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Chlamydia clinical presentation and diagnosis

Infections caused by C. trachomatis are believed to be the most common STD in the United States that has more than doubled in the past 10 years.

Clinical presentation

  • In comparison with gonorrhea, chlamydial genital infections are more frequently asymptomatic, and when present, symptoms tend to be less noticeable. Table Presentation of Chlamydia Infections summarizes the usual clinical presentation of chlamydial infections.
  • Similar to gonorrhea, chlamydia may be transmitted to an infant during contact with infected cervicovaginal secretions. Nearly two thirds of infants acquire chlamydial infection after endocervical exposure, with the primary morbidity associated with seeding of the infant's eyes, nasopharynx, rectum, or vagina.

Chlamydia clinical presentation and diagnosis

Diagnosis

Chlamydia clinical presentation and diagnosis

  • Culture of endocervical or urethral epithelial cell scrapings is the most specific method for detection of chlamydia, but sensitivity is as low as 70%. Between 3 and 7 days are required for results.
  • Tests that allow rapid identification of chlamydial antigens in genital secretions are the direct fluorescent antibody test, the enzyme immunoassay (requires just 30 minutes for results), and the DNA hybridization probe.

Chlamydia clinical presentation and diagnosis

TABLE. Drug Therapy and Follow-up of Syphilis
 
Stage/Type of Syphilis Recommended Regimensa Follow-up Serology
Primary, secondary, or latent syphilis of less than 1-yr duration (early latent syphilis) Benzathine penicillin G 2.4 million units intramuscularly in a single doseb Quantitative nontreponemal tests at 6 and 12 months for primary and secondary syphilis; at 6, 12, and 24 months for early latent syphilisc
Latent syphilis of more than 1-yr duration (late latent syphilis) or syphilis of unknown duration Benzathine penicillin G 2.4 million units intramuscularly once a week for 3 successive weeks (7.2 million units total) Quantitative nontreponemal tests at 6, 12, and 24 monthsd
Neurosyphilis Aqueous crystalline penicillin G 18-24 million units intravenous (3-4 million units every 4 h or by continuous infusion) for 10-14 dayse or CSFf examination every 6 months until the cell count is normal; if it has not decreased at 6 months or is not normal by 2 yr, retreatment should be considered
Aqueous procaine penicillin G 2.4 million units intramuscularly daily plus probenecid 500 mg orally four times daily, both for 10-14 dayse
Congenital syphilis Aqueous crystalline penicillin G 50,000 units/kg intravenous every 12 h during the first 7 days of life and every 8 h thereafter for a total of 10 days or Quantitative nontreponemal tests every 2-3 months until nonreactive or titers have decreased 4-fold
Procaine penicillin G 50,000 units/kg intramuscularly daily for 10 days
Penicillin-allergic patientsg
Primary, secondary, or early latent syphilis Doxycycline 100 mg orally 2 times daily for 2 wkh,i or Same as for non-penicillin-allergic patients
Tetracycline 500 mg orally 4 times daily for 2 wkh,i
Latent syphilis of more than 1 year's duration (late latent syphilis) or syphilis of unknown duration Doxycycline 100 mg orally 2 times a day for 4 wki or Same as for non-penicillin-allergic patients
Tatracycline 500 mg orally 4 times daily for 4 wki
aRecommendations are those of the Centers for Disease Control. bSome experts recommend multiple doses of benzathine penicillin G or other supplemental antibiotics in addition to benzathine penicillin G in HIV-infected patients with primary or secondary syphilis; HIV-infected patients with early latent syphilis should be treated with the recommended regimen for latent syphilis of more than 1-yr duration. cMore frequent follow-up (i.e., 3, 6, 9, 12, and 24 months) recommended for HIV-infected patients. dMore frequent follow-up (i.e., 6, 12, 18, and 24 months) recommended for HIV-infected patients. eSome experts administer benzathine penicillin G 2.4 million units intramuscularly once per week for up to 3 weeks after completion of the neurosyphilis regimens to provide a total duration of therapy comparable to that used for late syphilis in the absence of neurosyphilis. fCSF, cerebrospinal fluid. gFor nonpregnant patients; pregnant patients should be treated with penicillin after desensitization. hAlthough less effective than either the doxycycline or tetracycline regimen, erythromycin 500 mg orally 4 times daily can be considered as an alternative regimen for nonpregnant patients. iPregnant patients allergic to penicillin should be desensitized and treated with penicillin.
TABLE. Presentation of Chlamydia Infections
  Males Females
General Incubation period – 35 days Incubation period – 7-35 days
Symptom onset – 7-21 days Usual symptom onset – 7-21 days
Site of infection Most common – urethra Most common – endocervical canal
Others – rectum (receptive anal intercourse), oropharynx, eye Others – urethra, rectum (usually due to perineal contamination), oropharynx, eye
Symptoms Over 50% of urethral and rectal infections are asymptomatic Over 66% of cervical infections are asymptomatic
Urethral infection – mild dysuria, discharge Urethral infection – usually subclinical; dysuria and frequency uncommon
Pharyngeal infection – asymptomatic to mild pharyngitis Rectal and pharyngeal infection – symptoms same as for men
Signs Scant to profuse, mucoid to purulent urethral or rectal discharge Abnormal vaginal discharge or uterine bleeding, purulent urethral, or rectal discharge can be scant to profuse
Rectal infection – pain, discharge, bleeding
Complications Epididymitis, Reiter's syndrome (rare) Pelvic inflammatory disease and associated complications (i.e., ectopic pregnancy, infertility)
Reiter's syndrome (rare)

Treatment

  • Single-dose azithromycin and 7-day doxycycline are the agents of choice.
  • For prophylaxis of ophthalmia neonatorum, various groups have proposed the use of erythromycin (0.5%) or tetracycline (1%) ophthalmic ointment in lieu of silver nitrate. Although silver nitrate and antibiotic ointments are effective against gonococcal ophthalmia neonatorum, silver nitrate is not effective for chlamydial disease and may cause a chemical conjunctivitis.
TABLE. Treatment of Chlamydial Infections
 
Infection Recommended Regimensa Alternative Regimen
Uncomplicated urethral, endocervical, or rectal infection in adults Azithromycin 1 g orally once, or doxycycline 100 mg orally 2 times daily for 7 days Ofloxacin 300 mg orally 2 times daily for 7 days, or levofloxacin 500 mg orally once daily for 7 days, or erythromycin base 500 mg orally 4 times daily for 7 days, or erythromycin ethyl succinate 800 mg orally 4 times daily for 7 days
Urogenital infections during pregnancy Erythromycin base 500 mg orally 4 times daily for 7 days, or amoxicillin 500 mg orally 3 times daily for 7 days Erythromycin base 250 mg orally 4 times daily for 14 days, or erythromycin ethyl succinate 800 mg orally 4 times daily for 7 days (or 400 mg orally 4 times daily for 14 days), or azithromycin 1 g orally as a single doseb
Conjunctivitis of the newborn or pneumonia in infants Erythromycin base 50 mg/kg/day orally in 4 divided doses for 14 daysc
aRecommendations are those of the Centers for Disease Control. bData are insufficient to recommend routine use of azithromycin in pregnant women at this time. cTopical therapy alone is inadequate and is unnecessary when systemic therapy is administered.
  • The only acceptable treatment for chlamydial ophthalmia neonatorum is systemic therapy with oral erythromycin, 50 mg/kg/day in four divided doses, for 10 to 14 days.

Evaluation of therapeutic outcomes

  • Treatment of chlamydial infections with the recommended regimens is highly effective; therefore, posttreatment cultures are not routinely recommended.
  • Infants with pneumonitis should receive follow-up testing, because erythromycin is only 80% effective.
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