Trichomoniasis is estimated to be the most prevalent nonviral STI worldwide, affecting approximately 2.6 million persons in the United States (838,1055). Because trichomoniasis is not a reportable disease (1056), and no recommendations are available for general screening for T. vaginalis, the epidemiology of trichomoniasis has largely come from population-based and clinic-based surveillance studies. The U.S. population-based T. vaginalis prevalence is 2.1% among females and 0.5% among males, with the highest rates among Black females (9.6%) and Black males (3.6%), compared with non-Hispanic White women (0.8%) and Hispanic women (1.4%) (1057,1058). Unlike chlamydia and gonorrhea, T. vaginalis prevalence rates are as high among women aged >24 years as they are for women aged <24 years (1057). Among persons attending nine geographically diverse STD clinics, the trichomonas prevalence was 14.6% among women (1059), and a study of STD clinic attendees in Birmingham, Alabama, identified a prevalence of 27% among women and 9.8% among men (1060). Symptomatic women have a four times higher rate of infection than asymptomatic women (26% versus 6.5%) (1061). Rates are also high among incarcerated persons of both sexes at 9%-32% of incarcerated women (386,387,391,392,1062) and 3.2%-8% of incarcerated men (388). Women with a history of incarceration are two to five times more likely to have T. vaginalis (387,388,1063,1064). Other risk factors for T. vaginalis include having two or more sex partners during the previous year, having less than a high school education, and living below the national poverty level (1065). Women with BV are at higher risk for T. vaginalis (1066). Male partners of women with trichomoniasis are likely to have infection (1067), although the prevalence of trichomoniasis among MSM is low (179,1068).
The majority of persons who have trichomoniasis (70%-85%) either have minimal or no genital symptoms, and untreated infections might last from months to years (137,1069,1070). Men with trichomoniasis sometimes have symptoms of urethritis, epididymitis, or prostatitis, and women with trichomoniasis sometimes have vaginal discharge, which can be diffuse, malodorous, or yellow-green with or without vulvar irritation, and might have a strawberry-appearing cervix, which is observed more often on colposcopy than on physical examination (1071). Although many persons might be unaware of their infection, it is readily passed between sex partners during penile-vaginal sex (910) or through transmission of infected vaginal fluids or fomites among women who have sex with women (275,294).
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Among persons who are sexually active, the best way to prevent genital trichomoniasis is through consistent and correct use of condoms (external or internal) (18). Partners of men who have been circumcised might have a somewhat reduced risk for T. vaginalis infection (1072,1073). Douching is not recommended because it might increase the risk for vaginal infections, including trichomoniasis (1074).
T.vaginalis causes reproductive morbidity and has been reported to be associated with a 1.4-times greater likelihood of preterm birth, premature rupture of membranes, and infants who are small for gestational age (1075). T. vaginalis was also determined to be associated with a 2.1-fold increased risk for cervical cancer in a meta-analysis (1076). Another meta-analysis of six studies reported a slightly elevated but not statistically significant association between T. vaginalis and prostate cancer (1077).
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T. vaginalis infection is associated with a 1.5-fold increased risk for HIV acquisition and is associated with an increase in HIV vaginal shedding, which is reduced with T. vaginalis treatment among women without viral suppression (1078,1079). Among women with HIV infection, T. vaginalis infection is associated with increased risk for PID (1080-1082).
Diagnostic testing for T. vaginalis should be performed for women seeking care for vaginal discharge. Annual screening might be considered for persons receiving care in high-prevalence settings (e.g., STD clinics and correctional facilities) and for asymptomatic women at high risk for infection (e.g., multiple sex partners, transactional sex, drug misuse, or a history of STIs or incarceration). However, data are lacking regarding whether screening and treatment for asymptomatic trichomoniasis in high-prevalence settings for women at high risk can reduce any adverse health events and health disparities or reduce community infection burden. Decisions about screening can be guided by local epidemiology of T. vaginalis infection. Routine annual screening for T. vaginalis among asymptomatic women with HIV infection is recommended because of these adverse events associated with trichomoniasis and HIV infection.
Extragenital T. vaginalis is possible but highly uncommon compared with genital infections. A study of 500 men in San Francisco, California, reported a 0.6% rate of rectal T. vaginalis (1083); however, this might reflect deposition of T. vaginalis DNA and not necessarily active infection. Few studies of extragenital T. vaginalis among women have been published. The efficacy, benefit, and cost-effectiveness of extragenital screening are unknown, and no tests are FDA cleared for extragenital testing; therefore, rectal and oral testing for T. vaginalis is not recommended.
Diagnostic Considerations
Wet-mount microscopy traditionally has been used as the preferred diagnostic test for T. vaginalis among women because it is inexpensive and can be performed at the POC; however, it has low sensitivity (44%-68%) compared with culture (1084-1086). To improve detection, clinicians using wet mounts should attempt to evaluate slides immediately after specimen collection because sensitivity decreases quickly to 20% within 1 hour after collection (1087). More highly sensitive and specific molecular diagnostic options are available, which should be used in conjunction with a negative wet mount when possible.
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NAATs are highly sensitive, detecting more T. vaginalis infections than wet-mount microscopy among women (1060). The Aptima T. vaginalis assay (Hologic) is FDA cleared for detection of T. vaginalis from symptomatic or asymptomatic women. Reliable samples include clinician-collected endocervical swabs, clinician-collected vaginal swabs, female urine specimens, and liquid Pap smear specimens collected in PreservCyt Solution (Hologic) (698,1088). This assay detects RNA by transcription-mediated amplification with a sensitivity of 95.3%-100% and specificity of 95.2%-100%, compared with wet mount and culture (1088,1089). Among women, vaginal swabs and urine specimens have <100% concordance (1084). This assay has not been FDA cleared for use among men and should be internally validated in accordance with CLIA regulations before use with urine or urethral swabs from men. The Probe Tec TV Qx Amplified DNA Assay (Becton Dickinson) is FDA cleared for detection of T. vaginalis from vaginal (patient-collected or clinician-collected) swabs, endocervical swabs, or urine specimens from women and has sensitivity of 98.3% and specificity of 99.6%, compared with wet mount and culture (1090). Similar to the Aptima T. vaginalis assay, this test is only FDA cleared for use among women and should be internally validated for use with men. The Max CTGCTV2 assay (Becton Dickinson) is also FDA cleared for detection of T. vaginalis in patient-collected or clinician-collected vaginal swab specimens and male and female urine specimens, with sensitivity and specificity of 96.2%-100% and 99.1%-100%, respectively, depending on the specimen type, compared with wet mount and culture (1091). GeneXpert TV (Cepheid) is a moderately complex rapid test that can be performed in ≤1 hour and can be used at the POC (1092). It has been FDA cleared for use with female urine specimens, endocervical swabs, patient-collected or clinician-collected vaginal specimens, and male urine specimens, with sensitivity and specificity of 99.5%-100% and 99.4%-99.9% (1007), respectively, compared with wet mount and culture.
Multiple FDA-cleared rapid tests are available for detecting T. vaginalis with improved sensitivities and specificities, compared with wet mount. The Osom trichomonas rapid test (Sekisui Diagnostics) is an antigen-detection test that uses immunochromatographic capillary flow dipstick technology that can be performed at the POC by using clinician-obtained vaginal specimens. Results are available in approximately 10-15 minutes, with sensitivities of 82%-95% and specificity of 97%-100%, compared with wet mount, culture, and transcription-mediated amplification (1089,1093,1094). A study of 209 women aged 14-22 years reported that >99% could correctly perform and interpret a vaginal self-test by using the Osom assay, with a high correlation with clinician interpretation (96% agreement; κ = 0.87) (1094). The Osom test should not be used with men because of low sensitivity (38% compared with Aptima) (1095). The Solana trichomonas assay (Quidel) is another rapid test for the qualitative detection of T. vaginalis DNA and can yield results <40 minutes after specimen collection. This assay is FDA cleared for diagnosing T. vaginalis from female vaginal and urine specimens from asymptomatic and symptomatic women with sensitivity >98%, compared with NAAT for vaginal specimens, and >92% for urine specimens (1096). The Amplivue trichomonas assay (Quidel) is another rapid test providing qualitative detection of T. vaginalis that has been FDA cleared for vaginal specimens from symptomatic and asymptomatic women, with sensitivity of 90.7% and specificity of 98.9%, compared with NAAT (1097). Neither the Osom assay nor the Affirm VP III test is FDA cleared for use with specimens from men.
Culture, such as the InPouch system (BioMed Diagnostics), was considered the most sensitive method for diagnosing T. vaginalis infection before molecular detection methods became available. Culture has sensitivity of 44%-75% and specificity of <100% (698,1086,1098). For women, vaginal secretions are the preferred specimen type for culture because urine culture is less sensitive (698,1099,1100). For men, culture specimens require a urethral swab, urine sediment, or semen. To improve diagnostic yield, multiple specimens from men can be used to inoculate a single culture. Cultures require an incubator and are necessary for T. vaginalis drug susceptibility testing. The InPouch specimen should be examined daily for 5 days over a 7-day period to reduce the possibility of false negatives (1101).
Although T. vaginalis might be an incidental finding on a Pap test, neither conventional nor liquid-based Pap smears are considered diagnostic tests for trichomoniasis; however, women with T. vaginalis identified on a Pap smear should be retested with sensitive diagnostic tests and treated if infection is confirmed (1102,1103).
Treatment
Treatment reduces symptoms and signs of T. vaginalis infection and might reduce transmission. Treatment recommendations for women are based on a meta-analysis (1104) and a multicenter, randomized trial of mostly symptomatic women without HIV infection (1105). The study demonstrated that multidose metronidazole (500 mg orally 2 times/day for 7 days) reduced the proportion of women retesting positive at a 1-month test of cure visit by half, compared with women who received the 2-g single dose. No published randomized trials are available that compare these doses among men.
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