chlamydia%20-%20uncomplicated%20anogenital%20infection
CHLAMYDIA - UNCOMPLICATED ANOGENITAL INFECTION

Chlamydia is a gram negative obligate intracellular bacteria that causes sexually-transmitted infection.

Chlamydia trachomatis is the primary cause of pelvic inflammatory disease (PID) in women which may lead to ectopic pregnancy, infertility, or chronic pelvic pain.
Most infected females are asymptomatic.
But some females may experience vaginal discharge, dysuria, lower abdominal pain, abnormal vaginal bleeding (postcoital or intermenstrual) or breakthrough bleeding, dyspareunia, conjunctivitis, proctitis and reactive arthritis.

Principles of Therapy

  • Syndromic management approach may be used in health care facilities where equipment and trained personnel for determining STI etiology are not available
  • Syndromic management is based on consistent groups of symptoms and easily recognized signs, and treatment will cover the most common or serious organisms involved in causing the syndrome
    • Using syndromic management in cases of vaginal discharge is limited especially if cervical infections are the cause (gonococcal or Chlamydia)

Clinical Observations Associated with Cervical Infections

  • Cervical mucopus
  • Cervical ectropion
  • Cervical friability
  • Bleeding between menses or during sexual intercourse

Evaluation and Treatment of Sex Partners

  • Sex partners of STI patients are likely to be infected and should be offered treatment to prevent further STI transmission and reinfection
  • Sex partners of STI patients may be asymptomatic; thus the importance of partner notification and management
  • 60-75% co-infection has been noted in sexual partners of Chlamydia-positive patients
    • All sex partners of patient during the 60 days preceding the onset of symptoms (or the most recent sex partner if the sexual exposure is >60 days) should be evaluated, tested and treated
    • Screening and treatment for Chlamydia infection is advised for all sex partners of asymptomatic patient in the last 90 days (or the most recent sex partner if the sexual exposure is >90 days) 
  • Sex partners of patients positive for Chlamydia should also receive the standard Chlamydia regimen (ie Azithromycin 1 g orally or Doxycycline 100 mg 12 hourly x 7 days)
  • Patients and their sex partners should be instructed to abstain from sexual intercourse until they and their partners have completed the treatment
    • Continue abstinence x 7 days after a single-dose regimen or until the completion of a 7-day regimen or 3 weeks if the patient was given Erythromycin
  • Patient-delivered Therapy
    • In situations where the sex partner of the female patient with Chlamydia will not seek treatment, the patient may be the one to deliver therapy to their partners in the form of medication or prescription
    • A trend towards a decrease in recurrent or persistent Chlamydia infection with partner-delivered therapy compared to a standard partner referral has been seen in some studies
    • The approach may not be permitted in some settings

Pharmacotherapy

Syndromic Management

In areas where resources allow for lab tests to screen women

  • Empiric therapy should be considered when:
    • Prevalence of C trachomatis is high in the patient population and the patient is unlikely to return for treatment

In areas where lab tests to screen women are not available

  • The justification for empiric treatment becomes stronger as the prevalence of chlamydial infections in the patient population becomes higher
    • Patients with positive risk assessment and vaginal discharge should be offered treatment for chlamydial cervicitis

General Antibiotic Principles for C trachomatis Infections

  • For improved compliance, single-agent treatment for C trachomatis is recommended
  • In patients presenting with buboes, the decision to treat for LGV, granuloma inguinale and chancroid depends on the local prevalence of these diseases

Preferred Agents

  • Azithromycin and Doxycycline are equally successful in treating genital Chlamydia infection with cure rates of 97% and 98% respectively

Azithromycin

  • Recommended agent for anogenital chlamydial infection
  • Preferred treatment if noncompliance is suspected since it is given as a single dose
  • Recommended agent for pregnant patients with genital Chlamydia infection

Doxycycline

  • Recommended agent for both anogenital infection and LGV
  • Preferred 1st-line treatment for non-pregnant LGV-positive patients
  • Long history of extensive successful use in the treatment of C trachomatis, but must be given x 7 days
  • Patients allergic to Doxycycline may be given Azithromycin or Erythromycin

Alternative Agents

Penicillins

  • Amoxicillin
    • Alternative agent for anogenital infection
    • Recommended alternative agent for pregnant women
    • May cause latency and re-emergence of infection rather than eradication as shown by in vitro studies

Macrolide

  • Erythromycin
    • Alternative agent for anogenital infection and LGV
    • Less efficacious than Azithromycin or Doxycycline primarily due to GI side effects that lessen patient’s compliance
    • Alternative regimen for pregnant women except for the estolate salt which may cause drug-related hepatotoxicity

Quinolones

  • Levofloxacin
    • Effective alternative treatment for anogenital infection
  • Ofloxacin
    • Alternative agent for anogenital infection with similar efficacy to Azithromycin and Doxycycline

Tetracyclines

  • Alternative agents for uncomplicated genital chlamydia infection
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