The clinical correlates of genital Chlamydia infection in the era of nucleic acid testing

Abstract

The recent increase in the diagnosis of sexually transmitted infections and the introduction of Nucleic Acid Amplification Technique (NAAT) for Chlamydia trachomatis require redress of the clinical correlates. The increased awareness by the medical profession and public community, coupled with the sensitivity of the NAAT for Chlamydia leads to more diagnosis and the identification of conditions, which would have been labelled differently (e.g. cervicitis) or acquired a different diagnosis (non-specific urethritis). Our study indicates that 70% of women and 38% of men had additional genitourinary condition. This suggests that a patient presenting with Chlamydial infection requires assessment to exclude sexually associated conditions. The majority of patients (80% of women and 75% of men), diagnosed with Chlamydia presented with symptoms. On occasions, there may have been a contribution of symptoms from other associated infections. These findings relate with our semi-rural, mostly Caucasian and stable population. We expect a higher profile of sexually-related conditions with Chlamydia for patients in inner cities. A study for this group of patients is essential.

Keywords

genital Chlamydia infection clinical nucleic acid test

Introduction

The clinical recognition of genitourinary and/or systemic conditions presenting as a result of Chlamydial infection in the past, was dependant on the retrospective diagnosis of Chlamydia trachomatis in an identified clinical condition (e.g. urethritis, cervicitis, pelvic inflammatory disease [PID]).

The prospective identification of disease conditions, associated with chlamydial infection was hampered by several factors. The majority of patients presenting were mainly symptomatic, genitourinary practice was disease oriented and the complicated methods of investigation (including urethral swabs for men and speculum and intra-cervical swabs for women) led to reluctance in the public and medical communities to undertake investigation.¹ There is a lack of publications, in English literature that examines the clinical presentation of genital Chlamydial infection in the era of nucleic acid testing. The recent availability of Nucleic Acid Amplification Techniques (NAAT) lead to more testing and more diagnosis of genital Chlamydia and makes the study clinically relevant. The high sensitivity and specificity of the test would reflect on a better accuracy of analysis. Many cases identified in the past as non-specific cervicitis in women and urethritis in men, could have been associated with a positive Chlamydia test.²

Background and population

The genitourinary (GU) medicine clinic in Stafford provides Primary, Secondary and Tertiary care services for sexually transmitted infections (STIs) and sexual health. NAAT for C. trachomatis was introduced in June 2003 and was well established practice during the study period. The clinic provides services for semi-rural areas and two small towns of some 90,000 population each. The majority of the residents are Caucasian (over 99%). A Community Chlamydia Screening Programme was underway, but had not yet started during the study period.

The local population is relatively stable (when compared with similar groups of inner cities). The GU medicine patients’ social profile is relatively less stable (when compared with a similar local group, of non-GU medicine attendees). The assessment period coincided with national public awareness about STIs, with television and newspaper programmes reporting on STIs and GU medicine clinics. This reflected on some 20% increase in new patient attendees, as compared with the previous year. During the period between 2000 and 2005, the GU medicine department experienced a steep and gradual increase in the number of Chlamydia cases, from 110 to 505 (some fivefold increase). The majority of patients presenting to the GU medicine clinic request tests to exclude sexually transmitted conditions and, therefore, serology tests, for HIV, syphilis and hepatitis B, culture tests for gonorrhoea and NAAT for Chlamydia are offered to all patients.

Clinical experience suggests that some patients attend with the knowledge that the partner has had some kind of infection, although s/he does not know the diagnosis (i.e. being Chlamydia or otherwise). We suspect this could influence the incidence of those presenting with or without symptoms.

Material, Method and Analysis

(1)

We conducted a retrospective case note review of patients who reported positive for C. trachomatis by NAAT, during calendar year starting from September 2005. We identified patients’ subgroups, on clinical presentation and the final diagnosis of STIs and/or sexually-related conditions.

(2)

A total of 516 patients reported positive for Chlamydia, 247 men (47.87%) and 269 women (52.13%). Six patients were identified under the age of 15 and 13 patients above the age of 41; with 153 women (67.7%) and 73 men (32.3%) in the age group of 16–20 and 78 women (45%) and 95 men (54.9%) in the age group of 21–25 years, respectively. Sixty of the male patients (60/247) were asymptomatic (24.29%), and 56 of the women (56/269) were asymptomatic (20.88%). The rest of the two patient groups presented with symptoms (Table 1). On occasions, the presence of a secondary infection (e.g. gonorrhoea) would have contributed to these symptoms (e.g. discharge and dysuria).

Table 1

Symptoms, at the time of first presentation, for patients who were later diagnosed with Chlamydia

	Women (%)	Men (%)
Dysuria	25(9)	80 (32)
Discharge110	(40)	71 (28)
Partner treated for Chlamydia	58 (21)	62 (25)
Chlamydia diagnosed in primary care (GP/FP)	9	6
Contact tracing slip	15	5
Frequency	–	3
Inter-menstrual bleeding (IMB)	13	–
Post-coital bleeding (PCB)	20 (7)	–
Lower abdominal pain	10	–
Dyspareunia	16	–

GP/FP=general practice/family planning

(3)

We identified patients who came for assessment as a result of contact tracing of a partner with Chlamydia. There were 120 (23.25%) during the period, 62 (25%) were men and 58 (21%) were women.

(4)

Eighty male patients (32%) presented with dysuria, 71 (28%) with discharge, three with frequency of micturition, 73 had a history of girlfriend being treated for Chlamydia (five of whom had contact tracing slips for Chlamydia and six were referred by general practitioners following the diagnosis of Chlamydia. One male patient was referred via another GU medicine clinic).

(5)

One hundred and ten (40%) female patients complained of discharge, 25 (0.9%) of dysuria, 13 of inter-menstrual bleeding, 20 of post-coital bleeding, 10 of lower abdominal pain, 82 women had a history of a partner being treated for Chlamydia (15 had contact tracing slips for Chlamydia and nine were referred from family planning clinics, following the positive diagnosis of Chlamydia).

Observations

(1)

Clinicians and authors note a discrepancy between the current high prevalence of diagnosed cases of genital Chlamydia infections and the relatively low number of complications (e.g. PID) and sequelae as compared with what we have experienced in the past,³ with a plausible explanation. The general awareness of Chlamydia and its complications, over the past two decades, have led the public and medical communities to take active steps towards its investigation, early diagnosis and treatment. The improved technology and increased sensitivity of NAAT, and the ease with which test samples could be provided, would translate to the early treatment of the incumbent patient and consequently the prevention of complications. Changes in society and culture meant that casual sexual intercourse, short-term and multiple relationships, serial monogamous relationships, have all led to increased attendance at GU medicine clinics, with requests for investigations to rule out STIs. This pattern of social and medical changes would lead to early diagnoses and treatment; which would understandably circumvent progression to complications. The frequent attendance, testing, examination and treatment of the incumbent patient leads to the early interception of the cascade of infection and complications.

(2)

There is a contention that patients diagnosed with Chlamydia do not need any further assessment to exclude other STIs, and we examined the data to seek an answer. We observe that 51 sexually-related conditions were identified in 247 men and 179 were identified in 269 women (Table 2).

Table 2

Concomitant sexually-related conditions

	Women	Men
Gonorrhoea	31	25
Candidiasis	39	2
Warts	17	18
Bacterial vaginosis	77	–
Herpes genitalis	2	–
Molluscum contagiosum	1	3
Urinary tract infection	10	–
Trichomoniasis	1	–
Pelvic inflammatory disease	1
Balanitis	–	3
Total conditions	179	51

(3)

3) C. trachomatis was the sole diagnosis in 233 patients, with no other identifiable sexually-related condition (45.15%); 153 were men and 80 were women (62 and 30%, respectively).⁴ This indicates that 38% of male and 70% of female patients with Chlamydia have evidence of other sexually-related conditions and must be investigated.

(4)

Our data indicate that 25 male patients (10.12%) and 31 women (11.52%) had concomitant gonorrhoea.⁵

(5)

The clinic was successful in identifying and treating 250 partners, who were Chlamydia contacts of the study group (130 women and 120 men.⁶ This represents a success rate of contact tracing of 48.45%. We note that some 120 patients were initially referred as being sex partners of diagnosed Chlamydia cases, which influences the overall success rate.

(6)

Fifty-six (10.8%) patients declined serology tests (to exclude associated HIV, syphilis and/or hepatitis B).

(7)

There was no Chlamydia-associated PID or epididymo-orchitis in the study group.

Conclusions

C. trachomatis genital tract infection is more readily identifiable in women than in men, by a small margin (52.13% versus 47.87%). It is not possible to speculate on whether this is a reflection of better female patients’ presentation and seeking health care or higher incidence of Chlamydia in women (due to readiness of the vaginal receptacle to harbour the infection), or a combination of both.⁷

The majority of patients were symptomatic, in both sexes, 20.81% women and 24.29% men only were asymptomatic. Associated conditions, like gonorrhoea, would have had a recognizable contribution to symptoms, in most male and some female patients. Bacterial vaginosis would have contributed to the number of female patients presenting with discharge (which correlate with other studies).^3,8

We observe the low number of referral of patients diagnosed with Chlamydia from Community Care Services. This could be the result of the perception that a patient with Chlamydial infection does not need further tests to exclude other STIs.^{9

11} Notably, 25% of our GU medicine Chlamydia-positive male patients and 21% of women were also Chlamydia contacts.

Our examination of the possibility of associated genitourinary and sexually-related conditions identified 179 conditions in 269 women and 51 conditions in the 247 men. Chlamydia was the sole diagnosis for 153 men and 80 women. This indicates that 38% of men and 70% of women had additional genitourinary condition.^{12

15} and must be investigated. The association of 31 cases of gonorrhoea in women and 25 in men is significant in our population (as it comes from a very low incidence of gonorrhoea in our semi-rural population).

We note that there were no cases of syphilis, HIV and/or hepatitis B in the Chlamydia-positive patients during the period in question. As the numbers are relatively low in our semi-rural community, we do not propose extrapolating a clinical advice to reduce or eliminate serology tests for these patients. We believe that we have a duty of care to rule out STIs, including syphilis, HIV and hepatitis B, for patients who request assurance of the absence of STIs.

We would like to express reservation that these findings relate to our semi-rural, mostly Caucasian, relatively stable group of patients. We do not expect the findings to be similar to those of inner cities, mixed ethnic populations or socially unstable client groups. We suspect that the incidence of sexually-related conditions in association with Chlamydia are higher for these groups of patients. Similar studies for these groups of patients are necessary and urgently required, to streamline practice with evidence-based medicine.

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