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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

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ESSAY 206 - CHLAMYDIA

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		Posted by Srivas P. Tue Aug 8, 2006 04:48 am
Chlamydia Trachomatis infection is one of the commonest sexually transmitted infections and the sequelae of chlamydial infection are severe and can have lifelong implications whereas effective management will result in considerable health benefit. Hence, the necessity for effective screening. It can cause infertility, ectopic pregnancies, PID, bartholinitis, endometritis and chronic pelvic pain and a disseminated infection can cause Reiter?s syndrome and also can cause epidydimo-orchitis in her partner. Chlamydia has been estimated to account for 40% of ectopic pregnancies and 50% cases of Acute PID. But Chlamydial infections are asymptomatic in 70% woman and 50% of males and may be so for many months and thereby transmission to partners is unchecked. To routinely test the whole population is too vast a proposition and hence not cost effective. The second approach is to give prophylactic treatment for high risk groups for Chlamydia and prevent morbidity. This misses low risk groups and also partner tracing is not possible with chances of re-infection. The third approach is to screen symptomatic groups and do chlamydia testing in probable high risk groups. This includes woman undergoing TOP, woman with other STIs, sexual partners having Chlamydia, woman undergoing instrumentation for HSG or IUCD, mothers with infants having ophthalmia neonatorum and neonatal pneumonitis. Testing for chlamydia should also be offered to attenders at GUM clinic (both sexes). In clinics woman attend for getting TOP, there is 6-10% incidence of Chlamydia and 25% risk of getting post operative salpingitis if she is untreated. So the best approach would be to give antibiotics and also screen for Chlamydia so that contact tracing can be done. By preventing this PID and avoiding tubal blocks there is a tremendous saving to the NHS in terms of preventing necessity for infertility treatment later. Opportunistic screening should also be offered to women aged over 25 with a new sexual partner or who have had two or more partners in the past 12 months as this detects 87% infection while testing only 50 % population. So this is a very effective target population for screening and is cost effective. The success of any screening programme for chlamydia will be dependent on successful partner notification and effective treatment of partners. GUM clinics are well placed to undertake contact tracing and to detect co-infections. Partner tracing should be done for 6 months in asymptomatic cases and for 4 weeks in symptomatic cases. Successful screening also requires reliable tests which are acceptable to the patients. Chlamydia testing is noninvasive and first void urine sample can detect Chlamydia with nearly 100% success using PCR and it avoid the necessity of contacts to attend the clinic personally avoiding absenteeism. Urethral and endocervical swabs give positive results in 60-80% cases using culture and antigen tests. Any screening programme thus proposed should be properly audited and evaluated for best results.
		Posted by Balakrishnan V. Tue Aug 8, 2006 09:14 am
Chlamydia is the most common sexually transmitted infection in U.K. It has serious morbidity of PID, salpingitis, tubal blockadge, sub fertility, ectopic pregnancy and chronic pelvic pain. Also during pregnancy it causes spontaneous miscarriage, preterm labour and neonatal conjunctivitis. So it is imperative to diagnose it and treat it before it causes irreversible damage. For universal screening the WHO screening criterias must be fulfilled i.e the condition should be common and effective treatment should be available. The screening test itself should be reliable, specific, sensitive and cost effective. Chlamydia screening dose satisfies all of these criterias. The opportunistic screening which is currently practiced in most of NHS trusts only screen high risk patients which are undergoing termination of pregnancy, infertility investigations, are young ( less than 25) and those who had more than one partner within last year. This screening misses many patients who are asymptomatic and contact tracing is not offered to their male partners. The diagnostic tests of chlamydia also vary in specificity and sensitivity and costs. Endocervical swab or first void urine is taken for dignostic tests like cell culture, enzyme immunoassay, direct fluorescent antibody testing and the latest and the most expensive nucleic acid amplification techniques which has more than 90 % sensitivity and 99% specificity. This test will be ideal for large scale screening and it will be cost effective if we compare it to complications of chlamydia which are costing ?52 million to NHS in the U.K The treatment of chlamydia is also effective and ecnomical. Usually doxycycline for seven days or azithromycin in a single dose are used. Considering all these facts I strongly recommend that chlamydia screening should be done routinely in gynae procedures. Followup is important to see contact tracing, treatment efficacy and exclude re infection. There should be unit protocol of chlamydia screening of gynae patients and audit should be done to see its effectiveness.
		Posted by Kishor S. Tue Aug 8, 2006 02:06 pm
Chlamydia is the most common sexually transmitted bacterial infection in the U.K. The proposition of routine screening in gynaecological practice can be considered as two sides of a coin having both ?for and against? arguments. The arguments in favour are: most acute chlamydial infections are asymptomatic (upto 70% in females and 50% in males) and thus remain undiagnosed, but they remain infectious for many months. The late sequelae are severe and infected woman can have PID, ectopic pregnancy and lifelong complications such as infertility and chronic pelvic pain. During pregnancy it causes spontaneous miscarriage, preterm labour and neonatal conjunctivitis. Therefore, early detection and treatment of asymptomatic infection will prevent its long-term morbidity and reduce onward disease transmission. In the UK the annual cost of Chlamydia and its complications is estimated to be more than ? 100 million and there is growing evidence in other countries like USA and Denmark that targeted screening of risk population can significantly reduce the morbidity associated with its infection and late sequelae. Economic analyses have demonstrated cost-benefit and cost-effectiveness. The treatment available (doxycycline for seven days or azithromycin in a single dose) is effective. Thus it fulfills the WHO criteria for universal screening in that the infection is common and effective treatment is available. The arguments against the proposition are: the magnitude of the population to be screened is too vast and hence may not be cost effective. There has been lack of comprehensive systematic review about the prevalence in the UK, hence the difficulty in the estimate of anticipated number. Therefore National Chlamydia Screening Programme (NCSP) is undertaking only opportunist screening targeting sexually active women and men under 25. Secondly, reliable diagnostic tests and acceptable collection of sample are required. Chlamydia is intra-cellular gram negative bacteria, can only be grown in cell culture systems and poses a difficulty in diagnostic techniques. Presently used test is Nucleic acid amplification test and requires a repeat confirmation test. It is expensive but has more than 90 % sensitivity and 99% specificity. First void urine sample can detect Chlamydia with nearly 100% success using this test. ELISA detects Chlamydia antigens and is less sensitive. It requires constant modernization in order to maintain accuracy. Manpower training and education is essential. Considering all these, though routine screening of Chlamydia is an idealist proposition but in view of the evidence available about the prevalence, magnitude of population and cost and man power involved, it should be focused on only the targeted population.
		Posted by neera B. Tue Aug 8, 2006 08:47 pm
Chlamydia is the commonest bacterial sexually transmitted infection in the UK. It can cause acute urethritis, UTI, PID, vaginal discharge and long term squelae like ectopic pregnancy, infertility, chronic pelvic pain and recurrent PID.Sensitive noninvasive easily available diagnostic tests likePCR in endocervical swab and urine are available.Single dose oral treatment with minimal side-effects likesingle dose azithromycin is available which effectively treats current diseaseas well as prevents long term sequelae. If routine screening is performed, there is no discrimination between high risk and other patients, hence compliance with screening is better and social embarresment and feeling of guilt is lesser. However routine screening entails cost of increased infrastructure to the NHS, more of trained lab staff and trained personnel will be needed to collect swabs.Routine screening will help to pick up more asymptomatic patients, who could be missed by risk based screening. Hence routine screening and treatment of the lady ,tracing and treatment of her contacts through GUM clinic is ideal, but may not be feasible. So selective screening for high risk groups should be offered which includes sexually active women under 25 yrs. , those with 2 or more sexual partners in the preceeding 1 yr., change of sexual partner in past 6 months, those presenting with symptoms of chlamydia infections, those attending GUM clinics, female partners of men attanding GUM clinic, prior to intrauterine instrumentation like termination of pregnancy.
		Posted by Freha Z. Wed Aug 9, 2006 03:06 am
Chlamydia Trachomatis is the commonest sexually transmitted bacterial pathogen in developed countries and responsible for at least half of all cases of non specific genital infection. It causes urethral syndrome in young women. Local infection can result into skenitis and bartholinitis. Ascending infection in females causes endometritis resulting in menorrhagia. Most important complication is silent pelvic inflammatory disease leading to chronic pelvic pain, tubal damage resulting in infertility. It can also result in perihepatitis and disseminated infection can lead to Reiter\'s syndrome. It can be diagnosed by ELISA(60% sensitivity), PCR/LCRare much more sensitive and can be done on morning urine sample. Treatment is simple and cheap, Doxycycline 100mg twice a day for 7 days or single dose Azithromycin 1g. Universal screening is justified if the condition is common and there is recognised diagnostic tehnique and which is true for chlamydia. The main disadvantage of universal screening is cost. Another concern is what shoud be the frequency of test. It will require special equipment and trained personnel. But it will reduce morbidity, prevent tubal infertility( therefore reduces cost of subsequent treatment), contact tracing and their treatment. Considering all the advantages universal screening may be cost effective. The other option is Selective screening of at risk patients. This can identify large proportions of affected women and their partners. But it is argued that selective screening can be discriminatory and people might not attend. The incidence of chlamydial infection in women attending for termination of pregnancy is 5-28%. Untreated are 3 times more likely to develop sepsis than treated women. Current RCOG guidelines recommend administering anti-chlamydial treatment to young women before termination to prevent upper genital tract infection.This may avoid cost of screening but this approach leaves women vulunerable to re-infection from an undiagnosed partner if sexual relationship continues. By screening long term sequele of infertility can be prevented. Screening provides opportunity for counselling about protection against other STDs and their sequele. For screen positive there is advantage of contact tracing. The screening strategies should be re-audited.
		Posted by Ismatara B. Wed Aug 9, 2006 05:06 am
Chlamydia is an important problem and is the most common and treatable sexually transmitted infection in the UK and the incidence is rising. It is asymptomatic in 70% of women and 50% of men. Chlamydia can cause acute urethral syndrome, urethritis, mucopurulent cervicitis, salpingitis, endometritis, rarely Reiter?s syndrome and also prenatal infection (70% of infants delivered vaginally acquired the infection eg neonatal conjunctivities). If untreated there are long term consequences of Chlamydia: Pelvic inflammatory disease (PID) in 30% cases, infertility (6 fold increase of Tubal factor infertility), ectopic pregnancy, chronic pelvic pain. In the UK annual cost of chlamydia and its complication is estimated to be more than ₤100 million. So it is imperative to diagnose and treat it before irreversible damage. The entire squeal is preventable if it is treated in asymptomatic phase except infertility. The screening test for chlamydia is reliable, available, and cost effective with improved sensitivity and specificity. Treatment is also cheap and effective. Evidence suggests that screening for chlamydia can reduce the prevalence of CT infection in both men and women and incidence of PID. Now the most available method is NAAT PCR (Nucleic acid amplification tests- Polymerase chain reaction) of the urine and endocervical swab. It has sensitivity 90% and specificity 99%. First void urine sample provides an alternative. It is accurate (about 100% success using PCR), noninvasive and acceptable to the patient. Treatment is also easy, cheap and cost-effective. A single course of antibiotics (Doxycycline 100mg B.D. for 7 days or Azythromycin 1gm-a single dose) for the treatment of uncomplicated case has eased the management ensuring high compliance of chlamydia infection. All of these fulfill the criteria for WHO screening. If routine screening is performed, it can pick up more asymptomatic patient who can be missed by selective screening There is no discrimination between high risk and normal population, so patient compliance is better with lesser feeling of guilt and social embarrassment.And other STDs can be picked up at the same time and managed.But the magnitude of the population to be screened is vast and may not be cost effective (increase cost for infrastructure to the NHS), more trained laboratory personnel and staff is needed to collect swabs. Hence routine screening and treatment of the patient, contact tracing and treatment of contact and involvement of GUM clinic is ideal but not feasible. On the other hand prophylactic antibiotic treatment of high risk women for chlamydia is other option. Both symptomatic and asymptomatic chlamydia infection should lead to contact tracing because blind treatment results in reduction of new and recurrent PID of asymptomatic carriers. Selective screening should be offered to high risk women which include all women presenting with symptoms of chlamydia infection, all sexually active woman under 25 year, those with 2 or more sexual partners or change of sexual partner in the last year, those attending GUM clinics, female partners of men attending GUM clinic, women seeking termination of pregnancy or infertility treatment and undergoing uterine instrumentation (HSG).This will detect 87% infection and testing only 50% population. In UK National Chlamidia Screening Programme (NCSP) has undertaken selective screening as this is cost effective and reliable. But selective screening can be discriminatory and people might not attend. Considering all these any programmed screening proposed should be properly audited and evaluated for best results.
		Posted by Samir A. Sat Aug 12, 2006 11:22 pm
Chlamydia is the commonest STD in the UK and the incidence is increasing.It is commonest below age of 25 year, asymptomatic in 70% of females and 50% of males affected. Chlamedial infection in females causes pelvic inflamatory disease (PID), tubal disease, pelvic adhesions, ectopic pregnancy,menstrual disorders and chronic pelvic pain. In males it causes urethritis and epidydmo-orchitis. In asymptomatic infected women PID flares up folloeing TOP (surgical termination of pregnancy), HSG (Hystro Salpingography), Laparoscopy and dye surgery and IUCD insertion especially in antibiotic prophylaxis (Doxycycline for 7 days or single dose of Azithromycin) was not given. Chlamydia creeinig fulfil the WHO criteria for disease screening. It is a common disease, mostly asymptomatic, causing significant morbidity, easy to treat ( by antibiotics ), diagnostic teste are non inasive ( first void urine based PCR testing as well as cervical swab PCR), safe and available with very high sensitivity ( near to 100% in urine PCR ) and specificity ( 90% ). Universal screening to all women is ideal since it detects all asymptomaic cases with early treatment, hence dramatically decrease complications, trce partenrs and does not create discrimination. However it is coastly, especially the prevalance of the disease is much lower above 25-30 comparing to women below 25. So a lot money will be spent un-necessairly. Targeted screening (the current programm in the UK) is screening of the women at high risk of the disease.This includes women younger than 25, women who have more than 2 partners over the last 12 months or with a new partener for last 6 months, women with other STDs, women undergoing TOP, HSG, Lap & dye or IUCD.Cotact tracing is done in this programm.This screening is more coast effective than blnket routine screening, however it might miss some cases and carry some discrimination to the targeted women and so compliance might be affected negatively. Non screened cases undergoing gynaecological internentions should be given antibiotic prophylaxis. To sum up, in my opinion Targeted Screening is preferable and coast effective rather than blanket routine screening.
		Posted by afroz S. Mon Aug 14, 2006 06:18 am
Chlamydia trachomatis is one of the most common sexually transmitted infection in the world including UK. The infection is asymptomatic in 70% of women.It is common in young age group.It is one of the most common cause of PID which leads to tubal factor for infertility & increased risk of ectopic pregnancy. It also cause chronic pelvic pain.The treatment of this infection includes Tetracycline or clindamycin which is simple and cheap and has better patient compliance due to single dose therapy. The screening test using PCR has high sensitivity and specificity.It is acceptable to the patient by taking endocervical or urethral swabs which is a simple,non-invasive and safe procedure. The screeing allows contact tracing and treatment of affected partner. It is cost effective. Screening for Chlamydia reduces the prevalence of Chlamydia infection in women and it\'s consequences. The routine screening has disadvantages like cost implications. Psychological morbidity due to guilt if screened positive. Other infections for eg. Gonorrhea can cause PID and similar sequele. Some patients might refuse screening. Referral to GUM clinic and contact tracing is required. ELISA test for screeing is less sensitive and specific. Selective screening is preferred to routine screening in high risk patients like patients attending GUM clinics, for termination of pregnancy, instrumentation of the uterus like HSG or hysteroscopy,patients with symptoms of Chlamydia infection,with multiple sexual partners. The different protocols for women undergoing gynecological procedures are screen and treat which allows contact tracing & treatment of screened positive cases. The 2nd protocol is treating all women without screening which leads to unnecessary treatment of unaffected women. This does not allow contact tracing, hence Re-infection cannot be prevented.