Chlamydia
Cheryl A. Glass and Leslie B. Norman
Definition
A.Chlamydia is a sexually transmitted infection (STI) caused by the Chlamydia trachomatis bacterium.
Incidence
A.The World Health Organization (WHO) estimates more than one million STI are acquired every day worldwide. Each year, there are an estimated 357 million new infections with one of four STIs: chlamydia, gonorrhea, syphilis, and trichomoniasis. Chlamydia is the most frequently reported sexually transmitted organism in the United States. About 1.6 million cases of chlamydia were diagnosed in 2016. Chlamydia is not a Centers for Disease Control and Prevention (CDC) reportable infection; however, local health department notification is required. Every state has its own list of reportable diseases.
B.Testing and screening recommendations:
1.Males:
a.The CDC notes that although chlamydia screening programs have demonstrated a reduction rate of pelvic inflammatory disease (PID), there is insufficient evidence to recommend routine screening in sexually active men because of feasibility, efficacy, and cost-effectiveness.
b.Consider screening in clinical settings such as correctional facilities, or in populations of high burden of infection such as men having sex with men (MSM).
2.Females:
a.The primary focus of chlamydia screening should be to detect chlamydia, to prevent complications such as PID, and to test and treat partners:
i.Annual screening of all sexually active women age less than 25 years is recommended.
ii.Screen older women (>25 years) at increased risk for infection:
•New sex partner.
•More than one sex partner.
•Sex partner with concurrent partners.
•Sex partner who has a STI.
3.Routine oropharyngeal screening for chlamydia is not recommended.
Pathogenesis
A.C. trachomatis is an intracellular bacterium with parasitic properties. It is transmitted by sexual contact or perinatally when a vaginal delivery occurs through an infected birth canal.
Predisposing Factors
A.History of STIs.
B.Multiple sexual partners.
C.Early age at first coitus.
D.Unprotected intercourse.
E.Inconsistent condom use.
F.Gay.
G.Bisexual.
H.MSM.
I.Factors contributing to increase of STIs in older adults:
1.Undereducated: Older adults are less likely to perceive themselves at risk. Safe sex and STI prevention education came in the 1980s dealing with the HIV crisis and during the time older adults were middle aged and married. Seniors may feel sex education is only directed to youth and prevention of pregnancy.
2.Medications for erectile dysfunction have contributed to more men being able to engage in sexual activity throughout their older years.
3.Online dating lowers the chance that partners know the background and sexual history of people they date.
4.Women are postmenopausal and do not worry about getting pregnant with new partners
Common Complaints
A.Up to 80% of those infected are asymptomatic.
B.Mucopurulent cervical, vaginal, or urethral discharge.
C.Dysuria.
D.Urinary frequency and urgency.
E.Pelvic pain (dull or severe).
Other Signs and Symptoms
A.Cervical friability.
B.Cervical motion tenderness.
C.Uterine and/or adnexal tenderness.
Subjective Data
A.Elicit history of onset of symptoms, location, frequency, duration, aggravating and alleviating factors, and associated symptomatology.
B.Question the patient about sexual partners, sexual habits, and history of other STIs.
Physical Examination
A.Inspect:
1.Males: Observe for anal and/or urethral discharge.
2.Female pelvic exam: Observe for anal and/or vaginal discharge.
3.Female speculum exam: Inspect vaginal wall and cervix for discharge and irritation.
B.Palpate:
1.Males:
a.Palpate inguinal lymph nodes.
b.Milk penis for discharge.
c.Palpate the groin.
2.Females:
a.Palpate the inguinal lymph nodes.
b.Bimanual exam:
i.Milk urethra.
ii.Palpate periurethral and Bartholin glands for exudate.
iii.Assess for cervical motion tenderness.
iv.Assess for uterine and adnexal tenderness.
Diagnostic Tests
It is important to obtain a thorough sexual history from the patient and to screen all orifices used during sexual contact (i.e., oropharynx, rectum).
A.Culture samples from urethra (men only), endocervix, rectum, oropharyngeal, and conjunctiva as indicated:
1.Rectal and oropharyngeal testing for persons engaging in receptive anal or oral intercourse can be diagnosed by testing at the anatomic site of exposure:
a.Brush or swab the oropharynx.
b.Insert the brush or swab 1 to 2 cm into endocervix, urethra (males only), or rectum.
c.Rotate for 30 seconds, withdraw, and place in appropriate culture media for transport.
B.The nucleic acid amplification test (NAAT) is the recommended and most sensitive test:
1.NAATs are Food and Drug Administration (FDA)-cleared for use with vaginal swab specimens collected by a provider or self-collected in a clinical setting. Self-collected vaginal swab specimens are equivalent in sensitivity and specificity to collection by providers.
2.Optimal urogenital specimen types for chlamydia screening using NAAT include:
a.Men: First catch urine.
b.Women: Vaginal swabs.
3.NAATs are not FDA-cleared for use with rectal or oropharyngeal swab specimens.
4.Some NAATs have been FDA-cleared for use on liquid-based cytology specimens.
Differential Diagnoses
A.Chlamydia.
B.Gonorrhea.
C.Urethritis.
D.Mycoplasma genitalium.
Plan
A.General interventions:
1.Culture samples immediately for timely treatment. Consider testing for other STIs such as gonorrhea, syphilis, HIV, and trichomoniasis.
B. 
See Section III: Patient Teaching Guide Chlamydia
:
1.Inform the patient of the need for partner notification and treatment. Notification is recommended for any partner with whom the patient has had sexual contact as soon as possible but within 30 days of the onset of symptoms or 60 days if asymptomatic.
2.Stress the importance of completing treatment regimen.
3.Advise the patient to avoid sexual intercourse after single-dose therapy or until treatment completion and for 7 more days following the last day of antibiotic treatment and resolution of symptoms, if present.
4.Repeat infections place women at an elevated risk for PID and other complications.
5.Persons who have chlamydia and HIV infection should receive the same treatment regimen as those who do not have HIV infection.
C.Pharmaceutical therapy:
1.The (2015) CDC recommends the following regimens:
a.Azithromycin 1 g by mouth in a single dose:
i.To maximize adherence onsite, directly observed single-dose therapy with azithromycin should always be available for person for whom adherence with multiday dosing is a concern OR
b.Doxycycline 100 mg by mouth twice daily for 7 days.
2.Alternative regimen—one of the following:
a.Levofloxacin 500 mg orally once daily for 7 days OR
b.Erythromycin base 500 mg by mouth four times daily for 7 days OR
c.Erythromycin ethylsuccinate 800 mg by mouth four times daily for 7 days OR
d.Ofloxacin 300 mg by mouth twice daily for 7 days OR
e.Levofloxacin 500 mg by mouth daily for 7 days.
Follow-Up
A.The CDC recommends that patients follow up in 3 to 4 weeks for a test-of-cure repeat culture if therapeutic adherence is in question, symptoms persist, or reinfection is suspected:
1.The use of chlamydial NAATs at less than 3 weeks after completion of therapy is not recommended because of the continued presence of nonviable organisms that can lead to false-positive results.
2.If retesting is not possible, retest whenever the person presents again for medical care within a 12-month period following initial treatment.
Consultation/Referral
A.Consult or refer the patient to a physician when treatment with the recommended dosage fails if patient noncompliance and reexposure have been ruled out.
Individual Considerations
A.Pregnancy:
1.Doxycycline is contraindicated in the second and third trimester of pregnancy.
2.Ofloxacin and levofloxacin present a low risk to the fetus during pregnancy; however there is a potential for toxicity during breastfeeding.
3.All pregnant women diagnosed with chlamydial infection should be retested in 3 to 4 weeks following treatment (preferably by NAAT).
4.For women older than 25 years of age, those with new partners, and/or those at high risk for infection, repeat chlamydial testing during the third trimester should be performed.
5.All pregnant women diagnosed with chlamydial infection during the first trimester should be retested at 3 to 4 weeks following treatment, and again in 3 months after treatment.
6.Rescreen during the third trimester to prevent maternal postnatal complications and chlamydial infection in the infant.
7.The CDC recommends the following regimens for pregnant women:
a.Recommended: Azithromycin 1 g orally in a single dose.
b.Alternative regimens:
i.Amoxicillin 500 mg orally three times a day for 7 days OR
ii.Erythromycin base 500 mg by mouth four times daily for 7 days OR
iii.Erythromycin base 250 mg by mouth four times daily for 14 days OR
iv.Erythromycin ethylsuccinate 800 mg by mouth four times daily for 7 days OR
v.Erythromycin ethylsuccinate 400 mg by mouth four times daily for 14 days.
B.Adults: Untreated or long-standing chlamydial infection in women may lead to infertility.
C.Older adults:
1.Medicare offers free STI screening and treatment for seniors.
2.Clinicians need to address the STI issue by including questions about sexual activity in their senior patient assessment.
3.Seniors are at increased risk for STIs due to a weaker immune system and hormone changes.