International Journal of srD & AIDS 1992: 3: 434-436
Prevalence of urogenital Chlamydia trachomatis infection in EI Salvador. II. Gynaecology outpatients Ana Berta Canas Posada sse'. Jon Jonasson MD PhD 2, Leonor de Linares MD MSc1 and Solgun Bygdeman MD PhD 2 lDepartment of Microbiology, Faculty of Medicine, University of £1 Salvador; and 2Karolinska Institute, Department of Clinical Bacteriology, Huddinge Hospital, Stockholm, Sweden Summary: The prevalence of urogenital infection caused by Chlamydia trachomatis was examined in 100 non-pregnant women with cervicitis, and 100 healthy women, in San Salvador City, El Salvador. Pharmacia Chlamydia EIA test was used for the detection of chlamydial antigen in urethral and cervical specimens from all the women. Direct immunofluorescence was used for confirmative tests on the EIA positive and the negative gray zone samples. C. trachomatis antigen was detected in 28% of the women with cervicitis compared with 5% in the group of healthy women (P < 0.001). The cervicitis group were also screened for Neisseria gonorrhoeae which was isolated from 12% of them. One strain out of 12 was beta-lactamase producing (PPNG). Five per cent of the women with cervicitis had simultaneous C. trachomatis and N. gonorrhoeae infections. Keywords: Chlamydia trachomatis, Neisseria gonorrhoeae, cervicitis, healthy women, El Salvador
MATERIALS AND METHODS
A principal cause of cervicitis is infection caused by Chlamydia trachomaiis), Furthermore, C. trachomatts is a major cause of salpingitis', tubal infertilityand acute pelvic inflammatory disease (PID)3. The prevalence of chlamydial infection differs among various population groups with risk factors such as age, sexual activity, use of oral contraceptives, racial and socio-economic conditions and previous exposure to sexually transmitted diseases being more important than the geographic location of the country under investigationv". The prevalence of chlamydial infection in El Salvador is not well known, since laboratory investigations of this disease are not performed routinely owing to the lack of adequate resources. The aim of the present study was to obtain data about the prevalence of C. trachomatis in two different groups of women-non-pregnant gynaecology outpatients with the clinical diagnosis of cervicitis and healthy women attending for cervical cytology. The women with cervicitis were also investigated for prevalence of gonorrhoea.
Correspondence to: Ass. Prof. Solgun Bygdeman, Department of Clinical Microbiology, F72, Huddinge Hospital, S-141 86 Huddinge, Sweden
Study population Non-pregnant women, attending with vaginal discharge, dysuria and/or lower abdominal pain at either the Salvador City or the Health Center of the University of El Salvador from April to September 1989 were considered for the study. Those who, upon examination by the gynecologist, were given the clinical diagnosis of cervicitis were included in the cervicitis group (n == 100). The selection was consecutive with a maximum of 2 patients per session. The second group (Pap group), consisted of 100 consecutive healthy non-pregnant women who came to the same clinics for their annual Papanicolau smear. Each patient was interviewed using a standardized questionnaire. Information was obtained about age, marital status and present symptoms. After verbal consent had been obtained, specimens were collected. Sampling and laboratory methods Specimens for the laboratory diagnosis of C. trachomatis infection using the Pharmacia Chlamydia EIA test (EIA) (Pharmacia Diagnostics AB, Uppsala, Sweden) were taken from the urethra and the cervix of all women using standard techniques. A direct
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Canas et al. Prevalence of C. trachomatis in gynaecology outpatients in El Salvador
immunofluorescence test, MicroTrak Chlamydia trachomatis Direct Specimen Test (DFA) (Syva Company, Palo Alto/ USA), used for the confirmation of EIA positive and negative /gray zone/ results was performed on the transport media of the samples. The EIA and DFA tests were performed as described9 • Specimens with an absorbance value within 0.02 units below the cut-off value were considered to be in the negative /gray zone'. A sample with an absorbance ratio (absorbance/cutoff value) above or equal to 1.0 was considered positive, and those below 1.0 negative. All micro~copical analysis were performed by the same Investigator. . A woman was classified as Chlamydia positive if (1) one or both samples were positive by EIA and confirmed by DFA with at least one elementary body (EB), or (ii) negative by EIA (gray zone), in one or both samples, but positive by DFA with three or more EBs. In the cervicitis group specimens from the urethra and the cervix were also taken for N. gonorrhoeae culture before sampling for the detection of chlamydial antigen. They were directly inoculated o~to freshly prepared hematin agar plates with and without antibiotics (polymyxin, 2.5 mgll and vancomycin, 1.5 mg/l). With the same swab a smear was made, which was Gram stained. After inoculation, the hematin agar plates were immediately placed in a candle jar and incubated at 37°C ~or 48 h. Suspected gonococcal colonies were Investigated by oxidase reaction and Gram stain. The Phadebact Monoclonal GC Test (Pharmacia ~iagnostics AB, Uppsala, Sweden) was used for ~dentification and serogrouping of the gonococci Into serogroups WI and WII/III. The test was performed according to the instructions of the manufacturer. Each confirmed gonococcal strain was tested for the presence of beta-lactamase production by the nitrocephin disk test l O and the clover-Ieaf' test!'. The smears from the endocervix and from the ~rethra were Gram stained and analysed for Intracellular diplococci and number of polymorphonUclear leucocytes.
All women in the cervicitisgroup had signs and/or symptoms of a genital infection at the time of investigation; 27 of the women had abnormal vaginal discharge and dysuria, 23 had abnormal vaginal discharge and lower abdominal pain, and 50 of them had abnormal vaginal discharge only. Chlamydia trachoma tis antigen detection
Cervicitis group The prevalence of Chlamydia infected women in the cervicitis group was 28%. In 5 women the infection was found only in the urethra. Twenty-three of the 28 Chlamydia positive women were positive for both EIA and DFA tests in at least one site (Table 1). The EIA absorbance ratio varied from 1.01 to 10.75/ and 1 to > 100 EBs were found in the DFA test. However, in 4 women the EIA test was positive with an absorbance ratio between 1.16 and 4.21/ but in the DFA test no EBs could be found. These women were classified as Chlamydia negative. In 6 women the EIA test was negative in the gray zone, but the DFA test was positive in 5 of them with 3 to 5 EBs and, thus, these 5 women were classified as Chlamydia positive. According to our criteria 72 women were considered Chlamydia negative. The EIA test was negative below the gray zone for 67 of these women and consequently the DFA test was not performed. Pap group In the Pap group/ 5 women were clearly positive by EIA and DFA tests (Table 1). The absorbance ratio ranged from 1.00 to 8.3 and in the DFA test the range of EBswere from 4 to 16. Another woman was EIA negative in the gray zone; when the DFA test was performed EBs were not found and, thus, this woman was classified as Chlamydia negative. Hence, the prevalence of chlamydial infection was 5%. The 5 Chlamydia positive women were infected in both the urethra and the cervix. Only one of the 5 Chlamydia positive women had mild inflammatory changes on the Papanicolau smear. The others had 'normal' smears.
Statistical analysis Descriptive statistics and correlation analysis with the chi-square test were performed using the computer program Quest (University of Umea, Sweden).
Table 1. Outcome ofconfirmatory chlamydial tests by DFAon EIA positive and gray zone negative samples DFA EIA
The women in the cervicitis group were of the same age as those in the Pap group (median age 24 and 25 years, range 14-46 years and 17-57 years). The proportion of unmarried women was equal in the two groups (76% and 73%).
5 0 5
0 1 1
Pap group +
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International Journal of SID & AIDS Volume 3 November/December 1992
The prevalence of gonorrhoea in the cervicitis group was 12%. The patients were positive in both the urethra and the cervix. Nine of the 12 isolates belonged to serogroup WIIIIII, and 3 to serogroup WI. Only one of the strains was beta-Iactamase producing (PPNG). Intra- and/or extra-cellular Gram negative diplococci were found in the smears from 10 of the 12 women with positive gonococcal culture. All the patients with gonorrhoea showed 10 or more leukocytes per field of view in the smear compared with 64% (56/88) of those with negative gonococcal culture (P=0.03). Comparison between gonorrhoea and urogenital chlamydial infection
Gonorrhoea and/or chlamydial infection was found in a total of 35 out of 100 non-pregnant women with cervicitis. Five of these women were infected with both organisms. C. trachomatis was detected significantly more often than N. gonorrhoeae, ie 28% vs 12% (P