Chlamydia Overview

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Chlamydia Overview

Contents

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

Guideline References

OVERVIEW

  • 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

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    suspect chlamydia infection 05_Chlamydia2

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    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

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    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

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    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

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    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)

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    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

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    Follow-up

    • 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

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    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. http://www.bmj.com/cgi/reprint/bmj.39402.463854.AEv1. 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. http://www.urotoday.com/prod/pdf/bashh/C4A_2009_2001c.pdf.
    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. http://www.bashh.org/documents/61/61.pdf.
    4. British Association for Sexual Health and HIV Clinical Effectiveness Group. 2007 UK national guideline on the management of non-gonococcal urethritis. www.bashh.org/guidelines.
    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. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2168544/pdf/1343-07.pdf. 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. http://www.cdc.gov/std/laboratory/2014LabRec/2014-lab-rec.pdf. PMID: 24622331
    8. Centers for Disease Control and Prevention. STD surveillance case definitions. CDC. http://www.cdc.gov/std/stats/CaseDefinitions-2014.pdf. 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. http://www.bashh.org/documents/92/92.pdf.
    10. Expert Working Group on Canadian Guidelines for Sexually Transmitted Disease. Canadian STD guidelines 1998. http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/std-mts98/index.html. 1998.
    11. Herring A, Richens J. Lymphogranuloma venereum. Sex Transm Infect. 2006 Dec;82(Suppl 4):iv23-iv25. http://www.ncbi.nlm.nih.gov/pubmed/?term=17151048. PMID: 17151048
    12. Horner PJ, Daniels D, Fitzgerald M, et al. UK national guideline for the management of genital tract infection with Chlamydia trachomatis. http://www.bashh.org 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. http://www.pharmacy.gov.my/v2/en/documents/national-antibiotic-guideline-nag-2nd-edition.html. Dec 2014. Accessed 16 Jul 2015.
    15. Ministry of Health Singapore. Management of genital ulcers and discharges. MOH (Singapore). http://www.moh.gov.sg/mohcorp/uploadedFiles/Publications/Guidelines/Clinical_Practice_Guidelines/Mx%20of%20Genital%20Ulcers%20 and%20Discharges%20Summary%20Booklets.pdf. May 2009.
    16. Radcliffe K. European STD guidelines. Int J STD AIDS. 2001 Oct;12(Suppl 3):1-102. http://www.iusti.org/sti-information/pdf/guidelines.pdf. PMID: 11589789
    17. Scottish Intercollegiate Guidelines Network. Management of genital Chlamydia trachomatis infection: a national clinical guideline. SIGN. http://www.sign.ac.uk/pdf/sign109.pdf. 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. http://www.ncbi.nlm.nih.gov/pubmed/21160459. Accessed 01 Jun 2012. PMID: 21160459
    22. World Health Organization. Guidelines for the management of sexually transmitted infections. WHO. http://www.who.int/hiv/pub/sti/pub6/en/. 2001.