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Vol. 90. Issue 6.
Pages 329-402 (01 June 2019)
Vol. 90. Issue 6.
Pages 329-402 (01 June 2019)
Scientific Letter
DOI: 10.1016/j.anpede.2018.05.012
Open Access
Is the vertical transmission of Chlamydia trachomatis a little known problem in Spain?
¿Es la transmisión vertical de Chlamydia trachomatis un problema poco reconocido en España?
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Luis Piñeiroa,
Corresponding author
, Javier Korta-Muruab,d, Sheila López-Cuestab, Izaskun Lasac, Gustavo Cillaa
a Servicio de Microbiología, Hospital Universitario Donostia-Instituto BioDonostia, San Sebastián, Guipúzcoa, Spain
b Servicio de Pediatría, Hospital Universitario Donostia-Instituto BioDonostia, San Sebastián, Guipúzcoa, Spain
c Servicio de Ginecología, Hospital Universitario Donostia-Instituto BioDonostia, San Sebastián, Guipúzcoa, Spain
d Departamento de Pediatría, Facultad de Medicina, EHU-UPV, San Sebastián, Guipúzcoa, Spain
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Tables (2)
Table 1. Clinical characteristics of vertical transmission of Chlamydia trachomatis: 103 cases of exposure (October 2010–September 2015).
Table 2. Studies on the vertical transmission of Chlamydia trachomatis that used molecular techniques for its detection.
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Dear Editor:

Infection by Chlamydia trachomatis is an important public health problem worldwide, and C. trachomatis is the most frequent bacterial cause of sexually transmitted diseases. The infection can be acquired by passage through the birth canal and may cause neonatal nasopharyngitis and/or conjunctivitis (usually with onset 5–12 days post birth) and pneumonia in the first 3 months of life.1,2 The aetiological diagnosis of these infections is important, as the symptoms overlap with those caused by other microorganisms and treatments that do not include a macrolide may not be effective against C. trachomatis. The aim of our study was to establish the rate of perinatal transmission of infection by C. trachomatis.

We conducted a prospective study between October 2010 and September 2015 by performance of real-time nucleic acid amplification tests (NAATs) (Cobas® 4800 CT/NG, Roche) to assess for the presence of C. trachomatis in 103 newborns of infected mothers identified by screening during the puerperium period at the Hospital Universitario Donostia (HUD).3 The research project was approved by the Ethics Committee of the HUD (memorandum 9/2010). All the participants, as is done routinely in all newborns delivered at the HUD, received ocular prophylaxis with a topical cream (active ingredient: tobramycin through October 2013, and chlortetracycline hydrochloride thereafter). We assessed newborns for vertical transmission 7–10 days post birth by means of a physical examination and collection of a throat swab specimen, supplemented with an eye swab specimen in cases where conjunctivitis was suspected and routinely in the last year under study. Infected newborns received an oral course of erythromycin for 14 days while this formulation was available in hospital, and thereafter a 3-day course of azithromycin. They remained in follow-up for 3 months (parents were directed to seek care if the child developed symptoms of conjunctivitis, pneumonia or nasopharyngitis), and we contacted the family by phone at the end of the follow-up period to confirm the absence of symptoms.

We found evidence of vertical transmission in 11 newborns (10.7%; 5 male and 6 female), with the cases distributed uniformly throughout the period under study. This percentage rose to 15.5% (11/71) if we excluded newborns delivered by caesarean section and/or born to mothers that had received antibiotherapy in the 48h prior to delivery (Table 1). C. trachomatis was detected in 8.7% (9/103) of pharyngeal samples and 17.6% (6/34) of eye samples (P=.15). Seven of the infected newborns were asymptomatic, while 4 (3.9% of the total included in the follow-up) had conjunctivitis, in one case associated with cold symptoms. All infected newborns received antibiotherapy (7 erythromycin, 4 azithromycin), with early resolution of infection observed in 7 out of the 8 that attended the appointment scheduled for microbiological follow-up 15 days later; in another patient, the cultures remained positive for C. trachomatis and the symptoms (conjunctivitis) persisted for 2 months due to poor adherence to treatment by the parents.

Table 1.

Clinical characteristics of vertical transmission of Chlamydia trachomatis: 103 cases of exposure (October 2010–September 2015).

Clinical characteristics  Vertical transmission (%)  P (Fisher exact test) 
Prepartum antibiotherapya.03* 
Yes  0/30 (0)   
No  11/73 (15.1)   
Mode of delivery.35 
Caesarean section  0/13 (0)   
Vaginal  11/90 (12.2)   
Gestational age
<35  0/4 (0)   
≥35  11/99 (11.1)   
Birth weight.60 
<25000/7 (0)   
≥250011/96 (11.5)   
Maternal age.35 
<25  6/42 (14.3)   
≥25  5/61 (8.2)   
Primiparous mother.45 
Yes  4/53 (7.6)   
No  7/80 (8.8)   
Forceps/vacuum delivery
Yes  1/11 (9.1)   
No  10/92 (10.9)   
Neonatal ocular prophylaxis
Tobramycin  8/72 (11.1)   
Tetracycline  3/31 (9.7)   
a

Beta lactam antibiotic (penicillin or amoxicillin/clavulanic acid) <48h before delivery (colonisation by Streptococcus agalactiae, caesarean section or other causes of intrapartum fever).

*

P=.11 if caesarean deliveries were excluded (0/20 vs 11/59).

The data on the rate of vertical transmission of C. trachomatis is scarce for Europe and non-existent for Spain. In Germany, a study that used culture for diagnosis and excluded newborns delivered by caesarean section or born to mothers treated with antibiotherapy before delivery found a prevalence of neonatal ophthalmia due to C. trachomatis of 15.2% (15/230) in newborns that received topical antibiotics for ocular prophylaxis.5 Few recent studies have investigated the perinatal transmission of C. trachomatis using NAATs, and they have reported higher rates (24%–75%), although it is difficult to compare reported rates due to the methodological differences between studies (Table 2). In Spain, assuming a prevalence of infection by C. trachomatis in women in childbirth of 1%3 and a rate of vertical transmission of 10.7%, we estimate that there would be 446 cases a year of infection in newborns (with colonisation of the nose, throat and/or eyes) based on the total births in 2015 (http://www.ine.es/prensa/np980.pdf), and that this figure would increase to approximately 750 if throat and eye swab specimens had been obtained and analysed routinely.

Table 2.

Studies on the vertical transmission of Chlamydia trachomatis that used molecular techniques for its detection.

Author (citation), country, period under study  Sample  Perinatal transmission (%)a 
Yu et al. (Curr Microbiol. 2009;58:315–320), China, Apr 03–Feb 04  Nasopharynx  8/33 (24.2%): 6/9 (66.7%) by vaginal delivery and 2/24 (8.3%) by caesarean section 
Chojnacka et al. (Ginecol Pol. 2012;83:116–121), Poland, 2004–2009  Nasopharynx and conjunctiva  6/8 (75%). Deliveries before 34 weeks’ gestation 
Justel et al. (Emerg Infect Dis. 2015;21:471–473), Angola, Dec 11–Feb 12  Conjunctiva  4/8 (50%) 
a

For all three studies, it is unknown whether neonatal ocular prophylaxis was used.

The rapid detection and treatment of infected newborns allowed the prevention of additional cases of conjunctivitis and future respiratory infection. We ought to highlight that in our study, all newborns received ocular prophylaxis immediately after birth. Although this intervention probably contributed to reducing the vertical transmission of C. trachomatis, it is only partially successful4 and less effective compared to its use against Neisseria gonorrhoeae. In addition, the risk of neonatal ophthalmia due to C. trachomatis is currently greater compared to the risk due to N. gonorrhoeae, as the former is more prevalent in pregnant women.3,5 For all the above reasons, the health authorities in some countries recommend screening pregnant women (which requires definition of the target population based on the prevalence of infection by age groups) and treating those infected, while the usefulness of neonatal prophylaxis remains under debate.1,3,6 Screening during pregnancy would allow the prevention of complications in the mother (pelvic inflammatory disease, sterility, etc.) and reduce the burden of disease in newborns, as maternal infection would be controlled before delivery.

In conclusion, based on our findings, we estimate that at least 1 in 1000 newborns in Spain acquires a C. trachomatis infection during birth, despite the routine implementation of ocular prophylaxis in newborns.

Funding

This study was partially funded by a grant from the Fondo de Investigación Sanitaria (FIS PI10/02191).

References
[1]
K.A. Workowski, G.A. Bolan, Centers for Disease Control and Prevention.
Sexually transmitted diseases treatment guidelines, 2015.
MMWR Recomm Rep, 64 (2015), pp. 1-137
[2]
J. Martins, C. Ribeiro Luís, T. Correia de Aguiar, J.M. Garrote Marcos, M. João Rocha Brito.
Chlamydia trachomatis infection in the first year of life.
An Pediatr (Barc), 74 (2011), pp. 298-302
[3]
L. Piñeiro, A. Lekuona, G. Cilla, I. Lasa, L.P. Martinez-Gallardo, J. Korta, et al.
Prevalence of Chlamydia trachomatis infection in parturient women in Gipuzkoa, Northern Spain.
Springerplus, 5 (2016), pp. 566
[4]
M.R. Hammerschlag, C. Cummings, P.M. Roblin, T.H. Williams, I. Delke.
Efficacy of neonatal ocular prophylaxis for the prevention of chlamydial and gonococcal conjunctivitis.
N Engl J Med, 320 (1989), pp. 769-772
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O. Peuchant, C. Le Roy, C. Desveaux, A. Paris, J. Asselineau, C. Maldonado, et al.
Screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium should it be integrated into routine pregnancy care in French young pregnant women?.
Diagn Microbiol Infect Dis, 82 (2015), pp. 14-19
[6]
M.R. Hammerschlag, T. Smith-Norowitz, S.A. Kohlhoff.
Keeping an eye on Chlamydia and Gonorrhea conjunctivitis in infants in the United States, 2010–2015.
Sex Transm Dis, 44 (2017), pp. 577

Please cite this article as: Piñeiro L, Korta-Murua J, López-Cuesta S, Lasa I, Cilla G. ¿Es la transmisión vertical de Chlamydia trachomatis un problema poco reconocido en España? An Pediatr (Barc). 2019;90:395–397.

Previous presentations: This study was presented at the XIX National Congress of the Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica; May 28–30, 2015; Seville, Spain. Also at the Scientific Meeting of the Sociedad Vasco-Navarra de Pediatría, V Memorial of Professor Juan Rodríguez Soriano; October 16, 2015; San Sebastian, Spain.

Copyright © 2018. Asociación Española de Pediatría
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