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Chlamydia (Pathophysiology (Transmission Sexual contact (vaginal, rectal,…
Chlamydia
Pathophysiology
Transmission
Sexual contact (vaginal, rectal, oral)
Mechanism
Infects the urethra in men
Infects endocervix/urethra in women
Can also infect conjunctiva, rectum, nasophrynx
Types
Uncomplicated - not ascended to upper genital tract
Complicated - ascended to upper genital tract
(PID in women, epididymo-orchitis in men)
Agent
Chlamydia trachomatis, obligate intracellular bacterium
Clinical
presentation
Asymptomatic
Most women (70%)
50% men
Vaginal
Discharge (increased, discoloured, smelly)
Vaginal bleeding (IMB, PCB)
Deep dyspareunia
Dysuria
Pelvic pain
Penile
Discharge
Dysuria
Swollen painful testicles
Polyarthritis
Rectal
Discharge
Anal discomfort
Risk factors
UPSI
Low SEC
New/multiple sexual partners
Age <25y
Epidemiology
Commonest bacterial STI in UK
Common in 15-24y
2-10% of 15-24y
Diagnosis
Examination
Male genital examination
Erthyma, swelling of testicles
Discharge from urethral meatus
Female bimanual examination
Cervical excitation, adnexal tenderness,
abdo/pelvic tenderness
Speculum examination
Discharge, erythematous cervix,
may bleed on contact
PR examination
Erythema, tenderness (proctitis)
Investigations
Bedside
Obs (check for sepsis)
Swabs
Female: endocervical (symptomatic, goes into OS) or vulvovaginal (asymptomatic) (gram stain, NG/CT NAAT)
Men: urethral swab, FPU (gram stain, MCS, NG/CT NAAT)
Both: rectal/oral (NG/CT NAAT)
If proctitis or HIV+, rectal swab for LGV
Bloods
HIV, syphilis, HCV, HBV
History
Reproductive
Gynae: menses, bleeding, contraception, smears
Obs: gravity/parity, deliveries, complications
DH
Current meds
Recent abx
Allergies
PMH
Previous STIs, treatments
Chronic medical conditions
Abdo/pelvic surgery
SH
Sexual contacts (who, when, type of partner)
Type of sex (oral, anal, vaginal, receptive or passive)
Partners in last 3m and 12m
BBV risk (HIV status partners, abroad, IVDU, exchanged money for sex, medical procedures/blood transfusions abroad)
PC/HPC
Discharge, pain, swelling, dysuria
Complications
Female
PID
Endometritis and salpingitis
Chronic pelvic pain
Pregnancy complications
Ectopic pregnancy
PPROM, preterm delivery, low birth weight,
post-partum endometritis, neonatal chlamydia
Infertility
Risk after PID, increasing
risk if infected multiple times
Both
Conjunctivitis
Autoinnoculation/splash
Sexually-acquired reactive arthritis (SARA)
Polyarthritis of weight-bearing joints
Psychological
Anxiety, distress
Lymphogranuloma venereum (LGV)
Infection of lymphatic system
Commonest in MSM, particularly HIV+
Perihepatitis
Fitz-Hugh-Curtis syndrome
Male
Epididymo-orchitis
Pain, swelling, inflammation of epididpymis +/or testicles
Management
Medical
Abx
Indication: all patients suspected/confirmed
E.g. doxycyclin 100mg BD 7d; OR azithromycin 1g STAT then 500mg OD 2d
MOA: destroy intracellular CT bacteria
SEs: N+V, diarrhoea
CI: doxy in pregnancy/breastfeeding
Conservative
Information and advice
Abstain SI until self and partner finished treatment
(or 7d after azithromycin STAT)
Written information about chlamydia
Screening for other STIs
Check about ongoing contraception
FU repeat test 3-6m in high risk (i.e. 16-25y)
Contact tracing
Refer to GUM clinic
Test and treat partners from last 6m
Referral
If no response to treatment, PID
Definition
Sexually transmitted bacterial
infection caused by C trachomatis
Prognosis
Persist or spontaneous resolution
(clearance increases with duration of infection;
50% resolve within 12m)
Screening
Indications
Partner has proven/suspected STI
Sexually active <25y annually
Concerns about sexual exposure
Previous chlamydia tx past 3m
2+ partners in past 12m
Women seeking ToP
Attendance at GUM clinic