What is Chlamydia Trachomatis Infections?
Chlamydia is a sexually transmitted disease caused by the bacteria chlamydia trachomatis. It can also be transferred from mother to child during vaginal childbirth. It is common among sexually active adolescents and young adults. The incubation period can occur from 1 to 3 weeks post exposure.
Just like gonorrhoea, it can infect the transitional epithelium and columnar epithelium of the urethra, endocervix and extend its way up to the endometrium of uterus, endosalpinx (fallopian tubes) and the pelvic peritoneum.
Complications of Chlamydia Trachomatis
It is associated with an increased risk of ectopic pregnancy, pelvic inflammatory disease and tubal infertility in women. During pregnancy, it can increase the risk of still birth, chorioamnionitis, premature rupture of membrane, abortion and also preterm labor.
In males, it may cause male infertility, orostatitis, epididymal cysts and epididymitis. It can also cause reactive arthritis and conjunctivitis in both sexes. Infected neonates can lead to pneumonia and conjunctivitis.
Clinical Presentation of Chlamydia Trachomatis
In about 80% of women and 50% of men with Chlamydia, they may not have any symptoms.
In women, they may present with the following:
1.Acute bartholinitis (inflammation of the bartholin glands on the vagina)
2.Postcoital or intermenstrual bleeding
3.Cervical contact bleeding and mucopurulent cervicitis (inflammation of cervix with pus discharge).
4.Purulent vaginal discharge
5.Pelvic Inflammatory Disease (inflammation of the female genital tract above the cervix)
6.Urethritis the inflammation of urethra. May present with painful urination even in the absence of significant bacteria in urine.
7.Some may have some anal discharge or discomfort
8.If oral sex is involved, chlamydia may cause sore throat and inflammation of the pharynx
9.It can also cause proctitis (inflammation of the rectum) especially for those who involve anal sex.
Men may present with the following:
1.Discharge from the urethral
2.Painful urination also known as dysuria
3.Epididymitis which is the inflammation of the epididymis the tube that attaches to the upper part of each testicle.
4.It can also cause vague lower abdomen pain
5.Some may have some anal discharge or discomfort
6.If oral sex is involved, chlamydia may cause sore throat and inflammation of the pharynx
7.It can also cause proctitis (inflammation of the rectum) especially for those who involve anal sex
Lymphogranuloma Venereum (LGV)
LGV is caused by the Chlamydia serotypes L1-L3 and like chlamydia Trachomatis it is a sexually transmitted disease. Most patients do not have symptoms. However some may have small papules or herpes alike lesion which slowly turn into ulcer over at the genitalia area. It may also cause unilateral enlargement of lymph node which eventually will result in the formation of an abscess.
Who should be screened for Chlamydia Trachomatis?
1.Anyone diagnosed with Gonorrhoea should be screened for Chlamydia as they often co-exist.
2.Any patients with Lymphogranuloma Venereum, trachoma (chronic inflammatory disease of the eye) or inclusion conjunctivitis should also be screened for chlamydia.
3.All males who have gonorrhoea urethritis (inflammation of urethra), epididymitis (inflammation of the epididymis a tube that attaches to the upper part of each testicle) and non gonorrhoea cause of urethritis should be screened.
4.Patient diagnosed with Reiter Syndrome (a systemic rheumatic disease which causes arthritis, conjunctivitis and also inflammation of the urinary, genitalia and gastrointestinal systems) or proctitis (inflammation of the rectum) must be screened.
5.Female patients with mucopurulent cervicitis (inflammation of cervix), urethritis (inflammation of urethra), pelvic inflammatory disease, tubal infertility and proctitis (inflammation of the rectum) should be screened.
6.Pregnant women suspected to have chlamydia should be tested as it may cause complications in pregnancy.
7.Sexual contacts of chlamydia infected persons and high risk men/women who have multiple partners should also be screened.
8.Neonates who have conjunctivitis and pneumonias should also be tested.
Diagnosis of Chlamydia
For females, sampling can be taken from the cervical or vaginal swabs. As for the males, samples are taken from the urethral swabs. First Void Urine are as sensitive as urethral swabs samples in males but in females the cervical/vaginal swabs are still preferred means for testing. The tests available include:
1.NAAT nucleic acid-based amplification tests are very sensitive (90-95%) and specific. It is the gold standard for testing for chlamydia. Polymerase Chain Reaction (PCR) can be used to test a range of specimens from the cervix, vagina, urethra, rectum, pharynx and conjunctival.
2.Antigen Detection Methods: Direct Fluorescant Antibody (DFA) is a rapid specific and sensitive (50-90%) test. Enzyme immunoassay (EIA) has lower sensitivity (50-70%) but highly specific test (>95%). It is inexpensive and can be used on large number of specimens.
3.Cell culture for chlamydia: This used to be the gold standard but it is expensive. It is 100% specific but not so sensitive (70-80%). Culture takes time before results are back so it is no longer in use.
4.Serological tests: Blood specimens taken to test for chlamydia antibodies in acute infection are unpredictable. It is not useful to diagnose acute chlamydia as chlamydia species tend to cross react. High risk individuals also may already have antibodies present due to past infections.
5.Giemsa-stained direct smear: This is to look for inclusion bodies within infected cells. It is only useful for eye involvement of chlamydia.
Recommended treatment for uncomplicated cervical, urethral, pharyngeal and rectal infections in adults with chlamydia
Antibiotics like doxycycline 100 mg twice daily for 1 week or azithromycin 1 gram single dose will eradicated the chlamydia trachomatis bacteria.
Alternative antibiotics for patients who are allergic/unable to tolerate those above can try alternative antibiotics like tetracycline 500 mg 4 times daily for a week or ofloxacin 200 mg twice daily for 1 week or erythromycin 500 mg 4 times daily for one week.
Recommended treatment for pregnant women with chlamydia
Antibiotics like tetracyclines and ofloxacin are contraindicated in pregnancy because of possible adverse effects on the fetus. Treatment is usually commenced with azithromycin 1 gram one single dose or amoxicillin 500 mg thrice daily for 1 week or erythromycin 500 mg 4 times daily for a week.
Treament regime for patients with pelvic inflammatory disease and epididymo-orchitis
Treatment is commenced with antibiotics like doxycycline 100 mg twice daily for 2 weeks or ofloxacin 400mg twice daily for 14 days.
Treatment Regime for infants with pneumonia
Infants usually do not spike fever and rarely wheeze. They may have repetitive staccato cough. Chest x ray may reveal bilateral diffuse infiltrates. Specimens from the nasopharynx or tracheal aspirates should be tested for chlamydia. Mothers and their sex partners should also be screened and treated.
Infants can be treated with syrup erythromycin 50mg per kg per day in 4 divided doses for a period of 14 days.
Treatment regimens for neonates with chlamydia trachomatis conjunctivitis
Specimen should be taken from the everted eyelid and tested for chlamydia. Other possible causes of conjunctivitis in neonates are gonorrhoea conjunctivitis and gram negative conjunctivitis. Early treatment is necessary as chlamydia can also lead to pneumonia.
Mothers and their sex partners should also be screened and treated. Neonates can be treated with syrup erythromycin as in pneumonia case at a dose of 50 mg per kg per day in 4 divided doses for a period of 4 days.
Sex partners of males who have symptoms within the last 60 days should be traced and contacted for chlamydia screening and treatment if tested positive. The sex partners of females should be looked back to the last 3 months instead.
Follow up post treatment
Generally, a test of cure post treatment is not necessary except for the high risk groups which include infants, children and pregnant. This special group of patients should be tested 4 weeks after treatment. Anyone whose symptoms persist or suspected of reinfection should be tested again. Besides testing for chlamydia, high risk patients should also be tested for Syphilis and HIV. If negative they should be tested 3 months later due to the window period before seroconversion.