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DESCRIPTION
In the United States, chlamydial genital infection occurs frequently among sexually active adolescents and young adults. Asymptomatic infection is common among both men and women. Sexually active adolescent women should be screened for chlamydia infection at least annually, even if symptoms are not present. Annual screening of all sexually active women aged 20-25 years is also recommended, as is screening of older women with risk factors (e.g., those who have a new sex partner and those with multiple sex partners). An appropriate sexual risk assessment should always be conducted and may indicate more frequent screening for some women.
CHLAMYDIAL INFECTION IN ADOLESCENTS & ADULTS
Several important sequelae can result from C. Trachomatis infection in women; the most serious of these include pelvic inflammatory disease (PID), ectopic (tubal) pregnancy, and infertility. Some women who have apparently uncomplicated cervical infection already have additional upper-reproductive tract infection. A recent investigation of patients in a health maintenance organization demonstrated after screening and treatment of cervical infection can reduce the likelihood of PID.
Chlamydia trachomatis are bacteria that live and reproduce inside human cells. Although scientists now classify Chlamydia trachomatis as bacteria, unlike other bacteria, they are difficult to identify with typical laboratory tests; however, like other bacteria, chlamydial infections can be cured by certain antibiotics.
Chlamydia trachomatis infections are probably the most common form of sexually transmitted disease in the United States today, with between three and four million new infections each year.
In industrialized countries Chlamydia Trachomatis infections are more common than gonorrhea, another STD, but many people contract both infections simultaneously. Doctors estimate that among patients with gonorrhea, approximately 25% of men and 30% to 50% of women also have chlamydial infections. Experts believe that 5% to 25% of all pregnant women in the United States currently have chlamydial infections, and these mothers can infect their infants with Chlamydia at birth. About 25% of the infected children will develop a chlamydial conjunctivitis, and about 10% will develop chlamydial pneumonia.
CHLAMYDIA INFECTIONS AMONG INFANTS
Prenatal screening of pregnant women can prevent chlamydial infections among neonates. Pregnant women under 25 years of age are at high risk for infection. Local or regional prevalence surveys of chlamydial infection can be conducted to confirm the validity of suing the CDC recommendations in particular settings.
C. trachomatis infection of neonates results from perinatal exposure to the mother's infected cervix. The prevalence of C. trachomatis infection among pregnant women does not vary by race/ethnicity or socioeconomic status. Neonatal ocular prophylaxis with silver nitrate solution or antibiotic ointments does not prevent perinatal transmission of C. trachomatis from mother to infant. However, ocular prophylaxis with those agents does prevent gonococcal ophthalmia and therefore should be continued.
Initial C. trachomatis perinatal infection involves mucous membranes of the eye, oropharynx, urogenital tract, and rectum. C. trachomatis infection in neonates is most often recognized by conjunctivitis th at develops 5-12 days after birth. Chlamydia is the most frequent identifiable infectious cause of ophthalmia neonatorum. C. trachomatis also in a common cause of subacute, afebrile pneumonia with onset from 1 to 3 months of age. Asymptomatic infections also can occur in the oropharynx, genital tract, and rectum of neonates.
SIGNS & SYMPTOMS
Chlamydia trachomatis causes infections that can affect the eyes, lungs, or urogenital (urinary-genital) area, depending on the age of the person infected and how the infection is transmitted.
Chlamydial trachomatis infection is one of the most common sexually transmitted diseases (STDs) in the United States. Females with a chlamydial infection may have vaginal redness and discomfort accompanied by a vaginal discharge. Males may have a discharge from the urethra (the opening where urine comes out) and burning upon urination. Depending on the extent of the infection, there may occasionally be a low-grade fever. People with chlamydial infections often have no symptoms at all. Although an infected person may have no symptoms, he can still spread the infection to other sexual partners.
Chlamydia trachomatis infections may spread to the upper reproductive tract, including the uterus, fallopian tubes, and ovaries and may cause pelvic inflammatory disease. Scarring of the fallopian tubes after Chlamydia trachomatis infection may cause permanent damage to the reproductive system, resulting in infertility. Chlamydial infections also increase the risk that bacteria will cause secondary infections in the pelvic organs, genitals, or rectum. Most females with chlamydial infections will be asymptomatic (they will not have any symptoms). However, an asymptomatic infection can flare up after weeks or months and cause the symptoms described above.
A pregnant woman with chlamydial infection of the genital tract can pass it to her child during birth. In newborns, the infection causes conjunctivitis or pneumonia. Newborns with chlamydial conjunctivitis (an infection that causes inflammation of the inside of the eyelid and surface of the eyeball) usually are alert and have no fever. Their eyes (one or both) are red and swollen and have a thick, yellowish discharge.
Infants with chlamydial pneumonia may have no fever, but their breathing is abnormally rapid. They may cough, vomit, and have a bluish or grayish skin coloring. About half of all newborns with chlamydial pneumonia also have had chlamydial conjunctivitis.
MoonDragon's Obgyn Information: STDs - Chlamydia
DURATION
Newborns with chlamydial conjunctivitis are usually cured after 10 to 14 days of antibiotic treatment, but relapses are common. Without antibiotic treatment, infants with chlamydial conjunctivitis may develop chlamydial pneumonia.
Newborns with chlamydial pneumonia usually improve after 5 to 7 days of antibiotic treatment, but treatment continues for 3 weeks.
Genital chlamydial infections can be cured with oral antibiotics. Sexual partners must also be treated with antibiotics. (Note: Penicillin is not effective against chlamydial infection.)
CONTAGIOUSNESS
Chlamydia trachomatis infections are contagious, and all sexual partners of someone with a genital chlamydial infection need to be notified and treated with antibiotics, even if they don't have evident symptoms.
If a pregnant woman has a genital chlamydial infection, her newborn child is in danger of infection during delivery. Of all children born to mothers with genital chlamydial infections, about 25% develop chlamydial conjunctivitis and 10% develop pneumonia. Many others have laboratory evidence of infection without symptoms.
INCUBATION
The incubation period for genital chlamydial infections is about 1 week. Since many patients may have either only mild symptoms or no symptoms at all, they may be unsure when they were infected.
In newborns, chlamydial conjunctivitis has an incubation period of 5 to 14 days, but may appear as early as 3 days or as late as 5 to 6 weeks after birth. Infants with chlamydial pneumonia are most often brought for a health care provider's treatment when they are 3 to 16 weeks old, but most of the late-presenting infants have mild symptoms of respiratory illness for several weeks before they come to medical attention.
PREVENTION
Sexually active people can prevent genital chlamydial infections by abstaining from intercourse or by using latex condoms during intercourse. Whenever a person receives antibiotic treatment for a genital chlamydial infection, her sexual partners must also be treated, even if symptoms of chlamydia infection are not evident. Because those with chlamydial infections may not initially display symptoms, sexual partners are often reluctant to believe that they could be infected and may avoid medical evaluation. They mistakenly believe that they can't be infected if they don't have symptoms. In addition, infected individuals may be infected with other STDs that require additional tests to identify.
Chlamydial infections in newborns can be prevented by treating infected mothers before delivery. The mother's sexual partners must also be treated. At birth, newborns are given a prophylactic (disease-preventing) medicine in their eyes (usually erythromycin ointment) to prevent infections from both chlamydia and gonorrhea.
WHEN TO CALL YOUR HEALTH CARE PROVIDER
For infants, call your child's health care provider if one or both of your child's eyes are red, swollen, or wet with a thick discharge. Also call your child's health care provider if your newborn has a persistent cough (even without a fever), is breathing abnormally fast, stops eating well, or shows a bluish tint to the skin, lips, or fingernails.
Sexually active people should call a health care provider if a sexual partner reports a possible sexually transmitted disease. Specifically, males should call if there is a discharge from the tip of the penis; females should call if there is a thick, yellowish discharge from the vagina.
PROFESSIONAL TREATMENT
Chlamydial infections must be treated with antibiotics. A health care provider should evaluate any possible infection. If chlamydial infection is a possibility, the health care provider may order laboratory tests to confirm it. Tests for gonorrhea or syphilis (which also are done at the time of an evaluation for a possible urogenital infection) will not reveal chlamydia. Chlamydia must be tested for specifically. Whether or not there are symptoms, sexually active people should be routinely screened for chlamydial infection as well as for other sexually transmitted diseases. Some health care professionals suggest that sexually active people should be screened for sexually transmitted diseases every 6 months.
CDC TREATMENT RECOMMENDATIONS FOR CHLAMYDIAL INFECTION
(2002 CDC STD Treatment Guidelines)
Treating infected patients prevent transmission to sex partners. In addition, treatment of chlamydia in pregnant women usually prevents transmission of C. trachomatis to infants during birth. Treatment of sex partners helps to prevent re-infection of the woman and infection of other partners.
Co-infection with C. trachomatis often occurs among patients who have gonococcal infection, therefore, presumptive treatment of such patients for chlamydia is appropriate (dual therapy for gonococcal and chlamydial infections). The following recommended treatment regimens and alternative regimens cure infection and usually relieve symptoms.
RECOMMENDED TREATMENT REGIMENS
Azithromycin: 1 g orally or a single dose.
OR
Doxycycline: 100 mg orally twice a day for 7 days.
ALTERNATIVE TREATMENT REGIMENS
Erythromycin base; 500 mg orally four times a day for 7 days.
OR
Erythromycin ethylsuccinate: 800 mg orally four times a day for 7 days.
OR
Ofloxacia: 300 mg orally twice a day for 7 days.
OR
Levofloxacin: 500 mg orally for 7 days.
The results of clinical trials indicate that azithromycin and doxycycline are equally efficacious if the 7 day regimen is followed as prescribed. Azithromycin should be used by health care providers to treat patients for whom compliance is in question (patients who have problems taking medication as instructed for the 7 day period). In populations that have erratic health care seeking behavior, poor compliance with treatment, or unpredictable follow-up, azithromycin may be more cost effective because it enables the provision of single-dose drug oral therapy. Doxycycline costs less than azithromycin, and it has been used extensively for a longer period. Erythromycin is less efficacious than either azithromycin or doxycycline, and gastrointestinal side effects frequently discourage patients from complying with this regimen. Ofloxacin is similar in efficacy to doxycycline and azithromycin, but it is more expensive to use and offers no advantage with regard to the dosage regimen. Levofloxacin has not been evaluated for treatment of C. trachomatis infection in clinical trials, but because its pharmacology and in vitro microbiological activity are similar to that of ofloxacin, levofloxacin may be substituted in doses of 500 mg once a day for 7 days. Other quinolones either are not reliably effective against chlamydial infection or have not been adequately evaluated.
To maximize compliance with recommended therapies, medications for chlamydial infections should be dispensed on site, and the first dose should be directly observed. To minimize further transmission of infection, patients treated for chlamydia should be instructed to abstain from sexual intercourse until all of their sex partners are treated.
FOLLOW-UP
Patients do not need to be retested for chlamydia after completing treatment with doxycycline or azithromycin unless symptoms persist or re-infection is suspected. A test of cure may be considered 3 weeks after completion of treatment with erythromycin. The validity of chlamydial culture testing at <3 weeks after completion of therapy for patients who were treated successfully could yield fake-positive results because of continued excretion of dead organisms.
A high prevalence of C. trachomatis infection is found in women who have had chlamydial infection in the preceding several months. Most post-treatment infections result from re-infection, often occurring because patient's sex partners were not treated or because the patient resumed sex among a network of persons with a high prevalence of infection. Repeat infection confers an elevated risk of PID and other complications when compared with initial infection. Therefore, recently infected women are a high priority for repeat testing for c. trachomatis. For these reasons, health care providers should consider advising all women with chlamydial infection to be rescreened 3-4 months after treatment. Some specialists believe rescreening is an especially high priority for adolescents. Providers are also strongly encouraged to rescreen all women treated for chlamydial infection whenever they next present for care within the following 12 months, regardless of whether the patient believes that her sex partners were treated.
Rescreening is distinct from early retesting to detect therapeutic failure (test-of-cure). Except in pregnant women, test-of-cure is not recommended for persons treated with recommended regimens, unless therapeutic compliance is in question.
MANAGEMENT OF SEX PARTNERS
Patients should be instructed to refer their sex partners for evaluation, testing, and treatment. The following recommendations on exposure intervals are based on limited evaluation. Sex partners should be evaluated, tested, and treated if they had sexual contact with the patient during the 60 days preceeding onset of symptoms in the patient or diagnosis of chlamydia. The most recent sex partner should be evaluated and treated even if the time of the last sexual contact was greater than 60 days before symptom onset of diagnosis.
Patients should be instructed to abstain from sexual intercourse until they and their sex partners have completed treatment. Abstinence should be continued until 7 days after a single-dose regimen or after completion of a 7-day regimen. Timely treatment of sex partners is essential for decreasing the risk for re-infecting the initial patient.
SPECIAL CONSIDERATIONS - PREGNANCY
Doxycycline and ofloxacin are contraindicated in pregnant women. However, clinical experience and preliminary data suggest that azithromycin is safe and effective. Repeat testing (preferably by culture) 3 weeks after completion of therapy with the following regimens is recommended for all pregnant women, because these regimens may not be highly efficacious and the frequent side effects of erythromycin might discourage patient compliance with this regimen.
RECOMMENDED TREATMENT REGIMENS FOR PREGNANCY
Erythromycin base; 500 mg orally four times a day for 7 days.
OR
Amoxicillin; 500 mg orally three times a day for 7 days.
ALTERNATIVE TREATMENT REGIMENS FOR PREGNANCY
Erythromycin base; 2500 mg orally four times a day for 14 days.
OR
Erythromycin ethylsuccinate: 800 mg orally four times a day for 7 days.
OR
Erythromycin ethylsuccinate: 400 mg orally four times a day for 14 days.
OR
Azithromycin: 1 g orally or a single dose.
NOTE: Erythromycin estolate is contraindicated during pregnancy because of drug-related hepatotoxicity.
HIV INFECTION: Patients who have chlamydial infection and also are infected with HIV should receive the same treatment regimen as those who are HIV-negative.
OPHTHALMIA NEONATORUM CAUSED BY C. TRACHOMATIS
A chlamydial etiology should be considered for all infants aged ≤30 days who have conjuctivitis.
DIAGNOSTIC CONSIDERATIONS FOR OPHTHALMIA NEONATORUM
Sensitive and specific methods used to diagnosis chlamydial ophthalmia in the neonate include both tissue culture and nonculture tests (e.g., direct fluorescent antibody tests, enzyme immunoassays, and nucleic acid amplification tests). Specimens must contain conjunctival cells, not exudate alone. Specimens for culture isolation and nonculture tests should be obtained from the everted eyelid using a dacron-tipped swab or the swab specified by the manufacturer's test kit. A specific diagnosis of C. trachomatis infection confirms the need for treatment not only for the neonate, but also for the mother and her sex partner(s). Ocular exudate from infants being evaluated for chlamydial conjunctivitis should also be tested for N. gonorrhoeae.
RECOMMENDED REGIMEN FOR FOR OPHTHALMIA NEONATORUM
Erythromycin base OR Ethylsuccinate: 50 mg per kg per day orally, divided into four doses daily for 14 days.
Topical antibiotic therapy alone is inadequate for treatment of chlamydial infection and is unnecessary when systemic treatment is administered.
FOLLOW-UP
The efficacy of erthromycin treatment is approximately 80%; a second course of therapy may be required, and follow-up of infants to determine whether treatment was effective is recommended. The possibility of concomitant chlamydial pneumonia should be considered.
MANAGEMENT OF MOTHERS AND THEIR SEX PARTNERS
The mothers of infants who have chlamydial infection and the sex partners of these mothers should be evaluated and treated.
INFANT PNEUMONIA CAUSED BY C. TRACHOMATIS
Characteristic signs of chlamydial pneumonia in infants include:1. A repetitive staccato cough with tachypnea.
2. Hyperinflation and bilateral diffuse infiltrates on a chest radiograph.
Wheezing is rare, and infants are typically afebrile. Peripheral eosinophilia sometimes occurs in infants who have chlamydial pneumonia.
Because clinical presentations differ, initial treatment and diagnostic tests should encompass C. trachomatis for all infants aged 1-3 months who possibly have pneumonia.
DIAGNOSITIC CONSIDERATIONS FOR CHLAMYDIAL PNEUMONIA
Specimens for chlamydial testing should be collected brom the nasopharynx. Tissue culture is the definitive standard for chlamydial pneumonia. Nonculture tests (e.g., EIA, direct fluorescent antibody [DFA], and nucleic acid amplification [NAATs] can be used, although nonculture tests of nasopharyngeal specimens produce lower sensitivity and specificity than nonculture tests of ocular specimens. Tracheal aspirates and lung biopsy specimens, if collected, should be tested for C. trachomatis.
Because of the delay in obtaining test results for chlamydia, the decision to include an agent in the antibiotic regimen that is active against C. trachomatis must frequently be based on clinical and radiologic findings. The results of tests for chlamydial infection assist in the management of an infant's illness and determin the need for treating the mother and her sex partner(s).
RECOMMENDED REGIMEN FOR CHLAMYDIAL PNEUMONIA
Erythromycin base or ethylsuccinate: 50 mg per kg per day orally, divided into four doses daily for 14 days.
FOLLOW-UP
The effectiveness of erythromycin in treating pneumonia caused by C. trachomatis is approximately 80%; a second course of therapy may be required. Follow-up of infants is recommended to determin whether the pneumonia has resolved. Some infants with chlamydial pneumonia have abnormal pulmonary function tests later in childhood.
Mothers of infants who have chlamydial infection and the sex partners of those women should be evaluated and treated according to the recommended treatment of adults for chlamydial infections.
Infants born to mothers who have untreated chlamydia are at high risk for infection; however, prophylatic antibiotic treatment is not indicated, and the efficacy of such treatment is unknown. Infants should be monitored to ensure appropriate treatment if infection develops.
CHLAMYDIAL INFECTIONS AMONG CHILDREN
Sexual abuse must be considered a cause of chlamydial infection in preadolescent children, although perinatally transmitted C. trachomatis infection fo the nasopharyns, urogenital tract, and rectum may persist for more than 1 year.
DIAGNOSTIC CONSIDERATIONS
Nonculture tests for chlamydia (e.g., non-amplified probes [EIA and DEA]) should not be used because of the possibility of false-positive test results. With respiratory tract specimens, false-positive results can occur because of cross-reaction of test reagents with Chlamydia pneumoniae; with genital and anal specimens, false-positive results occur because of cross-reaction with fecal flora.
RECOMMENDED TREATMENT REGIMENS FOR CHILDREN
Children who weight ≤45 kg (approximately 100 lbs):
Erythromycin base OR ethylsuccinate: 50 mg per kg per day orally, divided into four doses daily for 14 days.
Children who weigh ≥45 kg (approximately 100 lbs) but are aged less than 8 years:
Azithromycin: 1 g orally or a single dose.
Children who are aged 8 years or older:
Azithromycin: 1 g orally in a single dose.
OR
Doxycycline; 100 mg orally, twice a day for 7 days.
OTHER MANAGEMENT CONSIDERATIONS
Follow established Sexual Assault or Abuse of Children Management protocols.
Follow-up: Follow-up cultures are necessary to ensure that treatment has been effective.
HOME TREATMENT
All chlamydial trachomatis infections need to be treated with antibiotics. Sexually active people being treated for genital chlamydial infections must tell their sexual partners about the infection so that they can also receive antibiotic treatment.
Newborns with chlamydial conjunctivitis may be treated with antibiotics at home. Since relapses are common, parents should watch for signs that the infection has returned.
Newborns with chlamydial pneumonia also need to be treated with antibiotics. Watch to see that your child continues to eat well and gets enough fluids. Ask your child's health care provider for instructions about fever and other signs of a relapse of chlamydial infection.
DIET
To optimize immune system, eat a diet consisting mainly of fresh vegetables and fruits, plus brown rice, raw seeds and nuts, turkey, white fish, and whole grains.
Avoid highly processed, fried, and junk foods, as well as chicken. Approximately one third of all chickens sold in this country contain pathogenic bacteria such as salmonella. Turkey is acceptable; such bacteria are not found in turkey.
Drink only steam-distilled water, sugar-free juices, and herbal teas.
Take acidophilus (or eat fresh homemade yogurt with active cultures) to replenish the "friendly" bacteria destroyed by antibiotics.
Unless otherwise specified, the dosages recommended for supplements are for adults. For a child between the ages of 12 and 17 years, reduce the dose to 3/4 the recommended amount. For a child between the ages of 6 and 12 years, use 1/2 the recommended dose. And for a child under the age of 6 years, use 1/4 the recommended amount. If you are pregnant or breastfeeding, you should consult with your midwife or health care provider before taking any herb, herbal formula, or supplement. Some herbs and herbal formulas should not be taken during pregnancy. Some nutritional supplement dosages should be adjusted for pregnancy or not taken at all.
HERBAL & HOLISTIC RECOMMENDATIONS
HERBS
Andiroba & Copaiba Oil. Apply to irritated area as needed. Relieves vaginal and rectal inflammation.
Arjuna Capsules. Take 500 mg every 8 hours. Contains luteolin, which kills gonorrhea and chlamydia bacteria. Arjun (Terminalia arjuna), 485 mg, 120 Vcaps
Astragalus Tincture. Use as directed on label. Helps to protect the immune system. and aids in healing. Astragalus Root Tincture, 100% Organic, 2 fl. oz.
Barberry, Coptis, Goldenseal or Oregon Grape root Tincture. Take 15-30 drops in 1/4 cup water 3 times daily. Contains berberine, which kills gonorrhea and chlamydia bacteria. Do not use barberry, coptis, goldenseal or Oregon grape root if you are pregnant or have gallbladder disease. Do not take these herbs with supplemental vitamin B-6 or with protein supplements containing the amino acid histidine. Do not take goldenseal on a daily basis for more than one week at a time, and DO NOT USE IT DURING PREGNANCY. Use it only under a health care provider's supervision. Do not use goldenseal if you have cardiovascular disease or glaucoma. Barberry Tincture, 100% Organic, 2 fl. oz., Goldenseal Root (Hydrastis canadensis) Tincture, 100% Organic, 2 fl. oz., Oregon Grape Root (Wild) Tincture, 100% Organic, 2 fl. oz.
Epimedium Tablets or Extract. Take as directed on the label or by dispensing herbalist. Use after suspected exposure. Antibacterial. Stimulates urination to keep bacteria from attaching to lining of urethra. Do not use epimedium if you have any kind of prostate disorder. Horny Goat Weed (Epimedium) Express Liquid Extract, 2 fl. oz.
Scutellaria Capsules. Take 1,000-2,000 mg 3 times daily. May act against antibiotic-resistant strains of gonorrhea and chlamydia. Do not use scutellaria if you have diarrhea. Blue Scullcap (Scutellaria lateriflora), Standardized, Nature's Way, 100 mg, 60 Vcaps, Scullcap Tincture, 100% Organic, 2 fl. oz.
Echinacea, pau d'arco and red clover aid in healing. Take in capsule, tincture or extract form or drink as tea. Take as directed on label. Echinacea Purpurea, Nature's Way, 400 mg, 100 Caps, Echinacea Tincture (Children), Orange Flavor, Alcohol Free, 100% Organic, 1 fl. oz., Echinacea Immune Support Tea, Yogi Tea, Certified Organic, 16 Tea Bags, Pau D'Arco (Purple Lapacho) Tincture, 100% Organic, 2 fl. oz., Pau D'Arco Tea, Incan Purple Lapacho, 48 Tea Bags, Pau D'Arco Extract, Incan Lapacho, 100% Natural Herbal, 4 fl. oz., Red Clover (Trifolium pratense) Herb Powder, 4 oz. Bulk, Red Clover Blossom & Herb, Nature's Way, 500 mg, 100 Caps, Red Clover Tincture, 100% Organic, 2 fl. oz.
TRADITIONAL CHINESE MEDICINE (TCM) FORMULAS
Dong Quai, Gentiana Longdancao, and Aloe Pill: A traditional Chinese herbal formula that treats gonorrhea and chlamydia with accompanying herpes infection. Do not use these herbs if you are trying to become pregnant.
Eight-Ingredient Pill with Rehmannia (Rehmannia-Eight Combination): A traditional Chinese herbal formula that increases urination, effectively flushing bacteria out of the genitourinary tract before they can cause damage. Use after suspected exposure.
Peony and Licorice Decoction: A traditional Chinese herbal formula that treats gonorrhea and chlamydia complicated by cramping and abdominal pain or pain around the anus. Do not use Peony and Licorice Decoction if you have an estrogen-sensitive disease, such as breast cancer, endometriosis, or fibrocystic breasts.
Note: Bulk herbs are available through Mountain Rose Herbs. See link below.
Mountain Rose Bulk Herbs
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