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infection&#46; The prevalence varies by region and gender&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Genital warts represent a significant public health problem&#46; The European Centers for Disease Prevention and Control &#40;ECDC&#41; surveillance report on STI in Europe and Red Nacional de Vigilancia Epidemiol&#243;gica &#40;RENAVE&#41; in Spain shows the epidemiological features and basic trends of the five STI under European Union &#40;EU&#41; surveillance&#58; <span class="elsevierStyleItalic">Chlamydia trachomatis</span> infection&#44; gonorrhoea&#44; syphilis&#44; congenital syphilis&#44; and Lymphogranuloma venereum &#40;LGV&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Chlamydia was the most common STI in Europe with 394&#46;163 cases reported in 2015&#46; In Spain&#44; 7&#46;162 new infections were notified in 2016&#46; The incidence rate was estimated to be 18 per 100&#44;000 &#40;with values ranging among different regions&#44; the highest was 46&#44;4 in Catalu&#241;a&#41;&#46; How 53&#37; of cases reported were in females&#46; The majority of reported cases continue to be among young people between 15 and 24 years of age&#44; suggesting that testing continues to be targeted towards groups at higher behavioural risk of STI while simultaneously aiming to reduce the risks of reproductive tract complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> But while trends in the number of chlamydia infections appear to have stabilised in recent years &#40;2011-2015&#44; increased by 4&#37; overall&#41;&#44; gonorrhoea rates have gone up by 79&#37; since 2008&#44; particularly among men&#46; With more than 75&#46; 000 reported cases in 2016&#44; gonorrhoea is the second most commonly notified STI in Europe&#44; and Spain is not an exception with 6&#46;456 cases reported&#44; 83&#37; in men&#46; Male to female ratio in Spain was 5&#58;1&#46; This increase seems to be linked to increased case numbers among men who have sex with men &#40;MSM&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6</span></a> The number and rate of reported syphilis cases has continued to increase in 2015 &#40;28 701 syphilis cases in Europe&#41;&#46; The increases continue to be driven by cases reported among men&#44; specifically among MSM &#40;62&#37;&#41;&#46; Trends among heterosexual men and women&#44; on the other hand&#44; appear stable or show a slight decrease&#46; Syphilis rates increased in Spain until 2011&#44; but there has been an stabilization since then with 3886 cases notified in 2015 and 3357 in 2016&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7</span></a> Following a decreasing trend&#44; the notification rate of congenital syphilis has stabilised since 2006&#46; 42 cases were reported in Europe in 2015 and four cases in Spain in 2016&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; the number of reported cases of LGV continued to increase in western and central European countries with 1787 in 2015&#46; Spain notified 248 cases in 2016&#46; Epidemiological investigations suggest that transmission is mainly among HIV-positive MSM engaging in high-risk practices&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9</span></a> Infection with the human immunodeficiency virus &#40;HIV&#41; and STIs are clearly interrelated&#44; sharing risks&#44; incidence and transmission mechanisms&#46; Currently&#44; the global rate of new HIV diagnoses in Spain is at levels similar to those of other countries in the WHO European Region&#46; Since 2003&#44; a record of new diagnoses of HIV infection in our country has been made&#44; with a stable number in the last 7 years&#44; standing at an average of 3293 cases&#47;year&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This review highlights the main diagnostic methods currently used for STIs community to ensure that effective interventions for STIs prevention&#44; screening&#44; diagnosis&#44; and treatment are made more widely available&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030"><span class="elsevierStyleItalic">Chlamydia trachomatis</span> infections</span><p id="par0035" class="elsevierStylePara elsevierViewall">Several factors may account for the increase of diagnosed CT infections&#44; including changes in sexual behaviour and lack of prevention and education&#44; but also more frequent testing with improved detection systems&#46; Testing for Chlamydia is indicated in patients with urogenital&#44; cervicitis&#44; pelvic inflammatory disease &#40;PID&#41;&#44; and extragenital infection by sexual transmission&#58; anorectal&#44; pharyngeal and ocular&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Initially&#44; all relevant clinical materials can be analyzed by molecular biology techniques&#46; Non invasive specimens are the preferred materials&#44; in particular for screening of asymptomatic persons&#46; First void urine and uretral swabs from male patients are equivalent regarding to performance of nucleid acid amplification test &#40;NAATs&#41;&#46; Collection of urine sample is much better accepted and therefore the recommended sample in men&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> To detect extra-genital CT infections&#44; testing of corresponding swabs or tissue samples is required&#46; CT infection of men who have sex with men &#40;MSM&#41; is frequently localized in the rectum or pharynx&#44; without causing any symptoms&#44; and it require testing of appropriate oral and anal swabs to be diagnosed&#46; In this case&#44; the only screening of an urine sample can lead to a infradiagnostic of the infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Diagnostic <span class="elsevierStyleItalic">Chlamydia trachomatis</span> &#40;CT&#41; infections</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Nucleic Acid AmplificationTest &#40;NAATs&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Only if <span class="elsevierStyleItalic">C&#46; trachomatis</span> NAATs are not available or affordable&#44; isolation of <span class="elsevierStyleItalic">C&#46; trachomatis</span> in cell culture or identification of C trachomatis by direct fluorescence assays &#40;DFA&#41; can be used for diagnosis of acute infections&#46; Validated and quality assured NAATs are recommended due to their superior sensitivity&#44; specificity and speed of diagnosis of both symptomatic and asymptomatic chamydial infections compared to all other diagnostic techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> Due to the high specificity of the appropriately validated C trachomatis NAATs and risk of loasing low positive result in repetead testing&#44; confirmatory testing of positive specimens is not recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> An important exception is represented by legal investigations in case of sexual assault&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The NAATs can use less invasively colleted specimens such as urine samples in men or vulvo-vaginal swabs in women and anorectal swabs in both genders&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Diagnostic sensitivity can be increased using coated magnetic beads nucleic acids nucleic acids were isolated in higher quantity and quality&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> These bead based extraction systems can be automated and use in several high-throughput systems that allow simultaneous testing of chlamydia and gonococci with sensitivity and specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> In order to increase the sensitivity of the technique&#44; these tests are based on the detection of genes present in high number of copies &#40;cryptic plasmid X06707 &#40;10 copies &#47;genome&#41; or 16S ADNr &#40;2 copies&#47;genome&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">NAATs have detected 10-30&#37; more <span class="elsevierStyleItalic">C&#46; trachomatis</span> positive specimens than culture in studies comparing the two methods&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> In some several studies&#44; results of different NAATs were show to be highly concordant&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a> The importance of genetic variation became evident with the appearance of the Swedish variant that was not detected by some commercial NAATs due to a deletion in the target region of these test&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The implementation of a 2<span class="elsevierStyleSup">nd</span> target region in NAATs represents an important improvement of NAATs&#44; allowing detection of new variants with deletions or recombination in one of the target region&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> As an example of systems that developed a modification of the technique Cobas Taqman CT&#47;NG v 2&#46;0 &#40;Roche&#41; and Artus <span class="elsevierStyleItalic">C&#46; trachomatis</span> plus RG Kit PCR &#40;Qiagen&#41;&#46; One limitation of all these diagnostic techniques is the lack of discrimination between the different biovars of <span class="elsevierStyleItalic">C&#46; trachomatis</span> related to different pathological processes that can be detected in urethral or cervical samples&#46; None of the above technique can discriminate between serovars D-K and serovars L1-L3 related with lymphogranuloma venereum &#40;LGV&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Point of care test &#40;POCTs&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Rapid point-of-care test provide a quick and easy test result&#44; and diagnosis and subsequent treatment can be provided at the same visit at clinic or even in remote setting&#46; Most POCTs are immune chromatographic test based on lateral flow technology and detec chamydia lipopolysaccharide antigen &#40;LPS&#41; in genital swabs or urine&#46; Compared with culture and NAATs&#44; these antigen based in POCTs are significantly less sensitive and less specific&#46; The antigen based POCTs were not recommended for <span class="elsevierStyleItalic">C&#46; trachomatis</span> testing of both asymptomatic screening and symptomatic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> POCTs with increased sensitivity have been developed and new POC NAATs &#40;e&#46;g&#46; Xpert assay of Cepheid CT&#47;NG&#41;&#46; This assay is based on real time PCR carried out in a closed system&#46; After application of the clinical sample to a cartridge&#44; the subsequent steps of nucleic acid isolation&#44; amplication and detection of PCR products proceed in a fully automated process&#46; Another commercial test POCTs NAATs use technology isothermal amplification&#44; like loop mediated isothermal ampllication &#40;LAMP&#41; or recombinase polymerase amplification &#40;RPA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Serology</span><p id="par0060" class="elsevierStylePara elsevierViewall">Testing for <span class="elsevierStyleItalic">C&#46; trachomatis</span> antibodies is not useful to diagnose local epithelial infectious of the lower genital tract&#44; because antibodies are detectable with a delay of several weeks&#44; antibody titers may be low&#44; and many serologic test are not able to differentiate antibodies against different chlamydia species&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The microinmmunefluorescence &#40;MIF&#41; test was long time considered the reference method of chamydia antibody testing but enzyme immunoassays &#40;EIA&#41; and inmunoblosts or line assays are currently used more frequently to detect clamydia infections&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a> The EIA technology is based on the detection of antigen by measuring a colored signal generated by the antigen reaction liposaccharides &#40;LPS&#41; with the antibody&#46; Traditionally they have enjoyed great popularity for being simple&#44; objective and automated techniques&#46; The specificity of EIA is low&#44; being able to give false positives due to the presence of bacterial lipopolisaccharides LPS&#46; Other techniques are based on direct staining of samples with fluorescein-labeled monoclonal antibodies &#40;DFA&#41;&#46; This last technique uses species-specific antibodies directed mainly against the antigen major outer membrane protein &#40;MOMP&#41; and to a lesser extent against the LPS&#46; The main advantages of the DFA techniques are its speed &#40;30&#8239;min&#41; and specificity close to 100&#37;&#44; the sensitivity is 85-90&#37;&#44; compared to the culture and does not require specific means of transport&#46; Among its drawbacks is the subjective interpretation and requires experienced staff&#44; low reproducibility and the volume of samples should not be high&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Cell Culture</span><p id="par0070" class="elsevierStylePara elsevierViewall">Until the end of the 20th century&#44; cell culture has been the reference standard against which all other tests have been compared&#46; But mainly due to the appearance of new diagnostic methods easier to implement&#44; fast and sensitive&#44; cell culture has been relegated to reference laboratories&#46; Established cell lines for isolation of <span class="elsevierStyleItalic">C&#46; trachomatis</span> include McCoy&#44; Hela 29&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The specimens for culture must be collected using special devices and transport media&#46; Sensitivity of culture may be impaired by inadequate specimen collection&#44; storage and transport&#44; toxic substances in clinical specimens and overgrowth of cell cultures by commensal bacteria and fungi&#46; Cell culture is a very specific technique&#44; however sensitivity is not very good 75-80&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;32</span></a></p></span></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Neisseria gonorrhoeae &#40;NG&#41; infections</span><p id="par0075" class="elsevierStylePara elsevierViewall">Gonorrhoea is the second most common bacterial sexually transmitted infection &#40;STI&#41; worldwide<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> although the prevalence of this infection varies among populations&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> From a localized lesion&#44; the microorganism can ascend to the upper genital tract to cause pelvic inflammatory disease&#44; epididymo-orchitis or disseminate as bacteraemia&#46; Due to this fact&#44; an appropriate diagnosis and an effective treatment of this infection are important factors contributing to public health control and to prevent serious complications&#46; However&#44; the increase of resistance to recommended treatments for gonorrhoea may seriously affect to infection control&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Diagnosis of NG infections</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Microscopy</span><p id="par0080" class="elsevierStylePara elsevierViewall">NG could be visualized on microscopy of a stained genital tract smear in symptomatic patients&#46; In men with urethral discharge&#44; microscopy &#40;x1000&#41; using Gram for identification of diplococci within polymorphonuclear leukocytes has good sensitivity &#40;&#8805;95&#37;&#41; and specificity &#40;&#8805;99&#37;&#41; as a rapid diagnostic test&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> However&#44; in asymptomatic men&#44; this technique has poor sensitivity &#40;&#8804;55&#37;&#41;&#44; as well as in identifying endocervical or rectal infection &#40;&#8804;55&#37; and &#8804;40&#37;&#44; respectively&#41;&#59; in these circumstances&#44; microscopy cannot be recommended as a test for ruling out infection&#46; In addition&#44; Gram stains of endocervical&#44; rectal&#44; or pharyngeal specimens also are not recommended to detect infection due to poor specificity as well as low sensitivity&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Culture</span><p id="par0085" class="elsevierStylePara elsevierViewall">Culture is the only diagnostic test that allows antimicrobial susceptibility testing&#44; remaining important to detect and monitor antimicrobial resistance&#46; Specimens should be obtained by using swabs other than those composed by wood and cotton because they may be inhibitory or toxic to NG&#46; Some transport systems can maintain gonococcal viability for up to 48&#8239;h in ambient temperature&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Swabs should be inserted 2-3&#8239;cm in the male urethra or 1-2&#8239;cm into the endocervical canal followed by 2-3 rotations&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Specimens from sterile sites could be cultured on nonselective medium &#40;e&#46;g&#46; chocolate agar&#41;&#44; whereas those from nonsterile locations are cultured on a selective mediun &#40;e&#46;g&#46; Martin-Lewis&#44; Thayer-Martin&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> which contain antimicrobial agents that inhibit the growth of other bacteria and fungi&#46; These media are incubated at 35&#8239;&#176;C in an atmosphere supplemented with 5&#37; CO<span class="elsevierStyleInf">2</span> and examined during at least 48-72&#8239;h&#46; Gram-negative diplococci and oxidase-positive colonies can be presumptively identified as NG&#46; Further additional biochemical tests are needed in order to confirm the diagnosis&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Culture should be carry out for antimicrobial sensitivity study in patients with persisting infection or if treatment failure is suspected&#46; Moreover&#44; characterization of isolates by molecular typing may be a useful tool to predict antimicrobial resistance due to the fact that some types are associated to decreased susceptibility to several antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> The sensitivity of culture is high for genital samples but strongly depend on the specimen collection&#44; transport&#44; storage and isolation procedures&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Nucleid acid amplification tests &#40;NAATs&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">NAATs techniques are recommended for detection of infections caused by NG with and without symptoms&#46; NAATs are more sensitive than culture&#44; they can be used on a wider range of specimen types&#44; and specimen quality&#44; transportation and storage are less strict&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#8211;43</span></a> NAATs are the sample of choice for testing asymptomatic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> These techniques show similar sensitivity in urine and urethral specimens from men&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> and also similar sensitivity in endocervical specimens taken from physicians and those self-taken form the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> However&#44; in women&#44; urine samples have lower sensitivity than genital swabs for testing&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Moreover&#44; NAATs are significantly more sensitive than culture for the detection of NG in pharyngeal and rectal samples&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;47</span></a> being the tests of choice for screening for these kind of infections&#46; However&#44; these techniques are not approved for testing specimens from these locations&#46; A summary of the commercially available and FDA &#40;Food and Drug Administration&#41;-cleared NAAT assay platforms for the detection of NG in the United States can be found in the current American guide for the diagnosis of these infections&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p></span></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085"><span class="elsevierStyleItalic">Treponema pallidum</span> &#40;syphilis&#41; infections</span><p id="par0105" class="elsevierStylePara elsevierViewall">Syphilis develops in stages&#44; and symptoms vary with each stage &#40;primary&#44; secondary&#44; latent&#44; and late or tertiary syphilis&#44; including neurosyphilis and cardiovascular syphilis&#41;&#46; But the stages may overlap&#44; and symptoms do not always occur in the same order&#46; Alternatively&#44; patients may be completely asymptomatic and only identified on routine screening&#46; The choice of method for diagnosing syphilis depends on the stage of disease and the clinical presentation&#46;</p><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Direct detection methods</span><p id="par0110" class="elsevierStylePara elsevierViewall">Dark field microscopy &#40;DFM&#41; and direct fluorescent antibody staining for <span class="elsevierStyleItalic">T&#46; pallidum</span> &#40;DFA-TP&#41; have been used in clinical laboratories for decades to visualization of the spirochete in lesion exudate from patients with primary and secondary syphilis&#46; However&#44; these methods are not available in all laboratories&#44; in addition to needing experienced personnel&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Nucleic acid amplification tests&#44; such as the polymerase chain reaction &#40;PCR&#41;&#44; have not been used routinely for syphilis diagnosis since a commercial test is not available or internationally approved&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> However&#44; PCR tests for syphilis can be performed for the diagnosis of neurosyphilis&#44; particularly among individuals infected with HIV&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a> It is considered that CSF PCR has little value for diagnosis of neurosyphilis due to its low sensitivity and specificity&#46; Its carrying out in blood is not recommended existence of inhibitory substances&#46; To do this test can be used fresh samples or frozen&#46; There are commercial formats&#44; validated for all types of samples&#44; so that it is essential to use the controls of corresponding validation&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Serological assays</span><p id="par0120" class="elsevierStylePara elsevierViewall">Serological testing is the most common method for syphilis screening&#44; diagnosis&#44; and follow-up of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Serological tests for syphilis can be divided into two types&#58; nontreponemal test &#40;NTTs&#41; and treponemal test &#40;TTs&#41;&#46; Both tests are used to confirm the infection and determine whether the disease is active&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">NTTs detect IgM and IgG antibodies to lipoidal antigens released from injured host cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;52</span></a> NTTs include Venereal Disease Research Laboratory &#40;VDRL&#41;&#44; rapid plasma reagin &#40;RPR&#41;&#44; and toluidine red unheated serum test &#40;TRUST&#41;&#46; Non treponemal antibodies become positive 10&#8211;15 days after the onset of the primary lesion&#46; NTTs lack sensitivity in primary and tertiary syphilis and its use as a screening test presents problems&#46; Without treatment&#44; titres increase at 1&#8211;2 years after infection and can gradually decline spontaneously and&#44; in some patients&#44; become non-reactive&#46; After treatment&#44; titres generally decline and in most immunocompetent individuals become non-reactive within 6 months&#46; However&#44; up to 20&#37; of individuals infected and correctly treated show persistently reactive NTTs low titre results&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">53&#44;54</span></a> False-positive results with this test can occur during pregnancy&#44; in patients with rheumatological diseases&#44; chronic infections &#40;HIV&#44; mycobacterial diseases&#41; and parenteral drug users&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">TTs use native or recombinant <span class="elsevierStyleItalic">T&#46; pallidum</span> antigens to detect specific antibodies to treponemal components&#46; These tests include the fluorescent treponemal antibody absorption assay &#40;FTA-ABS&#41;&#44; the <span class="elsevierStyleItalic">T&#46; pallidum</span> particle agglutination assay &#40;TPPA&#41;&#44; enzyme-linked immunoassays &#40;EIAs&#41;&#44; chemiluminescence immunoassays &#40;CIAs&#41;&#44; and immunochromatographic assays &#40;ICs&#41;&#46; Specific antibodies are the first to appear &#40;6&#8211;14 days after the primary chancre appears&#41; and persist throughout life&#59; TTs cannot be used to distinguish an active from a past or previously treated infection and&#44; therefore&#44; are not helpful for evaluation the effectiveness of antibiotic treatment&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">FTA-ABS is considered the <span class="elsevierStyleItalic">gold standard</span> in many middle-income and low-income countries but it has drawbacks like time consuming&#44; expensive and difficult to read&#46; This assay can be used in cerebrospinal fluid &#40;CSF&#41;&#46; Sensitivity of TTs varies 82&#8211;100&#37; depending on disease stage&#59; specificity is 99&#37;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In recent years&#44; rapid and inexpensive serologic tests for syphilis have been developed&#46; Rapid syphilis tests are ICs assays that use a whole blood sample&#44; require no equipment and minimal training and give a result in few minutes with a a sensitivity of 86&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Most tests use treponemal antigens but one IC test has been developed that enables the simultaneous detection of nontreponemal and treponemal antibodies in a single point of care device&#44;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56&#8211;58</span></a> and it can distinguish between new and previously treated infections&#46; The overall performance for diagnosis of active infection is 88&#46;3&#37; &#40;range 87&#46;1&#8211;89&#46;4&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56&#44;58</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Interpretation of reactive tests</span><p id="par0145" class="elsevierStylePara elsevierViewall">Screening using an initial automated treponemal test &#40;EIA or CLIA&#41; is done by many laboratories&#44; especially those with high sample volume&#46; A negative treponemal test likely indicates the absence of syphilis and generally no further testing is required&#46; However&#44; recent infection cannot be ruled out and repeat testing should be considered in patients who have had a recent risk exposure&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Reactive samples must be tested by a nontreponemal test to determine if disease is active&#46; A positive titer with a VDRL or RPR indicates active syphilis and follow-up serologic testing is performed to monitor treatment response&#46; When NTTs is not reactive in patients who report no history of syphilis treatment&#44; it could be very early syphilis&#44; longstanding latent syphilis&#44; or a biological false positive result&#46; Second different TTs should be performed&#46; Patients with positive second TTs are candidates for treatment if they have not been previously treated&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Special situations</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Neurosyphilis</span><p id="par0155" class="elsevierStylePara elsevierViewall">Examination of CSF in a patient with neurologic signs and symptoms must include total protein&#44; number of mononuclear cells and serologic test&#46; CSF laboratory abnormalities &#40;pleocytosis and an increased protein concentration&#41; are common in persons with neurosyphilis&#46; CSF-VDRL is highly specific but insensitive &#40;a positive CSF VDRL test is observed in only about 1&#58;3 cases of neurosyphilis&#41;&#46; Rapid plasma reagin testing on CSF is not recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In a person with neurologic signs or symptoms&#44; a reactive CSF-VDRL &#40;in the absence of blood contamination&#41; is considered diagnostic of neurosyphilis&#46; When CSF-VDRL is negative despite the presence of clinical signs of neurosyphilis&#44; and abnormal CSF cell count and&#47;or protein&#44; neurosyphilis should be considered&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The CSF FTA-ABS test is less specific for neurosyphilis than the CSF-VDRL but is highly sensitive&#46; In patients with suspicion of neurosyphilis but a negative CSF VDRL&#44; a CSF FTA-ABS test can be used to rule out neurosyphilis&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Congenital syphilis</span><p id="par0170" class="elsevierStylePara elsevierViewall">Because maternal nontreponemal and treponemal IgG antibodies can be transferred from mother to child&#44; treponemal testing of infant serum is not recommended&#46; A fourfold increase or more of the titre of a NTTs in the child&#8217;s as opposed to the mother&#8217;s serum &#40;both obtained simultaneously at birth&#44; is highly suggestive of congenital syphilis but its absence does not exclude a diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Children from mother with a positive treponemal test for syphilis and any evidence of congenital syphilis on physical examination&#44; or long bone x-ray suggestive&#44; or reactive CSF VDRL assay&#44; or elevated cerebrospinal fluid cell count or protein &#40;without other cause&#41; can support a diagnosis of congenital syphilis&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></span></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Infections caused by <span class="elsevierStyleItalic">Trichomonas vaginalis</span> &#40;TV&#41;</span><p id="par0175" class="elsevierStylePara elsevierViewall">TV is the most prevalent non-viral STI worldwide&#46; These infections represent the most common curable STI in young&#44; sexually active men and women&#46; In women&#44; trichomoniasis has been associated with poor reproductive health outcomes like low birth weight and premature birth&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> Thus&#44; early detection and treatment of TV infections are strongly recommended for symptomatic women and men&#46; For asymptomatic patients&#44; detection is only recommended for HIV-positive women&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Diagnosis of TV infections</span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conventional methods&#58; microscopy and culture</span><p id="par0180" class="elsevierStylePara elsevierViewall">Diagnosis of trichomoniasis is commonly based on the microscopy examination of wet preparations of vaginal and urethral discharges&#44; prostatic secretions&#44; and urine sediments&#46; Specimens should be mixed with a drop of physiologic saline &#40;but never refrigerated&#41; and examined microscopically within 1&#8239;h under low power &#40;magnification x100&#41;&#44; with reduced illumination&#46; The presence of actively motile trichomonas is diagnostic of the infection&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> Polymorphonuclear cells are often present in these preparations&#46; However&#44; although this technique is rapid and inexpensive the sensitivity is between 50-70&#37; and may be less in asymptomatic women&#46; The most important factor affecting the sensitivity of wet mount testing is the time between collection and examination of the specimen&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Culture of genital fluids has been considered the gold standard for diagnosis&#44; although it requires 18-24&#8239;h of incubation&#46; The sensitivity of the culture is greater than 80&#37; compared with the wet mount&#46; Amies gel agar transport medium might maintain the viability for culture of TV on swabs held at room temperature for 24&#8239;&#177;&#8239;6&#8239;h before inoculation of specimen into a culture pouch&#46; However&#44; the best practice is that specimens be collected properly and inoculated immediately into the appropriate medium&#44; such as modified Diamond&#39;s&#44; Trichosel&#44; or Holander&#39;s medium&#46; Culture systems or systems that allow direct inoculation&#44; transport&#44; culture&#44; and microscopic examination are commercially available&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Rapid detection tests&#58; point-of-care testing</span><p id="par0190" class="elsevierStylePara elsevierViewall">Several antigen detection methods have been developed&#44; being the main advantage that they are rapid and easy to perform&#46; A latex agglutination test have demonstrated an excellent sensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> An immunochromatographic capillary flow assay is commercially available for qualitative detection of TV antigens from vaginal swabs&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">63&#44;64</span></a> The OSOM <span class="elsevierStyleItalic">Trichomonas</span> Rapid Test Kit is a dipstick assay providing results in 10&#8239;min&#46; This test has demonstrated good sensitivity and specificity compared with other diagnostic methods&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> A rapid test has been developed for TV detection&#46; This assay uses novel electrochemical end-point detection using a multicopy region of the TV genome as the assay target&#46; The sensitivity and specificity achieved using this assay is comparable with that achieved for existing nucleic acid amplification test &#40;NAATs&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The Affirm VPIII is a nucleic acid hybridisation test that uses synthetic nucleic acid capture probes and colour development detection probes&#59; compared with NAATs&#44; this technique had a sensitivity of 46&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The AmpliVue assay uses isothermal helicase-dependent amplification &#40;HDA&#41; and targets a conserved repeat DNA sequence of TV&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> This technique has been recently approved by the FDA for vaginal swabs&#46; On the other hand&#44; Solana <span class="elsevierStyleItalic">Trichomonas</span> assay is an in vitro qualitative NAAT for the detection of TV also using the HDA technology and the Solana instrument&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> It was recently FD approved&#46; Compared with a NAAT assay&#44; the sensitivity&#47;specificity was 89&#46;7&#37;&#47;99&#46;0&#37; for swabs and 100&#37;&#47;98&#46;9&#37; for urines&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Finally&#44; the GeneXpert TV assay has been approved by the Food Drug Administration &#40;FDA&#41; for use with male urine&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">NAATs techniques</span><p id="par0210" class="elsevierStylePara elsevierViewall">These techniques have now become commercially available for the diagnosis of TV in women and have replaced culture as the gold standard test due to their excellent sensitivity and specificity&#46; Genital and urine samples are acceptable specimens&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> NAATs have not been approved for men by the FDA&#44; but these techniques have shown high sensitivity and specificity for this population&#46; Among women&#44; NAATs may detect a prevalence of threefold to fivefold higher than wet mount microscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Currently&#44; there are two robotic FDA-approved NAAT platforms for the detection of TV in women&#58; these include the Aptima TV assay &#40;Hologic Gen-Probe&#41;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> and the BD ProbeTec Q<span class="elsevierStyleSup">x</span> assay on the BD Viper system &#40;Becton Dickinson&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Studies using the <span class="elsevierStyleItalic">Trichomonas</span> Aptima Combo 2 assay have shown a superior performance compared to other methods&#46; This assay is approved for the detection of TV infections from a wide variety of specimens such as vaginal or endocervical samples&#44; ThinPrep liquid-based cytology samples&#44; and urine specimens&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">On the other hand&#44; the BD TV Q<span class="elsevierStyleSup">x</span> uses female vaginal or endocervical swabs as well as urine and liquid-based cytology&#46; This technique has demonstrated an excellent sensitivity and specificity&#44; and the time of detection is less than 5&#8239;h&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Another assay available outside the US is the Seeplex STD 6 ACE detection system &#40;Seegene&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> This assay is a multiplex PCR targeting unique genes of the specific pathogen&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Finally&#44; the BD MAX<span class="elsevierStyleItalic"><span class="elsevierStyleSup">TM</span></span> System provides an assay suitable for use with female urine and vaginal or endocervical swab samples&#46; Male urine has not yet been evaluated for TV&#46; This assay has a sensitivity &#8805; 91&#46;5&#37; and specificity &#8805; 98&#46;6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a></p></span></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Human papillomavirus &#40;HPV&#41; infections</span><p id="par0240" class="elsevierStylePara elsevierViewall">HPV cause the most frequent STI worldwide&#46; In Spain&#44; the prevalence of HPV infection in sexually active women is around 14&#37;&#44; although this prevalence may vary depending on the age group and the associated risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> More than 100 HPV genotypes have been identified and it is estimated that 40 of them are located in the anal and genital region&#46; Non-oncogenic genotypes &#40;low-risk genotypes&#41;&#44; mainly 6 and 11&#44; might cause benign manifestations such as condylomas or genital warts&#46; On the other hand&#44; oncogenic genotypes &#40;high-risk genotypes and probable&#47;possible high risk genotypes&#41; have been associated with the etiopathogenesis of the invasive cervical cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">76&#44;77</span></a> This type of cancer affects nearly 500&#44;000 women worldwide every year with a mortality of more than 270&#44;000 persons&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Cytology-based programmes have been the main approaches for screening&#44; but these are not often available in most of the low&#47;middle-income countries&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> The WHO 2014 cervical cancer screening guidelines recommend that screening should be carried out at least once between the ages of 39 and 49 years&#44; and this screening could be extended to women younger than 30 years if there is evidence of high risk for high-grade cervical intraepithelial neoplasia&#46; Testing for high-risk HPV genotypes has been incorporated into the screening and management algorithms elaborated by several scientific groups as well as for the FDA&#46; HPV testing is recommended in patients over the age of 30 years-old who demonstrate an initial non-type specific high-risk HPV-positive result along with a negative cervical cytology result&#44; and as triage in patients with undetermined cervical cytology results &#40;ASCUS&#44; atypical squamous cell of undetermined significance&#41;&#46; The primary methods for HPV diagnosis have been cytology and histology&#46; However&#44; the detection of HPV is facilitated by recent advances in molecular biology to detect HPV DNA sequences in clinical specimens such as hybrid capture and polymerase chain reaction &#40;PCR&#41;&#46;</p><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Diagnosis of HPV infections</span><p id="par0250" class="elsevierStylePara elsevierViewall">The adequate samples for HPV detection are both endocervical brushed specimens &#40;cervical exfoliated cells&#41; or endocervical biopsies collected in liquid medium&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a> The endocervical brush should be introduced in the 2&#47;3 of the endocervical canal followed by 4-5 rotations&#44; and cervical biopsies should be frozen as soon as possible&#46; Residual material from diagnostic formalin-fixed paraffin embedded blocks may also be used for HPV testing&#46; On the other hand&#44; urine samples have shown a lower sensitivity&#44; so it has been not recommended for HPV screening&#46; Also&#44; samples of external genitalia&#44; perineum&#44; anus and&#47;or oropharyngeal sites should be taken&#44; both in women and men&#44; if these locations are affected&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conventional and monolayer cytology</span><p id="par0255" class="elsevierStylePara elsevierViewall">The primary method for the detection of HPV is still the Papanicolaou stained smear&#46; The Pap smear screening test for cervical cancer was introduced by George Papanicolaou in 1941<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a> and it has been associated with a sustained reduction in cervical cancer incidence and mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a> However&#44; the effectiveness of this method has never been demonstrated in a randomized trial&#46; The Pap test aims to identify abnormal cells obtained from the transformation zone&#44; the junction of the ecto and endocervix&#44; where cervical dysplasia and cancers arise&#46; However&#44; the Pap smear procedure has some limitations such as that inadequate samples constitute about 8&#37; and false-negative rates close to 30&#37; have been reported&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Thin layer or liquid-based cytology has now been widely implemented worldwide and has theoretical advantages over conventional cytology&#44; mainly reducing the number of false-negative results&#46; However&#44; systematic reviews comparing conventional and liquid-based cytology have not consistently shown that liquid-based cytology detects significant cancer precursors more effectively than conventional cytology&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">83&#44;84</span></a></p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Histopathology</span><p id="par0265" class="elsevierStylePara elsevierViewall">Patients who have abnormal Pap smears but no evidence of cervical lesions could be evaluated by colposcopy and further biopsy&#46; The colposcopy can detect both low-grade and high-grade dysplasia but does not detect microinvasive lesions&#46; Stains resulting after biopsy could be used to detect antigens or HPV DNA&#46;</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">HPV nucleic acid detection</span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Commercially techniques for molecular HPV detection</span><p id="par0270" class="elsevierStylePara elsevierViewall">In the market&#44; there is currently more than 125 techniques for HPV detection&#46; These techniques can be differentiated in four types&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">DNA detection techniques&#58; the HPV DNA is detected from the capside region as well as from the E6 oncogen&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall">RNA detection techniques&#58; the RNAm is detected from the HPV E6&#47;7 oncogenes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">in situ</span> hibridization tecniques&#58; they have low sensitivity and specificity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall">Serological techniques&#58; only used for epidemiological purposes and vaccinal efficacy&#46;</p></li></ul></p><p id="par0295" class="elsevierStylePara elsevierViewall">According the technology used&#44; the main commercially available systems may be classified as follows&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1</span><p id="par0300" class="elsevierStylePara elsevierViewall">Signal amplification methods&#58; capture of RNA-DNA hybrids and Chemical Invader&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2</span><p id="par0305" class="elsevierStylePara elsevierViewall">Target DNA amplification methods&#58; PCR&#44; real-time PCR&#44; multiplex PCR&#44; transcription mediated amplication &#40;TMA&#41;&#44; dual priming oligonucleotide &#40;DPO&#41; and Matrix-assited laser desorption&#47;ionization time-of-flight mass spectrometry &#40;MALDI-TOF MS&#41;&#46;</p></li></ul></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Validation and FDA-approval</span><p id="par0310" class="elsevierStylePara elsevierViewall">In 2009&#44; an international expert committee proposed that any technology must be as accurate as the techniques used at this moment as the gold standard &#40;GP5&#43;&#47;GP6&#8239;&#43;&#8239;PCR and hybrid capture&#41;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a> in order to be used in the primary screening of cervix cancer in women&#46; This committee introduced some criteria based on both clinical sensitivity and specificity more than 0&#44;90 and 0&#44;98&#44; respectively&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">On the other hand&#44; the VALGENT protocol is an international network for the validation of genotyping HPV assays&#46; Moreover&#44; the FDA approval is achieved when a method establish their sensitivity and specificity by prospective studies performed in three or more sites&#46;</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">HPV detection techniques comparison</span><p id="par0320" class="elsevierStylePara elsevierViewall">Abbott Real Time HR-HPV and BD Onclarity HPV are two DNA amplification techniques by RT-PCR fully automated&#46; Abbott technology allows the process of the primary tube and reports genotypes 16&#47;18 and others non 16&#47;18 differently&#46; This method is mainly indicated for laboratories with high workload&#46; BD Onclarity use SDA &#40;Strand Displacement Amplification&#41; technology and amplify the E6&#47;7 region&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Anyplex II HPV HR &#40;Seegene&#41; is based on multiplex RT-PCR with DPO and TOCE technology&#46; This method allows the genotyping of 14 genotypes in the same reaction and their relative quantification&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">The Xpert HPV genotyping system &#40;Cepheid&#41; is the fastest test &#40;1&#8239;h&#41;&#46; With this method&#44; we may obtain the genotyping of HPV-16 and other 5 group of high-risk genotypes&#46; Due to their low rate of contamination&#44; it is recommended for laboratories low workload&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">Other techniques clinically validated are the virus detection by MALDI-TOF MS and by reverse-hybridization with arrays in microspheres &#40;Luminex&#41;&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Linear Array HPV Genotyping Kit &#40;Roche Diagnostics&#41; detects 37 genotypes&#44; very useful for studies of vaccine impact or for epidemiological purposes&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">Four techniques are FDA-approved for cytological screening of ASCUS or for screening with cytology and HPV at the same time&#58; hybrid capture &#40;Qiagen&#41;&#44; Cervista &#40;Hologic&#41;&#44; Cobas 4800 HPV &#40;Roche Diagnostics&#41; and APTIMA &#40;Hologic&#41;&#46; Only the Cobas HPV test is approved by FDA for population screening based on HPV detection&#46;</p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Hybrid Capture 2 High-Risk HPV DNA &#40;Digene&#41;</span><p id="par0350" class="elsevierStylePara elsevierViewall">It was the first method approved by the FDA &#40;March 2003&#41; for the detection of HPV oncogenic genotypes&#46; It is a liquid&#47;solid phase signal amplification method based on hybridization in solution of long synthetic RNA probes complementary to the genomic sequence of 13 high-risk &#40;16&#44; 18&#44; 31&#44; 33&#44; 35&#44; 39&#44; 45&#44; 51&#44; 52&#44; 56&#44; 58&#44; 59 and 68&#41; and 5 low-risk &#40;6&#44; 11&#44; 42&#44; 43&#44; and 44&#41; HPV types&#46; The hybrids are detected by some reactions that generate a luminescent signal that can be detected by chemiluminiscence&#46; The main limitation of this assay is that does not discriminate the genotype and the cross-reactivity that may lead to false-positive results&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Cervista HPV HR &#40;Hologic&#41;</span><p id="par0355" class="elsevierStylePara elsevierViewall">It was approved by the FDA in 2009&#46; This assay is based on <span class="elsevierStyleItalic">Invader</span> technology consisting of concurrent two-part isothermal reactions&#46; The main reaction detects the presence of specific viral DNA sequences&#44; while the second one generates fluorescence&#46; The presence of any of the 14&#8239;high-risk HPV genotypes could be detected &#40;16&#44; 18&#44; 31&#44; 33&#44; 35&#44; 39&#44; 45&#44; 51&#44; 52&#44; 56&#44; 58&#44; 59&#44; 66&#44; 68&#41;&#44; but not in an individualized manner&#46; However&#44; Cervista HPV 16&#47;18 identify HPV 16 and 18 individually&#46;</p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Cobas HPV Test &#40;Roche Diagnostics&#41;</span><p id="par0360" class="elsevierStylePara elsevierViewall">The Cobas 4800 system is an automated method that uses the primary sample obtained for the liquid-based cytology&#46; The results appear differentiated in four channels&#58; HPV 16&#44; HPV 18&#44; high-risk HPV non 16&#47;18 &#40;31&#44; 33&#44; 35&#44; 39&#44; 45&#44; 51&#44; 52&#44; 56&#44; 58&#44; 59&#44; 66&#44; and 68&#41; and &#946;-globin &#40;internal control&#41;&#46; The main advantages are the high sensitivity&#44; reproducibility&#44; and high-degree of automation&#46;</p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Aptima HPV Assay &#40;Hologic&#41;</span><p id="par0365" class="elsevierStylePara elsevierViewall">It is an assay that identify the presence of 14&#8239;high-risk genotypes by the identification of the viral RNAm from the E6&#47;7 oncogenes&#46; The presence of transcripts of the HPV oncogenes is a more accurate and specific marker of cell infection or transformation by hihg-risk HPV&#46; This method is useful in differentiating between episomal and integrated HPV oncogenic transcripts&#44; such as in cervical cancer&#46; This technique consist of three steps&#58; capture&#44; amplification by TMA system and detection by hybridization&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a> However&#44; the main problem with this technique is that RNA is much more labile than DNA and less available in most biological specimens&#46;</p></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Microarrays &#40;DNA chips&#41;</span><p id="par0370" class="elsevierStylePara elsevierViewall">Recent developments in combining molecular probes with silicon-based chips may lead to quick and relatively inexpensive diagnostics&#46; This technology requires the use of silicon chips&#59; the surface of the chip is covered with a fine layer of gold&#44; and molecular probes are attached to the surface of the chip&#46; Each of the molecular probes differs in the DNA target they are designed to hybridize&#46; If binding is detected&#44; the sample would be considered postive for HPV&#46;</p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Serological assays</span><p id="par0375" class="elsevierStylePara elsevierViewall">The majority of studies employed enzyme immunoassays&#44; but the main problem with the use of the serology is standardization and the establishment of an international standard assigning one unit measure or international unit&#46; Studies have demonstrated that about half of people exposed to HPV never developed measurable titers of antibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a></p></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Utility of P16<span class="elsevierStyleSup">INK4a</span></span><p id="par0380" class="elsevierStylePara elsevierViewall">The over-expression of this protein has been proposed as a tissue marker for high-risk HPV infection&#46; Positivity of this protein increases with lesion severity&#44; and a high percentage of HSIL cytology specimens are positive&#46; The sensitivity of P16<span class="elsevierStyleSup">INK4a</span> assays to detect CIN3 is similar to HPV DNA assays&#44; but the specificity needs to be improved&#46; Its role as a molecular prognosis factor is still an issue pending assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">89</span></a></p></span></span></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Herpes simplex virus genital infection</span><p id="par0385" class="elsevierStylePara elsevierViewall">Genital herpes is a common sexually transmitted disease &#40;STD&#41;&#46; It is caused by herpes simplex virus type 2 &#40;HSV-2&#41; or herpes simplex virus type 1 &#40;HSV-1&#41;&#46; Most people who have HSV-1 or HSV-2 do not have symptoms&#46;</p><p id="par0390" class="elsevierStylePara elsevierViewall">The laboratory diagnosis of genital herpes is recommended in confirmation of clinically suspected genital herpes or differential diagnosis with other ulcerative STIs or genital ulcerative dermatoses&#44; and in extra-genital complications of genital herpes&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">For active lesions&#44; collection of vesicular fluid or exudate from small vesicles with cotton or Dacron swab is the method of choice for collecting samples&#46; The laboratory methods for direct herpes diagnosis include viral culture&#44; antigen detection and DNA detection based on nucleic acid amplification by PCR&#46;</p><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Viral isolation</span><p id="par0400" class="elsevierStylePara elsevierViewall">Tube culture isolation is the traditional gold standard for HSV detection&#46; HSV grows readily in a wide variety of cell lines but the cell lines most frequently used for HSV culture are fibroblasts&#44; MRC-5 and Vero cells&#46; While the test has 100&#37; specificity for HSV-1 or HSV-2&#44; the sensitivity depends on the stage of the lesion at the time of specimen collection&#46; The sensitivity also varies from 75&#37; for first episodes to 50&#37; for recurrences&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">90&#44;91</span></a> Shell vial culture can reduce viral isolation times from one to seven days to 16 to 48&#8239;h&#46; However&#44; although these methods are rapid and specific&#44; they are slightly less sensitive than traditional tube cultures and are more expensive&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a></p></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Antigen detection</span><p id="par0405" class="elsevierStylePara elsevierViewall">Viral antigen can be detected by direct immunofluorescence assay &#40;DFA&#41; or enzyme immunoassay &#40;EIA&#41;&#46; The IF assay is a satisfactory ad rapid &#40;&#60;4&#8239;h&#41; method for diagnostic &#40;sensitivity 80&#37; and specificity 90&#37;&#41; but requires samples from fresh vesicles&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a></p></span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Virus detection by molecular biology</span><p id="par0410" class="elsevierStylePara elsevierViewall">PCR assays or other NAATs are the most sensitive test currently available to detect HSV in clinical samples&#46; Real-time PCR is faster&#44; less labor-intensive than traditional PCR and in the presence of active lesions&#44; PCR is the preferred test&#44; with sensitivity and specificity greater than 95&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">94&#44;95</span></a></p></span><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">Serological diagnosis</span><p id="par0415" class="elsevierStylePara elsevierViewall">Serologic testing may be useful in patients with recurrent genital symptoms or atypical symptoms and negative herpes simplex virus PCR&#46; In addition&#44; serological assay is useful knowing infection status in partner with genital herpes&#46; If genital lesions are present&#44; type-specific serology and direct virus testing can help to establish if the episode is a reactivation or a new HSV infection&#46;</p><p id="par0420" class="elsevierStylePara elsevierViewall">HSV IgM testing has limited availability in routine diagnostic settings and cannot be recommended in routine clinical practice&#46; Type-specific HSV IgG antibodies are negative in early stages of herpes disease&#44; and become detectable two weeks to three months after the onset of symptoms and persist indefinitely&#46; Type-specific HSV glycoprotein G based ELISA tests are recommended for serological diagnosis&#46; Primary HSV infections can be documented by seroconversion with paired sera&#46; The sensitivities of these IgG tests for the detection of HSV-2 antibody vary from 80 &#8211; 98&#37;&#44; and the specificities of these assays are &#8805; 96&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a> False-negative results can occur in period window of two weeks to three months after HSV exposure&#46;</p></span></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Mycoplasma genitalium infection</span><p id="par0425" class="elsevierStylePara elsevierViewall">Since the availability of molecular assays&#44; <span class="elsevierStyleItalic">M&#46; genitalium</span> has been associated with many adverse disease outcomes&#44; such as non gonococcal urethritis in men and many adverse reproductive sequelae in women like cervicitis&#44; endometritis&#44; preterm birth&#44; spontaneous abortation and pelvic inflammatory disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">96&#44;97</span></a> Other studies have reported promotion of HIV acquisition and shedding by antecedent <span class="elsevierStyleItalic">M&#46; genitalium</span> infection&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a> However&#44; <span class="elsevierStyleItalic">Mycoplasma hominis</span>&#44; <span class="elsevierStyleItalic">Ureaplasma urealyticum</span> &#40;previously <span class="elsevierStyleItalic">U&#46; urealyticum</span> biovar 2&#41; and <span class="elsevierStyleItalic">U&#46; parvum</span> &#40;earlier <span class="elsevierStyleItalic">U&#46; urealyticum</span> biovar 1&#41; are frequently found in the human urogenital tract in both healthy individuals and symptomatic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a></p><p id="par0430" class="elsevierStylePara elsevierViewall">A number of commercially produced <span class="elsevierStyleItalic">M&#46; genitalium</span> DNA amplification modalities have been described&#46; M genitalium specific oligonucleotide primers have been incorporated into single or multiplex PCR assay for six ITSs &#40;e&#46;g&#46; Seeplex STD6&#44; Seegene &#41; in urogenital specimens or vaginal and urine sample by PCR microrray &#40;STDetect chip&#44; Lab Genomics&#41;&#46; Other attempts to detect <span class="elsevierStyleItalic">M&#46; genitalium</span> DNA come in the context of assays designed for to detection of <span class="elsevierStyleItalic">M genitalium</span>&#44; <span class="elsevierStyleItalic">M&#46; hominis&#44; U&#46; urealyticum</span> and <span class="elsevierStyleItalic">U&#46; urealyticum</span> from male first void urine sample together with other pathogens &#40;e&#46;g&#46; FilmArray STI panel&#44; BioFire Diagnostic&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a></p><p id="par0435" class="elsevierStylePara elsevierViewall">There are also other assays that have CE marking &#40;Bio-rad DX CT&#47;NG&#47;MG&#44; Biorad&#41; &#40; Hyplex STD Mycoplasma test&#44; Amplex Bioystems &#41;&#44; the latter has shown a sensitivity and specificity of 87&#37; and 96&#37; for detection of <span class="elsevierStyleItalic">M&#46; genitalium</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">100</span></a></p><p id="par0440" class="elsevierStylePara elsevierViewall">There have been several published research assays that can detect macrolide resistance in samples know to be positive for <span class="elsevierStyleItalic">M&#46; genitalium</span>&#44; using detection of 23&#8239;s RNA gene mutations that are associated with resistance by PCR and melt curve analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">101</span></a> Plex Zyme and PlexPrime recently developed in 23 S asay a multiplex qPCR assay for detection of <span class="elsevierStyleItalic">M&#46; genitalium</span> and the 5 mutations associated with macrolide resistence&#44; the assay was evaluated in 400 samples from 254 consecutively infected participants&#44; 56&#37; schowed a macrolide resistance mutation and its sensitivity and specificity were 99&#44;1&#37; and 98&#46;5&#37; for <span class="elsevierStyleItalic">M&#46; genitalium</span> detection and 97&#46;4&#37; and 100&#37; for macrolide resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a></p></span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">HIV infection</span><p id="par0445" class="elsevierStylePara elsevierViewall">At present in our country surveillance data suggest a stabilization or decrease in HIV incidence in the face of apparent increases in the numbers of persons tested among key risk groups&#46; The reasons for these improving trends are not yet clear&#44; but in order to be sustained&#44; we must continue to refine systems for HIV testing and linking persons to care and prevention resources&#44; as appropriate&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">102</span></a></p><p id="par0450" class="elsevierStylePara elsevierViewall">HIV testing is often prompted by a defined exposure&#44; such as a needlestick injury&#44; condom failure&#44; or condomless sex&#46;</p><p id="par0455" class="elsevierStylePara elsevierViewall">Following an exposure that leads to infection&#44; there is a variable amount of time called the eclipse period in which no existing diagnostic test is capable of detecting HIV&#46; HIV RNA is the first reliable marker of infection&#59; 50&#37; of infected individuals have detectable plasma RNA within 12 days and levels peak between 20&#8211;30 days&#46; Beginning around day 15&#44; the HIV-1 capsid protein p24 reaches detectable levels in the plasma&#46; Antigenemia with p24 continues to rise through days 25&#8211;30&#44; at which point early anti-HIV antibodies are able to complex with circulating p24&#59; by day 50&#44; antigen is often cleared from the bloodstream entirely&#46;This short-lived detectability of p24 is therefore helpful in determining recency of infect&#44; but also makes its utility in diagnosis time limited&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">103&#8211;105</span></a></p><p id="par0460" class="elsevierStylePara elsevierViewall">All HIV diagnostic testing is guided by a common principle&#58; screen with a highly sensitive initial test and confirm reactive results with a different test that is both sensitive and highly specific&#46; This can be accomplished using two POC tests&#44; two laboratory-based assays&#44; or combinations thereof&#59; all of these strategies have been studied extensively&#46; Since the US Food and Drug Administration &#40;FDA&#41; approved the first HIV diagnostic test in 1985&#44; four additional &#8220;generations&#8221; of antibody tests for HIV have been developed&#59; each improves incrementally on its predecessor&#40;s&#41; in terms of performance and shortening of the window period&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">106&#44;107</span></a></p><p id="par0465" class="elsevierStylePara elsevierViewall">IgM&#47;IgG sensitive &#40;formerly third generation&#41; tests shorten the window period to the earliest threshold of IgM detection &#8211; a median of 23 days after infection&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">103</span></a></p><p id="par0470" class="elsevierStylePara elsevierViewall">Antigen&#47;antibody &#40;Ag&#47;Ab&#41; combination &#40;formerly fourth generation&#41; tests pair an IgM&#47;IgG sensitive antibody test with simultaneous&#44; separate p24 antigen detection&#46; Some of these p24&#47;IgM&#47;IgG sensitive tests report a reactive result if any element is detected&#44; while others yield separate results for p24&#44; anti-HIV-1 antibodies&#44; and anti- HIV-2 antibodies&#46; Detecting p24 shortens the median window period down to just 18 days following infection&#46;</p><p id="par0475" class="elsevierStylePara elsevierViewall">In contrast to complex&#44; automated laboratory-based platforms&#44; POC tests rely on one of two methods&#58; lateral flow&#44; in which the specimen is drawn through an antigen-impregnated strip by capillary action&#59; or flow-through&#44; in which the patient&#8217;s specimen and reagents are sequentially applied to a membrane embedded with HIV antigens&#46; Laboratory-based serum or plasma assays generally offer higher sensitivities&#44; but require venipuncture&#44; larger specimen volumes&#44; processing&#44; and skilled technicians&#46; POC tests are attractive alternatives for many applications&#44; but performance differs substantially depending on the specimen type&#59; tests using oral transudate are significantly less sensitive than those using whole blood&#44; and tests using whole blood are less sensitive than those using serum or plasma&#46;<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">108&#44;109</span></a></p><p id="par0480" class="elsevierStylePara elsevierViewall">In summary&#44; the laboratory test is one of a number of tools in the diagnosis of the patient with STIs&#44; and so the clinician should always be aware of the tests the laboratory offers and the results of any tests should be interpreted in the clinical context&#46; It is likely that POCT based on molecular biology will be more common in the future to allow rapid diagnosis&#44; but should be used with laboratory support&#46;</p></span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">Conflict of interest</span><p id="par0485" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Chlamydia trachomatis infections"
          "secciones" => array:1 [
            0 => array:3 [
              "identificador" => "sec0015"
              "titulo" => "Diagnostic Chlamydia trachomatis &#40;CT&#41; infections"
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                  "titulo" => "Nucleic Acid AmplificationTest &#40;NAATs&#41;"
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          "titulo" => "Neisseria gonorrhoeae &#40;NG&#41; infections"
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              "identificador" => "sec0045"
              "titulo" => "Diagnosis of NG infections"
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                  "titulo" => "Microscopy"
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          "titulo" => "Treponema pallidum &#40;syphilis&#41; infections"
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              "identificador" => "sec0070"
              "titulo" => "Direct detection methods"
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              "titulo" => "Special situations"
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                  "titulo" => "Neurosyphilis"
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          "titulo" => "Infections caused by Trichomonas vaginalis &#40;TV&#41;"
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              "identificador" => "sec0105"
              "titulo" => "Diagnosis of TV infections"
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                  "identificador" => "sec0110"
                  "titulo" => "Conventional methods&#58; microscopy and culture"
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                  "identificador" => "sec0115"
                  "titulo" => "Rapid detection tests&#58; point-of-care testing"
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                2 => array:2 [
                  "identificador" => "sec0120"
                  "titulo" => "NAATs techniques"
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          "identificador" => "sec0125"
          "titulo" => "Human papillomavirus &#40;HPV&#41; infections"
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            0 => array:2 [
              "identificador" => "sec0130"
              "titulo" => "Diagnosis of HPV infections"
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              "titulo" => "Conventional and monolayer cytology"
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            2 => array:2 [
              "identificador" => "sec0140"
              "titulo" => "Histopathology"
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            3 => array:3 [
              "identificador" => "sec0145"
              "titulo" => "HPV nucleic acid detection"
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                0 => array:2 [
                  "identificador" => "sec0150"
                  "titulo" => "Commercially techniques for molecular HPV detection"
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                1 => array:2 [
                  "identificador" => "sec0155"
                  "titulo" => "Validation and FDA-approval"
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                2 => array:2 [
                  "identificador" => "sec0160"
                  "titulo" => "HPV detection techniques comparison"
                ]
                3 => array:2 [
                  "identificador" => "sec0165"
                  "titulo" => "Hybrid Capture 2 High-Risk HPV DNA &#40;Digene&#41;"
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                  "identificador" => "sec0170"
                  "titulo" => "Cervista HPV HR &#40;Hologic&#41;"
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                  "titulo" => "Cobas HPV Test &#40;Roche Diagnostics&#41;"
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                  "identificador" => "sec0180"
                  "titulo" => "Aptima HPV Assay &#40;Hologic&#41;"
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                  "identificador" => "sec0185"
                  "titulo" => "Microarrays &#40;DNA chips&#41;"
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                  "identificador" => "sec0190"
                  "titulo" => "Serological assays"
                ]
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                  "identificador" => "sec0195"
                  "titulo" => "Utility of P16"
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          "identificador" => "sec0200"
          "titulo" => "Herpes simplex virus genital infection"
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              "identificador" => "sec0205"
              "titulo" => "Viral isolation"
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            1 => array:2 [
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              "titulo" => "Antigen detection"
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            2 => array:2 [
              "identificador" => "sec0215"
              "titulo" => "Virus detection by molecular biology"
            ]
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              "identificador" => "sec0220"
              "titulo" => "Serological diagnosis"
            ]
          ]
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          "identificador" => "sec0225"
          "titulo" => "Mycoplasma genitalium infection"
        ]
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          "identificador" => "sec0230"
          "titulo" => "HIV infection"
        ]
        13 => array:2 [
          "identificador" => "sec0235"
          "titulo" => "Conflict of interest"
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        14 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
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    "tienePdf" => true
    "fechaRecibido" => "2018-09-26"
    "fechaAceptado" => "2019-05-13"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1301707"
          "palabras" => array:5 [
            0 => "Sexually transmitted infections"
            1 => "Diagnosis"
            2 => "Nucleic acid amplification test"
            3 => "Culture"
            4 => "Point of care test"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1301708"
          "palabras" => array:5 [
            0 => "Infecciones de transmisi&#243;n sexual"
            1 => "Diagn&#243;stico"
            2 => "Prueba de amplificaci&#243;n de &#225;cidos nucleicos"
            3 => "Cultivo"
            4 => "Pruebas de diagn&#243;stico en el punto de atenci&#243;n"
          ]
        ]
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sexually transmitted infections &#40;STIs&#41; are one of the most frequent and universal Public Health problems&#46; Health professionals should be aware of the possibility of STIs due to their high morbidity and the presence of sequelae&#46; The delay in the diagnosis is one of the factors that justifies the difficulty to infections control&#46; Diagnostic tests allow the introduction of aetiological treatment and also leads to treating symptomatic and asymptomatic patients more effectively&#44; as well as to interrupt the epidemiological transmission chain without delay&#46; In this review we have made an update of the main existing diagnostic methods for the more important STIs&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las infecciones de transmisi&#243;n sexual &#40;ITS&#41; son uno de los problemas de salud p&#250;blica m&#225;s frecuentes y universales&#46; Debido a que las ITS son responsables de una alta morbilidad&#44; as&#237; como de secuelas graves&#44; es muy importante que todos los profesionales de la salud las tengan en cuenta en el momento de valorar al paciente&#46; La dificultad en el control de las ITS se debe principalmente al retraso diagn&#243;stico&#46; Las pruebas diagn&#243;sticas permiten realizar un manejo etiol&#243;gico&#44; as&#237; como facilitar un tratamiento m&#225;s efectivo tanto de los pacientes sintom&#225;ticos como de los asintom&#225;ticos&#44; y finalmente permitir&#225;n interrumpir de una forma m&#225;s precoz la cadena epidemiol&#243;gica de transmisi&#243;n&#46; En la presente revisi&#243;n&#44; se ha llevado a cabo una actualizaci&#243;n acerca de los principales m&#233;todos diagn&#243;sticos existentes en las ITS m&#225;s relevantes&#46;</p></span>"
      ]
    ]
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez-Granger J&#44; Espadafor L&#243;pez B&#44; Cobo F&#44; Blasco Morente G&#44; Sampedro Martinez A&#44; Tercedor S&#225;nchez J&#44; et al&#46; Actualizaci&#243;n en el diagn&#243;stico de las infecciones de transmisi&#243;n sexual&#46; Actas Dermosifiliogr&#46; 2020&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.ad.2019.05.008">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;ad&#46;2019&#46;05&#46;008</span></p>"
      ]
    ]
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Review
Update on the Diagnosis of Sexually Transmitted Infections
Actualización en el diagnóstico de las infecciones de transmisión sexual
J. Rodríguez-Grangera,
Corresponding author
, B. Espadafor Lópezb, F. Coboa, G. Blasco Morenteb, A. Sampedro Martineza, J. Tercedor Sánchezb, L. Aliaga-Martineza,c, A. Padilla-Malo de Molinad, J.M. Navarro-María
a Servicio de Microbiología, Hospital Universitario Virgen de las Nieves, Granada, Spain
b Servicio de Dermatología, Hospital Universitario Virgen de las Nieves, Granada, Spain
c Departamento de Medicina, Facultad de Medicina, Universidad de Granada, Granada, Spain
d Distrito Granada Nordeste, C. S. Purullena, Granada, Spain
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However&#44; there is a general lack of standardization among countries and many have yet to implement STI surveillance systems&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Each year&#44; there are estimated 357 million new cases of four curable STIs among people aged 15-49 years&#58; <span class="elsevierStyleItalic">Chlamydia trachomatis</span> is adquired by 131 million persons&#44; 78 million get <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span>&#44; 5&#46;6 million syphilis and 143 million contact trichomoniasis worldwide&#46; The prevalence of some viral sexually STI is similarly high&#46; More than 500 million people are living with virus herpes simplex type 2 infection&#46; However&#44; the epidemiology of HSV is changing and genital herpes is increasingly being caused by HSV-1 in industrialized countries&#46; Human papillomavirus &#40;HPV&#41; infection is the most prevalent sexually transmitted infection in men and women worldwide&#46; More than 290 million women have an humam papillomavirus &#40;HPV&#41; infection&#46; The prevalence varies by region and gender&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Genital warts represent a significant public health problem&#46; The European Centers for Disease Prevention and Control &#40;ECDC&#41; surveillance report on STI in Europe and Red Nacional de Vigilancia Epidemiol&#243;gica &#40;RENAVE&#41; in Spain shows the epidemiological features and basic trends of the five STI under European Union &#40;EU&#41; surveillance&#58; <span class="elsevierStyleItalic">Chlamydia trachomatis</span> infection&#44; gonorrhoea&#44; syphilis&#44; congenital syphilis&#44; and Lymphogranuloma venereum &#40;LGV&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Chlamydia was the most common STI in Europe with 394&#46;163 cases reported in 2015&#46; In Spain&#44; 7&#46;162 new infections were notified in 2016&#46; The incidence rate was estimated to be 18 per 100&#44;000 &#40;with values ranging among different regions&#44; the highest was 46&#44;4 in Catalu&#241;a&#41;&#46; How 53&#37; of cases reported were in females&#46; The majority of reported cases continue to be among young people between 15 and 24 years of age&#44; suggesting that testing continues to be targeted towards groups at higher behavioural risk of STI while simultaneously aiming to reduce the risks of reproductive tract complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> But while trends in the number of chlamydia infections appear to have stabilised in recent years &#40;2011-2015&#44; increased by 4&#37; overall&#41;&#44; gonorrhoea rates have gone up by 79&#37; since 2008&#44; particularly among men&#46; With more than 75&#46; 000 reported cases in 2016&#44; gonorrhoea is the second most commonly notified STI in Europe&#44; and Spain is not an exception with 6&#46;456 cases reported&#44; 83&#37; in men&#46; Male to female ratio in Spain was 5&#58;1&#46; This increase seems to be linked to increased case numbers among men who have sex with men &#40;MSM&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6</span></a> The number and rate of reported syphilis cases has continued to increase in 2015 &#40;28 701 syphilis cases in Europe&#41;&#46; The increases continue to be driven by cases reported among men&#44; specifically among MSM &#40;62&#37;&#41;&#46; Trends among heterosexual men and women&#44; on the other hand&#44; appear stable or show a slight decrease&#46; Syphilis rates increased in Spain until 2011&#44; but there has been an stabilization since then with 3886 cases notified in 2015 and 3357 in 2016&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7</span></a> Following a decreasing trend&#44; the notification rate of congenital syphilis has stabilised since 2006&#46; 42 cases were reported in Europe in 2015 and four cases in Spain in 2016&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; the number of reported cases of LGV continued to increase in western and central European countries with 1787 in 2015&#46; Spain notified 248 cases in 2016&#46; Epidemiological investigations suggest that transmission is mainly among HIV-positive MSM engaging in high-risk practices&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9</span></a> Infection with the human immunodeficiency virus &#40;HIV&#41; and STIs are clearly interrelated&#44; sharing risks&#44; incidence and transmission mechanisms&#46; Currently&#44; the global rate of new HIV diagnoses in Spain is at levels similar to those of other countries in the WHO European Region&#46; Since 2003&#44; a record of new diagnoses of HIV infection in our country has been made&#44; with a stable number in the last 7 years&#44; standing at an average of 3293 cases&#47;year&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This review highlights the main diagnostic methods currently used for STIs community to ensure that effective interventions for STIs prevention&#44; screening&#44; diagnosis&#44; and treatment are made more widely available&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030"><span class="elsevierStyleItalic">Chlamydia trachomatis</span> infections</span><p id="par0035" class="elsevierStylePara elsevierViewall">Several factors may account for the increase of diagnosed CT infections&#44; including changes in sexual behaviour and lack of prevention and education&#44; but also more frequent testing with improved detection systems&#46; Testing for Chlamydia is indicated in patients with urogenital&#44; cervicitis&#44; pelvic inflammatory disease &#40;PID&#41;&#44; and extragenital infection by sexual transmission&#58; anorectal&#44; pharyngeal and ocular&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Initially&#44; all relevant clinical materials can be analyzed by molecular biology techniques&#46; Non invasive specimens are the preferred materials&#44; in particular for screening of asymptomatic persons&#46; First void urine and uretral swabs from male patients are equivalent regarding to performance of nucleid acid amplification test &#40;NAATs&#41;&#46; Collection of urine sample is much better accepted and therefore the recommended sample in men&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> To detect extra-genital CT infections&#44; testing of corresponding swabs or tissue samples is required&#46; CT infection of men who have sex with men &#40;MSM&#41; is frequently localized in the rectum or pharynx&#44; without causing any symptoms&#44; and it require testing of appropriate oral and anal swabs to be diagnosed&#46; In this case&#44; the only screening of an urine sample can lead to a infradiagnostic of the infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Diagnostic <span class="elsevierStyleItalic">Chlamydia trachomatis</span> &#40;CT&#41; infections</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Nucleic Acid AmplificationTest &#40;NAATs&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Only if <span class="elsevierStyleItalic">C&#46; trachomatis</span> NAATs are not available or affordable&#44; isolation of <span class="elsevierStyleItalic">C&#46; trachomatis</span> in cell culture or identification of C trachomatis by direct fluorescence assays &#40;DFA&#41; can be used for diagnosis of acute infections&#46; Validated and quality assured NAATs are recommended due to their superior sensitivity&#44; specificity and speed of diagnosis of both symptomatic and asymptomatic chamydial infections compared to all other diagnostic techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> Due to the high specificity of the appropriately validated C trachomatis NAATs and risk of loasing low positive result in repetead testing&#44; confirmatory testing of positive specimens is not recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> An important exception is represented by legal investigations in case of sexual assault&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The NAATs can use less invasively colleted specimens such as urine samples in men or vulvo-vaginal swabs in women and anorectal swabs in both genders&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Diagnostic sensitivity can be increased using coated magnetic beads nucleic acids nucleic acids were isolated in higher quantity and quality&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> These bead based extraction systems can be automated and use in several high-throughput systems that allow simultaneous testing of chlamydia and gonococci with sensitivity and specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> In order to increase the sensitivity of the technique&#44; these tests are based on the detection of genes present in high number of copies &#40;cryptic plasmid X06707 &#40;10 copies &#47;genome&#41; or 16S ADNr &#40;2 copies&#47;genome&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">NAATs have detected 10-30&#37; more <span class="elsevierStyleItalic">C&#46; trachomatis</span> positive specimens than culture in studies comparing the two methods&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> In some several studies&#44; results of different NAATs were show to be highly concordant&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a> The importance of genetic variation became evident with the appearance of the Swedish variant that was not detected by some commercial NAATs due to a deletion in the target region of these test&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The implementation of a 2<span class="elsevierStyleSup">nd</span> target region in NAATs represents an important improvement of NAATs&#44; allowing detection of new variants with deletions or recombination in one of the target region&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> As an example of systems that developed a modification of the technique Cobas Taqman CT&#47;NG v 2&#46;0 &#40;Roche&#41; and Artus <span class="elsevierStyleItalic">C&#46; trachomatis</span> plus RG Kit PCR &#40;Qiagen&#41;&#46; One limitation of all these diagnostic techniques is the lack of discrimination between the different biovars of <span class="elsevierStyleItalic">C&#46; trachomatis</span> related to different pathological processes that can be detected in urethral or cervical samples&#46; None of the above technique can discriminate between serovars D-K and serovars L1-L3 related with lymphogranuloma venereum &#40;LGV&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Point of care test &#40;POCTs&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Rapid point-of-care test provide a quick and easy test result&#44; and diagnosis and subsequent treatment can be provided at the same visit at clinic or even in remote setting&#46; Most POCTs are immune chromatographic test based on lateral flow technology and detec chamydia lipopolysaccharide antigen &#40;LPS&#41; in genital swabs or urine&#46; Compared with culture and NAATs&#44; these antigen based in POCTs are significantly less sensitive and less specific&#46; The antigen based POCTs were not recommended for <span class="elsevierStyleItalic">C&#46; trachomatis</span> testing of both asymptomatic screening and symptomatic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> POCTs with increased sensitivity have been developed and new POC NAATs &#40;e&#46;g&#46; Xpert assay of Cepheid CT&#47;NG&#41;&#46; This assay is based on real time PCR carried out in a closed system&#46; After application of the clinical sample to a cartridge&#44; the subsequent steps of nucleic acid isolation&#44; amplication and detection of PCR products proceed in a fully automated process&#46; Another commercial test POCTs NAATs use technology isothermal amplification&#44; like loop mediated isothermal ampllication &#40;LAMP&#41; or recombinase polymerase amplification &#40;RPA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Serology</span><p id="par0060" class="elsevierStylePara elsevierViewall">Testing for <span class="elsevierStyleItalic">C&#46; trachomatis</span> antibodies is not useful to diagnose local epithelial infectious of the lower genital tract&#44; because antibodies are detectable with a delay of several weeks&#44; antibody titers may be low&#44; and many serologic test are not able to differentiate antibodies against different chlamydia species&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The microinmmunefluorescence &#40;MIF&#41; test was long time considered the reference method of chamydia antibody testing but enzyme immunoassays &#40;EIA&#41; and inmunoblosts or line assays are currently used more frequently to detect clamydia infections&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a> The EIA technology is based on the detection of antigen by measuring a colored signal generated by the antigen reaction liposaccharides &#40;LPS&#41; with the antibody&#46; Traditionally they have enjoyed great popularity for being simple&#44; objective and automated techniques&#46; The specificity of EIA is low&#44; being able to give false positives due to the presence of bacterial lipopolisaccharides LPS&#46; Other techniques are based on direct staining of samples with fluorescein-labeled monoclonal antibodies &#40;DFA&#41;&#46; This last technique uses species-specific antibodies directed mainly against the antigen major outer membrane protein &#40;MOMP&#41; and to a lesser extent against the LPS&#46; The main advantages of the DFA techniques are its speed &#40;30&#8239;min&#41; and specificity close to 100&#37;&#44; the sensitivity is 85-90&#37;&#44; compared to the culture and does not require specific means of transport&#46; Among its drawbacks is the subjective interpretation and requires experienced staff&#44; low reproducibility and the volume of samples should not be high&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Cell Culture</span><p id="par0070" class="elsevierStylePara elsevierViewall">Until the end of the 20th century&#44; cell culture has been the reference standard against which all other tests have been compared&#46; But mainly due to the appearance of new diagnostic methods easier to implement&#44; fast and sensitive&#44; cell culture has been relegated to reference laboratories&#46; Established cell lines for isolation of <span class="elsevierStyleItalic">C&#46; trachomatis</span> include McCoy&#44; Hela 29&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The specimens for culture must be collected using special devices and transport media&#46; Sensitivity of culture may be impaired by inadequate specimen collection&#44; storage and transport&#44; toxic substances in clinical specimens and overgrowth of cell cultures by commensal bacteria and fungi&#46; Cell culture is a very specific technique&#44; however sensitivity is not very good 75-80&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;32</span></a></p></span></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Neisseria gonorrhoeae &#40;NG&#41; infections</span><p id="par0075" class="elsevierStylePara elsevierViewall">Gonorrhoea is the second most common bacterial sexually transmitted infection &#40;STI&#41; worldwide<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> although the prevalence of this infection varies among populations&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> From a localized lesion&#44; the microorganism can ascend to the upper genital tract to cause pelvic inflammatory disease&#44; epididymo-orchitis or disseminate as bacteraemia&#46; Due to this fact&#44; an appropriate diagnosis and an effective treatment of this infection are important factors contributing to public health control and to prevent serious complications&#46; However&#44; the increase of resistance to recommended treatments for gonorrhoea may seriously affect to infection control&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Diagnosis of NG infections</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Microscopy</span><p id="par0080" class="elsevierStylePara elsevierViewall">NG could be visualized on microscopy of a stained genital tract smear in symptomatic patients&#46; In men with urethral discharge&#44; microscopy &#40;x1000&#41; using Gram for identification of diplococci within polymorphonuclear leukocytes has good sensitivity &#40;&#8805;95&#37;&#41; and specificity &#40;&#8805;99&#37;&#41; as a rapid diagnostic test&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> However&#44; in asymptomatic men&#44; this technique has poor sensitivity &#40;&#8804;55&#37;&#41;&#44; as well as in identifying endocervical or rectal infection &#40;&#8804;55&#37; and &#8804;40&#37;&#44; respectively&#41;&#59; in these circumstances&#44; microscopy cannot be recommended as a test for ruling out infection&#46; In addition&#44; Gram stains of endocervical&#44; rectal&#44; or pharyngeal specimens also are not recommended to detect infection due to poor specificity as well as low sensitivity&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Culture</span><p id="par0085" class="elsevierStylePara elsevierViewall">Culture is the only diagnostic test that allows antimicrobial susceptibility testing&#44; remaining important to detect and monitor antimicrobial resistance&#46; Specimens should be obtained by using swabs other than those composed by wood and cotton because they may be inhibitory or toxic to NG&#46; Some transport systems can maintain gonococcal viability for up to 48&#8239;h in ambient temperature&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Swabs should be inserted 2-3&#8239;cm in the male urethra or 1-2&#8239;cm into the endocervical canal followed by 2-3 rotations&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Specimens from sterile sites could be cultured on nonselective medium &#40;e&#46;g&#46; chocolate agar&#41;&#44; whereas those from nonsterile locations are cultured on a selective mediun &#40;e&#46;g&#46; Martin-Lewis&#44; Thayer-Martin&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> which contain antimicrobial agents that inhibit the growth of other bacteria and fungi&#46; These media are incubated at 35&#8239;&#176;C in an atmosphere supplemented with 5&#37; CO<span class="elsevierStyleInf">2</span> and examined during at least 48-72&#8239;h&#46; Gram-negative diplococci and oxidase-positive colonies can be presumptively identified as NG&#46; Further additional biochemical tests are needed in order to confirm the diagnosis&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Culture should be carry out for antimicrobial sensitivity study in patients with persisting infection or if treatment failure is suspected&#46; Moreover&#44; characterization of isolates by molecular typing may be a useful tool to predict antimicrobial resistance due to the fact that some types are associated to decreased susceptibility to several antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> The sensitivity of culture is high for genital samples but strongly depend on the specimen collection&#44; transport&#44; storage and isolation procedures&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Nucleid acid amplification tests &#40;NAATs&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">NAATs techniques are recommended for detection of infections caused by NG with and without symptoms&#46; NAATs are more sensitive than culture&#44; they can be used on a wider range of specimen types&#44; and specimen quality&#44; transportation and storage are less strict&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#8211;43</span></a> NAATs are the sample of choice for testing asymptomatic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> These techniques show similar sensitivity in urine and urethral specimens from men&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> and also similar sensitivity in endocervical specimens taken from physicians and those self-taken form the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> However&#44; in women&#44; urine samples have lower sensitivity than genital swabs for testing&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Moreover&#44; NAATs are significantly more sensitive than culture for the detection of NG in pharyngeal and rectal samples&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;47</span></a> being the tests of choice for screening for these kind of infections&#46; However&#44; these techniques are not approved for testing specimens from these locations&#46; A summary of the commercially available and FDA &#40;Food and Drug Administration&#41;-cleared NAAT assay platforms for the detection of NG in the United States can be found in the current American guide for the diagnosis of these infections&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p></span></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085"><span class="elsevierStyleItalic">Treponema pallidum</span> &#40;syphilis&#41; infections</span><p id="par0105" class="elsevierStylePara elsevierViewall">Syphilis develops in stages&#44; and symptoms vary with each stage &#40;primary&#44; secondary&#44; latent&#44; and late or tertiary syphilis&#44; including neurosyphilis and cardiovascular syphilis&#41;&#46; But the stages may overlap&#44; and symptoms do not always occur in the same order&#46; Alternatively&#44; patients may be completely asymptomatic and only identified on routine screening&#46; The choice of method for diagnosing syphilis depends on the stage of disease and the clinical presentation&#46;</p><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Direct detection methods</span><p id="par0110" class="elsevierStylePara elsevierViewall">Dark field microscopy &#40;DFM&#41; and direct fluorescent antibody staining for <span class="elsevierStyleItalic">T&#46; pallidum</span> &#40;DFA-TP&#41; have been used in clinical laboratories for decades to visualization of the spirochete in lesion exudate from patients with primary and secondary syphilis&#46; However&#44; these methods are not available in all laboratories&#44; in addition to needing experienced personnel&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Nucleic acid amplification tests&#44; such as the polymerase chain reaction &#40;PCR&#41;&#44; have not been used routinely for syphilis diagnosis since a commercial test is not available or internationally approved&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> However&#44; PCR tests for syphilis can be performed for the diagnosis of neurosyphilis&#44; particularly among individuals infected with HIV&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a> It is considered that CSF PCR has little value for diagnosis of neurosyphilis due to its low sensitivity and specificity&#46; Its carrying out in blood is not recommended existence of inhibitory substances&#46; To do this test can be used fresh samples or frozen&#46; There are commercial formats&#44; validated for all types of samples&#44; so that it is essential to use the controls of corresponding validation&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Serological assays</span><p id="par0120" class="elsevierStylePara elsevierViewall">Serological testing is the most common method for syphilis screening&#44; diagnosis&#44; and follow-up of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Serological tests for syphilis can be divided into two types&#58; nontreponemal test &#40;NTTs&#41; and treponemal test &#40;TTs&#41;&#46; Both tests are used to confirm the infection and determine whether the disease is active&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">NTTs detect IgM and IgG antibodies to lipoidal antigens released from injured host cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;52</span></a> NTTs include Venereal Disease Research Laboratory &#40;VDRL&#41;&#44; rapid plasma reagin &#40;RPR&#41;&#44; and toluidine red unheated serum test &#40;TRUST&#41;&#46; Non treponemal antibodies become positive 10&#8211;15 days after the onset of the primary lesion&#46; NTTs lack sensitivity in primary and tertiary syphilis and its use as a screening test presents problems&#46; Without treatment&#44; titres increase at 1&#8211;2 years after infection and can gradually decline spontaneously and&#44; in some patients&#44; become non-reactive&#46; After treatment&#44; titres generally decline and in most immunocompetent individuals become non-reactive within 6 months&#46; However&#44; up to 20&#37; of individuals infected and correctly treated show persistently reactive NTTs low titre results&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">53&#44;54</span></a> False-positive results with this test can occur during pregnancy&#44; in patients with rheumatological diseases&#44; chronic infections &#40;HIV&#44; mycobacterial diseases&#41; and parenteral drug users&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">TTs use native or recombinant <span class="elsevierStyleItalic">T&#46; pallidum</span> antigens to detect specific antibodies to treponemal components&#46; These tests include the fluorescent treponemal antibody absorption assay &#40;FTA-ABS&#41;&#44; the <span class="elsevierStyleItalic">T&#46; pallidum</span> particle agglutination assay &#40;TPPA&#41;&#44; enzyme-linked immunoassays &#40;EIAs&#41;&#44; chemiluminescence immunoassays &#40;CIAs&#41;&#44; and immunochromatographic assays &#40;ICs&#41;&#46; Specific antibodies are the first to appear &#40;6&#8211;14 days after the primary chancre appears&#41; and persist throughout life&#59; TTs cannot be used to distinguish an active from a past or previously treated infection and&#44; therefore&#44; are not helpful for evaluation the effectiveness of antibiotic treatment&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">FTA-ABS is considered the <span class="elsevierStyleItalic">gold standard</span> in many middle-income and low-income countries but it has drawbacks like time consuming&#44; expensive and difficult to read&#46; This assay can be used in cerebrospinal fluid &#40;CSF&#41;&#46; Sensitivity of TTs varies 82&#8211;100&#37; depending on disease stage&#59; specificity is 99&#37;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In recent years&#44; rapid and inexpensive serologic tests for syphilis have been developed&#46; Rapid syphilis tests are ICs assays that use a whole blood sample&#44; require no equipment and minimal training and give a result in few minutes with a a sensitivity of 86&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Most tests use treponemal antigens but one IC test has been developed that enables the simultaneous detection of nontreponemal and treponemal antibodies in a single point of care device&#44;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56&#8211;58</span></a> and it can distinguish between new and previously treated infections&#46; The overall performance for diagnosis of active infection is 88&#46;3&#37; &#40;range 87&#46;1&#8211;89&#46;4&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56&#44;58</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Interpretation of reactive tests</span><p id="par0145" class="elsevierStylePara elsevierViewall">Screening using an initial automated treponemal test &#40;EIA or CLIA&#41; is done by many laboratories&#44; especially those with high sample volume&#46; A negative treponemal test likely indicates the absence of syphilis and generally no further testing is required&#46; However&#44; recent infection cannot be ruled out and repeat testing should be considered in patients who have had a recent risk exposure&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Reactive samples must be tested by a nontreponemal test to determine if disease is active&#46; A positive titer with a VDRL or RPR indicates active syphilis and follow-up serologic testing is performed to monitor treatment response&#46; When NTTs is not reactive in patients who report no history of syphilis treatment&#44; it could be very early syphilis&#44; longstanding latent syphilis&#44; or a biological false positive result&#46; Second different TTs should be performed&#46; Patients with positive second TTs are candidates for treatment if they have not been previously treated&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Special situations</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Neurosyphilis</span><p id="par0155" class="elsevierStylePara elsevierViewall">Examination of CSF in a patient with neurologic signs and symptoms must include total protein&#44; number of mononuclear cells and serologic test&#46; CSF laboratory abnormalities &#40;pleocytosis and an increased protein concentration&#41; are common in persons with neurosyphilis&#46; CSF-VDRL is highly specific but insensitive &#40;a positive CSF VDRL test is observed in only about 1&#58;3 cases of neurosyphilis&#41;&#46; Rapid plasma reagin testing on CSF is not recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In a person with neurologic signs or symptoms&#44; a reactive CSF-VDRL &#40;in the absence of blood contamination&#41; is considered diagnostic of neurosyphilis&#46; When CSF-VDRL is negative despite the presence of clinical signs of neurosyphilis&#44; and abnormal CSF cell count and&#47;or protein&#44; neurosyphilis should be considered&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The CSF FTA-ABS test is less specific for neurosyphilis than the CSF-VDRL but is highly sensitive&#46; In patients with suspicion of neurosyphilis but a negative CSF VDRL&#44; a CSF FTA-ABS test can be used to rule out neurosyphilis&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Congenital syphilis</span><p id="par0170" class="elsevierStylePara elsevierViewall">Because maternal nontreponemal and treponemal IgG antibodies can be transferred from mother to child&#44; treponemal testing of infant serum is not recommended&#46; A fourfold increase or more of the titre of a NTTs in the child&#8217;s as opposed to the mother&#8217;s serum &#40;both obtained simultaneously at birth&#44; is highly suggestive of congenital syphilis but its absence does not exclude a diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Children from mother with a positive treponemal test for syphilis and any evidence of congenital syphilis on physical examination&#44; or long bone x-ray suggestive&#44; or reactive CSF VDRL assay&#44; or elevated cerebrospinal fluid cell count or protein &#40;without other cause&#41; can support a diagnosis of congenital syphilis&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></span></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Infections caused by <span class="elsevierStyleItalic">Trichomonas vaginalis</span> &#40;TV&#41;</span><p id="par0175" class="elsevierStylePara elsevierViewall">TV is the most prevalent non-viral STI worldwide&#46; These infections represent the most common curable STI in young&#44; sexually active men and women&#46; In women&#44; trichomoniasis has been associated with poor reproductive health outcomes like low birth weight and premature birth&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> Thus&#44; early detection and treatment of TV infections are strongly recommended for symptomatic women and men&#46; For asymptomatic patients&#44; detection is only recommended for HIV-positive women&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Diagnosis of TV infections</span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conventional methods&#58; microscopy and culture</span><p id="par0180" class="elsevierStylePara elsevierViewall">Diagnosis of trichomoniasis is commonly based on the microscopy examination of wet preparations of vaginal and urethral discharges&#44; prostatic secretions&#44; and urine sediments&#46; Specimens should be mixed with a drop of physiologic saline &#40;but never refrigerated&#41; and examined microscopically within 1&#8239;h under low power &#40;magnification x100&#41;&#44; with reduced illumination&#46; The presence of actively motile trichomonas is diagnostic of the infection&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> Polymorphonuclear cells are often present in these preparations&#46; However&#44; although this technique is rapid and inexpensive the sensitivity is between 50-70&#37; and may be less in asymptomatic women&#46; The most important factor affecting the sensitivity of wet mount testing is the time between collection and examination of the specimen&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Culture of genital fluids has been considered the gold standard for diagnosis&#44; although it requires 18-24&#8239;h of incubation&#46; The sensitivity of the culture is greater than 80&#37; compared with the wet mount&#46; Amies gel agar transport medium might maintain the viability for culture of TV on swabs held at room temperature for 24&#8239;&#177;&#8239;6&#8239;h before inoculation of specimen into a culture pouch&#46; However&#44; the best practice is that specimens be collected properly and inoculated immediately into the appropriate medium&#44; such as modified Diamond&#39;s&#44; Trichosel&#44; or Holander&#39;s medium&#46; Culture systems or systems that allow direct inoculation&#44; transport&#44; culture&#44; and microscopic examination are commercially available&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Rapid detection tests&#58; point-of-care testing</span><p id="par0190" class="elsevierStylePara elsevierViewall">Several antigen detection methods have been developed&#44; being the main advantage that they are rapid and easy to perform&#46; A latex agglutination test have demonstrated an excellent sensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> An immunochromatographic capillary flow assay is commercially available for qualitative detection of TV antigens from vaginal swabs&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">63&#44;64</span></a> The OSOM <span class="elsevierStyleItalic">Trichomonas</span> Rapid Test Kit is a dipstick assay providing results in 10&#8239;min&#46; This test has demonstrated good sensitivity and specificity compared with other diagnostic methods&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> A rapid test has been developed for TV detection&#46; This assay uses novel electrochemical end-point detection using a multicopy region of the TV genome as the assay target&#46; The sensitivity and specificity achieved using this assay is comparable with that achieved for existing nucleic acid amplification test &#40;NAATs&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The Affirm VPIII is a nucleic acid hybridisation test that uses synthetic nucleic acid capture probes and colour development detection probes&#59; compared with NAATs&#44; this technique had a sensitivity of 46&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The AmpliVue assay uses isothermal helicase-dependent amplification &#40;HDA&#41; and targets a conserved repeat DNA sequence of TV&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> This technique has been recently approved by the FDA for vaginal swabs&#46; On the other hand&#44; Solana <span class="elsevierStyleItalic">Trichomonas</span> assay is an in vitro qualitative NAAT for the detection of TV also using the HDA technology and the Solana instrument&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> It was recently FD approved&#46; Compared with a NAAT assay&#44; the sensitivity&#47;specificity was 89&#46;7&#37;&#47;99&#46;0&#37; for swabs and 100&#37;&#47;98&#46;9&#37; for urines&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Finally&#44; the GeneXpert TV assay has been approved by the Food Drug Administration &#40;FDA&#41; for use with male urine&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">NAATs techniques</span><p id="par0210" class="elsevierStylePara elsevierViewall">These techniques have now become commercially available for the diagnosis of TV in women and have replaced culture as the gold standard test due to their excellent sensitivity and specificity&#46; Genital and urine samples are acceptable specimens&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> NAATs have not been approved for men by the FDA&#44; but these techniques have shown high sensitivity and specificity for this population&#46; Among women&#44; NAATs may detect a prevalence of threefold to fivefold higher than wet mount microscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Currently&#44; there are two robotic FDA-approved NAAT platforms for the detection of TV in women&#58; these include the Aptima TV assay &#40;Hologic Gen-Probe&#41;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> and the BD ProbeTec Q<span class="elsevierStyleSup">x</span> assay on the BD Viper system &#40;Becton Dickinson&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Studies using the <span class="elsevierStyleItalic">Trichomonas</span> Aptima Combo 2 assay have shown a superior performance compared to other methods&#46; This assay is approved for the detection of TV infections from a wide variety of specimens such as vaginal or endocervical samples&#44; ThinPrep liquid-based cytology samples&#44; and urine specimens&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">On the other hand&#44; the BD TV Q<span class="elsevierStyleSup">x</span> uses female vaginal or endocervical swabs as well as urine and liquid-based cytology&#46; This technique has demonstrated an excellent sensitivity and specificity&#44; and the time of detection is less than 5&#8239;h&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Another assay available outside the US is the Seeplex STD 6 ACE detection system &#40;Seegene&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> This assay is a multiplex PCR targeting unique genes of the specific pathogen&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Finally&#44; the BD MAX<span class="elsevierStyleItalic"><span class="elsevierStyleSup">TM</span></span> System provides an assay suitable for use with female urine and vaginal or endocervical swab samples&#46; Male urine has not yet been evaluated for TV&#46; This assay has a sensitivity &#8805; 91&#46;5&#37; and specificity &#8805; 98&#46;6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a></p></span></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Human papillomavirus &#40;HPV&#41; infections</span><p id="par0240" class="elsevierStylePara elsevierViewall">HPV cause the most frequent STI worldwide&#46; In Spain&#44; the prevalence of HPV infection in sexually active women is around 14&#37;&#44; although this prevalence may vary depending on the age group and the associated risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> More than 100 HPV genotypes have been identified and it is estimated that 40 of them are located in the anal and genital region&#46; Non-oncogenic genotypes &#40;low-risk genotypes&#41;&#44; mainly 6 and 11&#44; might cause benign manifestations such as condylomas or genital warts&#46; On the other hand&#44; oncogenic genotypes &#40;high-risk genotypes and probable&#47;possible high risk genotypes&#41; have been associated with the etiopathogenesis of the invasive cervical cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">76&#44;77</span></a> This type of cancer affects nearly 500&#44;000 women worldwide every year with a mortality of more than 270&#44;000 persons&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Cytology-based programmes have been the main approaches for screening&#44; but these are not often available in most of the low&#47;middle-income countries&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> The WHO 2014 cervical cancer screening guidelines recommend that screening should be carried out at least once between the ages of 39 and 49 years&#44; and this screening could be extended to women younger than 30 years if there is evidence of high risk for high-grade cervical intraepithelial neoplasia&#46; Testing for high-risk HPV genotypes has been incorporated into the screening and management algorithms elaborated by several scientific groups as well as for the FDA&#46; HPV testing is recommended in patients over the age of 30 years-old who demonstrate an initial non-type specific high-risk HPV-positive result along with a negative cervical cytology result&#44; and as triage in patients with undetermined cervical cytology results &#40;ASCUS&#44; atypical squamous cell of undetermined significance&#41;&#46; The primary methods for HPV diagnosis have been cytology and histology&#46; However&#44; the detection of HPV is facilitated by recent advances in molecular biology to detect HPV DNA sequences in clinical specimens such as hybrid capture and polymerase chain reaction &#40;PCR&#41;&#46;</p><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Diagnosis of HPV infections</span><p id="par0250" class="elsevierStylePara elsevierViewall">The adequate samples for HPV detection are both endocervical brushed specimens &#40;cervical exfoliated cells&#41; or endocervical biopsies collected in liquid medium&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a> The endocervical brush should be introduced in the 2&#47;3 of the endocervical canal followed by 4-5 rotations&#44; and cervical biopsies should be frozen as soon as possible&#46; Residual material from diagnostic formalin-fixed paraffin embedded blocks may also be used for HPV testing&#46; On the other hand&#44; urine samples have shown a lower sensitivity&#44; so it has been not recommended for HPV screening&#46; Also&#44; samples of external genitalia&#44; perineum&#44; anus and&#47;or oropharyngeal sites should be taken&#44; both in women and men&#44; if these locations are affected&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conventional and monolayer cytology</span><p id="par0255" class="elsevierStylePara elsevierViewall">The primary method for the detection of HPV is still the Papanicolaou stained smear&#46; The Pap smear screening test for cervical cancer was introduced by George Papanicolaou in 1941<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a> and it has been associated with a sustained reduction in cervical cancer incidence and mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a> However&#44; the effectiveness of this method has never been demonstrated in a randomized trial&#46; The Pap test aims to identify abnormal cells obtained from the transformation zone&#44; the junction of the ecto and endocervix&#44; where cervical dysplasia and cancers arise&#46; However&#44; the Pap smear procedure has some limitations such as that inadequate samples constitute about 8&#37; and false-negative rates close to 30&#37; have been reported&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Thin layer or liquid-based cytology has now been widely implemented worldwide and has theoretical advantages over conventional cytology&#44; mainly reducing the number of false-negative results&#46; However&#44; systematic reviews comparing conventional and liquid-based cytology have not consistently shown that liquid-based cytology detects significant cancer precursors more effectively than conventional cytology&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">83&#44;84</span></a></p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Histopathology</span><p id="par0265" class="elsevierStylePara elsevierViewall">Patients who have abnormal Pap smears but no evidence of cervical lesions could be evaluated by colposcopy and further biopsy&#46; The colposcopy can detect both low-grade and high-grade dysplasia but does not detect microinvasive lesions&#46; Stains resulting after biopsy could be used to detect antigens or HPV DNA&#46;</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">HPV nucleic acid detection</span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Commercially techniques for molecular HPV detection</span><p id="par0270" class="elsevierStylePara elsevierViewall">In the market&#44; there is currently more than 125 techniques for HPV detection&#46; These techniques can be differentiated in four types&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">DNA detection techniques&#58; the HPV DNA is detected from the capside region as well as from the E6 oncogen&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall">RNA detection techniques&#58; the RNAm is detected from the HPV E6&#47;7 oncogenes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">in situ</span> hibridization tecniques&#58; they have low sensitivity and specificity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall">Serological techniques&#58; only used for epidemiological purposes and vaccinal efficacy&#46;</p></li></ul></p><p id="par0295" class="elsevierStylePara elsevierViewall">According the technology used&#44; the main commercially available systems may be classified as follows&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1</span><p id="par0300" class="elsevierStylePara elsevierViewall">Signal amplification methods&#58; capture of RNA-DNA hybrids and Chemical Invader&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2</span><p id="par0305" class="elsevierStylePara elsevierViewall">Target DNA amplification methods&#58; PCR&#44; real-time PCR&#44; multiplex PCR&#44; transcription mediated amplication &#40;TMA&#41;&#44; dual priming oligonucleotide &#40;DPO&#41; and Matrix-assited laser desorption&#47;ionization time-of-flight mass spectrometry &#40;MALDI-TOF MS&#41;&#46;</p></li></ul></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Validation and FDA-approval</span><p id="par0310" class="elsevierStylePara elsevierViewall">In 2009&#44; an international expert committee proposed that any technology must be as accurate as the techniques used at this moment as the gold standard &#40;GP5&#43;&#47;GP6&#8239;&#43;&#8239;PCR and hybrid capture&#41;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a> in order to be used in the primary screening of cervix cancer in women&#46; This committee introduced some criteria based on both clinical sensitivity and specificity more than 0&#44;90 and 0&#44;98&#44; respectively&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">On the other hand&#44; the VALGENT protocol is an international network for the validation of genotyping HPV assays&#46; Moreover&#44; the FDA approval is achieved when a method establish their sensitivity and specificity by prospective studies performed in three or more sites&#46;</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">HPV detection techniques comparison</span><p id="par0320" class="elsevierStylePara elsevierViewall">Abbott Real Time HR-HPV and BD Onclarity HPV are two DNA amplification techniques by RT-PCR fully automated&#46; Abbott technology allows the process of the primary tube and reports genotypes 16&#47;18 and others non 16&#47;18 differently&#46; This method is mainly indicated for laboratories with high workload&#46; BD Onclarity use SDA &#40;Strand Displacement Amplification&#41; technology and amplify the E6&#47;7 region&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Anyplex II HPV HR &#40;Seegene&#41; is based on multiplex RT-PCR with DPO and TOCE technology&#46; This method allows the genotyping of 14 genotypes in the same reaction and their relative quantification&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">The Xpert HPV genotyping system &#40;Cepheid&#41; is the fastest test &#40;1&#8239;h&#41;&#46; With this method&#44; we may obtain the genotyping of HPV-16 and other 5 group of high-risk genotypes&#46; Due to their low rate of contamination&#44; it is recommended for laboratories low workload&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">Other techniques clinically validated are the virus detection by MALDI-TOF MS and by reverse-hybridization with arrays in microspheres &#40;Luminex&#41;&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Linear Array HPV Genotyping Kit &#40;Roche Diagnostics&#41; detects 37 genotypes&#44; very useful for studies of vaccine impact or for epidemiological purposes&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">Four techniques are FDA-approved for cytological screening of ASCUS or for screening with cytology and HPV at the same time&#58; hybrid capture &#40;Qiagen&#41;&#44; Cervista &#40;Hologic&#41;&#44; Cobas 4800 HPV &#40;Roche Diagnostics&#41; and APTIMA &#40;Hologic&#41;&#46; Only the Cobas HPV test is approved by FDA for population screening based on HPV detection&#46;</p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Hybrid Capture 2 High-Risk HPV DNA &#40;Digene&#41;</span><p id="par0350" class="elsevierStylePara elsevierViewall">It was the first method approved by the FDA &#40;March 2003&#41; for the detection of HPV oncogenic genotypes&#46; It is a liquid&#47;solid phase signal amplification method based on hybridization in solution of long synthetic RNA probes complementary to the genomic sequence of 13 high-risk &#40;16&#44; 18&#44; 31&#44; 33&#44; 35&#44; 39&#44; 45&#44; 51&#44; 52&#44; 56&#44; 58&#44; 59 and 68&#41; and 5 low-risk &#40;6&#44; 11&#44; 42&#44; 43&#44; and 44&#41; HPV types&#46; The hybrids are detected by some reactions that generate a luminescent signal that can be detected by chemiluminiscence&#46; The main limitation of this assay is that does not discriminate the genotype and the cross-reactivity that may lead to false-positive results&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Cervista HPV HR &#40;Hologic&#41;</span><p id="par0355" class="elsevierStylePara elsevierViewall">It was approved by the FDA in 2009&#46; This assay is based on <span class="elsevierStyleItalic">Invader</span> technology consisting of concurrent two-part isothermal reactions&#46; The main reaction detects the presence of specific viral DNA sequences&#44; while the second one generates fluorescence&#46; The presence of any of the 14&#8239;high-risk HPV genotypes could be detected &#40;16&#44; 18&#44; 31&#44; 33&#44; 35&#44; 39&#44; 45&#44; 51&#44; 52&#44; 56&#44; 58&#44; 59&#44; 66&#44; 68&#41;&#44; but not in an individualized manner&#46; However&#44; Cervista HPV 16&#47;18 identify HPV 16 and 18 individually&#46;</p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Cobas HPV Test &#40;Roche Diagnostics&#41;</span><p id="par0360" class="elsevierStylePara elsevierViewall">The Cobas 4800 system is an automated method that uses the primary sample obtained for the liquid-based cytology&#46; The results appear differentiated in four channels&#58; HPV 16&#44; HPV 18&#44; high-risk HPV non 16&#47;18 &#40;31&#44; 33&#44; 35&#44; 39&#44; 45&#44; 51&#44; 52&#44; 56&#44; 58&#44; 59&#44; 66&#44; and 68&#41; and &#946;-globin &#40;internal control&#41;&#46; The main advantages are the high sensitivity&#44; reproducibility&#44; and high-degree of automation&#46;</p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Aptima HPV Assay &#40;Hologic&#41;</span><p id="par0365" class="elsevierStylePara elsevierViewall">It is an assay that identify the presence of 14&#8239;high-risk genotypes by the identification of the viral RNAm from the E6&#47;7 oncogenes&#46; The presence of transcripts of the HPV oncogenes is a more accurate and specific marker of cell infection or transformation by hihg-risk HPV&#46; This method is useful in differentiating between episomal and integrated HPV oncogenic transcripts&#44; such as in cervical cancer&#46; This technique consist of three steps&#58; capture&#44; amplification by TMA system and detection by hybridization&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a> However&#44; the main problem with this technique is that RNA is much more labile than DNA and less available in most biological specimens&#46;</p></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Microarrays &#40;DNA chips&#41;</span><p id="par0370" class="elsevierStylePara elsevierViewall">Recent developments in combining molecular probes with silicon-based chips may lead to quick and relatively inexpensive diagnostics&#46; This technology requires the use of silicon chips&#59; the surface of the chip is covered with a fine layer of gold&#44; and molecular probes are attached to the surface of the chip&#46; Each of the molecular probes differs in the DNA target they are designed to hybridize&#46; If binding is detected&#44; the sample would be considered postive for HPV&#46;</p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Serological assays</span><p id="par0375" class="elsevierStylePara elsevierViewall">The majority of studies employed enzyme immunoassays&#44; but the main problem with the use of the serology is standardization and the establishment of an international standard assigning one unit measure or international unit&#46; Studies have demonstrated that about half of people exposed to HPV never developed measurable titers of antibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a></p></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Utility of P16<span class="elsevierStyleSup">INK4a</span></span><p id="par0380" class="elsevierStylePara elsevierViewall">The over-expression of this protein has been proposed as a tissue marker for high-risk HPV infection&#46; Positivity of this protein increases with lesion severity&#44; and a high percentage of HSIL cytology specimens are positive&#46; The sensitivity of P16<span class="elsevierStyleSup">INK4a</span> assays to detect CIN3 is similar to HPV DNA assays&#44; but the specificity needs to be improved&#46; Its role as a molecular prognosis factor is still an issue pending assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">89</span></a></p></span></span></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Herpes simplex virus genital infection</span><p id="par0385" class="elsevierStylePara elsevierViewall">Genital herpes is a common sexually transmitted disease &#40;STD&#41;&#46; It is caused by herpes simplex virus type 2 &#40;HSV-2&#41; or herpes simplex virus type 1 &#40;HSV-1&#41;&#46; Most people who have HSV-1 or HSV-2 do not have symptoms&#46;</p><p id="par0390" class="elsevierStylePara elsevierViewall">The laboratory diagnosis of genital herpes is recommended in confirmation of clinically suspected genital herpes or differential diagnosis with other ulcerative STIs or genital ulcerative dermatoses&#44; and in extra-genital complications of genital herpes&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">For active lesions&#44; collection of vesicular fluid or exudate from small vesicles with cotton or Dacron swab is the method of choice for collecting samples&#46; The laboratory methods for direct herpes diagnosis include viral culture&#44; antigen detection and DNA detection based on nucleic acid amplification by PCR&#46;</p><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Viral isolation</span><p id="par0400" class="elsevierStylePara elsevierViewall">Tube culture isolation is the traditional gold standard for HSV detection&#46; HSV grows readily in a wide variety of cell lines but the cell lines most frequently used for HSV culture are fibroblasts&#44; MRC-5 and Vero cells&#46; While the test has 100&#37; specificity for HSV-1 or HSV-2&#44; the sensitivity depends on the stage of the lesion at the time of specimen collection&#46; The sensitivity also varies from 75&#37; for first episodes to 50&#37; for recurrences&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">90&#44;91</span></a> Shell vial culture can reduce viral isolation times from one to seven days to 16 to 48&#8239;h&#46; However&#44; although these methods are rapid and specific&#44; they are slightly less sensitive than traditional tube cultures and are more expensive&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a></p></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Antigen detection</span><p id="par0405" class="elsevierStylePara elsevierViewall">Viral antigen can be detected by direct immunofluorescence assay &#40;DFA&#41; or enzyme immunoassay &#40;EIA&#41;&#46; The IF assay is a satisfactory ad rapid &#40;&#60;4&#8239;h&#41; method for diagnostic &#40;sensitivity 80&#37; and specificity 90&#37;&#41; but requires samples from fresh vesicles&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a></p></span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Virus detection by molecular biology</span><p id="par0410" class="elsevierStylePara elsevierViewall">PCR assays or other NAATs are the most sensitive test currently available to detect HSV in clinical samples&#46; Real-time PCR is faster&#44; less labor-intensive than traditional PCR and in the presence of active lesions&#44; PCR is the preferred test&#44; with sensitivity and specificity greater than 95&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">94&#44;95</span></a></p></span><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">Serological diagnosis</span><p id="par0415" class="elsevierStylePara elsevierViewall">Serologic testing may be useful in patients with recurrent genital symptoms or atypical symptoms and negative herpes simplex virus PCR&#46; In addition&#44; serological assay is useful knowing infection status in partner with genital herpes&#46; If genital lesions are present&#44; type-specific serology and direct virus testing can help to establish if the episode is a reactivation or a new HSV infection&#46;</p><p id="par0420" class="elsevierStylePara elsevierViewall">HSV IgM testing has limited availability in routine diagnostic settings and cannot be recommended in routine clinical practice&#46; Type-specific HSV IgG antibodies are negative in early stages of herpes disease&#44; and become detectable two weeks to three months after the onset of symptoms and persist indefinitely&#46; Type-specific HSV glycoprotein G based ELISA tests are recommended for serological diagnosis&#46; Primary HSV infections can be documented by seroconversion with paired sera&#46; The sensitivities of these IgG tests for the detection of HSV-2 antibody vary from 80 &#8211; 98&#37;&#44; and the specificities of these assays are &#8805; 96&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a> False-negative results can occur in period window of two weeks to three months after HSV exposure&#46;</p></span></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Mycoplasma genitalium infection</span><p id="par0425" class="elsevierStylePara elsevierViewall">Since the availability of molecular assays&#44; <span class="elsevierStyleItalic">M&#46; genitalium</span> has been associated with many adverse disease outcomes&#44; such as non gonococcal urethritis in men and many adverse reproductive sequelae in women like cervicitis&#44; endometritis&#44; preterm birth&#44; spontaneous abortation and pelvic inflammatory disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">96&#44;97</span></a> Other studies have reported promotion of HIV acquisition and shedding by antecedent <span class="elsevierStyleItalic">M&#46; genitalium</span> infection&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a> However&#44; <span class="elsevierStyleItalic">Mycoplasma hominis</span>&#44; <span class="elsevierStyleItalic">Ureaplasma urealyticum</span> &#40;previously <span class="elsevierStyleItalic">U&#46; urealyticum</span> biovar 2&#41; and <span class="elsevierStyleItalic">U&#46; parvum</span> &#40;earlier <span class="elsevierStyleItalic">U&#46; urealyticum</span> biovar 1&#41; are frequently found in the human urogenital tract in both healthy individuals and symptomatic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a></p><p id="par0430" class="elsevierStylePara elsevierViewall">A number of commercially produced <span class="elsevierStyleItalic">M&#46; genitalium</span> DNA amplification modalities have been described&#46; M genitalium specific oligonucleotide primers have been incorporated into single or multiplex PCR assay for six ITSs &#40;e&#46;g&#46; Seeplex STD6&#44; Seegene &#41; in urogenital specimens or vaginal and urine sample by PCR microrray &#40;STDetect chip&#44; Lab Genomics&#41;&#46; Other attempts to detect <span class="elsevierStyleItalic">M&#46; genitalium</span> DNA come in the context of assays designed for to detection of <span class="elsevierStyleItalic">M genitalium</span>&#44; <span class="elsevierStyleItalic">M&#46; hominis&#44; U&#46; urealyticum</span> and <span class="elsevierStyleItalic">U&#46; urealyticum</span> from male first void urine sample together with other pathogens &#40;e&#46;g&#46; FilmArray STI panel&#44; BioFire Diagnostic&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a></p><p id="par0435" class="elsevierStylePara elsevierViewall">There are also other assays that have CE marking &#40;Bio-rad DX CT&#47;NG&#47;MG&#44; Biorad&#41; &#40; Hyplex STD Mycoplasma test&#44; Amplex Bioystems &#41;&#44; the latter has shown a sensitivity and specificity of 87&#37; and 96&#37; for detection of <span class="elsevierStyleItalic">M&#46; genitalium</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">100</span></a></p><p id="par0440" class="elsevierStylePara elsevierViewall">There have been several published research assays that can detect macrolide resistance in samples know to be positive for <span class="elsevierStyleItalic">M&#46; genitalium</span>&#44; using detection of 23&#8239;s RNA gene mutations that are associated with resistance by PCR and melt curve analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">101</span></a> Plex Zyme and PlexPrime recently developed in 23 S asay a multiplex qPCR assay for detection of <span class="elsevierStyleItalic">M&#46; genitalium</span> and the 5 mutations associated with macrolide resistence&#44; the assay was evaluated in 400 samples from 254 consecutively infected participants&#44; 56&#37; schowed a macrolide resistance mutation and its sensitivity and specificity were 99&#44;1&#37; and 98&#46;5&#37; for <span class="elsevierStyleItalic">M&#46; genitalium</span> detection and 97&#46;4&#37; and 100&#37; for macrolide resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a></p></span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">HIV infection</span><p id="par0445" class="elsevierStylePara elsevierViewall">At present in our country surveillance data suggest a stabilization or decrease in HIV incidence in the face of apparent increases in the numbers of persons tested among key risk groups&#46; The reasons for these improving trends are not yet clear&#44; but in order to be sustained&#44; we must continue to refine systems for HIV testing and linking persons to care and prevention resources&#44; as appropriate&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">102</span></a></p><p id="par0450" class="elsevierStylePara elsevierViewall">HIV testing is often prompted by a defined exposure&#44; such as a needlestick injury&#44; condom failure&#44; or condomless sex&#46;</p><p id="par0455" class="elsevierStylePara elsevierViewall">Following an exposure that leads to infection&#44; there is a variable amount of time called the eclipse period in which no existing diagnostic test is capable of detecting HIV&#46; HIV RNA is the first reliable marker of infection&#59; 50&#37; of infected individuals have detectable plasma RNA within 12 days and levels peak between 20&#8211;30 days&#46; Beginning around day 15&#44; the HIV-1 capsid protein p24 reaches detectable levels in the plasma&#46; Antigenemia with p24 continues to rise through days 25&#8211;30&#44; at which point early anti-HIV antibodies are able to complex with circulating p24&#59; by day 50&#44; antigen is often cleared from the bloodstream entirely&#46;This short-lived detectability of p24 is therefore helpful in determining recency of infect&#44; but also makes its utility in diagnosis time limited&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">103&#8211;105</span></a></p><p id="par0460" class="elsevierStylePara elsevierViewall">All HIV diagnostic testing is guided by a common principle&#58; screen with a highly sensitive initial test and confirm reactive results with a different test that is both sensitive and highly specific&#46; This can be accomplished using two POC tests&#44; two laboratory-based assays&#44; or combinations thereof&#59; all of these strategies have been studied extensively&#46; Since the US Food and Drug Administration &#40;FDA&#41; approved the first HIV diagnostic test in 1985&#44; four additional &#8220;generations&#8221; of antibody tests for HIV have been developed&#59; each improves incrementally on its predecessor&#40;s&#41; in terms of performance and shortening of the window period&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">106&#44;107</span></a></p><p id="par0465" class="elsevierStylePara elsevierViewall">IgM&#47;IgG sensitive &#40;formerly third generation&#41; tests shorten the window period to the earliest threshold of IgM detection &#8211; a median of 23 days after infection&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">103</span></a></p><p id="par0470" class="elsevierStylePara elsevierViewall">Antigen&#47;antibody &#40;Ag&#47;Ab&#41; combination &#40;formerly fourth generation&#41; tests pair an IgM&#47;IgG sensitive antibody test with simultaneous&#44; separate p24 antigen detection&#46; Some of these p24&#47;IgM&#47;IgG sensitive tests report a reactive result if any element is detected&#44; while others yield separate results for p24&#44; anti-HIV-1 antibodies&#44; and anti- HIV-2 antibodies&#46; Detecting p24 shortens the median window period down to just 18 days following infection&#46;</p><p id="par0475" class="elsevierStylePara elsevierViewall">In contrast to complex&#44; automated laboratory-based platforms&#44; POC tests rely on one of two methods&#58; lateral flow&#44; in which the specimen is drawn through an antigen-impregnated strip by capillary action&#59; or flow-through&#44; in which the patient&#8217;s specimen and reagents are sequentially applied to a membrane embedded with HIV antigens&#46; Laboratory-based serum or plasma assays generally offer higher sensitivities&#44; but require venipuncture&#44; larger specimen volumes&#44; processing&#44; and skilled technicians&#46; POC tests are attractive alternatives for many applications&#44; but performance differs substantially depending on the specimen type&#59; tests using oral transudate are significantly less sensitive than those using whole blood&#44; and tests using whole blood are less sensitive than those using serum or plasma&#46;<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">108&#44;109</span></a></p><p id="par0480" class="elsevierStylePara elsevierViewall">In summary&#44; the laboratory test is one of a number of tools in the diagnosis of the patient with STIs&#44; and so the clinician should always be aware of the tests the laboratory offers and the results of any tests should be interpreted in the clinical context&#46; It is likely that POCT based on molecular biology will be more common in the future to allow rapid diagnosis&#44; but should be used with laboratory support&#46;</p></span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">Conflict of interest</span><p id="par0485" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Chlamydia trachomatis infections"
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              "identificador" => "sec0015"
              "titulo" => "Diagnostic Chlamydia trachomatis &#40;CT&#41; infections"
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                  "titulo" => "Nucleic Acid AmplificationTest &#40;NAATs&#41;"
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              "titulo" => "Diagnosis of NG infections"
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          "titulo" => "Treponema pallidum &#40;syphilis&#41; infections"
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              "titulo" => "Direct detection methods"
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          "titulo" => "Infections caused by Trichomonas vaginalis &#40;TV&#41;"
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              "titulo" => "Diagnosis of TV infections"
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                  "titulo" => "Conventional methods&#58; microscopy and culture"
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                  "identificador" => "sec0115"
                  "titulo" => "Rapid detection tests&#58; point-of-care testing"
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                  "titulo" => "NAATs techniques"
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          "identificador" => "sec0125"
          "titulo" => "Human papillomavirus &#40;HPV&#41; infections"
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              "titulo" => "Diagnosis of HPV infections"
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              "titulo" => "Conventional and monolayer cytology"
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            2 => array:2 [
              "identificador" => "sec0140"
              "titulo" => "Histopathology"
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              "identificador" => "sec0145"
              "titulo" => "HPV nucleic acid detection"
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                  "titulo" => "Commercially techniques for molecular HPV detection"
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                  "titulo" => "Validation and FDA-approval"
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                  "identificador" => "sec0160"
                  "titulo" => "HPV detection techniques comparison"
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                  "titulo" => "Hybrid Capture 2 High-Risk HPV DNA &#40;Digene&#41;"
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                  "titulo" => "Cervista HPV HR &#40;Hologic&#41;"
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                  "titulo" => "Aptima HPV Assay &#40;Hologic&#41;"
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                  "titulo" => "Microarrays &#40;DNA chips&#41;"
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                  "titulo" => "Serological assays"
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                  "titulo" => "Utility of P16"
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          "titulo" => "Herpes simplex virus genital infection"
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              "titulo" => "Viral isolation"
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              "titulo" => "Antigen detection"
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              "titulo" => "Virus detection by molecular biology"
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              "titulo" => "Serological diagnosis"
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          "titulo" => "Mycoplasma genitalium infection"
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          "titulo" => "HIV infection"
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          "titulo" => "Conflict of interest"
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          "titulo" => "References"
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    "fechaRecibido" => "2018-09-26"
    "fechaAceptado" => "2019-05-13"
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          "clase" => "keyword"
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            0 => "Sexually transmitted infections"
            1 => "Diagnosis"
            2 => "Nucleic acid amplification test"
            3 => "Culture"
            4 => "Point of care test"
          ]
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      ]
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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            0 => "Infecciones de transmisi&#243;n sexual"
            1 => "Diagn&#243;stico"
            2 => "Prueba de amplificaci&#243;n de &#225;cidos nucleicos"
            3 => "Cultivo"
            4 => "Pruebas de diagn&#243;stico en el punto de atenci&#243;n"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sexually transmitted infections &#40;STIs&#41; are one of the most frequent and universal Public Health problems&#46; Health professionals should be aware of the possibility of STIs due to their high morbidity and the presence of sequelae&#46; The delay in the diagnosis is one of the factors that justifies the difficulty to infections control&#46; Diagnostic tests allow the introduction of aetiological treatment and also leads to treating symptomatic and asymptomatic patients more effectively&#44; as well as to interrupt the epidemiological transmission chain without delay&#46; In this review we have made an update of the main existing diagnostic methods for the more important STIs&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las infecciones de transmisi&#243;n sexual &#40;ITS&#41; son uno de los problemas de salud p&#250;blica m&#225;s frecuentes y universales&#46; Debido a que las ITS son responsables de una alta morbilidad&#44; as&#237; como de secuelas graves&#44; es muy importante que todos los profesionales de la salud las tengan en cuenta en el momento de valorar al paciente&#46; La dificultad en el control de las ITS se debe principalmente al retraso diagn&#243;stico&#46; Las pruebas diagn&#243;sticas permiten realizar un manejo etiol&#243;gico&#44; as&#237; como facilitar un tratamiento m&#225;s efectivo tanto de los pacientes sintom&#225;ticos como de los asintom&#225;ticos&#44; y finalmente permitir&#225;n interrumpir de una forma m&#225;s precoz la cadena epidemiol&#243;gica de transmisi&#243;n&#46; En la presente revisi&#243;n&#44; se ha llevado a cabo una actualizaci&#243;n acerca de los principales m&#233;todos diagn&#243;sticos existentes en las ITS m&#225;s relevantes&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez-Granger J&#44; Espadafor L&#243;pez B&#44; Cobo F&#44; Blasco Morente G&#44; Sampedro Martinez A&#44; Tercedor S&#225;nchez J&#44; et al&#46; Actualizaci&#243;n en el diagn&#243;stico de las infecciones de transmisi&#243;n sexual&#46; Actas Dermosifiliogr&#46; 2020&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.ad.2019.05.008">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;ad&#46;2019&#46;05&#46;008</span></p>"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
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                      "doi" => "10.1371/journal.pone.0143304"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLoS One&#46;"
                        "fecha" => "2015"
                        "volumen" => "10"
                        "paginaInicial" => "e0143304"
                        "link" => array:1 [ …1]
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            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Report on global sexually transmitted infection surveillance 2015"
                      "autores" => array:1 [
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            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sexually transmitted infections in Europe 2013"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
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                    ]
                  ]
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                    0 => array:1 [
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            3 => array:3 [
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Centro Nacional de Epidemiologi&#769;a&#46; Instituto de Salud Carlos III&#46; Vigilancia epidemiolo&#769;gica de las enfermedades de transmisi&#243;n sexual en Espa&#241;a&#46; Informe anual&#46; 2016 Available from&#58; <a target="_blank" href="http://www.isciii.es">http&#58;&#47;&#47;www&#46;isciii&#46;es</a>&#46;"
                ]
              ]
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            4 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chlamydia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:4 [
                        "titulo" => "ECDC&#46; Annual epidemiological report for 2015"
                        "fecha" => "2017"
                        "editorial" => "ECDC"
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                      ]
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                  ]
                ]
              ]
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                      "titulo" => "Gonorrhoea"
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                        0 => array:2 [ …2]
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Idiomas
Actas Dermo-Sifiliográficas
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