Chlamydial infection (chlamydia)

Chlamydial genital infection is widespread among adolescents and young adults in the United States. Asymptomatic infection occurs in both men and women. Even in the absence of symptoms, it is necessary to conduct an annual examination of sexually active adolescent girls for chlamydial infection with a routine gynecological examination.

It is also proposed to screen for chlamydial infection of young women aged 20-24 years, especially those who have new or multiple sexual partners and who use the means of barrier contraception inconsistently.

[1], [2], [3], [4], [5], [6]

Chlamydial infections in adolescents and adults

Chlamydial infection in women can lead to a number of complications, of which the most serious are PID, ectopic pregnancy and infertility. Some women with an uncomplicated cervical infection already seem to have subclinical damage to the upper sections of the reproductive tract. Recent clinical trials have demonstrated that screening and cervical infection can reduce the likelihood of PID.

[7], [8], [9], [10], [11]

Chlamydial infection in infants

Prenatal screening of pregnant women can prevent the development of chlamydial infection in children. Especially recommended screening in pregnant women under 25 years of age, having a new or multiple partners. Periodic studies of chlamydia prevalence are needed to confirm the validity of these recommendations in specific clinical settings.

The infection caused by C. Trachomatis in newborns is a consequence of perinatal infection from the cervix of the mother. The prevalence of Chlamydia infection in pregnant women in general is more than 5% regardless of racial, ethnic or socio-economic status. For the prevention of neonatal conjunctivitis caused by perinatal transmission of chlamydial infection from mother to child, the use of solutions of silver nitrate or ointments with antibiotics is ineffective. However, these measures prevent the development of gonococcal ophthalmia and therefore they should be performed (see Prevention of neonatal ophthalmia).

Initially chlamydial infection affects the mucous membranes of the eyes, oropharynx, urogenital tract and rectum. Infection caused by C. Trachomatis in newborns is often recognized based on the symptoms of conjunctivitis developing 5 to 12 days after birth. Chlamydias most often cause ophthalmia of newborns. C. Trachomatis is also the most common cause of subacute pneumonia, not accompanied by a rise in temperature, developing in the 1-3th month of a child's life. Infants can also have asymptomatic infections of the oropharynx, genital tract and rectum.

[12], [13], [14], [15], [16], [17],

Ophthalmia of newborns caused by C. Trachomatis

All infants with conjunctivitis at the age of up to 30 days should be examined for chlamydia.

Remarks on the diagnosis of chlamydia

Sensitive and specific methods for diagnosing chlamydial ophthalmia of newborns include: the isolation of C. Trachomatis using tissue culture and non-cultural tests - PIF and immunotests. The staining of Giemsa smears is a specific, but not sensitive, method for identifying C. Trachomatis. Samples for analysis should contain not only conjunctival exudate, but conjunctival cells. Samples for culture and non-cultural research should be selected from a century-long swab with a dacron tip or a tampon from a commercial set. A specific diagnosis of Chlamydia infection confirms the need for antichlamydia treatment not only for newborns, but for mothers and their sexual partners. The eye exudate obtained from children, which is investigated in C. Trachomatis, also needs to be examined on N. Gonorrhoeae.

Recommended scheme

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

Only local antibiotic use is not an adequate treatment for chlamydial infection and is not necessary if systemic treatment is prescribed.

Follow-up

The effectiveness of treatment with erythromycin is about 80%; may require a second course of treatment. It is recommended that children be followed up until they are cured. It is necessary to bear in mind the possibility of developing chlamydial pneumonia.

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).

[18], [19]

Pneumonia in infants caused by C. Trachomatis

Characteristic signs of chlamydial pneumonia in children are: frequent attacks of an abrupt cough, enlargement of the lungs and bilateral diffuse infiltrates on the roentgenogram of the chest. Sterentous breathing is rarely observed and, as a rule, the temperature does not increase. Sometimes children with chlamydial pneumonia in the peripheral blood are diagnosed with eosinophilia. Since in this disease the clinical manifestations often differ from those described above, in all infants with pneumonia at the age of 1-3 months, primary treatment and diagnostic tests should be conducted taking into account the possible infection caused by C. Trachomatis.

Diagnostic notes

For research on chlamydia, it is necessary to take material from the nasopharynx. Research in tissue culture remains the standard method for diagnosing chlamydial pneumonia; noncultural tests can be used, taking into account the fact that when studying the material from the nasopharynx, their sensitivity and specificity is lower than in the study of specimens obtained from the conjunctiva of the eye. If samples of aspirate from the trachea and biopsy samples of the lung tissue were obtained, then they should be examined in C. Trachomatis.

Microimmunofluorescence for the detection of C. Trachomatis antibodies is useful, but not available for most laboratories. An increase in IgM titer> 1:32 clearly indicates the presence of chlamydial pneumonia.

Because of the delay in obtaining the results of chlamydial tests, the inclusion of antichlamydia drugs in the treatment regimen should often be decided on the basis of clinical and roentgenological data. The test results help guide the sick child and indicate the need for treatment of the mother and her sexual partner.

[20], [21], [22], [23], [24], [25], [26],

Recommended treatment regimen

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

Follow-up

The effectiveness of treatment with erythromycin is approximately 80%; may require a second course of treatment. Further observation is necessary to ensure that the symptoms of pneumonia are resolved. Some children who have experienced chlamydial pneumonia, subsequently, are observed changes in the study of lung function.

Management of mothers and their sexual partners

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

[27], [28],

Infants born to mothers with chlamydial infection

Infants born to mothers with untreated chlamydial infection are classified as high risk for the disease, but preventive treatment should not be prescribed, since its effectiveness is unknown. If the symptoms of infection develop, children should be examined and treated.

[29], [30], [31], [32], [33], [34]

Chlamydial infection in children

Sexual violence should be considered as the cause of chlamydial infection in prepubescent children, although after infection in the perinatal period, C. Trachomatis may persist in the nasopharynx, urogenital tract and rectum for more than 1 year (see Sexual harassment of children and rape). In connection with the possible need for judicial investigation and indictment of sexual violence, the diagnosis of chlamydial infection in children in prepubescent age requires the use of a highly specific culture method. The results of culture isolation should be confirmed by the microscopic identification of characteristic cytoplasmic inclusions, preferably by fluorescein-conjugated monoclonal antibodies against C. Trachomatis.

Diagnostic notes

Do not use non-cultural tests for chlamydia because of the possibility of false positive results. When analyzing samples obtained from the respiratory tract, false positive results may be the result of cross-reactions with C. Pneumoniae; when using samples from the genital tract and rectum, false positive results can be observed due to cross-reactions with fecal microflora.

[35]

Recommended treatment regimens

Children weighing less than 45 kg

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

NOTE: The effectiveness of erythromycin treatment is about 80%; may require a second course of treatment.

Children with a body weight equal to or greater than 45 kg aged under 8 years

Azithromycin 1 g orally once Children aged 8 years and older

Azithromycin 1 g orally once or

Doxycycline 100 mg orally 2 times a day for 7 days

Other observations on patient management

See Sexual harassment of children and rape.

Follow-up

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

[36]

Treatment hpamidiynoy infection (chlamydia)

Treatment of infected patients prevents the risk of transmission of infection to sexual partners, and infected pregnant women - infection of C. Trachomatis fetus during childbirth. Treatment of sexual partners helps prevent reinfection in the index patient and infect other partners.

Due to the high prevalence of mixed C. Trachomatis infection and N. Gonorrhoeae, precautionary treatment of chlamydia in patients receiving treatment for gonorrhea should be conducted.

Complete cure and disappearance of symptoms is usually observed after the appointment 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 basic 500 mg orally 4 times a day for 7 days

Or Erythromycin ethyl succinate 800 mg orally 4 times a day for 7 days

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

As a result of the studies, the same efficacy of doxycycline and azithromycin was established. Clinical trials were initially conducted in populations where strict follow-up control after 7-day treatment was strongly recommended. Azithromycin should be given at least to patients who are in question of adherence to treatment.

In populations with a low level of recourse for medical care, poor adherence to treatment regimens, or follow-up, the administration of azithromycin may be more appropriate because its reception in a single dose can be done under the supervision of a doctor. Azithromycin is approved for use in persons younger than 15 years. Doxycycline has a longer history of intense use, and its advantage is low cost. Erythromycin is less effective than azithromycin or doxycycline, and its side effects on the gastrointestinal tract often contribute to patients' refusal to treat the drug. Ofloxacin is similar in effectiveness to doxycycline and azithromycin, but it is more expensive and does not have advantages in dosing. Other quinolones do not have reliable efficacy against chlamydial infection or their use for the treatment of chlamydia is not well understood.

To comply with the recommended therapy, drugs for the treatment of chlamydial infection should be given directly in the clinic, and the first dose should be administered under the supervision of a health worker. To reduce the risk of further spread of the infection, patients treated with chlamydia should be instructed to abstain from sexual intercourse within 7 days after single dose therapy or after completing a seven-day course of treatment. Also, patients should be advised to abstain from sexual intercourse until all their partners are cured, in order to reduce the risk of reinfection.

[37], [38], [39], [40], [41], [42], [43],

Follow-up

Because these drugs are highly effective, patients do not need to be re-examined for chlamydia after completing the full course of treatment with doxycycline or azithromycin, except in cases of persisting symptoms or suspected of reinfection. Control of cure can be recommended 3 weeks after the end of treatment with erythromycin. The reliability of the results of the culture test for chlamydia, conducted earlier than 3 weeks after completion of therapy, is not established. False-negative results can be obtained, since the amount of chlamydia may be small and they may not be detected. In addition, noncultural studies conducted before 3 weeks after completion of treatment in successfully treated patients can give false positive results due to the continued isolation of dead bacteria.

As a result of several studies, a high level of infection among women was detected several months after treatment, presumably due to reinfection. Repeated screening of women several months after treatment can be an effective strategy for detecting the disease in some populations, such as teenagers.

[44], [45]

Management of sexual partners

Patients should be instructed about the need for examination and treatment of sexual partners. Since data on the evaluation of infection time intervals are limited, further recommendations are controversial. Sex partners whose last sexual contact with the indicated patient occurred within the last 60 days after the onset of symptoms or diagnosis is to be examined and treated. If the last sexual contact took place before the established time interval, then this sexual partner must be treated.

Patients should be advised to abstain from sexual intercourse before they and their partners are fully cured. Since microbiological control of cure is generally not recommended, it should be refrained until the end of treatment (i.e., 7 days after the treatment regimen in a single dose or after the completion of the 7-day regimen). Timely treatment of partners is essential to reduce the risk of reinfection of the index patient.

Special Remarks

Pregnancy

Doxycycline and ofloxacin are contraindicated in pregnant women. The safety and effectiveness of azithromycin in pregnant and lactating women is not established. Repeated examination, preferably by culture, is recommended 3 weeks after completion of treatment according to the schemes described below, since none of these regimens have a sufficiently high efficacy and frequent side effects from the gastrointestinal tract with erythromycin may force the patient to disrupt the treatment regimen .

Recommended schemes for pregnant women

Erythromycin is the principal 500 mg orally 4 times a day for 7 days.

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

Alternative schemes for pregnant women

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

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

Or Erythromycin ethyl succinate 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 because of its hepatotoxicity. Preliminary data indicate that azithromycin can be safe and effective. However, data to recommend its routine use in pregnant women is not enough.

HIV infection

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