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Chlamydia

This quick reference on chlamydia on A4Medicine starts with some basic information about this common sexually transmitted infection. Presentation and complications are discussed with a further explanation of risk to the newborn. Testing including NAAT test is discussed and options of treatment are displayed clearly. In case the GP wishes to treat this condition a brief description of the current prescribing guidance of antibiotics is presented.

Chlamydia trachomatis Humans are the natural host Serovars associated with endemic trachoma are A , B , Ba and C Serovars associated with STIs are D, E, F, G ,H , I ,J and K Lymphogranuloma venereum L1 , L2 and L3  Genital chlamydia most commonly reported bacterial STI worldwide Men → affects urethra ( non-gonococcal urethritis ) ocassionally epididymitis Women →urethritis , cervicitis and pelvic inflammatory disease ( PVD ) Can also infect conjunctiva , rectum and nasopharynx Transmission -direct inoculation of infected secretions from one mucous membrane to another Infection has not ascended the upper genital tract -Uncomplicated infection    Spread to upper genital tract- PID in women
Epididymo-orchitis in men-Complicated

Epidemiology-Most common in people aged 16-25 At least 70 % of infected ♀ and 50 % of infected ♂ remain asymptomatic 2/3 of sexual partners of chlamydia + ve individuals will also be Chlamydia +ve Risk factors
○ Age < 25
○ More than 1 partner in the last year or a recent new sexual partner
○ Lack of consistent use of condoms Untreated infections may persist for > 1 yr ( 50 % cases ) About 95 % will clear spontaneously after 4 yrs

Lymphogranuloma venereum-Caused by L1 , L2 and L3 serotypes Outbreaks in HIV + ve ♂ pts who have sex with men Most presents with proctitis Asymptomatic infection may occur

Symptoms- 
 ↑ ed Vaginal discharge Post coital ( PCB ) or intermenstural bleeding ( IMB ) Purulent vaginal discharge Mucopurulent cervical discharge Dysuria ( sterile pyuria – may be Chlamydia ) Lower abdominal / pelvic pain Cervica motion tenderness Deep dyspareunia Cervicitis

 Dysuria Mucoid or mucopurulent urethral disharge Urethral discomfort / urethritis Epididymo-orchitis Reactive arthritis

Complications-PELVIC INFLAMMATORY DISEASE
○ 10-40 % will develop PID if not treated
○ risk ↑ es with each recurrence
○ can cause tubal factor infertility , ectopic pregnancy ,chronic pelvic pain
 EPIDIDYMO-ORCHITIS
 ADULT CONJUNCTIVITIS ( if eye exposed to secretions )
○ within 1-2 weeks after exposure
 NEONATAL CONJUNCTIVITIS
 SEXUALLY ACQUIRED REACTIVE ARTHRITIS ( SARA )
○ men > women
○ polyarthritis of wt bearing joints
 PERIHEPATITIS ( Fitz-Hugh-Curtis syndrome )
○ inflammation of hepatic capsule – RUQ pain can be referred to rt shoulder 
○ usually in ♀ with PID
○ rare
 PREGNANCY 
○ ↑ risk premature rupture of membranes
○ ↑ risk pre-term delivery and LBW
○ ↑ risk intra-partum pyrexia and late post partum endometritis
○ ↑ risk post-abortal PID
 
 Refer all ♀ to
 GUM clinic if PID suspected  Rectal infection is usually asymptomatic but anal discharge and anorectal discomfort may happen

Risks to newborn-Eye disease caused by trachoma biovar is called inclusion conjunctivitis Newborn acquires the infection during passage through an infected birth canal Starts a mucopurulent conjunctivitis 7-12 days after delivery Responds to erythromycin or tetracycline treatment 

Respiratory
 10-20 % infants may develop respiratory tract involvment 2-12 weeks after birth Presents with striking tachypnoe , charecteristic paroxysmal cough , absence of fever and eosinophilia Suspect if pneumonitis develops in a newborn who has inclusion conjunctivitis

Testing-Nucleic acid amplification tests ( NAAT ) Endocervical or vulvovaginal swab First catch urine ( FCU ) Kits for self taken VVSs or FCU available FCU ( specimen of choice ) Urethral swab Rectal swabs if indicated by history/ symptoms ( men and women ) to test for LGV ( Lymphogranuloma venerum ) HIV-positive ♂ who have sex with other ♂ Pharyngeal swabs- not done routinely NAAT samples- good for testing even few days after collection

Test 
Positive-Treat patient yourself and attend to partner notification + 
check for other STIs -Gonorrhoe , HIV , Syphilis , Hepatitis B
OR Treat patient yourself and refer to GU clinic for partner notification / screening for other STIs
OR Refer all patients to GU clinic Doxycyline 100 mg bd/7D 
( CI in pregnancy ) Azithromycin 1g po stat single dose Erythromycin 500 mg bd for 10-14 days Ofloxacin 200 mf bd/7D or 400 mg od/7 days ( CI in children and growing adults ) Pregnant-Azithromycin 1g single dose or Erythromycin 500 mg qds/7D or Erythromycin 500 mg bd/14 D or Amoxicillin 500 mg tds/7D

If uncertainity seek specialist advise Avoid sexual intercourse
 ( including oral sex ) until the person + partner (s) have completed treatment or waited 7 days after Azithromycin     Urgently refer GUM clinic if there is no response to 1st line Rx

Test of cure-Not routinely recommened if standard 1st line Rx used Consider if anything other than 1st line used Do test
○ pregnant ( ↓ efficacy of antibiotics )
○ non compliance suspected
○ symptoms persist TOC ( swab or urine ) no earlier than 3 weeks after completion of treatment Offer- repeat testing to all people < 25 diagnosed with chlamydia 3-6 months after rx Offer repeat test > 25s who are at ↑ risk of reinfection

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