Guideline 42: Summary of recommendations

Management of Genital Chlamydia trachomatis Infection
Summary of recommendations

Testing for genital Chlamydia trachomatis infection

It is important that the reason for, implications of, and results of any test carried out are explained to the individual being tested.

The recommended laboratory test is a nucleic acid amplification test (e.g. LCR or PCR).

PATIENTS WITH SYMPTOMS/SIGNS OF CHLAMYDIAL INFECTION

Testing for Chlamydia trachomatis infection should be performed in women and men with symptoms and signs which may be attributable to chlamydial infection:

Women
- vaginal discharge
- post coital/intermenstrual/breakthrough bleeding
- inflamed/friable cervix (which may bleed on contact)
- urethritis
- pelvic inflammatory disease
- lower abdominal pain in the sexually active
- reactive arthritis in the sexually active.
Men
- urethral discharge
- dysuria
- urethritis
- epididymo-orchitis in the sexually active
- reactive arthritis in the sexually active.

ASYMPTOMATIC PATIENTS

Testing for genital Chlamydia trachomatis infection should be performed in the following specific circumstances:

all women undergoing termination of pregnancy

all patients attending genitourinary medicine clinics
all patients with another sexually transmitted infection, including genital warts
sexual partners of those with chlamydial infection
mothers of infants with chlamydial conjunctivitis or pneumonitis
all women undergoing uterine instrumentation, including IUD insertion, who have risk factors for chlamydial infection.
semen and egg donors.

sexual partners of those with suspected chlamydial infection

Opportunistic testing could be considered in the following groups of women:

women younger than 25 years and sexually active
women aged 25 years or older with two or more partners in the last year or a change of sexual partner in the last year.

Antimicrobial treatment for genital chlamydial infection

Initiate treatment without waiting for laboratory confirmation of infection in patients with symptoms and signs attributable to chlamydial infection and their sexual partners.

UNCOMPLICATED INFECTION

Uncomplicated genital Chlamydia trachomatis infection may be treated with any one of the following (listed alphabetically):

azithromycin 1g stat
doxycycline 100 mg twice daily for 7 days
lymecycline 300 mg once a day for 10 days
minocycline 100 mg once a day for 9 days
ofloxacin 200 mg twice daily for 7 days.

Taking into account the issue of compliance with therapy, it is recommended that uncomplicated genital Chlamydia trachomatis infection is treated with azithromycin 1g stat.

UNCOMPLICATED INFECTION IN PREGNANCY

In pregnancy, uncomplicated genital chlamydial infection should be treated with:

erythromycin 500mg four times a day for 7 days
or
amoxycillin 500mg three times a day for 7 days.

All women undergoing termination of pregnancy should receive antimicrobial therapy effective against chlamydial infection at the time of the procedure.

UPPER GENITAL TRACT INFECTION IN WOMEN (CHLAMYDIAL SALPINGITIS / PID)

The recommended treatment for upper genital tract infection in women is:

doxycycline 100 mg twice daily for a minimum of 10 days plus metronidazole 200mg three times a day or 400 mg twice daily for the first 7 days
ofloxacin 400 mg twice daily may be used as an alternative to doxycycline
clindamycin 450 mg four times a day may be used as an alternative to metronidazole.

UPPER GENITAL TRACT INFECTION IN MEN (CHLAMYDIAL EPIDIDYMO-ORCHITIS)

The recommended treatment for upper genital tract chlamydial infection in men is:

doxycycline 100 mg twice daily for 7 to 14 days
or
oxytetracycline 250mg four times a day for 7 to 14 days

Follow up and test of cure

Follow up should be offered approximately two to three weeks after initiating therapy.

Patients should be interviewed at follow up with regard to compliance with therapy and risk of re-infection.

In those patients who have been compliant with therapy and in whom there is no risk of reinfection, a test of cure need not be performed.

Some patients, especially those who had asymptomatic chlamydial infection, may prefer the reassurance of test of cure.

Test of cure/re-infection established by molecular amplification assay should be performed a minimum of three weeks after the initiation of therapy, to avoid false positive results.

When women have been treated with amoxycillin in pregnancy, practitioners should maintain a high index of suspicion should symptoms suggestive of chlamydial infection develop in the infant.

Partner notification

Patients should be referred to trained health advisers for support with partner notification.

Patients should be offered the choice of patient, provider, or conditional referral for partner notification:

Patient referral: index patients themselves inform their sexual contacts to seek treatment.
Provider referral: the health care provider informs a patient's contacts anonymously that they should seek treatment.
Conditional referral: the health care provider notifies contacts if the patient has not done so after a given number of days.

In men with symptomatic chlamydial infection, contact all partners over the four weeks prior to onset of symptoms.

In women and asymptomatic men, contact all partners over the last six months or the most recent sexual partner (if outwith that time period).

Health education

Sexual health promotion should be an integral part of contraception provision wherever this is offered.

All patients with chlamydial infection should receive appropriate health education, including relevant reading materials.

Opportunities should be taken to deliver education in a wide variety of non-health care settings. Education about chlamydial infection should be integrated with other sexual health education and condom promotion initiatives.

Management of Genital Chlamydia trachomatis Infection Summary of recommendations

Management of Genital Chlamydia trachomatis Infection
Summary of recommendations