SOME ETIOLOGIES OF STI OBJECTIVES CHLAMYDIA TRENDING. Things are Heating Up: An Update on Emerging Sexually-transmitted Infection Agents

Transcription

1 Things are Heating Up: An Update on Emerging Sexually-transmitted Infection Agents Erik Munson Marquette University Milwaukee, Wisconsin SOME ETIOLOGIES OF STI Herpes simplex virus Human immunodeficiency virus Treponema pallidum Neisseria gonorrhoeae Sarcoptes scabiei Haemophilus ducreyi Chlamydia trachomatis Trichomonas vaginalis Ureaplasma urealyticum Mycoplasma genitalium Phthirus pubis Human papillomavirus Hepatitis A, B, C virus Molluscum contagiosum virus Calymmatobacterium granulomatis Principles and Practice of Infectious Diseases, 5th edition OBJECTIVES I. Appreciate the changing epidemiology of trichomoniasis and clinician ordering patterns on the basis of improved laboratory diagnostics II. Characterize the distribution of M. genitalium infection in females and males on the basis of a new diagnostic option III. Describe the evolution of molecular screening for human papillomavirus and application to cervical cytology WISCONSIN Milwaukee CHLAMYDIA TRENDING Metropolitan Statistical Area Mean Annual Rank Aggregate Rate/1, Memphis Milwaukee Virginia Beach-Norfolk Philadelphia Indianapolis Jacksonville San Antonio Richmond Saint Louis Birmingham United States NA Expert Rev. Anti Infect. Ther. 11: ; 213 1

2 In vitro CHALLENGE C. trachomatis Elementary Bodies RNA Amplification Result PCR Result Light Units (x1) Interpretation detected detected detected detected detected not detected detected not detected detected not tested.2 12 not detected not tested.2 14 not detected not tested.2 13 not detected not tested J. Med. Microbiol. 54: ; 25 HEPATITIS C CLINICAL DATA Hepatitis C patients with virological end-of-treatment (EOT) response may relapse after discontinuation of therapy Residual serum HCV RNA detected by RNA amplification in 34.6% of PCR-negative relapse patients Am. J. Gastroenterol. 96: ; 21 EXTRA-UROGENITAL GONOCOCCUS Source Modality Sensitivity (%) Specificity (%) Inherent robustness of transcription WHY?? Pharynx Rectum Culture DNA amplification (PCR) RNA amplification (TMA) Culture DNA amplification (PCR) RNA amplification (TMA) Sex. Transm. Dis. 35: ; 28 ~1, copies of rrna per C. trachomatis cell ~1 copies of plasmid DNA per C. trachomatis J. Clin. Microbiol. 35: ; 1997 Some, but not all, commercial amplification systems employ target capture TARGET CAPTURE TARGET CAPTURE ~ Magnetic Bead C. trachomatis probe C. trachomatis RNA Mucus BLOOD Epithelial cell Bacterial RNA Mucus BLOOD RNA BLOOD Bacterial RNA Mucus Magnetic C. trachomatis RNA C. trachomatis probe Epithelial cell ~ Bead RNA BLOOD Mucus Bacterial RNA Mucus Bacterial RNA BLOOD Magnetic Bead ~ C. trachomatis probe C. trachomatis RNA C. trachomatis RNA Magnetic C. trachomatis probe ~ Bead 2

3 LOCAL APPLICATION (21-216) Gender Source n Detection Rate (%) C. trachomatis N. gonorrhoeae Female Pharynx Rectum Male Pharynx Rectum Trich is just an itching disease; why should I care? Courtesy of K. L. Munson, Ph.D. SOCIAL/PUBLIC HEALTH I HIV transmission facilitated by T. vaginalis infection Sex. Transm. Dis. 31: ; relative risk for per-act probability of HIV transmission for T. vaginalis-positive women at start of two-year surveillance (P =.2) J. Infect. Dis. 25: ; 212 Estimated $167 million for T. vaginalis-attributable HIV infection Sex. Transm. Dis. 31: ; 24 SOCIAL/PUBLIC HEALTH II Human papillomavirus (HPV) / cervical neoplasia Difference in median time to clear HPV infection Arch. Pediatr. Adolesc. Med. 16: ; 26 Trichomonas vaginalis TMA SCREENING TMA clinical testing began in 27 Vaginal swab Cervical swab Female urine Urethral swab Male urine Three-year audit Number of Screens J. Clin. Microbiol. 49: ; 211 Male urogenital Female urogenital Total * 28 I 28 II 29 I 29 II 21 I 21 II Biannum TRANSCRIPTION-MEDIATED AMPLIFICATION STI Agent Percentage Detection from Females Initial Validation (n = 186) J. Clin. Microbiol. 46: ; 28 J. Clin. Microbiol. 49: ; 211 Community Audit (n = 7277) Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis

4 DETECTION RATE Specimen Percentage Detection Trichomonas vaginalis Chlamydia trachomatis Neisseria gonorrhoeae Endocervix 8.9 P = Vagina P <.4.4 Female urine J. Clin. Microbiol. 49: ; 211 J. Clin. Microbiol. 49: ; 211 OTHER T. vaginalis DETECTION Modality Performance Indices (%) Sensitivity Specificity Reference Wet mount microscopy Antigen detection Nucleic acid hybridization J. Clin. Microbiol. 46: ; 28 2 Diagn. Microbiol. Infect. Dis. 68: 66-72; 21 3 Sex. Transm. Infect. 86: ; 21 4 J. Clin. Microbiol. 54: 5-51; J. Clin. Microbiol. 49: ; 211 J. Clin. Microbiol. 5: ; 212 CLINICAL/PUBLIC HEALTH Non-gonococcal urethritis; prostatitis Sex. Transm. Dis. 7: ; 198 J. Chemother. 14: ; 22 HIV transmission Clinical condition T. vaginalis urethritis Non-T. vaginalis urethritis Median copies HIV RNA/mL semen 3.45 x x 1 5 Sex. Transm. Dis. 26: ; 1999 Odds ratio of 6.4 (95% CI ) for diagnosis of lethal prostate cancer in seropositive patients with documented history of T. vaginalis infection J. Natl. Cancer. Inst. 11: ; 29 J. Clin. Microbiol. 51: 11-14; 213 4

5 11 MILWAUKEE COUNTY ZIP CODES African American (7): Mean difference between African American and Caucasian populations was 43.9% per ZIP Caucasian (4): Mean difference between Caucasian and African American populations was 32.6% per ZIP RACE/ETHNICITY (Males) Parameter Geographical Region Race Majority African American Caucasian P value Percentage urine submissions Mean screenings per ZIP code Percentage detection of: Trichomonas vaginalis Chlamydia trachomatis Neisseria gonorrhoeae Number of Screens Female urine 29.% Male urine 13.2% Urethra Vagina.4% 6.3% * Cervix 51.1% Male urogenital Female urogenital Total Year J. Clin. Microbiol. 51: 11-14; 213 Expert Rev. Anti Infect. Ther. 15: ; 217 Int. J. Syst. Bacteriol. 33: ; 1983 CLINICAL SIGNIFICANCE (MALES) Increased M. genitalium molecular detection in males with acute non-gonococcal urethritis (NGU) than in males without NGU J. Eur. Acad. Dermatol. Venerol. 18: 1-11; 24 M. genitalium-positive males more likely to exhibit urethritis than C. trachomatis-positive males Sex. Transm. Infect. 8: ; 24 Male infertility; spermatozoa motility Clin. Microbiol. Rev. 24: ; 211 5

6 8 7 DETECTION RATE (MALES) P =.96 AGE OF POSITIVE MALES Detection Rate (percentage) P <.2 P =.2 Agent Median Mean Range Mycoplasma genitalium Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis All mean detection age comparison P.6, except N. gonorrhoeae vs. M. genitalium (P =.78) Mycoplasma genitalium Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis Agent Diagn. Microbiol. Infect Dis. 82: ; 215 Diagn. Microbiol. Infect Dis. 82: ; 215 STI CLINIC; M. genitalium ONLY Preferences 58.9% heterosexual 8.4% bisexual 32.6% homosexual Partners median 4 mean 5.18 range % symptomatic for urogenital disease Discharge 49.1% Dysuria 14.% Burning/tingling 35.1% Itching 14.% Diagn. Microbiol. Infect Dis. 82: ; 215 STI Phenotype Percentage of Patients Delineated by Healthcare Setting M. genitalium Chlamydia Neisseria Trichomonas STI Clinic Outpatient P value <.2 Any detection of Mycoplasma genitalium Any detection of Chlamydia trachomatis Any detection of Neisseria gonorrhoeae Any detection of Trichomonas vaginalis <.2 Diagn. Microbiol. Infect Dis. 82: ; 215 CLINICAL SIGNIFICANCE (FEMALES) Females with high-burden M. genitalium more likely to shed HIV-1 DNA than M. genitalium-negative females J. Infect. Dis. 197: ; 28 Associated w/ reproductive disease (meta-analysis) Cervicitis pooled OR 1.65 PID pooled OR 2.53 Pre-term birth pooled OR 2.33 Spontaneous abortion pooled OR 1.82 Clin. Infect. Dis. 61: ; 215 Detection Rate (percentage) DETECTION RATE (FEMALES) P =.5 P =.3 P <.2 Mycoplasma genitalium Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis Agent J. Clin. Microbiol. 54: ; 216 6

7 AGE OF POSITIVE FEMALES DETECTION % BY LOCATION Agent Median Mean Range Mycoplasma genitalium Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis M. genitalium, C. trachomatis mean detection age comparison P =.3 All T. vaginalis mean detection age comparisons P.9 Location n Chlamydia Neisseria Trichomonas M. genitalium Overall Detection Sole Detection a Outpatient OB/GYN # ER/urgent care # Outpatient OB/GYN # ER/urgent care # Urban family care # Suburban family care # ALL LOCATIONS a Percentage of M. genitalium detections not involving co-detection with another agent J. Clin. Microbiol. 54: ; 216 J. Clin. Microbiol. 54: ; 216 EMERGENT VERSUS SUBACUTE Setting n M. genitalium detection (%) T. vaginalis detection (%) P value Milwaukee STI Clinic 22 months, 1493 encounters 54.3% urine, pharyngeal, rectal 4.8% urine, pharyngeal 3.% urine ER/urgent care (6) Non-Emergency Department Outpatient OB/GYN (8) Inpatient OB/GYN (1) Suburban family care (2) Urban family care (3) J. Clin. Microbiol. 54: ; 216 J. Clin. Microbiol. 55: ; 217 METROPOLITAN INTERVENTION On-line HIV prevention intervention Targeted to HIV-negative YMSM in Chicago area; referrals by community-based organizations (CBO) Baseline, 3-mo follow-up for condomless anal sex Comparison to didactic intervention means impactprogram.org INTERVENTION MODULES Peer videos discussing connections to and support from family, community with respect to choices Stylized animation to follow on-line hook ups; focus on identifying triggers for unprotected sex Soap opera with diverse cast highlighting risks in making assumptions about partner monogamy or HIV status Animated virtual reality bar/club game discussing condom use and pitfalls of decision making under influence of drugs/alcohol Flash animation discussing power dynamics of dating relationship Illustrated story about having needs met within dating relationship Development of practical HIV and STI prevention plan AIDS Behav. 17: ; 213 7

8 MULTI-CENTER INTERVENTION On-line HIV prevention intervention (plus apps) 12 participants completed study 44% reduction in unprotected anal sex acts at end of follow-up AIDS Behav. 17: ; 213 Targeted to HIV-negative YMSM in three cities; referrals by CBO, recruitment via social media Baseline, 3, 6, 12-mo follow-up for STI and at-risk Comparison to didactic intervention means JMIR Res. Protoc. 6: e1; 217 BASELINE SCREENING (YMSM = 1113) Self-collected urine and rectal specimens tested for C. trachomatis and N. gonorrhoeae 15.1% positive for an STI 13.% positive for rectal STI (higher among AA) 3.4% positive for urethral STI Rectal chlamydia (~8%) > rectal gonorrhea Rectal STI associated with condomless receptive anal sex with casual partners Sex. Transm. Dis. 44: ; 217 Courtesy of Charlotte Gaydos, Dr.Ph. PURPOSE/GOAL OF HPV DETECTION EVOLUTION OF HPV DIAGNOSTICS Use molecular HPV testing to triage ASC-US patients Method Positive Negative Cytology 8.5% 97.9% H c 2 1.% 99.5% Chemistry Product Manufacturer Mechanism Hybrid capture H c 2 Digene (Qiagen) DNA hybridization Invader Cervista Third Wave (Hologic) DNA hybridization PCR Cobas 48 Roche DNA amplification TMA APTIMA HPV Gen-Probe (Hologic) RNA transcription J. Natl. Cancer Inst. 93: ; 21 8

9 CERVISTA EVALUATION CERVISTA TOO POSITIVE?? Percentage Detection Cytologic Classification P value Cervista H c 2 HSIL LSIL ASC-US NILM Total Diagn. Microbiol. Infect. Dis. 71: ; 211 Am. J. Clin. Pathol. 134: ; 21 RETROSPECTIVE COMPARISON RETROSPECTIVE COMPARISON Percentage Detection Cytologic Classification P value Cervista H c 2 HSIL LSIL ASC-US NILM Percentage Detection Cytologic Classification P value Cervista H c 2 ASC-US; age < ASC-US; age NILM; age < NILM; age J. Clin. Microbiol. 51: ; 213 J. Clin. Microbiol. 51: ; 213 TRANSCRIPTION PROSPECTIVE COMPARISON 5S subunit Evidence of bioactivity Evidence of persistence 8.9% 2.4% 15.7% RIBOSOME Cervista positive/gen-probe positive Cervista negative/gen-probe negative Cervista positive/gen-probe negative Cervista negative/gen-probe positive 3S subunit P A messenger RNA Detection of E6/E7 transcripts from high-risk HPV 73.% 1% of underlying CIN2+ detected by both assays J. Clin. Microbiol. 52: ; 214 9

10 HPV PCR 226 ThinPrep vials subjected to Cervista; also HPV PCR via Cobas % concordant positive 56.7% concordant negative 2.7% Cervista negative; Cobas positive 15.% Cervista positive; Cobas negative Majority adjudicated as low-risk HPV or as HPV-negative 112th General Meeting American Society for Microbiology RETROSPECTIVE COMPARISON Percentage Detection Cytologic Classification P value Cervista HPV TMA HSIL ASC-H LSIL ASC-US NILM <.2 Cumulative <.2 J. Clin. Microbiol. 52: ; 214 CERVISTA POSITIVES Pool of 14 high-risk HPV oligonucleotides distributed among three mixes Cervista negative/ TMA positive Frequency DNA extract Mix Mix 2 Mix 3 Hybridization signal versus background: Positive if one or two mixes exceeds Positive if all three exceed 1.92 (triple-positive; TP) Cervista positive/ TMA negative J. Clin. Microbiol. 52: ; 214 Frequency ASC-H ASC-US ASC-US ASC-H ASC-US ASC-US LSIL LSIL LSIL LSIL NILM NILM NILM NILM HSIL HSIL RELATIVE LUMINESCENT OUTPUT SUMMARY General benefits of commercial RNA amplification TMA Result n Mean Cervista Luminescence from: a Mix 1 b Mix 2 b Mix 3 b Genomic DNA positive negative c 2.61 c 3.14 c 19.4 d a From Cervista TP specimens b TP hybridization signal versus background exceeds 1.92 for all three mixes c P <.1 versus mean luminescence from TMA positive specimens d P =.5 versus mean luminescence from TMA positive specimens J. Clin. Microbiol. 52: ; 214 Changing epidemiology of trichomoniasis on basis of highly-accurate molecular assay M. genitalium dichotomy within females and males on basis of novel molecular assay Increased specificity of HPV molecular diagnostics as testing methods have evolved 1