Guidelines 2016 – Chlamydia Trachomatis Infection
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Chlamydia trachomatis infection is a parasitic STI of the reproductive tract mucous membrane of either sex.
II. ETIOLOGY
A. The causative organism is a small, obligate, intracellular, bacterium- like parasite (C. trachomatis) that develops within inclusion bodies in the cytoplasm of the host cells.
B. The incubation period is unknown.
III. HISTORY
A. What the patient may present with
1. Female
a. Vaginal discharge
b. Dysuria
c. Pelvic pain
d. Changes in menses
e. Intermenstrual spotting in cervical os
f. Postcoital bleeding
g. Frequently asymptomatic
h. Mucopurulent discharge
2. Male
a. Dysuria
b. Thick, cloudy penile discharge
c. Rarely asymptomatic
B. Additional information to be considered
1. Previous vaginal infections; diagnosis, treatment; compliance with treatment
2. Chronic illness
3. Sexual activity, new partner(s)
4. History of STI or PID
5. Known contact
6. Last intercourse, sexual contact, sex toys
7. Method(s) of birth control, other medications
8. Description of discharge
a. Onset
b. Color
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c. Odor
d. Consistency
e. Amount
f. Constant versus intermittent
g. Relationship to sexual contact
h. Relationship to menses
9. Use of vaginal deodorant sprays; deodorant tampons, panty lin- ers, pads; perfumed toilet tissue; douches
10. Change in laundry soaps, fabric softener, body soap
11. Clothing: consistent wearing of tight-crotched pants
12. Personal hygiene
13. Any drug allergies
14. Travel to Asia, Africa, Europe—lymphogranuloma venereum (LGV) Chlamydia (not detected by usual laboratory tests in the United States; see section on lymphogranuloma venereum [LGV] for symptoms and treatment)
IV. PHYSICAL EXAMINATION
A. Vital signs
1. Blood pressure
2. Temperature
B. Abdominal examination: check for guarded referred pain, rebound pain
C. External examination: observe perineum for edema, ulcerations, lesions, excoriations, erythema, enlarged, tender Bartholin’s glands
D. Vaginal examination (speculum)
1. Inspection of vaginal walls
2. Cervix (cervicitis), friability
3. Discharge, if present, is characteristically mucopurulent.
E. Bimanual examination: cervical motion tenderness, fullness in adnexa, tender uterus
V. LABORATORY EXAMINATION
A. Direct fluorescent antibody (DFA) test: secretions fixed on slide and stained with fluorescein-labeled monoclonal antibody specific for chlamydial antigens
B. Laboratory test for Chlamydia (sensitivities and specificities vary):
1. Enzyme-linked immunosorbent assay (ELISA) and enzyme- linked immunoassay (EIA): detection of chlamydial antigens
2. Nucleic acid amplification test (NAAT): vaginal, rectal, uro- genital (test for both Chlamydia and gonorrhea); finds the genetic material of Chlamydia and gonorrhea bacteria—example is the PCR
3. Nucleic acid hybridization tests (DNA probe test) for Chlamydia
DNA; not as sensitive as NAAT
4. DFA: quick test to find Chlamydia antigens
5. Chlamydia culture takes 5 to 7 days; used when child sexual abuse is suspected
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6. Rapid test with endocervical swab or brush; takes 30 minutes for results
C. Endocervical culture (only 100% specific test) in transport media; perform in medicolegal cases, such as rape, child sexual abuse
D. Serology test for syphilis if history indicates
E. Consider HIV testing
F. Consider hepatitis B and C testing
G. GC culture or NAAT
VI. DIFFERENTIAL DIAGNOSIS
A. Gonorrhea
B. Appendicitis
C. Cystitis
VII. TREATMENT
A. Medication
1. Azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice a day for 7 days
2. Alternative regimens
a. Erythromycin base 500 mg orally four times a day for 7 days or
b. Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days or
c. Levofloxacin 500 mg orally once daily for 7 days
d. Ofloxacin 300 mg orally twice a day for 7 days
3. In pregnancy
a. Azithromycin 1 g orally in single dose or
b. Amoxicillin 500 mg orally three times a day for 7 days
4. Alternative regimens in pregnancy
a. Erythromycin base 500 mg orally four times a day for 7 days or
b. Erythromycin base 250 mg orally four times a day for 14 days or
c. Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days or
d. Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days
B. For sexual contacts during 60 days preceding onset of patient’s symptoms or diagnosis of Chlamydia
1. Offer Chlamydia test prior to treatment
2. Start treatment prior to results of testing
3. Treat same as for the woman; do follow-up if symptoms persist and rescreening per 2015 CDC guidelines
C. General measures
1. Stress that the partner(s) should be treated
2. No intercourse for 7 days after single-dose treatment or until com- pletion of the 7-day treatment regimen
3. No intercourse until all sex partners are treated
4. Condom for backup birth control method for the remainder of cycle if on oral contraceptives
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5. Stress the importance of completing medication for the woman and partner
6. Stress that the use of feminine hygiene sprays, deodorants, or douches should be stopped
7. Stress the possibility of increased photosensitivity with medication
8. Inform the patient taking tetracycline that medication should be taken 1 hour before or 2 hours after meals and/or consumption of dairy products, antacids, or mineral-containing products
9. Return for reevaluation if symptoms persist or return after treatment
VIII. COMPLICATIONS
A. Women
1. PID
a. Pelvic abscess (ovarian)
b. Infertility, chronic pelvic pain, ectopic pregnancy
2. Abnormal Pap smear with cervicitis (30%–50%)
3. Postpartum endometritis
B. Men
1. Epididymitis, prostatitis
2. Reiter’s syndrome
C. Risk of acquiring HIV
D. Newborn
1. Conjunctivitis
2. Pneumonia
3. Urogenital tract, rectal infection
E. Urethritis
IX. CONSULTATION/REFERRAL
A. If no response to treatment as discussed previously
B. If complications develop
X. FOLLOW-UP
A. If no response to treatment or the possibility of reinfection is present
B. Test of cure not routinely required per CDC guidelines of 2015. If symptoms persist or reinfection is suspected, consider retesting women after treatment (rate of reinfection). Consider rescreening all women with Chlamydia infection approximately 3 months after treatment. Rescreen all women treated when they next present for care within 12 months.
C. Consider retesting 3 weeks after completion of treatment with erythromycin because the frequent GI side effects of the drug are often associated with noncompliance.
D. Repeat Pap smear if abnormal prior to treatment
E. Gonorrhea cultures if not done
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F. Serology test for syphilis
G. In some states, Chlamydia is a reportable disease.
Appendix I has information on C. trachomatis infection to photocopy or adapt for your patients.
See Bibliographies.
Website: www.cdc.gov/std/tg2015/tg-2015-Print.pdf