Chlamydia trachomatis in infertile women undergoing uterine instrumentation: Screen or treat

Ernest Hung, Yu Ng,1, Cora Suk Wai Ngai and Pak Chung Ho

Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong


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Dear Sir,

We read with interest ‘Chlamydia trachomatis in infertile women undergoing uterine instrumentation: Screen or treat’ (Land et al., 2002Go), proposing that prophylactic antibiotics should be given to all infertile women undergoing uterine instrumentation instead of screening for C. trachomatis and treating positive cases only. Universal screening was not considered by the authors to be cost-effective in view of the low incidence of detection of C. trachomatis in the endocervix of infertile women. Possible reactivation of C. trachomatis infection may also follow uterine instrumentation as a result of persistent micro-organisms in the upper genital tract despite adequate treatment. We would like to point out some of the problems that may arise from adopting the universal prophylaxis approach.

It is obvious that criteria for selective screening are not useful in infertility, as the majority of infertile women are >25 years old and the couples usually have stable monogamous relationships for several years prior to seeking infertility treatment. Therefore, all women presenting for infertility investigation should be screened for C. trachomatis (Royal College of Obstetricians and Gynaecologists, 1998Go). The cost-effectiveness of universal screening for C. trachomatis depends on the prevalence of asymptomatic infection. The threshold prevalence of C. trachomatis, over which universal screening is shown to be cost effective, varied from 3.1–10.0% (Sellors et al., 1992Go; Genc and Mardh, 1996Go; Marazzo et al., 1997; Howell et al., 1998Go; Paavonen et al., 1998Go). The variation in the threshold prevalence rate can be explained by the very wide range of direct and indirect costs used in the economic models (McIntosh et al., 1999). These studies mainly addressed the cost implications associated with prevention of infectious pelvic inflammatory episodes.

The prevalence of C. trachomatis in infertile women, which is much lower than other clinical settings (Macmillan et al., 2000Go), is 1.3% (95% CI 0.2–4.7%) (Eggert-Kruse et al., 1997Go) and 1.9% (95% CI 0.5–4.8%) (Macmillan and Templeton, 1999Go) using ligase chain reaction (LCR). The upper range of the prevalence in infertile women is still within the threshold prevalence rate (3.1–10.0%) for which universal screening is cost effective, even after taking into consideration unpublished data (J.A.Land et al., 2002Go) using polymerase chain reaction (PCR).

Other advantages of the screen and treat approach that cannot be offered by the universal prophylaxis approach include screening for other sexually transmitted diseases in the women and treatment of sexual partners when chlamydial infection is detected. These steps help to reduce the spread of sexually transmitted diseases in the community. Recurrent chlamydial infections are a common problem even after completion of adequate and appropriate antibiotic therapy and are usually thought to be a consequence of reinfection. Re-screening of women for chlamydial infection a few months after treatment has been recommended as a routine prevention strategy (Whittington et al., 2001Go). The universal prophylaxis approach would not be able to detect these recurrent infections.

The risk of pelvic infection was mostly confined to patients with existing tubal damage and anaerobic bacteria were isolated more commonly than C. trachomatis (Forsey et al., 1990Go). It is unlikely that these infections after hysterosalpingography can be prevented by the universal prophylaxis approach, which may also contribute further to the development of persistent infection and resistance to antibiotics.

Efficient inhibition of chlamydial growth by tetracycline or azithromycin was readily shown in the conventional in-vitro system used for susceptibility testing in which antibiotics are usually added 48 h after the infectious agent or are sometimes added simultaneously. This did not reflect the situation in vivo for chlamydial infection. During natural infections, chlamydia sp. are usually exposed to antibiotics long after an infection has been well established. Using an in-vitro cell culture model with a longer incubation period of 20 days, prolonged treatment of ciprofloxacin/ofloxacin (Dreses-Werringloer et al., 2000) and azithromycin (Dreses-Werringloer et al., 2001) not only failed to eradicate chlamydia from host cells but also induced a persistent state, although these antibiotics were efficient in the usual susceptibility testing. The emergence of multiple drug-resistant C. trachomatis has been recently reported (Somani et al., 2000Go).

In conclusion, the screen and treat approach remains the most cost-effective way to prevent the development of infectious morbidity following uterine instrumentation. Routine antibiotic prophylaxis may be associated with an increased risk of persistent infection and development of multiple drug resistant chlamydia.


    Notes
 
1 To whom correspondence should be addressed. E-mail: nghye{at}hkucc.hku.hk Back


    References
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 Introduction
 References
 
Drese-Werringloer, U., Padubrin, I., Zeidler, H. and Köhler, L. (2001) Effects of azithromycin and rifampin on Chlamydia trachomatis infection in vivo. Antimicrob. Agents Chemother., 45, 3001–3008.[Abstract/Free Full Text]

Drese-Werringloer, U., Padubrin, I., Jürgens-Saathoff, B., Hudon, A.P., Zeidler, H. and Köhler, L. (2000) Persistence of Chlamydia trachomatis is induced by ciprofloxacin and ofloxacin in vitro. Antimicrob. Agents Chemother., 44, 3288–3297.[Abstract/Free Full Text]

Eggert-Kruse, W., Rohr, G., Demirakca, T., Rusu, R., Näher, H., Petzoldt, D. and Runnebaum, B. (1997) Chlamydia serology in 1303 asymptomatic infertile couples. Hum. Reprod., 12, 1464–1475.[Abstract]

Forsey, J.P., Caul, E.O., Paul, I.D. and Hull, M.G.R. (1990) Chlamydia trachomatis, tubal disease and the incidence of symptomatic and aysmptomatic infection following hysterosalpingraphy. Hum. Reprod., 5, 444–447.[Abstract]

Genc, M, and Mardh, A.A. (1996) A cost-effectiveness analysis of screening and treatment for Chlamydia trachomatis infection in asymptomatic women. Ann. Intern. Med., 124, 1–7.

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Macmillan, S., McKenzie, H., Flett, G. and Templeton, A. (2000) Which women should be tested for Chlamydia trachomatis? Br. J. Obstet. Gynecol., 107, 1088–1093.[ISI]

Marrazzo, J.M., Celum, C.L., Hillis, S.D., Fine, D., DeLisle, S. and Handsfield, H.H. (1997) Performance and cost-effectiveness of selective screening criteria for Chlamydia trachomatis infection in women. Implications for a national Chlamydia control strategy. Sex. Transm. Dis., 24, 131–141.[ISI][Medline]

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Royal College of Obstetricians and Gynaecologists (1998) Evidence-based clinical guidelines No. 2 The initial investigation and management of the infertile couple. RCOG Press, London, UK, pp 48–51.

Sellors, J.W., Pickard, L., Gafni, A., Goldsmith, C.H., Jang, D., Mahony, J.B. and Chernesky, M.A. (1992) Effectiveness and efficiency of selective vs universal screening for chlamydia infection in sexually active young women. Arch. Intern. Med., 152, 1837–1844.[Abstract]

Somani, J., Bhullar, V.B., Workowski, K.A., Farshy, C.E. and Black, C.M. (2000) Multiple drug-resistant Chlamydia trachomatis associated with clinical treatment failure. J. Infect. Dis., 181, 1421–1427.[ISI][Medline]

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