Chlamydial Genitourinary Infections Treatment & Management

Updated: Jul 14, 2017
  • Author: Shahab Qureshi, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
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Treatment

Approach Considerations

The keys to management of chlamydial infections are (1) arriving at the correct diagnosis and (2) ensuring that the patient complies with treatment.

Undiagnosed chlamydia can progress to pelvic inflammatory disease (PID), which may lead to relative or absolute infertility. This may be tragic if it occurs early in life before childbearing. Diagnostically evaluate all cases of suspected sexual abuse using chlamydial culture, not nonculture techniques.

Because of the personal nature and time-intensive diagnosis of sexually transmitted diseases (STDs), many physicians err by presuming that symptoms of an STI are caused by a urinary tract infection (UTI); therefore, patients often present with a history of multiple UTIs when, in fact, they may have had 1 or more STDs.

Adolescents are at high risk for noncompliance with treatment, especially if a patient is attempting to keep information away from parents. Single-dose, in-office treatment is increasingly being used to improve compliance and confidentiality. Partner treatment is crucial for prevention of reinfection.

Many clinicians err on the side of caution and hospitalize patients whenever PID is a concern or compliance with therapy is problematic. Consider PID an absolute indication for admission because of the potential for infertility and the poor compliance of many adolescents with prolonged treatment regimens.

Begin antibiotic therapy as soon as possible. Consider compliance, cost, and potential adverse effects. Consider treatment for possible gonorrhea coinfection. Send specimens from sites of infection to the lab for culture. Perform a pregnancy test; this can alter antibiotic treatment and patient follow-up care.

Consult obstetrics/gynecology for any patient with severe PID and any pregnant patient with chlamydial infection. Consult ophthalmology for patients with chlamydial conjunctivitis. Provide information and counseling to prevent future STDs, and consider referral for HIV testing. Encourage the patient to abstain from sexual intercourse until after treatment and testing of all partners is completed.

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Antibiotic Therapy

Two broad anatomical treatment categories of genital C trachomatis infection are recognized, as follows:

  • C trachomatis cervicitis/urethritis/epididymitis (D-K biovars): Lower genital tract or uncomplicated
  • C trachomatis salpingitis/endometritis (D-K biovars): Upper genital tract or complicated

Treatment of genitourinary chlamydial infection is clearly indicated when the infection is diagnosed or suspected. Chlamydiae are susceptible to antibiotics that interfere with DNA and protein synthesis, including tetracyclines, macrolides, and quinolones. [47] CDC recommends azithromycin and doxycycline as first-line drugs for the treatment of chlamydial infection. [33, 40] Medical treatment with these agents is 95% effective. Alternative agents include erythromycin, levofloxacin, and ofloxacin. [33] Rifalazil, a rifamycin that is highly active against C trachomatis and has a long half-life, has shown promise as a single-dose treatment for chlamydial nongonococcal urethritis and is currently being evaluated in women with uncomplicated genital infection. [48]

For many years, standard therapy for uncomplicated genital tract infection has been doxycycline 100 mg orally twice daily for 7 days. However, azithromycin given as a single 1-g dose is as effective as a 7-day course of doxycycline. [49, 50] The FDA released a warning on March 12, 2013, that azithromycin can cause potentially life-threatening arrhythmias. Patients with known QT-interval abnormalities or who take drugs to treat arrhythmias should receive doxycycline instead. Test of cure after treatment is unnecessary, but retesting is recommended at 3 months after therapy because of the high risk of reinfection in women and men. [40]

Azithromycin has also been shown to be effective in the treatment of nongonococcal urethritis, whether related to C trachomatis, genital mycoplasmas, or other organisms. [51] Ofloxacin 300 mg twice daily for 7 days and levofloxacin 500 mg once daily for 7 days are included as alternative agents in the 2015 CDC treatment guidelines [33] Azithromycin is now available as a generic drug, and its cost in the authors’ STD clinic (Indianapolis, IN) of about 60 cents per 1-g does is comparable to a 7-day course of doxycycline. A once-daily preparation of doxycycline (WC2031) was shown to be noninferior to the standard twice-daily regimen in both men and women and has been FDA approved for treatment of uncomplicated chlamydial genital infection in men and women. [52]

Lower genital infections caused by Chlamydia can be treated with single-dose, directly observed treatment. This practice is encouraged when possible to reduce noncompliance due to cost, confidentiality issues, motivational issues, and maturity issues.

Upper genital tract disease must be vigorously sought out because potential complications are serious, especially in adolescents. With the advent of newer, more sensitive DNA and antigen detection kits that use urine specimens instead of a pelvic examination, the potential to presume a chlamydial infection in uncomplicated lower tract disease is concerning.

Inadequately treated PID can lead to sepsis, infertility, and chronic pelvic pain. Many practitioners strongly advise admission for inpatient therapy and monitoring of response whenever PID is suspected because of a tendency of adolescents to minimize or ignore symptoms and eschew follow-up.

The management of PID, even when gonorrhea is present, should always include therapy directed against C trachomatis, as well as N gonorrhoeae and anaerobic bacteria. Randomized trials have shown that parenteral and oral regimens have similar clinical efficacy for mild to moderate PID, although doxycycline is given orally if possible because intravenous infusion is painful. [40]

With inpatient regimens for PID, evidence of significant clinical improvement and confidence in completion of medical therapy must be present before the patient is discharged. Recommended parenteral regimens include cefoxitin or cefotetan along with a 14-day course of doxycycline or, alternatively, clindamycin plus gentamicin or ampicillin-sulbactam plus doxycycline. [40]

Outpatient regimens for PID include initial single-dose intramuscular therapy with a second- or third-generation cephalosporin plus 14 days of doxycycline, with or without metronidazole 500 mg twice daily for 14 days. Because of the emergence of quinolone-resistant N gonorrhoeae, regimens that include a quinolone are no longer recommended for PID treatment.

Chlamydial conjunctivitis and pneumonia are usually treated for a total of 14 days.

Treatment also is indicated for sexual partners of the index case if the time of the last sexual encounter was within 60 days of onset, and it should be considered for longer periods for the last sexual partner. Treatment of chlamydial infection is indicated for patients being treated for gonorrhea, as well.

In June 2015, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics remain not recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC’s Gonococcal Isolate Surveillance Project (GISP), which showed that the percentage of fluoroquinolone-resistant gonorrhea cases in heterosexual men 6.7% in 2007, an 11-fold increase from 0.6% in 2001. [53, 40]

Pregnancy treatment considerations

Guidelines from the CDC recommend azithromycin 1 g orally as a single dose. Alternatives include amoxicillin 500 mg orally three times a day for 7 days as the preferred drug regimens for treating chlamydial infections in pregnancy, [54, 55] with erythromycin as another alternative. [40, 56, 57] Doxycycline, ofloxacin, and levofloxacin are contraindicated in pregnancy. Clindamycin is only partially effective in eradicating C trachomatis in men with nongonococcal urethritis, but it appears to be as efficacious as erythromycin in pregnant and nonpregnant women with C trachomatis infection. [58, 59, 60] Test-of-cure to document chlamydial eradication (preferably via NAAT) 3-4 weeks after therapy completion is recommended.

Posttherapy care

Follow-up culture is not recommended after azithromycin or doxycycline therapy, but it may be considered in pregnancy after erythromycin or amoxicillin therapy. Nonculture tests should be avoided in this circumstance to avoid positive results from nonviable organisms.

Patients should abstain from sexual intercourse for 7 days after single-dose therapy or until the end of a longer regimen. Patients also should refrain from sexual intercourse until all of their sex partners have been cured.

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Prevention

Individuals who are sexually active should be aware of the risks posed not only of genitourinary chlamydia infection but also by the whole gamut of STDs. Patients should be tested for other STDs or referred for other STD testing as appropriate. All sexual contacts should also be referred for testing and, if necessary, treatment.

In addition, patients should be aware that the most effective way of avoiding infection, other than abstaining from sexual activity, is to practice safe sex. This means using appropriate barrier protection (ie, latex condoms) with each sexual encounter.

The American College of Obstetricians and Gynecologists (ACOG) has released guidelines on expedited partner therapy for chlamydial and gonorrheal sexually transmitted diseases (STDs). [61, 62] While designed to prevent reinfection with chlamydia and gonorrhea, the recommendations can also be applied to other STDs. The ACOG recommendations include the following:

  • Expedited partner therapy to prevent reinfection, with legalization of expedited partner therapy
  • Counsel partners to undergo screening for HIV infection and other STDs
  • Expedited partner therapy contraindicated in cases of suspected abuse or compromised patient safety; pretreatment evaluation for abuse potential recommended
  • Expedited partner therapy medications and protocols based on CDC, state, and/or local guidelines
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Long-Term Monitoring

Patients with PID should be rechecked in 1-2 days to look for signs of clinical improvement. All patients treated for chlamydial infection should receive follow-up care with a primary care provider to reduce the risk of further infection and to screen for cervical cancer.

Test for chlamydial cure is not strictly necessary unless the patient thinks he or she may have been reinfected. However, follow-up at 3-4 weeks to repeat the examination and test for cure is advised because recurrent or persistent cases can lead to infertility. Retesting before 3-4 weeks may lead to a false-positive result on nonculture tests as a result of the shedding of dead organisms.

Perform partner testing and treatment to prevent reinfection.

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