the protocol, all enrolled infants underwent weekly surveillance cultures from birth till discharge. We investigated the frequency of the two different modalities of Candida colonisation in this population, as well as the clinical and outcome characteristics possibly related to them. RESULTS: Overall, Candida colonisation affected 54 of 336 infants (16.1%). Baseline (i.e., detected <3(rd) day of life) colonisation affected 16 (4.7%), and acquired 38 (11.4%), of the 54 colonised preterms. Infants with baseline colonisation had significantly higher birth weight (1229 ± 28 g vs. 1047 g ± 29, p = 0.01) and gestational age (30.2 wks ± 2.7 vs. 28.5 wks ± 2.6, p = 0.01), and were significantly more likely to limit progression from colonisation to invasive Candida infection when fluconazole prophylaxis was instituted (21.6% vs. 42.7%, p = 0.009). Isolation of C. parapsilosis was significantly more frequent in infants with acquired colonisation. CONCLUSIONS: Infants with baseline and acquired colonisation differ for demographics characteristics and for their response to fluconazole prophylaxis. This information may be useful for targeting more accurate management strategies for these two different groups of colonised preterms in NICU.

Vaginal and endocervical microorganisms in symptomatic and asymptomatic non-pregnant females: risk factors and rates of occurrence.

Physiological or non-physiological factors may affect the vaginal flora. The occurrence of genital microorganisms in non-pregnant females of all ages was studied, as were the risk factors associated with each microorganism. A retrospective analysis of vaginal and endocervical cultures and wet smears from 27,172 non-pregnant women, between 1996 to 2005, was performed taking into consideration clinical and socio-demographic characteristics. No microorganisms were observed in 55.7% of the individuals studied and 44.3% had positive cultures. There was no microbiological aetiology in 49% of women with genital symptoms. Poor hygiene, chemical irritants, sexual behaviour, vaginal blood, birth control type, and/or the lack of an oestrogen effect may have caused the symptoms. The highest occurrence of Gram-negative bacteria (p<0.01), mainly Escherichia coli, was observed in prepubescent girls. The highest occurrence of Candida species (p<0.01) was in women of childbearing age, and of Gram-positive bacteria (p<0.01) in menopausal women. Adolescents, particularly asymptomatic girls, carried more frequently Ureaplasma urealyticum and Chlamydia trachomatis (p<0.01). Hormonal contraception and consistent condom use was protective against bacterial vaginosis and U. urealyticum colonization. Users of intrauterine devices had an increased risk of bacterial vaginosis or of contracting U. urealyticum, Mycoplasma hominis and Candida species. Genital complaints were an independent indicator of Candida species, Gram-negative and Gram-positive bacteria, Trichomonas vaginalis and bacterial vaginosis.Chlamydia trachomatis infections were often asymptomatic. It is concluded that the hormonal milieu and non-physiological factors are major determinants of the vaginal flora. If diagnosis of genital infections is based on symptoms alone and not on culture results, it may be erroneous. Sexual abuse should be investigated when a child presents with a sexually transmitted disease.

Prevalence and risk factors for Chlamydia trachomatis infection in young women in north-west of Italy.

AIM: The aim of the study was to estimate the prevalence of Chlamydia trachomatis infection, risk factors and best predictors of infection in young sexually active women in north-west of Italy. METHODS: One thousand one hundred and eighty 18-24 years old women of family planning clinics and three STI Clinics over Turin city area underwent vaginal swabs to detect infection and completed a questionnaire. Logistic regression and multivariate analysis identified risk factors and a receiver operating characteristic (ROC) curve was used to assess the model accuracy. RESULTS: Overall prevalence of infection was 10.4% 2.71 times higher (P<0.001) among women afferent to STI clinics than family planning clinics. Higher among women of Eastern European, Asian and South American ethnic origin (P=0.012) compared to Western European or African ethnic origin. Age at first intercourse (P=0.006), absence of a stable partner (P<0.001) partner with urogenital complaints (P<0.001), number of lifetime partners (P<0.001) number of partners in the last 6 months (P<0.001) history of occasional intercourse (P<0.001) and of IST (P<0.007) resulted associated with chlamydial infection. Multivariate analysis showed setting, partner with urogenital complaints and number of lifetime partners as best predictors of infection. ROC curve on variables from multivariate analysis showed an AUC of 0.732. CONCLUSION: The study showed high rates of Chlamydial infection among sexually active women between 18-24 years in north-west area of Italy. Predictors of infection are related to sexual activity and to population sub-groups. Selective screening protocols should be supported by wider and more representative studies in order to increase knowledge and involve public opinion.

Oral supplementation with Lactobacillus casei subspecies rhamnosus prevents enteric colonization by Candida species in preterm neonates: a randomized study.

BACKGROUND: Colonization by Candida species is the most important predictor of the development of invasive fungal disease in preterm neonates, and the enteric reservoir is a major site of colonization. We evaluated the effectiveness of an orally supplemented probiotic (Lactobacillus casei subspecies rhamnosus; Dicoflor [Dicofarm spa]; 6 x 10(9) cfu/day) in the prevention of gastrointestinal colonization by Candida species in preterm, very low birth weight (i.e., < 1500-g) neonates during their stay in a neonatal intensive care unit. METHODS: Over a 12-month period, a prospective, randomized, blind, clinical trial that involved 80 preterm neonates with a very low birth weight was conducted in a large tertiary neonatal intensive care unit. During the first 3 days of life, the neonates were randomly assigned to receive either an oral probiotic added to human (maternal or pooled donors') milk (group A) or human milk alone (group B) for 6 weeks or until discharge from the NICU, if the neonate was discharged before 6 weeks. On a weekly basis, specimens obtained from various sites (i.e., oropharyngeal, stool, gastric aspirate, and rectal specimens) were collected from all patients for surveillance culture, to assess the occurrence and intensity of fungal colonization in the gastrointestinal tract. RESULTS: The incidence of fungal enteric colonization (with colonization defined as at least 1 positive culture result for specimens obtained from at least 1 site) was significantly lower in group A than in group B (23.1% vs. 48.8%; relative risk, 0.315 [95% confidence interval, 0.120-0.826]; P = .01). The numbers of fungal isolates obtained from each neonate (P = .005) and from each colonized patient (P = .005) were also lower in group A than in group B. L. casei subspecies rhamnosus was more effective in the subgroup of neonates with a birth weight of 1001-1500 g. There were no changes in the relative proportions of the different Candida strains. No adverse effects potentially associated with the probiotic were recorded. CONCLUSIONS: Orally administered L. casei subspecies rhamnosus significantly reduces the incidence and the intensity of enteric colonization by Candida species among very low birth weight neonates.

Cervicovaginal infections during pregnancy: epidemiological and microbiological aspects.

OBJECTIVE: The assessment of the association of cervicovaginal infections during pregnancy with preterm (pPROM) and term (PROM) premature rupture of membranes, preterm delivery, mid-trimester miscarriage and intrauterine death, and the definition of the risk factors that identify pregnant women who should have a cervicovaginal culture. METHODS: We retrospectively studied the relationship between pregnancy outcomes and cervicovaginal infections in 3217 pregnant women between January 1998 and December 1999. Microbiological assessment included Gram staining and specific cultures; bacterial vaginosis was diagnosed by Amsel's criteria. We also studied the medical, obstetric, sexual, demographic and social history of 11,212 pregnant women who underwent cervicovaginal culture between January 1992 and December 2001. RESULTS: Overall, 1425 of the 3217 cultures (44.3%) were positive. The micro-organisms most frequently found were: yeasts (44%), Ureaplasma urealiticum (29%); group B streptococcus (15%); and bacterial vaginosis (11%). Cervicovaginal cultures were found positive in 84.6% of pPROM, 55.0% of PROM, 50.8% of preterm deliveries, 43.8% of mid-trimester miscarriages, 31.4% of intrauterine deaths and in 33.5% of controls. Among the 11 212 cervicovaginal cultures considered in the second study, an overall 6301 (56.2%) were positive, 2711 (43%) in asymptomatic women. Cervicovaginal infections were associated with country of origin, age under 25 years, age at first intercourse under 15 years, more than ten partners, more than one partner in the past 6 months, prior abortions, past sexually transmitted diseases (STDs) and HIV infection. CONCLUSION: Cervicovaginal infections were significantly associated with PROM (p<0.0001), pPROM (p<0.0001) and preterm delivery (p<0.0001), but not with intrauterine death. The association with mid-trimester miscarriage approached statistical significance (p=0.06). The main risk factors for cervicovaginal infections were country of origin, age under 25 years, age at first intercourse under 15 years, more than ten partners, more than one partner in the past 6 months, prior abortions, past STDs and HIV infection.

Chlamydia trachomatis prevalence in North-West Italy.

AIM: Chlamydia (C.) trachomatis infection is the most common sexually transmitted disease (STD) among sexually active adolescents and young adults in Europe. The aim of this study was to determine the prevalence of C. trachomatis among sexually active women in Piedmont, Italy and the correlation between some risk factors and C. trachomatis infection. METHODS: In our study 31,419 sexually active women aged 12-55 were screened for C. trachomatis by Abbott's ligase chain reaction (LCR) using cervical swabs during the period 1997-2001 at St. Anna Obstetric-Gynecological Hospital, Turin. All the patients answered a specific questionnaire. RESULTS: In our analysis the prevalence of C. trachomatis infection was found to be 1.23%, and the average age among the infected patients was 36.98 years. Statistical analysis was performed using the chi squared test; a p<0.05 was considered significant. A correlation was found between a positive test result and the age at the first intercourse (p<0.001), the number of sexual partners in the preceding 6 months (p<0.001), the presence of symptoms (p<0.001), a low level of education (p<0.001) and an East-European and Central-Northern African citizenship (p<0.001). No statistically significant differences were found among the contraceptive methods used, whether an hormonal or a barrier type; a marked increment of the risk was observed when no contraception was used. CONCLUSION: Frequent microbiological examinations are desirable for patients whose anamnesis shows an augmented risk of contracting sexually transmitted infections in order to avoid long term complications from misdiagnosed or asymptomatic pathologies, as often happens with C. trachomatis.

Sexually transmitted diseases and pelvic inflammatory disease.

AIM: The aim of this study was to determine the prevalence in the Turin area of the pathogens most implicated in pelvic inflammatory disease (PID), with particular regard to which risk factors the population taken into consideration is exposed to. METHODS: From January 1st 1997 to December 31(st) 2001, 13809 women, aged between 14-54, all subjects being fertile and sexually active, were examined for the first time at St. Anna Hospital in Turin for the diagnosis of sexually transmitted diseases (STDs). A total of 5559 unselected patients were divided into 2 groups according to the presence (1721) or absence (3838) of subjective symptoms related to PID. Both groups underwent a cervico-vaginal bacteriological test for common pathogens, Candida spp., T. vaginalis, bacterial vaginosis, C. trachomatis, Mycoplasma spp., N. gonorrhoeae. The prevalence of each micro-organism was coupled with the anamnestic data collected from a pre-determined questionnaire submitted to all patients. The questionnaire collected personal data: age at the time of first sexual intercourse; the number of partners in the last 6 months; the type of contraceptives used. Statistical analysis was performed using a chi squared test. RESULTS: In our analysis 2 factors proved to be decisive for a correct PID diagnosis: a subjective symptomatology and an anamnesis mainly focused on risk factor evaluation. This result is in accordance with what has been emphasized many times in the literature, i.e. many of these infections have only a few or no symptoms at all. CONCLUSION: Greater attention to the anamnestic data collection would therefore be the key to focusing the clinical investigations on those who are at a major risk to contracting STDs.

[Development of a multiple PCR method for the identification of Ureaplasma parvum and Ureaplasma urealyticum]. / Desarrollo de un método de PCR-múltiple para la identificación de Ureaplasma parvum y Ureaplasma urealyticum.

Ureaplasma parvum and Ureaplasma urealyticum, also known as biovar parvum and biovar T960, respectively, could be associated with several disorders in men, women, and mainly, in newborn children with under weight. Several methods have been developed in order to identify the species or biovars of ureaplasmas. We developed a Multiplex-PCR method using the UPS-UPSA and UUS2-UUA2 primers, specific for U. parvum and U. urealyticum, respectively. This Multiplex-PCR method was used to identify cultures of clinical positive samples to Ureaplasma spp. by the "MYCOFAST Evolution-2" Kit. Of 56 positive cultures to Ureaplasma spp. from newborn children, 70% were U. parvum and 30% U. urealyticum; in 76 positive samples in women, 83% corresponded to U. parvum and 17% to U. urealyticum, while in 63 positive samples of men, 76% identified U. parvum and 24% U. urealyticum. The PCR-multiplex method showed specificity for the identification of the biovars or species of ureaplasmas of clinical interest.

Desarrollo de un método de PCR-múltiple para la identificación de Ureaplasma parvum y Ureaplasma urealyticum / [Development of a multiple PCR method for the identification of Ureaplasma parvum and Ureaplasma urealyticum]

Ureaplasma parvum and Ureaplasma urealyticum, also known as biovar parvum and biovar T960, respectively, could be associated with several disorders in men, women, and mainly, in newborn children with under weight. Several methods have been developed in order to identify the species or biovars of ureaplasmas. We developed a Multiplex-PCR method using the UPS-UPSA and UUS2-UUA2 primers, specific for U. parvum and U. urealyticum, respectively. This Multiplex-PCR method was used to identify cultures of clinical positive samples to Ureaplasma spp. by the [quot ]MYCOFAST Evolution-2[quot ] Kit. Of 56 positive cultures to Ureaplasma spp. from newborn children, 70

were U. parvum and 30

U. urealyticum; in 76 positive samples in women, 83

corresponded to U. parvum and 17

to U. urealyticum, while in 63 positive samples of men, 76

identified U. parvum and 24

U. urealyticum. The PCR-multiplex method showed specificity for the identification of the biovars or species of ureaplasmas of clinical interest.

Desarrollo de un método de PCR-múltiple para la identificación de Ureaplasma parvum y Ureaplasma urealyticum. / [Development of a multiple PCR method for the identification of Ureaplasma parvum and Ureaplasma urealyticum]

Ureaplasma parvum and Ureaplasma urealyticum, also known as biovar parvum and biovar T960, respectively, could be associated with several disorders in men, women, and mainly, in newborn children with under weight. Several methods have been developed in order to identify the species or biovars of ureaplasmas. We developed a Multiplex-PCR method using the UPS-UPSA and UUS2-UUA2 primers, specific for U. parvum and U. urealyticum, respectively. This Multiplex-PCR method was used to identify cultures of clinical positive samples to Ureaplasma spp. by the [quot ]MYCOFAST Evolution-2[quot ] Kit. Of 56 positive cultures to Ureaplasma spp. from newborn children, 70

were U. parvum and 30

U. urealyticum; in 76 positive samples in women, 83

corresponded to U. parvum and 17

to U. urealyticum, while in 63 positive samples of men, 76

identified U. parvum and 24

U. urealyticum. The PCR-multiplex method showed specificity for the identification of the biovars or species of ureaplasmas of clinical interest.

[Cervico-vaginal infections. Study of a population in the Turin area]. / Infezioni cervico-vaginali. Studio sulla popolazione dell'area torinese.

BACKGROUND: Aim of this study is to determine the prevalence, in the Turin area, of the pathogens chiefly involved in the genesis of the most common infections of the female genitalia. METHODS: This is a retrospective study. During the period of time beginning from January 1, 1997 and ending December 31, 1999, we examined 10,249 women from 14 years to 54 years of age, who were seen at the out-patient diagnosis service of the Sant'Anna Hospital. The patients' cervical specimens were screened for common germs, Candida spp., Trichomonas vaginalis, Bact. Vaginosis, Chlamydia trachomatis, Microplasms, and Neisseria gonorrhea. The prevalence of each micro-organism was found. The obtained data were cross-referenced with the risk factors in the clinical history of each patient. The chi(2) test with a C.I. of 95% was used for the statistical evaluations. RESULTS: It is shown by a detailed analysis of the data in our possession that an anamnesis oriented mainly for the evaluation of the various risk factors would be more effective than one oriented for the presence of a subjective symptomatology, since many of these infections are either weakly symptomatic or totally asymptomatic (especially in the case of C. trachomatis), as has been many times underlined in the international literature. CONCLUSIONS: Greater attention should be given to the collection of anamnestic information in order to more precisely target for examination those subjects at greater risk of contracting a sexually transmitted infection.

Epidemiology of urogenital infections caused by Chlamydia trachomatis and outline of characteristic features of patients at risk.

A study of Chlamydia trachomatis infection was conducted in two stages on 15,656 subjects at urogenital clinics of the Faculty of Medicine and Surgery at La Sapienza University in Rome, the S. Anna Hospital in Turin, and the Niguarda Hospital in Milan. The overall incidence of the disease was 6.4% in patients examined throughout the whole study period. The rate of positive cases was 5.8% for the 5270 patients examined up to 1990, and 6.7% for the 10,386 patients examined from 1990 to 1992, showing an increasing trend. There was a much higher positivity rate in men (9.8%) than in women (6.0%); the difference was statistically significant. Of all patients, 60%, were asymptomatic. In symptomatic patients, C. trachomatis was present in 18.5% of cases of non-gonococcal urethritis and in 12.8% of cases of salpingitis. The highest incidence of C. trachomatis infection was in women who had begun sexual activity at an early age, (under 25 years in age), had several sexual partners and used intra-uterine contraceptive devices or spermicides or both.

A study of the incidence of urogenital Chlamydia trachomatis in patients attending specialized departments of Rome, Milan and Turin, Italy.

A study of Chlamydia trachomatis was conducted in 5270 subjects seen at clinics of the Faculty of Medicine and Surgery at La Sapienza University in Rome, the S. Anna Hospital in Turin, and the Provincial Maternity Hospital Institute in Milan. In these areas, C. trachomatis was present in 5.8% of the cases examined; in addition it was present with statistically significant frequencies in cases of salpingitis (49.1) and epididymitis (21.7). It may also be found in cases of extrauterine pregnancy, sterility and abortion. Those most affected were women who had begun their sexual activity at an early age, were under 25, had several sexual partners and who used the coil and/or spermicides. A routine check for C. trachomatis should be considered for those women with those risk factors.

[Transcervical vs. transabdominal amniocentesis in the bacterial evaluation of the amniotic fluid]. / L'amniocentesi per via trans-cervicale versus l'amniocentesi per via trans-addominale nella valutazione batteriologica del liquido amniotico.

The authors compare the results of bacteriological research on amniotic fluid by transcervical and trans-abdominal amniocentesis. Eighty women at term of their pregnancy, scheduled for cesarean section, underwent a bacteriological vaginal test and a trans-cervical amniocentesis before and a trans-abdominal amniocentesis during cesarean section. The results obtained from both specimens of the amniotic fluid were the same in 90% of the cases. A negative bacteriological result of trans-cervical amniocentesis excluded a positive result of trans-abdominal amniocentesis. Instead, when a positive bacteriological result was obtained in trans-cervical amniocentesis, trans-abdominal amniocentesis gave a positive result in only 60% of the cases. We conclude that trans-cervical amniocentesis, besides being less dangerous, easy to perform and easily repeated, is sufficiently secure and reliable in bacteriological results as compared with trans-abdominal amniocentesis.

[Correlation of positivity for serum anti-chlamydia antibodies and tubal damage as a cause of infertility. Preliminary study]. / Correlazioni tra positività per anticorpi anti-chlamydia sierici e fattore tubarico come causa di infertilità. Studio preliminare.

Chlamydia Trachomatis is one of the most frequently bound aetiological agents in acute salpingitis. Chlamydia infection often runs asymptomatically or with slight symptomatology, so patients do not call in their doctor. This hypothesis is backed by the observation that serum antibody positivity for Chlamydia and tubal infertility are often found together. The purpose of the present study was to determine the positivity of serum antibodies for Chlamydia in infertile women observed at this Centre and compare it with a control group of non-sterile patients. Further, in those patients in whom antibody positivity exists, it was also proposed to seek tubal lesions at hysterosalpingography or coelioscopy. The antibody titre in infertile women is compared with that of the control group. The study was carried out in 30 sterile women and in 30 patients in the definitely fertile control group. The "Ipazyme" (Sorin) immunoperoxidase test was used to seek IgG and IgA anti-Chlamydia antibodies. The geometric mean of the antibody titre was calculated in those women with a titre equal to or greater than 64 for IgG antibodies and equal to or greater than 16 for IgA antibodies. It is now intended to study whether the titre is higher in infertile women compared to the control group and if positivity is more significant in these patients.

[Epidemiological findings on Chlamydia trachomatis infections of the female genitalia. Comparison of detection methods]. / Rilievi epidemiologici nella infezione da Chlamydia trachomatis dell'apparato genitale femminile. Confronto di metodi di accertamento.

Chlamydia trachomatis infection has been investigated by means of cell culture and fluorescent monoclonal antibody technique in 100 women, partly suffering from cervico-vaginal disease and partly asymptomatic, attending to cytologic investigations. The results from the two methods have been correlated to each other and to anamnesis, bacteriological tests and to the existence of specific anti-Chlamydia trachomatis antibodies, detected by indirect immunofluorescence.