Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in an urban public hospital pregnancy termination clinic

Abstract

This study is a follow-up observational study to assess the prevalence of chlamydia (CT) and gonorrhea (GC) among women who undergo a first-trimester surgical termination in a large public, urban hospital-based termination clinic, and to compare the rates to previously published data. We conducted a retrospective chart review on 4197 patients who underwent CT and GC testing before an elective, first-trimester surgical termination between 1 June 2014 and 31 May 2015. The prevalence rates were calculated and compared by chi square tests to previously published data from 1 January 2006 to 30 June 2006 from the same publicly-funded pregnancy termination clinic. Our study population comprised mostly of African Americans (86.8%), and more than half were aged less than 25 years. The overall prevalence of CT in our population was 9.6%, which was significantly different to the prevalence of 11.4% in 2006 (p value = 0.03). The overall prevalence of GC in our population was 1.9%, which was not significantly different to the prevalence of 2.6% in 2006. To conclude, this study demonstrates the high prevalence rate of CT-positive and GC-positive patients in our publicly-funded pregnancy termination clinic. The prevalence of infection with CT and GC in our study is higher than in other family planning clinics. Regular screening of all patients who undergo induced termination in pregnancy termination clinics can provide a valuable opportunity for physicians to counsel patients about sexually transmitted infection prevention and treatment prior to the procedure or distribution of medications.

Keywords

prevalence pregnancy termination clinic

Introduction

According to the Centers for Disease Control and Prevention (CDC), young people (aged 15–24) account for 27% of the sexually active population, but account for about half of all new sexually transmitted infections (STIs).¹ In the United States, Chlamydia trachomatis (CT) is one of the most serious and commonly reported STIs. Neisseria gonorrhoeae (GC) infections, although less commonly reported, can frequently coexist with CT. CT and GC infections can lead to pelvic inflammatory disease (PID) and subsequent infertility, chronic pain, and ectopic pregnancy.² Neonatal blindness and pulmonary complications are also the result of untreated CT.³

Active screening and proper treatment for CT and GC are crucial in the prevention of PID and potentially serious long-term sequelae in high-risk populations. A randomized controlled trial by Scholes et al. demonstrated that CT screening programs could reduce the incidence of PID by as much as 60%.⁴ Independent risk factors for CT and GC infection include sexual activity, age of less than 25 years, two or more sexual partners in the past year, Black race, douching within the past year, inconsistent condom use, and nulligravidity.^5,6

Currently, the CDC recommends annual CT and GC screening in sexually active females less than 25 years of age. A total of 1,422,976 CT infections were reported to the CDC in 2012 across the United States, which was the largest number of cases ever reported to the CDC for any medical condition.⁷ In 2011, among women 15 to 24 years of age who were screened at family planning clinics in all 50 states, CT positivity rates ranged from 3.4% to 19.1% and the median state-specific CT positivity rate was 13.5%.⁸ More specifically, in the state of Illinois, the rate of CT positivity in 2010 in women attending family planning clinics by age group was 11.4% in ages 15–19, 7.5% in ages 20–24, 4.9% in ages 25–29, and 2.5% in ages 30 and above.⁹

Gonorrhea prevalence is also an issue, with rates increasing each year since 2009. In 2012, there were 334,826 cases of GC reported to the CDC. Compared with any other age or sex group, women 20–24 years of age had the highest rate of gonorrhea (578.5 cases per 100,000 females), while women 15–19 years of age had the second highest rate (521.2 cases per 100,000 females).⁶ Cook County of Illinois had 12,042 reported cases of gonorrhea in 2012, the most out of any county or independent city.⁷

The high prevalence rates among high-risk populations are alarming. Patel et al. undertook a retrospective, observational study that examined the prevalence of CT and GC in 1974 women who presented to a publicly-funded pregnancy termination clinic between 1 January 2006 and 30 June 2006 and found comparatively high prevalence rates of 11.4% of CT-positive patients and 2.6% of GC-positive patients.¹⁰ This study is a follow-up observational study to assess the difference in prevalence of CT and GC among women undergoing first-trimester surgical termination in a public, urban hospital-based termination clinic and to compare rates to previously published data.

Materials and methods

We conducted a retrospective chart review on 4197 patients who underwent CT and GC testing before an elective, first-trimester surgical termination between 1 June 2014 and 31 May 2015 at a large public hospital pregnancy termination clinic. Seventy-six patients had missing values for CT and/or GC testing results, and after excluding these patients, our final sample size was 4121. All patients with STI testing data were included. This study was approved by the Cook County Health and Hospitals System Institutional Review Board.

All patients presenting for a first-trimester surgical termination, regardless of risk factors, were screened for CT and GC immediately before each procedure. We used BD Probe Tec ET CT/GC collection and test system (Becton Dickinson Diagnostic Systems, Sparks, MD). Specimens were analyzed in the hospital microbiology laboratory by using a strand displacement amplification test, which is an amplified DNA assay based on the simultaneous amplification and detection of target DNA. The results for testing were reported within one to three days after screening. In 2006, as per standard of care, every patient was given immediately post-procedure a seven-day 100-mg course of doxycycline to treat CT and one 500-mg tablet of ciprofloxacin to treat GC because results at time of procedure were unknown. In 2014–2015, as per standard of care, every patient was given immediately post-procedure a seven-day 100-mg course of doxycycline to treat CT. We did not screen for bacterial vaginosis, syphilis, or HIV, during either study period.

The prevalence rates were calculated and compared by chi square test using SAS 9.4 (Cary, NC) to previously published data from 1 January 2006 to 30 June 2006 from the same publicly-funded pregnancy termination clinic.

Results

During our study period, 397 of 4121 (9.6%) tested positive for CT and 80 of 4121 (1.9%) tested positive for GC. In 2006, 225 of 1874 (11.4%) women tested positive for CT and 51 of 1974 (2.6%) tested positive for GC. Although the prevalence rates remained high for both CT and GC, there was a statistically significant difference between the time periods for CT (p = 0.03), and no statistically significant difference between the time periods for GC (p = 0.11). To our knowledge, none of the patients in this study returned to our hospital with a post-abortal infection.

Table 1 lists the demographic and background characteristics of the study population in 2006 and 2014–2015. The mean age was 24 with ages ranging from 12 to 47 in our study group. Our study population comprised mostly of African Americans (86.8%) and more than half were less than age 25. The majority of the study group was enrolled in high school or a high school graduate.

Table 1.

Demographic and background characteristics of women tested for CT and GC.

Year	2006		2014–2015		P value
Total	1974		4121
Age
M (SD)	23.5 (±5.50)		24.7 (±5.50)		<0.0001
Range	10–46		12–47
Age
<15	26	1.3%	21	0.5%	<0.00001
15–19	474	24.0%	585	14.2%
20–24	727	36.8%	1754	42.6%
25–29	464	23.5%	995	24.1%
30–34	234	11.9%	500	12.1%
≥35	49	2.5%	266	6.5%
Race/ethnicity
Black	1855	94.0%	3579	86.8%	<0.00001
Hispanic	59	3.0%	411	10.0%
White	30	1.5%	70	1.7%
Other	30	1.5%	60	1.5%
Education
Less than high school	21	1.1%	67	1.6%	<0.00001
High school/high school graduate	1855	94.0%	2530	61.6%
Some college/college	98	4.9%	1510	36.8%
Previous elective abortion
0	869	44.0%	1762	42.8%	0.383
≥1	1105	56.0%	2351	57.1%
Insurance status
Aid	1184	60.0%	2277	55.3%	<0.00001
Noninsured	553	28.0%	1778	43.1%
Private insurance	237	12.0%	66	1.6%

CT: Chlamydia; GC: gonorrhea.

Table 2 demonstrates the prevalence of CT and GC by age groups in 2006 and 2014–2015. The overall CT prevalence rates were statistically different (p value <.05) in 2006 (11.4%) and 2014–2015 (9.9%). During 2006, the CT prevalence was highest in the 15- to 19-year age group at 18.8%. This remained similar at 19.0% in 2014–2015. However, the greatest increase in CT prevalence was seen in the <15-year age group. CT prevalence in this age group was higher, but not significantly different, in 2014–2015 compared to 2006 (15.4–28.6%).

Table 2.

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in patients undergoing termination by age group.

	2006			2014–2015				2006		2014–2015
	Number tested	Tested positive CT	Prevalence rates (%)	Number tested	Tested positive CT	Prevalence rates (%)	P value	Tested positive GC	Prevalence rates (%)	Tested positive GC	Prevalence rates (%)	P value
Age
<15	26	4	15.4	21	6	28.6	0.306	2	7.6	1	4.8	1
15–19	474	89	18.8	585	111	19	0.935	22	4.6	20	3.4	0.311
20–24	727	89	12.2	1754	199	11.3	0.526	17	2.3	46	2.6	0.682
25–29	464	34	7.3	995	54	5.4	0.156	9	1.9	7	0.7	0.035
30–34	234	9	3.8	500	22	4.4	0.728	1	0.4	6	1.2	0.44
≥35	49	0	0	266	5	1.9	1	0	0	0	0	0
Total	1974	225	11.4	4121	397	9.6	0.033	51	2.6	80	1.9	0.108

CT: Chlamydia; GC: gonorrhea.

The overall GC prevalence rates were similar in 2006 (2.6%) and 2014–2015 (1.9%). Younger patients consistently showed higher GC prevalence, with patients age 24 and below comprising the majority of positive results: 41 of the 51 patients (80.4%) in 2006 and 67 of the 80 patients (83.8%) in 2014–2015. The highest GC prevalence was seen in the <15-year age group in 2006 at 7.6% and in the <15-year age group in 2014–2015 at 4.8%. In 2006, 22 patients were co-infected and tested positive for CT and GC (1.2%) compared to 28 (0.7%) in 2014–2015. This is a moderately significant difference (p = 0.078).

Discussion

Termination care is an important opportunity to educate patients about reproductive health, which would include sexually transmitted infection. The prevalence of infection of CT and GC in our study is higher than in other Family Planning Clinics in the United States.⁹ Our study demonstrates the high prevalence rate of CT-positive (9.6%) and GC-positive (1.9%) patients in our publicly-funded pregnancy termination clinic and an alarmingly high prevalence rate of CT and GC in patients less than age 20. Our findings are consistent with previous data from 2006.

Regular screening of all patients undergoing induced termination in pregnancy termination clinics can also provide a valuable opportunity for physicians to counsel patients about STI prevention and treatment prior to the procedure or distribution of medications. By communicating the screening test results, reinfection and overall prevalence of infection could potentially be significantly decreased by aiding in the notification and subsequent treatment of sexual partners. While screening may be innately beneficial, without good communication and treatment follow-up, one may question the value of screening. In our setting, we have incorporated universal screening and empiric treatment as a method to eradicate infection in the short term. The benefit of patient notification and follow-up is the potential for educating for the long term, as well as expedited partner therapy. Lack of follow-up is pervasive in abortion care. We attempt to call patients three times and mail a certified letter to encourage follow-up for a positive result.

A known challenge in the termination setting is follow-up for care. In-person treatment may be a flawed strategy. Remote communication and treatment strategies may be an optimal way of effectively treating STIs for women who screen positive. Another challenge of implementing this screening protocol may be seen as cost-prohibitive to the termination clinic or the patient at the time; however, in the grand scheme of public health, this may prove to be cost-effective. The potential of the Affordable Care Act could make screening in such a setting more cost beneficial for the clinic or the patient.

In order to reduce post-abortal infections, perioperative prophylactic antibiotic coverage has been recommended routinely for surgical termination. The Society of Family Planning recommends the routine use of antibiotic prophylaxis, preferably doxycycline, before surgical termination.¹¹ Doxycycline is currently used by over 80% of US termination providers who use prophylactic antibiotics.¹² The current guidelines for post-abortal infection are not sufficient to adequately treat CT or GC infections. In settings with high prevalence, empiric treatment – treatment based on clinical experience and patient risk – might be a better option. In this way, the treatment serves two purposes: prophylactic (to prevent post-procedure infection) and empirical (to treat a possible CT infection).

For lack of faster turnaround of screening tests, our clinic opts to provide empiric therapy for Chlamydia, given the high rate, and targeted follow-up for patients with GC. Use of treatment doses of antibiotics with medical termination may decrease the risk of serious post-abortal infection, but universal requirement for such treatment has not been established. With routine prophylaxis of termination care, there is no indication that the presence of CT and GC increases their risk of immediate post-abortal infection.¹³ However, lack of treatment may place women at risk for PID from their baseline CT or GC infection in their future. STI screening for CT and GC at the time of termination may be an important opportunity to identify women at risk for continued infection and future PID. Due to our high rates of CT-positive women and a doxycycline shortage, we implemented empiric treatment for CT with 1 g of azithromycin to all women. While we do not know the long-term ramifications, all women who screen positive leave our center treated for their infection.

This study has several limitations. This study was conducted by a retrospective chart review of patients who had already undergone CT and GC testing before an elective, first-trimester surgical termination. Seventy-six surgical termination patients had missing values for CT and/or GC test results, most often because they denied testing. Due to the low percentage of patients with missing test results (<2% of our sample), we do not believe this will make a significant difference to the results. We also did not delete duplicate patients, i.e. those who came in for more than one termination during the time period. We did not delete these duplicated patients because patients receive STI testing and treatment after each termination, and thus a second positive should be considered another case and be counted in our prevalence rates. Differences between patients who receive or select medical terminations versus surgical were not assessed because during the study period, patients who received medical terminations did not routinely receive STI testing on the day of the procedure due to lack of additional staff necessary for specimen collection. Lastly, the compared time frames are of different lengths. The 2006 data are from a six-month time period, whereas the 2014 data are from a full year. Due to this, we do not capture a full year’s prevalence rate in 2006 and cannot account for possible seasonality trends or variation of CT and GC, or termination rates.

Given the direction of public health initiatives and the Affordable Care Act, consideration of better STI screening in termination clinics may be beneficial. High prevalence of CT/GC may also suggest higher than normal rates of other STIs, including hepatitis B, hepatitis C, syphilis, and HIV. Perhaps limiting to just CT/GC, while a step in the positive direction, may be a disservice for comprehensive care and this should be considered moving forward. Future research would also entail follow-up of treatment, reinfection, and prevalence of PID and surveillance of reinfection and assessing the cost-effectiveness and risk reduction of universal screening and empiric treatment in our population.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

Centers for Disease Control and Prevention. Infographic: sexually transmitted infections among young Americans, 2013. Available at: https://www.cdc.gov/nchhstp/newsroom/2013/sam-infographic-2013.html (accessed 11 January 2017).

Westrom

Joesoef

Reynolds

et al.

Pelvic inflammatory disease and fertility. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sex Transm Dis 1992; 19: 185–192.

Centers for Disease Control and Prevention. Chlamydia – CDC fact sheet (Detailed), http://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm#_ENREF_342015 (accessed 11 January 2017).

Scholes

Stergachis

Heidrich

et al.

Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996; 334: 1362–1366.

Stergachis

Scholes

Heidrich

et al.

Selective screening for Chlamydia trachomatis infection in a primary care population of women. Am J Epidemiol 1993; 138: 143–153.

Nelson

Zakher

Cantor

et al.

U.S. Preventive Services Task Force evidence syntheses, formerly systematic evidence reviews. Screening for gonorrhea and chlamydia: systematic review to update the US Preventive Services Task Force recommendations, Rockville, MD: Agency for Healthcare Research and Quality, 2014.

Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2012, Atlanta, GA: U.S. Department of Health and Human Services, 2012.

Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2011, Atlanta, GA: U.S. Department of Health and Human Services, 2011.

Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2010, Atlanta, GA: U.S. Department of Health and Human Services, 2010.

10.

Patel

Rashid

Godfrey

et al.

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae genital infections in a publicly funded pregnancy termination clinic: empiric vs. indicated treatment?

Contraception 2008; 78: 328–331.

11.

Achilles

Reeves

. Prevention of infection after induced abortion: release date October 2010: SFP guideline 20102. Contraception 2011; 83: 295–309.

12.

Lichtenberg

Paul

Jones

. First trimester surgical abortion practices: a survey of National Abortion Federation members. Contraception 2001; 64: 345–352.

13.

Sawaya

Grady

Kerlikowske

et al.

Antibiotics at the time of induced abortion: the case for universal prophylaxis based on a meta-analysis. Obstet Gynecol 1996; 87: 884–890.