Low Nicola, Redmond Shelagh, Uusküla Anneli, van Bergen Jan, Ward Helen, Andersen Berit, Götz Hannelore
Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, Bern, Switzerland, CH-3012.
Cochrane Database Syst Rev. 2016 Sep 13;9(9):CD010866. doi: 10.1002/14651858.CD010866.pub2.
Genital infections caused by Chlamydia trachomatis are the most prevalent bacterial sexually transmitted infection worldwide. Screening of sexually active young adults to detect and treat asymptomatic infections might reduce chlamydia transmission and prevent reproductive tract morbidity, particularly pelvic inflammatory disease (PID) in women, which can cause tubal infertility and ectopic pregnancy.
To assess the effects and safety of chlamydia screening versus standard care on chlamydia transmission and infection complications in pregnant and non-pregnant women and in men.
We searched the Cochrane Sexually Transmitted Infections Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, CINAHL, DARE, PsycINFO and Web of Science electronic databases up to 14 February 2016, together with World Health Organization International Clinical Trials Registry (ICTRP) and ClinicalTrials.gov. We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies.
Randomised controlled trials (RCTs) in adult women (non-pregnant and pregnant) and men comparing a chlamydia screening intervention with usual care and reporting on a primary outcome (C. trachomatis prevalence, PID in women, epididymitis in men or incidence of preterm delivery). We included non-randomised controlled clinical trials if there were no RCTs for a primary outcome.
Two review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias. We resolved disagreements by consensus or adjudication by a third reviewer. We described results in forest plots and conducted meta-analysis where appropriate using a fixed-effect model to estimate risk ratios (RR with 95% confidence intervals, CI) in intervention vs control groups. We conducted a pre-specified sensitivity analysis of the primary outcome, PID incidence, according to the risks of selection and detection bias.
We included six trials involving 359,078 adult women and men. One trial was at low risk of bias in all six specific domains assessed. Two trials examined the effect of multiple rounds of chlamydia screening on C. trachomatis transmission. A cluster-controlled trial in women and men in the general population in the Netherlands found no change in chlamydia test positivity after three yearly invitations (intervention 4.1% vs control 4.3%, RR 0.96, 95% CI 0.84 to 1.09, 1 trial, 317,304 participants at first screening invitation, low quality evidence). Uptake of the intervention was low (maximum 16%). A cluster-randomised trial in female sex workers in Peru found a reduction in chlamydia prevalence after four years (adjusted RR 0.72, 95% CI 0.54 to 0.98, 1 trial, 4465 participants, low quality evidence).Four RCTs examined the effect of chlamydia screening on PID in women 12 months after a single screening offer. In analysis of four trials according to the intention-to-treat principle, the risk of PID was lower in women in intervention than control groups, with little evidence of between-trial heterogeneity (RR 0.68, 95% CI 0.49 to 0.94, I 7%, 4 trials, 21,686 participants, moderate quality evidence). In a sensitivity analysis, the estimated effect of chlamydia screening in two RCTs at low risk of detection bias (RR 0.80, 95% CI 0.55 to 1.17) was compatible with no effect and was lower than in two RCTs at high or unclear risk of detection bias (RR 0.42, 95% CI 0.22 to 0.83).The risk of epididymitis in men invited for screening, 12 months after a single screening offer, was 20% lower risk for epididymitis than in those not invited; the confidence interval was wide and compatible with no effect (RR 0.80, 95% CI 0.45 to 1.42, 1 trial, 14,980 participants, very low quality evidence).We found no RCTs of the effects of chlamydia screening in pregnancy and no trials that measured the harms of chlamydia screening.
AUTHORS' CONCLUSIONS: Evidence about the effects of screening on C. trachomatis transmission is of low quality because of directness and risk of bias. There is moderate quality evidence that detection and treatment of chlamydia infection can reduce the risk of PID in women at individual level. There is an absence of RCT evidence about the effects of chlamydia screening in pregnancy.Future RCTs of chlamydia screening interventions should determine the effects of chlamydia screening in pregnancy, of repeated rounds of screening on the incidence of chlamydia-associated PID and chlamydia reinfection in general and high risk populations.
沙眼衣原体引起的生殖器感染是全球最常见的细菌性性传播感染。对性活跃的年轻人进行筛查以检测和治疗无症状感染，可能会减少衣原体传播，并预防生殖道疾病，尤其是女性的盆腔炎（PID），盆腔炎可导致输卵管性不孕和异位妊娠。
评估衣原体筛查与标准护理相比，对孕妇、非孕妇及男性衣原体传播和感染并发症的影响及安全性。
我们检索了Cochrane性传播感染小组专业注册库、Cochrane对照试验中央注册库（CENTRAL）、MEDLINE、EMBASE、LILACS、CINAHL、DARE、PsycINFO和Web of Science电子数据库，检索截至2016年2月14日的文献，同时检索了世界卫生组织国际临床试验注册平台（ICTRP）和ClinicalTrials.gov。我们还手工检索了会议论文集，联系了试验作者，并查阅了检索到的研究的参考文献列表。
针对成年女性（非孕妇和孕妇）及男性的随机对照试验（RCT），比较衣原体筛查干预措施与常规护理，并报告主要结局（沙眼衣原体患病率、女性盆腔炎、男性附睾炎或早产发生率）。如果没有针对主要结局的RCT，则纳入非随机对照临床试验。
两名综述作者独立评估试验是否纳入、提取数据并评估偏倚风险。我们通过共识或由第三位审阅者裁决来解决分歧。我们在森林图中描述结果，并在适当情况下使用固定效应模型进行荟萃分析，以估计干预组与对照组的风险比（RR，95%置信区间，CI）。我们根据选择和检测偏倚风险对主要结局盆腔炎发病率进行了预先设定的敏感性分析。
我们纳入了6项试验，涉及359,078名成年女性和男性。一项试验在评估的所有六个特定领域中偏倚风险较低。两项试验研究了多轮衣原体筛查对沙眼衣原体传播的影响。荷兰一项针对普通人群中女性和男性的整群对照试验发现，在每年三次邀请后，衣原体检测阳性率没有变化（干预组4.1%，对照组4.3%，RR 0.96，95%CI 0.84至1.09，1项试验，首次筛查邀请时317,304名参与者，低质量证据）。干预措施的接受率较低（最高16%）。秘鲁一项针对女性性工作者的整群随机试验发现，四年后衣原体患病率有所降低（校正RR 0.72，95%CI 0.54至0.98，1项试验，4465名参与者，低质量证据）。四项RCT研究了单次筛查提供后12个月衣原体筛查对女性盆腔炎的影响。根据意向性分析原则对四项试验进行分析，干预组女性患盆腔炎的风险低于对照组，试验间异质性证据较少（RR 0.68，95%CI 0.49至0.94，I² 7%，4项试验，21,686名参与者，中等质量证据）。在敏感性分析中，两项检测偏倚风险较低的RCT中衣原体筛查的估计效应（RR 0.80，95%CI 0.55至1.17）与无效应相符，且低于两项检测偏倚风险高或不明确的RCT（RR 0.42，95%CI 0.22至0.83）。单次筛查提供后12个月，受邀筛查的男性患附睾炎的风险比未受邀者低20%；置信区间较宽，与无效应相符（RR 0.80，95%CI 0.45至1.42），1项试验，14,980名参与者，极低质量证据。我们未发现关于衣原体筛查对妊娠影响的RCT，也未发现测量衣原体筛查危害的试验。
由于证据的直接性和偏倚风险，关于筛查对沙眼衣原体传播影响的证据质量较低。有中等质量证据表明，衣原体感染的检测和治疗可在个体水平上降低女性患盆腔炎的风险。缺乏关于衣原体筛查对妊娠影响的RCT证据。未来衣原体筛查干预措施的RCT应确定衣原体筛查对妊娠的影响、重复筛查对衣原体相关盆腔炎发病率以及普通人群和高危人群中衣原体再感染的影响。
