Chlamydia trachomatis: Difference between revisions
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Chlamydia trachomatis
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− | == |
+ | ==Background== |
+ | ===Microbiology=== |
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− | *Small, obligate intracellular [[Stain::Gram-negative]] [[Cellular shape::coccobacillus]] |
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+ | |||
+ | *Small, obligate intracellular [[Stain::Gram-negative]] [[Shape::coccobacillus]] |
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**Very difficult to Gram stain due to lack of peptidoglycan in cell wall |
**Very difficult to Gram stain due to lack of peptidoglycan in cell wall |
||
*Two forms exist: |
*Two forms exist: |
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Line 7: | Line 9: | ||
**'''Reticulate body (RB):''' replicative form |
**'''Reticulate body (RB):''' replicative form |
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*Virulence factors include lipopolysaccharide (LPS) |
*Virulence factors include lipopolysaccharide (LPS) |
||
+ | |||
+ | ===Risk Factors=== |
||
+ | |||
+ | *Sexual contact with chlamydia-infected person |
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+ | *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== |
==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]]) |
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+ | *Many are asymptomatic |
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*Presentation varies by serovar |
*Presentation varies by serovar |
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Line 15: | Line 26: | ||
!Serovars |
!Serovars |
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!Syndromes |
!Syndromes |
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− | |- |
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− | |D to K |
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− | |[[Urethritis]], [[PID]], neonatal infection |
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|- |
|- |
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|A to C |
|A to C |
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|[[Trachoma]] (chronic conjunctivitis) |
|[[Trachoma]] (chronic conjunctivitis) |
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+ | |- |
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+ | |D to K |
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+ | |[[Urethritis]], [[PID]], neonatal infection |
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|- |
|- |
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|L1 to L3 |
|L1 to L3 |
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|} |
|} |
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+ | ===Sexually-Transmitted Infection=== |
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− | ===Urethritis=== |
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*In men, most are symptomatic |
*In men, most are symptomatic |
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− | **Incubation |
+ | **Incubation period is 7 to 21 days in men |
− | **Purulent urethritis |
+ | **Purulent urethritis, urethral itch, dysuria, testicular pain |
+ | **Conjunctivitis |
||
+ | **Proctitis (often asymptomatic) |
||
+ | **Sequelae include [[epididymo-orchitis]] and [[reactive arthritis]] |
||
*In women, often asymptomatic |
*In women, often asymptomatic |
||
+ | **Cervicitis, vaginal discharge, dysuria, lower abdominal pain, abnormal vaginal bleeding, dyspareunia |
||
+ | **Conjunctivitis |
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+ | **Proctitis (often asymptomatic) |
||
+ | **Sequelae include [[pelvic inflammatory disease]], [[ectopic pregnancy]], [[infertility]], [[chronic pelvic pain]], and [[reactive arthritis]] |
||
+ | |||
+ | ===Lymphogranuloma Venereum=== |
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+ | |||
+ | *See [[Lymphogranuloma venereum#Clinical Presentation|lymphogranuloma venereum]] |
||
===Fitz-Hugh-Curtis syndrome=== |
===Fitz-Hugh-Curtis syndrome=== |
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*Liver capsular inflammation, possibly autoimmune |
*Liver capsular inflammation, possibly autoimmune |
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+ | |||
+ | ===Pediatric Infections=== |
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+ | |||
+ | *Serovars associated with STIs can also cause: |
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+ | **[[Conjunctivitis]] in neonates |
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+ | **Pneumonia in children under 6 months of age |
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+ | |||
+ | ===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== |
==Diagnosis== |
||
+ | *Molecular testing |
||
− | *Urine NAAT ~80% sensitive |
||
+ | **Urine NAAT is ~80% sensitive, and is preferred when there is no other indication for a pelvic examination |
||
− | *Self-collected vaginal swab better |
||
− | * |
+ | **Self-collected vaginal swab likely has better sensitivity, though |
+ | **MD-collected cervical swab best sensitivity (90+%) |
||
− | *No more serology! |
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+ | *Culture |
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+ | **For throat specimens |
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+ | **Done in cell culture |
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+ | *Serology |
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+ | **IgM antibodies can be helpful for diagnosting pneumonia in infants under 3 months of age |
||
+ | **Not helpful for diagnosing genital infections |
||
==Management== |
==Management== |
||
+ | === Adults === |
||
− | *For serovars L1-L3 (LGV): treat for 21 days |
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+ | |||
− | *In pregnant women, [[Is treated by::azithromycin]] is best |
||
+ | * 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) |
||
+ | * 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 |
||
{{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
- Incubation period is 2 to 3 weeks (Incubation period range::1 to 6 weeks)
- Many are asymptomatic
- Presentation varies by serovar
Serovars | Syndromes |
---|---|
A to C | Trachoma (chronic conjunctivitis) |
D to K | Urethritis, PID, neonatal infection |
L1 to L3 | Lymphogranuloma venereum (LGV) |
Sexually-Transmitted Infection
- In men, most are symptomatic
- Incubation period is 7 to 21 days in men
- Purulent urethritis, urethral itch, dysuria, testicular pain
- 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
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
- Active trachoma, with acute, mild, self-limited conjunctivitis
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
- doxycycline 100 mg PO bid for 21 days (see 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)
- 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