CHLAMYDIA


GENERAL FEATURES


• Chlamydia is a sexually transmitted infection (STI) caused by the bacterium Chlamydia trachomatis.


• It is the most frequent bacterial STI in the United States, with more than 1 million reported cases and an estimated 2 million unreported cases per year.


• Symptoms may be mild or absent, but complications from untreated infections can cause significant morbidity.


• Transmission occurs through vag­inal, anal, and oral sex as well as from mother to fetus.


• Risk of contracting a chlamydial infection is directly related to the number of sexual partners and other risk factors, which include inconsistent or improper use of barrier contraceptives, having partners with other recent or concurrent sexual partners, having a prior or current STI, low socioeconomic status, immunodeficiency, and being a young adult. Ejaculation does not have to occur for transmission of chlamydia.


• Reinfection is common if sexual partners are not treated.


CLINICAL ASSESSMENT


• When present, symptoms usually develop 1 to 3 weeks after infection.


• In women, symptoms may include abnormal or malodorous discharge, dysuria, urinary frequency, abdominal pain, postcoital bleeding, nausea, fever, intermenstrual bleeding, or dyspareunia. Women are frequently asymptomatic.


• In men, symptoms may include penile discharge, dysuria, burning, or pruritus at the urethral meatus. Men may also be asymptomatic.


• Anal symptoms may include bleeding, itching, or swelling.


• Complications of chlamydial infection in women include pelvic inflammatory disease, chronic pelvic pain, infertility, ectopic pregnancy, and increased risk of contracting HIV infection if exposed to the virus.


• Chlamydia may cause epididymitis in men.


• Reactive arthritis is characterized by urethritis, conjunctivitis, arthritis, and rash (keratoderma blennorrhagica) and occurs more frequently in men.


• Routine screening is recommended for all pregnant women. Women 25 years or younger and women older than 25 years with new or multiple partners should be screened annually.


DIAGNOSIS


• Tests are performed on body fluids through either urine sample or direct swabs of the urethral meatus in men or cervix in women.


• Nucleic acid amplification test (NAAT) can be used on urine, urethral, or cervical samples. DNA probe, enzyme-linked immunosorbent assay (ELISA), and direct fluorescent antibody tests (DFA) are frequently used but require direct swabs of the urethra or cervix. Rapid assay tests are currently in development.


TREATMENT


• Recommended treatment regimens are azithromycin (Zithromax, generics) 1 g for 1 day, or doxycycline, 100 mg twice daily for 7 days. Efficacy is the same even if patients miss some doses of doxycycline. Other options for treatment include ofloxacin (Floxin) 300 mg twice daily for 7 days, levofloxacin (Levaquin) 500 mg twice daily for 7 days, or erythromycin 500 mg 4 times daily for 7 days. 


• Patients should be instructed to abstain from sexual activity during treatment to reduce the risk of reinfection or transmission.


• Evaluation, testing, and treatment of partners are recommended. Partners can be treated presumptively.


• Test for cure is not necessary except when patients have persistent symptoms, are pregnant, or suspected to be nonadherent.


• In addition to treatment, patients should receive testing for other STIs, including HIV infection, and should receive counseling regarding safe sex practices and contraception.


GONORRHEA

GENERAL FEATURES


• Gonorrhea is caused by the bacterium Neisseria gonorrhoeae.


• More than 350,000 cases are reported annually, a number that has increased in recent years.


• Transmission occurs through contact with the penis, vagina, mouth, or anus and can also be transmitted from mother to fetus. Ejaculation does not have to occur for gonorrhea to be transmitted. 


• Coinfection with Chlamydia trachomatis is common.


• Risk factors include inconsistent or improper use of barrier contraceptives, multiple partners, being a young adult, sex work, drug use, having current or prior sexually transmitted infections, and having partners with multiple sexual contacts.


CLINICAL ASSESSMENT


• Symptoms usually develop 2 to 5 days after infection but may take as long as 30 days to manifest.


• Women are often asymptomatic. When present, symptoms are nonspecific and may be mistaken for bladder or other vaginal infections. Symptoms may include dysuria, vaginal discharge, and intermenstrual bleeding.


• Men are usually symptomatic but may have no symptoms. When evident, symptoms include dys­uria; white, yellow, or green dis­charge from the penis; or testicular edema. 


• Rectal symptoms include discharge, anal pruritus, rectal bleeding, and painful bowel movements; anorectal symptoms are generally only found in patients who participate in anoreceptive intercourse.


• Throat symptoms include sore throat and cervical lymphadenitis.


• Complications of gonorrhea in women include pelvic pain, infertility, ectopic pregnancy, and increased ability to contract HIV infection if exposed to the virus.


• The most common complication in men is epididymitis; postgonoccocal urethritis may also occur.


• Gonorrhea may also spread to joints and blood, causing gonococcal arthritis and gonococcemia.


DIAGNOSIS


• Gonorrhea testing can be performed on endocervical, urethral, vaginal, urine, liquid-based Pap test, oropharyngeal, and rectal specimens. Testing can also be performed on a joint aspiration if arthritis is present.


• Gram's stain testing may be performed in the office but is more sensitive for men than women. Nucleic acid amplification testing (NAAT) can be used to test endocervical, urethral, vaginal, urine, and liquid-based Pap samples. DNA probe can be used for endocervical and urethral samples. Cultures are recommended for testing oropharyngeal and rectal specimens but may also be used on endocervical, vaginal, and urethral samples.


TREATMENT


• There is increasing drug resistance to fluoroquinolones; therefore, their use is not recommended. For the same reason, treatment with peni­cillin or tetracycline (Helidac Therapy, Sumycin, generics) is not recommended.


• Recommended treatment options for gonorrhea include a single 
IM 125-mg injection of ceftriaxone (Rocephin, generics) or a single 400-mg oral dose of cefixime (Suprax). In patients with true immunoglobulin E (IgE)-mediated penicillin allergy, a single 2-g oral dose of azithromycin (Zithromax, generics) has been shown to be effective.


• Because coinfection with C trachomatis is common, treatment regimens should include coverage for both gonorrhea and chlamydial infection.


• Evaluation, testing, and treatment of partners are recommended; partners may be treated presumptively.


• Patients should be instructed to abstain from sexual activity until treatment is completed.


• Patients should receive testing for other sexually transmitted infections and receive counseling regarding contraception and safe sex practices. JAAPA


Amy Klingler practices family medicine and urgen care at the Salmon River Clinic, Stanley, Idaho. She has indicated no relationships to disclose relating to the content of this article.

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Dawn Colomb-Lippa, PA-C; Amy Mercantini Klingler, MS, PA-C, department editors


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