Chlamydia is a bacterial infection caused by Chlamydia trachomatis. The disease is transmitted mainly through sexual intercourse with an infected person. Infected mothers may transmit the infection to their newborns. As many as 60 percent of the infants born to women with chlamydia become infected. Chlamydia has a high prevalence, is easily transmitted, is associated with gonorrhea, and frequently lacks overt symptoms. Drug users are at high risk for infection with chlamydia as well as all other sexually transmitted diseases.
Chlamydia is one of the most common of the sexually transmitted diseases in the United States, with an estimated 4 million new cases occurring annually, according to the Centers for Disease Control and Prevention (CDC). Exact figures on the incidence of chlamydia are not available, since not all States require reporting of the disease to local or State health departments.
The rate of infection for chlamydia, as for all sexually transmitted diseases, is highest in adolescents, young adults, and among drug users. The prevalence of chlamydia among adolescent girls in drug treatment units has exceeded 10 percent in most studies. The prevalence has exceeded 5 percent in studies of adolescent boys.
The symptoms of chlamydia, if they occur, usually appear within 1 to 3 weeks after infection. If promptly and properly treated, chlamydia infection is not serious and causes no lasting damage. If it is inadequately treated, however, it can cause potentially serious complications.
Women may develop pelvic inflammatory disease (PID), an infection of the reproductive organs that is usually accompanied by pain in the lower abdomen and fever. Up to one half of PID cases result from chlamydial infection. Gonorrhea is the other leading cause of PID in women. PID also causes an estimated 100,000 women a year to become infertile.
An even more serious potential complication of PID is ectopic pregnancy, which occurs when an egg is fertilized in the fallopian tube. The growing embryo may cause the tube to rupture. Because of the resulting internal bleeding, a ruptured ectopic pregnancy is a life-threatening emergency to the woman.
Screening for chlamydial infection is strongly encouraged, particularly for high-risk pregnant women, adolescents, and patients with multiple sexual partners. Testing for chlamydia infection should be routinely included for adolescent girls and women of childbearing potential having pelvic examinations. Asymptomatic infection may cause mild or silent salpingitis, leading to infertility if untreated.
Patients should be counseled to refrain from sexual intercourse until treatment is completed. In addition, safer sex guidelines should be followed and condoms used during sexual intercourse to prevent reinfection.
The early symptoms of chlamydia are often mild or nonexistent, especially in women. Because of this, chlamydia is easily spread among sexual partners. When symptoms do appear, women may experience abdominal pain and dysuria (painful urination) and have a vaginal discharge.
Men infected with chlamydia can develop nongonococcal urethritis (NGU), an inflammation of the urinary tract that is characterized by a mucopurulent penile discharge and sometimes by pain during urination. Chlamydia causes approximately 40 percent of the cases of NGU.
Chlamydia also can cause epididymitis, an inflammation of the epididymis, a part of the male reproductive system in the testicles. Rectal infection in women and men who have sex with men is not uncommon and may cause proctitis. The rectal area is infected through either anal sex or by spread of the infection from the genital area.
Less commonly, the disease also leads to a disturbance in the body's immune system, resulting in chronic arthritis. Chlamydia may also cause acute conjunctivitis in adults.
The symptoms of chlamydia are similar to those of gonorrhea, and the diseases often occur simultaneously. Concurrent infection with both gonorrhea and chlamydia is twice as common in women as in men. Chlamydia infection is found in 35 to 45 percent of women with gonorrhea. Without testing, the two infections are difficult to distinguish in patients. Accurate initial testing and followup after treatment are essential.
Isolation of chlamydia in cell cultures of adequate urethral or cervical swabs is the preferred method of detection when feasible.
Nonculture methods include a direct microimmunofluorescent antibody, enzyme immunoassay, and nucleic acid probe tests. The tests are done using urethral or cervical (for women) swab specimens which must contain cells. These tests may be done on men with urethritis or proctitis and on women with acute mucopurulent cervicitis or salpingitis.
Patients with positive test results for chlamydia should be treated with an appropriate antibiotic regimen. All persons with gonorrhea, as well as their sexual partners, should be treated presumptively for probable co-infection with chlamydia.
When the prescribed treatment is completed, routine followup cultures are not needed. If the treatment is not properly completed, persons may be retested. Regardless of the followup test results, the person will require a new, complete course of appropriate antibiotic therapy, and for that reason rescreening may be unnecessary.
A new, single-dose therapy for the treatment of uncomplicated genital chlamydial infection was reported by researchers in September 1992 (Martin et al. 1992). A single dose of azithromycin, the prototype of a new group of antibiotics known as azalides, proved to be effective in the treatment of chlamydia in 96 percent of cases studied. The cost of the single dose treatment is significantly higher than the cost of the 7-day treatment regimen, but compliance is less of an issue.
The recommended treatment regimens for uncomplicated urethral, endocervical, or rectal chlamydia infections in nonpregnant patients are provided in table 1.
In order to prevent the spread of the disease, sex partners of symptomatic patients should be evaluated and treated for chlamydia if their last sexual contact with the index patient was within 30 days of onset of the index patient's symptoms. If the index patient is asymptomatic, sex partners whose last sexual contact with the index patient was within 60 days of diagnosis should be evaluated and treated.
Chlamydia can be passed from an infected mother to an infant during delivery and may lead to conjunctivitis or pneumonia in the newborn infant. For this reason, routine testing of all pregnant women for chlamydia is recommended.
Appropriate screening should be done at the first prenatal visit and during the third trimester. Women with untreated chlamydia at delivery may develop postpartum endometritis after vaginal delivery and require treatment.
The treatment of chlamydia in pregnancy is presented in table 2.
Chlamydia. In: Sexually Transmitted Diseases. Clinical Practice Guidelines--May 1991. Atlanta, GA: U.S. Department of Health and Human Services, 1991. pp. III-7-III-8.
A controlled trial of a single dose of azithromycin for the treatment of chlamydial urethritis and cervicitis. The New England Journal of Medicine 327(13):921-925, 1992.
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