Guideline sources The following summarized guidelines for the evaluation and management of Chlamydia trachomatis infection are prepared by our editorial team based on guidelines from the International Union Against Sexually Transmitted Infections (IUSTI/BASHH 2016) and the U.S. Preventive Services Task Force (USPSTF 2014). 1 2 3 4 4 4 5 Definition Chlamydia trachomatis infection is a common bacterial STI characterized primarily by urethritis in males and endocervicitis in females. 4 Epidemiology The obligate intracellular bacteria Chlamydia trachomatis is responsible for the disease and may be transmitted through oral, vaginal or anal sex. 4 Disease course The most common manifestations include urethritis in men and mucopurulent cervicitis, urethritis, and endometritis in women. Disease progression may lead to pelvic inflammatory disease, which in pregnancy results in premature delivery and puerperal and neonatal infections. 4 https://web.pathway.md/diseases/rech7jY1LrP5Tx5kA 1/5 6/29/23, 3:51 AM Chlamydia trachomatis infection Pathway Prognosis and risk of recurrence Chlamydia trachomatis infection during pregnancy is associated with an increased risk of perinatal mortality (RR 1.84, 95% CI 1.15-2.94). 5 Guidelines 1. Screening and diagnosis Indications for screening: As per USPSTF 2014 guidelines: Screen for chlamydia in sexually active females 24 years of age, and in older women who are at increased risk for infection. B Insufficient evidence to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. I Indications for screening: As per IUSTI/BASHH 2016 guidelines: Obtain annual Chlamydia trachomatis testing for all sexually active patients < 25 years of age. B Consider annual Chlamydia trachomatis testing for MSM. C 2. Diagnostic investigations Nucleic acid amplification tests: obtain NAATs (identifying Chlamydia trachomatis specific nucleic acid in clinical specimens) for diagnosis, due to their superior sensitivity, specificity, and speed. A Testing for other STIs: consider testing for other STIs - including gonorrhoea, syphilis, and human immunodeficiency virus - in patients with Chlamydia trachomatis infection. C 3. Medical management Management of uncomplicated urogenital infections (general population): Use one of the following agents as first-line treatment for uncomplicated Chlamydia trachomatis urogenital infections in patients who are not pregnant or breastfeeding: doxycycline (100 mg PO BID, for 7 days) azithromycin (1 g PO immediately, for one dose). A Show 2 more Management of uncomplicated urogenital infections (pregnancy or breastfeeding): use azithromycin (1 g PO immediately, for one dose) as first-line treatment for uncomplicated Chlamydia trachomatis urogenital infections in patients who are pregnant or breastfeeding. A https://web.pathway.md/diseases/rech7jY1LrP5Tx5kA 2/5 6/29/23, 3:51 AM Chlamydia trachomatis infection Pathway Show 2 more Management of uncomplicated rectal/pharyngeal infections: Use doxycycline (100 mg PO BID, for 7 days; contraindicated in pregnancy) as first-line treatment for uncomplicated rectal/pharyngeal Chlamydia trachomatis infections in patients who are not pregnant or breastfeeding. A Consider using azithromycin (1 g PO immediately, for one dose) as an alternative first-line treatment. B Updated evidence: CHLAZIDOXY In adult women positive for anorectal and vaginal Chlamydia trachomatis infection, doxycycline was superior to azithromycin with respect to microbiological anorectal cure. Olivia Peuchant et al. Lancet Infect Dis. 2022 May 9. Management of conjunctival infection: Use doxycycline (100 mg PO BID, for 7 days; contraindicated in pregnancy) as first-line treatment for Chlamydia trachomatis conjunctivitis in patients who are not pregnant or breastfeeding. A Consider using azithromycin (1 g PO immediately, for one dose) as an alternative first-line treatment. B 4. Patient education General principles: advise patients who test positive for Chlamydia trachomatis to abstain from sexual contact for seven days after they and their partners have completed treatment and their possible symptoms have resolved. B Behavioral counseling: provide intensive behavioral counseling for all sexually active adolescents and adults who are at increased risk for STIs. B 5. Follow-up and surveillance Testing for cure: Avoid routine test of cure in patients treated with first-line regimens. D Perform a test of cure in pregnancy, in complicated infections, if symptoms persist, if second-line or third-line regimens have been used, or if non-compliance to therapy or re-exposure of infection is suspected. B Testing for reinfection: offer repeated testing 3-6 months after diagnosis, to detect reinfections, to patients < 25 years of age, who test positive for Chlamydia trachomatis. B Contact notification: https://web.pathway.md/diseases/rech7jY1LrP5Tx5kA 3/5 6/29/23, 3:51 AM Chlamydia trachomatis infection Pathway Ensure contact notification is performed and documented by trained professionals at the time of diagnosis to improve outcome. B Evaluate, test and treat all sexual contacts within the preceding six months of onset of symptoms or diagnosis. B Clinical findings Symptoms Past medical history Burning on urination History of other STIs Lower urinary symptoms Proctitis Painful intercourse Urethritis Painful or difficult urination Vaginitis Postcoital bleeding Social history Rectal pain Testicular pain Multiple sexual partners Urethral discharge Rectal exam Past obstetric history Rectal blood Recurrent abortion Ocular exam Conjunctivitis Gynecologic exam Vaginal discharge Studies 2023 DoxyPEP In MSM and transgender women with bacterial STIs in the previous 12 months, doxycycline was superior to standard care with respect to any STIs per follow-up quarter, in pre-exposure prophylaxis cohort. Anne F Luetkemeyer et al. N Engl J Med. 2023 Apr 6. 2022 CHLAZIDOXY In adult women positive for anorectal and vaginal Chlamydia trachomatis infection, doxycycline was superior to azithromycin with respect to microbiological anorectal cure. Olivia Peuchant et al. Lancet Infect Dis. 2022 May 9. https://web.pathway.md/diseases/rech7jY1LrP5Tx5kA 4/5 6/29/23, 3:51 AM Chlamydia trachomatis infection Pathway References 1. Lanjouw E, Ouburg S, de Vries HJ et al. 2015 European guideline on the management of Chlamydia trachomatis infections. Int J STD AIDS. 2016 Apr;27 5 333 48. Open 2. LeFevre ML, U.S. Preventive Services Task Force. Screening for Chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 Dec 16;161 12 902 10. Open 3. LeFevre ML, U.S. Preventive Services Task Force. Behavioral counseling interventions to prevent sexually transmitted infections: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 Dec 16;161 12 894 901. Open 4. Meenakshi Malhotra, Seema Sood, Anjan Mukherjee et al. Genital Chlamydia trachomatis: an update. Indian J Med Res. 2013 Sep;138 3 303 16.2013 Sep;138 3 303 16. Open 5. Maria Jose Penna Maisonnette de Attayde Silva, Gilzandra Lira Dantas Florencio, Jose Roberto Erbolato Gabiatti et al. Perinatal morbidity and mortality associated with chlamydial infection: a meta-analysis study. Braz J Infect Dis. Nov-Dec 2011;15 6 533 9.Nov-Dec 2011;15 6 533 9. Open 6. Black CM. Current methods of laboratory diagnosis of Chlamydia trachomatis infections. Clin Microbiol Rev. 1997 Jan;10 1 160 84. Open 7. Meenakshi Malhotra, Seema Sood, Anjan Mukherjee et al. Genital Chlamydia trachomatis: An update. Indian J Med Res. 2013 Sep; 138 3 303 316. Open 8. Maria Jos Penna Maisonnette de Attayde Silva, Gilzandra Lira Dantas Flor ncio, Jos Roberto Erbolato Gabiatti et al. Perinatal morbidity and mortality associated with chlamydial infection: a meta-analysis study. Braz J Infect Dis. Nov-Dec 2011;15 6 533 9. Open 9. Ana Ximena Kiguen, Marcela Marram , Susana Ruiz et al. Prevalence, risk factors and molecular characterization of Chlamydia trachomatis in pregnant women from C rdoba, Argentina: A prospective study. PLoS One. 2019 May 31;14 5):e0217245. Open 10. Ir n Budai. Chlamydia trachomatis: milestones in clinical and microbiological diagnostics in the last hundred years: a review. Acta Microbiol Immunol Hung. 2007 Mar;54 1 5 22. Open 11. C B b ar, B de Barbeyrac. Genital Chlamydia trachomatis infections. Clin Microbiol Infect. 2009 Jan;15 1 4 10. Open 12. Olivia Peuchant, Edouard Lhomme, Pervenche Martinet et al. Doxycycline versus azithromycin for the treatment of anorectal Chlamydia trachomatis infection in women concurrent with vaginal infection CHLAZIDOXY study): a multicentre, open-label, randomised, controlled, superiority trial. Lancet Infect Dis. 2022 May 9;S1473 3099 22 00148 7. Open 13. Kimberly A Workowski, Laura H Bachmann, Philip A Chan et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70 4 1 187. Open 14. Ryoichi Hamasuna, Mitsuru Yasuda, Satoshi Takahashi et al. The JAID/JSC guidelines to Clinical Management of Infectious Disease 2017 concerning male urethritis and related disorders. J Infect Chemother. 2021 Apr;27 4 546 554. Open https://web.pathway.md/diseases/rech7jY1LrP5Tx5kA 5/5