Chlamydia trachomatis infection update - includes patient information sheet

Author: Cathryn B. Heath, John M. Heath
Date: Oct, 1995

The most common sexually transmitted disease (STD) in the United States is Chlamydia trachomatis infection, with more than 4 million cases reported each year.[1] Recent advances in epidemiology, laboratory testing and treatment of chlamydial infection are designed to help curb transmission and decrease the long-term sequelae of this devastating disease.

C. trachomatis is an intracellular parasitic pathogen that is similar in cell-wall membrane structure to gram-negative bacteria. Principal sites of adult infection include the genitourinary tract and rectum. Conjunctivitis, perihepatitis and reactive arthritis may result. Invasion occurs as the organism penetrates columnar epithelial cells at the site of initial exposure.

The prevalence rate of C. trachomatis infection ranges from 3 percent in women and men seen in an asymptomatic population to more than 20 percent in people screened in STD clinics.[2]

The frequently asymptomatic presentation of the chlamydial organism makes it difficult for the primary care physician to diagnose and treat an early infection. The role of asymptomatic women in the transmission of Chlamydia has been well recognized: as many as two-thirds of infected women are asymptomatic. As many as one-fourth of infected men are asymptomatic.[3]

Signs and Symptoms

One-third of women in whom Chlamydia is eventually detected have local signs of infection.[2] The most common symptom is vaginal discharge from mucopurulent cervicitis, although some women also have spotting with intercourse. Mucopurulent cervicitis causes the cervix to be friable, edematous and covered with a tenacious yellow-green discharge. Any woman with mucopurulent cervicitis on pelvic examination, whether vaginal discharge is present or not, should be screened for Chlamydia. A study of women with mucopurulent cervicitis confirmed that visualization of yellow mucopurulent cervicitis and the presence of 10 or more polymorphonuclear leukocytes per microscopic field (x1,000) in a Gramstained specimen strongly suggested cervical C. trachomatis infection and not gonorrhea or herpes.[4] Infection with C. trachomatis is confirmed on culture in one-third to one-half of women with mucopurulent cervicitis.[2]

Irregular menstrual bleeding, heavy menses or lower abdominal pain with uterine tenderness on examination are possible symptoms of endometritis, which is present in 40 percent of women with mucopurulent cervicitis from chlamydial infection.[3] Women with either unilateral or bilateral adnexal tenderness may also have chlamydial salpingitis, which may account for half of the cases of endoscopically confirmed salpingitis.[3]

From 3 to 5 percent of women with acute pelvic inflammatory disease have perihepatitis (Fitz-Hugh-Curtis syndrome) with symptoms of pleuritic right upper quadrant abdominal pain and tenderness, with or without pelvic pain. On examination, 40 percent of these women have a temperature above 38[degrees]C (100.4[degrees]F) and adnexal tenderness consistent with salpingitis.[5] Although it was first thought that these "violin-string" adhesions between the liver and the anterior abdominal wall were always caused by infection with Neisseria gonorrhoeae, 80 percent of patients with proven Fitz-Hugh-Curtis syndrome were found to be culturally or serologically positive for C. trachomatis, while only 10 percent were culturally positive for N. gonorrhoeae.[2]

Some women initially present with the long-term sequelae of chlamydial disease, such as ectopic pregnancy, infertility or chronic abdominal pain. Women with a history of pelvic inflammatory disease have a 7- to 10-fold increase in risk for ectopic pregnancy, compared with women who never had an infection.[5] In one group of women with tubal-factor infertility, association with Chlamydia IgA antibody was strong, even among women with no known history of pelvic inflammatory disease.[6]

Urinary tract infections caused by C. trachomatis are much more commonly symptomatic in men than in women. Both gonorrheal urethritis and C. trachomatis urethritis may cause "sterile" pyuria, and both infections may be asymptomatic. Up to 50 percent of men with nongonococcal urethritis are infected with Chlamydia. Nongonococcal urethritis presents with symptoms of dysuria and a white to clear urethral discharge. It has an incubation period of seven to 21 days. Screening studies in STD clinics show that half of the urethral and cervical cultures in infected women are positive for Chlamydia at both sites.[5]

In young heterosexual men presenting with symptomatic epididymitis, chlamydial infection is the leading cause. Therefore, men with testicular pain, with or without urethral discharge, should be tested for Chlamydia.

Reiter's syndrome, a clinical symptom complex consisting of reactive arthritis, conjunctivitis and nongonococcal urethritis, has also been associated with Chlamydia; therefore, patients with symptoms consistent with Reiter's syndrome should also be tested for chlamydial infection.7 Chlamydia can cause proctitis 1n men and women practicing receptive anal intercourse. Women and homosexual men with anorectal pain, tenesmus, bleeding and rectal discharge should be cultured for chlamydial infection.

Table 1 shows the prevalence rate of C. trachomatis infection in association with some of the most common clinical syndromes in patients with STDs.

TABLE 1Prevalence of Chlamydia Infection in Patients with STDs Chlamydia prevalence (%)Clinical syndrome Patients PartnersNongonoccocal urethritis 30 to 40 10 to 43Pelvic inflammatory disease 8 to 54 36Epididymitis (males younger than age 35) 50 40Gonococcal infections Males 5 to 30 40 Females 25 to 50 UnknownAdapted from Recommendations for the prevention and management of Chlamydiatrachomatis infections, 1993. Centers for Disease Control and Prevention.MMWRMorb Mortal Wkly Rep 1993;42(RR12):23.

Screening Asymptomatic Patients

Since so many men and women infected with Chlamydia are asymptomatic, the Centers for Disease Control and Prevention (CDC) recommends screening patients who are most likely to contract chlamydial infection.[1] With this goal in mind, selective screening of targeted populations in whom the prevalence rate has been shown to exceed 5 percent has been suggested. For women, these populations include those attending family planning clinics or STD clinics, and prison inmates.[1]

Table 2 presents office screening recommendations for asymptomatic groups of patients. Sexually active adolescents should be screened during routine pelvic examinations. In addition to these groups, women aged 20 to 24 who inconsistently use barrier contraceptives, who have a new sex partner or who have had more than one sex partner during the past three months could benefit from screening. In women older than age 24, Chlamydia screening may be helpful if they have had a new sex partner within the past three months and are not using barrier contraception. Since serious perinatal complications could result from chlamydial infections, women who are pregnant as well as those who are seeking an abortion should be screened.[1]

[TABULAR DATA OMITTED]

Adolescent males who are sexually active and men who are in the military, attending college or restrained in detention centers--populations in which the prevalence rate for Chlamydia is 5 percent or greater--are also good candidates for screening.[1] Any man seeking care in an STD clinic, where Chlamydia prevalence rates for males are as high as 20 percent, should be screened. Although routine screening of asymptomatic males has been difficult in the past because of the discomfort associated with urethral culture, the leukocyte esterase test (LET) for urine screening may be a more acceptable screening tool.

Some controversy exists as to whether Chlamydia testing is necessary in patients with symptoms consistent with chlamydial disease and for partners of patients known to be positive for Chlamydia. However, if the index patient is presently symptomatic, testing should be strongly considered since notifying partners may become a problem if definitive testing has not been performed. If the partner is unable or unwilling to come into the physician's office for evaluation and treatment, consideration should be given to treating that partner empirically in order to prevent reinfection of the index patient.

Hospitalization for intravenous therapy should be considered for women with a temperature above 38[degrees]C (100.4[degrees]F), who have peritonitis or pelvic abscesses, or who do not clinically respond to outpatient therapy. Intravenous cefoxitin (Mefoxin), 2 g every six hours, plus doxycycline, 100 mg every 12 hours (either intravenously or orally) is appropriate therapy in nonpregnant patients. Alternative regimens include clindamycin, 900 mg every eight hours, plus gentamicin (Garamycin), 1.5 mg per kg every eight hours until the patient is improved, followed by doxycycline, 100 mg orally twice daily, for a total of 14 days.[17] In hospitalized pregnant women, appropriate treatment is intravenous clindamycin or erythromycin and gentamicin until the patient is afebrile for 48 hours, followed by oral erythromycin, 500 mg every six hours, for a total of 14 days.

REFERENCES

[1.] Recommendations for the prevention an l management of Chlamydia trachomatis infections, 1993. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 1993;42(RR12):1-39. [2.] Holmes KK, Cates W Jr, Lemon SM, Stamm WE, eds. Sexually transmitted diseases. 2d ed. New York: McGraw-Hill, 1990. [3.] Kassler WJ, Cates W Jr. The epidemiology and prevention of sexually transmitted diseases. Urol Clin North Am 1992;19:1-12. [4.] Brunham RC, Paavonen J, Stevens CE, Kiviat N, Kuo CC, Critchlow CW, et al. Mucopurulent cervicitis--the ignored counterpart in women of urethritis in men. N Engl J Med 1984;311:1-6. [5.] Adimora AA. Sexually transmitted diseases. Companion handbook. New York: McGraw-Hill, 1994. [6.] Sellors JW, Mahony JB, Chernesky MA. Rath DJ. Tubal factor infertility: an association with prior chlamydial infection and asymptomatic salpingitis. Fertil Steril 1988;49:451-7. [7.] Stamm WE, Holmes K Chlamydial infections. In: Wilson JD, et al., eds. Harrison s Principles of internal medicine. 12th ed. New York: McGraw-Hill, 1991 :765-70. [8.] Herrmann BF, Johansson AB, Mardh PA. A retrospective study of efforts to diagnose infections by Chlamydia trachomatis in a Swedish county. Sex Transm Dis 1991;18:233-7. [9.] Britton TF, Delisle S, Fine D. STDs and family planning clinics: a regional program for chlamydia control that works. Am J Gynecol Health 1992;6(3):24-31. [10.] Biro FM, Reising SF, Doughman JA, Kollar LM, Rosenthal SL. A comparison of diagnostic methods in adolescent girls with and without symptoms of chlamydia urogenital infection. Pediatrics 1994; 93:476-80. [11.] Shafer MA, Schachter J, Moncada J, Keogh J, Pantell R, Gourlay L, et al. Evaluation of urine-based screening strategies to detect Chlamydia trachomatis among sexually active asymptomatic young males. JAMA 1993;270:2065-70. [12.] Genc M, Ruusuvaara L, Mardh PA. An economic evaluation of screening for Chlamydia trachomatis in adolescent males. JAMA 1993;270:2057-64. [13.] Nettleman MD, Jones RB, Roberts SD, Katz BP, Washington AE, Dittus RS, et al. Cost-effectiveness of culturing for Chlamydia trachomatis. A study in a clinic for sexually transmitted diseases. Ann Intern Med 1986;105:189-96. [14.] Nettleman MD, Bell TA. Cost-effectiveness of prenatal testing for Chlamydia trachomatis. Am J Obstet Gynecol 1991;164(5 Pt 1):1289-94. [15.] Martin DH, Mroczkowsh TF, Dalu ZA, McCarty J, Jones RB, Hopkins SJ, 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;327:921-5. [16.] Sanford JP, et al., eds. Guide to antimicrobial therapy, 1994. Dallas: Antimicrobial Therapy, Inc., 1994. [17.] Drugs for sexually transmitted diseases. Med Lett Drugs Ther 1994;36(913):1-6.

CATHRYN B. HEATH, M.D. is assistant professor of family medicine at State University of New York (SUNY) Health Science Center at Syracuse. She is a graduate of Hahneman University School of Medicine, Philadelphia, and completed a residency at St. Vincent Health Center family practice residency, Erie, Pa.

JOHN M. HEATH, M.D. is assistant professor of family medicine at SUNY Health Science Center at Syracuse. He is a graduate of Hahneman University School of Medicine, Philadelphia, and completed a residency at St. Vincent Health Center family practice residency, Erie. He also completed a fellowship in geriatrics at the University of Cincinnati College of Medicine.

Address correspondence to Cathryn Heath M.D. SUNY Health Science Center at Syracuse, 475 Irving Ave., Suite 200, Syracuse, NY 13210.

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