The challenges of detecting gonorrhoea and chlamydia in rectal and pharyngeal sites: could we, should we, be doing more? | Sexually Transmitted Infections

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The challenges of detecting gonorrhoea and chlamydia in rectal and pharyngeal sites: could we, should we, be doing more?

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Re:Pharyngeal and Rectal Testing for Chlamydia trachomatis in MSM: Evidence Base
Peter Watson
Published on: 13 May 2016
Pharyngeal and Rectal Testing for Chlamydia trachomatis in MSM: Evidence Base
Sarah Alexander
Published on: 13 May 2016
Evidence, please
Peter G Watson
Published on: 13 May 2016
The challenge of detecting gonorrhoea (GC) – we can, we should, we already do more.
Mrinalini Mahto
Published on: 13 May 2016

Published on: 13 May 2016
Re:Pharyngeal and Rectal Testing for Chlamydia trachomatis in MSM: Evidence Base
- Peter Watson, Consultant
I thank Dr Alexander for her reply. However I question the assumption that Chlamydia trachomatis is always a pathogen, wherever it is found. Before we embark on what could be a costly programme of screening for C. trachomatis in the throat and the rectum, do we not need some evidence that the detection and treatment of asymptomatic infection in those sites will be associated with clinical benefit in the patients and th...
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I thank Dr Alexander for her reply. However I question the assumption that Chlamydia trachomatis is always a pathogen, wherever it is found. Before we embark on what could be a costly programme of screening for C. trachomatis in the throat and the rectum, do we not need some evidence that the detection and treatment of asymptomatic infection in those sites will be associated with clinical benefit in the patients and their partners and a sustained elimination of the infection?
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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Published on: 13 May 2016
Pharyngeal and Rectal Testing for Chlamydia trachomatis in MSM: Evidence Base
- Sarah Alexander
Dear Editors,
Pharyngeal and Rectal Testing for Chlamydia trachomatis in MSM: Evidence Base
Dr Watson requests the evidence base that screening asymtomatic Men who have Sex with Men (MSM) for C. trachomatis in the throat and the rectum confers either the patient or their contacts any benefit. When considering this question it is important to remember that our current knowledge regarding the natural hi...
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Dear Editors,
Pharyngeal and Rectal Testing for Chlamydia trachomatis in MSM: Evidence Base
Dr Watson requests the evidence base that screening asymtomatic Men who have Sex with Men (MSM) for C. trachomatis in the throat and the rectum confers either the patient or their contacts any benefit. When considering this question it is important to remember that our current knowledge regarding the natural history of chlamydia infection is currently incomplete and consequently when Chlamydia is detected - irrespective of site or symptomatology- it is always regarded as a pathogen.
To date there is strong evidence base that the rectum is a very important reservoir of Chlamydia infection in MSM.1,2,3,4,5,6,7 In recent years several large studies have been undertaken and the prevalence of rectal Chlamydia in MSM attending sexual health clinics has been determined to be in the range of 6.96 - 11%. 1,2,3,4,5,6,7 Whilst it is undeniable that the vast majority of the non-LGV associated rectal Chlamydia infection seen, is asymptomatic,2,4 it is widely acknowledged that it is a reservoir for potential onward transmission. 1,2,3,4,5,6,7
Currently fewer studies have been undertaken examining the pharynx as a site for C. trachomatis infection. However it is noteworthy that in the studies that have been undertaken, the prevalence of pharyngeal C. trachomatis has been consistently found to 1-2% 5,6,7,8. Interestingly studies have also shown that ~66-100% of chlamydia infections in the pharynx occurred without concurrent urethral Chlamydia infection, and consequently if urine testing alone had been performed the infection would have gone undetected. 5,8
Several studies examining MSM behaviour have highlighted that urethral Chlamydia infection can be associated with insertive unprotected anal intercourse, insertive oral sex and other non-intercourse receptive anal practises9,10. This information suggests that extra-genital Chlamydial infection (both pharyngeal and rectal) is transmitted to sexual contacts. These contacts may go on to develop symptoms - this is more likely if a urethral infection is acquired- or maybe in turn, will exist as a further reservoir of Chlamydia infection. Both scenarios are undesirable and where possible would be ideally avoided.
Finally it is important to put this discussion into context: in my original editorial I advocated for the increased use of dual NAATs to test extra-genital specimens (which would enable the detection of both chlamydia and gonorrhoea) and improving the availability of rectal and pharyngeal testing to all MSM who are at risk of infection.11 This is important because any patient attending a sexual health service for an STI screen does so to ensure that they are either (i) absent from infection or (ii) if an STI is detected- to receive appropriate therapy-. Given the high prevalence of asymptomatic extra-genital Chlamydia and gonococcal infections in MSM, offering both pharyngeal and rectal screening would be undeniably beneficial to both the individual concerned and their sexual contacts.
Yours Sincerely
Sarah Alexander
Sexually Transmitted Bacteria Reference Laboratory Health Protection Agency
References
1. Clinic-based testing for rectal and pharyngeal Neisseria gonorrhoeae and Chlamydia trachomatis infections by community-based organizations--five cities, United States, 2007. Centers for Disease Control and Prevention (CDC). MWR Morb Mortal Wkly Rep. 2009 Jul 10;58(26):716-9.
2. Ward H, Alexander S, Carder C, Dean G, French P, Ivens D, Ling C, Paul J, Tong W, White J, Ison CA. The prevalence of lymphogranuloma venereum infection in men who have sex with men: results of a multicentre case finding study. Sex Transm Infect. 2009 Jun;85(3):173-5.
3. van der Helm JJ, Hoebe CJ, van Rooijen MS, Brouwers EE, Fennema HS, Thiesbrummel HF, Dukers-Muijrers NH. High performance and acceptability of self-collected rectal swabs for diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae in men who have sex with men and women. Sex Transm Dis. 2009;36(8):493-7.
4. Annan, N.T., A K Sullivan, A Nori, P Naydenova, S Alexander, A McKenna, B Azadian, S Mandalia, M Rossi, H Ward and N Nwokolo. Rectal chlamydia_a reservoir of undiagnosed infection in men who have sex with men. Sex Transm Inf 2009;85;176-179.
5. Ota KV, Tamari IE, Smieja M, Jamieson F, Jones KE, Towns L, Juzkiw J, Richardson SE. Detection of Neisseria gonorrhoeae and Chlamydia trachomatis in pharyngeal and rectal specimens using the BD Probetec ET system, the Gen-Probe Aptima Combo 2 assay and culture. Sex Transm Infect. 2009 Jun;85(3):182-6. Epub 2009 Jan 6.
6. Benn PD, Rooney G, Carder C, Brown M, Stevenson SR, Copas A, Robinson AJ, Ridgway GL. Chlamydia trachomatis and Neisseria gonorrhoeae infection and the sexual behaviour of men who have sex with men. Sex Transm Infect. 2007 Apr;83(2):106-12.
7. Kent CK, Chaw JK, Wong W, Liska S, Gibson S, Hubbard G, Klausner JD. Prevalence of rectal, urethral, and pharyngeal chlamydia and gonorrhea detected in 2 clinical settings among men who have sex with men: San Francisco, California, 2003. Clin Infect Dis. 2005 Jul 1;41(1):67-74. Epub 2005 May 26.
8. D J Templeton, F Jin, J Imrie, G P Prestage, B Donovan, P H Cunningham, J M Kaldor, S Kippax, A E Grulich. Prevalence, incidence and risk factors for pharyngeal chlamydia in the community based Health in Men (HIM) cohort of homosexual men in Sydney, Australia Sex Transm Infect 2008;84:361-363.
9. Jin F, Prestage GP, Mao L, et al. Incidence and risk factors for urethral and anal gonorrhoea and chlamydia in a cohort of HIV-negative homosexual men: the Health in Men Study. Sex Transm Infect 2007;83:113-9.
10. Lafferty WE, Hughes JP, Handsfield HH. Sexually transmitted diseases in men who have sex with men. Acquisition of gonorrhea and nongonococcal urethritis by fellatio and implications for STD/HIV prevention. Sex Transm Dis. 1997 May;24(5):272-8.
11. Alexander, S. The challenges of detecting gonorrhoea and chlamydia in rectal and pharyngeal sites: could we, should we, be doing more? Sex Transm Infect. 2009;85:159-160.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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Published on: 13 May 2016
Evidence, please
- Peter G Watson, consultant, genitourinary medicine
It is a shame that Dr Alexander's opening sentence: "It is important that all men who have sex with men (MSM) accessing sexual health-care are tested for Neisseria gonorrhoeae and Chlamydia trachomatis (CT) at all anatomical sites where they may be at risk of infection.", is not referenced.
I should appreciate being directed to the evidence that screening asymtomatic MSM for CT in the throat or rectum confers t...
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It is a shame that Dr Alexander's opening sentence: "It is important that all men who have sex with men (MSM) accessing sexual health-care are tested for Neisseria gonorrhoeae and Chlamydia trachomatis (CT) at all anatomical sites where they may be at risk of infection.", is not referenced.
I should appreciate being directed to the evidence that screening asymtomatic MSM for CT in the throat or rectum confers them or anyone else with any benefit. A simple number needed to screen per defined benefit would do.
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Conflict of Interest:
None declared.
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Published on: 13 May 2016
The challenge of detecting gonorrhoea (GC) – we can, we should, we already do more.
- Mrinalini Mahto, Consultant Genitourinary Medicine Dept
- Other Contributors:
  Harry Mallinson
Dear Editor,
In a recent leading article Alexander (1) citing in particular recent work with men who have sex with men (MSM) in the USA (2), has suggested that when examining extra-genital specimens from high risk patient groups, GC culture should be replaced by GC nucleic acid amplification tests (NAATs). We agree with this conclusion but believe that the higher sensitivity of GC NAATs should be promoted to allow imp...
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Dear Editor,
In a recent leading article Alexander (1) citing in particular recent work with men who have sex with men (MSM) in the USA (2), has suggested that when examining extra-genital specimens from high risk patient groups, GC culture should be replaced by GC nucleic acid amplification tests (NAATs). We agree with this conclusion but believe that the higher sensitivity of GC NAATs should be promoted to allow impact on wider populations. There is already growing evidence in the UK that GC NAATs (with alternative target confirmation to avoid issues of low positive predictive value) can accurately detect substantial numbers of cases beyond those found by culture and by current diagnostic service structures. A Scottish study (3) found more than double the cases of GC when testing throat and rectum of men by NAATs instead of culture but also reported extra cases among females tested.
We have recently reported on detection of GC (when testing for Chlamydia) by use of the APTIMA Combo2 (AC2) assay with alternative target confirmation (4). In a GU medicine clinic AC2 detected some 20% extra cases of GC beyond culture. Also compared to self-referral at a GU medicine clinic, community tests made a substantial contribution to the overall number of GC cases found (40 community versus 35 Macclesfield GU clinic). There were no culture- positive but AC2 negative results in any of our patients. Of over15000 tests performed both at the community and at the GU medine clinic, only one was positive for GC by AC2 but unconfirmed by the alternative assay. In the community, over 60% of GC infections occurred in chlamydia negatives so dual testing at the outset would find more GC cases than reflex testing of those screened chlamydia positive. Wider considered use of GC NAATs should be encouraged.
M Mahto
Department of GU Medicine
Cheshire East Community Health (Central and Eastern Cheshire PCT)
Macclesfield, SK11 6JL, UK
H Mallinson
Haytor
Crosby
Liverpool
L23, UK
Correspondence to: Dr M Mahto, Consultant Physician
Genitourinary Medicine Department
Assura Health and Wellness Centre
Sunderland Street
Macclesfield, SK11 6JL, UK Email - mrinalini.mahto@echeshire-tr.nwest.nhs.uk
References
1. Alexander S. The challenges of detecting gonorrhoea and chlamydia in rectal and pharyngeal sites: could we, should we, be doing more? Sex Transm Infect 2009;85:159-160
2. Ota KV, Tamari IE, Smieja M et al. Detection of Neisseria gonorrhoeae and Chlamydia trachomatis in pharyngeal and rectal specimens using the BD Probetec ET system, the Gen-probe Aptima Combo2 assay and culture. Sex Transm Infect 2009;85;182-6
3. Scottish Guidelines for Molecular testing of Neisseria gonorrhoeae. See http://www.hps.scot.nhs.uk/training/presentations.aspx?id=167
4. Mahto M, Zia S, Ritchie D and Mallinson H. Diagnosis, management and prevalence estimation of gonorrhoea: influences of Aptima Combo 2 assay with alternative target confirmation. International Journal of STD and AIDS 2009;20:315-319
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Conflict of Interest:
None declared.
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