Chlamydial infection

Chlamydia infection in Men

At least 85% of men with urethral chlamydia infection are symptomless. The others have the symptoms or urethritis (see section on Urethritis in Men). Symptomatic men usually develop signs of infection within seven to 28 days of intercourse with an infected partner. Rectal infection with the oculogenital genotypes of C. trachomatis is usually symptomless; infection with lymphogranuloma venereum (LGV) genotypes is almost always associated with severe anorectal symptoms including discharge, bleeding and tenesmus (Section 12).
In MSM with severe anorectal symptoms, request LGV typing on the laboratory form. The sample sent for chlamydia testing is sufficient – no additional sample required.

Diagnosis: A positive chlamydia NAAT results from a urine, urethral or rectal sample

Chlamydia infection in Women

Uncomplicated chlamydial infection is symptomless in about 80% of women, the others may have symptoms:

• Increased vaginal discharge (resulting from cervicitis).
• Post-coital bleeding
• Intermenstrual/breakthrough bleeding
• Deep dyspareunia.
• Lower abdominal or pelvic pain.
• Rectal symptoms as in MSM. LGV infection is almost unheard of in women.

Diagnosis: A positive chlamydia NAAT result from a vulvovaginal, cervical, urethral or rectal sample. The genital sample of choice in women is a vulvovaginal swab. See Chapter 1 for routine samples.

In Both Men and Women

1. Conjunctivitis resulting from auto-inoculation of infected genital secretions may occur. The diagnosis is made by gently scraping the lower fornices of the conjunctival sac and sending for Chlamydia NAAT (request Chlamydia: Eye on NaSH).
2. Reactive arthritis. Ask for senior GUM review.

Testing for chlamydia is now performed as a dual NAAT test for both Chlamydia trachomatis and Neisseria gonorrhoea. Tests for chlamydia should routinely be done as part of an STI screen including syphilis and HIV serology. See Section 1.

Men who have sex with women:

All men:

• First voided specimen of urine for detection of Chlamydia trachomatis and Neisseria gonorrhoea

Men with signs of discharge or urethral inflammation:

• Urethral smear for Gram-smear microscopy if urethral discharge noted.

Men who have sex with men (MSM)

All MSM:

• Pharyngeal sample for dual NAAT testing for N.gonorrhoea and C.trachomatis.
  Note: Pharyngeal testing for C.trachomatis is of unproven benefit. It is not possible to suppress the chlamydia result on the dual NAAT in use in our laboratory, so NAAT testing for N.gonorrhoea inevitably involves testing for chlamydia too. There is no indication for routinely testing for pharyngeal chlamydial infection.
• First voided specimen of urine for detection of Chlamydia trachomatis and Neisseria gonorrhoea.
• Rectal sample for dual NAAT testing for N.gonorrhoea and C.trachomatis.

Men with signs of discharge or urethral inflammation:

• Urethral smear for Gram-smear microscopy if urethral discharge note
• Urethral culture Neisseria gonorrhoea (it is usually more efficient to take this sample at the same time, rather than repeating examination if the urethral slide is positive for GNID)

All women:

• Vulvovaginal swab for dual NAAT testing for N. gonorrhoea and C. trachomatis. This can be a self-taken swab
• A pharyngeal sample for dual NAAT testing for N. gonorrhoea and C. Trachomatis can be taken at patient request (this more usually relates to concerns about pharyngeal gonococcal infection). It is not necessary to routinely offer pharyngeal NAAT testing in MSW and women.

The majority of sexually transmitted infection (STI) guidelines have until recently recommended a 1g single dose of azithromycin (SDA) or 7 days of doxycycline as standard treatment for uncomplicated urogenital and oral chlamydia infection. Mycoplasma genitalium (MGen) is emerging as a significant sexually transmitted pathogen and coinfection rates of 3%-15% with chlamydia have been reported. Recent data demonstrate an increasing prevalence of macrolide resistance in MGen, likely due to the widespread use of SDA to treat STIs, and the limited availability of diagnostic tests for MGen. In addition, SDA has also been shown to be less effective than doxycycline for rectal CT in MSM, and a meta-analysis of rectal specimens in women showed significant rates of concomitant rectal infections in women with urogenital infection, with no association between reported anal intercourse and rectal infection. This has important implications for treatment, as undertreated rectal chlamydia infection may potentially contribute to re-infection rates. As a consequence of its potential to select for macrolide resistance in MGen and its inadequacy as a treatment for rectal CT, the British Association for Sexual Health
and HIV (BASHH) no longer recommends SDA for treatment of uncomplicated chlamydia infection at any site, regardless of the gender of the infected individual.

Treatment of uncomplicated urethral, vulvovaginal, cervical, rectal or pharyngeal infection
and
Contacts of Chlamydia infection:

1st line: **Doxycycline 100mg bd for 7 days
OR
Individuals who are allergic to, or have an intolerance of tetracyclines, or those who are pregnant or breast feeding, should be treated with an extended course of Azithromycin:

**Azithromycin – 1g as a single dose, followed by 500mg daily for 2 days

**Doxycline is contra-indicated in pregnancy

** Azithromycin not licensed for use in pregnancy. While adverse pregnancy outcomes are unlikely with a 2g dose, women should be advised of the lack of data. It is first choice for treatment in pregnancy.

• Partner notification should be discussed with all patients.
• It is not necessary to record PN outcomes for all patients. PN
  recording is required only for those in high risk groups.

High Risk Groups

Partner notification should be recorded on Partner Notification paperwork and documented on the Nash Clinical note that Partner notification has been carried out.

• MSM
• Patients under 16
• Vulnerable adults
• Pregnant women
• Commercial sex workers
• Patients with repeated infections
• Patients asking for a provider referral to be done
• Any patient a clinician feels needs more structured PN
• For symptomatic men in these groups, all partners within the preceding four weeks should be contacted.
• For symptomless men and in women in these groups, all partners within the preceding six months should be contacted, or, if the most recent sexual contact had been before that time, the last partner should be contacted.

Low Risk Groups

• For patients who do not fall within the high risk or complex group, PN should be discussed but it is not necessary to record each individual contact.
• For symptomatic men in these groups, all partners within the preceding four weeks should be contacted by the patient.
• For symptomless men and in women in these groups, all partners within the preceding six months should be contacted by the patient, or, if the most recent sexual contact had been before that time, the last partner should be contacted.

Give a Chlamydia leaflet. For each partner, the patient can choose either to inform the partner only, or provide them with a leaflet. Use the insert headings to discuss the main points about PN, which are:

• Breaking the chain of infection
• Timely treatment for regular partners to avoid re-infection
• Treating ex contacts/partners
• Provider referral and how it works
• How to contact the Nurse Specialists

Record in the clinical note “PN discussed. Leaflet given.”

Patient Information

• The infection is transmitted by sexual intercourse.
• Long term (months or years) symptomless infection may precede
  symptoms in men and women.
• Infection does not necessarily indicate infidelity by partner.
• Advise no sex until seven days after the start of treatment of index and regular partners of which antibiotic regime used.
• The potential for complications (PID in women, epididymitis in men, and reactive arthritis in both men and women).

Follow-Up

• Routine test of cure is NOT necessary.
• Test of cure should be offered to individuals with rectal infection treated with extended course of Azithromycin.
• Test of cure should be offered to pregnant women with chlamydial infection at any site.
• If required TOC should be carried out not less than 3 weeks after
  completion of treatment.

Contacts of Chlamydia

• If 14 days or over since last sexual contact with index patient, and
  asymptomatic then offer screening and await results
• If under 14 days then offer treatment
• If index is regular partner then offer treatment.