How Soon Can I Test Again for Chlamydia After Treatment
Sexual practice Transm Dis. 2018 February; 45(2): 132–137.
What Is the Optimal Time to Retest Patients With a Urogenital Chlamydia Infection? A Randomized Controlled Trial
Jannie J. van der Captain
From the *Department of Infectious Diseases, Public Health Service (GGD) Amsterdam, Amsterdam; †Centre for Environmental Prophylactic and Security, National Establish of Public Wellness and the Environment, Bilthoven; ‡Amsterdam Infection & Immunity Institute (AI&Ii), §Department of Dermatology Academic Medical Center, University of Amsterdam, Amsterdam; and ¶ Centre for Infectious disease Control, National Institute of Public Health and the Environs, Bilthoven, The Netherlands
Rik H. Koekenbier
From the *Section of Infectious Diseases, Public Health Service (GGD) Amsterdam, Amsterdam; †Centre for Ecology Rubber and Security, National Institute of Public Health and the Environs, Bilthoven; ‡Amsterdam Infection & Amnesty Establish (AI&II), §Department of Dermatology Academic Medical Center, Academy of Amsterdam, Amsterdam; and ¶ Center for Communicable diseases Control, National Institute of Public Health and the Environment, Bilthoven, The Netherlands
Martijn Southward. van Rooijen
From the *Section of Infectious Diseases, Public Health Service (GGD) Amsterdam, Amsterdam; †Centre for Environmental Safety and Security, National Plant of Public Health and the Environment, Bilthoven; ‡Amsterdam Infection & Immunity Institute (AI&Two), §Section of Dermatology Academic Medical Center, University of Amsterdam, Amsterdam; and ¶ Center for Infectious Affliction Control, National Establish of Public Health and the Environment, Bilthoven, The Netherlands
Maarten F. Schim van der Loeff
From the *Department of Infectious Diseases, Public Health Service (GGD) Amsterdam, Amsterdam; †Centre for Environmental Rubber and Security, National Institute of Public Wellness and the Environment, Bilthoven; ‡Amsterdam Infection & Immunity Plant (AI&II), §Department of Dermatology Academic Medical Center, University of Amsterdam, Amsterdam; and ¶ Centre for Infectious Illness Control, National Institute of Public Health and the Environment, Bilthoven, The netherlands
Henry J.C. de Vries
From the *Department of Infectious Diseases, Public Health Service (GGD) Amsterdam, Amsterdam; †Centre for Environmental Prophylactic and Security, National Institute of Public Health and the Environment, Bilthoven; ‡Amsterdam Infection & Immunity Institute (AI&Ii), §Department of Dermatology Academic Medical Centre, Academy of Amsterdam, Amsterdam; and ¶ Centre for Infectious disease Control, National Institute of Public Wellness and the Environment, Bilthoven, The Netherlands
Received 2017 May xxx; Accepted 2017 Aug 4.
Abstract
Background
Chlamydia trachomatis is a common, ofttimes recurring sexually transmitted infection, with serious adverse outcomes in women. Electric current guidelines recommend retesting after a chlamydia infection, but the optimum timing is unknown. We assessed the optimal retest interval afterwards urogenital chlamydia treatment.
Methods
A randomized controlled trial among urogenital chlamydia nucleic acid amplification test positive heterosexual clients of the Amsterdam sexually transmitted infection clinic. Afterwards treatment, patients were randomly assigned for retesting eight, xvi, or 26 weeks later. Patients could choose to do this at dwelling (and send a cocky-nerveless sample by mail) or at the clinic. Retest uptake and chlamydia positivity at follow-upward were calculated.
Results
Betwixt May 2012 and March 2013, 2253 patients were included (45% men; median age, 23 years; interquartile range, 21–26). The overall uptake proportion within 35 weeks after the initial visit was significantly higher in the 8-week grouping (77%) compared with the 16- and 26-calendar week groups (67% and 64%, respectively, P < 0.001), and the positivity proportions amidst those retested were comparable (P = 0.169). The proportion of people with a diagnosed recurrent chlamydia infection among all randomized was similar betwixt the groups (n = 69 [viii.6%], north = 52 [vii.4%], and n = 69 [nine.3%]; P = 0.4).
Conclusions
Patients with a contempo urogenital chlamydia are at high risk of recurrence of chlamydia and retesting them is an constructive way of detecting chlamydia cases. We recommend inviting patients for a re-test viii weeks after the initial diagnosis and treatment.
Chlamydia trachomatis (CT) is the virtually prevalent bacterial sexually transmitted infection (STI) worldwide1 and is by and large asymptomatic. Left untreated, chlamydia can have serious complications like pelvic inflammatory disease, ectopic pregnancy and infertility.2 Reinfections can increase the probability of complications.3 Sexually transmitted infection clinic clients with a urogenital chlamydia infection have a high reinfection rate.4,5 Retesting tin can be an effective strategy to prevent onward transmission and belatedly sequelae. National guidelines in several countries differ regarding the recommended timing of retesting of chlamydia, ranging from 3 to 12 months after initial diagnosis and treatment.6–10 Cohort studies regarding retesting have been inconclusive on the optimal timing.four,v A modeling study estimated a height in reinfections between 2 and five months.xi Studies on the uptake of retesting oftentimes show a low uptake (range of reattendance between 17% and 89%).12,13
At the Amsterdam STI dispensary, chlamydia retest uptake inside 35 weeks was 28% (678/2384), and retest positivity was 21% (142/678) amidst heterosexual clients testing urogenital chlamydia positive in 2010 (unpublished information). To our knowledge no randomized studies have been performed on the optimal timing of retesting, considering the effect on uptake and on the proportion of patients with reinfections.14 We postulated that the proportion being retested would be lower with a subsequently timing of retest and that the proportion positive would be higher with a later timing of retest. If so, we envisioned an optimum timing to offer a retest, which would provide the highest yield of diagnosed reinfections. We tested this hypothesis in a parallel-grouping randomized controlled trial. Nosotros assessed the proportion uptake of chlamydia retesting and the proportion positive amongst patients assigned and invited to get retested, 8, 16, or 26 weeks later on treatment.
MATERIALS AND METHODS
Written report Setting and Study Population
The STI clinic of the Amsterdam Public Health Service in Amsterdam, the Netherlands, is a low-threshold clinic serving approximately xl,000 clients annually.xv Clients may attend the clinic anonymously, free of charge, and without referral by a medical doctor. Clients with at least i of the following indications were tested at the dispensary: age, younger than 25 years, men who have sex with men, built-in in an STI or human immunodeficiency virus (HIV) endemic country, having received money and/or goods for sexual activity, having paid for sex, 3 or more partners in the previous six months, reporting a sexual partner from an STI and HIV owned country, notified by a sexual partner, or having STI-related symptoms (ie, symptoms the patient relates to having a possible STI). Clients younger than 25 years without any of the other abovementioned indications were routinely tested for chlamydia only, all other clients were routinely tested for chlamydia, gonorrhoea, and syphilis, and HIV using an opt-out strategy.16 For this report, all heterosexual patients of the Amsterdam STI clinic testing positive for urogenital chlamydia were included in the study between May 2012 and March 2013, and followed up through Dec 2013.
Randomization, Specimen Collection, and Testing Procedures
Patients with a positive urogenital CT nucleic acid amplification examination were randomized for chlamydia retesting, either 8, 16, or 26 weeks after they received treatment, advised on partner notification, and counselled. The randomization process was automated within the electronic patient file, and the moment of clicking a button determined the randomization category, which switched invisibly every ii seconds. Later on clicking, the randomization category appeared on the screen, and the patient was informed by the nurse when to expect an invitation for retesting. Patients were gratis to choose between 2 retest options: either collect a self-sample at domicile with a habitation collection kit (urine for men and vaginal swab for women), or return to the clinic for an on-site self-nerveless sample. Those who chose domicile collection received an electronic mail 7 days before the scheduled time of retest, informing them they would receive a self-collection kit inside the adjacent calendar week, with a preaddressed render envelope. To those who chose to render to the clinic, an email with an open invitation was sent 7 days before the scheduled time of retest. Regardless of the chosen option, email and/or SMS reminders were sent vii and xiv days later on the scheduled retest time to all patients who failed to provide a retest sample at the planned appointment.
Urine samples and cocky-collected vaginal swabs were tested using the Tigris direct tube sampling system for the detection of CT rRNA (Hologic Inc., San Diego, Calif). When the retest issue was available (approximately 7 days after providing the sample), patients received an online code to obtain their test outcome.
Statistical Assay
Patients were included in the written report but once. To appraise determinants of choice for sample collection location (home collection versus clinic based collection), nosotros performed univariable logistic regression analysis and examined the event of the following variables: sexual practice, age, ethnicity and assigned retest interval. Historic period was divided into iv categories based on the median and interquartile range (IQR); ethnicity was divided into 2 categories (Dutch and not-Dutch). Variables that were associated with sample collection location at P values of 0.1 or less in the univariable assay were entered into a multivariable model. We checked for interactions between age and sex in the final model.
For each private, nosotros used the results of their start retest afterwards inclusion regardless whether this retest was at their chosen testing location. For each randomization group, we assessed the number, per centum, and chlamydia positivity proportion of those who: (A) returned more ane calendar week before the assigned date, (B) returned at assigned engagement (this was divers as a visit in the flow >1 week earlier, until six weeks after the assigned appointment), (C) returned >half-dozen weeks after the assigned engagement just no later than 35 weeks (viii months) later inclusion, and (D) those who did not return within 35 weeks of inclusion. The primary outcomes were (1) the number and percentage retested and (two) the proportion CT positive of all included in the study arm. The Kaplan-Meier product limit method was used to estimate the cumulative probability of retesting upward to 35 weeks later inclusion, stratified by randomization arm. Those who retested more than than 35 weeks after inclusion or did not retest were censored at 35 weeks. Among those who retested CT positive upwards to 35 weeks, the median time to a positive retest was calculated.
To appraise determinants of uptake of retesting till 35 weeks after the assigned date, we performed univariable logistic regression assay and examined the effect of the following variables: sex, age, ethnicity, and assigned retest interval. Because the choice of test location was influenced by assigned test interval, and may thus be on the causal pathway between assigned test interval and test uptake, we excluded chosen test location from the multivariable model. Variables that were associated with uptake of retesting at P values of 0.1 or less in the univariable analysis were entered into a multivariable model. We considered a P less than 0.05 equally statistically significant. Analyses were performed with SPSS package version 21.0 (SPSS Inc., Chicago, Ill), STATA version 11.2 (College Station, Tex) and R version three.2.2, logistf package (Vienna, Austria).17
Ethics Argument
The study was reviewed by the ideals committee of the Bookish Medical Heart, University of Amsterdam, kingdom of the netherlands. The board exempted the written report from a full review and written patient consent because it was a modification of current exercise and did non apply to the Dutch law "Medical Enquiry Involving Human Subjects Act." The study was registered at the International Standard Randomized Controlled Trials under number ISRCTN12159453.
RESULTS
Study Population
Betwixt May 2012 and March 2013, 25,840 consultations among 22,285 heterosexual clients were performed at the clinic. In 2867 consultations, urogenital chlamydia was diagnosed. We merely included patients at their first positive chlamydia exam. In full, 2253 patients were included of whom 45% were men, 75% had a Dutch ethnicity, and the median historic period was 23 years (IQR, 21–26; range, 14–66 years). Eight hundred five (36%), 703 (31%), and 745 (33%), respectively, were randomly scheduled to a retest after eight, 16, and 26 weeks (Tabular array 1).
Table one
Full general Characteristics of Heterosexual Patients With Urogenital Chlamydia, by Assigned Retest Intervals, May 2012 to March 2013, STI Clinic Amsterdam, kingdom of the netherlands
Preferred Testing Location
Later randomization, patients chose their preferred retest location; 947 (42%) opted for the home collection kit and 1306 (58%) to reattend the clinic. Table 2 shows the univariable and multivariable logistic regression analyses of the determinants associated with home testing equally the preferred choice for chlamydia retesting. In multivariable assay, choosing domicile sample collection was significantly associated with female person sexual practice (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.05–1.50), older age (OR, 2.12; 95% CI, 1.64–ii.73 for those aged ≥26 years compared with those aged <21 years), Dutch ethnicity (OR, 1.90; 95% CI, 1.55–2.34 compared with not-Dutch ethnicity) and being assigned to the 8-week group (OR, 1.42; 95% CI, 1.16–1.76 compared with the 26-calendar week group).
Tabular array 2
Univariable and Multivariable Logistic Regression Analyses of Determinants Associated With Preference of Chlamydia Retest Collection Location (Home vs Clinic-based Drove) Among Heterosexual Patients With Urogenital Chlamydia at the STI Clinic in Amsterdam, kingdom of the netherlands, May 2012 to Dec 2013
Uptake Proportions for Chlamydia Retesting
In full, 1572 (lxx%) patients retested within 35 weeks later inclusion, and retesting was significantly college in the eight-calendar week group (n = 620, 77%) compared with the 16-calendar week group (n = 474, 67%, P < 0.001) and compared with the 26-calendar week group (n = 478, 64%, P < 0.001). Figure one shows the cumulative probability of retesting upwards to 35 weeks afterwards inclusion for each randomization group. The cumulative probability of retesting for the total group was 18.0% (95% CI, xvi.5–19.6) at 8 weeks, 42.7% (95% CI, 40.7–44.eight) at 16 weeks, 60.5% (95% CI, 58.4–62.5) at 26 weeks, and 69.0 (95% CI, 67.i–70.nine) at 35 weeks.
Cumulative probability of retesting up to 35 weeks after inclusion, by randomization grouping.
In full, 1475 (65%) were retested prior, or upwardly to vi weeks after the assigned appointment of retesting, of whom 290 (13%) were retested earlier than ane calendar week before their scheduled retest. This occurred significantly more often in the 26-weeks group (22%) compared to the 16- (thirteen%) and 8-week (v%) groups (P < 0.001; Table 3A). Of the 160 patients in the 26-calendar week group who returned earlier their assigned engagement, 101 (63%) retested inside xvi weeks. The uptake proportion of retesting in the menstruation 1 calendar week or less before vi weeks or less after the assigned date was significantly higher for patients assigned to the viii-calendar week grouping (65%) compared with those assigned to the sixteen- (l%) and 26-week (42%) groups (P < 0.001 and P < 0.001, respectively). Among those who did not return upwards to six weeks subsequently the assigned retest date the majority, 185 (75%), 229 (89%), and 267 (97%) in the 8-, 16-, and 26-week groups, respectively, did not return at all up to 35 weeks subsequently study inclusion (P < 0.001). A minor proportion did render more than vi weeks afterwards the assigned retest date merely 35 weeks or less afterward report inclusion, ranging betwixt 61 (eight%) in the 8-week group and seven (1%) in the 26-week group (P < 0.001).
Tabular array 3A
Uptake of Retesting Among Patients Assigned to One of 3 Retest Intervals, Report Period May 2012 to December 2013, Sexually Transmitted Infections Clinic Amsterdam, kingdom of the netherlands
Positivity Proportions for Chlamydia Retesting
Of 1572 patients who provided a retest sample, 7 had a missing or invalid test result, and examination results were available for 1565 (99.6%). The proportion CT positives in the period from inclusion till 35 weeks was 11%, 11% and 14% for the 8-, 16- and 26-week groups, respectively, and this did not differ significantly between the groups (P = 0.169). In the period from inclusion till 35 weeks amidst those with a positive retest, the median time to a positive retest was 8.0 weeks (IQR, 7.6–10.9 weeks) for patients assigned to the viii-calendar week group and 16.0 weeks (IQR, 15.4–17.3 weeks), and 23.four (IQR, 12.9–26.7 weeks) for those assigned to the sixteen- and 26-week groups, respectively (P < 0.001).
In the flow 1 calendar week or less before to six weeks or less later the assigned date (8, 16 or 26 weeks), the proportion CT positives was ix%, nine% and 11%, respectively, and did non differ significantly between the groups (P = 0.617; Table 3B). Amongst those who returned more than half dozen weeks subsequently the assigned date up to 35 weeks afterwards report inclusion, the proportion CT positives did not significantly differ between the groups (P = 0.305), whereas among those who returned more than i week earlier their assigned date, the proportion CT positives was significantly higher in the 8-calendar week group (38%) compared with the 16-week (thirteen%) and 26-week (23%) groups (P = 0.007).
Tabular array 3B
Proportion of Patients Positive for Chlamydia trachomatis by Assigned Retest Interval, Study Period May 2012 to Dec 2013, Sexually Transmitted Infections Dispensary Amsterdam, holland
STI-Related Symptoms
At report inclusion, 788 (35%) reported STI-related symptoms. Upon return, 110 (38%) of those who returned more than than ane week before the assigned date and 35 (36.1%) of those who returned more than 6 weeks after the assigned engagement upward to 35 weeks later on report inclusion reported STI-related symptoms (P = 0.745). STI-related symptoms did not significantly differ between those included in the 8-calendar week group (51%) and those in the sixteen-calendar week (34%) and 26-week (37%) groups, respectively, among those who returned more than than 1 calendar week before the assigned date (P = 0.183). Of those who returned ane calendar week or less earlier to vi weeks or less after the assigned date, only 21 (2%) reported STI-related symptoms, which did not differ significantly betwixt the randomization groups (P = 0.428).
Determinants for Uptake of Testing
Table 4 shows the univariable and multivariable logistic regression analyses of determinants associated with chlamydia retesting through 35 weeks after assigned date. In multivariable assay, retesting was significantly associated with the female sex (OR, 1.73; 95% CI, 1.42–ii.09), older age (OR, 1.46; 95% CI, 1.11–1.93 for those anile 21–22 years, compared with <21 years), Dutch ethnicity (OR, 1.43; 95% CI, 1.16–1.76 compared with not-Dutch ethnicity), and earlier assigned retest interval (OR, 1.xc; 95% CI, one.51–2.37 for the 8-calendar week group compared with the 26-week group).
Table 4
Univariable and Multivariable Logistic Regression Analyses of Determinants Associated With Uptake of Chlamydia Retesting Among Heterosexual Patients With Urogenital Chlamydia; Retested Till 35 Weeks Subsequently Treatment Versus not Retested Within 35 Weeks; at the STI Clinic Amsterdam, holland, May 2012 to December 2013
Subgroup Analysis
Nosotros performed several subgroup analyses. When only including patients younger than 25 years, similar results in the primary outcomes were establish compared to the main results (supplemental digital content table 1A, 1B, 2A, 2B, http://links.lww.com/OLQ/A195). When we analyzed men and women separately, we found that in the catamenia from inclusion through 35 weeks, the uptake proportion of retesting did not significantly differ betwixt men and women in each randomization group (P = 0.550). The proportion CT-positive men was significantly college compared with women in this menstruum for those assigned to the 8-week group (16% and 8%, respectively; P = 0.002), but not for those assigned to the 16-week group (xiii% and 10%, respectively; P = 0.258) and 26-calendar week group (18% and 12%, respectively; P = 0.059) (supplemental digital content table 3A, 3B, 4A, 4B, http://links.lww.com/OLQ/A195).
Discussion
To our noesis, this is the start randomized clinical trial on the optimal timing of retesting, because its effect on uptake and diagnosed reinfections. Nosotros testify that inviting STI dispensary urogenital CT patients to retest for chlamydia is a viable strategy to identify reinfections. The retest uptake was loftier, and amidst those who retested up to 35 weeks after the treatment visit, the positivity proportion was substantial, between eleven% and 15%. Considering the chance of reinfection is partly determined by the length of the period of exposure, we expected that the positivity proportion would increment with increasing time to retest. Yet, the positivity proportion did not differ significantly between the randomization groups. On the other manus, we anticipated that the invitation time for retesting would be negatively correlated with the uptake proportion. This was confirmed, the uptake proportion decreased with a later invitation time for retesting and was lowest amidst patients assigned to the 26-week grouping. The uptake proportion inside 35 weeks later the initial visit was 77% in the 8-week group and 64% in the 26-week group. However, fifty-fifty in the 26-week groups, the uptake was considerable compared with 28% uptake of retesting in the aforementioned clinic in the twelvemonth before this study (unpublished data). The median time to actual retest was significantly shorter in the 8-week grouping compared with the 16- and 26-week groups. We consider eight weeks the optimal time for an invitation to retest for urogenital chlamydia because this group showed the highest uptake proportion, whereas the median time to retest was shortest and patients had a comparable positivity proportion compared to the 16- and 26-calendar week groups. Moreover, 22% of patients scheduled in the 26-week group retested less than i week before their assigned retest moment, indicating that this may be too long.
National guidelines in several countries differ regarding the recommended timing of retesting varying from 3 to 12 months afterwards the initial positive resulthalf-dozen–9 and also differ regarding the appropriate target population. For case, the UK national guideline restricts retesting to young patients under the historic period of 25 years due to lack of sufficient evidence for retesting patients over 25 years.nine We did subgroup analyses past sex and age and observed that the uptake proportion and positivity proportion were comparable between patients younger and older than 25 years. Therefore, we recommend that retesting should not exist restricted to young patients merely.
A limitation of this study is that we did not collect data on sexual behavior, or partner modify, nor did nosotros verify partner treatment between the initial test and retest, so we cannot assess retesting rates in subgroups defined by perceived hazard for reinfection. Moreover, we did not include a randomization group of 3 months (12 weeks), although this cutoff point is used in several guidelines8,10 and might exist a suitable interval for retesting. Because the uptake decreased with prolonged retest intervals and was significantly lower in the sixteen-week retest group compared with the 8-week group, nosotros advice to invite for a retest to exist washed no afterwards than 3 months afterwards handling. On the other hand, the optimal time to detect new infections rather than to detect nonviable material from the initial infection has been debated. A retest of at to the lowest degree 8 weeks after initial diagnosis and treatment has therefore been recommended.18 In addition, prevention of reinfection past effective partner notification and education to minimize chlamydia infections remain paramount.
Lastly, since this report was performed in a STI clinic setting in kingdom of the netherlands serving a high-risk population, the results might not be generalizable to lower risk populations and other regions.
Compared with previously described efforts to retest chlamydia-positive STI dispensary clients,13,nineteen we constitute a high overall retest uptake (lxx%), especially when the time to invited retest was short (8 weeks). As opposed to these previous studies, in which patients were not offered a choice between self-sampling at habitation or sampling at the clinic, we offered patients a selection regarding the location of sample collection (home-based vs dispensary-based) and in addition, email and/or SMS reminders were sent. This might explain the loftier uptake in our setting. Of note, the pick for sample drove location was made after patients were told their scheduled retest date. It is of interest that patients assigned to a shorter interval time to retest more oft preferred home drove.
In conclusion, this clinical trial regarding the optimal timing of retesting, invitation for retesting 8 weeks after initial handling appears the optimal time to retest heterosexual patients after initial diagnosis and handling of urogenital chlamydia infection. Patients assigned to the 8-calendar week group showed the highest uptake proportion, whereas the median time to retest was shortest, and patients had a comparable positivity proportion compared with the 16- and 26-calendar week groups.
Footnotes
This work was supported by the inquiry and development fund of the STI dispensary of the Public Wellness Service Amsterdam, Amsterdam, the Netherlands (projection no 2385).
Conflict of Interest: None alleged.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5770107/
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