Reply to Dukers-Muijrers et al
Year: 2019
Type: letter
Abstract: To the Editor—Dukers-Muijrers et al provide new data that are complementary to those from our study [1]. Namely, they found that over one quarter of women who had viable Chlamydia trachomatis detected in the rectum before receiving azithromycin treatment also had viable C. trachomatis detected 4 weeks after treatment, suggesting possible treatment failures. They also note that over half of women with intermittent C. trachomatis–positive results (or “blips”) of rectal specimen tests showed evidence of viable C. trachomatis. Together, the data from our study and those from Dukers-Muijrers et al add key pieces to the puzzle of the clinical significance of rectal C. trachomatis among women. We now have data to demonstrate that, among women, (1) rectal C. trachomatis is prevalent, commonly cooccurs with vaginal C. trachomatis, and is not associated with reporting anal sex [2]; (2) detection of rectal C. trachomatis via nucleic acid amplification testing likely represents the presence of viable bacteria in the rectum; and (3) failure of azithromycin treatment for rectal C. trachomatis occurs somewhat frequently. Together, these findings suggest that limiting rectal screening to women who only report anal sex will miss a substantial number of cases but that providing azithromycin treatment to women with vaginal C. trachomatis without regard to whether they have concurrent rectal C. trachomatis could result in persistent rectal C. trachomatis. Thus, the following question remains—what additional evidence is needed to recommend routine screening for rectal infections among women? Arguably, the strongest evidence would demonstrate that these infections lead to adverse health outcomes. As we have previously noted [1], data from animal models suggest that autoinfection from the rectum to the vagina occurs [3–5], which could lead to ongoing transmission and reproductive tract morbidity. But the extent to which autoinfection occurs in humans is still unclear, and the most appropriate study design to directly test that hypothesis is equally unclear. A longitudinal study of daily rectal and vaginal specimen collection is a logical study design choice, but for such a study to demonstrate the occurrence of autoinfection, one would need to observe that women with isolated rectal C. trachomatis (ie, rectal C. trachomatis in the absence of vaginal C. trachomatis) subsequently acquired vaginal C. trachomatis in the absence of reported condomless vaginal sex. However, even that evidence would merely be strongly suggestive of autoinfection, rather than definitive. But does our inability to generate such definitive evidence mean that we should not implement rectal C. trachomatis screening for women? Given that C. trachomatis infection rates are at an all-time high in the United States [6], it seems inappropriate to ignore the existing evidence demonstrating that these infections occur in women somewhat frequently. Although the way forward is not well defined, identifying the population of women who would most benefit from routine rectal screening is paramount and is needed to define the public health response to rectal C. trachomatis. Financial support. This work was supported by the National Institutes of Health (grant U19 AI113173 to C. M. K.). Potential conflicts of interest. C. M. K. has received donations of specimen collection kits and reagents from Hologic. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Author: Christine M Khosropour
Institution: University of Washington
Language: French
Subfield: Microbiology
Field: Immunology and Microbiology
Domain: Life Sciences
Open Access status: green
OpenAlex ID: W2945940120