Chlamydia infection (chlamydia)

Chlamydial genital infection is common among adolescents and young adults in the United States. Asymptomatic infection occurs in both men and women. Even in the absence of symptoms, sexually active adolescent girls should be screened for chlamydial infection annually during a routine pelvic exam.

It is also proposed to screen young women aged 20–24 years for chlamydial infection, especially those with new or multiple sexual partners and who do not consistently use barrier contraception.

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Chlamydial infections in adolescents and adults

Chlamydial infection in women can lead to a number of complications, the most serious of which are PID, ectopic pregnancy, and infertility. Some women with uncomplicated cervical infection are likely to have subclinical upper reproductive tract disease. Recent clinical trials have shown that screening and treatment for cervical infection may reduce the incidence of PID.

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Chlamydial infection in infants

Prenatal screening of pregnant women can prevent chlamydial infection in children. Screening is particularly recommended for pregnant women younger than 25 years with new or multiple partners. Periodic chlamydia prevalence studies are needed to confirm the validity of these recommendations in specific clinical settings.

Infection with C. trachomatis in neonates results from perinatal transmission from the mother's cervix. The prevalence of chlamydial infection in pregnant women is generally greater than 5%, regardless of racial, ethnic, or socioeconomic status. Silver nitrate solutions or antibiotic ointments are not effective in preventing neonatal conjunctivitis caused by perinatal transmission of chlamydial infection from mother to child. However, these measures prevent the development of gonococcal ophthalmia and should be used (see Prevention of Ophthalmia Neonatalis).

Chlamydial infection initially affects the mucous membranes of the eyes, oropharynx, urogenital tract, and rectum. Infection with C. trachomatis in neonates is often recognized based on symptoms of conjunctivitis that develops 5 to 12 days after birth. Chlamydia is the most common cause of ophthalmia neonatorum. C. trachomatis is also the most common cause of subacute, fever-free pneumonia that develops in the first to third month of life. Newborns may also have asymptomatic infections of the oropharynx, genital tract, and rectum.

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Ophthalmia neonatorum caused by C. trachomatis

All infants with conjunctivitis under 30 days of age should be tested for chlamydia.

Notes on the diagnosis of chlamydia

Sensitive and specific methods for diagnosing chlamydial ophthalmia neonatorum include: isolation of C. trachomatis using tissue culture and non-culture tests - PIF and immunoassays. Giemsa staining of smears is a specific but not sensitive method for identifying C. trachomatis. Samples for analysis should contain not only conjunctival exudate, but also conjunctival cells. Samples for cultural and non-culture studies should be collected from the everted eyelid with a swab with a Dacron tip or a swab from a commercial kit. A specific diagnosis of chlamydial infection confirms the need for antichlamydial treatment not only for newborns, but also for mothers and their sexual partners. Ocular exudate obtained from children, which is tested for C. trachomatis, should also be tested for N. gonorrhoeae.

Recommended scheme

Erythromycin 50 mg/kg/day orally, divided into 4 doses, for 10-14 days.

Topical antibiotics alone are not adequate treatment for chlamydial infection and are not necessary if systemic treatment is prescribed.

Follow-up observation

The cure rate of erythromycin treatment is about 80%; a second course of treatment may be required. Follow-up observation of children until they are cured is recommended. The possibility of chlamydial pneumonia should be kept in mind.

Management of mothers and their sexual partners

Mothers of children with chlamydial infection and their sexual partners should be examined and treated (see Chlamydial infection in adolescents and adults).

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Pneumonia in infants caused by C. trachomatis

Characteristic features of chlamydial pneumonia in children include frequent attacks of hacking cough, lung expansion, and bilateral diffuse infiltrates on chest radiograph. Wheezing is rare, and fever is usually not present. Children with chlamydial pneumonia occasionally have eosinophilia in the peripheral blood. Because clinical manifestations in this disease often differ from those described above, all infants with pneumonia between 1 and 3 months of age should have initial treatment and diagnostic testing that includes possible infection with C. trachomatis.

Diagnostic Notes

Chlamydial testing requires a nasopharyngeal swab. Tissue culture remains the standard method for diagnosing chlamydial pneumonia; nonculture tests may be used, but their sensitivity and specificity are lower for nasopharyngeal specimens than for conjunctival specimens. If tracheal aspirates and lung biopsies are obtained, they should be tested for C. trachomatis.

Microimmunofluorescence for detection of C. trachomatis antibodies is a useful but unavailable method for most laboratories. An increase in IgM titer >1:32 clearly indicates the presence of chlamydial pneumonia.

Because of the delay in obtaining chlamydial test results, the inclusion of antichlamydial drugs in the treatment regimen often must be decided on the basis of clinical and radiographic data. Test results help manage the sick child and indicate the need for treatment of the mother and her sexual partner.

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Recommended treatment regimen

Erythromycin base 50 mg/kg/day orally, divided into 4 doses, for 10-14 days.

Follow-up observation

Erythromycin is about 80% effective; a second course of treatment may be needed. Follow-up is needed to ensure that the pneumonia symptoms have resolved. Some children who have had chlamydial pneumonia have subsequent changes in lung function tests.

Management of mothers and their sexual partners

Mothers of children with chlamydial infection and their sexual partners should be examined and treated according to the regimens recommended for adults (see Chlamydial infection in adolescents and adults).

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Babies born to mothers with chlamydia infection

Infants born to mothers with untreated chlamydial infection are considered a high-risk group for the disease, but preventive treatment should not be given because its effectiveness is unknown. If symptoms of infection develop, infants should be evaluated and treated.

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Chlamydia infection in children

Sexual abuse should be considered as a cause of chlamydial infection in prepubertal children, although C. trachomatis may persist in the nasopharynx, urogenital tract, and rectum for more than 1 year after perinatal infection (see Child Sexual Abuse and Rape). Because of the potential for prosecution and prosecution of sexual abuse, a highly specific culture method is needed to diagnose chlamydial infection in prepubertal children. Culture results should be confirmed by microscopic identification of characteristic cytoplasmic inclusions, preferably with fluorescein-conjugated monoclonal antibodies against C. trachomatis.

Diagnostic Notes

Non-culture tests for chlamydia should not be used because of the potential for false-positive results. When testing respiratory tract specimens, false-positive results may result from cross-reactions with C. pneumoniae; when testing genital and rectal specimens, false-positive results may result from cross-reactions with faecal flora.

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Recommended treatment regimens

Children weighing less than 45 kg

Erythromycin base 50 mg/kg/day orally, divided into 4 doses for 10-14 days.

NOTE: Erythromycin treatment is about 80% effective; a second course of treatment may be required.

Children weighing 45 kg or more and under 8 years of age

Azithromycin 1 g orally once Children aged 8 years and older

Azithromycin 1 g orally once or

Doxycycline 100 mg orally 2 times daily for 7 days

Other considerations for patient management

See Child Sexual Abuse and Rape.

Follow-up observation

Follow-up care is necessary to ensure that treatment is effective.

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Treatment of chlamydial infection (chlamydia)

Treatment of infected patients prevents the risk of transmission to sexual partners and, in infected pregnant women, infection of the fetus with C. trachomatis during delivery. Treatment of sexual partners helps prevent reinfection in the index patient and infection of other partners.

Due to the high prevalence of mixed infection with C. trachomatis and N. gonorrhoeae, preventive treatment for chlamydia should be administered to patients receiving treatment for gonorrhea.

Complete cure and resolution of symptoms is usually achieved after administration of the following recommended or alternative treatment regimens.

Recommended schemes

Azithromycin 1 g orally in a single dose,

Or Doxycycline 100 mg orally 2 times a day for 7 days,

Alternative schemes

Erythromycin base 500 mg orally 4 times a day for 7 days

Or Erythromycin ethylsuccinate 800 mg orally 4 times daily for 7 days

Or Ofloxacin 300 mg orally 2 times a day for 7 days

Studies have shown that doxycycline and azithromycin are equally effective. Clinical trials were initially conducted in populations where follow-up monitoring of cure after a 7-day treatment regimen was strongly recommended. Azithromycin should be given at least to those patients in whom compliance is questionable.

In populations with low rates of health care utilization, poor adherence, or poor follow-up, azithromycin may be more appropriate because it can be administered as a single dose under physician supervision. Azithromycin is approved for use in individuals younger than 15 years. Doxycycline has a longer history of intensive use and has the advantage of being less expensive. Erythromycin is less effective than azithromycin or doxycycline, and its gastrointestinal side effects often prevent patients from using the drug. Ofloxacin is similar in efficacy to doxycycline and azithromycin, but it is more expensive and does not have dosing advantages. Other quinolones do not have reliable efficacy against chlamydial infection or their use in the treatment of chlamydia has not been adequately studied.

To ensure adherence to the recommended treatment regimen, medications for chlamydia infection should be given in the clinic, and the first dose should be administered under the supervision of a health care professional. To reduce the risk of further transmission, patients treated for chlamydia should be instructed to abstain from sexual intercourse for 7 days after single-dose therapy or after completing a 7-day course of treatment. Patients should also be advised to abstain from sexual intercourse until all partners have been cured, to reduce the risk of reinfection.

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Follow-up observation

Because these drugs are highly effective, patients do not need to be retested for chlamydia after completing a full course of doxycycline or azithromycin unless symptoms persist or reinfection is suspected. A test of cure may be recommended 3 weeks after completion of erythromycin therapy. The reliability of chlamydial cultures performed earlier than 3 weeks after completion of therapy has not been established. False-negative results may occur because the number of chlamydiae may be small and may not be detected. In addition, noncultures performed earlier than 3 weeks after completion of therapy in successfully treated patients may yield false-positive results because of continued shedding of dead bacteria.

Several studies have found high rates of infection in women several months after treatment, presumably due to reinfection. Rescreening women several months after treatment may be an effective strategy for detecting the disease in some populations, such as adolescents.

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Management of sexual partners

Patients should be instructed to have their sexual partners examined and treated. Because data on the timing of infection are limited, further recommendations are controversial. Sexual partners whose last sexual contact with the patient occurred within 60 days of symptom onset or diagnosis should be examined and treated. If the last sexual contact occurred before this time, the sexual partner should be treated.

Patients should be advised to abstain from sexual intercourse until they and their partners are completely cured. Because microbiological verification of cure is generally not recommended, abstinence should be encouraged until treatment is completed (i.e., 7 days after a single-dose regimen or after completion of a 7-day regimen). Prompt treatment of partners is essential to reduce the risk of reinfection of the index patient.

Special Notes

Pregnancy

Doxycycline and ofloxacin are contraindicated in pregnant women. The safety and efficacy of azithromycin in pregnant and lactating women have not been established. Repeat testing, preferably by culture, is recommended 3 weeks after completion of treatment with the regimens described below, since none of these regimens is particularly effective and the frequent gastrointestinal side effects with erythromycin may force the patient to discontinue treatment.

Recommended regimens for pregnant women

Erythromycin base 500 mg orally 4 times a day for 7 days.

Or Amoxicillin 500 mg orally 3 times a day for 7-10 days.

Alternative regimens for pregnant women

Erythromycin base 250 mg orally 4 times a day for 14 days,

Or Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days,

Or Erythromycin ethylsuccinate 400 mg orally 4 times a day for 14 days,

Or Azithromycin 1 g orally in a single dose

NOTE: Erythromycin estolate is contraindicated during pregnancy due to its hepatotoxicity. Preliminary data suggest that azithromycin may be safe and effective. However, there are insufficient data to recommend its routine use in pregnant women.

HIV infection

Patients with HIV infection and chlamydial infection should receive the same treatment as patients without HIV infection.