Sexually Transmitted Infections, Bacteria

Clinical Background

Sexually-transmitted infections (STIs) constitute a major health burden in the U.S.; reported incidence among adolescents is increasing, and these diseases are frequently asymptomatic.

For information regarding HSV, HPV and HIV, refer to specific topic in ARUP Consult®

Most common STIs
- Bacterial infections
  - Chlamydia trachomatis
  - Neisseria gonorrhea
  - Trichomonas vaginalis
  - Bacterial vaginosis (BV) infection
  - Treponema pallidum (syphilis)
  - Refer to syphilis topic in ARUP Consult®
- Viral infections
  - Human immunodeficiency virus (HIV)
  - Herpes simplex virus (HSV)
  - Human papilloma virus (HPV)

Bacterial infectious agents other than Treponema pallidum.

Chlamydia trachomatis
- Epidemiology
  - Prevalence - >800,000 cases annually in U.S.
  - Age - highest incidence in 15-25 year olds
  - Organisms - gram-negative obligate intracellular parasite
- Risk Factors
  - Multiple sex partners
  - Non-Caucasian
  - Younger age
  - Coinfection with gonorrhea or HIV
  - Non-use of barrier methods
  - Previous history of STI
  - Infected with HIV
- Clinical Presentation
  - Asymptomatic
  - Urethritis, cervicitis, salpingitis
  - Oropharyngeal disease
  - Pelvic inflammatory disease (PID)
  - Neonatal infection
Neisseria gonorrhea
- Epidemiology
  - Prevalence - >350,000 reported cases annually in U.S.
  - Age - highest in 15-25 year olds
  - Organism - nonmotile gram-negative diplococcus
- Risk Factors
  - Multiple sex partners
  - Non-Caucasian
  - Younger age
  - Coinfection with gonorrhea or HIV
  - Non-use of barrier methods
  - Previous history of STI
  - Infected with HIV
- Clinical Presentation
  - Cervicitis, urethritis, salpingitis
  - PID
  - Oropharyngeal disease
  - Neonatal infection
Trichomonas vaginalis
- Epidemiology
  - Prevalence - accounts for 15-20% of cases of vulvovaginitis
  - Age - highest in 15-25 year olds
  - Organism - flagellated protozoan
- Risk Factors
  - Multiple sex partners
  - Non-Caucasian
  - Younger age
  - Coinfection with gonorrhea or HIV
  - Non-use of barrier methods
  - Previous history of STI
  - Infected with HIV
- Clinical Presentation
  - Vulvovaginitis, cervicitis,urethritis
  - Copious pruritic discharge strawberry cervix
  - Pregnant females
    - Increased risk of HIV transmission
    - Preterm labor, premature rupture of membranes
    - Low birth weight
Bacterial vaginosis
- Epidemiology
  - Prevalence - 16% of pregnant women
  - Organism
    - Gardnerella vaginalis - gram-variable nonmotile coccobacillus
      - Most common organism responsible for BV
    - Other agents include Mycoplasma hominis and Ureaplasma urealyticum
- Risk Factors
  - Douching
  - Non-use of barrier methods
  - Multiple sex partners
  - Non-Caucasian
- Clinical Presentation
  - Malodorous vaginal discharge
  - Vulvovaginitis, cervicitis, salpingitis
  - Pregnant females
    - Increased risk of HIV transmission
    - Preterm labor
    - Premature rupture of membranes
    - Postpartum endometriosis
- Current U.S. Preventative Services Task Force (USPSTF) for STI screening
  - Directed at three populations - non-pregnant women, pregnant women and men
  - Need to consider risk factors (both behavioral and demographic) that increase risk of STI to determine if screening is necessary
  - No guidelines for what ages to stop screening or how often to screen
  - Non-pregnant
    - If engaging in high-risk sexual behavior, screen for Chlamydia, gonorrhea, HIV and syphilis
    - If <25 years and non high risk, screen for Chlamydia and gonorrhea
  - Pregnant women
    - Screen all for hepatitis B, HIV and syphilis
    - If high risk, screen the same as for high risk non-pregnant women
  - Men
    - No screen necessary if not engaging in high risk behaviors
    - If high risk behaviors, screen for HIV and syphilis

Refer to STI topic at www.arupconsult.com for a table of Comparisons of STI Screening Recommendations for Sexually Active Nonpregnant Women

Refer to STI topic at www.arupconsult.com for a table of Comparisons of STI Screening Recommendations for Pregnant Women

Treatment
- Centers for Disease Control (CDC) recommends treatment of all STIs
  - Treatment of infected patient’s partner(s) is also recommended

See Also

Herpes Simplex Virus - HSV

Human Immunodeficiency Virus - HIV

Human Papillomavirus - HPV

Treponema pallidum - Syphilis

Tests

Tests generally appear in the order most useful for common clinical situations

Test name: Chlamydia trachomatis by Amplified Detection (APTIMA®)

ARUP #: 0060243

Methodology: Target Amplification Nucleic Acid Probe

Use:

Diagnose infection with Chlamydia trachomatis from endocervical and urethral sources

Limitations:

Culture may be required in certain clinical contexts for diagnosing Chlamydia trachomatis and Neisseria gonorrhoeae infections to meet applicable laws and regulations

Test name: Chlamydia trachomatis DFA

ARUP #: 0060287

Methodology: Direct Fluorescent Antibody Stain

Use:

Diagnose infection with Chlamydia trachomatis

Limitations:

Sensitivity of this method is dependant on adequacy of smear

Follow-up:

Test name: Chlamydia trachomatis & Neisseria gonorrhoeae by Amplified Detection (APTIMA®), M4/UTM specimens

ARUP #: 0060774

Methodology: Target Amplification Nucleic Acid Probe

Use:

Diagnose infection with Chlamydia trachomatis and Neisseria gonorrhoea

Limitations:

Culture may be required in certain clinical contexts for diagnosing Chlamydia trachomatis and Neisseria gonorrhoeae infections to meet applicable laws and regulations

Test name: Chlamydia trachomatis & Neisseria gonorrhoeae by Amplified Detection (APTIMA®)

ARUP #: 0060241

Methodology: Target Amplification Nucleic Acid Probe

Use:

Diagnose infection with Chlamydia trachomatis and Neisseria gonorrhoeae from genitourinary sources

Limitations:

Follow-up:

Test name: Chlamydia trachomatis & Neisseria gonorrhoeae DNA Probe

ARUP #: 0060224

Methodology: DNA Probe

Use:

Diagnose infection with Chlamydia trachomatis and Neisseria gonorrhoeae from endocervical and urethral specimens

Limitations:

Less sensitive than amplification based methods

Culture is recommended for Chlamydia trachomatis and Neisseria gonorrhoeae detection to meet applicable laws and regulations or for use in suspected failure of therapy

Test name: Chlamydia trachomatis Culture

ARUP #: 0065012

Methodology: Cell Culture/Immunofluorescence

Use:

Diagnose infection with Chlamydia trachomatis
Culture should be ordered in cases of suspected sexual abuse or suspected failure of therapy
Historically, the gold standard for diagnosis

Limitations:

Follow-up:

Test name: Chlamydia trachomatis & Neisseria gonorrhoeae by Amplified Detection (APTIMA®), ThinPrep™

ARUP #: 0060734

Methodology: Target Amplification Nucleic Acid Probe

Use:

Diagnose infection with Chlamydia trachomatis and Neisseria gonorrhoeae from genitourinary sources

Limitations:

Culture may be required in certain clinical contexts for diagnosing Chlamydia trachomatis and Neisseria gonorrhoeae infections to meet applicable laws and regulations

Follow-up:

Test name: Gonorrhea Culture

ARUP #: 0060110

Methodology: Standard reference procedures for N. gonorrhoeae culture and identification

Use:

Diagnose infection with gonorrhea
Historically, the gold standard for diagnosis

Recommended for Neisseria gonorrhoeae detection in cases of suspected sexual abuse or suspected failure of therapy

Limitations:

Follow-up:

Test name: Neisseria gonorrhoeae DNA Probe

ARUP #: 0060223

Methodology: DNA Probe

Use:

Direct DNA probe testing is appropriate only for endocervical and urethral specimens
Nucleic-acid amplification tests (NAAT) are superior to direct DNA probe testing for detection of Neisseria gonorrhoea

Limitations:

Nucleic-acid amplification tests (NAAT) are superior to direct DNA probe testing for detection of Neisseria gonorrhoea

Additional Tests Available

Test name: Vaginal Pathogens DNA Direct Probes

ARUP #: 0065153

Methodology: Nucleic Acid Probe

Comments: Not recommended

Test name: Neisseria gonorrhoea Antibodies, Total

ARUP #: 0099685

Methodology: Complement Fixation

Comments:

Test name: Chlamydia trachomatis DNA Probe

ARUP #: 0065059

Methodology: DNA Probe

Comments: Less sensitive than amplification-based methods

Test name: Neisseria gonorrhoeae by Amplified Detection (APTIMA®)

ARUP #: 0060244

Methodology: Target Amplified Nucleic Acid Probe

Comments: Positive results are confirmed using an alternative nucleic acid target in accordance with the CDC Control Guidelines (2002 Screening Guidelines)Culture may be required in certain clinical contexts for diagnosing Chlamydia trachomatis and Neisseria gonorrhoeae infections to meet applicable laws and regulations

Test name: Chlamydia trachomatis & Neisseria gonorrhoeae DNA Probe

ARUP #: 0060224

Methodology: DNA Probe

Comments:

Test name: Neisseria gonorrhoeae DNA Probe

ARUP #: 0060223

Methodology: DNA Probe

Comments:

Test name: Neisseria gonorrhoea Antibodies, Total

ARUP #: 0099685

Methodology: Complement Fixation

Comments:

Test name: Chlamydia Direct Antigen Detection, DFA

ARUP #: 0097782

Methodology: Direct Fluorescent Antibody

Comments:

Test name: Ureaplasma urealyticum & Mycoplasma hominis Culture

ARUP #: 0065031

Methodology: Culture

Comments:

References

Guidelines

Kropp RY, Latham-Carmanico C, Steben M, Wong T, Duarte-Franco E. What's new in management of sexually transmitted infections? Canadian Guidelines on Sexually Transmitted Infections, 2006 Edition. Can Fam Physician. 2007;53(10):1739-1741.

Meyers DS, Halvorson H, Luckhaupt S. Screening for chlamydial infection: an evidence update for the U.S. Preventive Services Task Force. Ann Intern Med. 2007;147(2):135-142.

Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2007;147(2):128-134.

Cited References

Meyers, D., Wolff, T., Gregory, K., et al. USPSTF Recommendations for STI Screening. Originally published in Am Fam Physician 2008;77:819-824. Agency for Healthcare Research and Quality, Rockville, MD. (Accessed on July 15, 2008)

General References

Chapin KC. Molecular tests for detection of the sexually-transmitted pathogens Neisseria gonorrhoeae and Chlamydia trachomatis. Med Health R I. 2006;89(6):202-204.

Chernesky MA, Jang DE. APTIMA transcription-mediated amplification assays for Chlamydia trachomatis and Neisseria gonorrhoeae. Expert Rev Mol Diagn. 2006;6(4):519-525.

Forsum U, Hallen A, Larsson PG. Bacterial vaginosis--a laboratory and clinical diagnostics enigma. APMIS. 2005;113(3):153-161.

French P. Syphilis. BMJ. 2007;334(7585):143-147.

Frenkl TL, Potts J. Sexually transmitted infections. Urol Clin North Am. 2008;35(1):33-46.

Geisler WM. Management of uncomplicated Chlamydia trachomatis infections in adolescents and adults: evidence reviewed for the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis. 2007;44 Suppl 3:S77-S83.

Hammerschlag MR. Chlamydia and Chlamydiales: beyond Chlamydia trachomatis. Pediatr Infect Dis J. 2007;26(7):639-640.

Low N. Chlamydia (uncomplicated, genital). Clin Evid. 2006;(15):2129-2135.

Manavi K. A review on infection with Chlamydia trachomatis. Best Pract Res Clin Obstet Gynaecol. 2006;20(6):941-951.

Marrazzo JM, Martin DH. Management of women with cervicitis. Clin Infect Dis. 2007;44 Suppl 3:S102-S110.

McLean CA, Stoner BP, Workowski KA. Treatment of lymphogranuloma venereum. Clin Infect Dis. 2007;44 Suppl 3:S147-S152.

Moran J. Gonorrhoea. Clin Evid. 2006;(15):2162-2168.

Newman LM, Moran JS, Workowski KA. Update on the management of gonorrhea in adults in the United States. Clin Infect Dis. 2007;44 Suppl 3:S84-101.

Olshen E, Shrier LA. Diagnostic tests for chlamydial and gonorrheal infections. Semin Pediatr Infect Dis. 2005;16(3):192-198.

Peate I. Syphilis: clinical presentation, diagnosis and treatment. Nurs Stand. 2007;22(10):48-55.

Peeling RW, Holmes KK, Mabey D, Ronald A. Rapid tests for sexually transmitted infections (STIs): the way forward. Sex Transm Infect. 2006;82 Suppl 5:v1-v6.

Peeling RW, Mabey D, Herring A, Hook EW III. Why do we need quality-assured diagnostic tests for sexually transmitted infections?. Nat Rev Microbiol. 2006;4(12):909-921.

Skidmore S, Horner P, Mallinson H. Testing specimens for Chlamydia trachomatis. Sex Transm Infect. 2006;82(4):272-275.

Spigarelli MG. Urine gonococcal/Chlamydia testing in adolescents. Curr Opin Obstet Gynecol. 2006;18(5):498-502.

Stoner BP. Current controversies in the management of adult syphilis. Clin Infect Dis. 2007;44 Suppl 3:S130-S146.

van de Laar MJ, Morre SA. Chlamydia: a major challenge for public health. Euro Surveill. 2007;12(10):E1-E2.

Zetola NM, Engelman J, Jensen TP, Klausner JD. Syphilis in the United States: an update for clinicians with an emphasis on HIV coinfection. Mayo Clin Proc. 2007;82(9):1091-1102.

Zetola NM, Klausner JD. Syphilis and HIV infection: an update. Clin Infect Dis. 2007;44(9):1222-1228.

Medical Reviewers

Carney, Heather, M.D. Assistant Medical Director, Transfusion Services at ARUP Laboratories; Pathology, University of Utah

Petti, Cathy A., M.D. Medical Director, Infectious Diseases at ARUP Laboratories; Assistant Professor, Pathology and Medicine, University of Utah

Comprehensive Review: July 2008
Last Update: July 2008