Chlamydia Overview


Clinical Assessment
Risk Assessment
Clinical Assessment of Patient w/ Inguinal Swelling
HIV/STI Counseling & Testing
Evaluation & Treatment of Sex Partners
Diagnosis of LGV
Empiric Therapy
Antibiotic Therapy 
Patient Education

Guideline References


  • Chlamydia trachomatis infection is the most common sexually transmitted bacterial infection & the primary cause of pelvic inflammatory disease (PID) in women which may lead to ectopic pregnancy, infertility, or chronic pelvic pain
    • Most infected females are asymptomatic; possible symptoms are:
    • Vaginal discharge
    • Dysuria
    • Lower abdominal pain
    • Abnormal vaginal bleeding (postcoital or intermenstrual) or breakthrough bleeding
    • Dyspareunia
    • Conjunctivitis
    • Proctitis
    • Reactive arthritis

    Below is the overview of disease management of Chlamydia - Uncomplicated Anogenital Infection:

    overview of management of chlamydia 05_Chlamydia1


    suspect chlamydia infection 05_Chlamydia2


    Clinical Assessment

    Physical Exam
    • Perform general assessment & look for signs of sexually transmitted infection (STI)
    • Examine mucocutaneous regions including the pharynx
    • External genitalia should be inspected for anatomical irregularities, cutaneous lesions, inflammation, & urethral discharge
    • Perianal inspection
      • Digital rectal exam & anoscopy should be considered if patient has practiced receptive anal intercourse or has rectal symptoms
    • Inguinal lymph nodes should be palpated
    Illuminated Speculum Exam
    • Visualize cervix & vaginal walls
    • Evaluate vaginal & endocervical discharges
    • Observe for cervical mucopus, ectropion, friability
    • If resources are available, obtain specimens
      • Cervical swab may be sent for Chlamydia test, gonorrhea culture
      • Vaginal swab may be sent for Chlamydia test, for Gram stain & Trichomonas slide
    Bimanual Pelvic Exam
    • Detect uterine or adnexal masses, tenderness or cervical motion tenderness


    Risk Assessment

    • In some settings, certain demographic & behavioral risk factors have been frequently associated w/ cervical infection (the following should be adjusted for local, social, behavioral & epidemiological situations)
    • Women at risk for cervicitis have a higher likelihood of cervical infection than those who are risk-negative
    • Women w/ vaginal discharge & positive risk assessment should, therefore, be offered treatment for gonococcal & chlamydial cervicitis
    • Annual screening of Chlamydia infection is advised for all sexually active nonpregnant women ages ≤24 yr & older nonpregnant women w/ risk factors
    • Pregnant women at risk should be screened at 1st prenatal visit & at 3rd trimester if she continues to be at high risk
    Women at Higher Risk for Infection
    • Age ≤24 yr (>5x higher risk than age 30 yr)
    • Sexual contact w/ known case of STI
    • IV drug users
    • Street involvement (youth on the streets, sex workers)
    • New or ≥2 sex partners in the past yr
    • Previous STI
    • Lack of barrier contraception

    Below is the overview of disease management of Lymphogranuloma Venereum:

    chlamydia lymphogranuloma venereum 05_Chlamydia3


    Clinical Assessment of Patient w/ Inguinal Swelling

    • Lymphogranuloma venereum (LGV) is a systemic disease caused by L1, L2, L3 serovars of C trachomatis
    Clinical Manifestation of LGV Primary LGV
    • Incubation period of 3-30 days
    • Painless papule (1-6 mm) at inoculation sites (eg vulva, vagina, penis, rectum, oral cavity, cervix)
      • These papules may ulcerate but are self-limited
      • Genital ulcer may occur at the site of inoculation but is usually healed by the time patients are seen in the clinic

    Secondary LGV
    • Occurs 2-6 wk from appearance of primary lesion
    • Accompanying symptoms may be present (eg fever, chills, malaise, myalgia, arthralgia, arthritis, pneumonitis or hepatitis)
      • Cardiac symptoms, meningitis & ocular inflammation may also be present
    • Abscesses & draining sinuses occur in <1/3 of patients
    • Lymph node, anus &/or rectum may be involved
      • Lymphadenopathy is characterized by a “groove sign” (ie swollen inguinal nodes above & femoral nodes below the level of the inguinal ligament)
      • Anorectal involvement is characterized by acute hemorrhagic proctitis/proctocolitis

    Tertiary/Chronic LGV
    • More common in females
    • Lymphatic obstruction may cause genital elephantiasis
    • Genital & rectal strictures & fistula may occur at this stage


    HIV/STI Counseling & Testing

    • STI consultation allows for an opportunity to discuss patient’s risk factors for STIs & HIV
    • Determine patient’s risk for HIV & discuss HIV testing
    • Testing for HIV is recommended & should be offered to all persons seeking evaluation & treatment for STIs
      • Pretest & post-test counseling as well as informed consent are part of the testing procedure
      • Concomitant infection w/ HIV may complicate management & control of some STIs
    • Patient diagnosed w/ Chlamydia should be encouraged to undergo screening against other STIs apart from HIV (eg hepatitis B, syphilis)


    Evaluation & Treatment of Sex Partners

    • Sex partners of STI patients are likely to be infected & should be offered treatment to prevent further STI transmission & reinfection
    • Sex partners of STI patients may be asymptomatic; thus the importance of partner notification & management
    • 60-75% co-infection has been noted in sexual partners of Chlamydia-positive patients
      • All sex partners of patient during the 60 days preceding the onset of symptoms (or the most recent sex partner if the sexual exposure is >60 days) should be evaluated, tested & treated
      • Screening & treatment for Chlamydia infection is advised for all sex partners of asymptomatic patient in the last 90 days (or the most recent sex partner if the sexual exposure is >90 days)
    • Sex partners of patients positive for Chlamydia should also receive the standard Chlamydia regimen (ie Azithromycin 1 g orally or Doxycycline 100 mg 12 hrly x 7 days)
    • Patients & their sex partners should be instructed to abstain from sexual intercourse until they & their partners have completed the treatment
      • Continue abstinence x 7 days after a single-dose regimen or until the completion of a 7-day regimen or 3 wk if the patient was given Erythromycin
    • Patient-delivered Therapy
      • In situations where the sex partner of the female patient w/ Chlamydia will not seek treatment, the patient may be the one to deliver therapy to their partners in the form of medication or prescription
      • A trend towards a decrease in recurrent or persistent Chlamydia infection w/ partner-delivered therapy compared to a standard partner referral has been seen in some studies
      • The approach may not be permitted in some settings



    • Patients treated w/ recommended or alternative regimens do not need to be re-tested for Chlamydia after completing treatment unless symptoms persist or re-infection is suspected or adherence to treatment is in question
    • Test of cure 3-4 wk after completing therapy is recommended in pregnant patients
      • Culture is the only test used to evaluate efficacy of treatment
      • NAAT done <3 wk after treatment is completed may yield false-positive results due to the presence of dead organisms
    • Test for cure may be considered after 3 wk in those treated w/ Erythromycin
    • A follow-up face-to-face or phone interview w/in 4 wk of treatment is advisable
    • Most post-treatment infections result from reinfection
    • Test for re-infection is advised 3 mth after treatment completion or w/in the following 3-12 mth


    Chlamydia Symptomsâ–¶

    Version: 4 Aug 2015

    Guideline References:
    1. Alexander S, Barber P, Goh BT, et al. New point of care Chlamydia rapid test--bridging the gap between diagnosis and treatment: performance evaluation study. Nov 30, 2007. BMJ. 2007 Dec;335(7631):1190-1194. PMID: 18055487
    2. Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases. Clinical effectiveness guideline for the management of Chlamydia trachomatis genital tract infection.
    3. British Association for Sexual Health and HIV Clinical Effectiveness Group. 2006 UK national guideline for the management of genital tract infection with Chlamydia trachomatis.
    4. British Association for Sexual Health and HIV Clinical Effectiveness Group. 2007 UK national guideline on the management of non-gonococcal urethritis.
    5. Buttress ND, Canong L, Celis RL, et al. Prevalence of Chlamydia trachomatis infection among low- and high-risk Filipino women and performance of Chlamydia rapid test in resource-limited settings. Oct 17, 2007. J Clin Microbiol. 2007 Dec;45(12):4011-4017. PMID: 17942659
    6. Carder C, Mercey D, Benn P. Chlamydia trachomatis. Sex Transm Infect. 2006 Dec;82(Suppl 4):iv10-iv12. doi: 10.1136/sti.2006.023069. PMID: 17151043
    7. Centers for Disease Control and Prevention. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae-2014. MMWR Recomm Rep. 2014 Mar;63(RR-02):1-19. PMID: 24622331
    8. Centers for Disease Control and Prevention. STD surveillance case definitions. CDC. 10 Dec 2013. Accessed 29 Apr 2014.
    9. Clinical Effectiveness Group of the British Association for Sexual Health and HIV (CEG/BASHH). 2006 national guideline for the management of lymphogranuloma venereum.
    10. Expert Working Group on Canadian Guidelines for Sexually Transmitted Disease. Canadian STD guidelines 1998. 1998.
    11. Herring A, Richens J. Lymphogranuloma venereum. Sex Transm Infect. 2006 Dec;82(Suppl 4):iv23-iv25. PMID: 17151048
    12. Horner PJ, Daniels D, Fitzgerald M, et al. UK national guideline for the management of genital tract infection with Chlamydia trachomatis. guidelines.asp#guides. 2006.
    13. MacDonald N, Wong T. Canadian guidelines on sexually transmitted infections, 2006. CMAJ. 2007 Jan;176(2):175-176. PMID: 17224598
    14. Ministry of Health Malaysia. National antibiotic guideline 2014, 2nd edition. Pharmaceutical Services Divisions, Ministry of Health Malaysia. Dec 2014. Accessed 16 Jul 2015.
    15. Ministry of Health Singapore. Management of genital ulcers and discharges. MOH (Singapore). and%20Discharges%20Summary%20Booklets.pdf. May 2009.
    16. Radcliffe K. European STD guidelines. Int J STD AIDS. 2001 Oct;12(Suppl 3):1-102. PMID: 11589789
    17. Scottish Intercollegiate Guidelines Network. Management of genital Chlamydia trachomatis infection: a national clinical guideline. SIGN. Mar 2009.
    18. US Preventive Services Task Force. Screening of chlamydial infection: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2007 Jul;147(2):128-134. PMID: 17576996
    19. Van Vranken M. Prevention and treatment of sexually transmitted diseases: an update. Am Fam Physician. 2007 Dec;76(12):1827-1832. PMID: 18217521
    20. White J, O'Farrell N, Daniels D. 2013 UK National Guideline for the management of lymphogranuloma venereum: Clinical Effectiveness Group of the British Association for Sexual Health and HIV (CEG/BASHH) Guideline development group. Int J STD AIDS. 2013 Aug;24(8):593-601. doi: 10.1177/0956462413482811. Accessed 29 Apr 2014. PMID: 23970591
    21. Workowski KA, Berman S, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR. 2010 Dec;59(RR-12):1-110. Accessed 01 Jun 2012. PMID: 21160459
    22. World Health Organization. Guidelines for the management of sexually transmitted infections. WHO. 2001.