Sexually Transmitted Infections: Chlamydia Trachomatis

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Chapter 46 Sexually Transmitted Infections: Chlamydia Trachomatis

INTRODUCTION

Description: The second most common sexually transmitted disease (STD) and most common bacterial STD is infection caused by Chlamydia trachomatis. More common than Neisseria gonorrhoeae by 3-fold, infections with C. trachomatis can be the source of significant complications and infertility.
Prevalence: Twenty percent of pregnant patients, 30% of sexually active adolescent women. Up to 40% of all sexually active women have antibodies suggesting prior infection. In 2005, 976,445 chlamydia infections were reported to the Centers for Disease Control and Prevention (CDC) from 50 states and the District of Columbia (496.5 cases per 100,000 females), up 5.1% from 2004.
Predominant Age: 15 to 30 years (85%), peak age 15 to 19 years. The Centers for Disease Control and Prevention recommend screening all sexually active women younger than age 26 years.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Infection by the obligate intracellular organism C. trachomatis. Chlamydia has a long incubation period (average, 10 days) and may persist in the cervix as a carrier state for many years.
Risk Factors: The risk of contracting chlamydial infection is five times greater with three or more sexual partners and four times higher for patients using no contraception or nonbarrier methods of birth control. Other factors are age younger than 26 years, new partner within the preceding 3 months, other sexually transmitted diseases, vaginal douching.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Frequently asymptomatic
• Cervicitis; pelvic inflammatory disease (PID); or, much less common, lymphogranuloma venereum
• Less common: nongonococcal urethritis and inclusion conjunctivitis
• Eversion of the cervix with mucopurulent cervicitis supports the diagnosis but not pathognomic

DIAGNOSTIC APPROACH

Differential Diagnosis

• Gonorrhea
• PID
• Septic abortion
• Appendicitis
• Gastroenteritis
• Associated Conditions: Infertility, ectopic pregnancy, mucopurulent cervicitis, PID, chronic pelvic pain, and endometritis.

Workup and Evaluation

Laboratory: Cultures on cycloheximide-treated McCoy cells are specific and may be used to confirm the diagnosis, but these cultures are expensive, difficult to perform, and often not available. Two clinical screening tests are an enzyme-linked immunoassay (enzyme-linked immunosorbent assay) performed on cervical secretions and a monoclonal antibody test carried out on dried smears. When trying to obtain cervical cultures for chlamydia, plastic or metal-shafted rayon or cotton-tipped swabs are preferred. Wood-shafted or calcium alginate swabs reduce the yield of material when transport media are used because of leeching of toxic products into the media. Newer screening techniques using patientcollected vaginal swabs or urine specimens may be used but are not widely available.
Imaging: No imaging indicated. Ultrasonography may demonstrate free fluid in the cul-de-sac when pelvic inflammation is present.
Special Tests: None indicated.
Diagnostic Procedures: Physical examination, suspicion, and cervical culture.

Pathologic Findings

This infection tends to involve the mucosal layers and not the entire structure. As a result, extensive damage may occur without dramatic symptoms if the fallopian tubes become infected.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation and diagnosis.
Specific Measures: Aggressive antibiotic therapy should be instituted in those suspected of infection. Approximately 45% of patients with chlamydial infection have coexisting gonorrhea; the therapy chosen should consider this.
Diet: No specific dietary changes indicated.
Activity: No restriction. (Sexual continence required until infection is resolved.)
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP009 (How to Prevent Sexually Transmitted Diseases). Patients should be advised to have all sexual partners seen for diagnosis and treatment.

Drug(s) of Choice

Azithromycin (1 g PO, single dose) compares favorably with the standard 7-day course of doxycycline, while providing better compliance and fewer side effects. A meta-analysis of 12 randomized clinical trials of azithromycin versus doxycycline for the treatment of genital chlamydial infection demonstrated that the treatments were equally efficacious, with microbial cure rates of 97% and 98%, respectively.
Doxycycline (100 mg PO twice a day for 7 days) may also be used.
Contraindications: Quinolones (Ofloxacin), tetracyclines (including doxycycline), and erythromycin estolate are contraindicated in pregnancy and should not be used.
Precautions: Pregnant patients with chlamydial infections should be treated with azithromycin, amoxicillin (500 mg PO three times a day for 7 days), erythromycin base, or erythromycin ethylsuccinate.

Alternative Drugs

Erythromycin (erythromycin base 500 mg PO four times a day for 7 days or erythromycin ethylsuccinate 800 mg PO four times a day for 7 days) may be substituted for tetracycline in patients who are tetracycline-sensitive or pregnant. For patients who cannot tolerate erythromycin, amoxicillin (500 mg PO three times a day for 7 to 10 days) may be substituted.
Ofloxacin (300 mg PO twice a day for 7 days).
Levofloxacin (500 mg orally once daily for 7 days).

FOLLOW-UP

Patient Monitoring: Follow-up evaluation for cure with culture or other tests (3 to 4 weeks after therapy) and screening for other sexually transmitted diseases should be performed. (As with all sexually transmitted diseases, all sexual partners within the preceding 30 days should be screened and treated for probable infections.)
Prevention/Avoidance: Use of barrier contraception (condoms, diaphragm), limitation or elimination of risky behavior (sexual promiscuity).
Possible Complications: Infertility, chronic pelvic pain. If PID occurs, the risk of infertility roughly doubles with each subsequent episode resulting in a 40% rate of infertility after only three episodes. Women with documented salpingitis have a 4-fold increase in their rate of ectopic pregnancy and 5% to 15% of women require surgery because of damage caused by PID.
Expected Outcome: If detected early, successful treatment with minimal sequelae may be expected. Significant permanent damage is common despite treatment because of the indolent course of most infections and thus the late institution of therapy.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy. Neonatal conjunctivitis and ophthalmia neonatorum may result if an infant does not receive adequate prophylaxis. Even with standard protection (1% AgNO3 or 0.5% erythromycin ointment), complete protection is not assured.
ICD-9-CM Codes: 099.5.

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REFERENCES

Level I

Adair CD, Gunter M, Stovall TG, et al. Chlamydia in pregnancy: a randomized trial of azithromycin and erythromycin. Obstet Gynecol. 1998;91:165.

Jacobson GF, Autry AM, Kirby RS, et al. A randomized controlled trial comparing amoxicillin and azithromycin for the treatment of Chlamydia trachomatis in pregnancy. Am J Obstet Gynecol. 2001;184:1352.

Silverman NS, Sullivan M, Hochman M, et al. A randomized, prospective trial comparing amoxicillin and erythromycin for the treatment of Chlamydia trachomatis in pregnancy. Am J Obstet Gynecol. 1994;170:829.

Level II

Cook RL, Hutchison SL, Ostergaard L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae.. Ann Intern Med. 2005;142:914.

Lau C-Y, Qureshi AK. Azithromycin versus doxycycline for genital chlamydial infections: a meta-analysis of randomized clinical trials. Sex Transmit Dis. 2002;29:497.

Lyss SB, Kamb ML, Peterman TA, et al. Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhoeae in sexually transmitted disease clinics in the United States. Ann Intern Med. 2003;139:178.

Martin DH, Mroczkowski TF, Dalu ZA, et al. A controlled trial of a single dose of azithromycin for the treatment of chlamydial urethritis and cervicitis: the azithromycin for Chlamydial Infections Study Group. N Engl J Med. 1992;327:921.

Ness RB, Trautmann G, Richter HE, et al. Effectiveness of treatment strategies of some women with pelvic inflammatory disease: a randomized trial. Obstet Gynecol. 2005;106:573.

Ostergaard L, Andersen B, Olesen F, Moller JK. Efficacy of home sampling for screening of Chlamydia trachomatis: randomized study. BMJ. 1998;317:26.

Peterman TA, Tian LH, Metcalf CA, et alRESPECT-2 Study Group. High incidence of new sexually transmitted infections in the year following a sexually transmitted infection: a case for rescreening. Ann Intern Med 145 2006 564-572 Summary for patients in: Ann Intern Med. 2006;145:I44.

Tanaka M, Nakayama H, Sagiyama K, et al. Evaluation of a new amplified enzyme immunoassay (EIA) for the detection of Chlamydia trachomatis in male urine, female endocervical swab, and patient-obtained vaginal swab specimens. J Clin Pathol. 2000;53:350.

Level III

American College of Obstetricians and Gynecologists. Sexually transmitted diseases in adolescents. ACOG Committee Opinion 301. Washington, DC: ACOG, 2004.

Centers for Disease Control and Prevention. Recommendations for the prevention and management of Chlamydia trachomatis infections, 1993. MMWR. 1993;42:1.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR. 2006;55:21. 38.

Crossman SH. The challenge of pelvic inflammatory disease. Am Fam Physician. 2006;73:859.

Eckert LO, Lentz GM. Infections of the lower genital tract. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:600.

Faro S. Chlamydia trachomatis: female pelvic infection. Am J Obstet Gynecol. 1991;164:1767.

Jones RB. New treatments for Chlamydia trachomatis.. Am J Obstet Gynecol. 1991;164:1789.

Lee HH, Chernesky MA, Schachter J, et al. Diagnosis of Chlamydia trachomatis genitourinary infection in women by ligase chain reaction assay of urine. Lancet. 1995;345:213.

Low N. Screening programmes for chlamydial infection: when will we ever learn? BMJ. 2007;334:725.

Mangione-Smith R, McGlynn EA, Hiatt L. Screening for chlamydia in adolescents and young women. Arch Pediatr Adolesc Med. 2000;154:1108.

Miller KE. Diagnosis and treatment of Chlamydia trachomatis infection. Am Fam Physician. 2006;73:1411.

Morrison RP. New insights into a persistent problem—Chlamydial infections. J Clin Invest. 2003;111:1647.

Osser S, Persson K. Chlamydial antibodies in women who suffer miscarriage. Br J Obstet Gynaecol. 1996;103:137.

Peipert JF. Clinical practice. Genital chlamydial infections. N Engl J Med. 2003;349:2424.

Skolnik NS. Screening for Chlamydia trachomatis infection. Am Fam Physician. 1995;51:821.

Stamm WE. Chlamydia trachomatis infections: progress and problems. J Infect Dis. 1999;179:S380.

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