Chlamydia trachomatis: Difference between revisions

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Chlamydia trachomatis
m (Text replacement - "Clinical Presentation" to "Clinical Manifestations")
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== Microbiology ==
 +
==Background==
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* Small, obligate intracellular [[Stain::Gram-negative]] [[Cellular shape::coccobacillus]]
  
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** Very difficult to Gram stain due to lack of peptidoglycan in cell wall
  
−
* Two forms exist:
  
−
** '''Elementary body (EB):''' spore-like form than can survive short times outside the body
  
−
** '''Reticulate body (RB):''' replicative form
  
−
* Virulence factors include lipopolysaccharide (LPS)
  
   
  +
===Microbiology===
−
== Clinical Manifestationss ==
  
  +
−
* Presentation varies by serovar
  
  +
*Small, obligate intracellular [[Stain::Gram-negative]] [[Shape::coccobacillus]]
  +
**Very difficult to Gram stain due to lack of peptidoglycan in cell wall
  +
*Two forms exist:
  +
**'''Elementary body (EB):''' spore-like form than can survive short times outside the body
  +
**'''Reticulate body (RB):''' replicative form
  +
*Virulence factors include lipopolysaccharide (LPS)
  +
  +
===Risk Factors===
  +
  +
*Sexual contact with chlamydia-infected person
  +
*New sexual partner, or more than two sexual partners in the past year
  +
*Previous STI
  +
*Specific populations: people who inject drugs, incarcerated people, sex trade workers, street-living youth
  +
  +
==Clinical Manifestations==
  +
  +
*Incubation period is [[Usual incubation period::2 to 3 weeks]] ([[Incubation period range::up to 6 weeks|Incubation period range::1 to 6 weeks]])
  +
*Many are asymptomatic
  +
*Presentation varies by serovar
   
 
{| class="wikitable"
  
{| class="wikitable"
−
! Serovars
 +
!Serovars
−
! Syndromes
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!Syndromes
 
|-
  
|-
−
| D to K
 +
|A to C
  +
|[[Trachoma]] (chronic conjunctivitis)
−
| [[Urethritis]], [[PID]], neonatal infection
  
 
|-
  
|-
−
| A to C
 +
|D to K
  +
|[[Urethritis]], [[PID]], neonatal infection
−
| [[Trachoma]] (chronic conjunctivitis)
  
 
|-
  
|-
−
| L1 to L3
 +
|L1 to L3
−
| [[Lymphogranuloma venereum]] (LGV)
 +
|[[Lymphogranuloma venereum]] (LGV)
 
|}
  
|}
   
  +
===Sexually-Transmitted Infection===
−
=== Urethritis ===
  
  +
−
* In men, most are symptomatic
  
  +
*In men, most are symptomatic
−
** Incubation or 7 to 21 days in men
  
  +
**Incubation period is 7 to 21 days in men
−
** Purulent urethritis
  
  +
**Purulent urethritis, urethral itch, dysuria, testicular pain
−
* In women, often asymptomatic
  
  +
**Conjunctivitis
  +
**Proctitis (often asymptomatic)
  +
**Sequelae include [[epididymo-orchitis]] and [[reactive arthritis]]
  +
*In women, often asymptomatic
  +
**Cervicitis, vaginal discharge, dysuria, lower abdominal pain, abnormal vaginal bleeding, dyspareunia
  +
**Conjunctivitis
  +
**Proctitis (often asymptomatic)
  +
**Sequelae include [[pelvic inflammatory disease]], [[ectopic pregnancy]], [[infertility]], [[chronic pelvic pain]], and [[reactive arthritis]]
  +
  +
===Lymphogranuloma Venereum===
  +
  +
*See [[Lymphogranuloma venereum#Clinical Presentation|lymphogranuloma venereum]]
  +
  +
===Fitz-Hugh-Curtis syndrome===
  +
  +
*Liver capsular inflammation, possibly autoimmune
  +
  +
===Pediatric Infections===
  +
  +
*Serovars associated with STIs can also cause:
  +
**[[Conjunctivitis]] in neonates
  +
**Pneumonia in children under 6 months of age
  +
  +
===Trachoma===
  +
  +
*Chronic [[keratoconjunctivitis]] caused by recurrent infection
  +
*Leading infectious cause of blindness worldwide
  +
*Spread via direct contact of ocular or nasal secretions and via fomites, and possibly via eye-seeking flies including [[Musca sorbens]]
  +
*Presents with two phases:
  +
**Active trachoma, with acute, mild, self-limited [[conjunctivitis]]
  +
***May be asymptomatic
  +
***Usually detected with screening
  +
**Cicatricial disease causing conjunctival scarring
  +
***Scar tissue distorts the eyelid margin, causing entropion (the eyelid turned inwards)
  +
***Entropion causes trichiasis, where the eyelashes rub against the eye and cause scarring
  +
***Eventually leads to blindness
  +
  +
==Diagnosis==
  +
  +
*Molecular testing
  +
**Urine NAAT is ~80% sensitive, and is preferred when there is no other indication for a pelvic examination
  +
**Self-collected vaginal swab likely has better sensitivity, though
  +
**MD-collected cervical swab best sensitivity (90+%)
  +
*Culture
  +
**For throat specimens
  +
**Done in cell culture
  +
*Serology
  +
**IgM antibodies can be helpful for diagnosting pneumonia in infants under 3 months of age
  +
**Not helpful for diagnosing genital infections
  +
  +
==Management==
  +
  +
=== Adults ===
  +
  +
* Non-pregnant, non-lactating adults with urethral, endocervical, rectal, or conjunctival infection
  +
  +
*First-line: [[Is treated by::doxycycline]] 100 mg PO bid for 7 days
  +
**Preferred, especially for rectal infection
  +
*Alternative if adherence likely to be poor: [[azithromycin]] 1 g PO once
  +
*Alternative: [[ofloxacin]] 300 mg PO bid for 7 days
  +
*Alternative: [[erythromycin]] 2 g/day PO in divided doses for 7 days
  +
*Alternative: [[erythromycin]] 1 g/day PO in divided doses for 14 days
  +
  +
=== Children ===
  +
*Consider child abuse when chlamydia is diagnosed in a prepubertal child
  +
**However, perinatal infection can persist for up to 3 years
  +
*≤7 days old
  +
**Infants ≤2 kg: [[erythromycin]] 20 mg/kg/day PO in divided doses for 14+ days
  +
**Infants >2 kg: [[erythromycin]] 30 mg/kg/day PO in divided doses for 14+ days
  +
*8 days to 1 month old: [[erythromycin]] 40 mg/kg/day PO in divided doses for 14+ days
  +
*1 month to 9 years: [[azithromycin]] 12-15 mg/kg (max 1 g) PO once
  +
**Alternative: [[erythromycin]] 40 mg/kg/day PO in divided doses (max 500 mg qid for 7 days or 250 mg qid for 14 days)
  +
**Alternative: [[sulfamethoxazole]] 75 mg/kg/day PO in divided doses (max 1 g bid) for 10 days
  +
*9-18 years: [[doxycycline]] 2.5 mg/kg (max 100 mg) PO bid for 7 days
  +
**Alternative, if adherence likely to be poor: [[azithromycin]] 12-15 mg/kg (max 1 g) PO once
  +
**Alternative: [[erythromycin]] 40 mg/kg/day PO in divided doses (max 500 mg qid for 7 days or 250 mg qid for 14 days)
  +
**Alternative: [[sulfamethoxazole]] 75 mg/kg/day PO in divided doses (max 1 g bid) for 10 days
  +
  +
=== Pregnant or Nursing Women ===
  +
  +
* Pregnant and nursing women with urethral, endocervical, and rectal infections
  +
  +
*[[Azithromycin]] is generally considered safe for this purpose, while [[doxycycline]] and [[fluoroquinolones]] are contraindicated
  +
*Options include any of:
  +
**Alternative: [[amoxicillin]] 500 mg PO tid for 7 days
  +
**Alternative: [[erythromycin]] 2 g/day PO in divided doses for 7 days
  +
**Alternative: [[erythromycin]] 1 g/day PO in divided doses for 14 days
  +
**Alternative if adherence is likely to be poor: [[azithromycin]] 1 g PO once
  +
*Ensure that exposed neonates are tested shortly after birth and treated if positive, with monitoring for development of conjunctivitis or pneumonia
  +
  +
=== Lymphogranuloma Venereum ===
  +
  +
* [[doxycycline]] 100 mg PO bid for 21 days (see [[Lymphogranuloma venereum#Management|LGV-specific page]] for details)
  +
  +
=== Trachoma ===
  +
*Usually addressed in mass drug administration projects using [[azithromycin]] or topical [[tetracycline]]
  +
*Often needs surgery to correct trichiasis
  +
  +
=== Treatment Failure ===
   
  +
* Reinfection (most common)
−
=== Fitz-Hugh-Curtis syndrome ===
  
  +
* Non-adherence
−
* Liver capsular inflammation, possibly autoimmune
  
  +
* Vomiting
  +
* True resistance, though it is rare and difficult to assess susceptibility
   
−
== Diagnosis ==
 +
==Prevention==
−
* Urine NAAT ~80% sensitive
  
−
* Self-collected vaginal swab better
  
−
* MD-collected cervical swab best (90+%)
  
−
* No more serology!
  
   
−
== Management ==
 +
===Trachoma===
−
* For serovars L1-L3 (LGV): treat for 21 days
  
−
* In pregnant women, [[Is treated by::azithromycin]] is best
  
   
  +
*Mass drug administration using [[azithromycin]] for communities with high prevalence
  +
*Facial cleanliness
  +
*Improved sanitation and hygiene
 
{{DISPLAYTITLE:''Chlamydia trachomatis''}}
  
{{DISPLAYTITLE:''Chlamydia trachomatis''}}
 
[[Category:Bacteria]]
  
[[Category:Bacteria]]

Latest revision as of 21:00, 21 December 2021

Background

Microbiology

  • Small, obligate intracellular Gram-negative coccobacillus
    • Very difficult to Gram stain due to lack of peptidoglycan in cell wall
  • Two forms exist:
    • Elementary body (EB): spore-like form than can survive short times outside the body
    • Reticulate body (RB): replicative form
  • Virulence factors include lipopolysaccharide (LPS)

Risk Factors

  • Sexual contact with chlamydia-infected person
  • New sexual partner, or more than two sexual partners in the past year
  • Previous STI
  • Specific populations: people who inject drugs, incarcerated people, sex trade workers, street-living youth

Clinical Manifestations

Serovars Syndromes
A to C Trachoma (chronic conjunctivitis)
D to K Urethritis, PID, neonatal infection
L1 to L3 Lymphogranuloma venereum (LGV)

Sexually-Transmitted Infection

Lymphogranuloma Venereum

Fitz-Hugh-Curtis syndrome

  • Liver capsular inflammation, possibly autoimmune

Pediatric Infections

  • Serovars associated with STIs can also cause:
    • Conjunctivitis in neonates
    • Pneumonia in children under 6 months of age

Trachoma

  • Chronic keratoconjunctivitis caused by recurrent infection
  • Leading infectious cause of blindness worldwide
  • Spread via direct contact of ocular or nasal secretions and via fomites, and possibly via eye-seeking flies including Musca sorbens
  • Presents with two phases:
    • Active trachoma, with acute, mild, self-limited conjunctivitis
      • May be asymptomatic
      • Usually detected with screening
    • Cicatricial disease causing conjunctival scarring
      • Scar tissue distorts the eyelid margin, causing entropion (the eyelid turned inwards)
      • Entropion causes trichiasis, where the eyelashes rub against the eye and cause scarring
      • Eventually leads to blindness

Diagnosis

  • Molecular testing
    • Urine NAAT is ~80% sensitive, and is preferred when there is no other indication for a pelvic examination
    • Self-collected vaginal swab likely has better sensitivity, though
    • MD-collected cervical swab best sensitivity (90+%)
  • Culture
    • For throat specimens
    • Done in cell culture
  • Serology
    • IgM antibodies can be helpful for diagnosting pneumonia in infants under 3 months of age
    • Not helpful for diagnosing genital infections

Management

Adults

  • Non-pregnant, non-lactating adults with urethral, endocervical, rectal, or conjunctival infection
  • First-line: doxycycline 100 mg PO bid for 7 days
    • Preferred, especially for rectal infection
  • Alternative if adherence likely to be poor: azithromycin 1 g PO once
  • Alternative: ofloxacin 300 mg PO bid for 7 days
  • Alternative: erythromycin 2 g/day PO in divided doses for 7 days
  • Alternative: erythromycin 1 g/day PO in divided doses for 14 days

Children

  • Consider child abuse when chlamydia is diagnosed in a prepubertal child
    • However, perinatal infection can persist for up to 3 years
  • ≤7 days old
    • Infants ≤2 kg: erythromycin 20 mg/kg/day PO in divided doses for 14+ days
    • Infants >2 kg: erythromycin 30 mg/kg/day PO in divided doses for 14+ days
  • 8 days to 1 month old: erythromycin 40 mg/kg/day PO in divided doses for 14+ days
  • 1 month to 9 years: azithromycin 12-15 mg/kg (max 1 g) PO once
    • Alternative: erythromycin 40 mg/kg/day PO in divided doses (max 500 mg qid for 7 days or 250 mg qid for 14 days)
    • Alternative: sulfamethoxazole 75 mg/kg/day PO in divided doses (max 1 g bid) for 10 days
  • 9-18 years: doxycycline 2.5 mg/kg (max 100 mg) PO bid for 7 days
    • Alternative, if adherence likely to be poor: azithromycin 12-15 mg/kg (max 1 g) PO once
    • Alternative: erythromycin 40 mg/kg/day PO in divided doses (max 500 mg qid for 7 days or 250 mg qid for 14 days)
    • Alternative: sulfamethoxazole 75 mg/kg/day PO in divided doses (max 1 g bid) for 10 days

Pregnant or Nursing Women

  • Pregnant and nursing women with urethral, endocervical, and rectal infections
  • Azithromycin is generally considered safe for this purpose, while doxycycline and fluoroquinolones are contraindicated
  • Options include any of:
    • Alternative: amoxicillin 500 mg PO tid for 7 days
    • Alternative: erythromycin 2 g/day PO in divided doses for 7 days
    • Alternative: erythromycin 1 g/day PO in divided doses for 14 days
    • Alternative if adherence is likely to be poor: azithromycin 1 g PO once
  • Ensure that exposed neonates are tested shortly after birth and treated if positive, with monitoring for development of conjunctivitis or pneumonia

Lymphogranuloma Venereum

Trachoma

  • Usually addressed in mass drug administration projects using azithromycin or topical tetracycline
  • Often needs surgery to correct trichiasis

Treatment Failure

  • Reinfection (most common)
  • Non-adherence
  • Vomiting
  • True resistance, though it is rare and difficult to assess susceptibility

Prevention

Trachoma

  • Mass drug administration using azithromycin for communities with high prevalence
  • Facial cleanliness
  • Improved sanitation and hygiene
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