Retrospective study on the characteristics of common urogenital tract pathogens in Beijing

doi:10.21203/rs.3.rs-5285563/v1

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Retrospective study on the characteristics of common urogenital tract pathogens in Beijing

https://doi.org/10.21203/rs.3.rs-5285563/v1

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Background: This study aims to investigate the infection status of Mycoplasma genitalium (MG), Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Ureaplasma urealyticum (UU) among male and female patients in Beijing, with the objective of providing a foundation for clinical diagnosis and treatment.

Methods: A comprehensive collection of 7,373 urine and vaginal swab samples was obtained from male and female patients admitted to the China-Japan Friendship Hospital between December 2019 and March 2024. The detection of MG-RNA, CT-RNA, NG-RNA, and UU-RNA was performed using a real-time fluorescent nucleic acid isothermal amplification assay (SAT). Subsequently, the infection status was analyzed across different variables, including sex, age, and diagnosis.

Results: The overall positive detection rates for MG, CT, NG, and UU among all patients were 2.70% (199/7373), 3.76% (277/7373), 1.84% (136/7373), and 21.99% (1621/7373), respectively. Notably, the detection rate of UU was significantly higher compared to the other three pathogens, with the difference being statistically significant (P < 0.01). Among male patients, the infection rates for MG, CT, NG, and UU were 2.76% (173/6268), 3.72% (233/6268), 1.99% (125/6268), and 16.16% (1013/6268), respectively. In females, the infection rates for MG, CT, NG, and UU were 2.35% (26/1105), 3.98% (44/1105), 1.00% (11/1105), and 55.02% (608/1105), respectively. The infection rate of UU in females was significantly higher than that in males, whereas the infection rate of NG was higher in males than in females. These differences were statistically significant (P < 0.05).

Conclusions: UU is the predominant infection of the urogenital tract in both male and female patients in the Beijing area. Therefore, it is imperative to enhance early screening and monitoring in clinical diagnosis and treatment, and to initiate early clinical intervention.

Mycoplasma genitalium

Chlamydia trachomatis

Neisseria gonorrhoeae

Ureaplasma urealyticum

Sexually transmitted infections

Urogenital tract infections represent a significant and detrimental category of transmissible diseases on a global scale. MG, CT, NG and UU are four prevalent pathogenic microorganisms responsible for urogenital tract diseases in humans. These pathogens are primarily transmitted through sexual contact and are associated with urogenital tract inflammation in both males and females, infertility, and other adverse health outcomes^{[1, 2]}. Sexually transmitted infections (STIs) caused by NG and CT are common causes of vaginitis and can lead to tubal infertility, one of the most common causes of infertility^{[3, 4]}. UU infection can adversely impact the morphology and quality of male sperm, thereby constituting a significant etiological factor in male infertility^{[5, 6]}. MG is a sexually transmitted infection pathogen in the urogenital tract, with an estimated prevalence of 7.3% in high-risk populations worldwide^[7], and can cause acute and chronic nongonococcal urethritis in men, and cervicitis and ovulation infertility in women^[8–10].

The global burden of STIs remains substantial, with the World Health Organization (WHO) estimating that over 1 million individuals contract STIs daily^[11]. Beijing, characterized by its advanced economic development and substantial population mobility, exhibits a high incidence of disease infection and transmission. In recent years, the rising prevalence of MG, CT, NG and UU, coupled with the occurrence of mixed infections involving multiple pathogens, has significantly complicated clinical diagnosis and treatment^[12–14]. The diversity of pathogens and the emergence of drug resistance pose significant challenges to healthcare practitioners. To elucidate the infection status of four types of pathogens in female patients with urogenital tract infections in the Beijing area, comprehensive detection of MG, CT, NG and UU was conducted among male and female outpatients at the Beijing China-Japan Friendship Hospital over the past four years. The study analyzed infection status across different genders, age groups, and diagnostic categories to provide a laboratory basis for clinical diagnosis and treatment.

Subjects

From December 2019 to March 2024, 7373 urine and vaginal swab samples were collected from 6268 male and 1105 female patients at the China-Japan Friendship Hospital. The patients, aged 12 to 99 years with an average age of 35.30 ± 9.04 years, typically presented with urogenital infection symptoms like frequent urination, urgency, and abdominal pain. The research protocol follows the principles outlined in the Declaration of Helsinki II and was approved by the hospital Ethics Committee.

Reagents and instruments

Reagents and Instruments: The sample preservation solution, as well as the extraction and amplification reagents, were procured from Shanghai Rendu Biotechnology Co., LTD^[15]. The methodological approach was established using Tianlong fluorescence quantitative PCR.

Specimen collection and preservation

Swab samples were collected by inserting a medical cotton swab into the male urethral opening or the female cervical opening to a depth of approximately 1 to 2 cm. The swab was then rotated for one week, left in place for 10 seconds, and subsequently removed. The swab head was immersed in 1 mL of 0.9% NaCl solution, pressed against the tube wall to expel excess liquid, and then 0.5 mL of sample preservation solution was added to the mixture. This constituted the sample to be analyzed. For urine specimens, the first urine of the morning or the first 1 mL of urine after a prolonged period (at least 1 hour) without urination was collected. This urine sample was then mixed with 1 mL of urine preservation solution and stored 2–8 ℃ for further analysis.

Sample processing and nucleic acid extraction

Take 1.5 mL clean EP tubes and add 400 µL of the sample to be tested. Subsequently, add 100 µL of nucleic acid extraction solution (pre-mixed prior to use). Seal the tube and shake it for 30 seconds. Incubate the tube at 60°C for 5 minutes, followed by a 10-minute incubation at room temperature. Place the EP tube on a magnetic bead separation device. Once the magnetic beads have adhered to the tube wall, use a pipette to remove any bubbles and liquid from the tube, ensuring the magnetic beads are retained. Wash the tube twice with washing solution, adding 1 mL of washing solution each time and shaking to mix thoroughly.

Subsequently, the EP tube was removed from the magnetic bead separation device, and 40 µL of amplification detection liquid was added to each tube, followed by thorough shaking and mixing. A 30 µL aliquot of magnetic bead suspension was then transferred into a new microreaction tube.

Nucleic acid amplification detection and result interpretation

The reaction tube was incubated at 60°C for 10 minutes and subsequently at 42°C for 5 minutes, during which the enzyme was preheated to 42°C. The microreaction tube was maintained at 42°C, after which 10 µL of the preheated enzyme was added. The tube was then sealed, shaken at 1,200 rpm for 15 seconds, and mixed thoroughly. Promptly transfer the microreaction tube to the fluorescence detector and initiate the reaction procedure immediately. Simultaneous amplification and testing (SAT) were conducted under the following conditions: 1 minute per cycle at 42°C for a total of 40 cycles. The fluorescein channel was configured as FAM, and fluorescence signals were collected at one-minute intervals^[16]. The reaction volume was set to 40 µL. Negative and positive controls were included for each pathogen in every batch. Based on the analysis of the amplification curve and cycle number interpretation, samples with a dt value of ≤ 35 were classified as positive. Samples with dt values between 35 and 40 require retesting, while samples with dt values of 40 or no dt values were deemed negative.

Statistical analysis

Data analysis was conducted using Excel 2019 and SPSS 24, with comparisons among groups performed using the χ² test. P < 0.05 was considered to indicate statistical significance.

Analysis of the overall infection of MG, CT, NG and UU

In the comprehensive analysis of the infection rates of MG, CT, NG, and UU, it was observed that UU exhibited the highest infection rate, significantly surpassing those of the other three pathogens. Laboratory testing revealed infection rates of 2.7% (199/7373) for MG, 3.76% (277/7373) for CT, 1.84% (136/7373) for NG, and 21.99% (1621/7373) for UU. Specifically, among male subjects, the infection rates were 2.76% (173/6268) for MG, 3.72% (233/6268) for CT, 1.99% (125/6268) for NG, and 16.16% (1013/6268) for UU. In females, the infection rates for MG, CT, NG, and UU were 2.35% (26/1105), 3.98% (44/1105), 1.00% (11/1105), and 55.02% (608/1105), respectively. The infection rate of UU in females was significantly higher compared to males, whereas the infection rate of NG was higher in males than in females. These differences were statistically significant (P < 0.05) (Table 1).

Table 1

Infection of four pathogens in male and female patients (%).
	n	MG	CT	NG	UU
Male	6268	173(2.76)	233(3.72)	125(1.99)	1013(16.16)
Female	1105	26(2.35)	44(3.98)	11(1.00)	608(55.02)
Total	7373	199(2.70)	277(3.76)	136(1.84)	1621(21.99)
χ²		0.593	0.182	5.176	827.114
P		>0.05	>0.05	<0.05	<0.05

Comparison of positive rates of 4 pathogens in males and females of different ages

Statistically significant differences were observed in the rates of CT, NG, and UU infections across different male age groups (P < 0.05). The highest positive detection rates for CT, NG, and UU were found in individuals under 20 years of age, with rates of 11.54%, 11.54%, and 23.08%, respectively. Conversely, the lowest infection rates for CT and UU were observed in individuals over 51 years old, at 2.15% and 10.74%, respectively. The lowest NG infection rate was recorded in the 31-40year age group, at 1.36%. No significant differences were found in the MG infection rates across the various age groups (P > 0.05) (Table 2).

Significant differences were observed in the infection rates of MG, CT, NG, and UU across various female age groups (P < 0.05). The highest positive detection rates for MG, CT, and NG were found in individuals under 20 years of age, with rates of 5.88%, 17.65%, and 5.88%, respectively. Conversely, the highest infection rate for UU was 61.82% in the 21 to 30-year age group. The lowest infection rates for MG, CT, and NG were observed in the 41 to 50-year age group, with rates of 0.57%, 0.57%, and 0%, respectively. The lowest UU infection rate, observed at 30.10%, occurred in individuals over 51 years of age, with minimal differences noted between the 31–40 and 41–50 age groups (Table 3). This phenomenon may be attributable to the fact that UU is a component of the normal flora in the female reproductive tract and is typically infectious. Consequently, the infection rate of UU in women across all age groups is significantly higher than that in men.

Table 2

Analysis of infection in male patients of different ages.
Age	n	MG positive		CT positive		NG positive		UU positive
Age	n	rate [n (%)]	percentage (%)	rate [n (%)]	percentage (%)	rate [n (%)]	percentage (%)	rate [n (%)]	percentage (%)
≤ 20	52	4(7.69)	2.31	6(11.54)	2.58	6(11.54)	4.80	12(23.08)	1.186.1
21 ~ 30	1875	54(2.88)	31.21	80(4.27)	34.33	46(2.45)	36.80	330(17.60)	32.58
31 ~ 40	3022	73(2.42)	42.20	108(3.57)	46.35	41(1.36)	32.80	481(15.92)	47.48
41 ~ 50	900	31(3.44)	17.92	30(3.33)	12.88	22(2.44)	17.60	145(16.11)	14.31
≥ 51	419	11(2.63)	6.36	9(2.15)	3.86	10(2.39)	8.00	45(10.74)	4.44
Total	6268	173	100	233	100	125	100	1013	100
χ²		7.749		13.896		33.805		13.924
P		>0.05		<0.05		<0.05		<0.05

Table 3

Analysis of infection in female patients of different ages.
Age	n	MG positive		CT positive		NG positive		UU positive
Age	n	rate [n (%)]	percentage (%)	rate [n (%)]	percentage (%)	rate [n (%)]	percentage (%)	rate [n (%)]	percentage (%)
≤ 20	17	1(5.88)	3.85	3(17.64)	6.82	1(11.54)	9.09	10(58.82)	1.646.1
21 ~ 30	351	17(4.84)	65.38	19(5.41)	43.18	4(2.45)	36.36	217(61.82)	35.69
31 ~ 40	458	5(1.09)	19.23	17(3.71)	38.64	3(1.36)	27.27	253(55.24)	41.61
41 ~ 50	176	1(0.57)	3.85	1(0.57)	2.27	0(2.44)	0	97(55.11)	15.95
≥ 51	103	2(1.94)	7.69	4(3.88)	9.09	3(2.39)	27.27	31(30.10)	5.10
合计	1105	26	100	44	100	11	1	608	100
χ²		16.083		15.638		10.343		32.526
P		<0.05		<0.05		<0.05		<0.05

Analysis of co-infection of pathogens in male and female patients

Among both males and females, the positive rate and proportion of UU and CT co-infection were the highest, significantly surpassing those of other co-infections, with the differences being statistically significant (P < 0.05). This was followed by UU and MG co-infection. Additionally, the positive rate of NG and CT co-infection did not show a significant difference between men and women (P > 0.05). In men, three-pathogen infections were observed, specifically CT + NG + MG and UU + CT + MG, although the infection rates were low. No co-infection involving the three pathogens was identified in women (Table 4).

Table 4

Analysis of co-infection of pathogens in male and female patients.
Pathogen	Male			Female			χ² χ²	p
Pathogen	No (n)	rate (%)	percentage (%)	No (n)	rate (%)	percentage (%)	χ² χ²	p
UU + CT	53	0.85	51.96	28	2.53	52.83	24.646	< 0. 05
UU + NG	5	0.08	4.9	7	0.63	13.21	17.725	< 0. 05
UU + MG	24	0.38	23.53	17	1.54	32.08	22.684	< 0. 05
CT + NG	6	0.10	5.88	1	0.09	1.89	0.003	> 0. 05
CT + MG	5	0.08	4.9	0	0	0	0.882	> 0. 05
NG + MG	4	0.06	3.92	0	0	0	0.706	> 0. 05
CT + NG + MG	1	0.02	0.98	0	0	0	0.176	> 0. 05
UU + CT + MG	4	0.06	3.92	0	0	0	0.706	> 0. 05

Pathogen detection in patients with different clinical symptoms

In women, the detection rate of UU in those diagnosed with genitourinary inflammation (including conditions such as vulvitis, urethritis, cervicitis, and pelvic inflammatory disease), menstrual irregularities, and human papillomavirus (HPV) infection was significantly higher compared to other clinically diagnosed patients, with a statistically significant difference observed (χ² = 19.66, P < 0.01). Furthermore, the detection rate of MG was highest in the HPV infection group, and this difference was also statistically significant (χ² = 14.79, P < 0.05). Among males, UU detection was highest in erectile dysfunction patients, with a statistically significant difference (χ² = 45.79, P < 0.01). CT, NG, and MG detection rates were highest in patients with genitourinary inflammation (e.g., urethritis, prostatitis) and were significantly higher than in other groups (P < 0.01) (Table 5).

Table 5

Analysis of co-infection of pathogens in male and female patients
Female				Male
Disease	No	Pathogen	Positive rate (n, %)	Disease	No	Pathogen	Positive rate (n, %)
Inflammation of genitourinary system	633	UU	378(59.72)	Inflammation of genitourinary system	4439	UU	738(16.63)
		CT	25(3.95)			CT	200(4.51)
		NG	9(1.42)			NG	118(2.66)
		MG	15(2.37)			MG	151(3.40)
Irregular menstruation	139	UU	75(53.96)	Hypogonadism	192	UU	37(19.27)
		CT	4(2.88)			CT	2(1.04)
		NG	1(0.72)			NG	0(0)
		MG	1(0.72)			MG	1(0.52)
HPV infection	125	UU	65(52.00)	HPV infection	559	UU	93(16.64)
		CT	11(8.8)			CT	10(1.79)
		NG	0(0)			NG	1(0.18)
		MG	8(6.4)			MG	8(1.43)
Hypogastralgia	78	UU	37(47.44)	Erectile dysfunction	240	UU	61(25.42)
		CT	2(2.56)			CT	4(1.67)
		NG	0(0)			NG	2(0.83)
		MG	0(0)			MG	2(0.83)
Medical examination	48	UU	22(45.83)	Medical examination	214	UU	32(14.95)
		CT	1(2.08)			CT	2(0.93)
		NG	1(2.08)			NG	0(0)
		MG	2(4.17)			MG	0(0)
Others	78	UU	29(37.18)	Others	624	UU	52(8.33)
		CT	1(1.28)			CT	15(2.4)
		NG	0(0)			NG	4(0.64)
		MG	0(0)			MG	11(1.76)

The prevalence of STIs in China has been increasing in recent decades^[17]. The primary factors contributing to this rise include shifts in sexual attitudes, engagement in high-risk behaviors, an increase in the floating population, and inadequate sex education^[18]. It is important to note that STIs are preventable, and the majority can be effectively cured or managed if diagnosed in a timely manner^[18]. Therefore, early detection is essential for controlling the spread of STIs. This study investigated the prevalence of sexually transmitted disease (STD) pathogens in the Beijing area, with a comparative analysis of infection types across different genders and age groups, aiming to inform the development of effective surveillance and prevention strategies.

A total of 7,373 samples were collected from the outpatient department of the China-Japan Friendship Hospital in Beijing between December 2019 and March 2024. The findings revealed infection rates of 2.7% for MG, 3.76% for CT, 1.84% for NG, and 21.99% for UU. The majority of infections were attributed to a single pathogen, with co-infections being relatively uncommon. The infection rate of Ureaplasma urealyticum (UU) was significantly higher than that of the other three pathogens, and the infection rate of female was significantly higher than that of male, aligning with infection patterns observed in certain regions of China^[19–21]. Males exhibit a markedly higher susceptibility to co-infections, potentially attributable to increased sexual activity. Our findings also showed that almost 80% of MG, UU, CT and NG infections occurred in young people aged 21–40 years, similar to those reported in Zhejiang and Shanghai, China^{[21, 22]}.

MG is recognized as a significant pathogen in human genitourinary tract infections. Notably, in 1981, Tully isolated two MG strains from 13 male patients with nongonococcal urethritis^[23]. The incidence of MG has surpassed that of CT and NG in female patients attending gynecology and venereal disease outpatient clinics in hospitals across the United States and Canada^[24]. MG has been implicated in a range of diseases and may pose a greater threat to reproductive health than UU^[25]. According to the World Health Organization's Guidelines for the Diagnosis of Sexually Transmitted Diseases (2021), nucleic acid amplification tests are the sole recommended diagnostic method for MG. In this study, the prevalence of MG infection (2.7%) was observed to be higher than that of NG (1.84%). Currently, MG detection is conducted in only a limited number of institutions in China, resulting in a paucity of clinical data on its prevalence. It is recommended that MG be included as a routine screening item for high-risk populations.

The detection rate of UU in both male and female urogenital tract diseases was the highest, corroborating numerous domestic and international studies. Previous research^[26] has indicated that UU infections are more prevalent in females, which may be attributed to the higher colonization rate of UU in the female urogenital tract. Additionally, a significant proportion of individuals infected with mycoplasma remain undiagnosed and untreated due to the absence of overt symptoms. Furthermore, the anatomical and physiological characteristics of the female genitourinary system may facilitate a higher susceptibility to mycoplasma invasion. UU is a prevalent pathogen among women in this region, particularly affecting those aged 21–40, likely due to active sexual activity. Women under 20 have the highest infection rate, possibly due to low resistance and inadequate sexual health knowledge, though the small sample size may introduce statistical error. The male infection rate (16.16%) here is lower than the 35.5% reported by Liang et al. in Beijing^[26]. The likely reason, along with the cultural traits of the medical groups studied, is the adoption of advanced pathogen RNA detection technology that identifies RNA in live pathogens, reducing false positives by preventing environmental degradation.

HPV infection is a prevalent etiological factor in sexually transmitted infections. Our study indicates a significant likelihood of HPV co-infection with UU in both male and female subjects. Notably, the probability of HPV co-infection with CT in women is the highest among all examined disease types. Previous research has demonstrated that CT infection elevates the risk of HPV acquisition and persistence^[27–29]. Furthermore, both HPV and CT infections, which are predominantly asymptomatic, have the potential to develop into persistent co-infections. These persistent co-infections may serve as critical cofactors in the process of carcinogenesis^[30]. Routine screening for HPV and CT infection is essential to reduce the risk of cervical intraepithelial lesions.

This study systematically analyzed the prevalent pathogens responsible for reproductive tract infections in the Beijing region. Our findings indicate the necessity to enhance public awareness regarding accurate sexual knowledge, increase awareness of sexual health care, and implement screening for MG, CT, NG and UU among high-risk groups, including young men, women aged 20 to 40, and infertile couples. Additionally, we examined the correlation between sex and urogenital pathogens to facilitate early diagnosis and treatment of STIs, thereby mitigating adverse outcomes. This study is not without its limitations. Firstly, the data utilized spans only the past three years, thereby lacking long-term dynamic observation. Secondly, the sample size remains limited, potentially undermining the generalizability of the findings to the broader regional context. Future research endeavors should aim to expand the sample size and consider employing a multi-center joint study approach to more comprehensively evaluate the risk factors associated with urogenital tract pathogens in Beijing and other regions of China.

Ethics approval and consent to participate

The research protocol follows the principles outlined in the Declaration of Helsinki II and was approved by the hospital Ethics Committee.

Consent for publication

Not applicable.

Competing Interests

The authors declare that they have no competing interests.

Funding

This work was supported as follows: Elite Medical Professionals Project of China-Japan Friendship Hospital（NO.ZRJY2024-BJ02).

Authors' contributions

Conceptualization, M. Zhao, L.M. and YT.C.; Methodology, M. Zhao, Y.L. and XM.K.; Formal Analysis, M. Zhao, P.G., XM.K., and YW.J.; Investigation, M. Zhao, HY.Z. and M.L.; Data Curation, GX.D., HY.Z. and ZY.F.; Writing–Review and Editing, M. Zhao and YT.C.; Supervision, L.M. and YT.C.

Acknowledgements

We would like to acknowledge that there are no specific individuals or organizations to thank for this work.

Availability of data and material

All data generated or analyzed during this study are included in this published article.

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Editorial decision: Revision requested
03 Nov, 2024
Editor assigned by journal
24 Oct, 2024
Submission checks completed at journal
24 Oct, 2024
First submitted to journal
17 Oct, 2024

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Retrospective study on the characteristics of common urogenital tract pathogens in Beijing

Status:

Version 1

Abstract

Introduction

Materials and methods

Subjects

Reagents and instruments

Specimen collection and preservation

Sample processing and nucleic acid extraction

Nucleic acid amplification detection and result interpretation

Statistical analysis

Results

Analysis of the overall infection of MG, CT, NG and UU

Comparison of positive rates of 4 pathogens in males and females of different ages

Analysis of co-infection of pathogens in male and female patients

Pathogen detection in patients with different clinical symptoms

Discussion

Conclusions

Declarations

References

Additional Declarations

Status:

Version 1