Chlamydia trachomatis

The majority of women with Chlamydia infection are without symptoms. Many men are asymptomatic as well. Regular screening for Chlamydia, as recommended by the USPSTF, can significantly reduce the incidence of pelvic inflammatory disease (PID), one of the most serious sequelae of untreated infection. In women with untreated Chlamydia infection, in addition to PID, tubo-ovarian abscess, tubal scarring and ectopic pregnancy, and infertility can all result.

As previously mentioned, regular screening is currently recommended for all sexually active women under age 24, all pregnant women under 24, and at-risk pregnant and nonpregnant women over 24. Chlamydia testing can be performed on several liquid-based Papanicolaou (Pap) tests.

Donovan Bodies

Figure 16-5 Biopsy of granuloma inguinale lesion revealing "Donovan bodies" consistent with Klebsiella granulomatis.

(From Mandell GL, Bennett JE, Dolin R (eds). Mandell, Douglas, and Bennett's Principles and Practices of Infectious Diseases, 7th ed. Philadelphia, Churchill Livingstone, 2010.)

Figure 16-5 Biopsy of granuloma inguinale lesion revealing "Donovan bodies" consistent with Klebsiella granulomatis.

(From Mandell GL, Bennett JE, Dolin R (eds). Mandell, Douglas, and Bennett's Principles and Practices of Infectious Diseases, 7th ed. Philadelphia, Churchill Livingstone, 2010.)

Table 16-10 Treatment of Chancroid, Lymphogranuloma Venereum, and Granuloma Inguinale

Infection

Recommended Treatment

Alternate Treatment

Chancroid

Azithromycin, 1 g PO x 1 or

Ceftriaxone, 250 mg IM single dose or Ciprofloxacin, 500 mg bid for 3 days or Erythromycin base, 500 mg tid for 7 days

Lymphogranuloma venereum

Doxycycline, 100 mg bid for 21 days

Erythromycin base, 500 mg PO four times daily for 21 days

Granuloma inguinale

Doxycycline, 100 mg bid for at least 3 weeks until all lesions have completely healed

Azithromycin, 1 g PO once weekly for 3 weeks until all lesions have completely healed or

Ciprofloxacin, 750 mg PO four times daily for at least 3 weeks until all lesions have completely healed or

Erythromycin base, 500 mg four times daily for at least 3 weeks until all lesions have completely healed or

TMP/SMX, 1 DS bid for at least 3 weeks or until all lesions have completely healed

PO, Orally; IM, intramuscularly; bid, twice daily; tid, three times daily; qid, four times daily; TMP-SMX, trimethoprim-sulfamethoxazole; DS, double-strength tablet.

Endocervical swabs for nucleic acid amplification are acceptable when a conventional Pap smear is being used. Given the recent liberalization of recommendations about Pap testing for women under 21 years of age, urine nucleic acid amplification is a readily available alternative for Chlamydia testing. This can easily be done at a contraceptive counseling clinic. Urine testing is also an acceptable method of testing for men, in addition to a urethral swab. Rectal Chlamydia infection can occur in individuals who practice receptive anal intercourse. An FDA-approved method of testing should be used for screening and diagnosis of this infection.

Asymptomatic Chlamydia infection is treated with either a single dose of azithromycin, 1 g orally, the drug of choice, or doxycycline, 100 mg twice daily, for 7 days (Table 16-11). Patient-delivered partner therapy (PDPT), the practice of dispensing treatment to diagnosed patients to treat their partner(s), has proved effective in reducing reinfection rates and further spread of infection. EPT is legally allowable in 21 states and potentially allowable in another 21.

Chlamydia infection may present symptomatically in men or women with symptoms of dysuria and with discharge and with pelvic pain and dyspareunia in women. The discharge of C. trachomatis, versus that of Neisseria gonorrhoeae, is said to be more mucoid than purulent, although this characteristic

Table 16-11 Treatment of Urethritis and Cervicitis

Infection

Recommended Treatment

Alternate Treatment

Chlamydia trachomatis

Azithromycin, 1 g PO x 1 or Doxycycline, 100 mg bid for 7 days

Erythromycin base, 500 mg PO four times daily for 7 days or

Ofloxacin, 300 mg PO bid for 7 days or Levofloxacin, 500 mg PO once daily for 7 days

Neisseria gonorrhoeae: urethral, cervical, or rectal

Ceftriaxone, 125 mg IM x 1 Treat for C. trachomatis concurrently if this has not been ruled out.

Cefixime, 400 mg PO single dose

Neisseria gonorrhoeae:

pharynx

Ceftriaxone, 125 mg IM x 1 or

Treat for C. trachomatis concurrently if this has not been ruled out.

Nongonococcal urethritis

Azithromycin, 1 g PO single dose or

Doxycycline, 100 mg PO bid for 7 days

Erythromycin base, 500 mg PO qid for 7 days or

Ofloxacin, 300 mg PO bid for 7 days or Levofloxacin, 500 mg PO daily for 7 days

Trichomonas vaginalis

Metronidazole, 1 g PO x 1 or Tinidazole, 2 g PO x 1

Modified from Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines, 2010. MMWR 2010;59(No. RR-12).

is not specific enough to provide diagnostic accuracy. Symptomatic Chlamydia, without evidence of PID, is treated the same as asymptomatic infection. Many practitioners will treat presumptively for Chlamydia and gonorrhea in patients who present with the symptoms previously mentioned while they wait for confirmatory testing.

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