MG and PID. Dr Jeannie Oliphant Dr Sunita Azariah Auckland Sexual Health Service

Transcription

1 MG and PID Dr Jeannie Oliphant Dr Sunita Azariah Auckland Sexual Health Service

2 MG and NGNCU Strong relationship between M. genitalium and NGNCU Taylor-Robinson et al Clin. Micro. Rev;24(3):498

3 MG and PID?

4 Biological plausibility M. genitalium has been shown to cause salpingitis in non-human primate species

5 Biological plausibility M. genitalium has been shown to adhere to human spermatozoa

6 Case Control Study - UK 45 women with clinical PID (UK GUM clinics) 37 women undergoing tubal ligation Conclusion: PID assoc. with MG/CT (p<0.001) Cases n= 45 Controls n= 37 M. genitalium 6 (13%) 0 C. trachomatis 12 (27%) 0 Simms et al STI;79:154

7 Case Control Studies Controls should come from the same population as the cases.

8 Epidemiological data - PEACH Substudy of PEACH trial (USA): C. trachomatis 14% N. gonorrhoeae 15% Of 311 women with endometritis a sample of 50 women (NGNC) was tested for MG M. genitalium 14% (n=7) 12% Cx and 8% of endometrial +ve and infections highly correlated (p=0.0001) Haggerty et al Infect Dis O&G;28:30184

9 Epidemiological data - PEACH Substudy of PEACH trial of 586 women with paired cx/endometrial samples: Looking at repeat samples taken at 30 days for 88 MG +ve women 41% women had repeat MG +ve tests at 30 days 66% of women with MG had co infections making further analysis difficult Adj. RR chronic pelvic pain 1.3 ( ) Haggerty et al STI;84:338

10 Cross Sectional Study - Kenya 126 women with laparoscopically diagnosed salpingitis in Nairobi, Kenya (40% HIV +ve) M. genitalium 9 (7%) C. trachomatis 8 (6%) N. gonorrhoeae 21 (17%) One positive M. genitalium result from a single fallopian tube Cohen et al STI;81:463

11 Cohort Study POPI trial UK 2378 young women recruited to POPI trial Baseline prevalence: M. genitalium 3.3% C. trachomatis 5.8% 39 women developed PID over 12 months Risk of PID +ve test at baseline -ve test at baseline MG 3.9% 1.7% CT 10.0% 1.5%

12 Cohort Study POPI trial Relative risk of PID: M. genitalium 2.35 (95%CI ) * not statistically significant C. trachomatis 6.82 (95%CI ) Oakeshott et al CID;51:1160

13 Case Control Study Post TOP 2079 women requesting TOP in Sweden Baseline prevalence: M. genitalium 2.5% (n=49) C. trachomatis 2.8% (n=51) The women with infections at baseline were matched with negative controls (n=168) Routinely all women with CT were treated with doxycycline prior to TOP

14 Case Control Study Post TOP 6/49 women with MG post-top PID 0/51 women with CT (rx doxycycline) Post-TOP PID - comparing MG +ve and infection negative controls MG +ve Controls OR p value 6/49 4/168 (95%CI) 12.2% 2.4% 6.29 ( ) 0.01 Bjartling et al Int J O&G;117:361

15 2011 REVIEW Literature review conducted to inform CDC guidelines and concluded The frequency with which M. genitalium infected women develop PID remains largely unknown and the current PID treatment guidelines should not be changed. Manhart et al CID;53(S3):S129

16 Case Control Study Sweden 5519 women attending emergency Gynae outpt service in Sweden Prevalence: M. genitalium 2.1% (n=106) C. trachomatis 2.8% (n=138) Medical records for women with infections were compared to 451 negative controls PID cases diagnosed clinically

17 Case Control Study Sweden Odds ratio for PID: M. genitalium 9.00 (95%CI ) C. trachomatis (95%CI ) Bjartling et al AJOG;206:476 B j

18 2013 Review? Evidence supports a causative role for M. genitalium in PID 1. What proportion of PID is attributable to M. genitalium? Likely to be much smaller contribution than C. trachomatis in resource rich settings However this has implications for current PID guidelines

19 2013 Review? 2. What is the risk of developing PID for a woman with M. genitalium infection? Incidence of developing PID in POPI trial; M. genitalium 4% C. trachomatis 9.5% Prospective longitudinal studies following women with M. genitalium are needed to further explore the issue of causality

20 ASHS Aims: To estimate the prevalence of Mycoplasma genitalium in the population of women attending ASHS for a sexual health screen To investigate for the presence of any association between M. genitalium and a diagnosis of PID

21 ASHS Ethics approval: NTY/19/12/122 Data analysis A sample of 250 women compared to a sample of 90 with PID has an 80% power to detect a difference at the 5% level of significance if 10% of those with PID have a positive M. genitalium test compared to 2% in those without PID.

22 ASHS Baseline prevalence 261 women attending for sexual health screen over 2/12 period from April 2011 M. genitalium 8.4% (95% C.I ) C. trachomatis 10.7% (95% C.I ) Sex Health, 2013;10(30):263-7.

23 ASHS PID recruitment Clinical diagnosis of PID recent onset of LAP with a minimum finding of cervical excitation or uterine/fornix tenderness on examination Extra cervical swab taken for M. genitalium Samples stored - 80ºC until end of recruitment. Sent to Melbourne for analysis

24 ASHS Exclusion criteria: < 16 years of age No sexual intercourse in past 3 months Hx of LAP longer than one month Recent antibiotics (past 2 weeks) Pregnant or menstruating Hx of hysterectomy or cervix could not be located Delivery/intrauterine instrumentation in past one month Declined speculum examination

25 ASHS Recruitment From April 2011 to June women were treated for PID at ASHS 60 women fitted exclusion criteria 91 women (52.6%) were enrolled into the study

26 ASHS No difference in the age of those enrolled or not enrolled Proportionally more Māori and less NZ European were in the enrolled group No statistical difference in the rate of infections (CT/NG/TV)

27 Results 91 women recruited April 2011 June 2013 Median age 25 years (16 45) Most Māori (40%) 55 (60%) had a PHx of an STI 23 (25%) had a PHx of PID Nil 38 (42%) Condoms 20 (22%) COC 9 (10%) Depo provera 4 (4%) IUCD 14 (15%) Implant 5 (6%) TL 1 (1%)

28 Results M. genitalium 9 (9.9% C.I %) Most women with M. genitalium had co infections (67%) in contrast to the baseline group (23%) Overall 37% of women with PID had STI compared to 20% of baseline group

29 Demographics Characteristics No PID n=252(%) PID n=91(%) p < (45) 58(64) (55) 33 (36) NZ European 120 (48) 25 (28) <0.001 Māori 51 (20) 36 (40) Pacific Peoples 29 (11) 17 (19) Other 52 (21) 13 (14)

30 Symptoms Characteristic No PID PID n=252(%) n=91(%) p Vaginal d/c 107 (43) 56 (62) PCB 17 (7) 12 (13) IMB 17 (7) 18 (20) <0.001 Deep dyspareunia 8 (3) 29 (32) <0.001

31 Behaviour Characteristic No PID n=252(%) PID n=91(%) p New Sexual partner 138 (55) 58 (64) Smoking 93 (37) 48/90 (53) 0.007

32 Clinical findings Characteristic No PID n=252(%) PID n=91(%) p Microscopic cervicitis Cervical mucopus Cervical bleeding 131 (51) 48/81 (59) (13) 19 (21) (18) 24 (26) 0.082

33 Results Characteristic No PID PID n=252(%) n=91(%) p C. trachomatis 25 (10) 25 (28) <0.001 M. genitalium 22 (9) 9 (10) N. gonorrhoeae 5 (2) 5 (6) T. vaginalis 8/250 (3) 5 (6) BV 128 (51) 52/89 (58) 0.215

34 Logistic regression for PID Characteristic OR (95% CI) p value Age < ( ) 0.03 NZ European Māori 2.91 ( ) Pacific Peoples 2.03 ( ) Other 1.33 ( ) No New SP ( ) 0.23 C. trachomatis 2.44 ( ) 0.01 M. genitalium 0.91 ( ) 0.84

35 Summary Significantly more C. trachomatis diagnosed in the group of women with than without PID OR 2.44 ( ) p=0.01 No difference in the rate of M. genitalium comparing women with and without PID OR 0.91 ( ) p=0.84

36 Thank you Dr Sunita Azariah ASHS Joanna Stewart, Statistician Auckland University ASHS clinic staff and patients