High Prevalence of Co-Infections by Invasive and Non-Invasive <i>Chlamydia trachomatis</i> Genotypes during the Lymphogranuloma Venereum Outbreak in Spain

<div><p>The evolution of <i>Chlamydia trachomatis</i> is mainly driven by recombination events. This fact can be fuelled by the coincidence in several European regions of the high prevalence of non-invasive urogenital genotypes and lymphogranuloma venereum (LGV) outbreaks. This scenario could modify the local epidemiology and favor the selection of new <i>C</i>. <i>trachomatis</i> variants. Quantifying the prevalence of co-infection could help to predict the potential risk in the selection of new variants with unpredictable results in pathogenesis or transmissibility. In the 2009-2013 period, 287 clinical samples with demonstrated presence of <i>C</i>. <i>trachomatis</i> were selected. They were divided in two groups. The first group was constituted by 137 samples with <i>C</i>. <i>trachomatis</i> of the LGV genotypes, and the second by the remaining 150 samples in which the presence of LGV genotypes was previously excluded. They were analyzed to detect the simultaneous presence of non-LGV genotypes based on <i>pmpH</i> and <i>ompA</i> genes. In the first group, co-infections were detected in 10.9% of the cases whereas in the second group the prevalence was 14.6%, which is the highest percentage ever described among European countries. Moreover, bioinformatic analyses suggested the presence among men who have sex with men of a <i>pmpH</i>-recombinant variant, similar to strains described in Seattle in 2002. This variant was the result of genetic exchange between genotypes belonging to LGV and members of G-genotype. Sequencing of other genes, phylogenetically related to pathotype, confirmed that the putative recombinant found in Madrid could have a common origin with the strains described in Seattle. Countries with a high prevalence of co-infections and high migration flows should enhance surveillance programs in at least their vulnerable population.</p>