Screening and Treatment
This section contains discussion and/or specific guidelines for
the following topics:
is commonly defined as testing in asymptomatic populations. Because of
the frequently asymptomatic nature of chlamydial infections, screening becomes
essential to controlling disease incidence and preventing potential
complications. Screening is also essential to documenting disease prevalence in
subpopulations so that cost effective control strategies can be implemented.
Chlamydia screening at family planning and prenatal care clinics is particularly
cost-effective because of the large number of sexually active young women who
undergo pelvic examinations.
Published studies have
identified certain risk factors associated with increased risk of infection.
These risk factors include the following:
Age less than 25 years
(mostly among females 15 to 19)
New sex partner during
past 60 days
Multiple sex partners
during past 60 days
Non-use or inconsistent
use of barrier forms of contraceptives
The Centers for Disease
Control and Prevention currently recommend that the following populations be
screened for chlamydia:
Women being seen by adolescent care providers
Women undergoing induced abortion
Women attending STD clinics
Women in detention facilities.
In Family Practice,
OB-GYN, Internal Medicine and Pediatric clinics, clients who meet the following
criteria should be screened:
Women with mucopurulent cervicitis
active women < 20 years of age
active women 20-24 with one of the criteria listed below and women > 24 years of age with both criteria:
All males with urethritis
and epididymitis regardless of etiology should be screened and treated for
chlamydia. All male contacts to women with proven chlamydia infection require
treatment. Also requiring treatment are those males whose female partners have
been treated presumptively for a chlamydia associated syndrome such as
mucopurulent cervicitis or PID. To the extent possible, Family Planning
programs should provide opportunities for screening, treatment and counseling to
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Cervical and urethral specimens
The sensitivity of all
types of chlamydia tests is dramatically influenced by the quantity and quality
of cells obtained on the specimen swab. The greater the number of cells
collected and the less vaginal secretion contamination, the more likely a
chlamydial infection will be detected. Careful and thorough specimen
collection will increase the accuracy of client test results. Correct specimen
collection is essential to obtain samples of these columnar cells from the
endocervix or the urethra. The lack of specimen adequacy remains a serious
problem in many screening programs, and periodic cytologic evaluation of
specimen quality is recommended to evaluate specimen collection technique. Some
studies looking at specimen adequacy have found as many as 30% of specimens to
be inadequate, in spite of extensive clinician training.
Urine specimens for DNA
Urine specimens for antigen
detection and DNA amplification tests should be collected as directed by the
test manufacturer. Subjects should not have urinated within the previous hour,
and females should be instructed NOT to clean the perineal area prior to
urinating. The first catch of 10 to 20 ml of urine should be collected
in a clean collection cup and refrigerated immediately at 2 to 8º C. Urines
should not be left at room temperature since
the low pH and high urea content rapidly denature DNA present in the specimen,
especially at 25º C and above.
Collection of Cervical Specimen
from the Female
If a Pap smear is to be done, generally it
should be done first. However, blood in the specimen may interfere with
chlamydia and gonorrhea testing; therefore, for women who are strongly
suspected of being infected, specimen order should be at the discretion of the
Clean contaminating vaginal secretions from
the face of the exocervix with a swab, then discard that swab.
Collect other culture specimens such as for
gonorrhea before collecting chlamydia specimen.
Always use sterile swab recommended by
Insert appropriate swab into endocervix until
most of tip is not visible.
Rotate swab with firm pressure against
the walls of the endocervix for at least 10 - 20 seconds (see package insert).
Place swab in transport tube or bottle
Break off shaft of swab (raise swab well off
the bottom of tube or bottle before snapping shaft).
Cap tube or bottle tightly.
of Urethral Specimen from the Male
Collect other specimens such as for gonorrhea
and/or gram stain first.
Insert a sterile swab recommended by
manufacturer into the urethra.
Insert the swab a minimum of 2.5 cm or 1 inch.
Rotate at least 2 complete revolutions for 2-3
problems with specimen collection or handling
Too much blood or mucus
on Gen-Probe swab.
Failure to adequately
Failure to obtain
columnar epithelial cells on the swab.
Touching vaginal surfaces
when withdrawing swab.
Use of any swab other
than those included with collection kit.
Collection of specimen
from an unapproved site (vaginal, female urethral, rectal, pharyngeal, etc.).
Inadequate collection of
specimen using urethral discharge from males -- swab must be inserted 2-4 cm
Urine specimen stored at
other than refrigerator temperature.
Delay in transporting
specimen to the laboratory or other improper handling of the transport tube,
i.e. failing to properly seal the tube.
surprisingly uneducated about STDs. In a
1993 national survey of 1,000 women ages 18 to 60, almost two-thirds knew very
little about STDs other than HIV/AIDS.
Be sure to ask clients
about their risk history. Don’t assume
that they will know to ask you.
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The 2002 CDC Guidelines
for Treatment of Sexually Transmitted Diseases provide public health
oriented, concise, cost effective, and evidence based guidelines which were
developed in consultation with a group of nationally recognized experts in the
STD field. The 2002 Guidelines contain a number of important revisions and new
recommendations which were not in the 1993 edition. A complete set of the
Treatment Guidelines are included with this manual and should be replaced as
revisions are made.
One of the significant changes from
1993 recommendations is the new emphasis on generally awaiting
the results of sensitive tests (culture, DNA tests such as the Gen-Probe, or DNA
amplification tests such as PCR or LCR tests) to determine the need for
treatment. The reason for this is the recognition that most clinical cervicitis
is not caused by either gonorrhea or chlamydia and that most female clients with
MPC (mucopurulent cervicitis) do not have gonorrhea or chlamydia. Rather than
treat large numbers of women unnecessarily and raise false concerns that they
have a sexually transmitted disease, it is felt to be better to await specific
The diagnosis of MPC is
made when a purulent or mucopurulent endocervical exudate is visible in the
endocervical canal or on an endocervical swab specimen (a "positive swab test"),
if bleeding is easily induced by obtaining a specimen (a friable cervix), or if
an ectropion appears to be inflamed and edematous. The Guidelines discourage the
use of a cervical Gram stain to count leukocytes since this test has not been
standardized and has a low-predictive value. It is important to emphasize that
although MPC may be caused by gonorrhea or chlamydia; in most cases neither
organism is identified.
The 1998 Guidelines do, however,
recommend empirical treatment of MPC when:
the prevalence of one or
both of these infections is very high in the client population and
the client is considered
unlikely to return for treatment (such as young teenagers, homeless or
transient people, or clients in an urban STD clinic). In these situations a
client would be treated presumptively for chlamydia and for gonorrhea.
Any client who is the
sexual contact of a partner with gonorrhea or chlamydia should be examined,
tested for both infections, and treated "epidemiologically" with antibiotics. If
the partner is known to have gonorrhea, treat the client for both gonorrhea and
chlamydia. If the partner has chlamydia, then treat only for chlamydia.
Whenever possible, clients
with clinical signs or symptoms of disease should be tested for C.
trachomatis infection even though presumptive treatment may be given.
Testing is recommended because a positive test can facilitate referral and
treatment of sexual partners. Additionally, testing can facilitate client
management for those clients who may not respond as expected to initiated
therapies. Clients presumed to have chlamydia may be treated prior to test
result using the following criteria:
Presumptive Diagnosis Treatment
Criteria for Females
and other high risk factor (see above).
Signs and symptoms of PID
History of recent sexual
partner with confirmed Ct or GC.
History of recent sexual
partner with urethritis.
The treatment options for
presumed or confirmed positive Chlamydia trachomatis infections are
Non-Pregnant Female or any Male
The best treatment of
chlamydia in pregnancy is not completely clear at this time. Doxycycline
and ofloxacin are contraindicated, and pregnant women
frequently experience nausea and vomiting when taking erythromycin. Both
amoxicillin and azithromycin are better tolerated and have similar cure rates as
erythromycin. Azithromycin offers the significant advantage of a single dose
treatment and is widely used for treating chlamydia in pregnancy. Although it
has not yet been approved by the FDA for use in pregnancy, it has been shown to
be both safe and effective and its use has become standard in many communities.
Every pregnant woman diagnosed with a chlamydia infection should have a repeat
test three weeks after completion of therapy regardless of which treatment
regimen is used.
PID Treatment Options
PID comprises a spectrum of
inflammatory disorders of the upper genital tract among women and may include
any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic
peritonitis. No single therapeutic regimen has been established for persons
with PID. Many experts recommend that all clients with PID be hospitalized so
that supervised treatment with parenteral antibiotics can be initiated. PID
therapy must provide empiric, broad-spectrum coverage of likely pathogens.
Antimicrobial coverage should include N. Gonorrhoeae and C. trachomatis,
gram-negative facultative bacteria, anaerobes, and streptococci. Refer to
Pelvic Inflammatory Disease section in the 2002 Treatment Guidelines for complete treatment recommendations.
Follow Up for All Treated Clients
Clients must receive
complete education regarding their medications. Table 2 summarizes adverse
reactions, contraindications, interactions, use in pregnancy and lactation, and
age restrictions for the antibiotics commonly used in treating chlamydial
Used for Treating Chlamydial Infections
Anaphylaxis, GI upset
Photosensitivity, GI upset, rash, anaphylaxis
GI (cramping, nausea, vomiting, and diarrhea),
GI upset, hematologic abnormalities, rash,
Allergy to any macrolide antibiotic
History of allergy to erythromycin, clients
taking astemizole (Hismanol) and cisapride (Propulcid)
H2 blockers and antacids may interfere with
Antacids interfere with absorption
Theophylline, Digoxin, ergotamine, astemizole (Hismanol),
cisapride (Propulcid), and other long acting antihistamines
Antacids may interfere with absorption. May
increase levels of: cyclosporin, Theophylline, Coumadin. Use with care with
Cimetidine and nonsteroidal anti-inflammatory drugs.
Pregnancy & Lactation
Category B considered safe in pregnant women if
Category D (Known teratogen. Do not use in
pregnant or lactating women.)
Category B (No restrictions)
Category C (Not recommended for use in pregnant
or lactating women.)
Not indicated in clients <8 years of age
Should not be used in clients <17 years of age
The 2002 Treatment Guidelines now recommend
that all women with chlamydial infections be rescreened 3 to 4 months after
treatment is completed.
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Partner Examination and Treatment
The Centers for Disease
Control and Prevention has set standards for the management of sex partners to
chlamydia. These are summarized in the 2002 Guidelines for Treatment of
Sexually Transmitted Diseases. The standards include:
Refer all sex partners within the last 60 days or most
Two methods of partner
notification are provider referral and client self-referral. Only where
there are staff available for conducting the referral process can provider
referral be accomplished. All chlamydia positive clients should be told to
have their partners evaluated and treated. Clinics are strongly encouraged
to establish systems whereby follow-up for partner treatment is tracked.
Not only should sex
partners of known chlamydia positive clients be referred, but any woman
diagnosed with PID should be told to refer her partner(s) for evaluation and
treatment. A woman whose sex partner(s) is not treated is at continued risk
for persistent infection.
Evaluate and treat all sex partners
No person with
chlamydia can be considered adequately treated until his/her sex partner(s)
is also treated. Prevention of re-infection is critical to reducing the
serious long term consequences of chlamydia, e.g., chronic pelvic pain, PID,
in the Region VI project must provide for partner evaluation and treatment
of chlamydia positive clients. If such evaluation and treatment is not
provided on site, the clinic must provide to the client and any partners a
list of locations where evaluation and treatment will be provided.
Examination of a male
partner of a chlamydia positive female is strongly encouraged. Other
asymptomatic STDs may be detected on clinical exam or lab work.
Instruct clients to abstain from sex until they and their
partners are cured
All parties should be
instructed to abstain from sex until all concerned have completed the full
course of medication and any symptoms have subsided. Clients and their
partners should also be counseled to complete the full course of medication,
regardless of whether they have symptoms. Inadequate treatment will result
in continuation of infection.
Partner Management and Public
Partner management of both
male and female clients is a cost-effective public health strategy for
preventing Ct and its sequelae. Re-infection can be prevented with effective
partner management, and PID can be prevented with early diagnosis and treatment
of female sex partners of infected men. The extent to which PID and other
sequelae can be prevented is dependent on promptly bringing in all partners
before client’s therapy has been completed.
A list of specific topics
to be discussed when talking to the index client about partners is found in
Section III. At a minimum, the following items need to be addressed:
Critical exposure periods and who should be considered an
“at risk” partner
- Importance of contacting all partners
- Meaning of laboratory tests and likelihood of infection
- Where partner(s) can seek care
- Consequences to partners’ partners if not treated
- Discussion of possible partner reactions
Suggestions of techniques of how to communicate with partner
Return for screening in 3 to 4 months following treatment completion
Although partner notification has been a component of
STD programs in the
United States for many years, too
many partners are not receiving timely treatment for chlamydial infections.
Infected clients must be instructed in the importance of assisting
partners to seek treatment and in the importance of avoiding sexual intercourse
until all parties have completed their medications.
One dose medication regimens can be problematic if clients are not
carefully instructed to abstain from sexual intercourse until all of their sex
partners are cured.
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Young age (< 25 ) is a
significant risk factor for Ct.
Careful and thorough
specimen collection will increase the accuracy of client test results. Correct
specimen collection is essential to obtain samples of these columnar cells from
the endocervix or the urethra.
Whenever possible, clients
should be tested for chlamydia even though presumptive treatment may be given.
The medications most
commonly used to treat chlamydial infections include azithromycin, doxycycline,
erythromycin, and ofloxacin.
Health care providers must
assume a pro-active role in instructing clients regarding partner referral and
A clinician staffs your clinic only once or twice a month. You are concerned
after viewing visible pus on the swab that he/she is not adhering to proper
What effect will this have on the results?
A 26-year old female presents to your clinic because she was recently treated
for chlamydia and wishes to make sure that she is cured.
Is Gen-Probe appropriate to use in this situation? Why or Why Not?
(Case Study answers found in Appendix)
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