Management and follow up

All patients diagnosed with chlamydia should be:

• advised to avoid genital, oral or rectal sex until patient and partner have
  completed treatment (or wait 7 days after completion of treatment if treatment
  was azithromycin). If a test of cure is indicated (see ‘Test of Cure’ section)
  patients should abstain until they are in receipt of a negative result.
• encouraged to have testing for other STIs including HIV, syphilis and where
  indicated tested for hepatitis and offered hepatitis and HPV vaccination. If the
  patient is within the window periods then tests should be repeated at an
  appropriate interval.
• given detailed information on the natural history of chlamydia infection, as well as
  transmission, treatment and complications, and directed to clear accurate written
  or web based patient information.

NHS Inform (Scotland’s National Health Information Service)

www.nhsinform.scot/illnesses-and-conditions/sexual-and-reproductive/chlamydia/

NHS Inform (Scotland’s National Health Information Service) https://www.nhsinform.scot/illnesses-and-conditions/sexual-and-reproductive/lymphogranuloma-venereum-lgv

The British Association of Sexual Health and HIV produce leaflets on Chlamydia
and LGV available in print and screen versions
https://www.bashhguidelines.org/media/1133/ct-pil-screen-oct-2016.pdf

https://www.bashhguidelines.org/media/1033/lgv_pil_digital_2_2015.pdf

Structured discussions should take place with patients diagnosed with chlamydia on the basis of behavioural change theories to address factors that can reduce risk taking and improve self efficacy and motivation. In most cases this can be a brief intervention discussing condom use and re-infection. Some patients may require more in-depth risk reduction work and referral to a healthcare worker competent in motivational interviewing.

See section explaining the LGV confirmatory PCR service offered by SBSTIRL. Doxycycline and ofloxacin should not be used in pregnancy or when breast feeding.

Uncomplicated genital and pharyngeal chlamydia

Asymptomatic rectal chlamydia (LGV status unknown)

Asymptomatic rectal chlamydia (LGV negative)

Asymptomatic rectal chlamydia (LGV positive) and all symptomatic rectal chlamydia

*Please refer to Test of Cure section below

All patients diagnosed with chlamydia infection should see a Sexual Health Advisor (SHA) or a clinician appropriately trained in partner notification.

The look back period for all (except symptomatic males at urethral site) should be six months, or to the previous partner if no partners in the last 6 months.

The look back period for symptomatic males (urethral sites) should be four weeks before the onset of symptoms, or to the previous partner if no partners in the last 4 weeks. All sexual partners within the look back period should be offered and encouraged to take up testing.

Current partners should be tested then treated epidemiologically and advised to abstain from sex for one week following commencement of treatment. For partners who test positive and where a test of cure is indicated abstinence should continue until the test of cure is reported and negative. See ‘Test of cure’ section, below.

Genital or pharyngeal infection

A test of cure following treatment is not routinely indicated. Indications for a test of cure include:

• persistent symptoms after treatment
• concerns re adherence to treatment or reinfection
• pregnancy
• use of treatment other than azithromycin or doxycycline
• known LGV and treatment was not 21 days of doxycycline.

Rectal infection

A test of cure is needed unless the patient fulfils all of the following criteria:

• free of symptoms after treatment
• no concerns re adherence to treatment or re-infecton
• not pregnant
• was treated with 21 days of doxycyline irrespective of LGV testing or treated with 7 days of doxycyline and had a negative LGV test.

When indicated a test of cure should ideally be done no earlier than three weeks after
completion of treatment.

Patients who presented with complicated infection and in patients in whom there is the intention to do a test of cure should be followed up in person.

When there are outstanding issues following the initial interview with the SHA, patients should be given a follow up telephone interview. If apparent during telephone follow up that symptoms are present, arrange a clinical review in person.

At all follow up interviews:

• Check compliance with therapy.
• Check that genital, oral or rectal sex was avoided until patient and partner had completed treatment (or waited 7 days if treatment was azithromycin).
• Ensure completion of any outstanding partner notification work.

Further recommendations

Consideration should be given to re-treatment of patients who have failed to adhere to treatment instructions, or where azithromycin was used and the patient vomited within 2 hours of any dose.

If symptoms have not responded to treatment or recur soon after treatment, consideration should be given to treatment failure or reinfection.
In pregnancy, further testing is advised at 36 weeks gestation.

1. British Association of Sexual Heath and HIV Clinical Effectiveness Unit BASHH 2015 UK
   National Guideline for the Management of Infection with Chlamydia trachomatis (2015).
   https://www.bashhguidelines.org/media/1192/ct-2015.pdf [accessed 4th August 2022]
2. Update on the treatment of Chlamydia trachomatis (CT) infection BASHH Clinical
   Effectivesness Group September 2018 [accessed 4th August 2022] https://www.bashhguidelines.org/media/1191/update-on-the-treatment-of-chlamydia-trachomatis-infection-final-16-9-18.pdf [accessed 4th August 2022]
3. British Association of Sexual heath and HIV Clinical Effectiveness Unit BASHH UK National Guideline for the Management of Lymphogranuloma Venerum (2013) https://www.bashh.org/documents/2013%20LGV%20guideline.pdf [accessed 4th August 2022]
4. 2019 European Guideline on the Management of Lymphogranuloma Venereum
   https://onlinelibrary.wiley.com/doi/full/10.1111/jdv.15729 [accessed 4th August 2022]
5. UK National Guidelines for the Management of Pelvic Inflammatory Disease 2018
   https://www.bashhguidelines.org/media/1170/pid-2018.pdf [accessed 4th August 2022]
6. United Kingdom National Guideline for the Management of Pelvic Inflammatory Disease
   (2019 Interim Update) https://www.bashhguidelines.org/media/1217/pid-update-2019.pdf[accessed 4th August 2022]
7. Scottish Bacterial Sexually Transmitted Infections Reference Laboratory (SBSTIRL)
   Samples and Request Forms | Edinburgh and Lothians Laboratory Medicine LGV PCR form Dec 20.pdf (edinburghlabmed.co.uk) [accessed 4th August 2022]
8. Dr Kate Templeton, Head of Service, Regional Virus Laboratory Specialist Virology
   Centre, Edinburgh [pers comm. 4th August 2022]