Managing contacts of chlamydia: should clinics implement a test and wait process?

Abstract

British guidelines recommend epidemiological treatment for all chlamydia contacts during the look back period. Some UK sexual health clinics follow a test and wait process for chlamydia contacts presenting after 14 days of exposure. The aim of this retrospective service evaluation was to determine the potential impact of implementing such a process for chlamydia contacts at our clinic. We reviewed the patient records of 548 chlamydia contacts over a 1-year period, and 588 patients with chlamydia over a 5-month period. Demographic and clinical characteristics data were collected.

Chlamydia prevalence was 46% (254/548) in contacts, with prevalence varying by age (p=.008) and sexual risk (p=.04), but not by time since exposure (p=.29). For patients with chlamydia, there was a mean of 1.9 days between results notification and attending for treatment; a mean of 2.2 attempts were required to contact patients to return for treatment. Chlamydia prevalence in contacts is high. Not giving empirical treatment to contacts presenting after 14 days of exposure would result in 13.1% of the cohort needing to return for treatment. Patients found to have chlamydia returned promptly once informed of positive results.

Keywords

Chlamydia Europe treatment sexual contacts

Introduction

In England, sexual health services are provided free to all patients at the point of access and are funded via local government public health budgets.¹ The British Association for Sexual Health and HIV (BASHH) is the UK professional body for clinicians practicing in sexual health and HIV. As part of the remit of BASHH to improve the practice of managing sexually transmitted infections (STIs),² they set look-back intervals for partner notification in STIs. The look-back interval is defined as the time during which an index case may have been infectious and transmitted infection, and should be applied to all contacts whether or not condoms were used.³ BASHH sets the look-back period for partner notification of chlamydia infection as from four weeks prior to the onset of symptoms for male index cases with urethral symptoms, and as from six months prior to presentation for all other patients. Epidemiological treatment for all partners within the look-back period is recommended.³,⁴ This advice is similar to that found in European chlamydia guidelines where treatment for all partners from six months prior to presentation of the index patient is advised.⁵,⁶ In contrast, the Centers for Disease Control and Prevention of the United States of America advises epidemiological treatment for all partners from 60 days prior to presentation or symptom onset, and the most recent partner from prior to this if there are no partners within the 60-day time frame.⁷

The BASHH gonorrhoea guidelines published in 2011 recommended epidemiological treatment to all contacts in the look-back period.⁸ However, in an attempt to improve antibiotic stewardship, these guidelines were revised in 2019 and now recommend that those presenting as contacts of gonorrhoea after the two-week nucleic acid amplification test (NAAT) window period, should be tested and await results rather than being offered epidemiological treatment.⁹ Despite there being no such update to the UK chlamydia guidelines, some sexual health clinics within the UK have also similarly modified their pathway for chlamydia contacts, and recommend a test and wait process for such contacts presenting after 14 days of exposure.

Antibiotic stewardship has become of increasing concern in sexual health, particularly when managing gonorrhoea and Mycoplasma genitalium infections, due to evolving antibiotic resistance.¹⁰ Antibiotic resistance has not been a significant issue when managing chlamydia, and tetracyclines and macrolides remain highly effective in treating uncomplicated chlamydial infection. In vitro antibiotic resistance in Chlamydia trachomatis, when described, remains as a small number of case reports only, with uncertain epidemiological relevance.¹⁰ However, antibiotic resistance has been seen in other Chlamydia species, and so ongoing vigilance in cases of treatment failure is required.¹¹ Furthermore, STIs do not exist in isolation. Antibiotic recommendations for the treatment of chlamydia continue to be made¹² without considering the impact of antibiotic resistance evolution on other potential co-infections such as M. genitalium.¹³ Decisions over whether to treat contacts at presentation must weigh up potential benefits in antibiotic stewardship against potential clinical consequences in delaying treatment, recognising that there may be cost implications additionally.

The aim of this service evaluation was to determine the potential impact of implementing a test and wait process for patients presenting as contacts of chlamydia after 14 days of exposure at our large urban UK sexual health clinic. Our integrated sexual health service provides level 3 STI management including complex and specialist care, and level 2 sexual and reproductive care as defined by suggested national service specifications in England.¹ Our clinic is located in Liverpool, a city in the north west of England with a population of 498,000 people, and is one of the most deprived areas in the UK.¹⁴,¹⁵ We have over 30,000 patient attendances each year. The objectives of the evaluation were to determine the prevalence of chlamydia in chlamydia contacts, to determine the time to treatment in patients with chlamydia not treated on the day, and to estimate the costs to the clinic of a change to a test and wait process.

Method

Chlamydia contacts

For this service evaluation, a retrospective review of the electronic patient records of all chlamydia contacts presenting to our large urban UK sexual health service in 2018 was undertaken.

Inclusion criteria were contacts identified using the Genitourinary Medicine Clinic Activity Dataset (GUMCAD, the mandatory surveillance system for STIs in England) code PNC (chlamydia contact). Patients who were incorrectly coded as chlamydia contacts after review of the patient record were excluded.

Demographic data including gender, age at diagnosis, sexuality and ethnicity were extracted from the electronic patient records. Clinical characteristics data were also collected including time in days since sex with the reported index case, whether epidemiological treatment was accepted for chlamydia and if not the reason for declining this, the number of partners in the previous three months including the index case, and the chlamydia NAAT results at each mucosal site. In patients declining epidemiological treatment, the time to treatment in days and the number of attempts to recall for treatment were also extracted. Time since sex with the index case is recorded as a specific variable in our patient record.

Data were extracted by five members of the clinical team with double checking of 10% of data and any incomplete data by a further clinical team member.

Patients with chlamydia

A further retrospective review of the electronic patient records of all patients with chlamydia presenting over a 5-month period in 2018 was undertaken. Inclusion criteria were patients identified as having chlamydia using GUMCAD codes C4 (chlamydia), C4R (rectal chlamydia) and C4O (pharyngeal chlamydia). Patients incorrectly coded as having chlamydia after review of the NAAT results were excluded.

Demographic data were extracted from the electronic patient records as for chlamydia contacts. Clinical characteristics data were collected including whether the patient was symptomatic, chlamydia NAAT results at each site, the date the patient was informed of results, the date the patient attended for treatment including those treated on the day, and the antibiotic regimen given. The number and methods of patient follow up required to facilitate treatment following diagnosis were collected including texts, phone calls, letters, and face to face appointments. Over the 12 months following the chlamydia diagnosis, the number of new attendances, and any diagnoses of pelvic inflammatory disease and epididymo-orchitis were extracted.

Data were extracted by two members of the clinical team with double checking of 10% of data and any incomplete data by a further clinical team member.

Cost estimates

Potential costs of treatment for chlamydia were estimated using the cost to the clinic of providing a 7-day course of doxycycline 100 mg BD (£3.86). The cost of an appointment was estimated using the payment tariff to the clinic which is on a Payment by Results contract (where the clinic is paid for work done) with a cost of £135.00 for a new patient appointment, and £105.00 for a follow-up appointment. The cost of attempts to contact the patient to give results, were based on estimating the cost of an SMS (short message service or text) message based on 5 minutes of a band 6 nurse practitioner’s (senior staff nurse) time at £2.50. Chlamydia contacts without time since exposure data available were excluded from the cost estimate calculations.

The cost of treating all contacts at presentation (current clinic policy as recommended by UK guidance)³,⁴ was estimated as: (cost of initial appointment + cost of a 7-day course of doxycycline 100 mg BD + cost of SMS to provide results to the patient) × the number of contacts. The cost of a test and wait policy for contacts presenting after 14 days of exposure was estimated as follows: cost of treatment of all contacts presenting < 14 days ([cost of initial appointment + cost of a 7-day course of doxycycline 100 mg BD + cost of SMS for results] × the number of contacts presenting < 14 days) + cost of screening all contacts presenting > 14 days ([cost of initial appointment + cost of SMS for results] × number of contacts presenting > 14 days) + cost of treating all contacts presenting >14 days with confirmed chlamydia ([cost of follow up appointment + cost of doxycycline course + number of addition SMS required to recall patient for treatment] × number of contacts presenting > 14 days with confirmed chlamydia).

Potential costs were calculated for numbers of chlamydia contacts as analysed above. Those missing the patient record variable for time since sex with the index case, or where it was not possible to determine which partner from the previous 3 months was the index case were excluded from cost estimates.

Statistical analysis

Data recording and analysis were undertaken using Microsoft Excel 2010. Demographic data analyses were undertaken using simple percentages. To determine the prevalence of chlamydia in chlamydia contacts, those with a positive NAAT at one or more sites (pharynx, urine in males, vulvo-vaginal in females, or rectal) were considered as having chlamydia, and prevalence was compared by age category, time since exposure and sexual risk. Time to treatment in days was compared for patients with chlamydia not treated on the day versus those treated on the day of presentation. P values were calculated using chi-squared test.

This service evaluation was approved by the Trust’s Audit Department.

Results

Chlamydia contacts

5 patients were excluded as incorrectly coded as chlamydia contacts. 548 chlamydia contacts were identified in the 1-year evaluation period, with an overall chlamydia prevalence of 46% (254). Time since exposure to the index case was recorded in 86% (472) contacts and demographic data for all contacts and those recorded as presenting within and after 14 days of exposure is shown in Table 1.

Table 1.

Demographic data of chlamydia contacts presenting within and after 14 days of exposure.

	All contactsN = 548	Presenting within 14 days of exposureN = 305	Presenting after 14 days of exposureN = 167
Chlamydia prevalence	254 (46%)	147 (48%)	72 (43%)
Gender
Male	388 (71%)	192 (63%)	120 (72%)
Female	160 (29%)	113 (37%)	47 (28%)
Ethnicity
White British	468 (85%)	266 (87%)	135 (81%)
Black African		7 (3%)	5 (3%)
Sexuality
Heterosexual	473 (86%)	271 (89%)	146 (87%)
MSM		34 (11%)	21 (13%)
Age
Mean age (range)	27 years (16–77 years)	26 years (16–62 years)	31 years (23–77 years)
Patients <25 years	275 (50%)	159 (52%)	4 (2%)
Mean number of partners in last 3 months (range)	1.9 (0–25)	1.7 (1–9)	1.8 (0–22)
Mean number of partners in last 3 months (range)	Data available for 460 contacts (84%)	Data available for 279 contacts (91%)	Data available for 150 contacts (90%)

Those aged under 25 years of age were more likely to have chlamydia than those 25 years or older (52%, 143/275 versus 41%, 111/273 respectively, p = .008). There was no difference in chlamydia prevalence by time since exposure: 48% (147/305) within 14 days and 43% (72/167) after 14 days (p = .29), but prevalence varied by sexual risk: women 51% (81/160), heterosexual men 47% (149/319) and men who have sex with men 33% (23/69, p = .04).

Epidemiological treatment was offered to all contacts in line with BASHH guidance,³,⁴ and accepted by 98% (537) patients.

Patients with chlamydia

588 patients were identified with chlamydia during the 5-month evaluation period. The majority of patients were male (318, 54%), white British (476, 81%), and heterosexual (504, 86%) and 13% (75) presented as chlamydia contacts. Mean age was 26.5 years (range 14–76 years), with 52% (307) patients aged under 25 years of age.

46% (270) patients were treated for chlamydia at initial attendance either due to being a chlamydia contact, or because they presented with non-gonococcal urethritis (NGU), with 53% (309) treated at follow-up; 2% (9) patients were lost to follow-up prior to treatment. Of symptomatic patients not presenting as contacts, males were more likely to be treated at initial presentation than females (76%, 87/114 versus 21%, 19/91 respectively, p<.001) as they were often treated as NGU whilst NAAT results. The majority of patients were treated with a 7-day course of doxycycline 100 mg BD (86%, 499), or with azithromycin 1 g as a single dose (13%, 77) (as per the BASHH chlamydia guidelines at the time,⁴ but now superseded with azithromycin 1 g as a single dose, followed by 500 mg OD for two days).¹⁶

There was a mean of 7.5 days between presentation and treatment for those not treated initially, and of 1.9 days between results notification and attending for treatment. A mean of 2.2 attempts were required to contact patients to return for treatment. Patients who were not treated on the day had a mean of 1.1 new attendances at sexual health clinic over the next 12 months in comparison to 0.6 new attendances in those treated on the day.

In the subsequent 12 months, 2 patients represented with epididymo-orchitis (both treated at initial presentation), and 4 patients represented with pelvic inflammatory disease (2 treated at initial presentation).

Cost estimates

The cost of a test and wait policy for contacts presenting after 14 days of exposure was £157.06 per contact, in comparison with £140.41 per contact when all contacts are treated at presentation as shown in Table 2. This increase of £16.65 per contact, accounts for an increased number of follow-up appointments, and equates to increased costs to the clinic of £7,858.80 for the entire contact cohort per annum.

Table 2.

Financial implications of implementing a test and wait policy for contacts presenting after 14 days of exposure with time since exposure data available (N = 472).

Financial implications	Treat all contacts at presentation	Test and wait policy for contacts presenting after 14 days of exposure
Equation	(Cost of initial appointment + cost of doxycycline + cost of SMS for results) × the number of contacts	([Cost of initial appointment + cost of doxycycline + cost of SMS for results] × the number of contacts presenting < 14 days) + ([cost of initial appointment + cost of SMS for results] × number of contacts presenting > 14 days) + cost of treating all contacts presenting >14 days with confirmed chlamydia ([cost of follow up appointment + cost of doxycycline + cost of SMS to recall patient for treatment] × number of contacts presenting > 14 days with confirmed chlamydia).
Calculation	(£135.00 + £3.86 + £2.50) × 472	([£135 + £3.86 + £2.50] × 305) + ([£135 + £2.50] × 167) + (£105.00 + £3.86 + [1.2 × £2.50] × 72)
Total	£66,271.92	£74,131.22
Total per contact	£140.41	£74,131.22 / 472 = £157.06

Discussion

Chlamydia prevalence in contacts was high at 46%, and especially so in those aged under 25 years where over half of contacts had chlamydia infection. Those under 25 years of age, women and heterosexual men were all more likely to have chlamydia infection (p = .008 and .04 respectively). STI surveillance data from England and Wales also demonstrates increased prevalence in young people and women.¹⁷

A 2018 UK single centre audit of chlamydia contacts at a sexual health clinic over 5 months found a chlamydia prevalence of 64% in 102 contacts with a prevalence of 87% in those who were symptomatic and 57% in those who were asymptomatic at presentation.¹⁸ Although chlamydia prevalence was higher than in our study, their population appears broadly similar with 73% of patients being male, and 92% heterosexual. The authors concluded that antibiotics were best delayed until a laboratory-demonstrated diagnosis was available. A 2017 single centre audit in Australia of 100 asymptomatic contacts of STIs was undertaken on a very different population consisting of 97% MSM or bisexual men.¹⁹ 59 patients reported contact with chlamydia but only 7 had a confirmed NAAT diagnosis giving a prevalence of 12% in contacts, and the clinic has subsequently halted its use of empiric antibiotics for the treatment of STI contacts.

Implementing a test and wait policy which avoids empirical treatment of contacts presenting after 14 days of exposure would result in 16% (72/460) of the cohort needing to return for treatment. The potential clinical impact of untreated chlamydia infection is well defined, with increased risks of pelvic inflammatory disease, tubal infertility, ectopic pregnancy, and chronic pelvic pain, with prolonged exposure considered a major contributing factor for tubal tissue damage.^20–23 There are further risks of onwards transmission of untreated chlamydia from a cohort with high infection prevalence. Studies have demonstrated that high partner numbers may be associated with an early return to sex after treatment for chlamydia,²⁴ and although contacts in our study had a mean of 1.9 partners in the previous 3 months, the range included up to 25 partners. Rapid partner treatment has been shown to reduce reinfection of the index case, but modelling suggests that even a 3-day delay in partner treatment after treatment of the index case results in a 4.2% probability of reinfection.²⁵ Furthermore, there are psychosocial burdens of being diagnosed with an STI²⁶ which may be increased by delayed treatment.

However, in our review, once patients were notified of their positive result, they returned rapidly to clinic (within a mean of 1.9 days) with the majority of the total delay of a mean of 7.5 days being due to laboratory time. Numbers of potentially related adverse clinical events in the following year were too low to draw any conclusions, and may well be an underestimate as we only considered patients re-presenting to sexual health. The increasing use of rapid diagnostics in sexual health care may resolve many issues around time to treatment of contacts.²⁷ However, at present such point-of-care tests for chlamydia continue to be limited by time to result, limiting their utility as patients are unprepared to wait in clinic for results.²⁸,²⁹ Clinics should consider the use of alternative treatment pathways which have been demonstrated to be acceptable to or even preferred by patients, including rapid diagnostics followed by postal provision of medications.³⁰,³¹

There are potential small cost implications to clinic of changing policy to a test and wait process for those presenting after 14 days of exposure, which we estimate as £16.65 per contact. There are a number of limitations to these results - time since exposure was only available for 472/548 (86%) of chlamydia contacts, with those without these data available excluded. The use of a Payment by Results Tariff to calculate clinic costs may not reflect actual clinic costs, and we based recall expenses on SMS costs, but telephone consultations may also be required. Cost estimates are complex and will vary with local clinic structures and policies. A move to postal treatment would reduce costs of a follow-up appointment; however, this may actually result in a financial loss to a clinic on a Payment by Results Tariff. Moreover, a follow-up appointment may provide an opportunity to provide other opportunistic services including emergency or on-going contraception. Furthermore, the cost and inconvenience balance of the potential pathways to the patient and patient attitudes, are beyond the scope of this paper (and rarely considered when decisions around health service provision are made), but also need to be accounted for when treatment pathways are determined.

Antibiotic stewardship is a matter of significant concern in medicine including within sexual health,³² and has been identified as a key priority in the UK.³³ Doxycycline is not recommended in the UK as part of post-exposure prophylaxis in an attempt to avoid unknowable risks associated with potentially widespread, un-prescribed and unmonitored use of a tetracycline antibiotic, with significant potential to select resistance in STI pathogens and other species.³⁴ Beyond antibiotic resistance, unnecessary antibiotics carry further risks to patients including increased risk of complications, adverse events, and mortality rate.³⁵ Furthermore, the widespread potentially unnecessary use of antibiotics may impact on patients’ expectations and providers’ attitudes to prescribing.³⁶,³⁷ Much research around the management of chlamydia contacts has focussed on expedited partner therapy in order to reduce time to treatment,³⁸,³⁹ but it may be of more value to focus on expedited testing rather than epidemiological treatment in order to improve antibiotic stewardship.

There are a number of limitations to our study. The study is a single centre study in the UK and therefore cannot be considered to be representative of other centres. A previous smaller UK study found a higher prevalence of chlamydia in contacts which may affect outcomes.¹⁸ Our study is further limited by our specific clinic model of return to clinic for treatment which has since changed in the urgent clinic restructuring due to social distancing requirements as a result of COVID-19. Cost estimates are therefore difficult to extrapolate to other centres with different treatment models, and further research should focus on cost effectiveness of different service models,⁴⁰ especially given the radical changes to service provision for STIs and resultant opportunities for service improvement as a result of COVID-19.⁴¹

In conclusion, chlamydia is common in chlamydia contacts and implementing a test and wait pathway for contacts presenting after 14 days of exposure would result in 16% of the cohort requiring later treatment. The resultant delays could be partially offset by improving clinic pathways with the adoption of rapid diagnostics and postal treatment. Antibiotic stewardship benefits in avoiding unnecessary antibiotics is a key benefit of such a policy change, but must be balanced against potential risks for transmission, complications, loss to follow up, and cost.

Footnotes

Declaration of conflicting interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Emily Clarke

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