TY - JOUR
T1 - Controversies and evidence on Chlamydia testing and treatment in asymptomatic women and men who have sex with men: a narrative review
AU - Dukers-Muijrers, N.H.T.M.
AU - Evers, Y.J.
AU - Hoebe, C.J.P.A.
AU - Wolffs, P.F.G.
AU - de Vries, H.J.C.
AU - Hoenderboom, B.
AU - van der Sande, M.A.B.
AU - Heijne, J.
AU - Klausner, J.D.
AU - Hocking, J.S.
AU - van Bergen, J.
N1 - Funding Information:
This work is funded by a governmental organization grant from the Netherlands (ND): Organization for Health Research and Development (ZonMW Netherlands, registration number 50-53000-98-109 and 52-2008-002). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the paper.
Publisher Copyright:
© 2022, The Author(s).
PY - 2022/3/14
Y1 - 2022/3/14
N2 - Short summary Test-and-treat is a key strategy in the control of Chlamydia trachomatis (CT). We discuss recent controversies and present scientific evidence regarding urogenital, rectal, and pharyngeal CT test-and-treat strategies in women and in men who have sex with men (MSM). This should inform best practices for the prevention and management of the most common bacterial sexually transmitted infection (STI) worldwide.Background Chlamydia trachomatis (CT) is the most common bacterial sexually transmitted infection (STI) worldwide. CT is mainly asymptomatic. Test-and-treat strategies are widely implemented to prevent transmission and complications. Strategies are not without controversy in asymptomatic women and men who have sex with men (MSM). Concerns are emerging to test and treat asymptomatic persons for urogenital CT ('Controversy 1') and pharyngeal or rectal CT ('Controversy 2'), whereby testing symptomatic persons is not under debate. Opposed views in CT treatment involve using azithromycin versus doxycycline ('Controversy 3'). The objective of this review is to provide coverage of these public health and clinical controversies by reviewing the current scientific evidence. Methods A literature search was performed using PubMed for relevant publications between 2018 and September 2021, and iterative retrieval of additional relevant publications. Results Controversy 1. In women, the majority of asymptomatic CT are at the urogenital site, and detections mostly include viable CT. CT easily transmits to a partner and potentially also between the vaginal and rectal areas; the clinical impact of urogenital CT is established, although risks for adverse outcomes are uncertain. Wide-scale testing in asymptomatic women has not resulted in reduced prevalence. In MSM, evidence for the clinical impact of asymptomatic urogenital CT is lacking. Controversy 2. Rectal CT is common in women diagnosed with urogenital CT, but the clinical impact of asymptomatic rectal CT is uncertain. In MSM, rectal CT is common, and most CT infections are at the rectal site, yet the risk of longer term complications is unknown. In both sexes, pharyngeal CT is uncommon and has no documented clinical impact. Controversy 3. In the treatment of rectal CT, doxycycline has superior effectiveness to azithromycin. Evidence has also accumulated on the harms of test-and-treat strategies. Conclusions Current practices vary widely, from widescale test-and-treat approaches to more individual patient- and partner-level case management. Choosing which asymptomatic people to test at what anatomic site, and whether to test or not, requires an urgent (re-)definition of the goals of testing and treating asymptomatic persons. Treatment guidelines are shifting toward universal doxycycline use, and clinical practice now faces the challenge of implementation.
AB - Short summary Test-and-treat is a key strategy in the control of Chlamydia trachomatis (CT). We discuss recent controversies and present scientific evidence regarding urogenital, rectal, and pharyngeal CT test-and-treat strategies in women and in men who have sex with men (MSM). This should inform best practices for the prevention and management of the most common bacterial sexually transmitted infection (STI) worldwide.Background Chlamydia trachomatis (CT) is the most common bacterial sexually transmitted infection (STI) worldwide. CT is mainly asymptomatic. Test-and-treat strategies are widely implemented to prevent transmission and complications. Strategies are not without controversy in asymptomatic women and men who have sex with men (MSM). Concerns are emerging to test and treat asymptomatic persons for urogenital CT ('Controversy 1') and pharyngeal or rectal CT ('Controversy 2'), whereby testing symptomatic persons is not under debate. Opposed views in CT treatment involve using azithromycin versus doxycycline ('Controversy 3'). The objective of this review is to provide coverage of these public health and clinical controversies by reviewing the current scientific evidence. Methods A literature search was performed using PubMed for relevant publications between 2018 and September 2021, and iterative retrieval of additional relevant publications. Results Controversy 1. In women, the majority of asymptomatic CT are at the urogenital site, and detections mostly include viable CT. CT easily transmits to a partner and potentially also between the vaginal and rectal areas; the clinical impact of urogenital CT is established, although risks for adverse outcomes are uncertain. Wide-scale testing in asymptomatic women has not resulted in reduced prevalence. In MSM, evidence for the clinical impact of asymptomatic urogenital CT is lacking. Controversy 2. Rectal CT is common in women diagnosed with urogenital CT, but the clinical impact of asymptomatic rectal CT is uncertain. In MSM, rectal CT is common, and most CT infections are at the rectal site, yet the risk of longer term complications is unknown. In both sexes, pharyngeal CT is uncommon and has no documented clinical impact. Controversy 3. In the treatment of rectal CT, doxycycline has superior effectiveness to azithromycin. Evidence has also accumulated on the harms of test-and-treat strategies. Conclusions Current practices vary widely, from widescale test-and-treat approaches to more individual patient- and partner-level case management. Choosing which asymptomatic people to test at what anatomic site, and whether to test or not, requires an urgent (re-)definition of the goals of testing and treating asymptomatic persons. Treatment guidelines are shifting toward universal doxycycline use, and clinical practice now faces the challenge of implementation.
KW - Testing
KW - Treatment
KW - Urogenital
KW - Pharyngeal
KW - Rectal
KW - Extragenital
KW - Chlamydia trachomatis
KW - Women
KW - Men who have sex with men
KW - SEXUALLY-TRANSMITTED INFECTIONS
KW - NEISSERIA-GONORRHOEAE INFECTIONS
KW - TRACHOMATIS INFECTION
KW - PHARYNGEAL CHLAMYDIA
KW - GONOCOCCAL INFECTIONS
KW - GENITAL-INFECTION
KW - ORGANISM LOAD
KW - PRIMARY-CARE
KW - AZITHROMYCIN
KW - DOXYCYCLINE
U2 - 10.1186/s12879-022-07171-2
DO - 10.1186/s12879-022-07171-2
M3 - (Systematic) Review article
C2 - 35287617
SN - 1471-2334
VL - 22
JO - BMC Infectious Diseases
JF - BMC Infectious Diseases
IS - 1
M1 - 255
ER -