| Abstract|| |
Limited data are available on the prevalence of genital mycoplasmas and Chlamydia trachomatis (CT) among Indian patients with genital tract infections. The objectives of the study were to determine the prevalence of Ureaplasma urealyticum (UU), Mycoplasma hominis (MH), Mycoplasma genitalium (MG), and CT in patients with genital tract infections. The antimicrobial susceptibilities of UU and MH were also assessed. Endocervical swabs/urethral swabs and first void urine samples of patients (n = 164) were collected. UU and MH were detected by culture and multiplex polymerase chain reaction (PCR). MG and CT were identified by PCR. Ureaplasma isolates were further biotyped and serotyped. Antimicrobial susceptibility was done by microbroth dilution method. UU, MH, MG, and CT were detected in 15.2%, 5.4%, 1.2%, and 6% patients, respectively. Ureaplasma parvum serovar 3/14 was the most prevalent. All isolates of UU and MH were uniformly susceptible to doxycycline and josamycin. Routine screening for these pathogens and antimicrobial susceptibility testing is warranted to prevent sequel of infections and formulate treatment guidelines.
Keywords: Chlamydia trachomatis, genital mycoplasmas, genital tract infections
|How to cite this article:|
Saigal K, Dhawan B, Rawre J, Khanna N, Chaudhry R. Genital Mycoplasma and Chlamydia trachomatis infections in patients with genital tract infections attending a tertiary care hospital of North India. Indian J Pathol Microbiol 2016;59:194-6
|How to cite this URL:|
Saigal K, Dhawan B, Rawre J, Khanna N, Chaudhry R. Genital Mycoplasma and Chlamydia trachomatis infections in patients with genital tract infections attending a tertiary care hospital of North India. Indian J Pathol Microbiol [serial online] 2016 [cited 2019 Jul 17];59:194-6. Available from: http://www.ijpmonline.org/text.asp?2016/59/2/194/182019
| Introduction|| |
Genital mycoplasmas, namely Ureaplasma urealyticum (UU), Mycoplasma hominis (MH), Mycoplasma genitalium (MG), and Chlamydia trachomatis (CT) have emerged as common sexually transmitted disease (STD) pathogens both in developed and developing countries.
Genital mycoplasmas belong to the normal commensal flora of genital tract of human beings, with colonization rates between 60% and 80% worldwide. However, genital mycoplasmas are also implicated in invasive diseases such as urethritis, postpartum endometritis, chorioamnionitis, spontaneous abortion, and premature birth, as well as low birth weight, pneumonia, bacteremia, meningitis, and chronic lung disease in prematurely born infants. Certain genital mycoplasmas such as MG, Mycoplasma fermentans, Mycoplasma penetrans, and Mycoplasma pirum are candidate “cofactors” in the pathogenesis of acquired immune deficiency syndrome (AIDS). CT is the leading cause of sexually transmitted infections (STIs) with an annual detection of 92 million new cases worldwide, including 43 million from South-East Asia. CT is associated with an increased risk of pelvic inflammatory disease, ectopic pregnancy, and tubal infertility. Furthermore, chlamydial infections are associated with a 3–6 fold increase in the transmission of HIV infection. In our earlier study conducted on HIV patients, prevalence of UU, MH, and CT was found to be 6%, 1%, and 7%, respectively. Hence, documentation of these infections in high-risk populations can assist in designing HIV-risk reduction strategies as well.
Tetracyclines, macrolides, and quinolones are the major antimicrobials used in the treatment of genital mycoplasmas. However, their therapeutic efficacy may be unpredictable due to increasing resistance.
Limited studies are available from India on the prevalence of these infections in patients with genital tract infection. Although screening for conventional STIs (Neisseria gonorrhoeae and Treponema pallidum) is a routine practice in patients attending STD clinics, screening for genital mycoplasmas and CT infections is generally not done. Identification of these infections in sexually active adults can help formulate screening strategies and target prevention intervention promoting safer sexual practices.
The aim of this study was to determine the prevalence of UU, MH, MG, and CT in patients with genital tract infections. The antimicrobial susceptibilities of UU and MH isolates were also assessed to determine the most suitable treatment strategy.
| Materials and Methods|| |
All sexually active adults attending the STD clinic of a tertiary care hospital in New Delhi during January 2014 to September 2014 with symptoms of urethral or vaginal discharge were included in the study. Patients on prior treatment with antibiotics or antifungal agents within the past 4 weeks were excluded as were patients who tested positive for N. gonorrhoea, bacterial vaginosis, and vaginal candidiasis.
A total of 164 patients were enrolled in the study and were screened for infections with genital mycoplasmas and CT. An additional endocervical/urethral swabs (50 women and 17 men) were obtained from asymptomatic sexually active women/men. Ethics Committee approval for the study protocol and written informed patient consent were taken for this study.
Samples consisted of urethral/endocervical swabs and first voided urine for detection of genital mycoplasmas and CT. Swabs were transported in 2 ml of pleuropneumonia-like organisms medium broth (Difco, USA) containing urea for UU and arginine for MH. Serial 10-fold dilutions starting from 1:10 to 1:105 were prepared, and the broths were incubated at 37°C under 5% CO2 and were inspected twice daily in the absence of turbidity. The semi-quantitative cultures were positive for both Ureaplasma spp. and MH at a concentration of ≥105 color changing units per ml within 48 h of incubation. DNA was extracted using QIAamp Mini Kit (QIAGEN, Hilden, Germany) according to the manufacturer's instructions. A multiplex polymerase chain reaction (PCR) targeting the urease gene of Ureaplasma spp. and 16Sr DNA of MH was performed.Ureaplasma isolates were further biotyped and serotyped. A PCR was also performed to detect MG by targeting the 140 kDa adhesion gene using primers MgPa-1 and MgPa-3. To detect CT infection, a DNA PCR was performed targeting the cryptic plasmid using primers KL-1 and KL-2 and confirmed by a second PCR targeting the omp A gene.,
The isolates of UU and MH were subjected to antibiotic susceptibility testing against azithromycin (Hi-Media Laboratories, Mumbai, India), doxycycline (Hi-Media Laboratories, Mumbai, India), ofloxacin (Sigma-Aldrich, USA), and josamycin (Alexis Biochemicals, Switzerland) by microbroth dilution method. Cut-off minimum inhibitory concentrations (MICs) for susceptibility, intermediate, and resistance for josamycin, azithromycin, and ofloxacin were taken as ≤2, 4, and ≥8 μg/ml, respectively, and for doxycycline, the values were ≤4, 8, and ≥16 μg/ml, respectively. Statistical analysis was done using Pearson Chi-square for significance analysis.
| Results|| |
Of the total 164 patients enrolled in the study, 41 (28%) were positive for any of the above pathogens. Of these 41 patients, 29 were females and 12 were males with a mean age of 19–45 year (mean ± standard deviation, 29.970 ± 7.289 year).
UU was detected in 15.2% (25/164), and MH was detected in 5.4% (9/164) patients by culture and or PCR. MG was detected in 1.2% patients (2 male patients). In addition to genital mycoplasmas, CT was detected in 6% (10/164). Six (3.6%) of our patients were co-infected with more than one pathogen. Of these 6 patients, 3 were coinfected with UU, MH, and CT; two with UU and MH; and one with UU and MG.
All patients with Ureaplasma infection were harboring Ureaplasma parvum (Biovar 1). U. parvum serovar 3/14 was the most frequent (40%) followed by serovar 6 (28%) and serovar 1 (4.0%). All isolates of Ureaplasma were susceptible to ofloxacin and josamycin, but intermediate level resistance for doxycycline and azithromycin was noted in 4% and 8% of strains, respectively. All strains of MH were uniformly susceptible to doxycycline, ofloxacin, and josamycin.
Few studies have simultaneously investigated the relative frequency of genital mycoplasmas and CT in patients with genital tract infections. To the best of our knowledge, this is the first study to determine the prevalence of these infections in the Indian population.
| Discussion|| |
International data suggest an increase in genital Mycoplasma infections over the last decade. The prevalence of UU, CT, MH, and MG in our study was found to be 15.2%, 6%, 5.4%, and 1.2%, respectively. Regional variation in the prevalence of genital mycoplasmas has been reported ranging from 3.9% to 31% in Mexico  to 44.8% in China. The prevalence of MG in patients with nongonococcal urethritis ranges from 13% to 42%. An unusually low percentage of MG was found in our study as compared to Manhas et al. The reasons for this unexpected result cannot be explained. Further studies to investigate MG in patients with genital tract infections from India are needed.
Coexisting STIs facilitate the transmission and acquisition of other STIs, including HIV. Coinfections with these pathogens were observed in six of our patients. Strikingly, two of these patients were HIV positive as well. Detailed clinical profile was assessed for these six patients. Though coinfections were not associated with increase in severity of clinical manifestations, however, left undetected, these infections could be transmitted to their partners contributing to clinical morbidity.
In countries with scarce economic resources, syndromic treatment of STIs is appropriate for high-risk populations and symptomatic patients, whereas in asymptomatic individuals, risk scores and simple laboratory tests may be required to boost syndromic management algorithm sensitivity. Increased drug resistance in genital mycoplasmas is reported with global variations to the drugs of choice (tetracycline). All the UU isolates were sensitive to doxycycline and azithromycin. Thus, they continue to be the drugs of choice for treating genital mycoplasmas. However, an increasing MIC to both the drugs was observed thus warranting continuous monitoring of antimicrobial susceptibility pattern in our setting. All MH isolates were susceptible to josamycin, doxycycline, and ofloxacin as reported in previous studies. Our results are in agreement with those reported earlier.
Genotypic characterization of Ureaplasma is important because of the frequency with which ureaplasmas occur in healthy asymptomatic individuals. It has been suggested that only certain subgroups of the species are pathogenic. The most common biovar and serovar isolated in our study were biovar 1 (U. parvum) and serovar 3/14. Predominance of U. parvum serovar 3/14 was consistent with previous studies and suggests a possible pathogenic role of U. parvum serovar 3/14.
The high prevalence of genital mycoplasmas and chlamydial infections in our patients with genital tract infections, suggests that sexually active adults should be screened for these pathogens and barrier contraception methods should be promoted to decrease their spread and prevent long-term sequelae. Access to updated information about local patterns of antimicrobial resistance supports decision making to determine the best treatment options in patients with these infections. Considering the increasing MIC's observed for these pathogens as observed in our study warrants use of local in-vitro susceptibility testing to formulate treatment guidelines.
We thank Indian Council of Medical Research, New Delhi for financial support.
Financial support and sponsorship
We thank Indian Council of Medical Research, New Delhi for financial support.
Conflicts of interest
There are no conflicts of interest.
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Department of Microbiology, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None