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Vol. 40. Issue 7.
Pages 359-366 (August - September 2022)
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513
Vol. 40. Issue 7.
Pages 359-366 (August - September 2022)
Original article
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Clinical and epidemiological characteristics of Chlamydia trachomatis infection among sexually transmitted infection clinics patients
Características clínicas y epidemiológicas de la infección por Chlamydia trachomatis en pacientes de consultas de infecciones de transmisión sexual
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Josefina López-de Munaina,b,
Corresponding author
, Maria del Mar Cámara-Péreza, Miriam López-Martineza, Jose Angel Alava-Menicac, Leonora Hernandez-Ragpac, Manuel Imaz-Pérezc, Maria José Tejeiro-Pulidoa, Iker Mojas-Díeza, Mireia de la Peña-Triguerosa, Jose Luis Díaz-de Tuesta-del Arcoc, Josefa Muñoz-Sáncheza,b
a Servicio de Enfermedades Infecciosas, Hospital Universitario Basurto (OSI Bilbao-Basurto, Osakidetza), Bilbao, Spain
b Instituto de Investigación Biocruces, Bizkaia, Spain
c Servicio de Microbiología Clínica y Control de Infección, Hospital Universitario Basurto (OSI Bilbao-Basurto, Osakidetza), Bilbao, Spain
Related content
Enferm Infecc Microbiol Clin. 2022;40:349-5210.1016/j.eimce.2022.01.002
Manuel Rosa-Fraile, Juan-Ignacio Alós
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Abstract
Background

Chlamydia trachomatis (CT) infections are a public health problem because of its high incidence and consequences on reproductive health. Our aim is to describe the socio-demographic, behavioral and clinical characteristics of patients with CT infection in order to adapt preventive interventions for the highest risk groups.

Methods

Prospective case series of all patients diagnosed with CT between September 2016 and January 2019 in the reference STI clinics of Osakidetza (Basque Health Service) in Bizkaia (Spain).

Results

847 patients (88.2%) agreed to participate: 41% women, 33.8% heterosexual men and 25% men who has sex with men (MSM); 33% were immigrants and 26% were under the age of 25 (33% of the women). Only 20% systematically used condoms. 36% had previously had STI and 28% had simultaneously another STI. 55% of the infections were asymptomatic (70% among women). In MSM, the rectum was affected in 69.5% of cases, the urethra in 31.4%, and the pharynx in 14.5%. The cervix was affected in 86.5% of the women, the rectum in 17.6%, and the pharynx in 13.8%. A contact study was only carried out in 58% of cases. The reinfection rate at 4 weeks was 17% among those with criteria to perform a test of cure.

Conclusion

Our results justify implement opportunistic screening in women under the age of 25 and young immigrants of both sexes, by taking genital and extragenital samples, as well as developing appropriate guidelines for the notification and follow-up of contacts.

Keywords:
Chlamydia trachomatis
Epidemiology
Sexual behaviors
Asymptomatic infections
Screening
Sexually transmitted infections
Resumen
Introducción

Las infecciones por Chlamydia trachomatis (CT) son un problema de salud pública por su alta incidencia y consecuencias sobre la salud reproductiva. Nuestro objetivo es describir las características sociodemográficas, conductuales y clínicas de los pacientes con infección por CT para adaptar las intervenciones preventivas a los grupos con mayor riesgo.

Métodos

Serie de casos prospectiva de todos los pacientes diagnosticados de CT entre septiembre 2016-enero 2019 en las consultas de referencia para infecciones de transmisión sexual (ITS) de Osakidetza en Bizkaia.

Resultados

Aceptaron participar 847 pacientes (88,2%): 41% mujeres, 33,8% varones heterosexuales y 25% hombres que tenían sexo con hombres (HSH); 33% eran inmigrantes y 26% menores de 25 años (33% entre las mujeres). Utilizaban siempre preservativo un 20%. Un 36% habían tenido ITS anteriormente y 28% tenían otra ITS simultánea. El 55% de las infecciones fueron asintomáticas (70% entre las mujeres). El recto fue la localización más frecuente entre los HSH (69,5%), seguida de la uretra (31,4%) y faringe (14,5%). En las mujeres, la infección afectó principalmente el cérvix (86,5% de los casos), seguido del recto (17,6%) y faringe (13,8%). Se estudió a los contactos del 58% de los pacientes. La tasa de reinfección a las 4 semanas fue del 17% entre aquellos con criterios para realizar un test de cura.

Conclusión

Estos resultados justifican la implantación de cribados oportunistas en mujeres menores de 25 años e inmigrantes jóvenes de ambos sexos, con toma de muestras genitales y extra-genitales, y establecer guías apropiadas para la notificación de contactos.

Palabras clave:
Chlamydia trachomatis
Epidemiología
Conductas sexuales
Infecciones asintomáticas
Cribado
Infecciones de transmisión sexual
Full Text
Introduction

Chlamydia tracomatis (CT) infections are a relevant public health problem due to their high incidence and consequences on reproductive health: pelvic inflammatory disease, ectopic pregnancy, tubal infertility, chronic pelvic pain and other complications.1

The incidence of CT in Spain in 2019 was 44.18/100,000 people, with women aged 20–24 being the most affected (343.64/100,000).2 These figures are below those of the European Union as a whole (146/100,000), but it must be taken into account that notification of such cases to the Red Nacional de Vigilancia Epidemiológica [National Epidemiological Surveillance Network] is not yet implemented throughout the country. The countries with the highest rates, such as the United Kingdom (365/100,000) or Denmark (578/100,000), have screening programmes or generalised opportunistic screening systems, which do not exist in Spain.3 CT prevalence studies conducted in Spain in the last decade have focused mainly on young people, with estimates ranging from 4.1% to 8.5%.4–7

Regarding lymphogranuloma venereum (LGV), it has become an endemic infection since the first case was published in Spain in 2005, mainly affecting men who have sex with men (MSM) with high rates of co-infection with human immunodeficiency virus (HIV).8

Strategies for the control of sexually transmitted infections (STIs) must be based on the local epidemiological situation, which is why we carried out this study, the objective of which was to describe the sociodemographic, behavioural and clinical characteristics of patients with CT infection in Biscay to be able to adapt our primary and secondary prevention interventions to the groups with the highest risk of acquiring this STI.

Materials and methods

A descriptive study of proportional morbidity of a prospective case series, made up of all patients diagnosed with CT infection between September 2016 and January 2019 in the referral STI clinics in Osakidetza, in Biscay. These clinics serve the population of Biscay (1,152,651 inhabitants). The study was approved by the Clinical Research Ethics Committee of the Basque Country and the participants signed an informed consent form.

Following the usual care protocol, all patients (symptomatic or asymptomatic) who attended the clinics underwent a complete STI screening, which included serology for HIV, syphilis, hepatitis B and C, and taking samples from all the sites susceptible to infection: in MSM, from the pharynx, rectum and urethra; in heterosexual men, from the urethra; and in women, from the pharynx, vagina, endocervix, rectum (in case of anal intercourse) and urethra (if endocervical samples could not be taken). Samples of any lesions were also taken.

For the microbiological study, both culture and molecular biology techniques were used. For the Neisseria gonorrhoeae culture, the GC-Lect plate (BD GC-Lect Agar, Becton Dickinson, Heidelberg/Germany) was used and for the Trichomonas vaginalis culture, a Roiron medium (Difco, Sentmenat, Barcelona, Spain) was used. Molecular biology techniques were performed with the BD MAX CT/GC/TV2 real-time nucleic acid amplification (Becton Dickinson, Heidelberg/Germany) that simultaneously detects CT, N. gonorrhoeae and T. vaginalis in urine samples and endocervical, urethral, pharyngeal and rectal smears sent in universal transport medium (Copan). In CT-positive samples from MSM, regardless of the site, and in positive rectal samples from women, the presence of CT biovar L was studied using the RealCycler CHSL (Progenie) real-time polymerase chain reaction (PCR) technique that detects a specific sequence of the gene pmpH. For the detection of herpes simplex virus, RealCycler Monotest, herpesvirus type 1 + herpesvirus type 2 + varicella-zoster virus (Progenie Molecular, Valencia, Spain) was used in samples sent in universal transport medium (Copan).

The only inclusion criterion was having a CT isolate, and the exclusion criteria were being a temporary visitor to the region and/or not knowing the language which made it difficult to understand the informed consent.

The treatments were adjusted to the recommendations of the clinical practice guidelines.9,10 Patients were informed of the need to abstain from sexual relations for the necessary time and of the reasons for studying their sexual contacts. The contacts were notified through the index case, and were offered appointments to be seen within a maximum period of one week. A follow-up visit was scheduled for all of them to verify the remission of symptoms, check the study of contacts and perform a test of cure (TOC) in case of persistence of symptoms, suspected re-exposure, poor adherence to treatment, pregnancy and rectal infections treated with azithromycin.9,10 In suspected re-exposure and in pregnant women, samples were taken again from all sites susceptible to infection, while in the rest of the cases they were only taken from the initially affected sites. A positive TOC result was considered a reinfection when more than four weeks had passed since treatment,9–13 adherence to treatment had been good, and re-exposure was suspected.

The study variables were collected and entered in real time by the physicians in an electronic database designed for the project. Sexual orientation in men was categorised as MSM and MSW (men who only have sex with women). The women who agreed to participate had sexual relations only with men. Cases with urethral or rectal discharge, leukorrhea, dysuria, urethral discomfort, testicular pain, proctalgia, lower abdominal pain, dyspareunia, postcoital bleeding or pharyngeal discomfort were considered symptomatic.

Analysis

Measures of central tendency and dispersion were calculated for the quantitative variables and proportions for the categorical ones, with their 95% confidence intervals. Comparisons between subgroups were made using Student's-t and X2 tests. Factors associated with condom use, suspected re-exposure, and the study of contacts were identified by unconditional multiple logistic regression analysis. Statistical analyses were performed with SAS v9.4 (SAS Institute, Cary, NC, USA).

Results

During the 29 months of the study, 960 patients with CT infection were treated. Of these, 54 (5.6%) refused to participate, 18 (1.9%) were excluded because they were temporary visitors or due to a language barrier, and 40 (4.2%) could not be invited to participate because they did not return to the clinic. In total, 847 patients (88.2%) agreed to participate. No significant differences were observed in terms of sex, age or country of origin between those who agreed and those who refused or those who could not be invited to participate.

Demographic and behavioural characteristics

Most of the infections corresponded to men (58.9%), but when stratifying by sexual orientation, women ranked first (41.1%), followed by MSW (33.77%) and MSM (25.15%) (Table 1).

Table 1.

Demographic and behavioural characteristics of patients with Chlamydia trachomatis infection.

  Total (847)Men (499, 58.9%)  Women (348, 41.1%)
        MSM (213, 25.1%)MSW (286, 33.8%)       
  95% CI  95% CI  95% CI  p Valuea  95% CI  p Valueb 
Age
16−19  52/847  6.14  4.6−7.9  6/213  2.82  1.04−6.03  14/286  4.90  2.7−8.0  0.3654  32/348  9.2  6.3−12.7  0.0091 
20−24  168/847  19.83  17.2−22.7  33/213  15.49  10.9−21.0  51/286  17.83  13.6−22.8    84/348  24.14  19.7−29.0   
≥25  627/847  74.03  70.9−76.9  174/213  81.69  75.8−86.6  221/286  77.27  71.9−82.0    232/348  66.67  61.4−71.6   
Immigrant
Yes  277/847  32.7  29.5−36.0  53/213  24.88  19.2−31.2  92/286  32.17  26.8−37.9  0.0762  132/348  37.93  32.8−43.2  0.1309 
Stable partner
Yes  531/846  62.77  59.4−66.0  93/213  43.66  36.9−50.6  193/286  67.48  61.7−72.8  <0.0001  245/347  70.61  66.5−75.3  0.3971 
Partners in last monthc
Average  1.35  ----  1.26−1.45  2.08  ---  1.76−2.39  1.26  ---  1.13−1.39  <0.0001  1.0  ----  0.9−1.07  0.0003 
Partners in last 3 monthsc
Average  2.60  ----  2.32−2.88  5.44  ---  4.43−6.45  1.97  ---  1.77−2.18  <0.0001  1.48  ----  1.37−1.6  <0.0001 
Partners in last yearc
Average  6.99  ----  5.50−8.48  18.11  ---  12.3−23.9  4.0  ---  3.47−4.52  <0.0001  2.92  ----  2.5−3.3  0.001 
Time with partner
<1 month  26/517  5.03  3.3−7.3  1/93  1.08  0.03−5.8  15/189  7.94  4.5−12.7  <0.0001  10/235  4.26  2.06−7.69  0.2421 
1−6  165/517  31.91  27.9−36.1  17/93  18.28  11.0−27.6  70/189  37.04  30.1−44.3    78/235  33.19  27.2−39.6   
6−12  81/517  15.67  12.6−19.1  6/93  6.45  2.4−13.5  29/285  15.34  10.5−21.3    46/235  19.57  14.7−25.2   
>12  245/517  47.39  43.0−51.8  69/93  74.19  64.0−82.7  75/285  39.68  32.6−47.0    101/235  42.98  36.5−19.5   
Condom with regular partner
Genital/anal sex
Always  51/521  9.79  7.4−12.7  14/88  15.91  8.9−25.2  15/191  7.85  4.4−12.6  0.0445  22/242  9.09  5.8−13.4  0.6607 
Sometimes  90/521  17.27  14.1−20.8  18/88  20.45  12.6−30.4  29/191  15.18  10.4−21.0    43/242  17.77  13.2−23.2   
Never  380/521  72.94  68.9−76.7  56/88  63.64  52.7−73.6  147/191  76.96  70.3−82.7    177/242  73.14  67.1−78.6   
Oral sex
Always  3/518  0.57  0.12−1.65  2/92  2.17  0.26−7.6  0/192  ----  0.0090  1/244  0.41  0.01−2.26  0.7408 
Sometimes  2/528  0.38  0.05−1.36  0/92  ----  1/192  0.52  0.01−1.54    1/244  0.41  0.01−2.26   
Never  487/528  92.23  89.6−94.3  90/92  97.83  92.4−99.7  177/192  92.19  87.4−95.5    220/244  90.16  85.7−93.6   
Does not practise  36/528  6.82  4.8−9.3    14/192  7.29  4.0−11.9    22/244  9.02  5.7−13.3   
Condom with casual partners
Genital/anal sex
Always  239/621  38.49  34.6−42.4  116/191  60.73  53.4−67.7  58/211  27.49  21.5−34.0  <0.0001  65/219  29.68  23.7−36.2  0.6676 
Sometimes  224/621  36.07  32.3−40.0  64/191  33.51  26.8−40.6  83/211  39.34  32.7−46.3    77/219  35.16  28.8−41.9   
Never  158/621  25.44  22.0−29.0  11/191  5.76  2.9−10.0  70/211  33.18  26.8−39.9    77/219  35.16  28.8−41.8   
Oral sex
Always  12/645  1.86  0.96−3.23  3/200  1.50  0.31−4.3  5/220  2.27  0.74−5.22  0.0037  4/225  1.78  0.49−4.5  0.9473 
Sometimes  14/645  2.17  1.2−3.6  3/200  1.50  0.31−4.3  5/220  2.27  0.74−5.22    6/225  2.67  0.98−5.7   
Never  571/645  88.53  85.8−90.8  190/200  95.00  91.0−97.5  187/220  85.00  79.6−89.7    194/225  86.22  81.0−90.4   
Does not practise  48/645  7.44  5.5−9.7  4/200  2.00  0.55−5.04  23/220  10.45  6.7−15.2    21/225  9.33  5.8−13.9   
Condom for genital/anal sex
(regular partner and/or casual partners)
Always  166/834  19.90  17.2−22.8  88/209  42.11  35.3−49.1  34/282  12.06  8.5−16.4  <0.0001  44/343  12.83  9.5−16.8  0.7716 
Condom for oral sex
(regular partner and/or casual partners)
Always  7/760  0.92  0.3−1.9  3/208  1.44  0.3−4.16  3/254  1.18  0.24−3.41  0.8051  1/298  0.34  0.01−1.8  0.2431 
Substances (drugs and/or alcohol)
Yes  55/832  6.61  5.0−8.5  34/205  16.59  11.7−22.4  11/284  3.87  1.9−6.8  <0.0001  10/343  2.92  1.4−5.3  0.5070 
Sex worker
Yes  9/846  1.06  0.5−2.0  4/213  1.88  0.5−4.7  ---  0.0200  5/347  1.44  0.5−3.3  0.0415 
Pays for sex
Yes  17/846  2.01  1.2−3.2  2/213  0.94  0.1−3.35  13/286  4.55  2.4−7.6  0.0196  1/347  0.29  0.01−1.6  0.0003 

MSM: men who have sex with men; MSW: men who have sex with women.

a

Comparison MSM vs. MSW.

b

Comparison MSW vs. women.

c

Excluding sex workers.

The average age was 32.6 years (range 16–68), higher among MSM (36 years) than between MSW (32) and women (30) (p < 0.0001). One third (33.3%) of the women were under 25 years old vs. 20.8% of the men (p < 0.0001) and 9.2% were under 20 years of age. One third of the patients had been born outside of Spain, mainly in Latin America (75.5%). The proportion of immigrants reached 38% among women while among MSM it was 25% (p = 0.0014).

Overall, 62.7% had a regular partner and 37% had been with them for less than six months. There was no association between the length of a relationship and condom use, which was different between heterosexual patients (men or women) and MSM. The latter reported using a condom more in genital/anal sex, both with a regular partner (15.9% vs. 7.8% in MSW and 9% in women) and with casual partners (60.7% vs. 27.5% in MSW and 29.7% in women, p < 0.0001). Some 42% of the MSM always used a condom during genital/anal sex regardless of the type of partner (stable or casual) vs. 12% and 12.8% of MSW and women (p < 0.0001). Regarding oral sex, less than 1% of patients always used a condom.

MSM had more sexual contacts, 5.4 on average in the three months prior to diagnosis, vs. two for MSW and 1.5 for women (p < 0.0001), and 16.6% of them reported using drugs and/or alcohol linked to sexual activity vs. almost 4% of MSW and 3% of women (p < 0.0001).

Clinical characteristics

The main reason for consultation in men was due to symptoms (55%), while women came essentially for the study of contacts (39.9%) (p < 0.0001) (Table 2).

Table 2.

Clinical characteristics of patients with Chlamydia trachomatis.

  Total (847)Men (499)    Women (348, 41.1%)
        MSM (213, 25.1%)MSW (286, 33.8%)         
  95% CI  95% CI  95% CI  pa  95% CI  pb 
Initial visit
Reason for consultation
Symptoms  378/847  44.63  41.2−48.0  92/213  43.19  36.4−50.1  182/286  63.64  57.7−69.2  <0.0001  104/348  29.98  25.1−35.0  <0.0001 
Contact  250/847  29.52  26.4−32.7  49/213  23.00  17.5−29.2  62/286  21.68  17.0−26.9    139/348  39.94  34.7−45.3   
Screening  204/847  24.09  21.2−27.1  71/213  33.33  27.0−40.1  42/286  14.69  10.8−19.3    91/348  26.15  21.6−31.1   
Other  15/847  1.77  1.0−2.9  1/213  0.47  0.01−2.5  -----    14/348  4.02  2.2−6.6   
LGV
Yes  33/268  12.31  8.6−16.8  32/177c  18.08  12.7−23.7  1/23  4.35  0.1−21.9  <0.0001  0/68  ---  0.2527 
Symptoms
Yes  385/847  45.45  42.0−48.8  96/213  45.07  38.2−52.0  184/286  64.33  58.5−69.9  <0.0001  105/348  30.17  25.4−35.3  <0.0001 
Multiple site
Yes  127/837  15.17  12.9- 17.7  38/213  17.84  12.8−23.0  0/284  -----  <0.0001  73/340  21.47  17.2−26.2  <0.0001 
HIV infection
Yes  81/841  9.63  7.7−11.8  75/213  35.21  28.8−42.0  2/286  0.70  0.08−2.5  <0.0001  4/342  1.17  0.32−2.9  0.5463 
Previous STIs (not HIV)
Yes  306/846  36.17  32.9−39.5  152/213  71.36  64.8−77.3  74/286  25.87  20.9−31.3  <0.0001  80/347  23.05  18.7−27.8  0.6940 
Other simultaneous STI
Yes  243/847  28.69  25.6−31.8  114/213  53.52  46.6−60.3  64/286  22.38  17.7−27.6  <0.0001  65/348  18.68  14.7−23.2  0.2496 
Check-up visit
Attended check-up
Yes  790/847  93.27  91.4−94.8  198/213  92.9  88.6−96.0  269/286  94.06  90.6−96.5  0.4382  323/348  92.82  89.6−95.3  0.3651 
Contacts studied
Yes  457/780  58.59  55.0−62.0  75/194  38.66  31.7−45.9  159/267  59.55  53.4−65.5  <0.0001  223/319  69.91  64.5−74.9  0.0088 
Suspected re-exposure
Yes  117/780  15.00  12.6−17.7  17/196  8.67  5.1−13.2  46/264  17.42  13.0−22.5  0.0069  54/320  16.88  12.9−21.4  0.8608 
Persistence of symptoms
Yes  28/357  7.84  5.3−11.1  6/90  6.67  2.5−13.9  14/172  8.14  4.5−13.3  0.6698  8/95  8.42  3.7−15.9  0.9362 
Poor adherence
Yes  4/775  0.52  0.1−1.32  2/195  1.03  0.12−3.6  1/267  0.38  0.01−1.13  0.3992  1/318  0.31  0.01−1.74  0.8907 
CT in rectum treated with azithromycin
Yes  75/200  37.5  30.7−44.6  36/140  25.71  18.7−33.7  ---  ---  ---    39/60  65.0  51.6−76.8  <0.0001ɨ 
Criteria for test of cure
Yes  208/790  26.33  23.3−29.5  56/198  28.28  22.1−35.1  55/269  20.45  15.8−25.7  0.0493  97/323  30.01  25.1−35.3  0.0079 
Test of cure
Positive  37/183  20.22  14.6−26.7  8/47  17.02  7.6−30.8  16/54  29.63  17.9−43.6  0.1376  13/82  15.85  8.7−25.5  0.0550 
Positive test for cure in:
Pregnancy  1/4  25.0  3.41−71.0  ---  ---  ---  ---  ---  ---  ---  1/4  25.0  3.41−71.0  ---- 
Suspected re-exposured  31/114  27.2  19.3−36.3  6/18  33.3  13.3−59.0  13/44  29.55  16.8−45.2  0.7690  12/52  23.1  12.5−36.8  0.4718 
Persistence of symptomsd  6/28  21.4  9.8−39.9  0/6  ---  6/14  42.86  21.3- 67.4    0/8  ---   
Poor adherenced  1/4  25.0  3.41−71.0  0/2  ---  1/1  100  0.1−1.0    0/1  ---   
Rectal CT azithromycin treatmentd  11/52  21.1  11.0- 34.7  6/27  22.22  8.6- 42.2  ---  ---  ---  ---  5/25  20.0  8.4- 39.5  0.8446e 

CT: Chlamydia tracomatis; MSM: men who have sex with men; MSW: men who have sex with women; STI: sexually transmitted infection; LGV: lymphogranuloma venereum; HIV: human immunodeficiency virus.

a

Comparison MSM vs. MSW.

b

Comparison MSW vs. women.

c

In the first months of the study, not all MSM patients were screened for LGV.

d

A patient can be in more than one category.

e

comparison MSM vs. women.

There were 33 cases of LGV, all but one in MSM: 18% of the CT infections in MSM were LGV, 28 (87.5%) of which were located in the rectum, two (6.25%) in the urethra, one (3.1%) in the pharynx and one (3.1%) in a lesion. While 78.6% of the rectal LGVs presented with symptoms, the case detected in the pharynx and one of the two identified in the urethra were asymptomatic. Some 48.5% of LGVs occurred in patients with HIV infection.

81 patients (9.6%) had HIV infection: 35% of the MSM, 0.7% of the MSW, and 1.2% of the women (p < 0.0001). In nine cases it was a new infection, diagnosed at the same time as the CT (eight in MSM and one in a woman).

A history of STIs (excluding HIV) was also more frequent among MSM: 71.4% vs. 25.9% in MSW and 23% in women (p < 0.0001), as well as the presence of other concurrent STIs: 53.5% vs. 22.4% in MSW and 18.7% in women (p < 0.0001). Concurrent STIs in MSM were gonorrhoea (26.8%), early syphilis (21.1%), genital herpes (5.2%), warts (4.7%) and new diagnosis of HIV (3.7%); in MSW, gonorrhoea (8.7%), warts (7.3%) and genital herpes (4.5%); and in women, gonorrhoea (5.5%), genital herpes (4.3%), warts (2.3%) and trichomonas (1.8%).

In all, 64.3% of MSW had symptoms, higher than MSM (45%) and women (30.2%) (p < 0.0001), in whom the majority were asymptomatic infections.

In 17.8% of MSM and 21.5% of women, CT was isolated in more than one site (Table 3). The rectum was affected in 69.5% of MSM, the urethra in 31.4%, and the pharynx in 14.5%. Rectal infections were symptomatic in 34.5% of cases, urethral infections in 62.7%, and pharyngeal infections were all asymptomatic. The cervix was affected in 86.5% of women, the rectum in 17.6%, and the pharynx in 13.8%. Cervical infections were symptomatic in 33% of cases, rectal infections in 1.7%, and pharyngeal infections were always asymptomatic.

Table 3.

Sites of Chlamydia trachomatis infection.

  MSM (213)MSW (284)*Women (340)**
Site  Symptoms  Symptoms  Symptoms 
Rectum  114  53.5  45  39.5          15  4.4 
Rectum + pharynx  17  8.0  17.6          1.5  20 
Urethra  47  22.0  30  63.8  282  98.3  182  64.0  10  2.9  10 
Urethra + rectum  17  8.0  12  70.5          0.6  50 
Urethra + pharynx  1.4  33.3          0.9  33.3 
Lesion  1.9  100  0.7  100         
Pharynx  10  4.7          11  3.2 
Pharynx + conjunctiva  0.4  100                 
Cervix                  231  67.9  90  38.9 
Cervix + pharynx                  25  7.3  16.0 
Cervix + rectum                  35  10.3  8.6 
Cervix + rectum + pharynx                  0.9 

MSM: men who have sex with men; MSW: men who have sex with women.

*

n = 286, in 2 cases the site was not recorded.

**

n = 348, in 8 cases the site was not recorded.

Table 4 shows the clinical characteristics of the patients whose reasons for consultation were a study of contacts or an STI screening. Among the former, 98% were asymptomatic and almost a quarter had an extragenital infection (rectum/pharynx). In addition to CT infection, 18.4% had other STIs, mainly gonococcal infections (12%) and four new cases of HIV were diagnosed, all in MSM. Among those who came for screening, more than half (54%) had a history of STIs and 44% had another STI in addition to CT (14% warts, 12% syphilis, 12% herpes and 7% gonorrhoea).

Table 4.

Clinical characteristics of patients with Chlamydia trachomatis according to reason for consultation.

  Study of contactsScreening
  Total (250)MSM (49)MSW (62)Women (139)Total (204)MSM (71)MSW (42)Women (91)
 
Absence of symptoms  245  98.0  45  91.8  62  100  138  99.3  204  100  71  100  42  100  91  100 
Site
Genitala  191  76.7  13  26.5  62  100  116  84.0  126  62.3  15  21.1  42  100  69  78.4 
Extra-genitalb  58  23.3  36  73.5      22  16.0  75  37.3  56  78.9  19  21.6 
Multiple sites  54  21.7  12  24.5  42  30.4  35  17.4  12  16.9  23  26.1 
LGV  0.8  4.0  2.9  8.4 
History of STIs (not HIV)  59  23.8  29  59.2  13  21.3  17  12.3  110  54.5  56  78.8  16  38.1  38  42.7 
HIV  18  7.2  16  32.6  1.6  0.7  34  16.8  32  45.1    2.2 
Other simultaneous STI  46  18.4  22  44.9  8.0  19  13.6  90  44.1  38  53.5  23  54.7  29  31.8 

MSM: men who have sex with men; MSW: men who have sex with women; STI: sexually transmitted infection; LGV: lymphogranuloma venereum; HIV: human immunodeficiency virus.

a

Cervix/urethra.

b

Rectum/pharynx.

Check-up visit (Table 2)

The average time between diagnosis and check-up visit was 41 days (median 40 days) and 790 patients (93.3%) attended. Of these, 208 (26.3%) met one or more criteria to perform a TOC, although it was only performed in 183 (88%), obtaining 37 positive results (20.2%). In all of these, four weeks had passed since treatment. 11 (21.1%) patients with rectal infection treated with azithromycin had a positive TOC, eight had had unprotected intercourse after treatment, but in the other three it could be a failure of azithromycin. Four of the six patients with persistent symptoms and a positive TOC had also been exposed to a possible reinfection, while the other two, treated with azithromycin, denied having had sexual intercourse since treatment. Reinfection was considered to have occurred in 32 of the 183 cases who underwent a TOC (17.5%; 4% of the total) and possible azithromycin failure in 5.7% of the rectal CT infections treated this antibiotic. In all, 380 of the 582 patients who did not meet the criteria for a TOC also had one (some doctors requested it for all their patients). The result was positive in nine cases (2.3%).

It was only possible to do the study of contacts in 58.6% of the cases.

Multivariate analysis

After adjusting for age, sexual orientation, country of origin, HIV infection and substance use, inconsistent condom use was 50% more frequent among immigrants and five times more frequent among MSW and women than among MSM. The same characteristics were associated with suspected re-exposure: 75% more frequent among immigrants and twice as frequent among MSW and in women than among MSM. Assessment of contacts was twice as likely among MSW as among MSM and three times as likely among women (Table 5).

Table 5.

Factors associated with the use of condoms, the study of contacts and the suspicion of re-exposure. Multivariate analysis, logistic regression.

  Non-regular use of condomsSuspected re-exposureStudy of contacts
  ORa  95% CI  p Value  ORa  95% CI  p Value  ORa  95% CI  p Value 
Country of origin      0.0597      0.0075      NS 
Spain  Reference      Reference           
Other  1.54  0.98−2.40    1.75  1.16−2.63         
Sexual orientation      <0.0001      0.0356      <0.0001 
MSM  Reference      Reference      Reference     
MSW  5.35  3.32−8.62    2.13  1.16−3.90    2.23  1.54−3.27   
WSM  5.20  3.30−8.19    2.05  1.13−3.73    3.62  2.47−5.29   

MSM: men who have sex with men; MSW: men who have sex with women; 95% CI: 95% confidence interval; WSM: women who have sex with men; NS: not significant; ORa: odds ratio adjusted for age, sexual orientation, country of origin, HIV infection and drug use.

Discussion

This study provides, to our knowledge, the most exhaustive clinical-epidemiological description carried out in Spain of a prospective case series of CT infection, including a high number of patients (847) of both sexes with an age range between 16 to 68 years.

The majority of the cases corresponded to women (one in three under 25 years of age) followed by MSW and MSM. Immigrants, who in the Basque Country constitute 10% of the population, accounted for 33% of the cases (38% among the women), with 75% of them coming from Latin America. This is consistent with what has been reported in other studies5,7 and with the higher prevalence of CT infection in this region, especially in women.14

Women had fewer sexual partners and, although their use of condoms in genital/anal sex was very low (12%), it was similar to that of MSW. That women were more affected may be due to biological characteristics such as cervical ectopia in young women, which make them more vulnerable to CT infection. On the other hand, if men have more sexual partners, they can transmit the infection to multiple women, increasing the incidence and prevalence of infection among them.14

One of the difficulties in controlling CT infections is their frequently asymptomatic nature.10 Our results do not deviate from the model: 70% of women, 55% of MSM and 36% of MSW did not present symptoms. This shows the need for an active search for cases, because without screening, these silent infections will not be diagnosed or treated, perpetuating their transmission. To date, the only activity to control CT infection in the Basque Country and most of Spain consists of managing symptomatic cases, when more than half are asymptomatic and, with the exception of Catalonia,15,16 there are no recommendations for the detection of infections asymptomatic in any population subgroup. Prevalence studies in the general sexually active population are necessary to determine whether the implementation of population screening programmes would be justified and cost-effective. However, our results, in line with prevalence studies in our setting,5–7 show the need to at least carry out opportunistic screenings in women under 25 years of age and young immigrants of both sexes, with genital and extragenital sampling.

Rectal involvement, as in other studies,17,18 was greater than urethral involvement in MSM (69.5% vs. 31.4%). If only genital samples had been taken (urethra/urine in men and cervix in women), we would not have detected 68.5% of infections among MSM or 13.5% among women. Many cases of CT infection are missed if samples are not collected from all susceptible sites, and therefore patients must be asked about their sexual practices and explained the reason for doing so. This entails more consultation time and evidently higher costs, but not doing so favours the continued transmission of the infection, the consequences of which can be more expensive than its early detection and treatment.

In 42% of patients we could not study any contacts, a worrying result, although somewhat better than that obtained in the evaluation of compliance in the study of contacts by Vilela et al.19 The probability that contacts are infected is high: the estimated probability of transmission of CT in a single sexual act is 10%20 and the concordance of infection between couples is 75%.21 The fact that a large part of CT infections are asymptomatic increases the value of studying contacts, since it may be the only way to treat these cases.22 In fact, 98% of the patients in our study whose reason for consultation was having had sex with someone who had a CT infection were asymptomatic and 21.7% of them were infected in more than one anatomical site.

Notifying contacts is essential for controlling CT transmission. In Spain, it is done through the index case, which is problematic when the contacts are unknown, when the relationship with them has ended or when the contagion has occurred outside the usual partner. There are no notification guidelines adapted to our epidemiological situation, and it is crucial to develop them and provide the necessary means for their implementation, as well as to evaluate new notification methods based on new technologies.23

One in four patients who returned for a check-up met one or more criteria to perform a TOC: 17% of them had been reinfected and in 6% of the rectal CT infections treated with azithromycin there was suspicion of treatment failure. This has implications for care: it is not enough to prescribe a therapy to patients with CT infection at the time of diagnosis, but they must be given a follow-up appointment to verify whether or not they require a TOC and to take samples if they do. On the contrary, our results show the poor performance of TOCs in the absence of the criteria established in the STI guidelines.

This study has several limitations. It was carried out in the Osakidetza STI clinics in Biscay, so its results may not exactly represent what happens in the general population. Even so, they are the referral STI clinics of the public health system and provide follow-up of more than 82% of CT infections reported to the Basque Government's Department of Health by the microbiology laboratories of Biscay. Therefore, we consider that, in the absence of population studies, these results are valuable to approximate the epidemiological situation of our population. The reinfection rate may be overestimated, since we established the minimum time between treatment and TOC at four weeks, based on European and American clinical practice guidelines and other publications,9–13 but the recommendations in this regard are inconsistent and some suggest postponing the TOC for up to six weeks because of the possibility of false-positive results due to the detection of non-viable organisms until this amount of time this passed. Finally, the estimated therapeutic failure for azithromycin in rectal infections (6%), although less than the 17% obtained in the meta-analysis by Kong et al.,24 must be considered with caution, since it was not molecularly determined if it was the same strain.

In conclusion, although the generalisation of molecular techniques has facilitated the diagnosis of CT infections, it is evident that their management is not as simple as taking a urine sample or a vaginal smear and prescribing an antibiotic. We are faced with infections that are mostly asymptomatic, which can cause severe complications, frequently extragenital, in more than one anatomical site and with other concurrent STIs, which mainly affect young women, often immigrants, with a history of previous STIs, who barely use condoms and sometimes become reinfected within a short period of time. To ensure quality care, STIs require specialised clinics, equipped with the necessary resources and integrated with primary care, reproductive health services, school health services and community organisations.

Funding

This study was funded by the Department of Health of the Basque Government (file 2015111136).

Conflicts of interest

The authors declare that they have no conflicts of interest.

Acknowledgements

To Gonzalo Grandes, head of the Biscay Primary Care Research Unit (Instituto de Investigación BioCruces-Bizkaia [BioCruces-Bizkaia Research Institute]) for reviewing the manuscript.

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Please cite this article as: López-de Munain J, Cámara-Pérez MM, López-Martinez M, Alava-Menica JA, Hernandez-Ragpa L, Imaz-Pérez M, et al. Características clínicas y epidemiológicas de la infección por Chlamydia trachomatis en pacientes de consultas de infecciones de transmisión sexual. Enferm Infecc Microbiol Clin. 2022;40:359–366.

Copyright © 2021. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica
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