Home Blog PA Boards 106: Clinical Pearls for Chlamydia and Gonorrhea

PA Boards 106: Clinical Pearls for Chlamydia and Gonorrhea

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Chlamydia and gonorrhea are the two most common sexually transmitted diseases in the United States. The main reason to screen women is to reduce risk of infertility, PID, complications of pregnancy (ectopic, PROM, and SA), and chronic pain. The main reason to screen men is to stop transmission of disease.

Infants born to infected mothers may have neonatal conjunctivitis, pneumonia, pharyngitis, arthritis, and gonococcemia.

MSM are at higher risk with 15% of patients having chlamydia and/or gonorrhea.
RF: New sex partner in past 60 days, multiple sex partners, no condom use, <25 years of age, prior STI, and drug use.

Women <25 years of age should be screened annually. Women >25 years of age should be screened annually if they have risk factors. Men are only screened if they are at risk (unsure if this improves outcomes).

Symptoms

Women:
The cervix is the most commonly affected site and the majority of women are asymptomatic (85%). If symptoms occur, they may have: purulent or mucopurulent vaginal discharge, intermenstrual vaginal bleeding, post-coital bleeding, dyspareunia, dysuria, and/or urinary frequency.

A small percentage of women who have cervictitis may also have urethritis giving UTI like symptoms. Pyuria may be seen on UA but the dipstick will not show bacteria.

PID occurs when infection ascends to the upper genital tract (anything above the cervix). Patients have pelvic pain, cervical motion tenderness, adnexal tenderness, with or without fever.
Perihepatitis (Fitzhugh-Curtis syndrome): inflammation of the liver capsule due to PID. Leads to RUQ pain and/or pleuritic pain.

Men:
Half of men are asymptomatic and if symptoms are present the majority will be from urethritis: mucoid or watery urethral discharge (difficult to notice) and dysuria. If discharge is present, those with gonorrhea tend to have more copious amounts but can present identical to other causes.
Chlamydia and gonorrhea are the most common pathogens associated with epididymitis in patients under 35. Patients present with testicular pain/tenderness, swelling, and hydrocele.
1% of male patients will develop reactive arthritis.

Chlamydia in men and women can also lead to conjunctivitis and pharyngitis.

Diagnosis

Diagnosed in both men and women using NAAT (nucleic acid amplification testing) in the urine or via swabs. In women vaginal swabs are preferred (higher sensitivity) when compared to endocervical sampling. When the urine is being collected the genital areas should not be pre cleaned and it should be first catch urine.

Consider take a sample of the rectal area if at risk as many infections may only be found at this site.

Treatment

Chlamydia:
Azithromycin 1 gram and doxycycline (non pregnant women) 100mg BID for 7 days are first line. Second line agents include levofloxacin 500 mg orally once daily for seven days and ofloxacin 300 mg orally twice daily for seven days. Women who are pregnant who can’t tolerate azithromycin can be treated with amoxicillin 500mg TID for 7 days (less effective).

Gonorrhea:
Ceftriaxone 250mg IM is first line in both pregnant and non-pregnant patients. Patients with isolated gonorrhea should also be given azithromycin (added activity against gonorrhea and possible co-infection treatment for chlamydia) – doxycycline is an acceptable alternative to azithromycin.

If ceftriaxone administration is not available cefixime should be offered. If severe allergy exists, then alternate options include: high dose azithromycin (2 grams) with gentamycin or gemifloxacin. Azithromycin 2 grams monotherapy has a theoretical cure rate of 99% but GI side effects make this difficult to use.

Patients should have improvement of symptoms after 3 days – if they don’t there might be treatment failure.

Test of cure vs retesting. Test of cure can be done 3 weeks AFTER treatment in pregnant women, patients with persistent symptoms, and patients who were treated with second line medications. Retesting should be performed on all patients 3 months after treatment.

Primary treatment failure is rare for chlamydia as there have not been any resistance to first line medications. But, this is possible in patients who have gonorrhea. Such patients should have cultures sent for antibiotic selection.

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Andrew