Use of cell culture and a rapid diagnostic assay for Chlamydia trachomatis screening.

OBJECTIVE: To compare a rapid, office-based test with standard cell culture for screening of women for Chlamydia trachomatis infections. DESIGN AND SETTINGS: An 8-month prospective crossover trial used alternating screening protocols in two Baltimore (Md) sexually transmitted disease clinics from January 2 through August 14, 1991. PARTICIPANTS: Consecutive women attending the two clinics who had no indication for administration of antichlamydial antibiotic therapy (eg, history of recent sexual contact with a partner with a sexually transmitted disease, mucopurulent cervicitis, pelvic inflammatory disease, known gonorrhea, or previously diagnosed Chlamydia infections). INTERVENTIONS: Chlamydia screening was offered according to one of two protocols. Use of the two screening protocols was alternated between clinics each month. In the "rapid test clinic," eligible women were screened with both a 30-minute enzyme immunoassay test and tissue culture. Patients screened with the rapid test were asked to remain in the clinic until their rapid assay results were available so that, if positive, the patients could be treated. In the "routine screening clinic," eligible women were screened for Chlamydia by cell culture. Women identified as being infected with Chlamydia by screening culture were later confidentially notified of their test results by health department disease intervention specialists and referred for therapy. MAIN OUTCOME MEASURES: Performance of screening tests for bringing infected patients to therapy; time intervals between initial clinic visits and therapy; and pelvic inflammatory disease occurring between initial visits and therapy. RESULTS: Chlamydia cultures were positive in 100 (6.6%) of 1526 women screened with the solid-phase immunoassay, 47 of which were detected and treated on the basis of rapid test results. In contrast, 93 (74%) of 126 women with positive screening cultures returned to the clinic and received therapy. The median interval between testing and therapy for women with positive screening cultures was 14 days, and three (3.2%) developed pelvic inflammatory disease in the interval between testing and return for therapy. CONCLUSIONS: Neither cell culture nor a rapid diagnostic test performed well for ensuring therapy of women with Chlamydia infections. The sensitivity of the rapid diagnostic test was low, and nearly one fourth of the women with positive screening cultures did not return for therapy. Evaluation of screening for Chlamydia should consider the utility of strategies for bringing patients to treatment, as well as the more usual measures of test performance, such as sensitivity, specificity, and predictive values.

Routine serologic screening for syphilis in hospitalized patients: high prevalence of unsuspected infection in the elderly.

BACKGROUND AND OBJECTIVES: To evaluate the potential yield of routine serologic testing for syphilis in hospitalized patients. STUDY DESIGN: Sera from consecutive patients admitted to an inpatient general medical service of a Baltimore hospital were tested using the RPR and FTA-ABS tests for syphilis. Two hundred ninety-one (149 males and 142 females) of 344 patients (85%) hospitalized during the study period participated, with ages ranging from 17 to 98 years. Seventy-seven percent of participants were African-American. Results of serologic tests for syphilis and human immunodeficiency virus were correlated with questionnaire responses. Associations were sought between results of serologic testing and demographic characteristics, medical problems, and a history of syphilis. RESULTS: No patient had an admitting diagnosis of syphilis. Thirty-seven patients (13%) had both reactive RPR and FTA-ABS tests. Although serologic evidence of syphilis was significantly associated with age older than 50 years and with a history of syphilis, 59% of patients with both reactive RPR and FTA-ABS tests did not give a history of syphilis. Ten percent of patients were HIV seropositive; however HIV seropositivity was not significantly associated with serologic evidence of syphilis. CONCLUSION: Unsuspected latent syphilis was common in this population. Routine serologic screening for syphilis should be considered in some hospitals.

Comparison of ciprofloxacin and ceftriaxone as single-dose therapy for uncomplicated gonorrhea in women.

Although women bear the brunt of gonococcal infection-related morbidity, few large studies of gonorrhea treatment in women have been conducted. In a multicenter, double-blind, placebo-controlled trial, 181 evaluable women with uncomplicated gonorrhea were treated with ciprofloxacin (250 mg orally; 94 women) or ceftriaxone (250 mg intramuscularly; 87 women). Twenty-four percent of the participants were infected with antibiotic-resistant Neisseria gonorrhoeae. Cervical gonorrhea was cured in 100% (93 of 93) of the women treated with ciprofloxacin and 99% (83 of 84) receiving ceftriaxone. All pharyngeal (n = 5) or rectal (n = 20) infections treated with ciprofloxacin were cured, as were ceftriaxone-treated patients with pharyngeal (n = 6) or rectal (n = 21) infection. Geometric mean MICs (range) for 248 pretreatment isolates were: penicillin, 0.28 (0.015 to 8.0); tetracycline, 0.46 (0.06 to 4); ciprofloxacin, 0.003 (0.002 to 0.015); and ceftriaxone, 0.004 (0.001 to 0.125) microgram/ml. Both drugs were well tolerated. Despite the high prevalence of antibiotic-resistant gonococci in these populations, 250 mg of oral ciprofloxacin was as effective as an injection of ceftriaxone.

Cocaine hydrochloride and benzoylecgonine have no in vitro inhibitory effect against Neisseria gonorrhoeae.

We evaluated 72 clinical Neisseria gonorrhoeae isolates for in vitro susceptibility to cocaine hydrochloride and its metabolite benzoylecgonine and to penicillin, tetracycline, erythromycin, ceftriaxone, and ofloxacin. Although there was a wide range of susceptibilities to the antimicrobial agents, cocaine and its major metabolite, benzoylecgonine, had no demonstrable antigonococcal activity. Cocaine use is frequently associated with outbreaks of sexually transmitted disease. We hypothesized that the dramatically decreasing incidence of gonorrhea over the past 15 years may be in part due to pharmacological effects of cocaine. However, since cocaine and its metabolite have no in vitro antigonococcal activity, this hypothesis is unlikely.

Evaluation of Syva enzyme immunoassay for detection of Chlamydia trachomatis in genital specimens.

Detection of Chlamydia trachomatis infection was evaluated by culture and a new Syva enzyme immunoassay (EIA) in 1,012 patients at two Baltimore, Md., sexually transmitted disease clinics. The overall chlamydia prevalence determined by culture was 12%. For 506 fresh cervical and urethral specimens, the sensitivity of Syva EIA was 90% and its specificity was 94% compared with culture. Discordant Syva EIA results were further evaluated by staining the sediment in centrifuged culture transport media and Syva EIA transport tubes with a fluorescent monoclonal antibody to C. trachomatis to detect elementary bodies. Reanalysis of the data after use of this technique to resolve discordant results increased sensitivity and specificity to 92 and 96%, respectively. A subsample of 307 fresh cervical specimens was also tested in a three-way comparison using Abbott Chlamydiazyme, Syva EIA, and culture. In this sample, compared with culture, the sensitivity and specificity of Syva EIA were 87 and 95%, respectively, and for Chlamydiazyme they were 77 and 98%, respectively. Syva EIA is a 4-h, easy-to-perform enzyme-linked immunosorbent assay which has a high sensitivity with fresh genital specimens and offers an excellent alternative to culture.