Jess Gaddie adapted from presentation by Rachel Coyne Chlamydia Most common bacterial STI in Britain Caused by Chlamydia trachomatis Transmission through unprotected sexual intercourse Can be easily diagnosed and treated ID: 531120
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Slide1
Chlamydia Trachomatis – Diagnosis and management
Jess
Gaddie
(adapted from presentation by Rachel Coyne)Slide2
Chlamydia
Most common bacterial STI in Britain
Caused by Chlamydia trachomatis
Transmission through unprotected sexual intercourseCan be easily diagnosed and treatedUndiagnosed infections may persist for months or yearsRisk factors : - <25s - new sexual partner - >1 sexual partner in last 12 months
British Society of Sexual Health and HIV. 2006 UK National Guideline for the Management of Genital. http://www.bashh.org/documents/65.pdf Slide3
Clinical features
Women
MenNone (70%)
None
(50%)
Vaginal discharge
Urethral discharge
Irregular bleeding
Dysuria
Abdominal
pain +
dysparunia
Testicular
pain
Dysuria
Cervicitis + contact bleedingSlide4
Clinical features
Rectal Infections
- May be asymptomatic
- Rectal discharge/bleeding- Anorectal discomfortLymphgranuloma venereum (LGV) - Caused by one of 3 invasive
serovars
of Chlamydia
tranchomatis
- Seen most commonly in men who have sex with men (MSM)
- Associated with more severe rectal symptoms - Requires longer courses of treatmentPharyngeal Infections- Asymptomatic
White J et al. 2013 UK national guideline for the
managment
of
Lymphgraunoma
venereum
.
Int
J STD AIDS 2013 Aug;24(8):593-601Slide5
Complications
Pelvic Inflammatory Disease
Est
35% caused by CT in the UKAcute pelvic pain +/- sepsisLong-term complications – chronic pelvic pain, ectopic pregnancy, subfertility Price MJ et at. Proportion of pelvic inflammatory disease caused by chlamydia trachomatis; consistient
picture from different methods. J infect dis. 2016
aug
15; 21(4):617-24Slide6
Complications
Epididymo-orchitis
Adult conjunctivitisReactive arthritis
May increase the risk of transmission of HIV
Increased persistence of Human Papilloma Virus (HPV)
Pregnant women – neonatal conjunctivitis and pneumoniaSlide7
Chlamydia prevalence
Region
Number Chlamydia
TestsPositive tests
Percent population tested
Percent of tests positive
Detection rate per 100 000
London
285 398
22 89127%8%
2 200
ENGLAND
958 371
58 428
22%
8%
1 861
Data: PHE, Chlamydia testing 15-24 year olds in 2015 Slide8Slide9
LA
Tests
Positives
% testedDetection/100 000
Barnet
7 822
562
18
1 293
Hackney79891 161
40.8
3 764
Lewisham
17 655
1 911
50.2
5 434
Hackney Coverage
rate
London coverage
rate
England coverage
rate
40.8%
27.4%
22.5%
Coverage
rates for CT testing 2015 in 15-24 year oldsSlide10
National Chlamydia Screening Programme (NCSP)
High proportion of asymptomatic disease requires screening of ‘at risk’ individuals
Screening is acceptable and sensitive.
NCSP recommends screening of <25s annually or with each new sexual partnerScreening should be opportunistic – e.g. non-GUM clinical settings, non-clinical settings, increased availability of home-testing - Natsal-3 survey demonstrated relatively high rates of coverage. 54% sexually active women 15-24 and 35% young men had had a chlamydia test in the last year53% of chlamydia infections in 15-24 year olds were diagnosed in non-GUM settings in 2015
Public Health England. The National Chlamydia Screening Programme: An Overview. available online at http://www.chlamydiascreening.nhs.uk/ps/overview.aspSlide11
Impact of screening
Facilitates earlier diagnosis and treatment of chlamydia, and other sexually transmitted infections
Reduced complications of chlamydia infection
- 36% lower risk of developing PID within one yearReduced transmission to partnersPublic Health England. Opportunisitic Chlamydia Screening of Young Adults in England - An evidence summary. 2014. http://www.chlamydiascreening.nhs.uk/ps
/resources/evidence/Opportunistic%20Chlamydia%20Screening_Evidence%20Summary_April%202014.pdfSlide12
Diagnosis
Screening test must be:
- Acceptable to general population
- Sensitive – low rate of false negatives, ability to pick up infection in asymptomatic men and women - Specific – low rate of false positivesSlide13
Diagnosis – Nucleic Acid Amplifications Tests (NAATs)
Amplify nucleic acid sequences specific to the organism being detected
Single sample used to screen for Chlamydia and Gonorrhoea
Can produce a positive signal from even a single copy of target DNA or RNA90-95% sensitivity for Chlamydia - Tissue culture 60-80% - Enzyme immunoassays 40-70%95-99% specificityJohnson RE et al. Screening Tests to Detect Chlamydia trachomatis and Neisseria gonorrhoea Infections 2002. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5115a1.htmSlide14
NAATS – Available commercial assays
Abbott
RealTime
PCR assay (Abbott m2000, Abbott Diagnostics) BD ProbeTec ET, Strand displacement amplification (SDA, Becton Dickinson) COBAS Taqman, Polymerase chain reaction assay (Real-time PCR, Roche Diagnostics) GenProbe Aptima assay, Transcription mediated amplification assay (TMA, GenProbe)
British Society for Sexual Health and HIV. Chlamydia trachomatis - UK Testing Guidelines. 2010, http://www.bashh.org/documents/3352.pdfSlide15
Sites to be sampled - Women
Endocervical
swabs &
Vulvovaginal swab (VVS)Vulvovaginal Swabs (VVS)Obtained by inserting the swab 2-3cm into vagina and rotating for 10-30 secondsCan be self-taken or clinician obtained - Higher sensitivity than endocervical swabs in diagnosing Chlamydia in both symptomatic and asymptomatic women: 97%
vs
88%, p=<0.00001
Non invasive
Easily carried out in both clinical and non clinical settingsSlide16
Sites to be sampled - Men
First voided urine
Hold urine for 1-2 hours prior to sample collection
First 15-50ml urine passedEqual sensitivity as urethral swabsNon invasiveEasily preformed in clinical and non-clinical settingsSlide17
Rectal and Pharyngeal Samples
NAATs unlicensed for use at extra-genital sites
Evidence suggests NAATs perform well at extra-genital sites
Recommended in men who have sex with men (MSM) and commercial sex workers at risk of extra-genital chlamydia infectionSlide18
When to test
Symptoms of sexually transmitted infection
Annually/ new sexual partner
Timing – 2 weeks after potential exposure Slide19
Treatment
Recommended regimens:
1g azithromycin stat
100mg doxycycline bd 7 days (contraindicated in pregnancy)Rectal and pharyngeal infection:Asymptomatic – 100mg doxycycline bd 7 days (if LGV negative)Symptomatic – 100mg doxycycline bd 14-21 daysAlternative regimens:
Erythromycin 500mg
bd
10-14 days
Ofloxacin
200mg
bd or 400mg od 7 daysBritish Society of Sexual Health and HIV. 2006 UK National Guideline for the Management of Genital. http://www.bashh.org/documents/65.pdf Slide20
Treatment
No sexual intercourse for 7 days
Partner notification and treatment
- Patient symptomatic: Partners in last 4 weeks - Patient asymptomatic: Partners in last 6 monthsRetreatment if vomiting occurs within 3 hours of taking azithromycinSlide21
Follow-up
Following up partner notification
Reinforcing health education
Ensuring compliance with treatment and abstinence from sexual intercourse until partner(s) have completed antibiotics (if treated with azithromycin waiting seven days). Re-treat non-compliant and/or re-exposed individuals. CT test may remain positive for up to 6 weeks after treatment of infection, therefore routine STI screening after 3-4 months is recommended.Slide22
ANY QUESTIONS?