Article

Effectiveness of Chlamydia Trachomatis expedited partner therapy in pregnancy

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Abstract

Background: Expedited partner therapy for chlamydia trachomatis has had mixed efficacy in different populations, but data are lacking on the efficacy in a pregnant population. Objectives: Evaluate the real-world effectiveness of establishing a prenatal expedited partner therapy program in eradicating chlamydia before delivery. To examine the maternal and neonatal outcomes among women treated for chlamydia in pregnancy compared among those that received expedited partner therapy to those that underwent standard partner-referral testing and treatment. Study design: An expedited partner therapy program was implemented on August 21, 2019 at a public hospital in a county with high chlamydia prevalence. Pregnant women were provided with single-dose packets of azithromycin to treat partner(s) following diagnosis of chlamydia. We prospectively studied pregnant women treated in the expedited partner therapy program who delivered at our institution in the same year and compared outcomes to a historical cohort from the year prior that had traditional partner-referral for testing and treatment. We excluded women with concurrent gonorrhea, human immunodeficiency virus, syphilis, or current intimate partner violence. The primary outcome was chlamydia reinfection or no-cure at repeat testing 4-6 weeks following treatment or at the 36-week prenatal care screening. Secondary outcomes included obstetric, maternal, and neonatal outcomes including prelabor rupture of membranes, chorioamnionitis, endometritis, neonatal intensive care unit admission, neonatal sepsis, pneumonia, and conjunctivitis. Results: The rate of chlamydia was 3.6% over a 2-year period in our delivered population. In the year following implementation of expedited partner therapy, 471 women (mean [SD] age, 23.8 [5.3] years) were diagnosed with chlamydia delivered at our institution, compared with 419 women (mean [SD] age, 23.4 [5.5] years) the previous year. There were no differences in race, parity, prenatal care attendance, or concomitant sexually transmitted infections. Compared to the pre-expedited partner therapy group, the frequency of reinfection in the post-expedited partner therapy group was not statistically different (60/471 (13%) versus 61/419 (15%), OR 0.86 (95%CI 0.58, 1.26)). In a per-protocol analysis, 72 (17%) of pre-expedited partner therapy and 389 (83%) of post-expedited partner therapy groups actually received expedited partner therapy; reinfection was not statistically different between groups (p=0.47). There were no differences in secondary outcomes, although a trend toward improved rates of endometritis was noted in the post-expedited partner therapy group (OR 0.13, 95%CI 0.02, 1.02). Conclusions: Implementation of a prenatal expedited partner therapy program did not significantly affect the frequency of chlamydia reinfection before delivery. Treatment of chlamydia in an inner-city population has multiple factors that lead to successful treatment. Future efforts to reduce sexually transmitted infection and chlamydia reinfection rates in an at-risk population include exploring patient education and safe sex practices beyond expedited partner therapy alone during pregnancy.

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... However, there are challenges in studying EPT in real-world settings, such as how to determine valid outcomes to measure and homing in on populations with the same risk factors for infection. 4,5 A women's emergency unit setting within a safety-net county hospital poses a unique challenge related to the rapid rates of patient turnover leading to test results pending at discharge. A traditional combination nucleic acid amplification test for chlamydia and gonorrhea typically takes 1 to 4 days, whereas patients typically spend less than 12 hours in the emergency department (ED). ...
... 18 The increase in offered EPT from 2019 to 2020 was likely influenced by a healthcare improvement initiative that was implemented at the system level mid-August 2019. 4,9 Because the intervention occurred halfway through the pre-COVID year, it is difficult to generalize the findings through the context of pre-COVID-19 and during COVID-19. Despite the increase in EPT, rates of repeat infections remained consistent between 2019 and 2020, which may be due to the large proportion of pregnant patients in both cohorts, as previous studies have conflicting findings between the effectiveness of EPT in the pregnant patient population versus the general female population. ...
... Despite the increase in EPT, rates of repeat infections remained consistent between 2019 and 2020, which may be due to the large proportion of pregnant patients in both cohorts, as previous studies have conflicting findings between the effectiveness of EPT in the pregnant patient population versus the general female population. 4,9 In addition, there are different follow-up recommendations on repeat testing between the populations, which further confounds the mixed groups in relation to this secondary outcome. 18 In the future, it is paramount to identify the high-risk populations at the clinical site in which the patient is being seen, as it may be beneficial for clinicians to be more partial to treating high-risk patients empirically rather than waiting for confirmatory results. ...
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Introduction: Chlamydia is the most frequently reported sexually transmitted infection (STI). COVID-19 exacerbated the challenges in treating and preventing new C. trachomatis (CT) infections. This study examined the impact of COVID-19 on treating CT-positive patients discharged from a safety-net women's emergency unit. Methods: This was a pre and post retrospective cohort study. CT-positive females seen in the women's emergency unit were evaluated. Patients discharged in 2019, the 'pre-COVID-19' group, and those discharged in 2020, the 'COVID-19' group were compared. The primary outcome was CT treatment within 30 days and secondary outcomes included prescription dispensation, repeat tests taken, and expedited partner treatment (EPT). A sub-group of patients discharged prior to treatment who entered a nurse-led follow-up program were also evaluated. Results: Of the 1,357 cases included, there were no differences in successful 30-day treatment (709/789(89.9%) vs. 568/511(89.9%), p = 0.969) or repeat positive CT test (74/333(22.2%) vs. 46/211(21.8%), p = 0.36) between pre-COVID-19 and COVID-19. However, the patients who picked up their prescription (196/249(78.7%) vs. 180/206(87.4%), p = 0.021) and those who were prescribed EPT (156/674(23.1%) vs. 292/460(63.5%), p < 0.001) increased. Findings in the sub-group of patients who entered the follow-up program were consistent with those in the full cohort. Conclusions: The COVID-19 pandemic did not change treatment patterns of CT positive patients in this safety-net women's emergency unit. However, patients were more likely to pick up their medications during COVID-19. Despite the perseverance of these programs through the pandemic, most patients are discharged prior to positive results and a fair amount remain untreated.
... There may be benefit for "expedited" partner treatment as was attempted to be demonstrated for another STI (i.e. chlamydia), for which medication was given to the patient for her to provide it to her sexual partner [18]. Borrowing from that same concept, a known sexual contact who is presumed to have syphilis according to the acquired serologic record, could be offered parenteral penicillin treatment by an appropriate primary care physician (PCP). ...
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Some sexually transmitted infections have posed a particular epidemiologic problem for some communities, in that racial/ethnic disparities have been demonstrated. Syphilis represents a specific example of such an infection, compounding the medical problem further by adding to the serious consequences of its vertical perinatal transmissibility to the neonate, in addition to its sexual, or horizontal, transmission. The recently rising incidence of syphilis in the pregnant woman and the potential for the rising incidence of congenital syphilis should be a cause for global concern. However, what may be concluded as a problem within communities of color, may actually be a problem relating more closely with a socioeconomic disparity. Multiple deliberate measures may be needed to affect its eradication, which is naturally possible, given the longtime availability of the simple curable medical compound of penicillin.
... All patients were treated with pabolizumab 2 mg/kg for 21 d for 5 courses, resulting in complete remission in 3 patients and death due to progression in 1 patient [16]. Two cases of very high-risk GTN treated with pabolizumab were reported with equally satisfactory results [17]. In this study, one patient treated with pabolizumab 200 mg (21 d course) was assessed to be in complete remission on imaging after 5 courses and entered clinical follow-up; the other patient had been treated for 3 courses at the time of writing and was also in complete remission, with no grade III-IV side effects. ...
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... Expedited partner therapy (EPT) enables providers to prescribe treatment for partners of patients diagnosed with an STI, without the partner having to establish direct care. 4 This cohort study evaluated a prenatal EPT programme in Dallas, Texas, a high Chlamydia trachomatis (CT) prevalence area. Investigators evaluated the effect of EPT on rates of CT infection before delivery compared with the traditional partner referral, testing and treatment approach used the year before. ...
Article
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Bacteria in the genus Chlamydia comprise three species, C. trachomatis, C. psittaci and C. pneumoniae. C. trachomatis infection is common, varying in prevalence in women from 0% to 37%. In the United States, the prevalence rate is estimated currently to be about 5%. Pregnancy may predispose to an increased chance of infection with C. trachomatis, through physiological immunosuppression and/or cervical ectopy. Maternal antibodies to C. trachomatis provide limited, if any, protection for the newborn. C. trachomatis causes pelvic inflammatory disease—which can result in tubal infertility or ectopic pregnancy and postabortal or late postpartum endometritis. It may also cause chorioamnionitis and premature delivery of the fetus. The incidence of vertical transmission of chlamydiae from mother to baby varies; if the mother is untreated, 20–50% of the newborns will develop conjunctivitis and 10–20% will develop pneumonia. C. psittaci infection in pregnancy is rare, but can cause spontaneous abortion. Whether C. pneumoniae infection in pregnancy has any influence on the outcome has not been ascertained. C. trachomatis can be detected by one or more of several methods; enzyme immunoassays are the least sensitive, but the most widely used. Screening for C. trachomatis in pregnancy may be of benefit in areas of high prevalence, and is generally regarded as being cost-effective if the prevalence rate is more than 5%. Pregnant women are best treated with erythromycin, 250 mg four times daily for 7 days. This will prevent infection of the newborn in more than 90% of cases. The infected neonate should be treated with erythromycin, given systemically and also with topical tetracycline if conjunctivitis is present.
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Concurrent patient-partner treatment (CPPT) is the provision of treatment to the index patient and their sexual partner(s) and appears to be an effective method of preventing repeat sexually transmitted infections. The objectives of the study were to determine whether CPPT reduces the prevalence of a positive test of cure (TOC) for chlamydia and/or gonorrhea infection in pregnant women. We conducted an observational cohort study of 241 pregnant women aged 15 to 40 years diagnosed with chlamydia and/or gonorrhea receiving prenatal care at an urban teaching hospital. Pregnant women and their sexual partner(s) received CPPT consisting of azithromycin and/or cefpodoxime for treatment of chlamydia and/or gonorrhea infection, respectively, or patient referral consisting of an antibiotic prescription to the pregnant woman and advice for partner screening and therapy. Odds ratios (ORs) and survival estimates were calculated by χ or Fisher exact test, multivariable logistic regression, and Kaplan-Meier. Forty-five pregnant women with chlamydia and/or gonorrhea received CPPT and were less likely to have a positive TOC (OR = 0; P < 0.001) and repeat positive chlamydia infection (OR = 0; P = 0.12) compared with 196 women that were treated and counseled on the patient referral treatment strategy for their sexual partners. CPPT shortened the median time to cure (4.4 weeks, standard deviation = 2.3) versus standard patient referral (5.1 weeks, standard deviation = 5.2). There were no repeat positive chlamydia infections in the CPPT group compared with 19 (18.1%) in the patient referral group. CPPT decreased the prevalence of a positive TOC for chlamydia infection among pregnant women.
Article
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Article
Determining the magnitude of chlamydia and gonorrhea reinfection is critical to inform evidence-based clinical practice guidelines related to retesting after treatment. PubMed was used to identify peer-reviewed English language studies published in the past 30 years that estimated reinfection rates among females treated for chlamydia or gonorrhea. Included in this analysis were original studies conducted in the United States and other industrialized countries that reported data on chlamydia or gonorrhea reinfection in females. Studies were stratified into 3 tiers based on study design. Reinfection rates were examined in relation to the organism, study design, length of follow-up, and population characteristics. Of the 47 studies included, 16 were active cohort (Tier 1), 15 passive cohort (Tier 2), and 16 disease registry (Tier 3) studies. The overall median proportion of females reinfected with chlamydia was 13.9% (n = 38 studies). Modeled chlamydia reinfection within 12 months demonstrated peak rates of 19% to 20% at 8 to 10 months. The overall median proportion of females reinfected with gonorrhea was 11.7% (n = 17 studies). Younger age was associated with higher rates of both chlamydia and gonorrhea reinfection. High rates of reinfection with chlamydia and gonorrhea among females, along with practical considerations, warrant retesting 3 to 6 months after treatment of the initial infection. Further research should investigate effective interventions to reduce reinfection and to increase retesting.
Article
The effect of Chlamydia trachomatis on pregnancy outcome and the effect of treatment of positive cervical cultures was studied by culturing 11,544 women for chlamydia at their first prenatal visit. Chlamydia culture was positive in 2433 (21.08%) and prevalence was related to age and race. Of the positive cultures, 1110 were classified as untreated. The untreated group demonstrated a significant increase in the incidence of premature rupture of the membranes and low birth weight and a decrease in survival when compared with either those with positive cultures who received treatment (N = 1323) or those with negative cultures (N = 9111). Screening of populations at high risk of chlamydia is recommended and treatment of chlamydia-positive patients may improve pregnancy outcome.
Article
Bacteria in the genus Chlamydia comprise three species, C. trachomatis, C. psittaci and C. pneumoniae. C. trachomatis infection is common, varying in prevalence in women from 0% to 37%. In the United States, the prevalence rate is estimated currently to be about 5%. Pregnancy may predispose to an increased chance of infection with C. trachomatis, through physiological immunosuppression and/or cervical ectopy. Maternal antibodies to C. trachomatis provide limited, if any, protection for the newborn. C. trachomatis causes pelvic inflammatory disease--which can result in tubal infertility or ectopic pregnancy and postabortal or late postpartum endometritis. It may also cause chorioamnionitis and premature delivery of the fetus. The incidence of vertical transmission of chlamydiae from mother to baby varies; if the mother is untreated, 20-50% of the newborns will develop conjunctivitis and 10-20% will develop pneumonia. C. psittaci infection in pregnancy is rare, but can cause spontaneous abortion. Whether C. pneumoniae infection in pregnancy has any influence on the outcome has not been ascertained. C. trachomatis can be detected by one or more of several methods; enzyme immunoassays are the least sensitive, but the most widely used. Screening for C. trachomatis in pregnancy may be of benefit in areas of high prevalence, and is generally regarded as being cost-effective if the prevalence rate is more than 5%. Pregnant women are best treated with erythromycin, 250 mg four times daily for 7 days. This will prevent infection of the newborn in more than 90% of cases. The infected neonate should be treated with erythromycin, given systemically and also with topical tetracycline if conjunctivitis is present.
Article
This study was undertaken to determine the association between genitourinary tract infection with Chlamydia trachomatis and spontaneous preterm birth. Genitourinary tract infection with C trachomatis was determined with a ligase chain reaction assay of voided urine samples collected at 24 weeks' gestation (22 weeks' to 24 weeks 6 days' gestation) and 28 weeks' gestation (27 weeks' to 28 weeks 6 days' gestation). Case patients (spontaneous preterm birth at <37 weeks' gestation; n = 190) and control subjects (delivery at >/=37 weeks' gestation, matched for race, parity, and center; n = 190) were selected from 2929 women enrolled in the Preterm Prediction Study of the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Genitourinary C trachomatis infection (11% overall) was significantly more common among the case patients than among the control subjects at 24 weeks' gestation (15.8% vs 6.3%; P =.003) but not at 28 weeks' gestation (12.6% vs 10.9%; P =.61). Women with chlamydia infection were more likely to have bacterial vaginosis (57.1% vs 32.9%; P =.002) and a short cervical length (</=25 mm; 33.0% vs 17.9%; P =.02) but not a body mass index <19.8 kg/m(2) (35.0% vs 23.9%; P =.17) or a positive fetal fibronectin test result (7.1% vs 9.5%; P =.62). After adjustment for risk factors for spontaneous preterm birth, women with C trachomatis infection at 24 weeks' gestation were 2 times as likely as uninfected women to have a spontaneous preterm birth at <37 weeks' gestation (odds ratio, 2.2; 95% confidence interval, 1.03-4.78) and 3 times as likely to have a spontaneous preterm birth at <35 weeks' gestation (odds ratio, 3.2; 95% confidence interval, 1.08-9.57). Genitourinary C trachomatis infection at 24 weeks' gestation was associated with a 2-fold to 3-fold increased risk of subsequent spontaneous preterm birth.
Article
Repeated infection with C trachomatis increases the risk for serious sequelae: pelvic inflammatory disease, ectopic pregnancy, infertility, and chronic pelvic pain. A substantial proportion of women treated for C trachomatis infection are reinfected by an untreated male sex partner in the first several months after treatment. Effective strategies to ensure partner treatment are needed. The goal of the study was to determine whether repeated infections with C trachomatis can be reduced by giving women doses of azithromycin to deliver to male sex partners. A multicenter randomized controlled trial was conducted among 1,787 women aged 14 to 34 years with uncomplicated C trachomatis genital infection diagnosed at family planning, adolescent, sexually transmitted disease, and primary care clinics or emergency or other hospital departments in five US cities. Women treated for infection were randomized to one of two groups: patient-delivered partner treatment (in which they were given a dose of azithromycin to deliver to each sex partner) or self-referral (in which they were asked to refer their sex partners for treatment). The main outcome measure was C trachomatis DNA detected by urine ligase chain reaction (LCR) or polymerase chain reaction (PCR) by 4 months after treatment. The characteristics of study participants enrolled in each arm were similar except for a small difference in the age distribution. Risk of reinfection was 20% lower among women in the patient-delivered partner treatment arm (87/728; 12%) than among those in the self-referral arm (106/726; 15%); however, this difference was not statistically significant (odds ratio, 0.80; 95% confidence interval, 0.62-1.05; = 0.102). Women in the patient-delivered partner treatment arm reported high compliance with the intervention (82%). Patient-delivered partner treatment for prevention of repeated infection among women is comparable to self-referral and may be an appropriate option for some patients.
Article
Many sex partners of persons with gonorrhea or chlamydial infections are not treated, which leads to frequent reinfections and further transmission. We randomly assigned women and heterosexual men with gonorrhea or chlamydial infection to have their partners receive expedited treatment or standard referral. Patients in the expedited-treatment group were offered medication to give to their sex partners, or if they preferred, study staff members contacted partners and provided them with medication without a clinical examination. Patients assigned to standard partner referral were advised to refer their partners for treatment and were offered assistance notifying partners. The primary outcome was persistent or recurrent gonorrhea or chlamydial infection in patients 3 to 19 weeks after treatment. Persistent or recurrent gonorrhea or chlamydial infection occurred in 121 of 931 patients (13 percent) assigned to standard partner referral and 92 of 929 (10 percent) assigned to expedited treatment of sexual partners (relative risk, 0.76; 95 percent confidence interval, 0.59 to 0.98). Expedited treatment was more effective than standard referral of partners in reducing persistent or recurrent infection among patients with gonorrhea (3 percent vs. 11 percent, P=0.01) than in those with chlamydial infection (11 percent vs. 13 percent, P=0.17) (P=0.05 for the comparison of treatment effects) and remained independently associated with a reduced risk of persistent or recurrent infection after adjustment for other predictors of infection at follow-up (relative risk, 0.75; 95 percent confidence interval, 0.57 to 0.97). Patients assigned to expedited treatment of sexual partners were significantly more likely than those assigned to standard referral of partners to report that all of their partners were treated and significantly less likely to report having sex with an untreated partner. Expedited treatment of sex partners reduces the rates of persistent or recurrent gonorrhea or chlamydial infection.
ACOG Committee Opinion no. 737: expedited partner therapy